1
|
Lian Y, Li J, Liang W, Zhong M. Comparison and Validation of Different Risk Assessment Models in Patients with Venous Thromboembolism During Pregnancy and Postpartum: A Retrospective Study in China. Int J Gen Med 2023; 16:95-106. [PMID: 36644567 PMCID: PMC9833322 DOI: 10.2147/ijgm.s391005] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/16/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction Venous thromboembolism (VTE) causes maternal mortality and morbidity. This study compares the predictive performance of three risk assessment models (Caprini model, Wells Score, and RCOG model) for VTE risk in Chinese patients during pregnancy and postpartum. Materials and Methods We conducted a retrospective study in Nanfang Hospital of Southern Medical University and the Third Affiliated Hospital of Guangzhou Medical University from January 2003 to January 2022. Patients were risk-classified using the three risk assessment models, and the models were evaluated for accuracy. Results A total of 302 patients with confirmed VTE during pregnancy and postpartum were identified. Of these, 142 (47.0%) were diagnosed during pregnancy and 160 (53.0%) postpartum. A total of 276 (91.4%) patients had DVT only, 14 (4.6%) had PE only, and 12 (4.0%) were diagnosed with both. Of the 142 antepartum patients, 140 were categorized at moderate or above-risk levels by the Caprini model, 134 in the Wells Score model, and 112 in the RCOG model, respectively. The number of postpartum patients at moderate or above-risk levels identified by the Caprini, Wells Score, and RCOG models were 160, 152, and 118. The Caprini model significantly stratified VTE patients into a moderate or high-risk level (p < 0.05, Friedman Test). The Caprini model was also more effective at assessing the risk of VTE among postpartum patients than antepartum patients (p < 0.05, Friedman Test). Conclusion We have demonstrated that the Caprini model is an effective prediction tool for the maternal population during peripartum, especially in the postpartum period. Results from the Caprini model will help obstetricians or physicians stratify potential risk patients and guide prophylaxis decisions. The RCOG model was not particularly useful in Chinese VTE patients during pregnancy and postpartum. Multicenter prospective validations of the RCOG model in Chinese maternal populations are needed.
Collapse
Affiliation(s)
- Yanqin Lian
- Department of Operating Room, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jia Li
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Weizhang Liang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China,Correspondence: Weizhang Liang, Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, No. 63 Duobao Road, Guangzhou, Guangdong Province, 510515, People’s Republic of China, Tel +86 20 81292539, Email
| | - Mei Zhong
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China,Mei Zhong, Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong Province, 510515, People’s Republic of China, Tel +86 20 61641901, Email
| |
Collapse
|
2
|
Lili X, Shunlan D, Lixu J. Predictive Model for Pulmonary Embolism in Pregnant and Postpartum Women: A 10-Year Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231209930. [PMID: 37908100 PMCID: PMC10621299 DOI: 10.1177/10760296231209930] [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: 07/26/2023] [Revised: 09/09/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023] Open
Abstract
Background: Pulmonary embolism (PE) in pregnant and postpartum women is fatal, and risk assessment is crucial for effective and safe management, the aim of this retrospective study was to establish a nomogram for predicting the risk of PE in pregnant and postpartum women. Methods: Totally 343 subjects suspected of PE at the Obstetrics Department of Affiliated Dongyang Hospital of Wenzhou Medical University from January 2012 to December 2021 were retrospective analyzed in our study. Pregnant women suspected of PE and who underwent computed tomographic pulmonary angiography examination were included in the study. The least absolute shrinkage and selection operator regression technique was used to select the best prediction features, and multivariate logistic regression is used to build the prediction model. Bootstrap resampling 1000 times was used to validate the model visualized by nomogram. Evaluate the performance of the model from three aspects: identification, calibration and clinical utility. Results: Our predictive model indicated that chest tightness, anhelation, lactate, and D-dimer were associated with PE. The area under the receiver operating characteristic curve of the model was 0.836 (95% CI: [0.770-0.902]), indicating that our model had a good differential diagnostic performance. Good consistency between prediction and real observation was presented as the calibration curve. Decision curve analysis indicated that our model had a good net clinical benefit. Conclusions: We developed a novel numerical model for selecting risk factors for PE in pregnant and postpartum women. Our results may help obstetricians and gynaecologists to develop individualized treatment plans and PE prevention strategies.
Collapse
Affiliation(s)
- Xu Lili
- Department of Obstetrics, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| | - Du Shunlan
- Department of Obstetrics, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| | - Jin Lixu
- Department of Obstetrics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
3
|
Nikvarz N, Seyedi Z. Improved utilisation of venous thromboembolism prophylaxis in renal-impaired patients following a clinical pharmacist intervention. Eur J Hosp Pharm 2022; 29:40-43. [PMID: 34930793 PMCID: PMC8717764 DOI: 10.1136/ejhpharm-2019-002030] [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: 07/02/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To evaluate the role of the clinical pharmacist in improving venous thromboembolism (VTE) prophylaxis prescription in patients with renal impairment (RI). METHODS This was an interventional cross-sectional study conducted in a nephrology ward. Patients' risk scores for VTE and bleeding during hospitalisation (evaluated by the Caprini Risk Assessment Model (RAM), Padua Prediction Score and IMPROVE Bleeding Risk Score, respectively), and the rate of VTE prophylaxis administration to patients, were evaluated before and after a clinical pharmacist's intervention. RESULTS In the pre-intervention phase, 34.8% of high-VTE-risk patients, of whom 12.5% were also at high risk of bleeding, received pharmacological prophylaxis. Moreover, 22.2% of low-VTE-risk patients received prophylaxis. In the intervention phase, prophylaxis was administered to all high-risk patients (mechanical prophylaxis in 7% of patients with a high risk of both VTE and bleeding, and heparin in the remainder) and to 3.3% of those at low risk of VTE. CONCLUSIONS The clinical pharmacist's intervention using RAMs can improve the rate of thrombosis prophylaxis prescription in patients with RI who have a high risk of VTE.
Collapse
Affiliation(s)
- Naemeh Nikvarz
- Herbal and Traditional Medicines Research Center and Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kerman University of Medical Sciences, Kerman, Iran (the Islamic Republic of)
| | - Zahra Seyedi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kerman University of Medical Sciences, Kerman, Iran (the Islamic Republic of)
| |
Collapse
|
4
|
Gervaso L, Dave H, Khorana AA. Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:173-190. [PMID: 34396323 PMCID: PMC8352228 DOI: 10.1016/j.jaccao.2021.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.
Collapse
Key Words
- ASCO, American Society of Clinical Oncology
- ASH, American Society of Hematology
- AT, antithrombin
- ATE, arterial thromboembolism
- CAT, cancer-associated thrombosis
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- CVA, cerebrovascular event
- DOAC, direct oral anticoagulant
- DVT, deep venous thrombosis
- ESMO, European Society of Medical Oncology
- GI, gastrointestinal
- HR, hazard ratio
- ICH, intracranial hemorrhage
- ISTH, International Society on Thrombosis and Haemostasis
- KS, Khorana score
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- MM, multiple myeloma
- NNT, number needed to treat
- PE, pulmonary embolism
- PPV, positive predictive value
- RAM, risk assessment model
- SPE, segmental pulmonary embolism
- SSC, Scientific and Standardization Committee
- SSPE, subsegmental pulmonary embolism
- UHF, unfractionated heparin
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- VVT, visceral vein thrombosis
- arterial thromboembolism
- cancer-associated thrombosis
- prophylaxis
- risk assessment models
- treatment
- venous thromboembolism
Collapse
Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, Istituto Europeo di Oncologia, European Institute of Oncology, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Heloni Dave
- Maharaja Sayajirao University, Medical College, Vadodara, Gujarat, India
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Obura MO, van Valkengoed IG, Rutters F, 't Hart LM, Rauh SP, Moll van Charante EP, Snijder MB, Beulens JWJ. Performance of Risk Assessment Models for Prevalent or Undiagnosed Type 2 Diabetes Mellitus in a Multi-Ethnic Population-The Helius Study. Glob Heart 2021; 16:13. [PMID: 33598393 DOI: 10.5334/gh.846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Most risk assessment models for type 2 diabetes (T2DM) have been developed in Caucasians and Asians; little is known about their performance in other ethnic groups. Objective(s): We aimed to identify existing models for the risk of prevalent or undiagnosed T2DM and externally validate them in a multi-ethnic population currently living in the Netherlands. Methods: A literature search to identify risk assessment models for prevalent or undiagnosed T2DM was performed in PubMed until December 2017. We validated these models in 4,547 Dutch, 3,035 South Asian Surinamese, 4,119 African Surinamese, 2,326 Ghanaian, 3,598 Turkish, and 3,894 Moroccan origin participants from the HELIUS (Healthy LIfe in an Urban Setting) cohort study performed in Amsterdam. Model performance was assessed in terms of discrimination (C-statistic) and calibration (Hosmer-Lemeshow test). We identified 25 studies containing 29 models for prevalent or undiagnosed T2DM. C-statistics varied between 0.77–0.92 in Dutch, 0.66–0.83 in South Asian Surinamese, 0.70–0.82 in African Surinamese, 0.61–0.81 in Ghanaian, 0.69–0.86 in Turkish, and 0.69–0.87 in the Moroccan populations. The C-statistics were generally lower among the South Asian Surinamese, African Surinamese, and Ghanaian populations and highest among the Dutch. Calibration was poor (Hosmer-Lemeshow p < 0.05) for all models except one. Conclusions: Generally, risk models for prevalent or undiagnosed T2DM show moderate to good discriminatory ability in different ethnic populations living in the Netherlands, but poor calibration. Therefore, these models should be recalibrated before use in clinical practice and should be adapted to the situation of the population they are intended to be used in.
Collapse
|
6
|
Saoud R, Heidar NA, Cimadamore A, Paner GP. Incorporating Prognostic Biomarkers into Risk Assessment Models and TNM Staging for Prostate Cancer. Cells 2020; 9:E2116. [PMID: 32957584 PMCID: PMC7564222 DOI: 10.3390/cells9092116] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023] Open
Abstract
In current practice, prostate cancer staging alone is not sufficient to adequately assess the patient's prognosis and plan the management strategies. Multiple clinicopathological parameters and risk tools for prostate cancer have been developed over the past decades to better characterize the disease and provide an enhanced assessment of prognosis. Herein, we review novel prognostic biomarkers and their integration into risk assessment models for prostate cancer focusing on their capability to help avoid unnecessary imaging studies, biopsies and diagnosis of low risk prostate cancers, to help in the decision-making process between active surveillance and treatment intervention, and to predict recurrence after radical prostatectomy. There is an imperative need of reliable biomarkers to stratify prostate cancer patients that may benefit from different management approaches. The integration of biomarkers panel with risk assessment models appears to improve prostate cancer diagnosis and management. However, integration of novel genomic biomarkers in future prognostic models requires further validation in their clinical efficacy, standardization, and cost-effectiveness in routine application.
Collapse
Affiliation(s)
- Ragheed Saoud
- Department of Surgery (Section of Urology), University of Chicago, Chicago, IL 60637, USA;
| | - Nassib Abou Heidar
- Department of Surgery (Division of Urology), American University of Beirut Medical Center, Beirut 11-0236, Lebanon;
| | - Alessia Cimadamore
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, 60126 Ancona, Italy;
| | - Gladell P. Paner
- Department of Surgery (Section of Urology), University of Chicago, Chicago, IL 60637, USA;
- Department of Pathology, University of Chicago, Chicago, IL 60637, USA
| |
Collapse
|
7
|
Dimakakos E, Kotteas E, Gomatou G, Katsarou T, Vlahakos V, Vathiotis I, Talagani S, Dimitroulis I, Syrigos K. Do we need prophylactic anticoagulation in ambulatory patients with lung cancer? A review. Vasc Med 2020; 25:255-262. [PMID: 32146869 DOI: 10.1177/1358863x19899160] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous thromboembolism is a common complication of malignancy. Lung cancer is considered one of the most thrombogenic cancer types. Primary thromboprophylaxis is not currently recommended for all ambulatory patients with active cancer. In the present narrative review we aim to summarize recent data on the safety and efficacy of primary thromboprophylaxis as well as on venous thromboembolism risk assessment, focusing on ambulatory patients with lung cancer. A potential benefit from prophylactic anticoagulation with low molecular weight heparins in terms of venous thromboembolism risk reduction and increased overall survival in patients with lung cancer, without a significant increase in bleeding risk, has been reported in several studies. Recent studies also reveal promising results of direct oral anticoagulants regarding their efficacy as primary thromboprophylaxis in patients with cancer, including those with lung cancer. However, the use of different study methodologies and the heterogeneity of study populations among the trials limit the extraction of definite results. More randomized, controlled trials, restricted to a well-characterized population of patients with lung cancer, are greatly anticipated. The use of risk assessment tools for stratification of venous thromboembolic risk is warranted. The development of an accurate and practical risk assessment model for patients with lung cancer represents an unmet need.
Collapse
Affiliation(s)
- Evangelos Dimakakos
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Elias Kotteas
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Georgia Gomatou
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Theodora Katsarou
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Vassilis Vlahakos
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Ioannis Vathiotis
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Sofia Talagani
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Ioannis Dimitroulis
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| | - Konstantinos Syrigos
- Oncology Unit, 3rd Department of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital for Chest Diseases, Athens, Greece
| |
Collapse
|
8
|
Fotiou D, Gavriatopoulou M, Terpos E. Multiple Myeloma and Thrombosis: Prophylaxis and Risk Prediction Tools. Cancers (Basel) 2020; 12:E191. [PMID: 31940972 DOI: 10.3390/cancers12010191] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022] Open
Abstract
Thromboembolism in multiple myeloma (MM) patients remains a common complication that renders the optimization of our thromboprophylaxis practice necessary. This review aims to make clear the need for the development of more accurate risk assessment tools and means of thrombosis prevention. Current clinical practice is guided by available guidelines published by the IMWG in 2014, but the extent to which these are implemented is unclear. Recently, several groups developed clinical scores for thrombosis risk in MM in an attempt to improve risk stratification, but these have not been validated or used in clinical practice so far. Research in this field is increasingly focusing on understanding the unique coagulation profile of the MM patient, and data on potential biomarkers that accurately reflect hypercoagulability is emerging. Finally, promising evidence on the effectiveness of direct oral anticoagulants (DOACs) in the context of thrombosis prevention in MM patients is increasingly becoming available. The critical appraisal of the above research areas will establish the necessity of combining disease-specific clinical risk factors with coagulation biomarkers to allow more effective risk stratification that will eventually lead to the reduction of this significant complication. Results from ongoing clinical trials on the role of DOACs are much anticipated.
Collapse
|
9
|
Riondino S, Ferroni P, Zanzotto FM, Roselli M, Guadagni F. Predicting VTE in Cancer Patients: Candidate Biomarkers and Risk Assessment Models. Cancers (Basel) 2019; 11:cancers11010095. [PMID: 30650562 PMCID: PMC6356247 DOI: 10.3390/cancers11010095] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/07/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
Risk prediction of chemotherapy-associated venous thromboembolism (VTE) is a compelling challenge in contemporary oncology, as VTE may result in treatment delays, impaired quality of life, and increased mortality. Current guidelines do not recommend thromboprophylaxis for primary prevention, but assessment of the patient's individual risk of VTE prior to chemotherapy is generally advocated. In recent years, efforts have been devoted to building accurate predictive tools for VTE risk assessment in cancer patients. This review focuses on candidate biomarkers and prediction models currently under investigation, considering their advantages and disadvantages, and discussing their diagnostic performance and potential pitfalls.
Collapse
Affiliation(s)
- Silvia Riondino
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Patrizia Ferroni
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Human Sciences & Quality of Life Promotion, San Raffaele Roma Open University, 00166 Rome, Italy.
| | - Fabio Massimo Zanzotto
- Department of Enterprise Engineering, University of Rome "Tor Vergata", 00133 Rome, Italy.
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Fiorella Guadagni
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Human Sciences & Quality of Life Promotion, San Raffaele Roma Open University, 00166 Rome, Italy.
| |
Collapse
|
10
|
Abstract
Acutelly-ill hospitalised medical patients are at risk of venous thromboembolism (VTE), both in-hospital and in the immediate post-discharge period, and mortality from VTE is thought to be particularly high in this patient population. However, despite previous mandates from international antithrombotic guidelines such as those of the American College of Chest Physicians (ACCP) for the "universal" use of thromboprophylaxis in hospitalised medical patients, global audits suggest that implementation of thromboprophylaxis continues to be challenging because of the perceived higher risk of bleeding and lower risk of VTE than that reported in clinical trials. Recent population-based studies also reveal that a "universal" hospital-only thromboprophylactic strategy does not reduce the community burden of VTE from this population, which may constitute nearly one quarter of the attributable risk of VTE. Lastly, four large randomised placebo-controlled trials of extended thromboprophylaxis have failed to show a definitive net clinical benefit in hospitalised medical patients. Recent large-scale efforts in deriving and validating scored VTE and bleed risk assessment models (RAMs) have been completed in the medically-ill population. In addition, an elevated D-dimer as a new biomarker to identify at-VTE risk medically ill patients has also undergone prospective evaluation. This paper will review current concepts of VTE and bleed risk in hospitalised medical patients, both in the hospital as well as the post-hospital discharge period, and will discuss new paradigms of thromboprophylaxis in this population using an individualised, patient-centered approach.
Collapse
Affiliation(s)
- Alex C Spyropoulos
- Alex C. Spyropoulos, MD, FACP, FCCP, FRCPC, Professor of Medicine - Hofstra Northwell School of Medicine, Professor - The Merinoff Center for Patient-Oriented Research, The Feinstein Institute for Medical Research, System Director - Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, 130 E 77th St, New York, NY 10075, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
| | | |
Collapse
|
11
|
Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin 2017; 67:93-99. [PMID: 28094848 DOI: 10.3322/caac.21388] [Citation(s) in RCA: 3263] [Impact Index Per Article: 466.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The American Joint Committee on Cancer (AJCC) staging manual has become the benchmark for classifying patients with cancer, defining prognosis, and determining the best treatment approaches. Many view the primary role of the tumor, lymph node, metastasis (TNM) system as that of a standardized classification system for evaluating cancer at a population level in terms of the extent of disease, both at initial presentation and after surgical treatment, and the overall impact of improvements in cancer treatment. The rapid evolution of knowledge in cancer biology and the discovery and validation of biologic factors that predict cancer outcome and response to treatment with better accuracy have led some cancer experts to question the utility of a TNM-based approach in clinical care at an individualized patient level. In the Eighth Edition of the AJCC Cancer Staging Manual, the goal of including relevant, nonanatomic (including molecular) factors has been foremost, although changes are made only when there is strong evidence for inclusion. The editorial board viewed this iteration as a proactive effort to continue to build the important bridge from a "population-based" to a more "personalized" approach to patient classification, one that forms the conceptual framework and foundation of cancer staging in the era of precision molecular oncology. The AJCC promulgates best staging practices through each new edition in an effort to provide cancer care providers with a powerful, knowledge-based resource for the battle against cancer. In this commentary, the authors highlight the overall organizational and structural changes as well as "what's new" in the Eighth Edition. It is hoped that this information will provide the reader with a better understanding of the rationale behind the aggregate proposed changes and the exciting developments in the upcoming edition. CA Cancer J Clin 2017;67:93-99. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Mahul B Amin
- Professor and Chairman, UTHSC Gerwin Chair for Cancer Research, Department of Pathology and Laboratory Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Frederick L Greene
- Medical Director, Cancer Data Services, Levine Cancer Institute, Charlotte, NC
| | - Stephen B Edge
- Vice President, Healthcare Outcomes and Policy, Department of Cancer Prevention and Control, Roswell Park Cancer Institute, Buffalo, NY
- Professor of Oncology, Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY
| | - Carolyn C Compton
- Chief Medical Officer, Complex Adaptive Systems Initiative, Arizona State University, Scottsdale, AZ
- Professor of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jeffrey E Gershenwald
- Professor of Surgery and Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Laura Meyer
- Eighth Edition Project Manager and Managing Editor, American Joint Committee on Cancer, Chicago, IL
| | - Donna M Gress
- Technical Specialist and Technical Editor, American Joint Committee on Cancer, Chicago, IL
| | - David R Byrd
- Section Chief of Surgical Oncology and Professor of Surgery, University of Washington, Seattle, WA
| | | |
Collapse
|
12
|
Rosenberg D, Eichorn A, Alarcon M, McCullagh L, McGinn T, Spyropoulos AC. External validation of the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) for medical patients in a tertiary health system. J Am Heart Assoc 2014; 3:e001152. [PMID: 25404191 PMCID: PMC4338701 DOI: 10.1161/jaha.114.001152] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hospitalized medical patients are at risk for venous thromboembolism (VTE). Universal application of pharmacological thromboprophylaxis has the potential to place a large number of patients at increased bleeding risk. In this study, we aimed to externally validate the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk assessment model in a hospitalized general medical population. Methods and Results We identified medical discharges that met the IMPROVE protocol. Cases were defined as hospital‐acquired VTE and confirmed by diagnostic study within 90 days of index hospitalization; matched controls were also identified. Risk factors for VTE were based on the IMPROVE risk assessment model (aged >60 years, prior VTE, intensive care unit or coronary care unit stay, lower limb paralysis, immobility, known thrombophilia, and cancer) and were measured and assessed. A total of 19 217 patients met the inclusion criteria. The overall VTE event rate was 0.7%. The IMPROVE risk assessment model identified 2 groups of the cohort by VTE incidence rate: The low‐risk group had a VTE event rate of 0.42 (95% CI 0.31 to 0.53), corresponding to a score of 0 to 2, and the at‐risk group had a VTE event rate of 1.29 (95% CI 1.01 to 1.57), corresponding to a score of ≥3. Low‐risk status for VTE encompassed 68% of the patient cohort. The area under the receiver operating characteristic curve was 0.702, which was in line with the derivation cohort findings. Conclusions The IMPROVE VTE risk assessment model validation cohort revealed good discrimination and calibration for both the overall VTE risk model and the identification of low‐risk and at‐risk medical patient groups, using a risk score of ≥3. More than two thirds of the entire cohort had a score ≤2.
Collapse
Affiliation(s)
- David Rosenberg
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Ann Eichorn
- Krasnoff Quality Management Institute, North Shore LIJ Health System, Manhasset, NY (A.E.)
| | - Mauricio Alarcon
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| | - Alex C Spyropoulos
- Department of Medicine, Hofstra North Shore LIJ School of Medicine, Manhasset, NY (D.R., M.A., L.M.C., T.M.G., A.C.S.)
| |
Collapse
|
13
|
Mahan CE, Liu Y, Turpie AG, Vu JT, Heddle N, Cook RJ, Dairkee U, Spyropoulos AC. External validation of a risk assessment model for venous thromboembolism in the hospitalised acutely-ill medical patient (VTE-VALOURR). Thromb Haemost 2014; 112:692-9. [PMID: 24990708 DOI: 10.1160/th14-03-0239] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [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: 03/17/2014] [Accepted: 04/30/2014] [Indexed: 11/05/2022]
Abstract
Venous thromboembolic (VTE) risk assessment remains an important issue in hospitalised, acutely-ill medical patients, and several VTE risk assessment models (RAM) have been proposed. The purpose of this large retrospective cohort study was to externally validate the IMPROVE RAM using a large database of three acute care hospitals. We studied 41,486 hospitalisations (28,744 unique patients) with 1,240 VTE hospitalisations (1,135 unique patients) in the VTE cohort and 40,246 VTE-free hospitalisations (27,609 unique patients) in the control cohort. After chart review, 139 unique VTE patients were identified and 278 randomly-selected matched patients in the control cohort. Seven independent VTE risk factors as part of the RAM in the derivation cohort were identified. In the validation cohort, the incidence of VTE was 0.20%; 95% confidence interval (CI) 0.18-0.22, 1.04%; 95%CI 0.88-1.25, and 4.15%; 95%CI 2.79-8.12 in the low, moderate, and high VTE risk groups, respectively, which compared to rates of 0.45%, 1.3%, and 4.74% in the three risk categories of the derivation cohort. For the derivation and validation cohorts, the total percentage of patients in low, moderate and high VTE risk occurred in 68.6% vs 63.3%, 24.8% vs 31.1%, and 6.5% vs 5.5%, respectively. Overall, the area under the receiver-operator characteristics curve for the validation cohort was 0.7731. In conclusion, the IMPROVE RAM can accurately identify medical patients at low, moderate, and high VTE risk. This will tailor future thromboprophylactic strategies in this population as well as identify particularly high VTE risk patients in whom multimodal or more intensive prophylaxis may be beneficial.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Alex C Spyropoulos
- Alex C Spyropoulos, MD, FACP, FCCP, FRCPC, Director - Anticoagulation Services and Clinical Thrombosis, North Shore-LIJ Health System at Lenox Hill Hospital, Professor of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
| |
Collapse
|
14
|
Thaler J, Ay C, Kaider A, Reitter EM, Haselböck J, Mannhalter C, Zielinski C, Marosi C, Pabinger I. Biomarkers predictive of venous thromboembolism in patients with newly diagnosed high-grade gliomas. Neuro Oncol 2014; 16:1645-51. [PMID: 24987133 DOI: 10.1093/neuonc/nou106] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [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: 11/13/2022] Open
Abstract
BACKGROUND High-grade gliomas (HGGs) are among the most prothrombotic of malignancies. METHODS We performed a prospective study to investigate 11 potential biomarkers for prediction of venous thromboembolism (VTE) in newly diagnosed HGG patients who had undergone a neurosurgical intervention. In addition, we tested 2 VTE risk assessment models (RAMs). The strongest predictors of VTE, which were identified by statistical forward selection, were used for the first RAM. The parameters used for the second RAM were both predictive of VTE and available in routine clinical practice. RESULTS One hundred forty-one HGG patients were included in this study, and 24 (17%) of them developed VTE during follow-up. An association with the risk of future VTE was found for the following parameters: leukocyte count, platelet count, sP-selectin, prothrombin-fragment 1 + 2, FVIII activity, and D-dimer. The first RAM included low platelet count (<25th percentile of the study population) and elevated sP-selectin (≥75th percentile). The cumulative VTE probability after 12 months was 9.7% for score 0 (n = 76), 18.9% for score 1 (n = 59), and 83.3% for score 2 (n = 6). The second RAM included low platelet count (<25th percentile), elevated leukocyte count, and elevated D-dimer (≥75th percentile). The probability of VTE was 3.3% for score 0 (n = 63), 23.0% for score 1 (n = 53), and 37.7% for score 2 (n = 22) or score 3 (n = 3). CONCLUSIONS We identified biomarkers suitable for assessing the VTE risk in newly diagnosed HGG patients. The application of 2 RAMs allowed identification of patients at high risk of developing VTE. We could also define patients at low risk of VTE, who would most probably not benefit from extended primary thromboprophylaxis.
Collapse
Affiliation(s)
- Johannes Thaler
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Alexandra Kaider
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Eva-Maria Reitter
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Johanna Haselböck
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Christine Mannhalter
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Christoph Zielinski
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Christine Marosi
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria (J.T., C.A., E-M.R., J.H., I.P.); Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna General Hospital, Vienna, Austria (J.T., C.A., E-M.R., C.Z., C.MAR., J.H., I.P.); Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria (C.MAN.); Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria (C.Z., C.MAR.); Center for Medical Statistics, Informatics and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria (A.K.)
| |
Collapse
|
15
|
Challa VR, Swamyvelu K, Shetty N. Assessment of the clinical utility of the Gail model in estimating the risk of breast cancer in women from the Indian population. Ecancermedicalscience 2013; 7:363. [PMID: 24171047 PMCID: PMC3797657 DOI: 10.3332/ecancer.2013.363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Indexed: 01/15/2023] Open
Abstract
Introduction Breast cancer screening programmes are based on various risk models to assess the risk of breast cancer in the general population. The aim of the present study is to predict the efficacy of the Gail model (GM) in the Indian population. We did a retrospective calculation of the Gail score from the hospital records of patients with breast cancer and benign breast disease. Materials and methods The Gail score was calculated in three groups. The three groups were made up of 104 patients with confirmed breast cancer (Group A), 100 patients with confirmed benign breast diseases (Group B), and 100 patient attendants (Group C). Statistical analysis The data analysis was done using SPSS 15.0, Medcal 9.0.1. Results The median Gail score in the three groups of patients was 7.5±3.04 in patients with breast cancer, 8.2±1.4 in patients with benign breast diseases, and 7.8±1.7 in normal people. The median Gail score was lower in patients with breast cancer when compared with normal people. Conclusion The GM is not useful in identifying the risk of breast cancer in Indian women. There is a need for further studies to evaluate other genetic and environmental factors to create an appropriate model for the Indian population.
Collapse
Affiliation(s)
- Vasu Reddy Challa
- Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka 560029, India
| | | | | |
Collapse
|