Antithrombotic Prophylaxis Research Articles

COVID-19 IN PATIENTS WITH MYELOPROLIFERATIVE NEOPLASMS: THE RISK OF THROMBOEMBOLIC EVENTS AND CURRENT OPTIONS FOR ANTITHROMBOTIC PROPHYLAXIS

Aim: to provide a literature review of the presently available data on the risk of thromboembolic events and current options for antithrombotic prophylaxis in patients with myeloproliferative neoplasms (MPN) patients with concomitant coronavirus disease 2019 (COVID-19).
 Material and methods. The thematic scientific papers, published predominantly during the last decade (including the references regarding SARS-CoV-2 infection (COVID-19) of the last three years), constituted the study material. The research methodology involved bibliosemantic method and structural and logical analysis.
 Results and discussion. MPN and SARS-CoV-2 infection (COVID-19) are both conditions with inherently enhanced susceptibility to thromboembolic events (venous and arterial). Along with the specific pathophysiological pathways, MPN and COVID-19, in case of their constellation, share overlapping pathomechanisms of hypercoagulability. As of today, the antithrombotic prophylaxis in MPN/COVID-19 patients (primary and secondary) is carried out according to the guidelines and algorithms, including those regarding general principles of the use of anticoagulants (oral or parenteral) and antiplatelet agents, and those specifically addressed to MPN or SARS-CoV-2 infection. These documents are constantly updating as the results of ongoing trials become available. Considering the relatively low prevalence of MPN, and the absence of specific guidelines, devoted to MPN in tandem with SARS-CoV-2 infection, the conduction of global registry studies is of crucial importance, aiming to provide a continuous and thorough collection and analysis of the data, related to the characteristics of this particular patients` population, pathological background and clinical features of thromboembolic complications, as well as short- and long-term outcomes.
 Conclusion. The comprehensive study of basic, epidemiological and clinical data regarding various aspects of thrombosis/thromboembolism in case of MPN/COVID-19 constellation, is a multidisciplinary task, which should be performed with an ultimate goal to improve already implemented and develop novel approaches to antithrombotic management of such patients.

Cervical dissection in emergency neurology: diagnostic and treatment algorithms

The epidemiology of cervical artery dissection (CAD), which is often not thought to be the cause of ischemic stroke and transient ischemic attack (TIA), is discussed. The pathomorphology and pathogenesis of CAD, the key feature of which is the development of intramural hematoma, as well as predisposing conditions, triggers and associated conditions, in particular migraine, are reviewed. The clinical picture of diseases — local symptoms (headache and/ or neck pain, Horner’s syndrome, caudal cranial nerve involvement, cervical radicular syndrome, pulsatile tinnitus) and ischemic events (ischemic stroke or TIA) is presented. Modern approaches to urgent neuro- and angioimaging in CAD are reflected, including the possibilities of CT angiography (direct and indirect signs) and fat sat MRI (crescent symptom). Issues of reperfusion therapy (intravenous thrombolysis, thrombectomy and stenting) are discussed. The course of disease and secondary antithrombotic prophylaxis are analyzed.

AUGS-IUGA Joint clinical consensus statement on enhanced recovery after urogynecologic surgery.

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery. A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members. All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs. The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

Lupus anticoagulant in an elderly woman with dementia: a clinical case report with many questions and few answers

We describe the clinical case of an elderly woman with dementia, suffering from bilateral soleal venous thrombosis, despite antithrombotic prophylaxis, after orthopedic surgery. An isolated anti-cardiolipin antibodies positivity, however pre-existing for at least seven years, was found in a patient with previous cerebral ischemia and treated intermittently with aspirin. During the coronavirus disease 2019 (COVID-19) pandemic lockdown, to promote patient compliance, we practiced anticoagulant therapy with edoxaban: resolution of venous thrombosis was achieved. Longlasting medical treatment is discussed.

Thrombosis in multiple myeloma: risk stratification, antithrombotic prophylaxis, and management of acute events. A consensus-based position paper from an ad hoc expert panel.

The introduction of new therapeutic agents for multiple myeloma (MM), including proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies, has improved the outcomes of patients but, in parallel, has changed the frequency and epidemiology of thrombotic events. Thrombosis is now a significant cause of morbidity and mortality in MM patients, and optimal thromboprophylaxis is far from being reached. Moving from the recognition that the above issue represents an unmet clinical need, an expert panel assessed the scientific literature and composed a framework of recommendations for improving thrombosis control in patients who are candidates for active treatment for MM. The panel generated key clinical questions using the criterion of clinical relevance through a Delphi process. It explored four domains, i.e., thrombotic risk factors and risk stratification, primary thromboprophylaxis, management of acute thrombotic events, and secondary thromboprophylaxis. The recommendations issued may assist hematologists in minimizing the risk of thrombosis and guarantee adherence to treatment in patients with MM who are candidates for active treatment.

Coagulation and Anticoagulation in Fontan Patients.

Patients with a Fontan circulation for single-ventricle physiology are at increased risk of developing thromboembolic events. Thromboembolic events can lead to failure of the Fontan circulation, chronic sequelae in case of stroke, and early mortality. Controversies exist regarding the substrates, risk factors, and optimal detection methods for thromboembolic events. Despite the major clinical implications, there is currently no consensus regarding the optimal antithrombotic therapy to prevent or treat thromboembolic events after the Fontan procedure. In this review we aimed to untangle the available literature regarding antithrombotic prophylaxis and treatment for pediatric and adult Fontan patients. A decision-tree algorithm for thromboprophylaxis in Fontan patients is proposed. Additionally, the current state of knowledge is reviewed with respect to the epidemiology, pathophysiology, and detection of thromboembolic events in Fontan patients, and important evidence gaps are highlighted.

Antithrombotic prophylaxis for symptomatic outpatients with COVID-19: less is consistently more

COVID-19 is associated with an inflammatory vascular and hypercoagulable response leading to increased risk of venous and arterial thromboembolism. Microvascular pulmonary thrombosis also contributes to clinical deterioration, hospitalisation, respiratory failure, and death. Early in the pandemic, observational studies in outpatients who had never been hospitalised reported rates from 18% to 23% of pulmonary embolus on CT imaging in emergency departments, and autopsy reports found pulmonary embolus as the probable cause of death in patients never hospitalised who died at home from COVID-19.

P1525: MANAGEMENT OF AUTOIMMUNE HAEMOLYTIC ANAEMIA DURING PREGNANCY OR POST-PARTUM: AN INTERNATIONAL MULTI-CENTRE EXPERIENCE.

Background: Autoimmune haemolytic anaemia (AIHA) during pregnancy is a rare finding, and few is known about maternal and foetal outcomes. AIHA may either develop or relapse during gestation and postpartum or be an issue in a patient on active therapy who becomes pregnant. AIHA management during pregnancy and lactation is not standardized and drug use is often limited by safety concerns. Aims: We studied AIHA impact on pregnancy focusing on disease severity, treatment need and maternal/foetal outcome. Methods: Through a multicentric retrospective cohort study, we identified 38 pregnancies occurred in 28 women from 1997 to 2021 in 10 European centres in Italy, Denmark, France, the Netherlands, USA, and Spain. All included patients had a previous AIHA history or developed/exacerbated AIHA during gestation or postpartum. AIHA was classified according to the direct antiglobulin test. Results: We registered 18 warm AIHA (10 IgG; 8 IgG+C3d), 2 cold agglutinin disease, 3 mixed and 5 atypical forms (Table 1). Evans syndrome (i.e., association of AIHA and immune thrombocytopenia or neutropenia) was present in 4. Mean age at AIHA diagnosis was 27 (3-39) and at pregnancy 32 (21-41) years. AIHA diagnosis predated pregnancy in 15 women and had required at least 1 therapy line in all of them, and ≥2 lines in 12 (rituximab, N=7; cytotoxic immunosuppressants, N=6; splenectomy, N=5). Among these 15 patients, 6 had a relapse during pregnancy, 3 during postpartum and 9 were on active treatment at the time of pregnancy (steroids, N=8; cyclosporine, N=1; azathioprine, N=1; the latter stopped after positive pregnancy test). A patient with a previous AIHA, relapsed as immune thrombocytopenic purpura during pregnancy. Further 8 patients had an AIHA onset during gestation and 2 postpartum. A patient had AIHA onset during the postpartum of the 1st pregnancy and relapsed during the 2nd one. In the 20 women experiencing AIHA during pregnancy/postpartum, median Hb and LDH levels were 6,4 g/dL (3,1 – 8,7) and 588 UI/L (269-1631), respectively. Management consisted in blood transfusions (N=10) and prompt establishment of steroid therapy+/-IVIG (N=20), all with response (complete N=13, partial N=7). After delivery, rituximab was necessary in 4 patients and cyclosporine was added in one. Anti-thrombotic prophylaxis was given in 7 patients. Overall, we registered 10 obstetric complications (10/38, 26%), including 4 early miscarriages, a premature rupture of membranes, a placental detachment, 2 preeclampsia, a postpartum infection and a biliary colic. Apart from the case of biliary colic and one of the two cases of preeclampsia, 8/10 complications occurred during active haemolysis and treatment for AIHA. Nine foetal adverse events (9/38, 24%) were reported: a transitory respiratory distress of the new-born in a mother with active AIHA, 3 cases of foetal growth restriction, a preterm birth, an infant reporting neurologic sequelae, a case of AIHA of the new-born requiring intravenous immunoglobulins, blood transfusions and plasma exchange, and 2 perinatal deaths. The latter both occurred in women on active AIHA therapy and were secondary to a massive placental detachment and a symptomatic SARS-CoV-2 infection. Image:Summary/Conclusion: AIHA developing/reactivating during pregnancy or postpartum is rare (about 5%) but mainly severe requiring steroid therapy and transfusions. Importantly, severe maternal and foetal complications may occur in up to 26% of cases mostly associated with active disease, pinpointing the importance of maintaining a high level of awareness. Passive maternal autoantibodies transfer to the foetus seems a rare event.

Abstract 522: Preoperative D-dimer and Tissue Factor activity predict postoperative venous thromboembolism in glioma patients

Abstract Background: Venous thromboembolism (VTE) is a debilitating and life-threatening condition that is common in patients with cancer, especially glioma. There are no widely-accepted antithrombotic prophylaxis guidelines for glioma patients, partly because of the risk of iatrogenic intracerebral hemorrhage. Effective VTE risk assessment models exist for other cancers, but not glioma. Our prior publications suggested a protective role of IDH1 mutations (IDHmut) against VTE, and a direct correlation between circulating Tissue Factor (TF), a procoagulant secreted by cancers, and VTE in glioma patients. Others have found a correlation between inflammatory markers and cancer-associated VTE, but this has not yet been proven in gliomas. Our objective was to evaluate glioma patients for increased VTE risk by assessing clinical, histologic, molecular, and plasma-based markers. Methods: The Northwestern University Nervous System Tumor Bank provided preoperative arterial plasma, tumor tissue, and clinical-pathological data from 165 newly diagnosed glioma patients. Molecular profiling was done by GlioSeq NGS. Twelve candidate VTE biomarkers (D-dimer, E-Selectin, ICAM-1, VCAM-1, Granzyme B, IFNγ, TNFα, IL-2, IL-4, IL-6, IL-10, and IL-13) were analyzed using the automated microfluidic multiplex Ella࣪ platform. TF procoagulant activity was measured using a FXa chromogenic assay. Results: Of these patients (n=165), 33 (20%) experienced post-operative VTE. Clinical characteristics associated with increased VTE risk included advanced patient age, high body mass index, high tumor grade, prior history of VTE, coronary artery disease, hyperlipidemia, and hypertension. Of the targeted genetic screening panel (GlioSeq) on resected tumors, only IDHmut significantly correlated with VTE, being associated with reduced risk (OR=0.28; 95% CI=0.12-0.64, P=0.001). Among the plasma biomarkers, elevated circulating TF activity and D-dimer correlated with VTE risk. Circulating TF (>2.0pg/mL) was associated with VTE (Log-rank, P=0.002). D-dimer was elevated in patients that developed VTE (1,355±2,000 vs 605±1,061 ng/mL; P=0.004). High levels of D-dimer associated with worse median overall survival (2.5 vs. 46.9 months; Log-rank P<0.0001), and high D-dimer also developed VTE events quicker (95 vs 245 days; Log-rank P=0.001). Conclusions: This study identified multiple risk factors for glioma-associated VTE and may help identify which patients would benefit the most from prophylactic anticoagulation therapy following surgery. Citation Format: Amanda Alexander, Michael Drumm, Jonathan Lamano, Rodrigo Javier, Kathleen McCortney, Rachel Weller Roska, Kirsten Burdett, Denise M. Scholtens, Nathan Steere, Amanda Kubik, Yoav Noam, Craig Horbinski, Dusten J. Unruh. Preoperative D-dimer and Tissue Factor activity predict postoperative venous thromboembolism in glioma patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 522.

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

Outcomes of elderly patients with traumatic brain injury associated with the pre-injury antithrombotic prophylaxis type - A systematic review and meta-analysis.

Our review aims at comparing the morbidity and mortality-related risks associated with the pre-injury administration of VK-antagonists or DOACs in elderly patients with TBI. We performed a systematic search of the academic literature across five databases (Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE), following PRISMA guidelines. We conducted a random-effect meta-analysis to compare the influence of pre-injury VK-antagonists or DOACs administration on the overall intensive care unit and hospital stays of patients with TBI. We also evaluated the overall risks associated with VK-antagonists and with DOACs for intracranial hemorrhage progression, surgical intervention, and overall mortality in patients with TBI. From 973 studies, we found 11 eligible with 4,991 patients with traumatic brain injury (mean age, 77.82 ± 6.76 years). Our meta-analysis revealed insignificantly higher odds of surgical intervention (OR=1.72) and mortality (OR=1.07) associated with VK-antagonists administration than with DOACs administration. Similarly, we found that the intensive care unit (Hedge's g, 0.13) and hospital (g, 0.26) stays were insignificantly longer for individuals on VK-antagonists than for those on DOAC. Moreover, we observed insignificantly higher intracranial hemorrhage progression risks (OR=1.22) for individuals receiving DOACs than for those receiving VK-antagonists. This study provides evidence on the morbidity and mortality-related outcomes associated with the pre-injury administration of VK-antagonists or DOACs in patients with TBI. We found no significant differences between VK-antagonists and DOACs on the overall morbidity (hospital and intensive care unit stays, intracranial hemorrhage, and surgical intervention frequency) and mortality outcomes in elderly patients with TBI.

Presentation and Management of Acute Limb Ischemia Following Lower Extremity Revascularization: Insights from the VOYAGER PAD Trial

Acute limb ischemia (ALI) is a major adverse limb event associated with high morbidity and mortality. Despite the severity of this outcome, there are few large datasets including adjudicated ALI outcomes that have elucidated treatment approaches and outcomes after ALI. Data describing the presentation, initial care, and subsequent antithrombotic prophylaxis in patients with ALI after lower extremity revascularization (LER) for symptomatic peripheral artery disease (PAD) would provide valuable insights. The VOYAGER PAD trial randomized patients with PAD after LER to rivaroxaban 2.5 mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. Patients were randomized across 34 countries. Site-reported ALI was independently adjudicated by a clinical events committee. Each event was categorized by trained vascular specialists for etiology, relationship to index or subsequent LER, inpatient therapy, discharge treatment strategy, and hospital outcomes. Of the 6564 randomized patients, 390 (5.9%) had 516 total ALI events during follow-up. ALI etiology was in situ thrombosis in 97.8%, embolism from nonextremity source in 1.9%, and undetermined in 0.3%. Anatomic location was prior bypass in 49%, arterial stent in 31%, and native arterial segment (of these, three-quarters were prior endarterectomy, atherectomy, or angioplasty sites) in 18%. Fifty-eight percent of ALI were related to the index LER, 36% were related to a prior or subsequent nonindex LER, and 6% were at a non-LER arterial site. The initial intervention strategy (Fig 1) was thrombectomy in 41% (three-quarters were open and 71% required an additional open/endovascular revascularization or major amputation at some point in hospitalization). Thrombolysis was the initial strategy in 19% and 76% of these underwent an additional open/endovascular revascularization or major amputation during the hospitalization. Median hospital stay was 6 days. Fasciotomy occurred in 6% of patients, severe complications (ventilator, shock, or dialysis) occurred in 4%, major amputation in 13%, and mortality in 2.3%. Discharge antithrombotic background therapy (excluding study drug) was variable (Fig 2). ALI in the post-LER setting is frequent and largely in-situ thrombosis at the site of prior LER. Presentation with ALI is associated with prolonged hospitalization, the need for procedures and/or amputation and high inpatient mortality. Initial therapeutic approaches in patients presenting with ALI are varied as are approaches to thromboprophylaxis. These observations highlight the need for future research investigating the optimal approach to treating patients with ALI and therapeutic strategies to prevent recurrent complications.Fig 2Discharge Anti-Thrombotic Regimen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P130 A RARE CASE OF LARGE POST INFARCTION LEFT VENTRICULAR PSEUDOANEURYSM UNDERGOING CONSERVATIVE MANAGEMENT

Abstract Introduction Left ventricular pseudoaneurysm is a rare complication of myocardial infarction and its natural history is still unclear. Non invasive imaging improves detection ability and differential diagnosis with aneurysm. We present the case of large post infarction left ventricular pseudoaneurysm undergoing conservative management. Case Report A 81–years–old woman presented to emergency room complaining dyspnea and epigastric and right hemithoracic pain. Her past medical history included: chronic coronary syndrome, already undergoing CABG; recent inferior STEMI complicated with complete AVB, with ineffective RCA reperfusion attempt and bicameral pacemaker implantation; Paroxysmal AF in antithrombotic prophylaxis with DOAC. The ECG showed sinus tachycardia, HR 114 bpm, electro–induced ventricular complexes. Objectively, fine bilateral basal crackles were detected. Chest x–ray showed pulmonary congestion. The echocardiographic examination revealed: left ventricle with eccentric remodeling and severe depression of the contractile function (EF 35%), coarse neochamber in communication with the basal segment of the lower wall (D: 6.4 cm x 4.9 cm). The narrow neck, with a ratio <0.5 between inlet orifice diameter / neochamber diameter, suggested pseudoaneurysm. Working diagnosis of NSTEMI–ACS was made (usTnT peak: 344 pg / mL, NV: 0–15 pg / mL) complicated by heart failure. Progressive improvement in compensation was achieved through diuretic therapy. To improve diagnostic definition, cardio–synchronized chest CT with contrast medium was performed. The examination confirmed the voluminous neochamber, consistent with pseudoaneurysm, in correspondence with the mid–basal segments of the lower and inferior septal wall, with thinned walls and mass effect on the great cardiac vein, and highlighted the patency of the bypasses. The venous graft to OM was 5 mm distant from the posterior sternal surface. The case was discussed collectively in Heart Team, due to the high operative risk, the surgical option was rejected and a decision was made for conservative therapy. It was titled beta–blocker, ranolazine was introduced, heart failure therapy was implemented, introducing ARNI. The patient was discharged at home and is in follow–up at the outpatient clinic for heart failure. One month after discharge, she is in NYHA functional class II and she is asymptomatic for angor. The pseudoaneurysmatic dimensions are unchanged on echocardiographic control.

Rivaroxaban vs placebo for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer

AbstractThe clinical benefit of extended prophylaxis for venous thromboembolism (VTE) after laparoscopic surgery for cancer is unclear. The efficacy and safety of direct oral anticoagulants for this indication are unexplored. PROphylaxis of venous thromboembolism after LAParoscopic Surgery for colorectal cancer Study II (PROLAPS II) was a randomized, double-blind, placebo-controlled, investigator-initiated, superiority study aimed at assessing the efficacy and safety of extended prophylaxis with rivaroxaban after laparoscopic surgery for colorectal cancer. Consecutive patients who had laparoscopic surgery for colorectal cancer were randomized to receive rivaroxaban (10 mg once daily) or a placebo to be started at 7 ± 2 days after surgery and given for the subsequent 3 weeks. All patients received antithrombotic prophylaxis with low-molecular-weight heparin from surgery to randomization. The primary study outcome was the composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected deep vein thrombosis (DVT), or VTE-related death at 28 ± 2 days after surgery. The primary safety outcome was major bleeding. Patient recruitment was prematurely closed due to study drug expiry after the inclusion of 582 of the 646 planned patients. A primary study outcome event occurred in 11 of 282 patients in the placebo group compared with 3 of 287 in the rivaroxaban group (3.9 vs 1.0%; odds ratio, 0.26; 95% confidence interval [CI], 0.07-0.94; log-rank P = .032). Major bleeding occurred in none of the patients in the placebo group and 2 patients in the rivaroxaban group (incidence rate 0.7%; 95% CI, 0-1.0). Oral rivaroxaban was more effective than placebo for extended prevention of VTE after laparoscopic surgery for colorectal cancer without an increase in major bleeding. This trial was registered at www.clinicaltrials.gov as #NCT03055026.

Temporal Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients between 2004 and 2019.

Background: In the recent years, antithrombotic prophylaxis in patients with atrial fibrillation (AF) has changed significantly. The main aim of this study is to assess the temporal trends of antithrombotic therapy and identify factors predisposing oral anticoagulant (OAC) use in stroke prevention in AF patients. Methods: The present study is a retrospective, observational, single-center study, which includes consecutively hospitalized patients in the reference cardiology center from January 2004 to December 2019. Results: A total of 9656 patients (43.7% female, mean age 71.2 years) with AF between 2004–2019 are included. Among the total study population, in most of the patients (81.1%), OAC therapy was used, antiplatelet (APT) therapy was prescribed for 13.5% patients, heparins for 2.1% patients and 3.3% of patients did not receive any stroke prevention. OAC prescription significantly increased from 61.6% in 2004 to 97.4% in 2019. The independent predictors of OAC prescription were: the period of hospitalization, non-paroxysmal AF, age, hypertension, diabetes mellitus, previous thromboembolism, hospitalization due to electrical cardioversion, ablation or AF without any procedures. Conclusions: In hospitalized patients with AF, during sixteen years of the study period, a significant increase in OAC use and a decrease in APT use were noted. Factors other than these included in the CHA2DS2-VASc score were independent predictors of OAC use.

COVID-19 associated coagulopathy and thrombosis in cancer

Cancer patients are at risk for a more severe COVID-19 infection as well as an adverse outcome of such infection. This may be caused by the cancer itself (e.g haematological malignancies and lung cancer) or due to immune suppression caused by anti-cancer treatment. Severe COVID-19 infections are often complicated by a coagulopathy that clinically results in a high incidence of venous thromboembolic disease. Cancer itself is associated with a hypercoagulable state and a markedly increased incidence of thromboembolic complications, hence the combination of cancer and COVID-19 may amplify this risk. COVID-19 vaccination seems safe and effective in most cancer patients although adapted and bespoke vaccination schemes may increase the seroconversion rate and immune response in selected patients. Specific management strategies to improve outcomes of cancer patients in COVID-19 (e.g. higher intensity antithrombotic prophylaxis) are lacking and should be evaluated in clinical studies simultaneously focusing on efficacy and safety.

Direct Fixation of Fractures of the Posterior Malleolus Through a Postero-Medial Approach

Abstract Background and objective: Fractures of the posterior malleolus have long been neglected in the past. The decision for their fixation should be based on plain lateral radiographs. Recent studies have emphasized the important biomechanical function of the posterior tibial ridge. This has caused a trend towards more aggressive surgical treatment. The aim of this study was to present our experience with the direct fixation of complex ankle fractures engaging the posterior malleolus. We also tried to clarify the advantages and limitations of the posterior-medial surgical approach. Materials and Methods: For a period of 1,5 years we have operated 14 patients with posterior malleolus fractures. Their average age was 51 years. Eight of the patients were male, the rest 6 were females. Fractures were classified according to Bartoníček classification system. All patients had type 3 fractures. Direct open reduction was performed in all cases. Posterior buttress plate was used for the fixation of the fracture. Bone grafting was found necessary in one case. Functional assessment was done according to the criteria of the AOFAS (American Orthopedic Foot and ankle score). Follow up was done for an average period of 10 months. Results: All fractures united for an average period of 9 weeks (8-10 weeks). Six patients achieved an excellent functional result, 5 – a good one and 3 had an average result. The average AOFAS rating score was 84,02 (54-100). The average range of motion was 38° (15°-50°). There were no deep infections or septic arthritis. Three ankles had superficial skin necrosis that healed without any additional procedures. One patient had prolonged and substantial swelling of the leg, despite of the routine antithrombotic prophylaxis. Five patients needed their fibular plates removed due to local irritation. Conclusion: The direct reduction and fixation of the posterior malleolus fractures allow anatomical restoration of the ankle mortise. This is a prerequisite for an optimal functional recovery and appears to be a safe treatment strategy.

Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol

IntroductionMore than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%–0.5% fatal PE, and over 1000...

Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries.

In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC. Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively. The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team. Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit.

BackgroundRegional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group.MethodsConsecutive cardiovascular surgery patients treated with postdilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life.ResultsFifty-two patients underwent 193 sessions of continous veno-venous hemofiltration, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2–110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7–117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2–91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis.ConclusionsA postdilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone.