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Cherenko M, Appelman-Dijkstra NM, Priego Zurita AL, Biermasz NR, Dekkers OM, Klok FA, Reisch N, Aulinas A, Biagetti B, Cannavo S, Canu L, Detomas M, Devuyst F, Falhammar H, Feelders RA, Ferrau F, Gatto F, Grasselli C, van Houten P, Hoybye C, Isidori AM, Kyrilli A, Loli P, Maiter D, Nowak E, Pivonello R, Ragnarsson O, Steenaard RV, Unger N, van de Ven A, Webb SM, Yeste D, Ahmed SF, Pereira AM. Venous thromboembolism in Cushing syndrome: results from an EuRRECa and Endo-ERN survey. Endocr Connect 2024; 13:e240046. [PMID: 38614126 DOI: 10.1530/ec-24-0046] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/11/2024] [Indexed: 04/15/2024]
Abstract
Background Patients with Cushing syndrome (CS) are at increased risk of venous thromboembolism (VTE). Objective The aim was to evaluate the current management of new cases of CS with a focus on VTE and thromboprophylaxis. Design and methods A survey was conducted within those that report in the electronic reporting tool (e-REC) of the European Registries for Rare Endocrine Conditions (EuRRECa) and the involved main thematic groups (MTG's) of the European Reference Networks for Rare Endocrine Disorders (Endo-ERN) on new patients with CS from January 2021 to July 2022. Results Of 222 patients (mean age 44 years, 165 females), 141 patients had Cushing disease (64%), 69 adrenal CS (31%), and 12 patients with ectopic CS (5.4%). The mean follow-up period post-CS diagnosis was 15 months (range 3-30). Cortisol-lowering medications were initiated in 38% of patients. One hundred fifty-four patients (69%) received thromboprophylaxis (including patients on chronic anticoagulant treatment), of which low-molecular-weight heparins were used in 96% of cases. VTE was reported in six patients (2.7%), of which one was fatal: two long before CS diagnosis, two between diagnosis and surgery, and two postoperatively. Three patients were using thromboprophylaxis at time of the VTE diagnosis. The incidence rate of VTE in patients after Cushing syndrome diagnosis in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Conclusion Thirty percent of patients with CS did not receive preoperative thromboprophylaxis during their active disease stage, and half of the VTE cases even occurred during this stage despite thromboprophylaxis. Prospective trials to establish the optimal thromboprophylaxis strategy in CS patients are highly needed. Significance statement The incidence rate of venous thromboembolism in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Notably, this survey showed that there is great heterogeneity regarding time of initiation and duration of thromboprophylaxis in expert centers throughout Europe.
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Affiliation(s)
- M Cherenko
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - N M Appelman-Dijkstra
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - A L Priego Zurita
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - O M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
| | - F A Klok
- Department of Medicine, Division of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Netherlands
| | - N Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - A Aulinas
- Department of Endocrinology, Fundacio de Gestio Sanitaria Hospital de la Santa Creu i Sant Pau, IR-SantPau and CIBERER Unit 747 (ISCIII), Barcelona, Spain
| | - B Biagetti
- Department of Endocrinology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - S Cannavo
- Endocrine Unit, University Hospital AOU Policlinico G. Martino, Messina, Italy
| | - L Canu
- University Hospital Florence Careggi, Florence, Italy
| | - M Detomas
- Department of Internal Medicine, University Hospital Würzburg, Wuerzburg, Germany
| | - F Devuyst
- Department of Endocrinology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - H Falhammar
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - R A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Rotterdam, Netherlands
| | - F Ferrau
- Endocrine Unit, University Hospital AOU Policlinico G. Martino, Messina, Italy
| | - F Gatto
- IRCCS Ospedale Policlinico San Martino, Genova, Genoa, Italy
| | - C Grasselli
- Cardiovascular Medicine Unit, AUSL-IRCCS, Reggio Emilia, Italy
| | - P van Houten
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - C Hoybye
- Department of Endocrinology, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Kyrilli
- Department of Endocrinology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - P Loli
- Division of Endocrinology, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital Milan, Italy
| | - D Maiter
- Department of Endocrinology, Cliniques universitaires Saint-Luc - UCLouvain, Brussels, Belgium
| | - E Nowak
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università "Federico II" di Napoli, Naples, Italy
| | - O Ragnarsson
- Sahlgrenska Academy, Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine (O.R.), University of Gothenburg, Sweden
| | - R V Steenaard
- Department of Internal Medicine, Máxima MC, Veldhoven, Netherlands
| | - N Unger
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, Essen, Germany
| | - A van de Ven
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - S M Webb
- Department of Endocrinology, Fundacio de Gestio Sanitaria Hospital de la Santa Creu i Sant Pau, IR-SantPau and CIBERER Unit 747 (ISCIII), Barcelona, Spain
| | - D Yeste
- Pediatric Endocrinology Service, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. CIBER Enfermedades Raras, Instituto Carlos III, Madrid, Spain
| | - S F Ahmed
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, Netherlands
- University of Glasgow, Office for Rare Conditions, Glasgow, UK
- University of Glasgow, Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, UK
| | - A M Pereira
- Department of Endocrinology & Metabolism, Amsterdam University Medical Centre, Amsterdam, Noord-Holland, Netherlands
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2
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Burggraaf-van Delft JLI, la Roi-Teeuw HM, de Wit J, Klok FA, Cannegieter SC, Geersing GJ. [When to suspect pulmonary embolism: a balancing act]. Ned Tijdschr Geneeskd 2024; 168:D7788. [PMID: 38661169] [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] [Indexed: 04/26/2024]
Abstract
Pulmonary embolism (PE) is a common disease, which can present with a variety of symptoms. Optimal use of diagnostics is challenging given the tight and delicate balance between underdiagnosis and over-testing or overdiagnosis. Diagnostic delay occurs in a substantial part of patients, and seems more common in those with known cardiopulmonary disease or non-specific signs and symptoms. At the other end of the spectrum, the amount of diagnostic imaging increases. Increased use of diagnostic imaging in general leads to more harmful exposures and might result in overtreatment, as may be the case in subsegmental PE. Correct use of clinical prediction rules reduces the need for diagnostic imaging while PE can still be ruled out safely. This clinical lesson describes three cases of PE and provides an overview of factors that contribute to underdiagnosis or overdiagnosis. We provide recommendations to improve our balancing act for this challenging disease.
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Affiliation(s)
| | - Hannah M la Roi-Teeuw
- Universitair Medisch Centrum Utrecht, afd. Huisartsgeneeskunde en verplegingswetenschap, Utrecht
| | - J de Wit
- Leids Universitair Medisch Centrum
| | - F A Klok
- Leids Universitair Medisch Centrum, afd. Interne Geneeskunde - Trombose en Hemostase, Leiden
| | - S C Cannegieter
- Leids Universitair Medisch Centrum, afd. Klinische epidemiologie en afd. Trombose en Hemostase, Leiden
| | - G J Geersing
- Universitair Medisch Centrum Utrecht, afd. Huisartsgeneeskunde en verplegingswetenschap, Utrecht
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3
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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [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: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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4
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Chen Q, van Rein N, van der Hulle T, Heemelaar JC, Trines SA, Versteeg HH, Klok FA, Cannegieter SC. Coexisting atrial fibrillation and cancer: time trends and associations with mortality in a nationwide Dutch study. Eur Heart J 2024:ehae222. [PMID: 38619538 DOI: 10.1093/eurheartj/ehae222] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/24/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND AND AIMS Coexisting atrial fibrillation (AF) and cancer challenge the management of both. The aim of the study is to comprehensively provide the epidemiology of coexisting AF and cancer. METHODS Using Dutch nationwide statistics, individuals with incident AF (n = 320 139) or cancer (n = 472 745) were identified during the period 2015-19. Dutch inhabitants without a history of AF (n = 320 135) or cancer (n = 472 741) were matched as control cohorts by demographic characteristics. Prevalence of cancer/AF at baseline, 1-year risk of cancer/AF diagnosis, and their time trends were determined. The association of cancer/AF diagnosis with all-cause mortality among those with AF/cancer was estimated by using time-dependent Cox regression. RESULTS The rate of prevalence of cancer in the AF cohort was 12.6% (increasing from 11.9% to 13.2%) compared with 5.6% in the controls; 1-year cancer risk was 2.5% (stable over years) compared with 1.8% in the controls [adjusted hazard ratio (aHR) 1.52, 95% confidence interval (CI) 1.46-1.58], which was similar by cancer type. The rate of prevalence of AF in the cancer cohort was 7.5% (increasing from 6.9% to 8.2%) compared with 4.3% in the controls; 1-year AF risk was 2.8% (stable over years) compared with 1.2% in the controls (aHR 2.78, 95% CI 2.69-2.87), but cancers of the oesophagus, lung, stomach, myeloma, and lymphoma were associated with higher hazards of AF than other cancer types. Both cancer diagnosed after incident AF (aHR 7.77, 95% CI 7.45-8.11) and AF diagnosed after incident cancer (aHR 2.55, 95% CI 2.47-2.63) were associated with all-cause mortality, but the strength of the association varied by cancer type. CONCLUSIONS Atrial fibrillation and cancer were associated bidirectionally and were increasingly coexisting, but AF risk varied by cancer type. Coexisting AF and cancer were negatively associated with survival.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Tom van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Julius C Heemelaar
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Cardiovascular Imaging Research Center, Division of Cardiology, and Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Serge A Trines
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henri H Versteeg
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Medicine, Section of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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5
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Coutinho JM, van de Munckhof A, Aguiar de Sousa D, Poli S, Aaron S, Arauz A, Conforto AB, Krzywicka K, Hiltunen S, Lindgren E, Sánchez van Kammen M, Shu L, Bakchoul T, Belder R, van den Berg R, Boumans E, Cannegieter S, Cano-Nigenda V, Field TS, Fragata I, Heldner MR, Hernández-Pérez M, Klok FA, Leker RR, Lucas-Neto L, Molad J, Nguyen TN, Saaltink DJ, Saposnik G, Sharma P, Stam J, Thijs V, van der Vaart M, Werring DJ, Wong Ramos D, Yaghi S, Yeşilot N, Tatlisumak T, Putaala J, Jood K, Arnold M, Ferro JM. Reducing the global burden of cerebral venous thrombosis: An international research agenda. Int J Stroke 2024:17474930241242266. [PMID: 38494462 DOI: 10.1177/17474930241242266] [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] [Indexed: 03/19/2024]
Abstract
BACKGROUND Due to the rarity of cerebral venous thrombosis (CVT), performing high-quality scientific research in this field is challenging. Providing answers to unresolved research questions will improve prevention, diagnosis, and treatment, and ultimately translate to a better outcome of patients with CVT. We present an international research agenda, in which the most important research questions in the field of CVT are prioritized. AIMS This research agenda has three distinct goals: (1) to provide inspiration and focus to research on CVT for the coming years, (2) to reinforce international collaboration, and (3) to facilitate the acquisition of research funding. SUMMARY OF REVIEW This international research agenda is the result of a research summit organized by the International Cerebral Venous Thrombosis Consortium in Amsterdam, the Netherlands, in June 2023. The summit brought together 45 participants from 15 countries including clinical researchers from various disciplines, patients who previously suffered from CVT, and delegates from industry and non-profit funding organizations. The research agenda is categorized into six pre-specified themes: (1) epidemiology and clinical features, (2) life after CVT, (3) neuroimaging and diagnosis, (4) pathophysiology, (5) medical treatment, and (6) endovascular treatment. For each theme, we present two to four research questions, followed by a brief substantiation per question. The research questions were prioritized by the participants of the summit through consensus discussion. CONCLUSIONS This international research agenda provides an overview of the most burning research questions on CVT. Answering these questions will advance our understanding and management of CVT, which will ultimately lead to improved outcomes for CVT patients worldwide.
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Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anita van de Munckhof
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Diana Aguiar de Sousa
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Adriana B Conforto
- LIM-44, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Katarzyna Krzywicka
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Sini Hiltunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Lindgren
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Liqi Shu
- Brown University, Providence, RI, USA
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Rosalie Belder
- Netherlands Thrombosis Foundation, Voorschoten, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanessa Cano-Nigenda
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Isabel Fragata
- Stroke Center, Centro Hospitalar Universitário Lisboa Central, Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, and L Lopes Lab, Instituto de Medicina Molecular JLA, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Mirjam R Heldner
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | | | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronen R Leker
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lia Lucas-Neto
- North Lisbon University Hospital Center and Lisbon Medical School, Lisbon, Portugal
| | | | | | | | - Gustavo Saposnik
- Stroke Outcomes & Decision Neuroscience Research Unit, University of Toronto, Toronto, ON, Canada
| | - Pankaj Sharma
- Royal Holloway University of London, London, United Kingdom
| | - Jan Stam
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | | | - David J Werring
- UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Diana Wong Ramos
- Portugal AVC-União de Sobreviventes, Familiares e Amigos, Portugal
| | | | - Nilüfer Yeşilot
- Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jukka Putaala
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marcel Arnold
- Inselspital Bern, University Hospital and University of Bern, Bern, Switzerland
| | - José M Ferro
- Hospital da Luz, University of Lisbon, Lisbon, Portugal
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Sissingh NJ, Timmerhuis HC, Groen JV, de Jong MJP, Besselink MG, Boekestijn B, Bollen TL, Bonsing BA, Bouwense SAW, Hazen WL, Klok FA, van Santvoort HC, van Eijck CHJ, Verdonk RC, Mieog JSD, van Hooft JE. Splanchnic vein thrombosis in necrotizing pancreatitis: a post-hoc analysis of a nationwide prospective cohort. HPB (Oxford) 2024; 26:548-557. [PMID: 38336603 DOI: 10.1016/j.hpb.2024.01.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Treatment guidelines for splanchnic vein thrombosis in necrotizing pancreatitis are lacking due to insufficient data on the full clinical spectrum. METHODS We performed a post-hoc analysis of a nationwide prospective necrotizing pancreatitis cohort. Multivariable analyses were used to identify risk factors and compare the clinical course of patients with and without SVT. RESULTS SVT was detected in 97 of the 432 included patients (22%) (median onset: 4 days). Risk factors were left, central, or subtotal necrosis (OR 28.52; 95% CI 20.11-40.45), right or diffuse necrosis (OR 5.76; 95% CI 3.89-8.51), and younger age (OR 0.94; 95% CI 0.90-0.97). Patients with SVT had higher rates of bleeding (n = 10,11%) and bowel ischemia (n = 4,4%) compared to patients without SVT (n = 14,4% and n = 2,0.6%; OR 3.24; 95% CI 1.27-8.23 and OR 7.29; 95% CI 1.31-40.4, respectively), and were independently associated with ICU admission (adjusted OR 2.53; 95% CI 1.37-4.68). Spontaneous recanalization occurred in 62% of patients (n = 40/71). Radiological and clinical outcomes did not differ between patients treated with and without anticoagulants. DISCUSSION SVT is a common and early complication of necrotizing pancreatitis, associated with parenchymal necrosis and younger age. SVT is associated with increased complications and a worse clinical course, whereas anticoagulant use does not appear to affect outcomes.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands.
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mike J P de Jong
- Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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7
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Barati S, Mohammadpour MM, Sadrameli MA, Hosseini S, Maleki M, Golpira R, Bakhshandeh H, Kyavar M, Moosavi J, Mohebbi B, Talasaz AH, Barco S, Klok FA, Sadeghipour P. Applying a Computer-based Warfarin Management System at a Large Tertiary Cardiovascular Center in Iran. Crit Pathw Cardiol 2024:00132577-990000000-00073. [PMID: 38578971 DOI: 10.1097/hpc.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Regarding adjustments to warfarin dosage, numerous studies have shown that computerized methods are superior to those based on personal experience. OBJECTIVES To report the efficacy of a computer-based warfarin management system (WMS) in the Iranian population. METHODS By utilizing the existing dosing algorithms and obtaining expert opinions, we developed a computer-based WMS at a large tertiary cardiovascular center. The time in therapeutic range (TTR) and the number of international normalized ratio (INR) tests of clinic patients were compared before and after the implementation of WMS. RESULTS Overall, 803 patients with 5407 INR tests were included in the before phase and 679 patients with 4189 INR tests in the after phase. The mean TTR was 57.3% before and 59% after WMS implementation (mean difference, 1.64, 95% CI: -1.12 to 4.40). In the before phase, the mean number of INR tests was 6.7, which dropped to 6.1 tests in the after phase (mean difference, -0.61, 95% CI: -0.97 to -0.24). Only 54.5% of the warfarin dosing prescriptions were consistent with the dosing recommendations of the WMS, and adherence to the WMS was poorest in the highest INR target range. CONCLUSIONS For the first time in Iran, we demonstrated that a computerized system was as effective as a traditional experience-based method to monitor INR in VKA-anticoagulated patients. Furthermore, it could reduce both the number of INR tests and that of visits.
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Affiliation(s)
- Somayyeh Barati
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Ali Sadrameli
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Hosseini
- Heart Valve Diseases Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Golpira
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Kyavar
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran Iran
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Burggraaf-van Delft JLI, van Rein N, Bemelmans RHH, van den Berg JWK, Bruggeman CY, Cloos-van Balen M, Coppens M, Eefting M, Ende-Verhaar Y, van Es N, van Guldener C, de Jong WK, Kleijwegt F, Koster T, Kroon C, Kuipers S, Leentjens J, Luijten D, Mairuhu ATA, Meijer K, van de Ree MA, Roos R, Schrover I, Swart-Heikens J, van der Velden AWG, van den Akker-van Marle EM, le Cessie S, Geersing GJ, Middeldorp S, Huisman MV, Klok FA, Cannegieter SC. Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial. BMJ Open 2024; 14:e078676. [PMID: 38521524 PMCID: PMC10961563 DOI: 10.1136/bmjopen-2023-078676] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER NCT06087952.
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Affiliation(s)
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | | | - Coty Y Bruggeman
- Department of Internal Medicine, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marissa Cloos-van Balen
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs Eefting
- Department of Internal Medicine, Ikazia Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | - Yvonne Ende-Verhaar
- Department of Internal Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Coen van Guldener
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, North Brabant, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Fleur Kleijwegt
- Department of Internal Medicine, Rode Kruis Ziekenhuis, Beverwijk, Noord-Holland, The Netherlands
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Cees Kroon
- Department of Internal Medicine, Ziekenhuis Nij Smellinghe, Drachten, Friesland, The Netherlands
| | - Saskia Kuipers
- Department of Internal Medicine, ADRZ, Goes, Zeeland, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Karina Meijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marcel A van de Ree
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick Roos
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Ilse Schrover
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Swart-Heikens
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Stevens SM, Woller SC, Baumann Kreuziger L, Doerschug K, Geersing GJ, Klok FA, King CS, Murin S, Vintch JRE, Wells PS, Wasan S, Moores LK. Antithrombotic Therapy for VTE Disease: Compendium and Review of CHEST Guidelines 2012-2021. Chest 2024:S0012-3692(24)00292-7. [PMID: 38458430 DOI: 10.1016/j.chest.2024.03.003] [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: 01/16/2024] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024] Open
Abstract
The CHEST Antithrombotic Therapy for Venous Thromboembolism Disease evidence-based guidelines are now updated in a more frequent, focused manner. Guidance statements from the most recent full guidelines and two subsequent updates have not been gathered into a single source. An international panel of experts with experience in prior antithrombotic therapy guideline development reviewed the 2012 CHEST antithrombotic therapy guidelines and its two subsequent updates. All guideline statements and their associated patient, intervention, comparator, and outcome questions were assembled. A modified Delphi process was used to select statements considered relevant to current clinical care. The panel further endorsed minor phrasing changes to match the standard language for guidance statements using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) format endorsed by the CHEST Guidelines Oversight Committee. The panel appended comments after statements deemed as relevant, including suggesting that statements be updated in future guidelines because of interval evidence. We include 58 guidance statements from prior versions of the antithrombotic therapy guidelines, with updated phrasing as needed to adhere to contemporary nomenclature. Statements were classified as strong or weak recommendations based on high-certainty, moderate-certainty, and low-certainty evidence using GRADE methodology. The panel suggested that five statements are no longer relevant to current practice. As CHEST continues to update guidance statements relevant to antithrombotic therapy for VTE disease, this article serves as a unified collection of currently relevant statements from the preceding three guidelines. Suggestions have been made to update specific statements in future publications.
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Affiliation(s)
| | - Scott C Woller
- Department of Medicine, Intermountain Health, Murray, UT
| | | | - Kevin Doerschug
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, Department of General Practice and Nursing Science, University Medical Center Utrecht, Utrecht
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Christopher S King
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | - Susan Murin
- University of California Davis School of Medicine, Davis, CA
| | - Janine R E Vintch
- Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, CA
| | - Philip S Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Suman Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda MD
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10
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Buijs JT, van Beijnum R, Anijs RJS, Laghmani EH, Sensuk L, Minderhoud C, Ünlü B, Klok FA, Kuppen PJK, Cannegieter SC, Versteeg HH. The association of tumor-expressed REG4, SPINK4 and alpha-1 antitrypsin with cancer-associated thrombosis in colorectal cancer. J Thromb Thrombolysis 2024; 57:370-380. [PMID: 38066386 PMCID: PMC10961291 DOI: 10.1007/s11239-023-02907-6] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 03/26/2024]
Abstract
Novel biomarkers are needed to improve current imperfect risk prediction models for cancer-associated thrombosis (CAT). We recently identified an RNA-sequencing profile that associates with CAT in colorectal cancer (CRC) patients, with REG4, SPINK4, and SERPINA1 as the top-3 upregulated genes at mRNA level. In the current study, we investigated whether protein expression of REG4, SPINK4 and alpha-1 antitrypsin (A1AT, encoded by SERPINA1) in the tumor associated with CAT in an independent cohort of CRC patients. From 418 patients with resected CRC, 18 patients who developed CAT were age, sex, and tumor stage-matched to 18 CRC patients without CAT. Protein expression was detected by immunohistochemical staining and scored blindly by assessing the H-score (percentage positive cells*scoring intensity). The association with CAT was assessed by means of logistic regression, using patients with an H-score below 33 as reference group. The odds ratios (ORs) for developing CAT for patients with A1AThigh, REG4high, SPINK4high tumors were 3.5 (95%CI 0.8-14.5), 2.0 (95%CI 0.5-7.6) and 2.0 (95%CI 0.5-7.4) when compared to A1ATlow, REG4low, SPINK4low, respectively. The OR was increased to 24.0 (95%CI 1.1-505.1) when two proteins were combined (A1AThigh/REG4high). This nested case-control study shows that combined protein expression of A1AT and REG4 associate with CAT in patients with colorectal cancer. Therefore, REG4/A1AT are potential biomarkers to improve the identification of patients with CRC who may benefit from thromboprophylaxis.
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Affiliation(s)
- Jeroen T Buijs
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Robin van Beijnum
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Rayna J S Anijs
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - El Houari Laghmani
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Lily Sensuk
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Cas Minderhoud
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Betül Ünlü
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Suzanne C Cannegieter
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, LUMC, Leiden, The Netherlands
| | - Henri H Versteeg
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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11
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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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12
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Zian A, Overdevest GM, Schutte PJ, Klok FA, Steyerberg EW, Moojen WA, van der Gaag NA. Aspin: neurosurgical aspirin intervention prognostic study - perioperative continuation versus discontinuation of aspirin in lumbar spinal surgery, a randomized controlled, noninferiority trial. Trials 2024; 25:156. [PMID: 38424535 PMCID: PMC10905870 DOI: 10.1186/s13063-024-07945-w] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
RATIONALE Aspirin is typically discontinued in cranial and spinal surgery because of the increased risk of hemorrhagic complications, but comes together with the risk of resulting in an increase of cardiac and neurologic thrombotic perioperative events. OBJECTIVE The aim of this study is to investigate the non-inferiority of perioperative continuation of aspirin patients undergoing low complex lumbar spinal surgery, compared with the current policy of perioperative discontinuation of aspirin. STUDY DESIGN A randomized controlled trial with two parallel groups of 277 cases (554 in total). STUDY POPULATION Patients undergoing low complex lumbar spinal surgery and using aspirin. All patients are aged >18 years. INTERVENTION Peri-operative continuation of aspirin. STUDY OUTCOMES Primary study outcome: composite of the following bleeding complications: Neurological deterioration as a result of hemorrhage in the surgical area with cauda and/or nerve root compression. Post-surgical anemia with hemoglobin level lower than 5 mmol/l, requiring transfusion. Subcutaneous hematoma leading to wound leakage and pain higher than NRS=7. Major and/or minor hemorrhage in any other body system according to the definition of the International Society on Thrombosis and Haemostasis bleeding scale. Secondary study outcomes: Each of the individual components of the primary outcome Absolute mean difference in operative blood loss between the study arms Thrombo-embolic-related complications: Myocardial infarction Venous thromboembolism Stroke Arterial thromboembolism FURTHER STUDY OUTCOMES: Anticoagulant treatment satisfaction by the Anti-Clot Treatment Scale (ACTS) and general health by the Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) in the pre- and postoperative phase. NATURE AND EXTENT OF THE BURDEN AND RISKS ASSOCIATED WITH PARTICIPATION, BENEFIT, AND GROUP RELATEDNESS: Participation in this study imposes no additional risk to patients. Currently, there is no consensus on whether or not aspirin should be discontinued before cranial or spinal surgery. Currently, aspirin is typically discontinued in cranial and spinal surgery, because of a potential increased risk of hemorrhagic complication. An argument not based on a clinical trial. However, this policy might delay surgical procedures or carry the risk of resulting in an increase in cardiac and neurologic thrombotic perioperative events. It is unclear if the possibility of an increase in hemorrhage-related complications outweighs the risk of an increase in cardiac and neurologic thrombotic perioperative events. Furthermore, the Data Safety Monitoring Board (DSMB) will be asked for safety analysis by monitoring the study. There are no further disadvantages to participating in this study. Outcome measurements are recorded during admission and regular outpatient visits, and thus, do not require additional visits to the hospital.
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Affiliation(s)
- Ahmed Zian
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands.
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands.
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands.
| | - Gijsbert M Overdevest
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Pieter J Schutte
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Vascular Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Clinical Biostatistics and Medical Decision Making, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
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Martens ESL, Huisman MV, van Mens TE, Klok FA. The History of Diagnosing Venous Thromboembolism. Semin Thromb Hemost 2024. [PMID: 38373722 DOI: 10.1055/s-0044-1779484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
An accurate and prompt diagnosis of deep vein thrombosis and/or pulmonary embolism is important to prevent serious complications and mortality. Because the clinical presentation of venous thromboembolism (VTE) is often nonspecific, objective testing by means of radiological imaging is required to confirm the diagnosis. Historically, a diagnosis of VTE involved invasive imaging techniques like contrast venography or conventional pulmonary angiography. Technological developments toward more accurate and less invasive diagnostics have driven the implementation of a variety of newer technologies over the past decades, as well as the derivation and validation of clinical decision rules (CDRs) that can be used to rule out VTE in combination with D-dimer blood tests. In this narrative review, we provide a historical overview of the most notable developments in the imaging techniques and CDRs for VTE diagnosis.
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Affiliation(s)
- Emily S L Martens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs E van Mens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Willems L, Kurakula K, Verhaegen J, Klok FA, Delcroix M, Goumans MJ, Quarck R. Angiogenesis in Chronic Thromboembolic Pulmonary Hypertension: A Janus-Faced Player? Arterioscler Thromb Vasc Biol 2024. [PMID: 38328933 DOI: 10.1161/atvbaha.123.319852] [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] [Indexed: 02/09/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare form of pulmonary hypertension characterized by the presence of organized thrombi that obstruct pulmonary arteries, ultimately leading to right heart failure and death. Among others, impaired angiogenesis and inflammatory thrombosis have been shown to contribute to the progression of CTEPH. In this review, we summarize the 2-faced nature of angiogenesis in both thrombus formation and resolution in the context of CTEPH and highlight the dual role of angiogenesis and neovascularization in resolving venous thrombi. Furthermore, we discuss relevant in vitro and in vivo models that support the benefits or drawbacks of angiogenesis in CTEPH progression. We discuss the key pathways involved in modulating angiogenesis, particularly the underexplored role of TGFβ (transforming growth factor-beta) signaling in driving fibrosis as an integral element of CTEPH pathogenesis. We finally explored innovative treatment strategies that target angiogenic pathways. These strategies have the potential to pioneer preventive, inventive, or alternative therapeutic options for patients with CTEPH who may not qualify for surgical interventions. Moreover, they could be used synergistically with established treatments such as pulmonary endarterectomy or balloon pulmonary angioplasty. In summary, this review emphasizes the crucial role of angiogenesis in the development of in fibrothrombotic tissue, a major pathological characteristic of CTEPH.
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Affiliation(s)
- Lynn Willems
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven-University of Leuven, Belgium (L.W., J.V., M.D., R.Q.)
- Department of Cell and Chemical Biology, Leiden University Medical Centre, the Netherlands. (L.W., M.-J.G.)
| | - Kondababu Kurakula
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Free University Medical Center, the Netherlands (K.K.)
| | - Janne Verhaegen
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven-University of Leuven, Belgium (L.W., J.V., M.D., R.Q.)
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands. (F.A.K.)
| | - Marion Delcroix
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven-University of Leuven, Belgium (L.W., J.V., M.D., R.Q.)
- Clinical Department of Respiratory Diseases, University Hospital Leuven, Belgium (M.D.)
| | - Marie-José Goumans
- Department of Cell and Chemical Biology, Leiden University Medical Centre, the Netherlands. (L.W., M.-J.G.)
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery, Department of Chronic Diseases and Metabolism, KU Leuven-University of Leuven, Belgium (L.W., J.V., M.D., R.Q.)
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Marin-Romero S, Ballaz-Quincoces A, Gómez-Cuervo C, Marchena-Yglesias PJ, Lopez-Miguel P, Francisco-Albesa I, Pedrajas-Navas JM, Lumbierres M, Aibar-Arregui MA, Bosco Lopez-Saez J, Perez-Pinar M, Baeza-Martinez C, Riera-Mestre A, Peris-Sifre M, Porras-Ledantes JA, Criado-Garcia J, Elias-Hernandez T, Otero R, Barca-Hernando M, Muriel A, Klok FA, Jara-Palomares L. Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study. Thorax 2024; 79:144-152. [PMID: 38050187 PMCID: PMC10850838 DOI: 10.1136/thorax-2023-220580] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/16/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors. METHODS This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC. RESULTS Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed. CONCLUSIONS The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier. TRIAL REGISTRATION NUMBER NCT03953560.
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Affiliation(s)
- Samira Marin-Romero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | | | | | | | | | | | - Marina Lumbierres
- Respiratory Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | | | | | | | | | - Antoni Riera-Mestre
- Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
- Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
- Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain
| | - Marisa Peris-Sifre
- Internal Medicine Unit, Hospital Provincial Castellon, Castellon de la Plana, Spain
- CEU Cardenal Herrera University, Moncada, Spain
| | | | | | - Teresa Elias-Hernandez
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Remedios Otero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Maria Barca-Hernando
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Alfonso Muriel
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
- Biostatistics Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
- University of Alcala, Alcala de Henares, Spain
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Luis Jara-Palomares
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
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Kaptein FH, Guman NA, Lohle SB, Klok FA, Mairuhu AT, Kamphuisen PW, Es NV, Huisman MV. Treatment Patterns of Cancer-associated Thrombosis in the Netherlands: The Four Cities Study. TH Open 2024; 8:e61-e71. [PMID: 38298199 PMCID: PMC10827569 DOI: 10.1055/a-2214-8101] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024] Open
Abstract
Background Current guidelines recommend either low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) as first-line treatment in cancer-associated venous thromboembolism (VTE). Aim This study aimed to investigate treatment regimens for cancer-associated VTE over the past 5 years, explore predictors for initial treatment (LMWH vs. DOAC), and to assess the risks of recurrent VTE and bleeding. Methods This was a Dutch, multicenter, retrospective cohort study including consecutive patients with cancer-associated VTE between 2017 and 2021. Treatment predictors were assessed with multivariable logistic regression models. Six-month cumulative incidences for recurrent VTE and major bleeding (MB) were estimated with death as competing risk. Results In total, 1,215 patients were included. The majority (1,134/1,192; 95%) started VTE treatment with anticoagulation: 561 LMWH (47%), 510 DOACs (43%), 27 vitamin K antagonist (2.3%), and 36 other/unknown type (3.0%). The proportion of patients primarily treated with DOACs increased from 18% (95% confidence interval [CI] 12-25) in 2017 to 70% (95% CI 62-78) in 2021. Poor performance status (adjusted odds ratio [aOR] 0.72, 95% CI 0.53-0.99) and distant metastases (aOR 0.61, 95% CI 0.45-0.82) were associated with primary treatment with LMWH. Total 6-month cumulative incidences were 6.0% (95% CI 4.8-7.5) for recurrent VTE and 7.0% (95% CI 5.7-8.6) for MB. During follow-up, 182 patients (15%) switched from LMWH to a DOAC, and 54 patients (4.4%) vice versa, for various reasons, including patient preference, recurrent thrombosis, and/or bleeding. Conclusion DOAC use in cancer-associated VTE has increased rapidly over the past years. Changes in anticoagulation regimen were frequent over time, and were often related to recurrent thrombotic and bleeding complications, illustrating the complexity and challenges of managing cancer-associated VTE.
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Affiliation(s)
- Fleur H.J. Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Noori A.M. Guman
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Susan B. Lohle
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Pieter W. Kamphuisen
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Nick Van Es
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Ingemann-Molden S, Caspersen CK, Rolving N, Højen AA, Klok FA, Grove EL, Brocki BC, Andreasen J. Comparison of important factors to patients recovering from pulmonary embolism and items covered in patient-reported outcome measures: A mixed-methods systematic review. Thromb Res 2024; 233:69-81. [PMID: 38029548 DOI: 10.1016/j.thromres.2023.11.013] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Up to 50 % of patients recovering from pulmonary embolism (PE) experience negative long-term outcomes. Patient-reported outcome measures (PROMs) are important in identifying what matters to patients. We aimed to identify PROMs used in clinical studies and recommended by the International Consortium of Health Outcomes (ICHOM) and compare individual items with factors considered important by patients recovering from PE. METHODS This was a convergent mixed-methods systematic review, including quantitative studies, using PROMs and qualitative studies with non-cancer-related PE patients. Items from each PROM and qualitative findings were categorised using an International Classification of Function linking process to allow for integrated synthesis. RESULTS A total of 68 studies using 34 different PROMs with 657 items and 13 qualitative studies with 408 findings were included. A total of 104 individual ICF codes were used, and subsequently sorted into 20 distinct categories representing patient concerns. Identified PROMs were found to adequately cover 17/20 categories, including anxiety, fear of bleeding, stress, depression, dizziness/nausea, sleep disturbance, pain, dyspnea, fatigue, activity levels, family and friends, socializing, outlook on life, and medical treatment. PROMs from the ICHOM core set covered the same categories, except for dizziness/nausea. CONCLUSIONS No single PROM covered all aspects assessed as important by the PE population. PROMs recommended in the ICHOM core set cover 16/20 aspects. However, worrisome thoughts, hypervigilance around symptoms, and uncertainty of illness were experienced by patients with PE but were not covered by PROMS.
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Affiliation(s)
- Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.
| | | | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark; Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University Hospital and Aalborg University, Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Haemostasis Leiden University Medical Centre, Leiden, the Netherlands
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University Hospital, Aarhus, Denmark
| | - Barbara Cristina Brocki
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Aalborg, Denmark
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Guman NAM, Kaptein FHJ, Lohle SB, Mairuhu ATA, Klok FA, Huisman MV, Kamphuisen PW, van Es N. Discharge from the emergency department and outpatient clinic in cancer patients with acute symptomatic and incidental pulmonary embolism: A multicenter retrospective cohort study. Thromb Res 2024; 233:181-188. [PMID: 38101191 DOI: 10.1016/j.thromres.2023.12.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/27/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND It is unclear how often cancer patients with acute pulmonary embolism (PE) are discharged from the emergency department (ED) or outpatient clinic and whether direct discharge is safe. We assessed treatment setting and early safety outcomes in cancer patients with acute symptomatic and incidental PE. METHODS Cancer patients diagnosed with PE at the ED or outpatient clinic between August 2017 and May 2021 were included in Four Cities VTE Cancer, a Dutch multicenter retrospective cohort study. The main outcome was direct discharge versus hospitalization. Safety outcomes were cumulative 14-day mortality and PE-related readmission incidences. RESULTS We included 602 patients (median age 71 years; 49.5 % female) of whom 285 (47.3 %) were discharged directly and 317 (52.7 %) were hospitalized. The cumulative 14-day mortality incidence was 0.7 % (95 % CI, 0.1-2.4 %) in patients discharged directly and 9.0 % (95 % CI, 6.2-12.5 %) in those hospitalized. The cumulative 14-day PE-related readmission incidence was 1.8 % (95 % CI, 0.7-3.9 %) and 1.4 % (95 % CI, 0.5-3.3 %) in directly discharged and hospitalized patients, respectively. Of the 220 patients with incidental PE, 180 (81.8 %) were discharged directly compared to 105 of 382 (27.5 %) patients with symptomatic PE (P < 0.001). Mortality and readmission incidences in symptomatic and incidental PE were consistent with the main analysis. CONCLUSIONS About 28 % and 82 % of cancer patients with symptomatic or incidental PE, respectively, were discharged directly, with low 14-day mortality and PE-related readmission incidences. These data underline the need for PE risk stratification in oncological populations and suggest that clinicians successfully identify a proportion of patients in whom direct discharge is safe.
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Affiliation(s)
- N A M Guman
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands.
| | - F H J Kaptein
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S B Lohle
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands
| | - A T A Mairuhu
- Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P W Kamphuisen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands
| | - N van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary hypertension & Thrombosis, Amsterdam, the Netherlands
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de Jong CMM, van den Hout WB, van Dijk CE, Heim N, van Dam LF, Dronkers CEA, Gautam G, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, van Mens TE, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis. Thromb Haemost 2023. [PMID: 37984402 DOI: 10.1055/a-2213-9230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison. OBJECTIVES To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients. METHODS Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared. RESULTS All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. CONCLUSION One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences - Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Noor Heim
- National Health Care Institute, The Netherlands
| | - Lisette F van Dam
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Charlotte E A Dronkers
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gargi Gautam
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Gralum, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Anders von Heijne
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marcel M C Hovens
- Department of Vascular Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stan Kolman
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel A van de Ree
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | | | | | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Groeneveld NTA, Swier CEL, Montero-Cabezas J, Elzo Kraemer CV, Klok FA, van den Brink FS. Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review. J Clin Med 2023; 12:7755. [PMID: 38137824 PMCID: PMC10744085 DOI: 10.3390/jcm12247755] [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: 11/05/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.
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Affiliation(s)
- Niels T. A. Groeneveld
- Department of Anesthesiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands;
| | - Carolien E. L. Swier
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Carlos V. Elzo Kraemer
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
| | - Frederikus A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Floris S. van den Brink
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
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Kapteijn MY, Lanting VR, Kaptein FHJ, Guman NAM, Laghmani EH, Kuipers TB, Mei H, Goeman JJ, Mulder FI, van Duinen SG, Taphoorn MJB, Dirven L, Broekman MLD, van Es N, Klok FA, Koekkoek JAF, Versteeg HH, Buijs JT. RNA-sequencing to discover genes and signaling pathways associated with venous thromboembolism in glioblastoma patients: A case-control study. Thromb Res 2023; 232:27-34. [PMID: 37918288 DOI: 10.1016/j.thromres.2023.10.018] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/08/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Glioblastoma patients are at high risk of developing venous thromboembolism (VTE). Tumor-intrinsic features are considered to play a role, but the underlying pathophysiological mechanisms remain incompletely understood. OBJECTIVES To identify tumor-expressed genes and signaling pathways that associate with glioblastoma-related VTE by using next generation RNA-sequencing (RNA-Seq). METHODS The tumor gene expression profile of 23 glioblastoma patients with VTE and 23 glioblastoma patients without VTE was compared using an unpaired analysis. Ingenuity Pathway Analysis (IPA) core analysis was performed on the top 50 differentially expressed genes to explore associated functions and pathways. Based on full RNA-Seq data, molecular glioblastoma subtypes were determined by performing cluster analysis. RESULTS Of the 19,327 genes, 1246 (6.4 %) were differentially expressed between glioblastoma patients with and without VTE (unadjusted P < 0.05). The most highly overexpressed gene was GLI1, a classical target gene in the Sonic Hedgehog (Shh) signaling pathway (log2 fold change: 3.7; unadjusted P < 0.0001, adjusted P = 0.219). In line, Shh signaling was among the top canonical pathways and processes associated with VTE. The proportion of patients with the proneural/neural glioblastoma subtype was higher among those with VTE than controls. CONCLUSION Shh signaling may be involved in the development of glioblastoma-related VTE.
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Affiliation(s)
- Maaike Y Kapteijn
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Vincent R Lanting
- Amsterdam University Medical Center location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands; Tergooi Hospital, Department of Internal Medicine, Hilversum, the Netherlands
| | - Fleur H J Kaptein
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Noori A M Guman
- Amsterdam University Medical Center location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands; Tergooi Hospital, Department of Internal Medicine, Hilversum, the Netherlands
| | - El Houari Laghmani
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas B Kuipers
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Hailiang Mei
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Jelle J Goeman
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits I Mulder
- Amsterdam University Medical Center location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands; Tergooi Hospital, Department of Internal Medicine, Hilversum, the Netherlands
| | - Sjoerd G van Duinen
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Marike L D Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurosurgery, Haaglanden Medical Center, Den Haag, the Netherlands
| | - Nick van Es
- Amsterdam University Medical Center location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Henri H Versteeg
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen T Buijs
- Einthoven Laboratory for Vascular and Regenerative Medicine, Div. of Thrombosis & Hemostasis, Dept. of Medicine, Leiden University Medical Center, Leiden, the Netherlands.
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23
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van Mens TE, Klok FA, Levi M. [Pitfalls of searching online: all symptoms, diseases and adverse events appear correlated]. Ned Tijdschr Geneeskd 2023; 167:D7753. [PMID: 38175564] [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] [Indexed: 01/05/2024]
Abstract
When confronted with an unexpected clinical observation, such as a remarkable symptom in a patient with an unrelated rare disease, clinicians increasingly apply online literature search to support the observed correlation. Against a background of an exponential rise in medical publications and the well-documented problem of publication bias, the easy access to literature carries the risk of suggesting spurious correlations. The current paper expounds on this phenomenon. Queries in medical search engines often provide a number of hits, regardless of the plausibility of the correlation searched for. To quantify this, we recently performed a study involving 30.000 automated queries in PubMed using completely random search terms drawn from lists of diseases, symptoms and medications. This provided a background rate of PubMed hits. The data support that several hits by no means automatically indicate a relevant correlation, and underline need for judicious critical appraisal when searching for a correlation observed in daily practice.
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Affiliation(s)
- Thijs E van Mens
- LUMC, afd. Interne geneeskunde, Leiden
- Contact: Thijs E. van Mens
| | - F A Klok
- LUMC, afd. Interne geneeskunde, Leiden
| | - Marcel Levi
- Amsterdam UMC, afd. Interne geneeskunde, Amsterdam
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24
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Goncalves LN, van Velze V, Klok FA, Gal P, Vos RC, Hamming JF, van der Bogt KEA. High on-treatment platelet reactivity in peripheral arterial disease: A systematic review. Vascular 2023:17085381231214324. [PMID: 37950666 DOI: 10.1177/17085381231214324] [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] [Indexed: 11/13/2023]
Abstract
OBJECTIVES To highlight current evidence pertaining to the measurement methods and prevalence of high on-treatment platelet reactivity (HTPR) in patients with PAD, as well as to evaluate the relationship between HTPR and recurrent adverse cardiovascular and limb events in PAD patients. METHODS A systematic review of English-language literature on HTPR in patients with PAD. An electronic literature search of PubMed and Medline was performed in May 2021. RESULTS A total of 29 studies with a total number of 11,201 patients with PAD were identified. HTPR during clopidogrel treatment ranges from 9.8 to 77%, and during aspirin treatment ranges from 4.1 to 50% of PAD patients. HTPR was associated with adverse clinical outcomes. The need for limb revascularisation was higher in patients with HTPR during clopidogrel use. Similarly, HTPR during aspirin use in the PAD population was predictive of adverse cardiovascular events (HR 3.73; 95% CI, 1.43-9.81; p = .007). A wide range of techniques were applied to measure platelet resistance, without consensus on cut-off values. Furthermore, differing patient populations, a variety of antiplatelet regimens, and differing clinical endpoints highlight the high degree of heterogeneity in the studies included in this review. CONCLUSION No consensus on technique or cut-off values for HTPR testing has been reached. Patients with HTPR are potentially at a greater risk of adverse limb-related and cardiovascular events than patients sensitive to antiplatelet therapy illustrating the need for clinical implementation of HTPR testing. Future research must aim for consistent methodology. Adaptation of antiplatelet therapy based on HTPR results requires further exploration.
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Affiliation(s)
| | | | | | - Pim Gal
- Centre for Human Drug Research, Leiden, the Netherlands
| | - Rimke C Vos
- Clinical pharmacology and Toxicology, LUMC, Leiden, the Netherlands
| | - Jaap F Hamming
- Clinical pharmacology and Toxicology, LUMC, Leiden, the Netherlands
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25
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Stals MAM, Beenen LFM, Coppens M, Faber LM, Hofstee HMA, Hovens MMC, Huisman MV, van der Hulle T, Kaasjager KAH, Kruip MJHA, Mairuhu ATA, Middeldorp S, Ten Wolde M, Klok FA, van Es N. Performance of the 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS) in the diagnostic management of pulmonary embolism: An external validation study. Thromb Res 2023; 231:65-75. [PMID: 37816274 DOI: 10.1016/j.thromres.2023.09.010] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND The recently published 4-level Pulmonary Embolism Clinical Probability Score (4PEPS) integrates different aspects from currently available diagnostic strategies to further reduce imaging testing in patients with clinically suspected pulmonary embolism (PE). AIM To externally validate the performance of 4PEPS in an independent cohort. METHODS In this post-hoc analysis of the prospective diagnostic management YEARS study, the primary outcome measures were discrimination, calibration, efficiency (proportion of imaging tests potentially avoided), and failure rate (venous thromboembolism (VTE) diagnosis at baseline or follow-up in patients with a negative 4PEPS algorithm). Multiple imputation was used for missing 4PEPS items. Based on 4PEPS, PE was considered ruled out in patients with a very low clinical pre-test probability (CPTP) without D-dimer testing, in patients with a low CPTP and D-dimer <1000 μg/L, and in patients with a moderate CPP and D-dimer below the age-adjusted threshold. RESULTS Of the 3465 patients, 474 (14 %) were diagnosed with VTE at baseline or during 3-month follow-up. Discriminatory performance of the 4PEPS items was good (area under ROC-curve, 0.82; 95%CI, 0.80-0.84) as was calibration. Based on 4PEPS, PE could be considered ruled out without imaging in 58 % (95%CI 57-60) of patients (efficiency), for an overall failure rate of 1.3 % (95%CI 0.86-1.9). CONCLUSION In this retrospective external validation, 4PEPS appeared to safely rule out PE with a high efficiency. Nevertheless, although not exceeding the failure rate margin by ISTH standards, the observed failure rate in our analysis appeared to be higher than in the original 4PEPS derivation and validation study. This highlights the importance of a prospective outcome study.
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Laura M Faber
- Department of Hematology, Red Cross Hospital, Beverwijk, the Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, Medisch Centrum Haaglanden, The Hague, the Netherlands
| | - Marcel M C Hovens
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Karin A H Kaasjager
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud university medical center, Nijmegen, the Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands.
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26
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Barco S, Klok FA, Bikdeli B. Optimizing and Extending the Risk-Adapted Management of Acute Pulmonary Embolism beyond the Acute Phase: Progress in Pulmonary Embolism Research. Semin Thromb Hemost 2023; 49:783-784. [PMID: 37832583 DOI: 10.1055/s-0043-1775978] [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] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut
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27
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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28
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van der Horst SFB, van Rein N, van Mens TE, Huisman MV, Klok FA. Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: A narrative review. Thromb Res 2023; 231:135-140. [PMID: 37005194 DOI: 10.1016/j.thromres.2023.03.007] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Direct oral anticoagulants (DOACs) have become the cornerstone for prevention of thromboembolic events in patients with atrial fibrillation and patients with a history of venous thromboembolism. However, studies show that DOAC prescriptions are commonly inconsistent with guideline recommendations. DOAC dosing in the acutely ill patient could impose an even greater challenge. In this review, we describe the prevalence of inappropriate inpatient prescribing of DOACs and the associated rationales, predictors and clinical consequences. With the aim of promoting appropriate prescriptions of DOACs to hospitalized patients, we further outline DOAC dose reduction criteria justified by various guidelines, illustrating the complexities of appropriate dosing, especially in acutely ill patients. Moreover, we will discuss the impact of anticoagulant stewardship programs and the vital role that pharmacists may play in optimizing inpatient DOAC treatment.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands.
| | - N van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands; Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
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29
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van Maanen R, Martens ESL, Takada T, Roy PM, de Wit K, Parpia S, Kraaijpoel N, Huisman MV, Wells PS, Le Gal G, Righini M, Freund Y, Galipienzo J, van Es N, Blom JW, Moons KGM, Rutten FH, van Smeden M, Klok FA, Geersing GJ, Luijken K. Accuracy of physicians' intuitive risk estimation in the diagnostic management of pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost 2023; 21:2873-2883. [PMID: 37263381 DOI: 10.1016/j.jtha.2023.05.023] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND In patients clinically suspected of having pulmonary embolism (PE), physicians often rely on intuitive estimation ("gestalt") of PE presence. Although shown to be predictive, gestalt is criticized for its assumed variation across physicians and lack of standardization. OBJECTIVES To assess the diagnostic accuracy of gestalt in the diagnosis of PE and gain insight into its possible variation. METHODS We performed an individual patient data meta-analysis including patients suspected of having PE. The primary outcome was diagnostic accuracy of gestalt for the diagnosis of PE, quantified as risk ratio (RR) between gestalt and PE based on 2-stage random-effect log-binomial meta-analysis regression as well as gestalts' sensitivity and specificity. The variability of these measures was explored across different health care settings, publication period, PE prevalence, patient subgroups (sex, heart failure, chronic lung disease, and items of the Wells score other than gestalt), and age. RESULTS We analyzed 20 770 patients suspected of having PE from 16 original studies. The prevalence of PE in patients with and without a positive gestalt was 28.8% vs 9.1%, respectively. The overall RR was 3.02 (95% CI, 2.35-3.87), and the overall sensitivity and specificity were 74% (95% CI, 68%-79%) and 61% (95% CI, 53%-68%), respectively. Although variation was observed across individual studies (I2, 90.63%), the diagnostic accuracy was consistent across all subgroups and health care settings. CONCLUSION A positive gestalt was associated with a 3-fold increased risk of PE in suspected patients. Although variation was observed across studies, the RR of gestalt was similar across prespecified subgroups and health care settings, exemplifying its diagnostic value for all patients suspected of having PE.
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Affiliation(s)
- Rosanne van Maanen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Emily S L Martens
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. https://twitter.com/ESLmartens
| | - Toshihiko Takada
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Pierre-Marie Roy
- Department of Emergency Medicine, Angers University Hospital; MitoVasc UMR CNRS 6015 - INSERM 1083, Université Angers, Angers; and French Clinical Research Infrastructure (F-CRIN) Network, INvestigation Network On Venous Thrombo-Embolism (INNOVTE), Saint-Etienne, France
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Emergency Medicine, Queen's University, Kingston, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Oncology, McMaster University, Hamilton, Canada
| | - Noémie Kraaijpoel
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Yonathan Freund
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain
| | - Nick van Es
- Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Jeanet W Blom
- Department of General Practice, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maarten van Smeden
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kim Luijken
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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30
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de Jong CMM, Boon GJAM, Le YNJ, Barco S, Siegerink B, Klok FA. The Post-Venous Thromboembolism Functional Status Scale: From Call to Action to Application in Research, Extension to COVID-19 Patients, and Its Use in Clinical Practice. Semin Thromb Hemost 2023; 49:764-773. [PMID: 36940713 DOI: 10.1055/s-0043-1764467] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
A broad spectrum of long-term sequelae may be present in venous thromboembolism (VTE) survivors, affecting their quality of life and functioning. To monitor recovery and improve the prognosis of patients with persistent functional limitations, the development of a new outcome measure that could better capture the consequences of VTE was an unmet need. Starting as a call to action, the Post-VTE Functional Status (PVFS) scale was developed to meet this need. The PVFS scale is an easy-to-use clinical tool to measure and quantify functional outcomes after VTE by focusing on key aspects of daily life. As the scale was considered useful in coronavirus disease 2019 (COVID-19) patients as well, the Post-COVID-19 Functional Status (PCFS) scale was introduced early in the pandemic after slight adaptation. The scale has been well incorporated into both the VTE and COVID-19 research communities, contributing to the shift of focus toward patient-relevant functional outcomes. Psychometric properties have been evaluated, mainly for the PCFS scale but recently also for the PVFS scale, including validation studies of translations, showing adequate validity and reliability. In addition to serving as outcome measure in studies, guidelines and position papers recommend using the PVFS and PCFS scale in clinical practice. As broad use of the PVFS and PCFS scale in clinical practice is valuable to capture what matters most to patients, widespread implementation is a crucial next step. In this review, we discuss the development of the PVFS scale and introduction in VTE and COVID-19 care, the incorporation of the scale in research, and its application in clinical practice.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Y N Jenny Le
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Bob Siegerink
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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31
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Chu G, Seelig J, Cannegieter SC, Gelderblom H, Hovens MMC, Huisman MV, van der Hulle T, Trines SA, Vlot AJ, Versteeg HH, Hemels M, Klok FA. Thromboembolic and bleeding complications during interruptions and after discontinuation of anticoagulant treatment in patients with atrial fibrillation and active cancer: A daily practice evaluation. Thromb Res 2023; 230:98-104. [PMID: 37703801 DOI: 10.1016/j.thromres.2023.08.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND AIMS Cancer provides challenges to the continuity of anticoagulant treatment in patients with atrial fibrillation (AF), e.g. through cancer-related surgery or complications. We aimed to provide data on the incidence and reasons for interrupting and discontinuing anticoagulant treatment in AF patients with cancer and to assess its contribution to the risk of thromboembolism (TE) and major bleeding (MB). METHODS This retrospective study identified AF patients with cancer in two hospitals between 2012 and 2017. Data on anticoagulant treatment, TE and MB were collected during two-year follow-up. Incidence rates (IR) per 100 patient-years and adjusted hazard ratios (aHR) were obtained for TE and MB occurring during on- and off-anticoagulant treatment, during interruption and after resumption, and after permanent discontinuation. RESULTS 1213 AF patients with cancer were identified, of which 140 patients permanently discontinued anticoagulants and 426 patients experienced one or more interruptions. Anticoagulation was most often interrupted or discontinued due to cancer-related treatment (n = 441, 62 %), bleeding (n = 129, 18 %) or end of life (n = 36, 5 %). The risk of TE was highest off-anticoagulation and during interruptions, with IRs of 19 (14-25)) and 105 (64-13), and aHRs of 3.1 (1.9-5.0) and 4.6 (2.4-9.0), respectively. Major bleeding risk were not only increased during an interruption, but also in the first 30 days after resumption, with IRs of 33 (12-72) and 30 (17-48), and aHRs of 3.3 (1.1-9.8) and 2.4 (1.2-4.6), respectively. CONCLUSIONS Interruption of anticoagulation therapy harbors high TE and MB risk in AF patients with cancer. The high incidence rates call for better (periprocedural) anticoagulant management strategies tailored to the cancer setting.
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Affiliation(s)
- Gordon Chu
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jaap Seelig
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Internal Medicine, Maastricht University Medical Center and Cardiovascular Research Institute (CARIM), Maastricht, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Serge A Trines
- Department of Cardiology, Heart-Lung Center, Leiden University Medical Center, the Netherlands
| | - André J Vlot
- Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands
| | - Henri H Versteeg
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Martin Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Jervan Ø, Haukeland-Parker S, Gleditsch J, Tavoly M, Klok FA, Steine K, Johannessen HH, Spruit MA, Atar D, Holst R, Astrup Dahm AE, Sirnes PA, Stavem K, Ghanima W. The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial. Chest 2023; 164:981-991. [PMID: 37149257 DOI: 10.1016/j.chest.2023.04.042] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited. RESEARCH QUESTION Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea? STUDY DESIGN AND METHODS This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72 months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8 weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire). RESULTS A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95% CI, 17.7-88.3; P = .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95% CI, -0.09 to 0.00; P = .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention. INTERPRETATION In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03405480; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Stacey Haukeland-Parker
- Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Hege Hølmo Johannessen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway; Department of Health and Welfare, Østfold University College, Fredrikstad, Norway
| | - Martijn A Spruit
- Department of Research and Development, Ciro, Horn, The Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - René Holst
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hematology, Akershus University Hospital, Lørenskog, Norway
| | | | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Clinic of Internal Medicine, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
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Mavromanoli AC, Barco S, Ageno W, Bouvaist H, Brodmann M, Cuccia C, Couturaud F, Dellas C, Dimopoulos K, Duerschmied D, Empen K, Faggiano P, Ferrari E, Galiè N, Galvani M, Ghuysen A, Giannakoulas G, Huisman MV, Jiménez D, Kozak M, Lang IM, Meneveau N, Münzel T, Palazzini M, Petris AO, Piovaccari G, Salvi A, Schellong S, Schmidt KH, Verschuren F, Schmidtmann I, Toenges G, Klok FA, Konstantinides SV. Recovery of right ventricular function after intermediate-risk pulmonary embolism: results from the multicentre Pulmonary Embolism International Trial (PEITHO)-2. Clin Res Cardiol 2023; 112:1372-1381. [PMID: 36539534 PMCID: PMC10562278 DOI: 10.1007/s00392-022-02138-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Right ventricular (RV) function plays a critical role in the pathophysiology and acute prognosis of pulmonary embolism (PE). We analyzed the temporal changes of RV function in the cohort of a prospective multicentre study investigating if an early switch to oral anticoagulation in patients with intermediate-risk PE is effective and safe. METHODS Echocardiographic and laboratory examinations were performed at baseline (PE diagnosis), 6 days and 6 months. Echocardiographic parameters were classified into categories representing RV size, RV free wall/tricuspid annulus motion, RV pressure overload and right atrial (RA)/central venous pressure. RESULTS RV dysfunction based on any abnormal echocardiographic parameter was present in 84% of patients at baseline. RV dilatation was the most frequently abnormal finding (40.6%), followed by increased RA/central venous pressure (34.6%), RV pressure overload (32.1%), and reduced RV free wall/tricuspid annulus motion (20.9%). As early as day 6, RV size remained normal or improved in 260 patients (64.7%), RV free wall/tricuspid annulus motion in 301 (74.9%), RV pressure overload in 297 (73.9%), and RA/central venous pressure in 254 (63.2%). At day 180, the frequencies slightly increased. The median NT-proBNP level decreased from 1448 pg/ml at baseline to 256.5 on day 6 and 127 on day 180. CONCLUSION In the majority of patients with acute intermediate-risk PE switched early to a direct oral anticoagulant, echocardiographic parameters of RV function normalised within 6 days and remained normal throughout the first 6 months. Almost one in four patients, however, continued to have evidence of RV dysfunction over the long term.
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Affiliation(s)
- Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Hélène Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, La Tronche, France
| | | | - Claudio Cuccia
- Cardiovascular Department, Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- INSERM U1304-GETBO, FCRIN INNOVTE, Brest University, Brest, France
| | - Claudia Dellas
- Clinic of Paediatric Cardiology and Intensive Care, ACHD Center, University Medical Center Goettingen, Goettingen, Germany
| | - Konstantinos Dimopoulos
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Klaus Empen
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | | | - Emile Ferrari
- Service de Cardiologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero and Dipartimento DIMES-Università di Bologna, Bologna, Italy
| | - Marcello Galvani
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale Morgagni-Pierantoni, Forli, Italy
- Cardiovascular Research Unit, Fondazione Cardiologica Myriam Zito Sacco, Forli, Italy
| | | | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Center, Ljubljana, Slovenia
| | - Irene M Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero and Dipartimento DIMES-Università di Bologna, Bologna, Italy
| | - Antoniu Octavian Petris
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Giancarlo Piovaccari
- Department of Cardiovascular Diseases, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Aldo Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy
| | - Sebastian Schellong
- Department of Internal Medicine 2, Municipal Hospital Dresden, Dresden, Germany
| | - Kai-Helge Schmidt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Franck Verschuren
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Gerrit Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
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van Hylckama Vlieg MA, Nasserinejad K, Visser C, Bramer WM, Ashrani AA, Bosson JL, Crusan DJ, D'Alessio A, Fluharty ME, Ģībietis V, Hansson PO, Hara N, Jara-Palomares L, Kraaijpoel N, Mahé I, Marshall A, Ogino Y, Otero R, Versmissen J, Klok FA, Kruip MJ, van der Rijt CC, Geijteman EC. The risk of recurrent venous thromboembolism after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis: a systematic review and meta-analysis. EClinicalMedicine 2023; 64:102194. [PMID: 37731937 PMCID: PMC10507196 DOI: 10.1016/j.eclinm.2023.102194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Background The optimal duration of anticoagulation in patients with active cancer and venous thromboembolism (VTE) is unknown. Current clinical guidelines advocate anticoagulant therapy for 3-6 months and to continue anticoagulant therapy for as long as the cancer is active. However, an adequate systematic review on the rate of recurrent VTE after discontinuation of anticoagulant therapy has not been performed. Methods For this systemic review and meta-analysis, we searched Embase.com, Medline (Ovid), Web of Science, Cochrane Library, and Google Scholar, from database inception to February 16, 2023, for studies on anticoagulant therapy in patients with cancer and the recurrence of venous thromboembolism after discontinuation of this therapy. We included randomised controlled trials and cohort studies published in English that reported on patients who met the following: cancer and a first VTE, completed at least 3 months of anticoagulant therapy, were followed after discontinuation of anticoagulant therapy, and with symptomatic recurrent VTE as an outcome during follow-up. Study-level data were requested from study authors. The primary outcome was the rate of recurrent VTE after discontinuation of anticoagulant therapy. A Bayesian random-effects meta-analysis was used to estimate the rate of recurrent VTE per 100 person-years for the pooled studies at different time intervals after discontinuation of anticoagulation therapy. We also calculated the cumulative VTE recurrence rate at different time intervals. Forest plots were mapped and the results were summarized by the median and 95% credible interval (CIs). This study was registered with PROSPERO, CRD42021249060. Findings Of 3856 studies identified in our search, 33 studies were identified for inclusion. After requesting study-level data, 14 studies involving 1922 patients with cancer-associated thrombosis were included. The pooled rate of recurrent VTE per 100 person-years after discontinuation of anticoagulant therapy was 14.6 events (95% credible interval 6.5-22.8) in the first three months, decreasing to 1.1 events (95% CI 0.3-2.1) in year 2-3, and 2.2 events (95% CI 0.0-4.4) in year 3-5 after discontinuation of anticoagulant therapy. The cumulative VTE recurrence rate was 28.3% (95% CI 15.6-39.6%) at 1 year; 31.1% (95% CI 16.5-43.8%) at 2 years; 31.9% (95% CI 16.8-45.0%) at 3 years; and 35.0% (95% CI 16.8-47.4%) at 5 years after discontinuation of anticoagulant therapy. Interpretation This meta-analysis demonstrates a high rate of recurrent VTE over time after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis. Our results support the current clinical guidelines to continue anticoagulant therapy in patients with active cancer. Funding Erasmus MC.
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Affiliation(s)
| | - Kazem Nasserinejad
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Innovative Statistical Consulting, Therapeutics Development Team, Cytel Inc., Massachusetts, USA
| | - Chantal Visser
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wichor M. Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Aneel A. Ashrani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jean-Luc Bosson
- Department of Public Health, Grenoble-Alpes University Hospital and TIMC-IMAG, Grenoble, France
| | - Daniel J. Crusan
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Andrea D'Alessio
- Department of Medical Oncology and Internal Medicine, Policlinico San Marco, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
| | | | - Valdis Ģībietis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Region Västra Götaland, Sweden
| | - Nobuhiro Hara
- Department of Cardiology, IMS Katsushika Heart Center, Tokyo, Japan
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC/University of Amsterdam, Amsterdam, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris, INSERM, UMR_ S1140 Innovative Therapies in Haemostasis, Paris, France
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Yutaka Ogino
- Department of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Remedios Otero
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Jorie Versmissen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine and Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J.H.A. Kruip
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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de Jong CMM, de Wit K, Black SA, Gwozdz AM, Masias C, Parks AL, Robert-Ebadi H, Talerico R, Woller SC, Klok FA. Use of patient-reported outcome measures in patients with venous thromboembolism: communication from the ISTH SSC Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease. J Thromb Haemost 2023; 21:2953-2962. [PMID: 37394119 DOI: 10.1016/j.jtha.2023.06.023] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023]
Abstract
Patient-reported outcome measures (PROMs) are patient-completed instruments that capture patient-perceived health status and well-being. PROMs measure disease impact and outcomes of care as reported by those who experience the disease. After pulmonary embolism or deep vein thrombosis, patients may face a broad spectrum of complications and long-term sequelae beyond the usual quality-of-care indicators of recurrent venous thromboembolism (VTE), bleeding complications, and survival. The full impact of VTE on individual patients can only be captured by assessing all relevant health outcomes from the patient's perspective in addition to the traditionally recognized complications. Defining and measuring all important outcomes will help facilitate treatment tailored to the needs and preferences of patients and may improve health outcomes. The International Society on Thrombosis and Haemostasis Scientific and Standardization Committee Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease endorsed the International Consortium for Health Outcomes Measurement (ICHOM) VTE project on development of a standardized set of patient-centered outcome measures for patients with VTE. In this communication, the course and result of the project are summarized, and based on these findings, we propose recommendations for the use of PROMs during clinical follow-up of patients with VTE. We describe challenges to implementation of PROMs and explore barriers and enablers.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands. https://twitter.com/Cindy_de_Jong
| | - Kerstin de Wit
- Departments of Emergency Medicine and Medicine, Queen's University, Kingston, Ontario, Canada; Departments of Medicine and Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Stephen A Black
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, St Thomas' Hospital, King's College London, London, UK
| | - Adam M Gwozdz
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Vascular Surgery, Imperial College Healthcare National Health Service Trust, London, UK
| | - Camila Masias
- Miami Cancer Institute, Baptist Health South Florida, Florida International University-Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Anna L Parks
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Rosa Talerico
- Department of Medicine, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Intermountain Healthcare, Murray, Utah, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Jervan Ø, Dhayyat A, Gleditsch J, Haukeland-Parker S, Tavoly M, Klok FA, Rashid D, Stavem K, Ghanima W, Steine K. Demographic, clinical, and echocardiographic factors associated with residual perfusion defects beyond six months after pulmonary embolism. Thromb Res 2023; 229:7-14. [PMID: 37356172 DOI: 10.1016/j.thromres.2023.06.004] [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: 03/03/2023] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Residual perfusion defects (RPD) after pulmonary embolism (PE) are common. PRIMARY AIM This study aimed to determine the prevalence of RPD in a cohort diagnosed with PE 6-72 months earlier, and to determine demographic, clinical, and echocardiographic variables associated with RPD. METHODS Patients aged 18-75 years with prior PE, confirmed by computed tomography pulmonary angiography 6-72 months earlier, were included. Participants (N = 286) completed a diagnostic work-up consisting of transthoracic echocardiography and ventilation/perfusion scintigraphy. Demographic, clinical, and echocardiographic characteristics between participants with RPD and those without RPD were explored in univariate analyses using t-test or Mann-Whitney U test. Multiple logistic regression analysis was used to assess the association between selected variables and RPD. RESULTS RPD were detected in 72/286 patients (25.2 %, 95 % CI:20.5 %-30.5 %). Greater tricuspid annular plane systolic excursion (TAPSE) (adjusted odds ratio (aOR) 1.10, 95 % CI:1.00-1.21, p = 0.048) at echocardiographic follow-up, greater thrombotic burden at diagnosis, as assessed by mean bilateral proximal extension of the clot (MBPEC) score 3-4 (aOR 2.08, 95 % CI:1.06-4.06, p = 0.032), and unprovoked PE (aOR 2.25, 95 % CI:1.13-4.48, p = 0.021) were independently associated with increased risk of RPD, whereas increased pulmonary artery acceleration time was associated with a lower risk of RPD (aOR 0.72, 95 % CI:0.62-0.83, p < 0.001, per 10 ms). Dyspnoea was not associated with RPD. CONCLUSION RPD were common after PE. Reduced pulmonary artery acceleration time and greater TAPSE on echocardiography at follow-up, greater thrombotic burden at diagnosis, and unprovoked PE were associated with RPD.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Adam Dhayyat
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Stacey Haukeland-Parker
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Diyar Rashid
- Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Medicine, Østfold Hospital, Kalnes, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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Chu G, Valerio L, Barco S, Huisman MV, Konstantinides SV, Klok FA. External validation of AF-BLEED for predicting major bleeding and for tailoring NOAC dose in AF patients: A post hoc analysis in the ENGAGE AF-TIMI 48. Thromb Res 2023; 229:225-231. [PMID: 37566971 DOI: 10.1016/j.thromres.2023.08.001] [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: 04/26/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE AF-BLEED, a simple bleeding risk classifier, was found to predict major bleeding (MB) in patients with atrial fibrillation (AF) and identify AF patients at high risk of MB who might potentially benefit from a lower direct oral anticoagulant dose. This post hoc study aimed to externally validate these findings in the ENGAGE AF-TIMI 48 (Effective aNticoaGulation with factor Xa next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction study 48) trial. METHODS The ENGAGE AF-TIMI 48 trial randomized AF patients to higher-dose edoxaban regimen (HDER 60/30 mg) versus lower-dose edoxaban regimen (LDER 30/15 mg), with prespecified dose reduction criteria. AF-BLEED was calculated in the modified intention-to-treat cohort (n = 21,026 patients) used for primary outcome analysis. Annualized event rates and hazard ratios (HRs) were obtained for the primary composite outcome (PCO) and its single components (MB, ischemic stroke/systemic embolism and death) to compare LDER 30 mg with HDER 60 mg in both AF-BLEED classes. RESULTS AF-BLEED classified 2882 patients (13.7 %) as high-risk, characterized by a two- to three-fold higher MB risk than AF-BLEED classified low-risk patients. AF-BLEED classified high-risk patients randomized to LDER 30 mg demonstrated a 3.3 % reduction in MB at the cost of a 0.5 % increase in ischemic stroke/systemic embolism. LDER 30 mg resulted in a 3.1 % reduction of PCO compared to HDER 60 mg (HR of 0.81; 95%CI 0.65-1.01). Additional to existing dose reduction criteria, another 6 % of patients could potentially benefit of this dose adjustment strategy. CONCLUSION AF-BLEED could identify AF patients to be at high risk of major bleeding. Our findings support the hypothesis that LDER 30 mg might provide a reasonable option in AF patients with legitimate bleeding concerns.
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Affiliation(s)
- G Chu
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - L Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany
| | - S Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Anijs RJS, Chen Q, van der Hulle T, Versteeg HH, Klok FA, Lijfering WM, Cannegieter SC. Venous and arterial thromboembolism after colorectal cancer in the Netherlands: Incidence, predictors, and prognosis. Thromb Res 2023; 229:90-98. [PMID: 37421683 DOI: 10.1016/j.thromres.2023.06.028] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most prevalent cancer type. CRC-patients are at increased risk of venous and arterial thromboembolism (TE), but the magnitude of the risks, their predictors and consequences are not exactly known. OBJECTIVES We aimed to determine incidence, predictors and prognosis of TE after incident CRC in a large, unselected population. METHODS Using data from Statistics Netherlands and the Netherlands Comprehensive Cancer Organization, all incident CRC-patients were identified between 2013 and 2018 plus a sample of 1:2 age- and sex-matched control subjects. Incidence rates and cumulative incidences for TE were estimated. Predictor variables for TE were explored by univariable Cox regression. The association between TE and all-cause mortality was evaluated by multivariable time-dependent Cox regression. RESULTS 68,238 incident CRC-patients were matched to 136,476 controls. CRC-patients had a 1-year cumulative venous TE (VTE) incidence of 1.93 % (95%CI 1.83-2.04), versus 0.24 % (95%CI 0.21-0.27) in controls (HR 8.85; 95%CI 7.83-9.99). For arterial TE (ATE), this was 2.74 % (95%CI 2.62-2.87) in CRC versus 1.88 % (95%CI 1.81-1.95) in controls (HR 1.57; 95%CI 1.47-1.66). Cancer stage, surgery, chemotherapy and asthma were predictors for VTE, whereas age, prior ATE and Parkinson's disease were predictors for ATE. CRC patients with TE had an increased risk of all-cause mortality (VTE HR; 3.68 (95%CI 3.30-4.10, ATE HR; 3.05 (95%CI 2.75-3.39)) compared with CRC-patients without TE. CONCLUSIONS This Dutch nationwide cohort study adds detailed knowledge on the risk of VTE and ATE, their predictors and prognosis in CRC-patients. These findings may drive TE prophylactic management decisions.
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Affiliation(s)
- R J S Anijs
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Q Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T van der Hulle
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - H H Versteeg
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - W M Lijfering
- The Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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van Es N, Takada T, Kraaijpoel N, Klok FA, Stals MAM, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, Wells PS, de Wit K, van Smeden M, Geersing GJ. Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis. Eur Heart J 2023; 44:3073-3081. [PMID: 37452732 PMCID: PMC10917087 DOI: 10.1093/eurheartj/ehad417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/25/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION PROSPERO ID 89366.
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Affiliation(s)
- Nick van Es
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1247, Japan
| | - Noémie Kraaijpoel
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Milou A M Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Harry R Büller
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Yonathan Freund
- Emergency Department, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Bd de l'Hôpital, 75013 Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, C. de Arturo Soria, 270, 28033 Madrid, Spain
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold hospital, Kalnesveien 300, 1714 Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds vei 3, 0372 Oslo, Oslo, Norway
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 4820, USA
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
- Department of Oncology, McMaster University, Juravinski Cancer Centre, 699 Concession St. Suite 4-204, Hamilton, Ontario, Canada
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, UNIV Angers, 4 Rue Larrey, 49100 Angers, Maine-et-Loire, France
| | - Phil S Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, 76 Stuart Street, Kingston ON K7L 2V7, Canada
- Department of Medicine, McMaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, L8N 3Z5 Ontario, Canada
- Department of Health Evidence and Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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Kempers EK, Chen Q, Visser C, van Gorp ECM, Klok FA, Cannegieter SC, Kruip MJHA. Changes in incidence of hospitalization for cardiovascular diseases during the COVID-19 pandemic in The Netherlands in 2020. Sci Rep 2023; 13:12832. [PMID: 37553430 PMCID: PMC10409797 DOI: 10.1038/s41598-023-39573-w] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
This population-based cohort study aimed to describe changes in incidence of cardiovascular disease (CVD) hospital diagnoses during the COVID-19 pandemic in The Netherlands compared with the pre-pandemic period. We used Dutch nationwide statistics about hospitalizations to estimate incidence rate ratios (IRR) of hospital diagnoses of CVD during the first and second COVID-19 waves in The Netherlands in 2020 versus the same periods in 2019. Compared with 2019, the incidence rate of a hospital diagnosis of ischemic stroke (IRR 0.87; 95% CI 0.79-0.95), major bleeding (IRR 0.74; 95% CI 0.68-0.82), atrial fibrillation (IRR 0.73; 95% CI 0.65-0.82), myocardial infarction (IRR 0.78; 95% CI 0.72-0.84), and heart failure (IRR 0.74; 95% CI 0.65-0.85) declined during the first wave, but returned to pre-pandemic levels throughout 2020. However, the incidence rate of a hospital diagnosis of pulmonary embolism (PE) increased during both the first and second wave in 2020 compared with 2019 (IRR 1.30; 95% CI 1.15-1.48 and IRR 1.31; 95% CI 1.19-1.44, respectively). In conclusion, we observed substantial declines in incidences of CVD during the COVID-19 pandemic in The Netherlands in 2020, especially during the first wave, with an exception for an increase in incidence of PE. This study contributes to quantifying the collateral damage of the COVID-19 pandemic.
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Affiliation(s)
- Eva K Kempers
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Infectious Diseases, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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van der Horst SFB, Martens ESL, den Exter PL, Bos MHA, van Mens TE, Huisman MV, Klok FA. Idarucizumab for dabigatran reversal: A systematic review and meta-analysis of indications and outcomes. Thromb Res 2023; 228:21-32. [PMID: 37267671 DOI: 10.1016/j.thromres.2023.05.020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Idarucizumab has been approved to reverse the anticoagulant effect of dabigatran. However, there is little knowledge of the effectiveness and safety of idarucizumab in daily practice. AIMS This systematic review and meta-analysis aims to evaluate the use, effectiveness and outcomes of idarucizumab. METHODS A systematic literature search was performed up to September 8th 2022. Original studies including patients prescribed idarucizumab, evaluating prescription indications, prescription appropriateness, haemostatic efficacy and/or the occurrence of adverse events were eligible. Case-reports and studies performed in patients ≤18 years or in healthy volunteers were excluded. Study selection and data extraction were performed by two independent reviewers. Pooled estimates were calculated using the random-effects model, after Freeman-Tukey double-arcsine transformation. RESULTS Thirty studies comprising 3602 patients were included. Idarucizumab was prescribed for bleeding (63.1 %, 95%CI 57.0 %-69.0 %), invasive procedures (30.5 %, 95%CI: 24.1 %-37.2 %), to enable thrombolysis (range: 2.0 %-27.3 %), dabigatran intoxication without bleeding (range: 3.6 %-7.0 %) or unspecified reasons (range: 0.4 %-18.8 %). Overall, 2.8 % (95%CI 0.5 %-6.2 %) of prescription indications were reported to be inappropriate upon post-hoc evaluation. Hemostatic effectiveness was achieved in 77.7 % (95%CI 66.7 %-87.2 %) and peri-procedural haemostasis was normal in 98.5 % (95%CI 86.6 %-100 %) of patients. The pooled incidences of all-cause mortality and thromboembolic events at any follow-up duration were 13.6 % (95%CI 9.6 %-17.9 %) and 2.0 % (95%CI 0.8 %-3.4 %), respectively. CONCLUSION Idarucizumab was mainly prescribed in the setting of bleeding. The reported hemostatic effectiveness was good, especially perioperatively, and the incidence of thromboembolic events was low. Patients with dabigatran-associated bleeding or requiring an urgent procedure nonetheless face a high mortality risk.
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Affiliation(s)
- S F B van der Horst
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - E S L Martens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - P L den Exter
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M H A Bos
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Goedegebuur J, Abbel D, Accassat S, Achterberg WP, Akbari A, Arfuch VM, Baddeley E, Bax JJ, Becker D, Bergmeijer B, Bertoletti L, Blom JW, Calvetti A, Cannegieter SC, Castro L, Chavannes NH, Coma-Auli N, Couffignal C, Edwards A, Edwards M, Enggaard H, Font C, Gava A, Geersing GJ, Geijteman ECT, Greenley S, Gregory C, Gussekloo J, Hoffmann I, Højen AA, van den Hout WB, Huisman MV, Jacobsen S, Jagosh J, Johnson MJ, Jørgensen L, Juffermans CCM, Kempers EK, Konstantinides S, Kroder AF, Kruip MJHA, Lafaie L, Langendoen JW, Larsen TB, Lifford K, van der Linden YM, Mahé I, Maiorana L, Maraveyas A, Martens ESL, Mayeur D, van Mens TE, Mohr K, Mooijaart SP, Murtagh FEM, Nelson A, Nielsen PB, Ording AG, Ørskov M, Pearson M, Poenou G, Portielje JEA, Raczkiewicz D, Rasmussen K, Trinks-Roerdink E, Schippers I, Seddon K, Sexton K, Sivell S, Skjøth F, Søgaard M, Szmit S, Trompet S, Vassal P, Visser C, van Vliet LM, Wilson E, Klok FA, Noble SIR. Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool. Thromb Res 2023; 228:54-60. [PMID: 37276718 DOI: 10.1016/j.thromres.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs. METHODS The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe. RESULTS SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life. CONCLUSIONS We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.
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Affiliation(s)
- J Goedegebuur
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Abbel
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S Accassat
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - W P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Akbari
- Swansea University, Swansea, Wales, United Kingdom
| | - V M Arfuch
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - E Baddeley
- Cardiff University, Cardiff, United Kingdom
| | - J J Bax
- Department of Medicine - Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Becker
- University Medical Center Mainz, Mainz, Germany
| | | | - L Bertoletti
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Calvetti
- Assistance Publique-Hopitaux de Paris, Paris, France
| | - S C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Castro
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - N H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - N Coma-Auli
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - C Couffignal
- Hôpital Louis Mourier, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A Edwards
- Cardiff University, Cardiff, United Kingdom
| | - M Edwards
- Cardiff University, Cardiff, United Kingdom
| | - H Enggaard
- Aalborg University Hospital, Aalborg, Denmark
| | - C Font
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - A Gava
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - C Gregory
- Cardiff University, Cardiff, United Kingdom
| | - J Gussekloo
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - I Hoffmann
- Hôpital Bichat, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A A Højen
- Aalborg University Hospital, Aalborg, Denmark
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Jacobsen
- Aalborg University Hospital, Aalborg, Denmark
| | - J Jagosh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - M J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - L Jørgensen
- Aalborg University Hospital, Aalborg, Denmark
| | - C C M Juffermans
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - E K Kempers
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - A F Kroder
- Todaytomorrow, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L Lafaie
- Department of Geriatrics and Gerontology, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | | | - T B Larsen
- Aalborg University Hospital, Aalborg, Denmark
| | - K Lifford
- Cardiff University, Cardiff, United Kingdom
| | - Y M van der Linden
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands; Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - I Mahé
- Department of Innovative Therapies in Haemostasis, Hôpital Louis Mourier, APHP, Paris, France
| | - L Maiorana
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - A Maraveyas
- Clinical Sciences Centre Hull York Medical School University of Hull, Hull, United Kingdom
| | - E S L Martens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - D Mayeur
- Centre Georges-François Leclerc, Dijon, France
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - K Mohr
- University Medical Center Mainz, Mainz, Germany
| | - S P Mooijaart
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - A Nelson
- Cardiff University, Cardiff, United Kingdom
| | - P B Nielsen
- Aalborg University Hospital, Aalborg, Denmark
| | - A G Ording
- Aalborg University Hospital, Aalborg, Denmark
| | - M Ørskov
- Aalborg University Hospital, Aalborg, Denmark
| | - M Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - G Poenou
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J E A Portielje
- Department of Medicine - Internal medicine and Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - K Rasmussen
- Aalborg University Hospital, Aalborg, Denmark
| | - E Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - K Seddon
- Wales Cancer Research Centre, Cardiff, UK
| | - K Sexton
- Cardiff University, Cardiff, United Kingdom
| | - S Sivell
- Cardiff University, Cardiff, United Kingdom
| | - F Skjøth
- Aalborg University Hospital, Aalborg, Denmark
| | - M Søgaard
- Aalborg University Hospital, Aalborg, Denmark
| | - S Szmit
- Department of Cardio-Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - S Trompet
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - P Vassal
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L M van Vliet
- Department of Health, Medicine and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - E Wilson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Lee J, van Es N, Takada T, Klok FA, Geersing GJ, Blume J, Bossuyt PM. Covariate-specific ROC curve analysis can accommodate differences between covariate subgroups in the evaluation of diagnostic accuracy. J Clin Epidemiol 2023; 160:14-23. [PMID: 37295733 DOI: 10.1016/j.jclinepi.2023.06.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/01/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES We present an illustrative application of methods that account for covariates in receiver operating characteristic (ROC) curve analysis, using individual patient data on D-dimer testing for excluding pulmonary embolism. STUDY DESIGN AND SETTING Bayesian nonparametric covariate-specific ROC curves were constructed to examine the performance/positivity thresholds in covariate subgroups. Standard ROC curves were constructed. Three scenarios were outlined based on comparison between subgroups and standard ROC curve conclusion: (1) identical distribution/identical performance, (2) different distribution/identical performance, and (3) different distribution/different performance. Scenarios were illustrated using clinical covariates. Covariate-adjusted ROC curves were also constructed. RESULTS Age groups had prominent differences in D-dimer concentration, paired with differences in performance (Scenario 3). Different positivity thresholds were required to achieve the same level of sensitivity. D-dimer had identical performance, but different distributions for YEARS algorithm items (Scenario 2), and similar distributions for sex (Scenario 1). For the later covariates, comparable positivity thresholds achieved the same sensitivity. All covariate-adjusted models had AUCs comparable to the standard approach. CONCLUSION Subgroup differences in performance and distribution of results can indicate that the conventional ROC curve is not a fair representation of test performance. Estimating conditional ROC curves can improve the ability to select thresholds with greater applicability.
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Affiliation(s)
- Jenny Lee
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 2-1 Toyochi Kamiyajiro, Shirakawa, Fukushima, 961-0005, Japan
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeffrey Blume
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 2-1 Toyochi Kamiyajiro, Shirakawa, Fukushima, 961-0005, Japan; Department of Data Science, University of Virginia, Charlottesville, VA, USA
| | - Patrick M Bossuyt
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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Bonnesen K, Klok FA, Andersen MJ, Andersen A, Nielsen-Kudsk JE, Mellemkjær S, Sørensen HT, Schmidt M. Long-Term Prognostic Impact of Pulmonary Hypertension After Venous Thromboembolism. Am J Cardiol 2023; 199:92-99. [PMID: 37202325 DOI: 10.1016/j.amjcard.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/22/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/20/2023]
Abstract
Pulmonary embolism is a risk factor for chronic thromboembolic pulmonary hypertension (CTEPH), but the prognostic impact of CTEPH on venous thromboembolism (VTE) mortality remains unclear. We examined the impact of CTEPH and other pulmonary hypertension (PH) subtypes on long-term mortality after VTE. We conducted a nationwide, population-based cohort study of all adult Danish patients alive 2 years after incident VTE without previous PH from 1995 to 2020 (n = 129,040). We used inverse probability of treatment weights in a Cox model to calculate standardized mortality rate ratios (SMRs) of the association between receiving a first-time PH diagnosis ≤2 years after incident VTE and mortality (all-cause, cardiovascular, and cancer). We grouped PH as PH associated with left-sided cardiac disease (group II), PH associated with lung diseases and/or hypoxia (group III), CTEPH (group IV), and unclassified (remaining patients). Total follow-up was 858,954 years. The SMR associated with PH overall was 1.99 (95% confidence interval 1.75 to 2.27) for all-cause, 2.48 (1.90 to 3.23) for cardiovascular, and 0.84 (0.60 to 1.17) for cancer mortality. The SMR for all-cause mortality was 2.62 (1.77 to 3.88) for group II, 3.98 (2.85 to 5.56) for group III, 1.88 (1.11 to 3.20) for group IV, and 1.73 (1.47 to 2.04) for unclassified PH. The cardiovascular mortality rate was increased approximately threefold for groups II and III but was not increased for group IV. Only group III was associated with increased cancer mortality. In conclusion, PH diagnosed ≤2 years after incident VTE was associated with an overall twofold increased long-term mortality driven by cardiovascular causes.
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Affiliation(s)
- Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Denmark.
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Mads J Andersen
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Denmark
| | | | | | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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Luijten D, Talerico R, Barco S, Cannegieter SC, Delcroix M, Ende-Verhaar YM, Huisman MV, Konstantinidis S, Mairuhu ATA, van Mens TE, Ninaber M, Pruszczyk P, Vonk Noordegraaf A, Klok FA. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: an updated systematic review and meta-analysis. Eur Respir J 2023; 62:2300449. [PMID: 37321620 DOI: 10.1183/13993003.00449-2023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Talerico
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Suzanne C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marion Delcroix
- Department of Respiratory Diseases, University Hospital of Leuven, Leuven, Belgium
| | - Yvonne M Ende-Verhaar
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Albert T A Mairuhu
- Department of Vascular Medicine, Haga Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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van der Horst SFB, de Vries TA, Chu G, Bavalia R, Xiong H, van de Wiel KM, Mulder K, van Ballegooijen H, de Groot JR, Middeldorp S, Klok FA, Hemels ME, Huisman MV. Prevalence and Predictors of Nonadherence to Direct Oral Anticoagulant Treatment in Patients with Atrial Fibrillation. TH Open 2023; 7:e270-e279. [PMID: 37772087 PMCID: PMC10533218 DOI: 10.1055/a-2161-0928] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/25/2023] [Indexed: 09/30/2023] Open
Abstract
Background For most patients with newly diagnosed atrial fibrillation (AF), direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists. However, there is concern that the lack of monitoring may impair therapy adherence and therefore the anticoagulant effect. Objective To assess 1-year DOAC nonadherence in patients with AF and a treatment indication of at least 1 year in the Dutch health care setting, and to identify predictors of nonadherence. Methods We performed a near-nationwide historical cohort study in patients with a novel DOAC indication for AF. Data were obtained from a pharmacy database, covering 65% of all outpatient prescriptions dispensed in the Netherlands. The 1-year nonadherence was assessed by the proportion of days covered; the threshold was set at <80%. Robust Poisson regression analyses were performed to identify predictors of nonadherence. Results A total of 46,211 patients were included and the 1-year nonadherence was 6.5%. We identified male sex (risk ratio [RR] 1.23, 95% confidence interval [CI]: 1.15-1.33), younger age (age ≥60 to <70 years: RR: 1.15, 95% CI: 1.00-1.33, age <60 years: RR: 2.22, 95% CI: 1.92-2.57; reference age ≥85 years), a reduced DOAC dose (RR: 1.10, 95% CI: 1.00-1.22), a twice-daily dosing regimen (RR: 1.21, 95% CI: 1.12-1.30), and treatment with apixaban (RR: 1.16, 95% CI: 1.06-1.26, reference rivaroxaban) or dabigatran (RR: 1.25, 95% CI: 1.14-1.37) as independent predictors of 1-year nonadherence. Conclusion One-year nonadherence to DOACs was low yet relevant in patients with AF newly prescribed a DOAC. Understanding the predictors for nonadherence may help identify patients at risk.
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Affiliation(s)
| | - Tim A.C. de Vries
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
| | - Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
- Department of Internal Medicine, Alrijne Hospital, Leiden, The Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam UMC location University of Amsterdam, The Netherlands
- GGD Amsterdam, Amsterdam, The Netherlands
| | - Helen Xiong
- IQVIA Netherlands, Amsterdam, The Netherlands
| | | | | | | | - Joris R. de Groot
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
| | - Martin E.W. Hemels
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
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48
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Wang H, Klok FA, Rosendaal FR, Cushman M, van Hylckama Vlieg A. Health-related quality of life after first venous thromboembolism in individuals aged 70 years and older. Res Pract Thromb Haemost 2023; 7:102144. [PMID: 37601012 PMCID: PMC10439441 DOI: 10.1016/j.rpth.2023.102144] [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: 03/06/2023] [Revised: 06/06/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023] Open
Abstract
Background There is limited information on short- and long-term effects of venous thromboembolism (VTE) on health-related quality of life (HRQoL) in the elderly. Objectives To assess change in generic HRQoL and disease-specific HRQoL in patients 1 year after the VTE. Methods The Age and Thrombosis, Acquired and Genetic risk factors in the elderly (AT-AGE) study is a 2-center case-control study performed in Leiden, the Netherlands, and Vermont, United States, among individuals aged ≥70 years. We measured generic HRQoL using the 36-item Short Form Health Survey (SF-36) and disease-specific HRQoL using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire (VEINES-QoL/Sym) and the Pulmonary Embolism-Specific Quality of Life Questionnaire (PEmb-QoL). All patients completed these questionnaires shortly after their VTE and 1 year later, while controls completed the 36-item Short Form Health Survey questionnaire once. Linear regression for change in quality of life scores was performed and adjusted for potential confounders. Results For the current analysis, we included patients who were visited twice (n = 316) and controls (n = 427) with HRQoL information. Mean age of patients and controls was similar (78.8 vs 75.5 years). In patients who survived at least 1 year after the VTE, generic HRQoL improved for both summary scores, but it did not reach the level of the age-matched controls: physical and mental summary scores increased by 5.6 and 5.5 points, respectively, but compared with controls, remained 8.2 and 6.4 points lower. For disease-specific HRQoL, the Pulmonary Embolism-Specific Quality of Life Questionnaire overall score decreased from 21.7% to 15.2%, indicating improved HRQoL. Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire scores did not change over time. Conclusion Overall, the quality of life of patients with VTE was worse than that of controls after 1 year, indicating a long-term impact of VTE diagnosis in the elderly.
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Affiliation(s)
- Huijie Wang
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Sissingh NJ, Groen JV, Timmerhuis HC, Besselink MG, Boekestijn B, Bollen TL, Bonsing BA, Klok FA, van Santvoort HC, Verdonk RC, van Eijck CHJ, van Hooft JE, Mieog JSD. Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A national survey and case-vignette study. World J Gastroenterol 2023; 29:3328-3340. [PMID: 37377583 PMCID: PMC10292147 DOI: 10.3748/wjg.v29.i21.3328] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Splanchnic vein thrombosis (SVT) is a major complication of moderate and severe acute pancreatitis. There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.
AIM To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.
METHODS A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey. The threshold to assume group agreement was set at 75%.
RESULTS The response rate was 67% (n = 93). Seventy-one pancreatologists (77%) regularly prescribed therapeutic anticoagulation in case of SVT, and 12 pancreatologists (13%) for narrowing of splanchnic vein lumen. The most common reason to treat SVT was to avoid complications (87%). Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation (90%). Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation (76%) and splenic vein thrombosis as the least preferred location (86%). The preferred initial agent was low molecular weight heparin (LMWH; 87%). In the case vignettes, therapeutic anticoagulation was prescribed for acute portal vein thrombosis, with or without suspected infected necrosis (82% and 90%), and thrombus progression (88%). Agreement was lacking regarding the selection and duration of long-term anticoagulation, the indication for thrombophilia testing and upper endoscopy, and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.
CONCLUSION In this national survey, the pancreatologists seemed to agree on the use of therapeutic anticoagulation, using LMWH in the acute phase, for acute portal thrombosis and in the case of thrombus progression, irrespective of the presence of infected necrosis.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
- Department of Research and Development, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
- Department of Surgery, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam 1081 HZ, Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam 1105 AZ, Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Utrecht 3584 CX, Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein 3420 EM, Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
| | - Jan Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden 2333 ZA, Netherlands
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50
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van Mens TE, Klok FA, Levi M. Searching the literature to explain unexpected clinical observations: all that glitters is not gold. Eur J Intern Med 2023; 112:17-18. [PMID: 37059603 DOI: 10.1016/j.ejim.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 04/16/2023]
Affiliation(s)
- T E van Mens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands; Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - F A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M Levi
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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