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Bikdeli B, Jiménez D, Del Toro J, Piazza G, Rivas A, Fernández-Reyes JL, Sampériz Á, Otero R, Suriñach JM, Siniscalchi C, Martín-Guerra JM, Castro J, Muriel A, Lip GYH, Goldhaber SZ, Monreal M. Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism. J Am Heart Assoc 2021; 10:e021467. [PMID: 34459215 PMCID: PMC8649245 DOI: 10.1161/jaha.121.021467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/16/2022]
Abstract
Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90-day and 1-year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90-day all-cause (odds ratio [OR], 2.81; 95% CI, 2.33-3.38) and PE-related mortality (OR, 2.38; 95% CI, 1.37-4.14) and increased 1-year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10-9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all-cause mortality (OR, 1.91; 95% CI, 1.57-2.32) but not PE-related mortality (OR, 1.50; 95% CI, 0.85-2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90-day all-cause (OR, 2.28; 95% CI, 1.75-2.97) and PE-related (OR, 3.64; 95% CI, 2.01-6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division Brigham and Women's HospitalHarvard Medical School Boston MA.,Yale/YNHH Center for Outcomes Research & Evaluation New Haven CT.,Cardiovascular Research Foundation (CRF) New York NY
| | - David Jiménez
- Respiratory Department Hospital Ramón y Cajal (IRYCIS) Madrid Spain.,Medicine Department Universidad de Alcalá (IRYCIS) Madrid Spain.,CIBER de Enfermedades Respiratorias (CIBERES) Madrid Spain
| | - Jorge Del Toro
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Gregory Piazza
- Cardiovascular Medicine Division Brigham and Women's HospitalHarvard Medical School Boston MA
| | - Agustina Rivas
- Department of Pneumonology Hospital Universitario Araba Álava Spain
| | | | - Ángel Sampériz
- Department of Internal Medicine Hospital Reina Sofía Tudela, Navarra Spain
| | - Remedios Otero
- Department of Pneumonology Hospital Universitario Virgen del Rocío Seville Spain
| | - José María Suriñach
- Department of Internal Medicine Hospital Universitario Vall d'Hebron Barcelona Spain
| | | | | | - Joaquín Castro
- Department of Internal Medicine Hospital Santa Bárbara Puertollano, Ciudad Real Spain
| | - Alfonso Muriel
- Clinical Biostatistics Unit Hospital Universitario Ramón y CajalIRYCISCIBERESP: Universidad de Alcalá Madrid Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,Thrombosis Research Unit Aalborg University Aalborg Denmark
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division Brigham and Women's HospitalHarvard Medical School Boston MA
| | - Manuel Monreal
- Hospital Universitari Germans Trias i Pujol Badalona, Barcelona Spain.,Universidad Autónoma de Barcelona Spain
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Mehdipoor G, Jimenez D, Bertoletti L, Del Toro J, Fernández-Capitán C, Bura-Riviere A, Amado C, Valero B, Blanco-Molina Á, Otero R, Imbalzano E, Khorasani R, Prince MR, Bikdeli B, Monreal M. Imaging modalities for confirming pulmonary embolism during pregnancy: results from a multicenter international study. Eur Radiol 2021; 32:1238-1246. [PMID: 34331113 DOI: 10.1007/s00330-021-08161-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/01/2021] [Accepted: 06/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We explored the variations in use of imaging modalities for confirming pulmonary embolism (PE) according to the trimester of pregnancy. METHODS We included all pregnant patients with confirmed acute PE from RIETE, a prospective registry of patients with PE (03/2001-02/2020). Imaging modalities included computed tomography pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scan, or presence of signs of acute PE along with imaging-confirmed proximal deep vein thrombosis (pDVT) without pulmonary vascular imaging. We compared the imaging modalities to postpartum patients with PE, and other non-pregnant women with PE. RESULTS There were 157 pregnant patients (age: 32.7 ± 0.5), 228 postpartum patients (age: 33.9 ± 0.5), and 23,937 non-pregnant non-postpartum women (age: 69.5 ± 0.1). CTPA was the most common modality for confirming PE, from 55.7% in first trimester to 58.3% in second trimester, and 70.0% in third trimester. From first trimester to third trimester, V/Q scanning was used in 21.3%, 16.7%, and 18.3% of cases, respectively. Confirmed pDVT along with the presence of signs/symptoms of PE was the confirmatory modality for PE in 21.3% of patients in first trimester, 19.4% in second trimester, and 6.7% in third trimester. The proportion of postpartum patients confirmed with CTPA (85.5%) was comparable to that of non-pregnant non-postpartum women (83.2%). From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with PE diagnosed with CTPA (p = 0.039). CONCLUSION CTPA was the primary modality for confirming PE in all trimesters of pregnancy, although its proportional use was higher in later stages of pregnancy. KEY POINTS • Computed tomography pulmonary angiography (CTPA) was the primary modality of diagnosis in all trimesters of pregnancy among patients with confirmed pulmonary embolism, even in the first trimester. • From the first trimester of pregnancy to postpartum period, there was a linear increase in the proportion of patients with pulmonary embolism who were diagnosed based on CTPA. • In the postpartum period, use of CTPA as the modality to confirm pulmonary embolism was comparable to non-pregnant patients.
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Affiliation(s)
- Ghazaleh Mehdipoor
- Department of Medicine, Peconic Bay Medical Center, Northwell Health, Riverhead, NY, USA
- Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de Saint-Etienne and INSERM U1059 SAINBIOSE - CIC 1408, Université Jean-Monnet, Saint-Etienne, France
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Cristina Amado
- Department of Internal Medicine, Hospital Sierrallana, Santander, Spain
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Remedios Otero
- Department of Pneumonology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, A.O.U Policlinico "G. Martino", Messina, Italy
| | - Ramin Khorasani
- Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Martin R Prince
- Department of Radiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Research Foundation (CRF), New York, NY, USA
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Manuel Monreal
- Department of Internal Medicine, Hospital de Badalona Germans Trias i Pujol, Badalona, Spain.
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Blondon M, Jimenez D, Robert‐Ebadi H, Del Toro J, Lopez‐Jimenez L, Falga C, Skride A, Font L, Vazquez FJ, Bounameaux H, Monreal M, Prandoni P, Brenner, B, Farge‐Bancel D, Barba R, Di Micco P, Bertoletti L, Schellong S, Tzoran I, Reis A, Bosevski M, Malý R, Verhamme P, Caprini JA, My Bui H, Adarraga MD, Agud M, Aibar J, Aibar MA, Alfonso J, Amado C, Arcelus JI, Baeza C, Ballaz A, Barba R, Barbagelata C, Barrón M, Barrón‐Andrés B, Blanco‐Molina A, Botella E, Camon AM, Castro J, Caudevilla MA, Cerdà P, Chasco L, Criado J, de Ancos C, de Miguel J, Demelo‐Rodríguez P, Díaz‐Peromingo JA, Díez‐Sierra J, Díaz‐Simón R, Domínguez IM, Encabo M, Escribano JC, Falgá C, Farfán AI, Fernández‐Capitán C, Fernández‐Reyes JL, Fidalgo MA, Flores K, Font C, Francisco I, Gabara C, Galeano‐Valle F, García MA, García‐Bragado F, García‐Mullor MM, Gavín‐Blanco O, Gavín‐Sebastián O, Gil‐Díaz A, Gómez‐Cuervo C, González‐Martínez J, Grau E, Guirado L, Gutiérrez J, Hernández‐Blasco L, Jara‐Palomares L, Jaras MJ, Jiménez D, Joya MD, Jou I, Lacruz B, Lecumberri R, Lima J, Lobo JL, López‐Brull H, López‐Jiménez L, López‐Miguel P, López‐Núñez JJ, López‐Reyes R, López‐Sáez JB, Lorente MA, Lorenzo A, Loring M, Madridano O, Maestre A, Marchena PJ, Martín del Pozo M, Martín‐Martos F, Martínez‐Baquerizo C, Mella C, Mellado M, Mercado MI, Moisés J, Morales MV, Muñoz‐Blanco A, Muñoz‐Guglielmetti D, Muñoz‐Rivas N, Nart E, Nieto JA, Núñez MJ, Olivares MC, Ortega‐Michel C, Ortega‐Recio MD, Osorio J, Otalora S, Otero R, Parra P, Parra V, Pedrajas JM, Pellejero G, Pérez‐Jacoiste A, Peris ML, Pesántez D, Porras JA, Portillo J, Reig L, Riera‐Mestre A, Rivas A, Rodríguez‐Cobo A, Rodríguez‐Matute C, Rogado J, Rosa V, Rubio CM, Ruiz‐Artacho P, Ruiz‐Giménez N, Ruiz‐Ruiz J, Ruiz‐Sada P, Sahuquillo JC, Salgueiro G, Sampériz A, Sánchez‐Muñoz‐Torrero JF, Sancho T, Sigüenza P, Sirisi M, Soler S, Suárez S, Suriñach JM, Tiberio G, Torres MI, Tolosa C, Trujillo‐Santos J, Uresandi F, Usandizaga E, Valle R, Vela JR, Vidal G, Vilar C, Villares P, Zamora C, Gutiérrez P, Vázquez FJ, Vanassche T, Vandenbriele C, Verhamme P, Hirmerova J, Malý R, Salgado E, Benzidia I, Bertoletti L, Bura‐Riviere A, Crichi B, Debourdeau P, Espitia O, Farge‐Bancel D, Helfer H, Mahé I, Moustafa F, Poenou G, Schellong S, Braester A, Brenner B, Tzoran I, Amitrano M, Bilora F, Bortoluzzi C, Brandolin B, Ciammaichella M, Colaizzo D, Dentali F, Di Micco P, Giammarino E, Grandone E, Mangiacapra S, Mastroiacovo D, Maida R, Mumoli N, Pace F, Pesavento R, Pomero F, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tufano A, Visonà A, Vo Hong N, Zalunardo B, Kalejs RV, Maķe K, Ferreira M, Fonseca S, Martins F, Meireles J, Bosevski M, Zdraveska M, Mazzolai L, Caprini JA, Tafur AJ, Weinberg I, Wilkins H, Bui HM. Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study. J Thromb Haemost 2021; 19:408-416. [PMID: 33119949 DOI: 10.1111/jth.15146] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 06/02/2020] [Revised: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 01/16/2023]
Abstract
AIMS Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation. METHODS AND RESULTS We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24). CONCLUSION In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - David Jimenez
- Respiratory Department Hospital Ramón y Cajal and Medicine Department Universidad de Alcalá (IRYCIS) Madrid Spain
| | - Helia Robert‐Ebadi
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Jorge Del Toro
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | | | - Conxita Falga
- Department of Internal Medicine Hospital de Mataro Barcelona Spain
| | - Andris Skride
- Department of Cardiology Ospedale Pauls Stradins Clinical University Hospital Riga Latvia
| | - Llorenç Font
- Department of Haematology Hospital de Tortosa Verge de la Cinta Tarragona Spain
| | | | - Henri Bounameaux
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Manuel Monreal
- Department of Internal Medicine Hospital Germans Trias i Pujol Badalona Spain
- Universidad Catolica de Murcia Murcia Spain
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Majmudar K, Golemi I, Tafur AJ, Toro JD, Visonà A, Falgá C, Sahuquillo JC, Lorente MA, Tufano A, Weinberg I, Di Micco P, Monreal M. Outcomes after venous thromboembolism in patients with gastric cancer: Analysis of the RIETE Registry. Vasc Med 2020; 25:210-217. [PMID: 32000631 DOI: 10.1177/1358863x19893432] [Citation(s) in RCA: 4] [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] [Indexed: 12/12/2022]
Abstract
Gastric cancer is the fifth most common malignancy worldwide. Venous thromboembolism is an independent predictor of death among patients with gastric cancer. We aimed to describe the factors associated with mortality, thrombosis recurrence, and bleeding complications in patients with gastric cancer who develop venous thromboembolism. We included 612 patients with gastric cancer and venous thromboembolism in the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry from 2001 to 2018. We used Cox proportional hazard ratios and a Fine-Gray model to define factors associated with outcomes. The overall mortality at 6 months was 44.4%. Factors associated with increased 6-month mortality included immobility (HR 1.8, 95% CI 1.3-2.4; p < 0.001), anemia (HR 1.4, 95% CI 1.1-1.8; p < 0.02), and leukocytosis (HR 1.8, 95% CI 1.4-2.3; p < 0.001). Recurrent thrombosis occurred in 6.5% of patients and major bleeding complications in 8.5% of the cohort. Male sex was the main factor associated with thrombosis recurrence (HR 2.1, 95% CI 1.1-4.0; p < 0.02) and hemoglobin below 10 g/dL (HR 1.6, 95% CI 1.05-2.50; p = 0.03) the main factor associated with bleeding. In conclusion, patients with gastric cancer who develop venous thrombosis have a very high likelihood of death. Low hemoglobin in this population is associated with poor outcomes.
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Affiliation(s)
- Kaushal Majmudar
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Iva Golemi
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alfonso J Tafur
- Department of Medicine, Division of Vascular Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | | | | | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Ido Weinberg
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pierpaolo Di Micco
- Department of Medicine, UOC Medicina, Fatebenefratelli Hospital of Napoli, Italy
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Barcelona, Spain
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Murgier M, Bertoletti L, Darmon M, Zeni F, Valle R, Del Toro J, Llamas P, Mazzolai L, Villalobos A, Monreal M. Frequency and prognostic impact of acute kidney injury in patients with acute pulmonary embolism. Data from the RIETE registry. Int J Cardiol 2019; 291:121-126. [DOI: 10.1016/j.ijcard.2019.04.083] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/07/2019] [Accepted: 04/26/2019] [Indexed: 11/29/2022]
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Riera-Mestre A, Mora-Luján JM, Trujillo-Santos J, Del Toro J, Nieto JA, Pedrajas JM, López-Reyes R, Soler S, Ballaz A, Cerdà P, Monreal M. Natural history of patients with venous thromboembolism and hereditary hemorrhagic telangiectasia. Findings from the RIETE registry. Orphanet J Rare Dis 2019; 14:196. [PMID: 31399146 PMCID: PMC6688272 DOI: 10.1186/s13023-019-1172-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background Limited data exist about the clinical presentation, ideal therapy and outcomes of patients with hereditary hemorrhagic telangiectasia (HHT) who develop venous thromboembolism (VTE). Methods We used the data in the RIETE Registry to assess the clinical characteristics, therapeutic approaches and clinical outcomes during the course of anticoagulant therapy in patients with HHT according to initial presentation as pulmonary embolism (PE) or deep venous thrombosis (DVT). Results Of 51,375 patients with acute VTE enrolled in RIETE from February 2009 to January 2019, 23 (0.04%) had HHT: 14 (61%) initially presented with PE and 9 (39%) with DVT alone. Almost half (47.8%) of the patients with VTE had a risk factor for VTE. Most PE and DVT patients received low-molecular-weight heparin for initial (71 and 100%, respectively) and long-term therapy (54 and 67%, respectively). During anticoagulation for VTE, the rate of bleeding events (major 2, non-major 6) far outweighed the rate of VTE recurrences (recurrent DVT 1): 50.1 bleeds per 100 patient-years (95%CI: 21.6-98.7) vs. 6.26 recurrences (95%CI: 0.31–30.9; p = 0.020). One major and three non-major bleeding were epistaxis. No patient died of bleeding. One patient died shortly after being diagnosed with acute PE. Conclusions During anticoagulation for VTE in HHT patients, there were more bleeding events than VTE recurrences. Most bleeding episodes were non-major epistaxis.
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Affiliation(s)
- Antoni Riera-Mestre
- HHT Unit and VTE Unit, Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), C/ Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain. .,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
| | - José María Mora-Luján
- HHT Unit and VTE Unit, Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), C/ Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Cartagena, Universidad Católica de Murcia, Murcia, Spain
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Antonio Nieto
- Department of Internal Medicine, Hospital General Virgen De La Luz, Cuenca, Spain
| | | | - Raquel López-Reyes
- Department of Pneumonology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Silvia Soler
- Department of Internal Medicine, Fundació Hospital d'Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - Aitor Ballaz
- Department of Pneumonology, Hospital De Galdakao, Galdakao, Vizcaya, Spain
| | - Pau Cerdà
- HHT Unit and VTE Unit, Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), C/ Feixa Llarga s/n. L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Manel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol Badalona, Barcelona, Universidad Autónoma de Barcelona, Barcelona, Spain
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7
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Grandone E, Di Micco P, Villani M, Colaizzo D, Fernández-Capitán C, Del Toro J, Rosa V, Bura-Riviere A, Quere I, Blanco-Molina Á, Margaglione M, Monreal M. Venous Thromboembolism in Women Undergoing Assisted Reproductive Technologies: Data from the RIETE Registry. Thromb Haemost 2018; 118:1962-1968. [DOI: 10.1055/s-0038-1673402] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AbstractVenous thromboembolism (VTE) during or after assisted reproductive technologies (ART) is predicted to rise due to the increased number of women undergoing this technique. We present data collected in the RIETE registry up to October 2016. Overall, 41 (0.6%) out of 6,718 women of childbearing age with VTE had an ART-related event. Most of them underwent autologous ART cycles; 23 had isolated deep vein thrombosis (DVT) (56.1%), 12 isolated pulmonary embolism (PE) (29.3%) and 6 simultaneous occurrence of both the events (14.6%). VTE occurred in 20 successful and 21 unsuccessful (i.e. not resulting in a clinical pregnancy) ART cycles. No recurrence was observed at 90 days. Logistic regression showed that isolated PE was significantly more frequent than DVT alone or combined with PE in unsuccessful in vitro fertilization (IVF) (odds ratio [OR]: 4.13, 95% confidence interval [CI]: 1.4–12.4), as well as in contraceptive users (OR: 2.96, 95% CI: 1.95–4.5) and in puerperium (OR: 1.96, 95% CI: 1.16–3.3). After grouping isolated PE and DVT + PE, we found that PE was significantly more frequent in women with unsuccessful IVF and higher body mass index (OR: 5.0, 95% CI: 1.2–20.7 and OR: 1.0, 95%CI: 1.0–1.1, respectively). These data document a higher risk of PE in unsuccessful cycles than in successful ones. The risk is higher than that observed during pregnancy, puerperium and contraception.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, I.R.C.C.S. Casa Sollievo della Sofferenza, S. Giovanni Rotondo, Italy
| | - Pier Di Micco
- Department of Internal Medicine, Ospedale Fatebenefratelli, Napoli, Italy
| | - Michela Villani
- Thrombosis and Haemostasis Unit, I.R.C.C.S. Casa Sollievo della Sofferenza, S. Giovanni Rotondo, Italy
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. Casa Sollievo della Sofferenza, S. Giovanni Rotondo, Italy
| | | | - Jorge Del Toro
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | - Vladimir Rosa
- Department of Internal Medicine, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - Isabelle Quere
- Department of Vascular Medicine, Hôpital Saint Eloi, Montpellier, France
| | | | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitario Germans Trias i Pujol de Badalona, Universidad Católica de Murcia, Barcelona, Spain
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Jiménez D, Bikdeli B, Barrios D, Quezada A, Del Toro J, Vidal G, Mahé I, Quere I, Loring M, Yusen RD, Monreal M. Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol 2018; 269:327-333. [PMID: 30025658 DOI: 10.1016/j.ijcard.2018.07.059] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [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: 02/03/2018] [Revised: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limited information exists about the epidemiology, management and outcomes of hemodynamically unstable patients with acute pulmonary embolism (PE). We aimed to evaluate the prevalence and outcomes of unstable PE, and to assess the acute management in routine clinical practice. METHODS This study included 34,380 patients from the RIETE registry with PE between 2001 and 2016. Primary outcomes included all-cause and PE-specific 30-day mortality. We used multivariable adjustments to calculate hazard ratios among unstable patients who did and did not receive reperfusion. RESULTS Overall, 1207 patients (3.5%) presented with hemodynamic instability. All-cause 30-day mortality was 14% and 5.4% in those with versus those without hemodynamic instability (P < 0.001). Two hundred and thirty eight (20%) unstable patients received reperfusion therapy. After multivariable adjustment, reperfusion therapy was associated with non-significantly reduced 30-day all-cause mortality (hazard ratio [HR] 0.71; 95% CI, 0.45 to 1.10; P = 0.12), and significantly reduced 30-day PE-related mortality (HR 0.56; 95% CI, 0.31 to 0.99; P = 0.04). When limiting the adjusted analyses to unstable patients with right ventricular dysfunction, the difference was significant for both all-cause (HR 0.65; 95% CI, 0.42 to 1.00; P = 0.05) and PE-related mortality (HR 0.52; 95% CI, 0.30 to 0.92; P = 0.02). CONCLUSIONS In a multinational registry of patients with PE, prevalence of hemodynamic instability was 3.5%, with high associated 30-day mortality rates. Although use of reperfusion was associated with lower mortality rates, particularly in patients with right ventricular dysfunction, it was used in only a fifth of patients.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain.
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, NY, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Andrés Quezada
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gemma Vidal
- Department of Internal Medicine, Corporación Sanitaria Parc Taulí, Barcelona, Spain
| | - Isabelle Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, France
| | - Isabelle Quere
- Department of Vascular Medicine, Hôpital Saint Eloi, Montpellier, France
| | - Mónica Loring
- Department of Internal Medicine, Hospital Comarcal de Axarquía, Málaga, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Católica de Murcia, Murcia, Spain
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9
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Tafur AJ, Caprini JA, Cote L, Trujillo-Santos J, Del Toro J, Garcia-Bragado F, Tolosa C, Barillari G, Visona A, Monreal M. Predictors of active cancer thromboembolic outcomes. RIETE experience of the Khorana score in cancer-associated thrombosis. Thromb Haemost 2017; 117:1192-1198. [PMID: 28276571 DOI: 10.1160/th16-11-0840] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 11/07/2016] [Accepted: 02/23/2017] [Indexed: 12/14/2022]
Abstract
Even though the Khorana risk score (KRS) has been validated to predict against the development of VTE among patients with cancer, it has a low positive predictive value. It is also unknown whether the score predicts outcomes in patients with cancer with established VTE. We selected a cohort of patients with active cancer from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry to assess the prognostic value of the KRS at inception in predicting the likelihood of VTE recurrences, major bleeding and mortality during the course of anticoagulant therapy. We analysed 7948 consecutive patients with cancer-associated VTE. Of these, 2253 (28 %) scored 0 points, 4550 (57 %) 1-2 points and 1145 (14 %) scored ≥3 points. During the course of anticoagulation, amongst patient with low, moderate and high risk KRS, the rate of VTE recurrences was of 6.21 (95 %CI: 4.99-7.63), 11.2 (95 %CI: 9.91-12.7) and 19.4 (95 %CI: 15.4-24.1) events per 100 patient-years; the rate of major bleeding of 5.24 (95 %CI: 4.13-6.56), 10.3 (95 %CI: 9.02-11.7) and 19.4 (95 %CI: 15.4-24.1) bleeds per 100 patient-years and the mortality rate of 25.3 (95 %CI: 22.8-28.0), 58.5 (95 %CI: 55.5-61.7) and 120 (95 %CI: 110-131) deaths per 100 patient-years, respectively. The C-statistic was 0.53 (0.50-0.56) for recurrent VTE, 0.56 (95 %CI: 0.54-0.59) for major bleeding and 0.54 (95 %CI: 0.52-0.56) for death. In conclusion, most VTEs occur in patients with low or moderate risk scores. The KRS did not accurately predict VTE recurrence, major bleeding, or mortality among patients with cancer-associated thrombosis.
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Affiliation(s)
- Alfonso J Tafur
- Alfonso J. Tafur, MD, NorthShore University HealthSystem, 9650 Gross Point Road, Suite 4900, Skokie, IL 60076, USA, Tel.: +1 847 663 8050, Fax: +1 224 251 4407, E-mail:
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Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, López-Jiménez L, Farge-Bancel D, Yusen R, Monreal M. Right heart thrombi in pulmonary embolism. Eur Respir J 2016; 48:1377-1385. [PMID: 27799388 DOI: 10.1183/13993003.01044-2016] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/19/2016] [Indexed: 01/01/2023]
Abstract
There is a lack of comprehensive data on the prevalence, predictors and prognostic significance of right heart thrombi (RHT) in pulmonary embolism.In this study of patients with pulmonary embolism from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry, we assessed the prevalence and predictors of RHT, and the association between the presence of RHT and the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrences, and major bleeding through 30 days after initiation of pulmonary embolism treatment.Of 12 441 patients with pulmonary embolism and baseline echocardiographic data, 2.6% had RHT. The following increased the risk of RHT: younger age, previous bleeding, congestive heart failure, cancer, syncope, systolic blood pressure <100 mmHg, and arterial oxyhaemoglobin saturation <90%. Patients with RHT were significantly more likely to die from any cause (adjusted OR 2.50 (95% CI 1.62-3.84); p<0.001) and from pulmonary embolism (adjusted OR 4.29 (95% CI 2.45-7.48); p<0.001) during follow-up. RHT was associated with an increased risk of recurrence during follow-up (1.8% versus 0.7%; p=0.04). Major bleeding was similar in patients with and without RHT.In patients presenting with pulmonary embolism, RHT is relatively infrequent. Patients with RHT had a worse outcome when compared with those without RHT.
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Affiliation(s)
- Deisy Barrios
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain.,Both authors contributed equally to the manuscript
| | - Vladimir Rosa-Salazar
- Dept of Internal Medicine, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain.,Both authors contributed equally to the manuscript
| | - David Jiménez
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Jorge Del Toro
- Dept of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Roger Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Manuel Monreal
- Dept of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Universidad Católica de Murcia, Spain
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Trujillo-Santos J, Lozano F, Lorente MA, Adarraga D, Hirmerova J, Del Toro J, Mazzolai L, Barillari G, Barrón M, Monreal M, Alcalde M, Andújar V, Arcelus J, Barba R, Barrón M, Barrón-Andrés B, Bascuñana J, Blanco-Molina A, Bueso T, Casado I, Climent A, Conget F, del Molino F, del Toro J, Falgá C, Fernández-Capitán C, Font L, Gallego P, García-Bragado F, Gómez V, González J, González-Bachs E, Grau E, Guijarro R, Guil M, Gutiérrez J, Jara-Palomares L, Jaras M, Jiménez D, Jiménez R, Lecumberri R, Lobo J, López-Jiménez L, López-Montes L, López-Reyes R, López-Sáez J, Lorente M, Lorenzo A, Luque J, Madridano O, Marchena P, Martín-Antorán J, Mellado M, Monreal M, Morales M, Nauffal D, Nieto J, Núñez M, Ogea J, Otero R, Pagán B, Pedrajas J, Pérez-Rus G, Peris M, Porras J, Pons I, Riera-Mestre A, Rivas A, Rodríguez-Dávila M, Román P, Rosa V, Ruiz-Giménez N, Ruiz J, Sabio P, Samperiz A, Sánchez R, Soler S, Suriñach J, Tiberio G, Trujillo-Santos J, Uresandi F, Valero B, Valle R, Vela J, Villalobos A, Malfante P, Verhamme P, Peerlinck K, Wells P, Malý R, Hirmerova J, Kaletova M, Tomko T, Bertoletti L, Bura-Riviere A, Farès M, Grange C, Mahe I, Merah A, Quere I, Schellong S, Papadakis M, Braester A, Brenner B, Tzoran I, Zeltser D, Apollonio A, Barillari G, Ciammaichella M, Di Micco P, Duce R, Guida A, Maida R, Pace F, Pasca S, Piovella C, Pesavento R, Poggio R, Prandoni P, Rota L, Tiraferri E, Tonello D, Tufano A, Visonà A, Zalunardo B, Almeida S, Leal-Seabra F, Sousa M, Bosevski M, Alatri A, Bounameaux H, Calanca L, Mazzolai L, Serrano J. A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the lower limbs. Am J Med 2015; 128:90.e9-15. [PMID: 25242230 DOI: 10.1016/j.amjmed.2014.08.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 08/05/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND No prior studies have identified which patients with deep vein thrombosis in the lower limbs are at a low risk for adverse events within the first week of therapy. METHODS We used data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) to identify patients at low risk for the composite outcome of pulmonary embolism, major bleeding, or death within the first week. We built a prognostic score and compared it with the decision to treat patients at home. RESULTS As of December 2013, 15,280 outpatients with deep vein thrombosis had been enrolled. Overall, 5164 patients (34%) were treated at home. Of these, 12 (0.23%) had pulmonary embolism, 8 (0.15%) bled, and 4 (0.08%) died. On multivariable analysis, chronic heart failure, recent immobility, recent bleeding, cancer, renal insufficiency, and abnormal platelet count independently predicted the risk for the composite outcome. Among 11,430 patients (75%) considered to be at low risk, 15 (0.13%) suffered pulmonary embolism, 22 (0.19%) bled, and 8 (0.07%) died. The C-statistic was 0.61 (95% confidence interval [CI], 0.57-0.65) for the decision to treat patients at home and 0.76 (95% CI, 0.72-0.79) for the score (P = .003). Net reclassification improvement was 41% (P < .001). Integrated discrimination improvement was 0.034 for the score and 0.015 for the clinical decision (P < .001). CONCLUSIONS Using 6 easily available variables, we identified outpatients with deep vein thrombosis at low risk for adverse events within the first week. These data may help to safely treat more patients at home. This score, however, should be validated.
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Affiliation(s)
- Javier Trujillo-Santos
- Department of Internal Medicine, Complejo Hospitalario Universitario de Cartagena, Murcia, Spain
| | - Francisco Lozano
- Department of Angiology and Vascular Surgery, Complejo Asistencial de Salamanca, Salamanca, Spain
| | - Manuel Alejandro Lorente
- Department of Internal Medicine, Hospital de la Agencia Valenciana de Salud Vega Baja, Alicante, Spain
| | - Dolores Adarraga
- Department of Internal Medicine, Hospital de Montilla, Córdoba, Spain
| | - Jana Hirmerova
- Department of Internal Medicine, University Hospital Plzen, Plzen, Czech Republic
| | - Jorge Del Toro
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lucia Mazzolai
- Department of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Giovanni Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - Manuel Barrón
- Department of Pneumonology, Hospital San Pedro, Logroño, La Rioja, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
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Lecumberri R, Soler S, Del Toro J, Barba R, Rosa V, Ciammaichella MM, Monreal M. Effect of the time of diagnosis on outcome in patients with acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2010; 105:45-51. [PMID: 20886195 DOI: 10.1160/th10-07-0480] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 09/23/2010] [Indexed: 11/05/2022]
Abstract
The influence of the day of diagnosis (weekends vs. weekdays) on outcome in patients with acute venous thromboembolism (VTE) has not been thoroughly studied. We used the RIETE database to compare the clinical characteristics, treatment details, and mortality rate at 7 and 30 days, of all patients diagnosed with acute VTE on weekends versus those diagnosed on weekdays. Up to January 2010, 30,394 patients were included in RIETE, of whom 5,479 (18%) were diagnosed on weekends. Most clinical characteristics were similar in both groups, but patients diagnosed on weekends had less often cancer (20% vs. 22%; p=0.004), and presented more likely with pulmonary embolism (PE) than those diagnosed on weekdays (52% vs. 47%; p <0.001). Most patients in both groups received initial therapy with low-molecular-weight heparin (90% and 91%, respectively; p=0.01), then switched to vitamin K antagonists (72% and 71%, respectively; p=0.007). The 7-day mortality rate in patients presenting with PE was 2.75% in those diagnosed on weekends versus 3.00% in those diagnosed on weekdays (p=0.49). At 30 days, the mortality rate was 6.51% versus 6.06%, respectively (p=0.38). In patients presenting with deep vein thrombosis alone, the 7-day mortality rate in those diagnosed on weekends was 1.04% versuss 0.66% in those diagnosed on weekdays (p=0.053). The mortality rate at 30 days was of 3.41% versus 2.88% (p=0.14), respectively. In RIETE, the clinical characteristics, treatment strategies, and 7- and 30-day mortality rates of patients diagnosed on weekends were similar to those in patients diagnosed on weekdays.
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Affiliation(s)
- Ramón Lecumberri
- Department of Haematology, Clinica Universitaria de Navarra, Pamlona, Navarra, Spain
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