Anticoagulant Medication Research Articles

Direct annual healthcare costs in survivors of acute pulmonary embolism: estimates based on a prospective multicentre cohort study

Abstract Background Patients surviving acute pulmonary embolism (PE) necessitate long-term care and follow-up. However, the economic impact of PE on healthcare systems after the acute event remains largely unknown. Purpose To estimate the direct cost of PE during the first year after discharge from hospital for the index event, focusing on rehospitalizations, anticoagulant medication, and outpatient follow-up. Methods We analyzed the data from a multicentre cohort study of 1017 unselected patients with confirmed acute symptomatic PE in Germany. After the index episode, the costs of which were not considered, patients prospectively followed an outpatient visit plan at 3, 12 and 24 months. All rehospitalisations were documented with the main and accompanying diagnoses; hospital costs were calculated based on current reimbursement in the German Diagnosis Research Groups (G-DRG) system. The duration and type (central unique drug identifier) of anticoagulant treatment was documented at each visit. Per-patient costs of ambulatory follow-up visits and tests were calculated by multiplying (i) the costs of each visit/test (German ambulatory healthcare services reimbursement catalogue) by (ii) the probability π (0.0≤π≤1.0) of needing that specific service, based on the PE follow-up algorithm of the ESC Guidelines which we populated with the actual results per step in the present study (Figure). The primary analysis was conducted in all patients with ≥3-month follow-up. An additional sensitivity analysis included only the patients completing ≥12-month follow-up. We additionally identified the baseline predictors for the number of rehospitalizations and costs using multivariable zero-inflated Poisson and hurdle regression and accounting for censored data. Results Of 1017 enrolled patients, 958 (94%) were included in the primary analysis. Of them, 24% were rehospitalized, for a marginal mean of 0.34 (bootstrapped 95% CI: 0.30-0.39) readmissions per PE survivor. Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis) cancer, emerged as independent cost predictors by multivariable hurdle gamma regression (Table). Estimated overall rehospitalisation costs were €1138 (95% CI 896-1420) per patient (€1171 [908-1479] in the sensitivity analysis). Mean anticoagulation duration was 330 days, with estimated per-patient costs of €1050 (€1190 in the sensitivity analysis). Per-patient costs of ambulatory follow-up visits and tests were estimated at €182, yielding a total cost of illness per PE survivor of €2370-2543. For the entire country, the annual direct costs after acute PE would thus amount to €202-217 million. Conclusions By estimating per-patient costs and identifying major cost drivers of post-PE care, the present study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved overall cardiovascular prevention.TableFigure

A bioanalytically validated RP-HPLC method for simultaneous quantification of rivaroxaban, paracetamol, and ceftriaxone in human plasma: a combination used for COVID-19 management

Rivaroxaban is a direct oral anticoagulant medication that has been found to be beneficial for the management of thromboembolic events linked to the Corona virus disease 2019 (COVID-19) pandemic, which has resulted in more than 6 million deaths worldwide. Hence, a sensitive, selective, and green bioanalytically validated method was developed using RP-HPLC coupled with DAD for the simultaneous determination of rivaroxaban in human plasma, and two co-administered drugs, namely, paracetamol, an analgesic, and ceftriaxone, an antibiotic, that are used in the management of COVID-19. An Exsil 100 ODS C18 column (250 × 4.6 mm, 5 μm) was used as the stationary phase, and acetonitrile: water: methanol at a ratio of 60:30:10 (v/v/v) was used in isocratic mode as the mobile phase with a flow rate of 0.7 ml/min. The method was validated over a concentration range of 0.1–10.0 µg/mL for rivaroxaban, and 1.0–15.0 µg/mL for paracetamol and ceftriaxone. The lower limits of detection (LLODs) were found to be 0.03, 0.32, and 0.32 µg/ml for rivaroxaban, paracetamol, and ceftriaxone, respectively. Moreover, the lower limits of quantitation (LLOQs) were found to be 0.1, 0.96, and 0.98 µg/ml. The developed method showed excellent accuracy and precision for the determination of the aforementioned drugs. Four metrics were used to evaluate the greenness of the developed method. The results revealed that the suggested method is green, with values of 81 and 0.6 for the analytical eco-scale and analytical greenness assessment (AGREE), respectively.

Proton pump inhibitors and cardiovascular risk: a critical review.

Proton pump inhibitors (PPI) are widely used medications for gastrointestinal disorders. Recent research suggests a potential association between long-term PPI use and increased cardiovascular (CV) risk, creating a complex clinical dilemma. This review critically evaluates the current evidence for this association, considering the limitations of observational studies and the lack of definitive confirmation from randomized controlled trials.This review delves into the reported association between PPIs and adverse CV events, examining proposed mechanisms such as drug interactions, electrolyte imbalances induced by PPIs and their potential impact on cardiac and vascular function. Evidence suggests these mechanisms converge, with varying influence depending on patient populations.Clinicians require a risk-benefit analysis for each patient considering their CV risk profile. Alternative gastrointestinal therapies should be explored for high-bleeding risk patients. Medications with lower cytochrome-P450 interaction potential may be preferable among essential PPI users. Elucidating the specific mechanisms by which PPIs might influence CV health, assessing long-term vascular effects and investigating interactions with newer anticoagulant medications are crucial for future research.

Outcomes and management of Haemoptysis in the Fontan population

Abstract Background Patients with a Fontan circulation for palliation of a univentricular congenital heart defect commonly possess pulmonary vascular abnormalities including arteriovenous malformations (AVM), aortopulmonary and venous-venous collaterals (1). These vessels are prone to haemorrhage which may result in life-threatening haemoptysis (2). This risk is increased with oral anticoagulant medication, given to reduce the risk of thromboembolism in Fontan patients (3). Management of these patients is difficult, and strategies vary across institutions. Purpose We aim to describe our experience with managing adult Fontan patients presenting with haemoptysis in a tertiary centre with a large Fontan cohort. Methods We retrospectively reviewed the records of 410 adult Fontan patients. Individuals admitted to our institution with an episode of haemoptysis were included. Details relating to anticoagulation regimens, interventions and mortality of patients were captured. Results From a cohort of 410 Fontan patients, 35 haemorrhagic events were observed in 11 patients (2.68%). The median age at initial haemoptysis was 24.5 years (range 19 to 43 years). 6 of the 11 patients were female (54.5%). Haemoptysis recurred in 8 of the 11 patients (72.7%). 2 out of 11 had a prior history of haemoptysis in childhood. All patients were administered with oral vitamin K antagonists at presentation. 24 of the 35 events were managed conservatively with IV fluids, anticoagulation reversal and tranexamic acid (66.7%). 11 events required catheter-based interventions, with coil and/or plug embolization of bleeding vessels. Prior to intervention, CT successfully identified potential bleeding sites in 10 of the 11 events (90.9%) but could not visualise all vessels that were subsequently embolized. The most common culprits for haemoptysis were aortopulmonary collaterals, followed by AVMs and venous-venous collaterals. In severe cases, more extensive management was required including transfusions, bronchoscopy, intubation, surgical exploration (1 patient) and pneumonectomy (1 patient). 3 patients died following recurrent severe haemoptysis (27.3%), and 2 patients died of subsequent Fontan failure and sudden cardiac death respectively. Total mortality of the cohort is 5 out of 11 (45.5%) with a median follow up of 10.75 years (range 3 days to 27 years). Conclusions Haemoptysis is a rare but potentially fatal complication in patients who have undergone a Fontan procedure. The variability in presentation of this condition mandates an individualised approach to management with involvement of a multidisciplinary team. There is a high rate of recurrence following haemoptysis and a comprehensive assessment of all potential bleeding sites is necessary. CT is a useful tool to help facilitate this and guide further management. Our policy is to close all potential sources of bleeding as CT and invasive angiography rarely identifies an active point of bleeding.

Advanced Applications of Nanomaterials in Atherosclerosis Diagnosis and Treatment: Challenges and Future Prospects.

Atherosclerosis-induced coronary artery disease is a major cause of cardiovascular mortality. Clinically, conservative treatment strategies for atherosclerosis still focus on lifestyle interventions and the use of lipid-lowering and anticoagulant medications. Despite achieving some therapeutic effects, these approaches are limited by low bioavailability, long intervention periods, and significant side effects. With the advancement of nanotechnology, nanomaterials have demonstrated extraordinary potential in the biomedical field. Their excellent biocompatibility, surface modifiability, and high targeting capability not only enable efficient diagnosis of plaque progression but also allow precise drug delivery within atherosclerotic plaques, significantly enhancing drug bioavailability and reducing systemic side effects. Here, we systematically review the current research progress of nanomaterials in the field of atherosclerosis to summarize not only the types of nanomaterials but also their applications in both the diagnosis and treatment of atherosclerosis. Notably, in the context of plaque therapy, we provide a comprehensive overview of current nanomaterial applications based on their targeted therapeutic systems for different cell types within plaques. Additionally, we address the persistent challenge of clinical translation of nanomaterials by summarizing current issues and providing directions for innovation and improvement in nanomaterial design. Overall, we believe that this review systematically summarizes the applications and challenges of biomedical nanomaterials in atherosclerosis diagnosis and therapy, thereby offering insights and references for the development of therapeutic materials for atherosclerosis.

A Review on Venous Thrombosis: Management with anticoagulants

Thrombosis is the most common condition and the world's leading cause of death due to blood clot development in blood arteries. Thromboembolism includes classification based on where the thrombus gets attached to the blood vessels. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are two of the main causes of vascular death globally, making up venous thromboembolism (VTE). According to estimates, the yearly incidence rates of VTE in individuals with European ancestry vary from 104 to 183 per 100,000 person-years. Thrombus development and propagation are dependent upon the existence of anomalies in blood flow, blood vessel wall, and blood clotting components, which are together referred to as Virchow's triad. A comprehensive diagnostic approach, which includes clinical evaluation, D-dimer testing, ultrasonography, and lung scan, provided a non-invasive diagnosis for most outpatients with suspected venous thromboembolism. Anticoagulant medication is the primary and established treatment for people who have acute venous thromboembolism (VTE). Among the treatment options available, UFH & LMWH are found to be safe for the growing fetus as they appear to not cross the placenta. Oral anticoagulants targeting thrombin or factor Xa have been introduced, replacing vitamin K antagonists. In a study involving DOACs vs VKAs in patients with pre-existing heart conditions, patients receiving DOACs for non-valvular atrial fibrillation had predominantly superior efficacy and safety. Keywords: Venous thromboembolism, Anticoagulants, Deep vein thrombosis, Pulmonary embolism, Thrombus

Cystoid macular edema after low-energy femtosecond-assisted cataract surgery.

This study aimed to evaluate the occurrence of pseudophakic cystoid macular edema (PCME) post low-energy femtosecond laser-assisted cataract surgery (FLACS) in a high-volume surgical setting. The medical records of 242 FLACS patients were retrospectively reviewed. The central subfield macular thickness (CSMT) was measured via optical coherence tomography (OCT) before and 4-6weeks after surgery, and the results were compared for PCME detection. Macular edema was defined as a 10% increase in CSMT, a new onset of intraretinal fluid, or a decrease in visual acuity (VA). VA development in PCME patients was reviewed at 2-3months and 6months. The median patient age was 72years (49-92years). Among 242 eyes, seven eyes (2.89%) developed PCME. The median preoperative CSMT in these eyes was 255μm (minimum 231μm, maximum 326μm), whereas the median CSMT at 4-6weeks after surgery was 317μm (minimum 255μm, maximum 463μm). 4- to 6-week postoperative visual acuity decreased in comparison with 1-week postoperative values in three eyes of two patients, remained stable in two patients, and improved in one patient, whereas one patient did not return for his 1-week appointment but improved from 0.4 to 0.2 logMAR 2.5months postoperatively. By 3-6months, all eyes with PCME had gained visual acuity in comparison with their preoperative values. None of the PCME patients had diabetes or used prostaglandin analogues. Three patients were receiving anticoagulation medication. A 2.89% incidence of PCME after low-energy FLACS matched published standard phacoemulsification rates. In our series of uncomplicated cases, PCME caused only a transient postoperative decrease in visual acuity. What is known Increased prostaglandin levels have been detected in the aqueous humour of cataract patients after femtosecond laser application. Prostaglandins are mediators of inflammation. Femtosecond lasers come in low energy and high energy variants. There is contrasting evidence of increased incidence of PCME after femtosecond laser assisted cataract surgery (FLACS) What is new The incidence of PCME after low-energy FLACS in our high volume surgical setting is 2.89% Low-energy FLACS does not seem to have a causative effect on PCME.

A superior material with antithrombotic properties serves as a secure adsorbent for the elimination of bilirubin in vitro and in pig models

Hyperbilirubinemia is primarily treated through hemoperfusion, a process that utilizes biomaterials as adsorbents to eliminate excessive bilirubin from the bloodstream. However, extracorporeal circuits are prone to thrombus formation due to the frequent use of blood-contacting devices, potentially leading to treatment failure and adverse clinical outcomes. In this study, using a resin substance treated with sulfated polysaccharides (GLU-ERM-0100), we present a reliable and safe approach for removing excessive bilirubin from blood. The resin’s pore size facilitates bilirubin adsorption, while sulfonic and hydroxyl groups incorporated within the material enable like-heparinization. GLU-ERM-0100 serves as a temporary blood-thinning agent, binding coagulation factors in the extracorporeal circuit, thereby eliminating the need for conventional anticoagulant medications. Both in vitro and animal studies demonstrate the material’s exceptional bilirubin adsorption capacity and effective anticoagulation properties.

Impact of antiplatelet and anticoagulant drugs on postoperative bleeding in reverse total shoulder arthroplasty

BackgroundThe decision to withdraw or continue antiplatelet and anticoagulant drugs would be balanced on the bleeding risk and the cardiovascular risk. The purpose of this study was to investigate perioperative bleeding in reverse shoulder arthroplasty (RSA) to determine the impact of oral antiplatelet and anticoagulant medications in the absence of drug withdrawal. The hypothesis was that the continuation of antiplatelet and anticoagulant drugs would increase postoperative bleeding but to a limited extent. MethodsDuring the study period, RSA cases were prospectively included and retrospectively reviewed. Cases of revision for arthroplasty, proximal fracture, and cemented stem fixation were excluded. Cases with dual therapy of aspirin and clopidogrel and cases with heparin bridges were also excluded. Age, gender, height, weight, American Society of Anesthesiologists physical status anesthesia risk (ASA), smoking status, preoperative diagnosis, preoperative blood sampling data within one month of surgery (estimated glomerular filtration rate (eGFR), Prothrombin Time-International Normalized Ratio (PT-INR), and activated partial thromboplastin time (APTT)), surgical time, stem length (standard or short stem), and use of tranexamic acid were identified. The presence of diabetes mellitus, rheumatoid arthritis, and hypertension were confirmed as comorbidities. Hemoglobin (Hb) and hematocrit (Ht) values were recorded preoperatively and on the third postoperative day, and estimated blood loss was calculated by Gross formula using the change in preoperative Ht and postoperative day 3 Ht values. Multiple regression models were used to determine predictors of the estimated blood loss. P values less than .05 were considered statistically significant. Results315 RSA cases were analyzed (172 females, a mean age of 77.2 years). The estimated blood loss was 819 ml. The regression equation was statistically significant (P < .0001, R2=0.21), and aspirin, direct oral anticoagulants (DOAC), tranexamic acid, height, and surgery time were statistically significant explanatory variables, showing the predicted changes in bleeding volume for each drug were +283 ml for aspirin, +180 ml for DOAC, and -237 ml for tranexamic acid, respectively. Warfarin and cilostazol were not employed due to P values and Akaike's Information Criterion. Two blood transfusions (without antiplatelet or anticoagulant medications) were administered. One patient on aspirin had a cardiovascular event. ConclusionsThe current study showed that the use of aspirin and DOAC were significant predictors of increased perioperative blood loss, but the amount of increase was in the acceptable range, suggesting that continued antiplatelet and anticoagulant were relatively safe in primary RSA. Administration of tranexamic acid was shown to reduce bleeding significantly.

Comparison of ََQuality of Life and Treatment Satisfaction among Sample of Iraqi Patients Using Anticoagulant Therapy (Warfarin or Non-Vitamin K Antagonist Oral Anticoagulants)

Background: Oral anticoagulation medication, warfarin and non-vitamin k antagonist oral anticoagulants (NOAC) may require long term use which may affect patients’ satisfaction with their treatment and their quality of life (QOL). Objective: To compare the quality of life and treatment satisfaction among groups of patients using different anticoagulant therapies (warfarin and NOAC). Patients and methods: A cross-sectional study was performed at Ibn Al-Bitar Hospital for cardiac surgery in Baghdad in the period between December 2022 to May 2023. The study population included a convenient sample of patients receiving either warfarin or non-vitamin k antagonist oral anticoagulants treatment. The Arabic version of the short form 12 (SF-12) questionnaire and the Anti-Coagulant Treatment Satisfaction Scale (ACTS) questionnaire were used to assess the quality of life and satisfaction with treatment respectively. Results: The study included 181 patients in total. The mean physical and mental quality of life scores for study participants were 42.3±9.92 and 52.6±10.36 respectively. There was no significant difference in the QOL between patients taking warfarin and those on non-vitamin k antagonist oral anticoagulants treatment. The mean total satisfaction score was 65.4±6.73. Patients receiving non-vitamin k antagonist oral anticoagulants had significantly higher satisfaction compared to those receiving warfarin (P=0.000). The physical score correlated significantly with gender, educational level, employment status, number of chronic medications and number of chronic diseases. The total satisfaction score correlated significantly with gender, number of chronic medications, number of side effects and duration of anticoagulation. There was a significant correlation between the QOL and treatment satisfaction (P=0.000). Conclusion: Treatment with non-vitamin k antagonist oral anticoagulants showed comparable QOL and higher treatment satisfaction than that of warfarin. Better treatment satisfaction can improve patients’ QOL which may ultimately enhance their adherence to treatment.

Preparation and Characterization of Isradipine as Surfactant-Free Dry Emulsion

Background: Oral anticoagulation medication, warfarin, and non-vitamin K antagonist oral anticoagulants (NOAC) may require long-term use which may affect patients’ satisfaction with their treatment and their quality of life (QOL). Objective: To compare the quality of life and treatment satisfaction among groups of patients using different anticoagulant therapies (warfarin and NOAC). Methods: A cross-sectional study was performed at Ibn Al-Bitar Hospital for cardiac surgery in Baghdad in the period from December 2022 to May 2023. The study population included a convenient sample of patients receiving either warfarin or non-vitamin k antagonist oral anticoagulants treatment. The Arabic version of the short form 12 (SF-12) questionnaire and the Anti-Coagulant Treatment Satisfaction Scale (ACTS) questionnaire were used to assess the quality of life and satisfaction with treatment respectively. Results: The study included 181 patients in total. The mean physical and mental quality of life scores for study participants were 42.3±9.92 and 52.6±10.36 respectively. There was no significant difference in the QOL between patients taking warfarin and those on non-vitamin k antagonist oral anticoagulant treatment. The mean total satisfaction score was 65.4±6.73. Patients receiving non-vitamin k antagonist oral anticoagulants had significantly higher satisfaction compared to those receiving warfarin. The physical score correlated significantly with gender, educational level, employment status, number of chronic medications, and number of chronic diseases. The total satisfaction score correlated significantly with gender, number of chronic medications, number of side effects, and duration of anticoagulation. There was a significant correlation between the QOL and treatment satisfaction. Conclusion: Treatment with non-vitamin K antagonist oral anticoagulants showed comparable QOL and higher treatment satisfaction than that of warfarin. Better treatment satisfaction can improve patients’ QOL which may ultimately enhance their adherence to treatment.

Dual antiplatelet including clopidogrel and aspirin, cardiac MRI, and speckle tracking echocardiography parameters in ST-elevation myocardial infarction patients

Coronary artery disease is the medical term for atherosclerotic coronary disease, which causes the coronary arteries to constrict and inadequately provide blood to the heart. ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, &amp; unstable angina are the three conditions that comprise acute coronary syndromes. Studied cases with STEMI have been advised to take several drugs in addition to early reperfusion treatment, such as antiplatelet &amp; anticoagulant medications. The goal of antiplatelet medications is to stop platelets from aggregating together. Oral dual antiplatelet medication, which combines lifetime aspirin with an oral P2Y12 receptor inhibitor, is the main antiplatelet therapy in STEMI. Aspirin ought to be administered to all studied cases immediately following diagnosis, and a low dose of treatment should be continued indefinitely. Heart mortality and severe adverse cardiac events are strongly and independently correlated with the presence &amp; size of scarred tissue seen by cardiac MRI. Scar transmurality measured by cardiac MRI in studied cases with healed infarcts &amp; ventricular dysfunction predicts patient survival and functional recovery following revascularization. Patients with heart illnesses that have a history of ST-segment elevation myocardial infarction may be at risk for unfavorable results based on echocardiographic evaluation of cardiac structure &amp; function. Because speckle tracking echocardiography (STE) is quick and simple to do, it can be used in acute settings as well. It can be used for further risk stratification following revascularization, before invasive coronary angiography, or in cases when a diagnosis is unclear, if available.

Middle Meningeal Artery Embolization Reduces the Recurrence Rate of Chronic Subdural Hematoma: A Propensity Score Matching Analysis.

To evaluate the effect of middle meningeal artery embolization (MMAE) on chronic subdural hematoma (CSDH). The authors enrolled consecutive patients with CSDH who underwent burr hole craniostomy (BHC) between January 2020 and February 2023. The primary outcome was recurrence rate, defined as an increase of hematoma width on imaging compared with the immediate postoperative imaging at a 3-month follow-up. Secondary outcomes included the rate of complications and adverse prognosis. Cohorts were balanced using 1:2 propensity score matching (PSM). A total of 271 patients were eligible for this study and divided into the MMAE group (n=23) and the BHC group (n=205). Compared with the BHC group, there was more use of anticoagulant or antiplatelet medication (47.8% vs 22.4%, P=0.008), bilateral hematoma (19.5% vs 19.5%, P=0.043), and hematoma with septations (47.8% vs 21.5%, P=0.005) in the MMAE group. After PSM, 64 cases were finally successfully matched. The logistic analysis result showed that MMAE was associated with the decreased recurrence rate of CSDH in the cohort after PSM (OR 0.072, 95% CI: 0.322~0.746, P=0.028) but not with the improved clinical prognosis (OR 0.065, 95% CI: 0.533~4.786, P=0.562). MAAE has a positive therapeutic effect on reducing the recurrence rate of CSDHs as an adjunct postoperative treatment after burr hole surgery.

Detection of anticoagulant medication errors by triggers

Medication errors can cause preventable adverse events. For example, inappropriate use of anticoagulants (AC) can result in bleeding and thromboembolic complications. Detection and analysis of AC medication errors allow to reveal deficiencies in the safety systems in healthcare organizations. The study was aimed to develop a method of systematic detection of anticoagulant medication errors for consequent audit, analysis and development of medication safety improvement measures. The study was conducted in the multidisciplinary hospital and included 4924 patients admitted from January 2019 to December 2021 who received AC. Three laboratory triggers (international normalized ratio ≥4, serum creatinine ≥133 μmol/l, and glomerulofiltration rate <30 ml/min/1.73 m2) helped to reveal 4304 cases. Their matching with patient's data helped to develop combined triggers. Two clinical pharmacologists reviewed all cases identified by combined triggers for checking medication errors. The trigger was considered positive when anticoagulant medication error was detected in the history selected by combined trigger. Of the 4924 patients 253 (5.3%) were selected by combined triggers. Combined trigger allowed to reduce the amount of medical health records audit by 97.3%. Medication errors were detected in 137 patients. Positive predictive value of selected combined triggers varied from 0 to 63.9%. Aggregated positive predictive value of all combined triggers amounted to 54.2%. AC medication errors were detected in 2.8% patients. Method of systematic detection of AC medication errors using combined triggers in all hospitalized patients receiving AC allowed to reveal typical medication errors for consequent analysis and elaboration of measures to reduce preventable patient harm in healthcare settings.

Time Trends and Excess Mortality Compared to Population Controls after a First-Time Pulmonary Embolism or Deep Vein Thrombosis.

Recent data on temporal trends in excess mortality for patients with pulmonary embolism (PE) and deep vein thrombosis (DVT) compared with the general population are scarce. A nationwide Swedish register study conducted from 2006 to 2018 including 68,960 PE and 70,949 DVT cases matched with population controls. Poisson regression determined relative risk (RR) for 30-day and 1-year mortality trends while Cox regression determined adjusted hazard ratios (aHRs). A significance level of 0.001 was applied. In PE cases, both 30-day mortality (12.5% in 2006 to 7.8% in 2018, RR: 0.95 [95% CI: 0.95-0.96], p < 0.0001) and 1-year mortality (26.5 to 22.1%, RR: 0.98 [0.97-0.98], p < 0.0001) decreased during the study period. Compared with controls, no significant change was seen in 30-day (aHR: 33.08 [95% CI: 25.12-43.55] to 24.64 [95% CI: 18.81-32.27], p = 0.0015 for interaction with calendar year) or 1-year (aHR: 5.85 [95% CI: 5.31-6.45] to 7.07 [95% CI: 6.43-7.78], p = 0.038) excess mortality. The 30-day excess mortality decreased significantly (aHR: 39.93 [95% CI: 28.47-56.00) to 24.63 [95% CI: 17.94-33.83], p = 0.0009) in patients with PE without known cancer before baseline, while the excess 1-year mortality increased (aHR: 3.55 [95% CI: 3.16-3.99] to 5.38 [95% CI: 4.85-5.98], p < 0.0001) in PE cases surviving to fill a prescription of anticoagulation. In DVT cases, 30-day and 1-year mortality declined, while excess mortality compared with controls remained stable. In general, the improved mortality following PE and DVT paralleled population trends. However, PE cases without cancer had decreasing excess 30-day mortality, whereas those surviving to fill a prescription for anticoagulant medication showed increasing excess 1-year mortality.

Hematological Complications From Transcatheter Aortic Valve Replacement (TAVR): Recognition and Treatment.

Transcatheter aortic valve replacement (TAVR) has emerged as a pivotal intervention for patients with severe aortic stenosis who are at high or prohibitive surgical risk. Although TAVR is a minimally invasive procedure, it is linked to serious hematological problems, most notably thrombosis and bleeding. Numerous factors, such as procedural features, patient comorbidities, and anticoagulation management techniques, contribute to these complications. Bleeding complications can be major, minor, or life-threatening. They can be caused by problems with the vascular access site, anticoagulation medication, or coexisting conditions like renal dysfunction and frailty. Hemoglobin drop, overt bleeding, and hematoma signs must all be closely watched to identify bleeding. Careful selection and modification of anticoagulation medication, the use of vascular closure devices, and timely attention to bleeding sites are examples of management techniques. Thrombotic consequences, which include cerebrovascular accidents and valve thrombosis, are caused by endothelial injury, stent implantation, and patient hypercoagulability. Imaging modalities such as computed tomography and transesophageal echocardiography are used in the crucial process of detection. The goal of preventive care is to maximize anticoagulation regimens that are customized to each patient's risk profile, frequently striking a balance between the risk of thrombosis and bleeding. A multidisciplinary strategy that integrates surgical, hematological, and cardiology expertise is necessary for the effective management of these hematological complications. To improve patient outcomes, ongoing research attempts to improve risk stratification and create safer anticoagulation protocols. This review emphasizes how critical it is to identify bleeding and thrombotic events as soon as possible and treat them promptly to reduce the risk of negative outcomes for TAVR patients.

Nasal hemorrhage - risk factors and management in 707 outpatient and inpatient patients

Epistaxis is one of the most common emergencies in otorhinolaryngology. The spectrum ranges from mild, self-limiting cases to life-threatening hemorrhages. Depending on the severity and course of the condition, management can be either outpatient or involve inpatient monitoring, possibly with surgical treatment.A retrospective systematic evaluation was conducted on all outpatient and inpatient patient data diagnosed with epistaxis from January to December 2021. Epistaxis associated with tumors, trauma, and postoperative epistaxis were excluded.A total of 707 patients were included. Seasonally, the highest number of patients presented in January. Outpatient management was possible for 80.8% of the cases, while 19.2% required inpatient admission. Among the inpatients, 15.4% required surgical intervention. Within the entire study cohort, 61.1% of the patients were male. Among the inpatients who underwent surgical treatment, the proportion of male patients was even higher (81.0%). The majority (73.1%) of the inpatients were on at least one anticoagulant medication. Advanced age (p=0.044) and the presence of posterior epistaxis (p<0.001) were significantly associated with the need for inpatient treatment. No children required inpatient care.Epistaxis is a common condition in otorhinolaryngology, predominantly affecting older male patients and those on anticoagulant therapy in severe cases within the studied cohort. Surgical intervention under general anesthesia was infrequently necessary for the treatment of epistaxis in the overall study population (3%).

Acute Renal Infarction: A 12-Year Retrospective Analysis

Introduction: Acute renal infarction (ARI) is a relatively rare and underdiagnosed condition. Presenting symptoms are nonspecific, and imaging is the mainstay for diagnosis. This study attempts to characterize the profile of patients with ARI and identify possible risk factors. Methods: All inpatients admitted with diagnosis of ARI between 2010 and 2022 were included in this single-center retrospective observational study. Patients with chronic renal infarction, iatrogenic causes, and without radiographic evidence of ARI were excluded. Clinical, laboratory, and radiological findings of patients were collected. Patients were grouped into three groups based on probable etiology: cardiovascular, hypercoagulable disorders, and idiopathic, and analyzed. Results: Eighty-five patients were included. Mean age of patients was 61.6 ± 17.54 years. Cardiovascular group had the highest number of patients (49.4%) of which atrial fibrillation was the most common etiology (59.5%). Malignancy was the most common etiology in the hypercoagulable disorder group (69.3%). Patients in the idiopathic group were significantly younger and had higher mean body mass index than the other 2 groups at presentation. Smokers had 9 times higher risk of renal infarction in cardiovascular group and 1.7 times higher risk in hypercoagulable when compared to the idiopathic group. 48.2% of patients developed renal infarction though they were on antiplatelets/anticoagulants. Conclusion: ARI is a rare and often underdiagnosed condition that can have residual renal dysfunction. It is important to consider ARI as a differential especially in young patients with risk factors even if they are on anticoagulation medication.

Danger, Danger, Gaston Labat! Does zero-shot artificial intelligence correlate with anticoagulation guidelines recommendations for neuraxial anesthesia?

IntroductionArtificial intelligence and large language models (LLMs) have emerged as potentially disruptive technologies in healthcare. In this study GPT-3.5, an accessible LLM, was assessed for its accuracy and reliability in...

Accurately identifying incident cases of venous thromboembolism in the electronic health record: Performance of a novel phenotyping algorithm

BackgroundAccurate identification of incident venous thromboembolism (VTE) for quality improvement and health services research is challenging. The purpose of this study was to evaluate the performance of a novel incident VTE phenotyping algorithm defined using standard terminologies, requiring three key indicators documented in the electronic health record (EHR): VTE diagnostic code, VTE-related imaging procedure code, and anticoagulant medication code. MethodsRetrospective chart reviews were conducted to assess the performance of the algorithm using a random sample of phenotype(+) and phenotype(−) diagnostic encounters from primary care practices and acute care sites affiliated with five hospitals across a large integrated care delivery system in Massachusetts. The performance of the algorithm was evaluated by calculating the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity, using the phenotype(+) and phenotype(−) diagnostic encounters sample and target population data. ResultsBased on gold-standard manual chart review, the algorithm had a PPV of 95.2 % (95 % CI: 93.1–96.8 %), NPV of 97.1 % (95 % CI: 95.3–98.4 %), sensitivity of 91.7 % (95 % CI: 90.8–92.6 %), and specificity of 98.4 % (95 % CI: 98.1–98.6 %). The algorithm systematically misclassified a low number of specific types of encounters, highlighting potential areas for improvement. ConclusionsThis novel phenotyping algorithm offers an accurate approach for identifying incident VTE in general populations using EHR data and standard terminologies, and accurately identifies the specific encounter and date of diagnosis of the incident VTE. This approach can be used for measurement of incident VTE to drive quality improvement, research to expand the evidence, and development of quality metrics and clinical decision support to improve the diagnostic process.