High Risk Of VTE Research Articles

Thrombin generation (TG) and D-dimer levels for the identification of cancer patients at higher VTE risk enrolled in the HYPERCAN study

Thrombin generation (TG) and D-dimer levels for the identification of cancer patients at higher VTE risk enrolled in the HYPERCAN study

Validation of the Caprini risk assessment model for venous thromboembolism in Chinese hospitalized patients in a general hospital

Objective: To assess the validity of Caprini risk assessment model in prediction of venous thromboembolism in Chinese hospitalized patients in a general hospital. Methods: Medical record review was performed in Beijing Shijitan Hosital for all eligible hospitalized patients who underwent screening for venous thromboembolism between January and December 2015. The Caprini score of patients with or without venous thromboemboilism and incidence of venous thromboembolism in patients with various Caprini risk levels, surgery and medical patients was compared. Results: A total of 6 966 inpatients were enrolled. Three hundred and ninety-six patients developed venous thromboembolism. The Caprini median score of patients with venous thromboemboilism was 5 (3-7), which higher than 3(2-5) of patients without venous thromboembolism(Z=-13.68, P<0.01). Incidence of venous thromboembolism of patients in low, moderate, high, highest risk level was 1.0%, 1.8%, 5.7%, 10.6%, respectively. There was no statistically significant difference of incidence between low and moderate risk patients (OR=1.88, 95%CI: 0.89-3.99, P>0.05), but significant difference between moderate and high risk (OR=3.23, 95%CI: 2.06-5.06, P<0.01), high and highest risk patients (OR=1.97, 95%CI: 1.59-2.45, P<0.01). There was no incidence difference of venous thromboembolism between surgery and medical patients in the same Caprini level of low (χ(2)=3.58 , P>0.05), moderate(χ(2)=2.89, P>0.05), high(χ(2)=0.46, P>0.05), highest risk(χ(2)=1.61, P>0.05). Conclusion: Caprini risk assessment model can effectively predict the occurence of venous thromboembolism in Chinese hospitalized patients with high risk of VTE(Caprini score >2)in a general hospital.

Incidence, outcome and risk stratification tools for venous thromboembolism in advanced pancreatic cancer – A retrospective cohort study

IntroductionVenous thromboembolism (VTE) is frequent in advanced pancreatic cancer (APC). Recent studies demonstrated that the Khorana score - an established risk stratification tool for VTE in cancer - performs poorly in identifying pancreatic cancer patients at high risk for VTE. Materials and methodsWe performed a retrospective cohort study in order to define incidence, treatment and outcome of VTE as well as the performance of VTE risk stratification tools (Khorana score, CONKO score and aPTT ratio) in a “real life” clinical cohort of APC patients undergoing palliative chemotherapy. Results and conclusionsOne hundred and seventy-two eligible APC patients from our comprehensive cancer center were identified. VTE after start of palliative chemotherapy was diagnosed in 71 patients (41.3%). Most VTE events were asymptomatic (n=50, 29.1%) with only 21 symptomatic events (12.2%). On multivariate analysis - including age, performance status and carbohydrate antigen 19-9 (CA 19-9) - symptomatic VTE was an independent risk factor for death (hazard ratio [HR]: 2.22, 95% CI: 1.05–2.60, p<0.05). Khorana score, CONKO score and aPTT ratio alone were not able to predict the risk for symptomatic VTE. High risk patients could only be identified by using a combination of either Khorana or CONKO score with aPTT ratio (30% vs. 10% symptomatic VTE events in high vs. low risk patients, p<0.05). The combination of Khorana or CONKO score with aPTT thus may represent a novel risk stratification tool for symptomatic VTE in APC and should further be validated within prospective clinical trials.

Abstract 306: Impact of Venous Thromboembolism as Independent Predictor of Mortality Among Patients With Gastric Cancer

Background: Cancer-associated thrombosis is a predictor of death. Patients with gastric cancer (GC) are at higher risk for VTE when compared to other solid tumors. There is a paucity of data describing the impact of VTE in GC. Aim: To measure the impact of VTE as independent predictor of gastric cancer mortality. Methods: Single institution chart review of GC treated patients (2010-15). VTE events were objectively confirmed. GC was ascertained if biopsy proven and metastatic, or on active chemotherapy. Along with cancer specific data, we abstracted risk assessments tools, non-GC specific, validated for VTE and mortality prediction in cancer; including, the Khorana Score (KRS), platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR). Continuous variables are expressed by the by the median (interquartile range). Categorical variables are expressed as percentages. We used SPSS 23, specifically Kaplan-Meir curve and Cox proportional hazard were applied for main objectives. Results: We included 112 pts in the analysis, who were predominantly male (66%), 58 (51-64) year-old, with adenocarcinoma (84%) and advanced disease (59%). The median follow-up was 21.3 months (9.5-42.6). We measured high risk of VTE based on the KRS in 59%, 51% had an elevated NLR and 30% had an elevated PLR. VTE occurred in thirteen (12%) patients. The median time from diagnosis to VTE occurrence was 59 days (36-258). After multivariate analysis, the predictors of mortality were: VTE (Hazard Ratio (HR), 2.6; 95% CI, 1.1 to 6.0; p=0.02), Histological type (HR, 3.2; 95% CI, 1.1 to 9.2; p=0.03), Stage (HR, 2.9; 95%CI, 1.4 to 5.8; p&lt;0.01) and PLR (HR, 2.2; 95%CI, 1.3 to 3.9); p&lt;0.01). The one year overall survival of patients with VTE was lower than for those with no VTE (79% vs 41% p&lt;0.05) Conclusion: VTE is associated with worse survival among patients with GC. Moreover, this finding was independent of other cancer-specific variables. NLR and KRS were not associated with survival in our GC database.

Current guidelines do not sufficiently discriminate venous thromboembolism risk in urology

PurposeVenous thromboembolism (VTE) is the leading cause of noncancer death following major cancer surgery. Current thromboprophylaxis guidelines do not address procedure-specific risk of venous thromboembolism for urological patients. This project was created to determine the risk and timing of VTE after major urological surgery and to evaluate if surgical procedure was an independent risk factor for VTE after adjusting for previously established risk factors. Material and methodsThe American College of Surgeons׳ National Surgical Quality Improvement Program was used to create a cohort of patients who received major abdominal or pelvic urologic surgery between 2006 and 2014. The primary outcome was postoperative VTE. A Caprini score was calculated for each patient in our study to determine the risk of VTE. Multivariable logistic regression analyses were performed to determine the association between patient and procedural factors with venous thromboembolism. ResultsDuring the study period, 65,100 patients were eligible and 956 patients (1.5%) developed a venous thromboembolism. More than half of VTE events occurred after hospital discharge (n = 570; 60%). Radical cystectomy had the highest risk of VTE (299/5,976; 5.0%) and laparoscopic nephrectomy had the lowest risk (56/8,475; 0.7%). Most patients (58,782; 90%) were classified as high risk for VTE using the Caprini score. After adjusting for known risk factors, the risk of venous thromboembolism was significantly greater for radical cystectomy compared to laparoscopic nephrectomy (relative risk = 7.0; 95% CI: 5.0–9.2). ConclusionsThis study reports procedure-specific venous thromboembolism risk adjusting for known risk factors. These data demonstrate that procedure-specific thromboprophylaxis guidelines are needed in urology.

Newly Diagnosed Multiple Myeloma is Associated with Hypercoagulablity and High Risk of VTE. The Roadmap Study

Newly Diagnosed Multiple Myeloma is Associated with Hypercoagulablity and High Risk of VTE. The Roadmap Study

Abstract No. 203 - Prophylactic IVC filter placement in bariatric surgery patients: initial results from a prospective filter registry

Bariatric surgery patients are at moderate to high risk for VTE (1), but potential risks versus benefits of IVC filters in this group remain unclear (2). Indwelling filters may increase risk of VTE (3), and removal of filters in obese patients can be challenging (3). This study evaluated the incidence of VTE in bariatric patients receiving prophylactic IVC filters, their risk of filter-related complications, and outcomes from attempted filter retrieval. Over 4 years, 100 patients receiving an IVC filter prior to bariatric surgery were prospectively enrolled in a single-center IRB-approved study. Filters were placed if patients had BMI>50 kg/m2 and/or VTE risk factors per ASMBS guidelines (1), and all received mechanical (SCDs) and chemo-prophylaxis (UFH/LMWH). There were 29 men, 71 women, mean age = 49.0 ± 10.7 y; mean BMI = 58.0 ± 9.3. Retrievable filters were used (89 Gunther Tulip, 4 Option, 4 Denali, 2 ALN, 1 Celect) and patients underwent Roux-en-Y gastric bypass (n = 87) or sleeve gastrectomy (n = 13). All were contacted for follow-up and filter retrieval was attempted when no longer needed. All data were captured using REDCap. Postsurgical DVT occurred in 4(4%) (95%CI:1.0-10.0), at median 50 d (range: 17-94), and 1 patient (1%) (95%CI:0.03-5.0) developed acute low-risk PE at 23 days post-op, prior to filter removal. All VTE patients were successfully managed with therapeutic anticoagulation alone except one who also required thrombolysis to resolve IVC and iliofemoral DVT. Average filter dwell time was 146 d (range: 26-1548) and there were no major filter-related complications (0%). Retrieval was attempted in 96/100(96%) and successful in 96/96(100%). 28/96(29%) required advanced techniques for filter removal, and there were no major procedural complications (0%). Mean follow-up was 459.8 ± 407.7 days and 2 developed acute DVT > 1 year after filter retrieval, successfully treated with anticoagulation. Prophylactic IVC filters in combination with mechanical and chemoprophylaxis may help prevent life-threatening post-op PE in select bariatric surgery patients. The risk of filter-related complications was low, and retrieval success was high with adjunctive use of advanced techniques.

Newly Diagnosed Multiple Myeloma is Associated with Hypercoagulability and High Risk of VTE The ROADMAP Study

Newly Diagnosed Multiple Myeloma is Associated with Hypercoagulability and High Risk of VTE The ROADMAP Study

PO-53 - Prospective evaluation of risk assessment models and biological markers of hypercoagulability for the identification of high VTE risk patients with lung adenocarcinoma. The ROADMAP study

In patients with lung adenocarcinoma (LA), metastasis (MTS), advanced stage and chemotherapy (CTx) are risk factors for thromboembolism (VTE). Routine thromboprophylaxis is not recommended but individualized risk assessment is encouraged. The selection of the most relevant hypercoagulability biomarkers (HB) for incorporation into the risk assessment models (RAM) for VTE. Patients with documented LA eligible for CTx at distance of at least 3months from surgery or hospitalization were included. They were either CTx naive (NG) or had received CTx (OTG). Control group (CG) consisted of 30 healthy age & sex-matched individuals. We assessed them for thrombin generation (TG), P-Selectin, heparanase (HPA), procoagulant phospholipids (PPL), factor VIIa, D-Dimers (DDi) and Tissue Factor activity (TFa). Patients showed significantly shortened PPL and higher levels of TFa, DDi and HPA as compared to the CG. FVIIa levels were lower in patients compared to CG. The NG showed significantly shorter lag-time and lower ETP as compared to the OTG. It also showed significantly higher levels of HPA as compared to the OTG.The increase of TG and of HPA, P-Selectin, FVIIa was associated with the stage. Patients with MTS had higher levels of P-Selectin, TFa, DDi, FVIIa, TGT and HPA than those with localized or advanced disease.Patients with VTE had higher baseline levels of DDi, TGT, shorter PPL and lower levels of HPA as compared to those without. Patients who died within 3-months had higher baseline levels of DDi and lower HPA levels as compared to those who were alive. Increased PPL, TF pathway up regulation, DDi and HPA increase is a universal phenomenon in LA. CTx has an impact on TGT and HPA levels. Baseline values of TGT, PPL, HPA, DDi were related with mortality and thrombosis. The incorporation of HB in VTE-RAMs might improve their predictive value. This concept is being studied on an ongoing trial.

Individualized Risk Model for Venous Thromboembolism After Total Joint Arthroplasty

BackgroundVenous thromboembolism (VTE) after total joint arthroplasty (TJA) is a potentially fatal complication. Currently, a standard protocol for postoperative VTE prophylaxis is used that makes little distinction between patients at varying risks of VTE. We sought to develop a simple scoring system identifying patients at higher risk for VTE in whom more potent anticoagulation may need to be administered. MethodsUtilizing the National Inpatient Sample data, 1,721,806 patients undergoing TJA were identified, among whom 15,775 (0.9%) developed VTE after index arthroplasty. Among the cohort, all known potential risk factors for VTE were assessed. An initial logistic regression model using potential predictors for VTE was performed. Predictors with little contribution or poor predictive power were pruned from the data, and the model was refit. ResultsAfter pruning of variables that had little to no contribution to VTE risk, using the logistic regression, all independent predictors of VTE after TJA were identified in the data. Relative weights for each factor were determined. Hypercoagulability, metastatic cancer, stroke, sepsis, and chronic obstructive pulmonary disease had some of the highest points. Patients with any of these conditions had risk for postoperative VTE that exceeded the 3% rate. Based on the model, an iOS (iPhone operating system) application was developed (VTEstimator) that could be used to assign patients into low or high risk for VTE after TJA. ConclusionWe believe individualization of VTE prophylaxis after TJA can improve the efficacy of preventing VTE while minimizing untoward risks associated with the administration of anticoagulation.

VTE risk assessment in cancer. Who needs prophylaxis and who does not?

Venous thromboembolism (VTE) in patients with cancer is associated with an increased morbidity and mortality, and its prevention is of major clinical importance. However, the VTE rates in the cancer population vary between 0.5% - 20%, depending on cancer-, treatment- and patient-related factors. The most important contributors to VTE risk are the tumor entity, stage and certain anti-cancer treatments. Cancer surgery represents a strong risk factor for VTE, and medical oncology patients are at increased risk of developing VTE, especially when receiving chemotherapy or immunomodulatory drugs. Also biomarkers have been investigated for their usefulness to predict risk of VTE (e.g. elevated leukocyte and platelet counts, soluble P-selectin, D-dimer, etc.). In order to identify cancer patients at high risk of VTE and to improve risk stratification, risk assessment models have been developed, which contain both clinical parameters and biomarkers. While primary thromboprophylaxis with low-molecular-weight-heparin (LMWH) is recommended postoperatively for a period of up to 4 weeks after major cancer surgery, the evidence is less clear for medical oncology patients. Thromboprophylaxis in hospitalized medical oncology patients is advocated, and is based on results of randomized controlled trials which evaluated the efficacy and safety of LMWH for prevention of VTE in hospitalized medically ill patients. In recent trials the benefit of primary thromboprophylaxis in cancer patients receiving chemotherapy in the ambulatory setting has been investigated. However, at the present stage primary thromboprophylaxis for prevention of VTE in these patients is still a matter of debate and cannot be recommended for all cancer outpatients.

Prevalence of venous thromboembolism risk factors and prophylactic adequacy among general surgical patients in a tertiary care hospital

IntroductionVenous thromboembolism (VTE) is a disease manifested as deep vein thrombosis and pulmonary embolism. General surgical procedures are associated with significant risk of precipitating VTE, and despite the surging evidences, it is often overlooked. The study attempted at estimating the prevalence of VTE and bleeding risk factors coupled with the adequacy of thromboprophylaxis administered. MethodologyThe study spanning 1-year duration was executed through collection of data from patients older than 18 years, admitted to the general surgery department of a tertiary care hospital. The data were collected using internally validated data collection form and the appraisal of data was done using SPSS 18. ResultsAmong the 400 subjects enrolled, number of patients in low, moderate, and high risk, as per the Caprini score, was 24%, 35%, and 41%, respectively, with the difference being significant with p<0.001. Bleeding risk was positive in 28% subjects and 36% received any form of prophylaxis other than early ambulation. 28% subjects were identified to have received adequate thromboprophylaxis. ConclusionAlthough the prevalence of 41% individuals at high risk for VTE is comparable to the global prevalence of 41.5%, prophylactic adequacy of 28% was lower than the 33% observed globally. Meticulous planning coupled with operational interventions, such as institutional multidisciplinary thromboprophylactic team, can be an effective strategy at enhancing the prophylactic standards and thereby attaining optimal patient outcomes.

VTE risk assessment in cancer

SummaryVenous thromboembolism (VTE) in patients with cancer is associated with an increased morbidity and mortality, and its prevention is of major clinical importance. However, the VTE rates in the cancer population vary between 0.5% - 20%, depending on cancer-, treatment- and patient-related factors. The most important contributors to VTE risk are the tumor entity, stage and certain anticancer treatments. Cancer surgery represents a strong risk factor for VTE, and medical oncology patients are at increased risk of developing VTE, especially when receiving chemotherapy or immunomodulatory drugs. Also biomarkers have been investigated for their usefulness to predict risk of VTE (e.g. elevated leukocyte and platelet counts, soluble P-selectin, D-dimer, etc.). In order to identify cancer patients at high risk of VTE and to improve risk stratification, risk assessment models have been developed, which contain both clinical parameters and biomarkers. While primary thromboprophylaxis with lowmolecular- weight-heparin (LMWH) is recommended postoperatively for a period of up to 4 weeks after major cancer surgery, the evidence is less clear for medical oncology patients. Thromboprophylaxis in hospitalized medical oncology patients is advocated, and is based on results of randomized controlled trials which evaluated the efficacy and safety of LMWH for prevention of VTE in hospitalized medically ill patients. In recent trials the benefit of primary thromboprophylaxis in cancer patients receiving chemotherapy in the ambulatory setting has been investigated. However, at the present stage primary thromboprophylaxis for prevention of VTE in these patients is still a matter of debate and cannot be recommended for all cancer outpatients.

Circulating Platelet-Monocyte Aggregates Predict Venous Thromboembolism in Older Adults Undergoing Major Orthopedic Surgery

Background: Improvements in the early identification of older patients with a high post-operative VTE risk would potentially translate into more effective VTE prevention and management strategies.Objectives: We sought to establish whether measuring early indices of in vivo platelet activation following orthopedic surgery predicted VTE in older patients.Methods: We performed a prospective cohort study in 32 patients undergoing elective hip or knee arthroplasty who received warfarin thromboprophylaxis post-operatively. Patients were assessed for deep vein thrombosis post-operatively by compression ultrasonography (CUS) and followed for 30 days for clinical thrombotic events. Circulating levels of platelet-monocyte aggregates (PMAs), platelet surface p-selectin expression, and integrin αIIbβ3 activation were assessed immediately pre-operatively and on post-operative day 1 by flow cytometry. The procoagulant markers d-dimer and fibrinogen were measured in parallel.Results: The average age was 65.6±7.1 years and 43.8% were male (Table 1). VTE occurred in 40.6% (n=13/32) of patients a median of 3 days (IQR 2-3) after surgery. The majority of thrombotic events were deep vein thromboses that altered clinical management. Baseline clinical characteristics, age, weight, and laboratory values did not differ between patients who developed VTE post-operatively and those that did not. Post-operatively, circulating levels of PMAs were significantly increased in patients with VTE but essentially unchanged in patients without VTE (post-operative fold-change 2.02±0.36 vs. 0.75±0.14, p<0.001; Figure 1). P-selectin expression and integrin αIIbβ3 activation were not associated with VTE. Similarly, neither d-dimer nor fibrinogen predicted VTE. Receiver operating curve characteristic analyses demonstrated that increased circulating PMA levels performed well for predicting patients who developed VTE (AUC 0.87, 95% CI 0.75-0.99; p < 0.001) with a sensitivity and specificity of 77% and 83%, respectively (Figure 2).Conclusions: Increased circulating PMAs measured on post-operative day 1 are an early marker predicting VTE following orthopedic surgery in older adults.Table 1Characteristics of the patients with and without venous thromboembolism (VTE; central tendency data are reported as mean (±SD) unless otherwise specified; BMI: body mass index; DJD: degenerative joint disease; aPTT: activated partial thromboplastin time; *p < 0.05 versus without VTE).Overall (n=32)Without VTE (n=19)With VTE (n=13)P valueAge, years65.6 ± 7.165.6 ± 8.065.5 ± 5.70.95Male Gender, n (%)14 (43.8%)7 (36.8%)7 (53.8%)0.91BMI, kg/m230.8 ± 6.530.4 ± 6.531.4 ± 6.70.67Obesity (BMI ³ 30kg/m2), n (%)17 (53.1%)8 (47.4%)8 (61.5%)0.43Baseline, Pre-operative ValuesHemoglobin, mg/dL13.6 ± 1.213.5 ± 1.313.9 ± 1.10.29Platelets, K/uL282 ± 62274 ± 52292 ± 750.44White Blood Cell Count, K/uL7.4 ± 2.67.4 ± 3.17.3 ± 1.80.99INR1.0 ± 0.11.0 ± 0.11.0 ± 0.10.91Prothrombin Time, sec13.1 ± 0.613.1 ± 0.713.1 ± 0.70.92aPTT, sec31.4 ± 3.731.0 ± 2.432.0 ± 5.10.45Fibrinogen, mg/dL374 ± 70391 ± 61351 ± 770.13D-Dimer, µg/mL0.8 ± 0.80.8 ± 1.00.8 ± 0.60.94C-reactive protein6.8 ± 14.39.5 ± 18.63.3 ± 2.80.25Type of SurgeryTotal knee arthroplasty (TKA), n (%)23 (71.9%)13 (68.4%)10 (76.9%)0.70Unilateral TKA, n (%)20 (62.5%)13 (68.4%)7 (53.8%)0.07Bilateral TKA, n (%)3 (9.4%)0 (0%)3 (100%)0.07Total hip arthroplasty (THA), n (%)9 (29.1%)6 (31.6%)3 (23.1%)0.70Tourniquet time (for TKA), min.56.1 ± 12.655.5 ± 16.056.9 ± 7.00.80 [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Role of Extended Thromboprophylaxis after Abdominal and Pelvic Surgery in Cancer Patients: A Systematic Review and Meta-Analysis

IntroductionAbdominal or pelvic surgery for cancer increases the risk of postoperative venous thromboembolism (VTE) by 2- to 3-fold. The use of low-molecular weight heparin (LMWH) to prevent post-operative thrombotic events is recommended in high VTE-risk patients; however, the role of extended thromboprophylaxis in this setting is controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective observational studies to determine the effect of extended LMWH thromboprophylaxis on all VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic surgery for cancer.MethodsWe searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, conference abstracts, and trial registries with no language restriction. Studies were included if they compared extended duration (i.e., administration of prophylactic doses of LMWH for more than 2 weeks, up to 6 weeks) versus conventional duration of thromboprophylaxis (i.e., administration of LMWH for two weeks or less) after cancer surgery. Two reviewers independently performed study selection, data extraction, and quality assessment. Studies were evaluated according to a priori inclusion criteria and critically appraised using the Newcastle-Ottawa Quality Assessment Scale (NOQA). Pooled relative risk was estimated using a random effects model.ResultsThree RCTs and 4 observational studies were included, comprising 4807 adult patients who underwent open or laparoscopic abdominal or pelvic surgery for gastrointestinal, gynecological or urological cancers. The 3 RCTs employed screening for asymptomatic DVT using bilateral lower limb compression ultrasound or venography after 4 weeks of surgery. Most of studies were of good quality (NOQA higher or equal to 6). The extended thromboprophylaxis regimen was associated with a significantly reduced incidence of all VTE (2.6% [59/2292] vs 5.6% [124/2209]; RR=0.44 [95% CI 0.28-0.70]) and proximal DVT (1.4% [14/966] vs 2.8% [24/862]; RR=0.33 [95% CI 0.15-0.73]). No data were available for symptomatic DVT. There was no statistically significant difference in the incidence of symptomatic PE between the two groups (0.8% [8/966] vs 1.3% [11/862]; RR= 0.56 [95% CI 0.23-1.40]). We found no significant difference in major bleeding at 1.8% (14/787) in the extended thromboprophylaxis group vs 1.0% (7/713) in the short thromboprophylaxis group (RR=1.19 [95% CI 0.47-2.97]). There was no significant difference in all-cause mortality at 3 months (4.2% [30/720] vs 3.6% [23/643], respectively; RR= 0.79 [95% CI 0.47-1.33]). There was minor heterogeneity between the studies in all extracted outcomes.ConclusionExtended thromboprophylaxis with LMWH after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTE and proximal DVT, but had no impact on symptomatic PE, major bleeding or 3-month mortality. [Display omitted] DisclosuresLee:Pfizer: Consultancy, Honoraria; LEO Pharma: Consultancy, Honoraria; BMS: Research Funding; Bayer: Consultancy. Wu:Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Low-molecular-weight heparin and intermittent pneumatic compression for thromboprophylaxis in critical patients.

The efficacy and safety of physiotherapeutic prophylaxis for venous thromboembolism in critically ill patients with heparin contraindication remains unclear. In the present study it was hypothesized that physiotherapy prophylaxis with intermittent pneumatic compression (IPC) would be safe and effective for patients unable to receive low-molecular-weight heparin (LMWH). In addition, this study investigated whether a combined therapy of IPC with LMWH would be more effective for the prophylaxis of deep vein thrombosis (DVT) in critical patients. A total of 500 patients were divided into four groups according to the prophylaxis of DVT. The IPC group consisted of 95 patients with heparin contraindication that received IPC treatment; the LMWH group consisted of 185 patients that received an LMWH injection; the LMWH + IPC group consisted of 75 patients that received IPC treatment and LMWH injection; and the control group consisted of 145 patients that received no IPC treatment or injection of LMWH. Each patient was evaluated clinically for development of DVT and the diagnosis was confirmed by Doppler study. Venous thromboembolism was a common complication among the trauma patients with severe injuries. Patients responded positively to the treatment used in the intervention groups. Patients exhibited an improved response to LMWH + ICP compared with IPC or LMWH alone, while no significant difference was detected between the IPC and LMWH groups. These results were applicable to patients that had a Wells score of ≥3; however, no significant differences in DVT incidence were observed among the patients who had a Wells score of <3. In this observational study, LMWH + ICP appeared to be more effective than either treatment alone in treating critically ill trauma patients with severe injuries that are at high risk for VTE and bleeding simultaneously.

No higher risk of VTE with testosterone in men ≥40 years

No higher risk of VTE with testosterone in men ≥40 years

Intermittent Pneumatic Compression from a Surgical Perspective

Despite pharmacological prophylaxis, 50% of the surgical patients whose Caprini score is >10 develop VTE in the postoperative period suggesting that anticoagulation alone may not be sufficient especially in these high-risk patients. Clinical studies demonstrate that the clot nidus starts to form during the time of operation. Thus, in the postoperative period when pharmacological prophylaxis is initiated, high-risk patients may have already developed a blood clot for which prophylactic doses of anticoagulants would be suboptimal to treat. Therefore, VTE prophylaxis should start at the time of anesthesia induction. Due to bleeding risks associated with pharmacological agents, mechanical modalities, i.e. intermittent pneumatic compression (IPC) devices, with their proven effectiveness in reducing VTE in trauma and high bleeding-risk patients are invaluable tools that should be utilized during surgery frequently. They should be started in the beginning of the operation and then continued together with pharmacological prophylaxis in the postoperative period until full ambulation. Furthermore, there is strong evidence that application of IPCs to any limb, including foot and arm, is sufficient for their prophylactic effect making them suitable for almost any type of surgery. In conclusion, combined pharmacological and mechanical prophylaxis should be utilized more frequently in surgical patients who have high risk for VTE.

Рациональная контрацепция: как свести риск к минимуму?

The use of COCs, even low - and microdosed should be based on an individual assessment of the risk of thrombotic complications. It is advisable to combine the COC together with multivitamin complexes that affect the hemostatic system in the first place, vascular endothelial component (Duovit® for women). The therapeutic use of COCs in women high risk of VTE may together with antithrombotic drugs (heparin and LMWH).

Flamethrowers: blood cells and cancer thrombosis risk

Abstract Cancer patients are at an increased risk of venous thromboembolism. The clotting system is activated in most cancer patients, which is reflected by specific parameters such as an increased thrombin generation and elevated D-dimer levels. Blood cells, especially WBCs and platelets, play an important role in this activation process. Neutrophils and monocytes are subpopulations of WBCs that increase the thrombotic potential by different mechanisms. Neutrophils are activated by tumor cells and can release DNA, generating highly thrombogenic neutrophil extracellular traps. Monocytes are able to synthesize and express significant quantities of procoagulant tissue factor on their surfaces upon activation. An increased risk of VTE has been found in patients with solid tumors and elevated platelet count and in those with high-grade gliomas and low platelet count. Small circulating membrane vesicles, also called microparticles (MPs), which largely derive from platelets, contribute to the procoagulant potential. Specifically, procoagulant MPs could play a role in tumor-associated thrombosis in pancreatic cancer. Interventional studies are under way that are investigating the benefits of thromboprophylaxis in patients identified to be at high risk of VTE through risk-scoring models that include blood count parameters. The “flames” thrown by blood cells, such as neutrophil extracellular traps and MPs, although exciting, still have to be investigated for their usefulness in the clinical setting.