Deep Vein Thrombosis Events Research Articles

Concomitant Hip Arthroscopy and Periacetabular Osteotomy: Is there a Difference in Perioperative Complications compared with Periacetabular Osteotomy Alone?

ABSTRACT Purpose To evaluate the safety of hip arthroscopy combined with a periacetabular osteotomy (PAO) compared with PAO alone in treating concomitant intra-articular pathology in hip dysplasia. Materials and methods Forty-one patients (46 hips) with symptomatic hip dysplasia were retrospectively reviewed. Pre- and postoperative radiographic data and intraoperative data consisting of estimated blood loss, intraoperative and postoperative blood transfusions, operative time, and length of hospital stay were recorded. The complications occurring within the first 3 months after surgery including lateral femoral cutaneous and pudendal nerve neuropraxia, wound complications, and reoperations were recorded. Additionally, rates of deep venous thrombosis and other major adverse outcomes (myocardial infarction, pulmonary embolism, stroke, death) were examined. Results Twenty-one patients (24 hips) underwent PAO alone. Twenty patients (22 hips) underwent hip arthroscopy followed immediately by PAO. There were no significant differences in the 90-day complication rates between the two groups, comparing the rate of neuropraxia (p = 0.155) and wound complications (p = 0.6). Operative time for PAO alone was 179 minutes (standard deviation [SD] ± 37) compared with 251 minutes (SD ± 52) for combined hip arthroscopy and PAO (p < 0.001). No incidence of deep vein thrombosis or major adverse events was noted in either group. Preoperative lateral center edge angle (LCEA) and acetabular index (AI) were 14° and 20° respectively, in the PAO-alone group and 19° and 16° respectively, in the combined group. Postoperatively, LCEA was 29° in the PAO-alone group and 30° in the combined group. Postoperative AI was 11° in the PAO-alone group and 5° in the combined group. Conclusion This study demonstrates that hip arthroscopy in combination with PAO to treat intra-articular pathology shows no difference in 90-day complication rates when compared with PAO alone. Level of evidence Level III, retrospective comparative study How to cite this article Neumann JA, Rickert KD, Bradley KE, Lewis BD, France MA, Olson SA. Concomitant Hip Arthroscopy and Periacetabular Osteotomy: Is there a Difference in Perioperative Complications compared with Periacetabular Osteotomy Alone? The Duke Orthop J 2017;7(1):51-57.

Impact of acute kidney injury on coagulation in adult minimal change nephropathy.

A hypercoagulable state exists in patients with nephrotic syndrome (NS), which more easily leads to venous thromboembolism (VTE). However, whether acute kidney injury (AKI), a common complication of NS, affects the hypercoagulable state and VTE has rarely been elucidated. In this study, we aimed to explore coagulation changes and analyze relevant influencing factors in NS-AKI patients.A total of 269 consecutive NS patients with minimal change disease (MCD) between 2011 and 2016 were included in this observational study. Ninety-one cases were in the AKI group and 178 cases in the non-AKI group. The 1:1 propensity score matching (PSM) method was applied to match the baseline information. The coagulation biomarkers were compared, and the thrombosis events were recorded. Linear correlation was performed to detect any relation between D-dimer and clinical data.The PSM method gave matched pairs of 88 MCD patients with AKI and non-AKI patients, resulting in no differences in baseline information. The D-dimer, fibrinogen, and thromboelastography parameters maximum amplitude (MA), G values of the MCD-AKI patients were significantly higher than the levels of the MCD patients without AKI (D-dimer: 1.8 [1.0, 3.3] vs 1.1 [0.6, 1.7] mg/L, P < 0.001; fibrinogen: 7.0±2.0 vs 6.5 ± 1.4 g/L, P = 0.036; MA: 74.6 ± 5.0 vs 70.5 ± 5.3 mm, P = 0.020; G: 15.7 ± 5.3 vs 12.5 ± 3.3, P = 0.034). For the MCD patients, the serum creatinine, white blood cell count, and interleukin-6 levels in the patients with D-dimers >1 mg/L were significantly higher than those of patients with D-dimers ≤1 mg/L. The correlation analysis showed that the D-dimer level was correlated with serum creatinine, white blood cell count, and interleukin-6 (r = 0.410, P = < 0.001; r = 0.248, P = < 0.001; r = 0.306, P = < 0.001, respectively). Five deep vein thrombosis events occurred in the AKI group and 1 pulmonary embolism event occurred in the non-AKI group after adjusting the propensity score value. AKI appeared to have an association with higher incidence of VTE, but the difference was not statistically significant (RR: 4.9, 95% CI: 0.6–42.7, P = 0.154).The MCD-NS patients complicated with AKI had a more severe hypercoagulable state, which might be associated with the active inflammation of AKI that mediated activation of the coagulation system.

The Validity of Using ICD-9 Codes for Identifying Venous Thromboembolism Following Below Knee Surgery

Category: Other Introduction/Purpose: To determine the incidence of venous thromboembolism (VTE) after surgeries performed below the knee, previous studies have used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes to identify a DVT (deep vein thrombosis) or PE (pulmonary embolism) event. The purpose of this study was (1) to determine the incidence of VTE in a large cohort of patients who had undergone surgery below the knee, and (2) to assess the validity of the ICD-9-CM procedure codes used. Methods: Current Procedural Terminology codes and ICD-9-CM codes were used to identify patients who had undergone below knee surgery and a reported VTE. The medical records of 21,904 patients were evaluated to assess the validity of the VTE ICD-9-CM code against the documentation of DVT or PE in radiology reports. Positive predictive value (PPV) and sensitivity of ICD-9-CM codes were calculated. Results: The incidence of VTE was 2.5% (552/21,904). Of those patients identified as having VTE, 344 (62.3%) had a DVT, 130 (23.6%) had a PE, and 78 (14.1%) were recorded as having both a DVT and PE. The PPV of ICD-9-CM coding were 55.7% (327/587) for DVT, 84.4% (108/128) for PE, 60.2% (59/98) for DVT/PE combined, and 60.8% (494/813) for VTE in total. The resulting sensitivity scores were 95.1% (327/344) for DVT, 83.1% (108/130) for PE, 75.6% (59/78) for DVT/PE combined, and 89.5% (494/552) for VTE in total. Conclusion: The overall rate of VTE after below knee surgery was 2.5%. This study found that ICD-9 code use had an 89.5% sensitivity rate for VTE. Using ICD-9 codes to search for a VTE demonstrated a low PPV, however, because only 60.8% could be verified by a radiological study. By comprehensively assessing the incidence of VTE after below knee surgery, we illustrated a potential source of inaccuracy in the use of retrospective ICD-9 based data capture methodologies.

A5089 - Utilizing MBSAQIP Data to Evaluate Venous Thromboembolism Prophylaxis in Bariatric Patients at a Single Institution

Patients with obesity are at increased susceptibility of developing deep vein thrombosis (DVT) and venous thromboembolic events (VTE) due to their body habitus, potential acquired or genetic hypercoagulable states, and the surgical procedure itself. In literature, there have been many protocols for DVT/VTE prophylaxis but a general consensus has never been reached. In this study, we describe our experience with the use of moderately higher dose of low molecular weight heparin (LMWH) with longer duration for DVT/VTE prophylaxis, its safety and efficacy in higher risk bariatric surgery patients.

Limiting the Number of Lumens in Peripherally Inserted Central Catheters to Improve Outcomes and Reduce Cost: A Simulation Study.

BACKGROUND The number of peripherally inserted central catheter (PICC) lumens is associated with thrombotic and infectious complications. Because multilumen PICCs are not necessary in all patients, policies that limit their use may improve safety and cost. OBJECTIVE To design a simulation-based analysis to estimate outcomes and cost associated with a policy that encourages single-lumen PICC use. METHODS Model inputs, including risk of complications and costs associated with single- and multilumen PICCs, were obtained from available literature and a multihospital collaborative quality improvement project. Cost savings and reduction in central line-associated bloodstream infection and deep vein thrombosis events from institution of a single-lumen PICC default policy were reported. RESULTS According to our model, a hospital that places 1,000 PICCs per year (25% of which are single-lumen and 75% multilumen) experiences annual PICC-related maintenance and complication costs of $1,228,598 (95% CI, $1,053,175-$1,430,958). In such facilities, every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500. Moving from 25% to 50% single-lumen PICC utilization would result in total savings of $119,283 (95% CI, $74,030-$184,170) per year. Regardless of baseline prevalence, a single-lumen default PICC policy would be associated with approximately 10% cost savings. Findings remained robust in multiway sensitivity analyses. CONCLUSION Hospital policies that limit the number of PICC lumens may enhance patient safety and reduce healthcare costs. Studies measuring intended and unintended consequences of this approach, followed by rapid adoption, appear necessary. Infect Control Hosp Epidemiol 2016;37:811-817.

Venous thromboembolism after radical cystectomy: Experience with screening ultrasonography

ObjectivesTo detect the incidence of immediate postoperative deep vein thrombosis (DVT) using screening lower extremity ultrasonography (US) in patients undergoing radical cystectomy (RC) and to determine the rate of symptomatic pulmonary embolism (PE) after RC and identify risk factors for venous thromboembolic (VTE) events in a RC population. Patients and methodsWe performed a retrospective review of prospective data collected on patients who underwent RC between July 2008 and January 2012. These patients underwent screening US at 2/3days after RC to determine the rate of asymptomatic DVT. A chart review was completed to identify those who had a symptomatic PE. Univariate and multivariable analysis was used to identify risk factors associated with DVT, PE and total VTE events. ResultsIn all, 221 patients underwent RC and asymptomatic DVT was identified in 21 (9.5%) on screening US. Nine (4.5%) developed symptomatic PE at a median of 9days, of which no patients had positive lower extremity US postoperatively. Increased length of hospital stay, increased estimated blood loss, and lower body mass index were linked to risk of PE, and only a previous history of DVT was associated with postoperative DVT. ConclusionPatients who undergo RC are at high-risk for thromboembolic events and multimodal prophylaxis should be administered. Clinicians should be especially vigilant in those who demonstrate factors associated with higher risk for VTE events.

Metabolic Syndrome and Deep Vein Thrombosis After Total Knee and Hip Arthroplasty

BackgroundMetabolic syndrome (MS), defined as obesity, hypertension, hyperglycemia, and dyslipidemia, is prevalent among patients undergoing total joint arthroplasty (TJA). MS has proven to promote a proinflammatory and prothrombotic state in patients. Venous thromboembolism is one of the major complications of TJA. The purpose of this retrospective study is to identify whether MS and its components increase the risk of deep vein thrombosis (DVT) after TJA. MethodsWe retrospectively reviewed 1553 patients undergoing primary unilateral TJA from 2007 to 2014. MS was diagnosed based on the World Health Organization criteria. All subjects received venography after operation to screen for DVT. Symptomatic DVT events after TJA were also recorded. Univariate analysis and multivariate logistic regression analysis were used to identify the association of MS and its components with postoperative DVT. ResultsThe prevalence of MS in patients undergoing TJA was 5.1% (n = 79). A total of 335 patients (21.6%) were diagnosed with DVT by venography. Seventy-eight patients (5.0%) developed symptomatic DVT. In the total knee arthroplasty group, MS and obesity were related to postoperative DVT. MS alone was found to be associated with symptomatic DVT. In the total hip arthroplasty group, MS increased the risk of symptomatic DVT. However, obesity, rather than MS, was associated with total DVT after total hip arthroplasty. ConclusionsMS was a significant risk factor for DVT after TJA. Strategies to minimize the adverse effect of MS should be considered for these patients.

Bemiparin for thromboprophylaxis after benign gynecologic surgery: a randomized clinical trial

Venous thromboembolism (VTE) is the leading cause of mortality and morbidity in women following gynecologic surgery. To determine the efficacy of a second-generation low molecular weight heparin (bemiparin) for thromboprophylaxis after benign gynecologic surgery. We performed a single-blind randomized controlled trial including women in the moderate-risk, high-risk and highest-risk groups for developing VTE after benign gynecologic surgery. Participants were randomized at a 1:1 ratio into parallel groups to receive either seven daily doses of 3500IU of subcutaneous bemiparin or to a non-intervention group receiving standard rehydration and advice on ambulation. Participants were followed up for 7days and 30days postoperatively for symptomatic VTE, which was confirmed by compression Doppler ultrasound, magnetic resonance imaging, or computed tomographic pulmonary angiography, according to the type of VTE. In total, 387 participants were randomized to the bemiparin group and 387 to the non-intervention group. The incidence of symptomatic VTE (deep vein thrombosis and pulmonary embolism) events was lower (0/377) in participants who received bemiparin than in those who received no pharmacologic intervention (12/380, 3.2%; 95% confidence interval [CI]0.002-0.6). Logistic regression analysis showed significant associations between VTE and immobility (odds ratio [OR]7.1; 95%CI1.3-36.2), varicose veins (OR16.8; 95%CI3.1-76.2), and thrombophilia (OR39.3; 95%CI1.5-1006.7). There were no major bleeding events or side effects related to the use of bemiparin. Bemiparin was an effective thromboprophylactic agent for preventing venous thrombosis after benign gynecologic surgery.

History of deep vein thrombosis is a discriminator for concomitant atrial fibrillation in pulmonary embolism

BackgroundPulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 70% of all cases. Although, PE and DVT are commonly related to risk factors of Virchow's triad, both entities are linked to cardiovascular risk factors, but risk factors seem differently important in both entities. ObjectivesWe aimed to investigate clinical profile and outcome of patients with PE history stratified by concomitant DVT. Patients/MethodsData from the observational multi-center thrombEVAL-study were analyzed. ResultsThe sample (N=2,318) comprised 295 PE patients, of whom 69.2% (N=204) had DVT. Individuals without DVT were older and had higher prevalence of concomitant atrial fibrillation (AF), chronic lung diseases, coronary artery disease, heart failure and hypertension. Multivariable regression revealed an independent association of AF (Odds Ratio (OR) 3.17, 95% CI 1.63–6.18, P<0.001) and coronary artery disease (OR 2.31, 95% CI 1.15–4.66, P=0.019) with PE without DVT. There was higher frequency of permanent AF in individuals without DVT, whereas paroxysmal AF was more prevalent in individuals with DVT. All AF subtypes were independently associated with PE without DVT with increasing ORs from paroxysmal to permanent AF. PE patients with and without DVT did not differ in survival (P=0.32) and cost-relevant clinical outcome (P=0.26) during follow-up. AF in PE patients was associated with cost-relevant clinical outcome (Hazard Ratio (HR) 1.78, 95% CI 1.03–3.09, P=0.040), but no significant difference in survival (HR 0.93, 95% CI 0.35–2.50, P=0.88) was observed. ConclusionsHistory of DVT is a significant discriminator for clinical profile of PE patients. Individuals without DVT had more often cardiac and pulmonary disease with strongest association with AF. Data advocate a potential link between AF and PE.Clinical Trial Registration: URL: http://www.clinicaltrials.gov, Unique identifier NCT01809015.

Venous thromboembolism: An overview

Venous thromboembolism (VTE) is a disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). It is a common, lethal disorder that affects both hospitalized and nonhospitalized patients. PE and DVT are 2 clinical presentations of VTE and share the same predisposing factors. In most cases, PE is a consequence of DVT. This article discusses the predisposing factors, prevalence, and individuals who are at risk of developing this often life-threatening disease.

Older soft tissue sarcoma patients experience increased rates of venous thromboembolic events: a retrospective cohort study of SEER-Medicare data.

BackgroundVenous thromboembolic co-morbidities can have a significant impact on treatment response, treatment options, quality of life, and ultimately, survival from cancer. There is a dearth of published information on venous thromboembolic co-morbidity among older soft tissue sarcoma patients.MethodsSEER-Medicare linked data (1993–2005) was utilized for this retrospective cohort analysis (n = 3,480 soft tissue sarcoma patients). Non-cancer patients were frequency-matched by age to cancer patients at a ratio of 1:1; coverage and follow-up requirements were the same as for soft tissue sarcoma cases. Venous thromboembolic events were divided into three groups of interest: deep vein thrombosis, pulmonary embolism, and other thromboembolic events. Relative incidence rates of venous thromboembolic events in soft tissue sarcoma patients with a recent history of cardiovascular event or venous thromboembolic event (12 months before diagnosis) versus soft tissue sarcoma patients without such a recent history were calculated using the Cox proportional hazard models. The Cox proportional hazard model was used to build predictive models to identify important risk factors for each venous thromboembolic event of interest among soft tissue sarcoma patients. Relative incidence rate of VTEs in cancer patients (12 months after diagnosis) versus non-cancer cases (12 months after index date) was calculated using multivariable Cox proportional hazard models.ResultsWe observed that among older soft tissue sarcoma patients, 10.6% experienced a deep vein thrombosis, 3.0% experienced a pulmonary embolism, and 3.1% experienced other thromboembolic events in the 12 months after sarcoma diagnosis. On average, 60% of venous thromboembolic events occurred in the first 90 days after sarcoma diagnosis. The highest rates of deep vein thrombosis and pulmonary embolism after sarcoma diagnosis were seen in patients with sarcoma not otherwise specified (deep vein thrombosis: 204/1,000 p-y and pulmonary embolism: 50/1,000 p-y). Recent history of a venous thromboembolic event was the strongest predictor of a subsequent venous thromboembolic event after soft tissue sarcoma diagnosis.ConclusionVenous thromboembolic events are common and serious co-morbidities that should be closely monitored in older soft tissue sarcoma patients.

Analysis of the accuracy of the Wells scale in assessing the probability of lower limb deep vein thrombosis in primary care patients practice.

BackgroundThe clinical picture of deep vein thrombosis (DVT) is nonspecific. Therefore assessment of the probability of occurrence of DVT plays a very important part in making a correct diagnosis of DVT.The aim of our prospective study was to assess the accuracy of the Wells scale in primary care setting in diagnostic procedure of suspected deep vein thrombosis.MethodsIn the period of 20 - months (from 2007 to 2009) a group of residents from one of the urban districts of Warsaw, who reported to family doctors (22 primary care physicians were involved in the study) with symptoms of DVT were assessed on the probability of occurrence of deep vein thrombosis using the Wells scale. Family doctors were aware of symptoms of DVT and inclusion patients to this study was based on clinical suspicion of DVT.Patients were divided into three groups, reflecting probability of DVT of the lower limbs.To confirm DVT a compression ultrasound (CUS) test was established.We analyzed the relationship between a qualitative variable and a variable defined on an original scale (incidence of DVT versus Wells scale count) using the Mann–Whitney test. Chi-square test compared rates of DVT events in all clinical probability groups.Patient were follow up during 3 months in primary care setting.ResultsIn the period of 20 months (from 2007 to 2009) a total number of 1048 patients (male: 250 , female: 798 mean age: 61.4) with symptoms suggestive of DVT of the lower extremities entered the study. Among the 100 patients classified in the group with a high probability of DVT of the lower extremities, 40 (40%) patients (proximal DVT - 13; distal DVT - 27) were diagnosed with it (95% CI [30.94% -49.80%]). In the group with a moderate probability consisting of 302 patients, DVT of the lower extremities was diagnosed in 19 (6.29%) patients (95% CI [4.06% -9.62%]), (proximal DVT – 1; distal DVT - 18). Of the 646 patients with a low probability of DVT of the lower extremities distal DVT was diagnosed in 1 (0.15%) patient (95% CI [0.03% -0.87%]).ConclusionThe Wells scale used in primary care setting demonstrated a high degree of accuracy.

Study of the fibrinolytic process in a patient with antiphospholipid syndrome

The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antibodies against β2-Glycoprotein I (aβ2-GPI), cardiolipin (aCL) and lupus anticoagulant combined with venous or arterial thrombosis and/or foetal losses. A 28-year-old female was positive for aβ2-GPI, aCL, aPT (antibodies against prothrombin) and lupus anticoagulant. She had two miscarriages and a deep vein thrombosis event. The patient plasma fibrinogen and IgG concentrations were two times higher than control. Fibrinolysis was induced in vitro adding tPA, before clotting plasma with 0.03 or 0.6 IU/ml thrombin, and in purified system with normal fibrinogen in the presence of 0.5 mg/ml of patient or normal IgG. The APS patient had 1.5 and 1.9 times higher clot rate formation (CRL) and maximum absorbance (MaxAbsL) at both thrombin concentrations. At 0.6 IU/ml of thrombin, the patient delay on fibrin polymerization onset was corrected. The patient Lys50MA (time needed for 50% clot dissolution) was slower (P < 0.05) at 0.03 IU/ml of thrombin; however, the lysis rate was faster at both thrombin concentrations. After adjusting the polymerization and fibrinolytic parameters according to the sample plasma fibrinogen concentration, there were almost no differences between patient and control at 0.6 IU/ml. In an IgG-fibrinogen purified system, fibrinolysis was equivalent in the presence of patient or normal IgG. In conclusion, the patient IgG fraction has no inhibitors against proteins of the fibrinolytic pathway. The differences observed between the APS patient and the control were more evident at low thrombin concentration due to the presence of aPT.

Tranexamic acid and orthopedic surgery-the search for the holy grail of blood conservation.

Over the last decade an increasing amount of literature regarding the perioperative use of tranexamic acid (TXA) for bleeding control in orthopedic surgery has been published (1-6). While clinical trials found promising results regarding the reduction of blood loss and therefore a reduced rate of blood transfusions, concerns regarding prothrombotic adverse events including deep vein thrombosis, myocardial infarction, pulmonary embolism and cerebrovascular events have continued to dampen the enthusiasm and thus recommendations for wide spread use (7).

MP64-10 PERIOPERATIVE BLOOD TRANSFUSION IN BLADDER CANCER PATIENTS UNDERGOING RADICAL CYSTECTOMY IS ASSOCIATED WITH INCREASED MORBIDITY AND LENGTH OF STAY BUT NOT ADVERSE ONCOLOGIC OUTCOMES

You have accessJournal of UrologyBladder Cancer: Natural History and Pathophysiology1 Apr 2015MP64-10 PERIOPERATIVE BLOOD TRANSFUSION IN BLADDER CANCER PATIENTS UNDERGOING RADICAL CYSTECTOMY IS ASSOCIATED WITH INCREASED MORBIDITY AND LENGTH OF STAY BUT NOT ADVERSE ONCOLOGIC OUTCOMES Heather Chalfin, Jen-Jane Liu, Nilay Gandhi, Zhaoyong Feng, Bruce Trock, Steven Frank, and Trinity Bivalacqua Heather ChalfinHeather Chalfin More articles by this author , Jen-Jane LiuJen-Jane Liu More articles by this author , Nilay GandhiNilay Gandhi More articles by this author , Zhaoyong FengZhaoyong Feng More articles by this author , Bruce TrockBruce Trock More articles by this author , Steven FrankSteven Frank More articles by this author , and Trinity BivalacquaTrinity Bivalacqua More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2321AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Perioperative blood transfusion (PBT) has been associated with adverse oncologic outcomes, including cancer recurrence, death, and perioperative morbidity for certain malignancies, possibly via an immunologic mechanism. However, reports on the effects of PBT on bladder cancer survival are controversial. As chemotherapy is also immunosuppressive, we analyzed the effect of PBT on morbidity, cancer specific survival (CSS), and overall survival (OS) in a cohort of patients treated with neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) for bladder cancer. METHODS The Johns Hopkins Radical Cystectomy database was queried for patients who had undergone NAC followed by RC from 2001–2013. 119 patients had available PBT and outcome information. A multivariable Cox proportional hazards model was used to evaluate risk factors including pathologic stage, Charlson comorbidity index, age, race, year of surgery, surgical margin status, BT, and preoperative hemoglobin for bladder cancer specific survival (CSS) and overall survival (OS). Survival time was measured from cystectomy to death or last follow up. Logistic regression models were used to determine whether PBT was associated with morbidity, including drug resistant antibiotic infection, wound infection, sepsis, c.diff, disseminated intravascular coagulation, deep vein thrombosis, pulmonary embolism, respiratory or renal event, stroke, heart attack, and transient ischemic attack. RESULTS PBT significantly predicted OS (HR:1.26 (1.07-1.49), p=0.005), CSS (HR:1.32 (1.11-1.57), p=0.002) and morbidity (HR:1.67 (1.26-2.21), p=0.004) in univariate analysis. In multivariable models, PBT was significantly associated with morbidity (HR:1.77 (1.31-2.40), p=0.0002), but not CSS or OS. A dose response was observed for morbidity, with >2 units independently associated with morbidity. Median LOS was 7 days for non-transfused patients and 8 for those who received PBT (p=0.037). CONCLUSIONS PBT was associated with increased LOS and morbidity but did not predict OS or CSS. Although BT may be life-saving in certain patients undergoing RC, a restrictive transfusion strategy may prevent morbidity and decrease length of stay after RC. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e801 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Heather Chalfin More articles by this author Jen-Jane Liu More articles by this author Nilay Gandhi More articles by this author Zhaoyong Feng More articles by this author Bruce Trock More articles by this author Steven Frank More articles by this author Trinity Bivalacqua More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Carbon monoxide poisoning and risk of deep vein thrombosis and pulmonary embolism: a nationwide retrospective cohort study

BackgroundFew studies have investigated the relationship between carbon monoxide (CO) poisoning and risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Therefore, we conducted a nationwide longitudinal cohort study...

Safety and Efficacy of Tranexamic Acid in Total Knee Arthroplasty.

BackgroundThe prevalence of total knee arthroplasty (TKA) is increasing, which is one of the most frequent operations in orthopedic practice. To further investigate the safe and effective role of using tranexamic acid (TA) in reducing transfusion rate and blood loss in total knee arthroplasty.Material/MethodsThis meta-analysis was conducted according to the Cochrane methodology. Twenty-eight superior quality and well designed randomized controlled trials (RCT) were collected to analyze for this study. Patients who had undergone primary unilateral TKA were chosen. The software, RevMan 5.2, was used to analyze collected data.ResultsFinally, 28 RCTs were collected to analyze for this study. Total blood loss was dramatically decreased via the application of TA, by a mean of 420 ml [95% CI: −514 to −327]. A significant reduction about blood transfusion rate was also found in patients who received TA. [RD: −0.26, 95%CI: −0.33 to −0.19]. Moreover, no significant differences were found between TA and control groups in incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).ConclusionsThis meta-analysis demonstrates that the application of TA in TKA could decrease total blood loss and transfusion rate. On the other hand, the application of TA is not associated with high incidence of DVT or other adverse events. TA should be taken into account in routine use in primary knee arthroplasty to benefit the patients.

Adoption of Outpatient Treatment of Deep Vein Thrombosis in the U.S.: The Reasons for Geographic and Racial Differences in Stroke Study (REGARDS)

▪Introduction: Outpatient treatment of deep vein thrombosis (DVT) has been shown equivalent to inpatient treatment in clinical trials and results in cost savings and increased patient-convenience. Despite the advantages, there are few studies on the national uptake of outpatient care of DVT in the U.S. and there are no national surveillance studies of DVT. Through understanding the current treatment patterns of DVT, we can design interventions to reduce health care costs and increase patient convenience.Methods: Between 2003-07, 30,239 participants ≥45 years old were enrolled in REGARDS, a nationally representative cohort recruited from the contiguous U.S. By design, 55% were female, 41% were black, and 56% lived in the southeast. Venous thrombosis (VTE) events were ascertained through 2011, with identification by telephone interview, review of reported hospitalizations, and review of deaths and validated by physician review of hospital and outpatient records. Using all available information, characteristics of the VTE event and treatment were systematically recorded. Location of residence was defined by geocoding of the address with urbanicity defined by census tract, and other risk factors were obtained through surveys, telephone interviews, or an in-home visit. We used logistic regression to determine the predictors of outpatient treatment of DVT among those with DVT.Results: Over 5 years of follow-up 379 VTE events occurred (incident and recurrent); 185 were diagnosed with a pulmonary embolism and 53 occurred as a complication of hospitalization (and not eligible for outpatient treatment) leaving 141 DVT events potentially eligible for outpatient treatment. Only 28% of DVT events (39 of 141) were treated as an outpatient. Factors significantly associated with being treated as an outpatient include younger age, female sex, white race, later year of DVT diagnosis, and living in an urban area (Table). Other risk factors with high odds ratios that were not statistically significant were living outside the southeast of the U.S. and being a high school graduate (Table).Conclusions: In a contemporary, nationally representative cohort, only 28% of DVT events were treated as an outpatient. Adverse socioeconomic status, residence in a rural area, advancing age, race, and male sex were independently associated with lower likelihood of outpatient treatment. These data highlight the low proportion of DVTs currently treated on an outpatient basis, as well as disparities in the outpatient treatment of DVT. Outpatient DVT treatment has the potential to reduce the cost of medical care for DVT in the U.S.Table:Predictors of Outpatient treatment of DVTs in the REGARDS StudyVariablePrevalence of Factor(%, n)Odds ofOutpatient Treatment*Age (per 10 years younger)69 years (Median)1.90 (1.19, 3.02)Year of VTE (per 1 year later)2008 (Median, range 2003-11)1.35 (1.03, 1.77)Sex (female vs male)46.8% (66)2.41 (1.06, 5.47)Race (white vs black)66.0% (93)3.29 (1.30, 8.30)Region (elsewhere vs southeast)50.4% (71)2.00 (0.87, 4.63)High School Graduate (yes vs no)90.8% (128)4.51 (0.52, 38.82)Income >$20,000 (yes vs no)63.8% (90)2.63 (0.87, 7.94)Living in a Urban Area (yes vs no)75.2% (106)4.16 (1.25, 13.79)Adjusted for age, sex, race, VTE event year and region* DisclosuresNo relevant conflicts of interest to declare.

Is tranexamic acid clinically effective and safe to prevent blood loss in total knee arthroplasty? A meta-analysis of 34 randomized controlled trials.

Tranexamic acid (TXA) is well established as a versatile intraarticular and intravenous (IV) antifibrinolytic agent that has been successfully used to control bleeding after total knee arthroplasty (TKA). The present meta-analysis aimed at assessing the effectiveness and safety of TXA in reducing blood loss and transfusion in TKA. We searched the PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases from 1966 to December 2013. Only randomized controlled trials (RCTs) were included in the present study. Two independent reviewers identified the eligible studies, assessed their methodological quality, and extracted data. The data were using fixed-effects or random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Subgroup analysis was performed according to the IV or intraarticular administration of TXA. Thirty-four RCTs encompassing 2,594 patients met the inclusion criteria for our meta-analysis. Our meta-analysis indicated that when compared with the control group, the IV or intraarticular use of TXA significantly reduced total blood loss, postoperative blood loss, Hb loss, and transfusion rate as well as blood units transfused per patient after primary TKA, but did not reduce intraoperative blood loss. No significant difference in deep vein thrombosis (DVT), pulmonary embolism, or other adverse events among the study groups. IV or intraarticular use of TXA for patients undergoing TKA is effective and safe for the reduction blood loss and blood transfusion requirements, yet does not increase the risk of postoperative DVT. Level II.

Incidence of hospital readmission in patients diagnosed with DVT and PE: clinical burden of recurrent events.

Venous thromboembolism (VTE), which comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality and represents a considerable economic burden to the US healthcare system. Although it is well established that patients with an initial VTE are at increased risk for recurrent VTE, limited data exist on the clinical burden of a secondary DVT or PE event. The objective of this retrospective observational study was to conduct an epidemiologic evaluation, from a hospital perspective, of patients with an initial DVT or PE who experienced a recurrent event postdischarge requiring hospital readmission. Hospital claims containing DVT or PE as a primary diagnosis for hospitalisation during the period October 2009 to April 2013 were identified by retrospective analysis using the MarketScan database. The time to hospital readmission for DVT or PE was assessed using the MarketScan Treatment Pathways tool. Of 214,901 patient admissions identified with a diagnosis of DVT or PE at hospital admission, approximately 4% were subsequently readmitted to the hospital with a diagnosis of PE (8217) or DVT (9138). Of all readmitted patients with a diagnosis of DVT on initial admission, 66% were rehospitalised with a diagnosis of DVT, and 34% were rehospitalised with a diagnosis of PE. Of all readmitted patients with a diagnosis of PE on initial admission, 63% were rehospitalised with a diagnosis of PE and 37% with a diagnosis of DVT. Of all hospital readmissions with a diagnosis of PE or DVT, 62% and 58% occurred within the first 30 days following an initial PE or DVT event, respectively. The burden of DVT or PE is large, not only because of the initial hospitalisation event but also because of the high number of hospital readmissions, more than half of which occur within 30 days.