Administration Of Low Molecular Weight Heparin Research Articles

Clinical and electrocardiographic characteristics at admission of COVID-19/SARS-CoV2 pneumonia infection.

BackgroundThe aim of the present study was to compare clinical and electrocardiographic characteristics of patients with COVID-19 pneumonia in Modena, Emilia Romagna, Italy.MethodsPatients admitted to the emergency department for suspected COVID-19 pneumonia from March the 16th to April the 15th were enrolled in the study. COVID-19 pneumonia was confirmed by positive nasopharyngeal swab. Primary endpoint was 30-day mortality.Results201 patients were diagnosed with COVID-19 pneumonia. Compared to survivors, patients who died were older (79.7 ± 10.8 vs 65.6 ± 14.1, p < 0.001), with a more complex cardiovascular history, including coronary artery disease (CAD, 33.3% vs 13.3%, p = 0.004), atrial fibrillation (23.8 vs 8.8, p = 0.011) and chronic kidney disease (CKD 35.7% vs 7.0%, p < 0.001). 30-day mortality was 20,9% in these patients; atrial fibrillation (OR 12.74, 95% CI 3.65–44.48, p < 0.001), ST-segment depression (OR 5.30, 95% CI 1.50–18.81, p = 0.010) and QTc-interval prolongation (OR 3.17, 95% CI 1.24–8.10, p = 0.016) at ECG admission were associated to an increased mortality risk. On the contrary, sinus rhythm (OR 0.08, 95% CI 0.02–0.27, p < 0.001) and low-molecular weight heparin (LMWH) administration (OR 0.08, 95% CI 0.02–0.29, p < 0.001) were related to reduced mortality. At multivariate analysis, after adjustment for age, sex, diabetes, CAD, and MCA admission, sinus rhythm (HR 2.7, CI 95% 1.1–7.0, p = 0.038) and LMWH (HR 8.5, 95% CI 2.0–36.6, p = 0.004) were confirmed to be independent predictors of increased survival.ConclusionSinus rhythm at ECG admission in COVID-19 pneumonia patients was associated with greater survival as well as LMWH administration, which conferred an overall better outcome.

Meta-analysis of Different Pressing Time on the Incidence of Subcutaneous Hemorrhage of Low Molecular Weight Heparin Administration

To investigate the effect of different pressing time on the incidence of subcutaneous hemorrhage of low molecular weight heparin (LMWH) administration by meta-analysis. Cochrane Library, PubMed, MEDLINE, CINAHL, EMbase, Springer, EBSCO, China Biomedical Literature Database, CNKI, Wanfang Database, and VIP Database were searched. To screen the literature of randomized controlled trials with different pressing time in patients with subcutaneous LMWH injection from the establishment of the database to December 2020. The quality of the literature was evaluated and the data were extracted. Meta-analysis was performed by RevMan 5.3. A total of 17 randomized controlled trials were included. Meta-analysis showed that the bleeding rate of pressing for 5 min odds ratio (OR = 3.89, 95% confidence interval [CI]: 2.68-5.64, P < .05) or pressing for 10 min (OR = 1.99, 95% CI: 1.34-2.95) was significantly lower than that of pressing for 3 min. Moreover, the bleeding rate was significantly lower in the 5 min pressing (OR = 1.47, 95% CI: 1.18-1.82) and 10 min pressing(OR = 2.12, 95% CI: 1.61-2.77) than in the no compression group. It is the most suitable time to press 5 min after subcutaneous LMWH injection, which can better control the incidence of bleeding.

Monitoring of Low Molecular Weight Heparin Thromboprophylaxis with Alternative Methods to Anti-Factor Xa

Introduction: Initiating low molecular weight heparin (LMWH) thromboprophylaxis too early in patients with traumatic braininjury increases the risk of intracranial bleeding. Therefore, it is important to monitor LMWH and asses when it is safe to initiate.The aim of this research was to study alternative monitoring methods for LMWH than the standard method anti-factor Xa (antiFXa), and to investigate the peak anti-FXa level. We hoped to answer “How do rotational thromboelastometry (ROTEM) andSonoclot change at different LMWH concentrations added in vitro to blood from intensive care patients? How do point of careparameters change after subcutaneous LMWH administration on healthy volunteers with consecutive measurements to catch thepeak effect?”.Methods: Different concentrations of enoxaparin were added in vitro to citrated whole blood from fifteen intensive care patients.The first ten patients’ coagulation was analysed with ROTEM using the INTEM and NATEM assays, and the last five withSonoclot with a kaolin activator and ROTEM INTEM. Previously collected data was used from nine healthy volunteers that hadreceived subcutaneous enoxaparin. Citrated blood samples were collected before and after LMWH initiation and analysed withSonoclot kaolin and a chromogenic anti-FXa-assay. Friedman test, Dunn’s multiple comparison test and Spearman’s correlationtest were performed.Results: ROTEM INTEM CT, CFT, A10 and MCF were significantly affected with increasing in vitro enoxaparin from 0.4anti-FXa concentration. ROTEM NATEM CT was also prolonged at this LMWH concentration. Sonoclot’s parameters didn’tsignificantly change with increasing in vitro enoxaparin. The peak of in vivo LMWH was reached after 2 to 4 hours with avariation of peak anti-FXa between 0.3-0.5 IU/mL.Conclusions: ROTEM INTEM CT performed best and was prolonged at anti-FXa from 0.4-0.6 IU/mL. ROTEM INTEM shouldbe tested in neurointensive care to increase the safety of LMWH thromboprophylaxis and possibly to individualize the dosage. (Less)

Arterial Versus Venous Port Site Administration of Nadroparin for Preventing Thrombosis of Extracorporeal Blood Circuits in Patients Receiving Hemodiafiltration Treatment

IntroductionAdministration of low-molecular-weight heparins (LMWHs) is necessary for preventing extracorporeal circuit thrombosis during hemodialysis. A substantial amount of LMWH is removed with online hemodiafiltration (OL-HDF) when administered through the inlet site of the extracorporeal circuit. Consequently, administration of LMWH at the outlet site appears to be more efficient. In this study we aimed to compare the effects of nadroparin calcium (NAD) administered through the outlet versus the inlet port site in postdilution OL-HDF and assess the NAD dose reduction.MethodsForty-nine hemodialysis patients were included in 3 consecutive 6-week studies as follows: phase I, inlet port line; phase II, outlet port line; and phase III, outlet port line with reduced dose. We evaluated clotting in the hemodialyzer and venous bubble trap, the dialysis dose (Kt/V), and substitution volume.ResultsThirty four percent, 63%, and 66% were categorized as “white” during phases I, II, and III, respectively. During phases I, II, and III, 75%, 93%, and 95% of the venous bubble traps were “clean,” and 9%, 0.6%, and 0.4% of the dialyzers clotted, respectively. Average NAD dose was 0.43 ml during phase I and 0.3 ml during phase II. During phase III, the LMWH dose was reduced by 33% to 50% in 15 patients. In phase III, Kt/V improved from 1.64 to 1.75 and substitution volume increased from 20.18 to 21.96 L.ConclusionsWhen using OL-HDF, a single administration of NAD at the outlet port line allows for a significant dose reduction and was associated with improved dialysis performance.

Effects of low-molecular-weight heparin and aspirin in recurrent pre-eclampsia: A stratified cohort study.

To evaluate the effects of low-molecular-weight heparin (LMWH) combined with low-dose aspirin (LDA) in pregnant women with a history of pregnancy-related hypertensive disorders. In the current retrospective stratified cohort study, 33 women with previous hypertensive disorders of pregnancy treated with LMWH and LDA were compared with 37 control women who did not undergo LMWH or LDA treatment. Rates of pre-eclampsia recurrence, placental abruption, and other adverse outcomes for the fetuses and pregnant women were compared in the two groups. The pre-eclampsia recurrence rates were 12/33 (36.4%) in the LMWH+LDA group and 28/37 (75.7%) in the control group (P<0.01). In stratified cohort analysis, pregnant women with a history of early-onset pre-eclampsia, a body mass index of at least 24 (calculated as weight in kilograms divided by the square of height in meters), and aged less than 35years benefited from LMWH+LDA treatment. In women with chronic hypertension or a history of placental abruption there was no protective effect. There were no significant differences in other adverse outcomes such as placental abruption and small size for gestational age in fetuses or pregnant women in the two groups. Administration of LMWH+LDA only lowered the risk of pre-eclampsia recurrence in subgroups of pregnant women with a history of pregnancy-associated hypertensive disorders.

Выбор теста тромбоэластометрии для оценки эффекта профилактической дозы низкомолекулярных гепаринов

Цель исследования: изучить возможность использования тестов тромбоэластометрии (ТЭМ) для оценки эффекта профилактической дозы низкомолекулярных гепаринов (НМГ). Материалы и методы. В исследование включено 30 пациентов (14 мужчин и 16 женщин), которым выполнялась резекция печени в связи с метастатическим поражением колоректальным раком. Для профилактики тромботических осложнений в послеоперационном периоде использовали НМГ надропарин. У пациентов в первую неделю послеоперационного периода определяли активность антитромбина III (AT-III) и проводили ротационную ТЭМ, при которой исследовали 3 пробы крови: проба № 1 — утром натощак перед введением пациенту НМГ; проба № 2 — как и первая проба, но с добавлением в пробу НМГ in vitro до достижения целевой концентрации 0,5 МЕ / мл крови; проба № 3 — через 4 ч после подкожного введения НМГ. У 10 пациентов проведены тесты ТЭМ — INTEM и NATEM (нативный тест), в которых оценивали показатели CT, CFT, угол α, MCF; у 20 пациентов проведен только тест NATEM. Результаты. Средние показатели теста INTEM перед введением НМГ не выходили за рамки референтных значений, в тесте NATEM только показатель MCF превышал нормальные значения. После внесения в исследуемую пробу 0,5 МЕ / мл НМГ in vitro средние значения CT и CFT теста ТЭМ значимо удлинялись. Интервал CT теста INTEM был удлинен выше нормы в 2 наблюдениях, CFT теста INTEM превышал норму в 1 наблюдении. В тесте NATEM удлинение интервалов CT и CFT выше нормальных выявлено в 100% случаев. Показатели ТЭМ через 4 ч после введения НМГ были аналогичны результатам in vitro. Выявлены статистически значимые различия показателей нативного теста от активности AT-III, наибольшей чувствительностью и специфичностью из них обладали интервал CT и ΔCT. Заключение. Метод ротационной ТЭМ является перспективным прикроватным методом оценки антикоагулянтного эффекта профилактических доз НМГ. Использование этого метода в послеоперационном периоде позволит индивидуально дозировать антикоагулянты и повысить эффективность профилактики венозных тромбоэмболических осложнений. Objectives: to investigate the applicability of various types of thromboelastometry (TEM) to assess effects of low molecular weight heparins (LMWHs) administered in prevention doses. Patients/ Methods. The study included 30 patients (14 men and 16 women) who underwent liver resection due to metastatic lesions of colorectal cancer. LMWH (nadroparin) was used to prevent thrombotic complications in the postoperative period. In the first week of postoperative period antithrombin III (AT-III) activity was determined and rotational TEM was performed, in which 3 blood samples were examined: sample № 1 — in the morning, fasted, before LMWH administration; sample № 2 — like the first sample, but with in vitro LMWH addition to the sample to achieve the target concentration of 0.5 IU per 1 ml of blood; sample № 3–4 hours after subcutaneous LMWH administration. TEM tests — INTEM and NATEM (native test) were performed in 10 patients with CT, CFT, angle α, and MCF assessment; in 20 patients only NATEM test was performed. Results. The average values of INTEM test before LMWH administration were within the reference values, in NATEM test only MCF exceeded normal values. The average CT and CFT values in TEM test significantly increased after in vitro LMWH addition to the test sample. Elongation of CT interval in INTEM test was found in 2 cases, CFT in INTEM test exceeded the norm in 1 case. Elongation above normal of CT and CFT intervals in NATEM test was noticed in 100% of cases. TEM parameters in 4 hours after LMWH administration were similar to in vitro results. The statistically significant differences between native test parameters and AT-III activity were revealed; CT and ΔCT intervals had the greatest sensitivity and specificity. Conclusions. Rotational TEM is a perspective bedside method for anticoagulant effect assessment of LMWH prevention doses. Using this method in postoperative period will allow to dose anticoagulants individually and increase prophylaxis effectiveness of venous thromboembolic complications.

The role of anti-hypertensive treatment, comorbidities and early introduction of LMWH in the setting of COVID-19: A retrospective, observational study in Northern Italy

BackgroundThere is a great deal of debate about the role of cardiovascular comorbidities and the chronic use of antihypertensive agents (such as ACE-I and ARBs) on mortality on COVID-19 patients. Of note, ACE2 is responsible for the host cell entry of the virus. MethodsWe extracted data on 575 consecutive patients with laboratory-confirmed SARS-CoV-2 infection admitted to the Emergency Department (ED) of Humanitas Center, between February 21 and April 14, 2020.The aim of the study was to evaluate the role of chronic treatment with ACE-I or ARBs and other clinical predictors on in-hospital mortality in a cohort of COVID-19 patients. ResultsMultivariate analysis showed that a chronic intake of ACE-I was associated with a trend in reduction of mortality (OR: 0.53; 95% CI: 0.27–1.03; p = 0.06), differently from a chronic intake of ARB (OR: 1.1; 95% CI: 0.5-2.8; p=0.8). Increased age (ORs ranging from 3.4 to 25.2 and to 39.5 for 60–70, 70–80 and >80 years vs <60) and cardiovascular comorbidities (OR: 1.90; 95% CI: 1.1–3.3; p = 0.02) were confirmed as important risk factors for COVID-19 mortality. Timely treatment with low-molecular-weight heparin (LMWH) in ED was found to be protective (OR: 0.36; 95% CI: 0.21–0.62; p < 0.0001). ConclusionsThis study can contribute to understand the reasons behind the high mortality rate of patients in Lombardy, a region which accounts for >50% of total Italian deaths.Based on our findings, we support that daily intake of antihypertensive medications in the setting of COVID-19 should not be discontinued and that a timely LMWH administration in ED has shown to decrease in-hospital mortality.

Systemic thromboembolism from a misdiagnosed non‑bacterial thrombotic endocarditis in a patient with lung cancer: A case report

Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally-advanced non-small cell lung cancer with high expression levels of programmed death-ligand 1 (PD-L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti-coagulant therapy, before first-line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD-L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non-bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer-associated survival.

Efficacy and Safety of Low-Molecular-Weight Heparin on Prevention of Venous Thromboembolism after Laparoscopic Operation for Gastrointestinal Malignancy in Japanese Patients: A Multicenter, Open-Label, Prospective, Randomized Controlled Trial

The risk of venous thromboembolism (VTE) after surgery for malignancy in Japanese patients is unclear; therefore, standard prevention protocols have not been established, especially for minimally invasive procedures. We aimed to investigate the additional effect of low molecular weight heparin (LMWH) on prevention of VTE after laparoscopic surgery for gastrointestinal malignancy. From February 2013 to January 2017, 400 patients scheduled for laparoscopic surgery were included. Cases were randomly allocated to the physical therapy group (Control group; 201 patients) or to the combination-therapy group (LMWH group; 199 patients), in which enoxaparin sodium (20 mg [= 2000 IU] twice a day) was administered for 1 week postoperatively in addition to the physical therapy. A diagnosis of VTE was made by contrast-enhanced CT or ultrasonography when symptomatic or D-dimer was ≥10 μg/mL. VTE was observed in 1.2% and 4.0% of patients in the LMWH and Control groups, respectively (odds ratio [OR] 0.3, 95% confidence interval [CI] 0.03-1.53). Pulmonary embolism was confirmed only in the Control group (1.7%). No major bleeding occurred in either group. Logistic multiple regression analysis revealed that surgical time extension (OR 1.02, 95% CI 1.00-1.04) was a risk factor of VTE, while administration of LMWH (OR 0.21, 95% CI 0.03-0.99), male sex (OR 0.12, 95% CI 0.01-0.60), and early cancer (OR 0.17, 95% CI 0.02-0.82) reduced the risk of VTE. Postoperative LMWH administration is safe. The additional effect of LMWH administration on the physical therapy was not statistically proven in this study. However, it could be useful for the patients with risk factors such as female sex, long operation time, and higher cancer stage.

Preliminary Experience With Low Molecular Weight Heparin Strategy in COVID-19 Patients.

BackgroundHeparin administration in COVID-19 patients is recommended by expert consensus, although evidence about dosage, duration and efficacy are limited. We aim to investigate the association between different dosages of low molecular weight heparin (LMWH) and mortality among COVID-19 hospitalized patients.Methods and ResultsRetrospective study of 450 laboratory-confirmed COVID-19 patients admitted to Sant’Orsola Bologna Hospital from March 01 to April 10, 2020. Clinical, laboratory and treatment data were collected and analyzed. The in-hospital mortality between COVID-19 patients treated with standard prophylactic LMWH dosage vs. intermediate LMWH dosage was compared. Out of 450 patients, 361 received standard deep vein thrombosis (DVT) prophylaxis enoxaparin treatment (40-60mg daily) and 89 patients received intermediate enoxaparin dosage (40–60 mg twice daily) for 7 days. No significant differences in the main demographic characteristics and laboratory testings at admission were observed in the two heparin regimen subgroups, except for older age and prevalence of hypertension in the group treated with “standard” prophylaxis LMWH dosage. The intermediate LMWH administration was associated with a lower in-hospital all-cause mortality compared to the “standard” prophylactic LMWH dosage (18.8% vs. 5.8%, p = 0.02). This difference remained significant after adjustment with the propensity score for variables that differed significantly between the dosage groups (OR= 0.260, 95% CI 0.089–0.758, p=0.014).ConclusionsIntermediate LMWH dosage seems to be associated with lower incidence of mortality compared to standard DVT prophylaxys in hospitalized COVID-19 patients. Our study paves the way to further pathophysiological investigations and controlled studies of anticoagulation therapy in Covid-19 disease.

Effect of low or high doses of low‐molecular‐weight heparin on thrombin generation and other haemostasis parameters in critically ill patients with COVID‐19

The clinical picture of the coronavirus 2 (SARS-CoV-2)/COVID-19-related acute respiratory syndrome is often associated with a coagulopathy. An elevated D-dimer has been linked with an unfavorable prognosis in COVID-19 patients.

The Efficacy and Safety of Low Molecular Weight Heparin Administration to Improve Survival of Cancer Patients: A Systematic Review and Meta-Analysis.

Low molecular weight heparins (LMWH) are often used as a first-line therapy for the prevention of thrombosis in cancer patients. Preclinical evidence from animal models suggests that LMWH may have antimetastatic properties. Clinical evidence of this effect is inconclusive. The objective of this systematic review is to evaluate the effect of LMWH on overall survival in patients with solid tumor malignancies. MEDLINE, Embase, and The Cochrane Central Register of Controlled trials were searched from inception to November 26, 2018. We included randomized controlled trials that compared LMWH to placebo, a no-treatment arm, or a short-term prophylactic course of LMWH in adult patients with solid tumors. The primary outcome was overall survival. Secondary outcomes included progression-free survival, the occurrence of venous thromboembolism, and major bleeding events. The risk of bias was assessed in duplicate using the Cochrane Risk-of-Bias tool. Forty-five articles were included in the review. Overall, no difference in overall survival was observed between groups (risk ratio: 1.00; 95% confidence interval: 0.98-1.02; I2 = 36.5%). In our a priori defined subgroup analyses, the effect was not shown to vary by the type of LMWH, duration of LMWH use, length of study follow-up, comparator used in the study, or the setting in which the LMWH was administered. The majority of studies had an unclear risk of bias for at least one methodological criterion. Although LMWH is thought to possess antimetastatic properties and thus have the potential to improve survival in cancer patients, existing data do not support this hypothesis.

Prophylactic low-molecular-weight heparin administration protected against severe acute pancreatitis partially by VEGF/Flt-1 signaling in a rat model.

The present study was aimed to explore the effects and the underlying mechanism of prophylactic low-molecular-weight heparin (LMWH) treatment on taurocholate-induced severe acute pancreatitis (SAP) in a rat model. Rat SAP model was induced by injection of 4% sodium taurocholate into the pancreatic duct. LMWH was applied half an hour before the induction of pancreatitis at the dose of 200 IU/kg subcutaneous injection. The rats were euthanized at 1 h, 6 h, and 12 h after taurocholate-induced SAP. The inflammatory and oxidative response markers were assessed. And the vascular endothelial growth factor (VEGF) and Fms-related tyrosine kinase 1 (Flt-1) expression were evaluated by immunohistochemistry (IHC) and western blot methods. The expression of inflammatory and oxidative response markers increased after induction of SAP. IHC and western blot results showed the VEGF and Flt-1 expression were increased in SAP group. Prophylactic LMWH administration reduced the inflammatory and oxidative response markers expression and decreased the expression of VEGF and Flt-1. This study suggested that prophylactic LMWH treatment mitigated the severity of pancreatitis in rat SAP model by anti-inflammation and oxidative response. The underlying mechanism may result from downregulating VEGF/Flt-1 signaling of LMWH in SAP rat model.

Do Anti-Factor Xa Levels have any Impact on Pregnancy Outcome in Women with Previous Adverse Outcomes?

Low-molecular-weight heparin (LMWH) is used during pregnancy in women diagnosed with thrombophilia for prevention of thromboembolic events and prevention of recurrent pregnancy loss. Prophylactic dosing does not always achieve target anti-FXa levels of 0.2-0.6 IU/ml. We aimed to determine if anti-FXa levels, measured in the first trimester, have an influence on pregnancy outcome. Eighty-one first-trimester women with a history of adverse pregnancy outcomes under LMWH therapy during pregnancy were enrolled in this study. Anti-FXa levels were measured in the first trimester, and fetal and maternal outcomes were recorded. The mean age of women was 28±4 (19-40) and mean anti-FXa level 0.44±0.93 IU/ml. No bleeding or clotting complications were associated with LMWH administration. Anti-FXa levels did not have a relationship with gestational age at birth, fetal weight, type of delivery, cesarean indications, postpartum bleeding, APGAR scores, or admission to the neonatal intensive care unit (p>0.005). Anti-FXa levels were not correlated with live birth rates. Anti-FXa levels did not have an influence on pregnancy and fetal outcomes. The effect of LMWH on pregnancy outcomes may not be due to anticoagulant activity but other mechanisms.

Impact of Patent Foramen Ovale on Total Knee Arthroplasty Cerebrovascular Accident Perioperative Management.

Venous thromboembolism and ischemic stroke are major complications following total knee arthroplasty (TKA) and potentially are associated with a patent foramen ovale (PFO). Although this association has been shown in other surgical disciplines, it has not been demonstrated in patients undergoing TKA. This study was undertaken to determine whether patients with a PFO would have a significantly increased risk of cerebrovascular accident (CVA) following TKA. The Humana national database was used to identify TKA patients who were stratified by the presence of a PFO from 2007 to 2016. Ninety-day follow-up was used for the primary outcome of CVA. Potential confounding comorbidities also were investigated, including age, sex, anticoagulation, insurance type, arrhythmia, valvular disease, peripheral vascular disease, chronic kidney disease, and diabetes mellitus. Of 153,245 TKAs, a total of 2272 patients had strokes; 479 of these patients had a PFO. On multivariable analysis, PFO remained an independent predictor of CVA postoperatively (odds ratio, 3.824; 95% confidence interval, 2.614-5.406; P<.0001). Other significant comorbidities associated with CVA included arrhythmia, chronic kidney disease, diabetes mellitus, peripheral vascular disease, and coronary valve disease. Importantly, low-molecular weight heparin or factor Xa inhibitor administration postoperatively had a negative correlation with stroke (odds ratio, 0.762; 95% confidence interval, 0.663-0.871; P=.0001 and odds ratio, 0.749; 95% confidence interval, 0.628-0.885; P=.0009, respectively). The findings of the multivariable analysis indicate PFO is associated with early postoperative CVA within 90 days following TKA. If known preoperatively, appropriate referral should be made to a cardiologist for PFO management and anticoagulation to reduce the overall risk of stroke. [Orthopedics. 2020;43(3):e151-e158.].

D-Dimer Assay May Guide LMWH Treatment in Repeated Biochemical Pregnancy Losses in Women with Positive Antiphospholipid Antibody.

Do D-dimer levels influence the pregnancy outcomes after treatment with low molecular weight heparin (LMWH) in women of recurrent miscarriage (RM), repeated biochemical pregnancy losses (BPL), and a positive test for antiphospholipid antibodies (aPLs)? This study was a retrospective chart review of 569 RM patients who were identified as having a history of BPL and a positive aPL. These patients were grouped into three groups according to their treatment plan including those who received low dose aspirin (LDA) alone (group A), LDA plus LMWH after ovulation therapy (group B), and LDA plus LMWH after pregnancy confirmation (group C). We hypothesized that the administration of LMWH after ovulation increased the rates of live birth. D-dimer may predict the pregnancy outcome after treatment. The live birth rate of group B and group C is significantly higher than group A (86.96% and 66.80% vs. 52.89%, p < 0.0001, respectively). The live birth rate in group A, B, and C with elevated D-dimer is 36.92%, 90.52%, and 61.60% respectively. However, there is no significant difference in live birth rate among those who had normal baseline D-dimer. These results suggest that LMWH therapy is more effective in improving the live birth rate when given after ovulation than after pregnancy confirmation. The plasma D-dimer assay can possibly guide LMWH treatment appropriately.

Management Algorithm for Subclinical Hypoxemia in Coronavirus Disease-2019 Patients: Intercepting the "Silent Killer".

In the early stages of COVID-19 clinical illness, the ability to oxygenate is impaired However, the patient does not necessarily display the conventionally expected signs or symptoms of respiratory failure, including shortness of breath Given the above, HCP's must remain vigilant and proactively look for 'red flags' described herein, such as the appearance of =3%-5% drop in SpO2 after approximately 60 s of mild activity/ambulation, SpO2/FiO2 ratio <300, SpO2 <93% on room air, and the presence of hypoxemia without tachypnea [Figure 1] [4,11,12] In summary, this expert group views AH as the proverbial "canary in the coalmine" and the first harbinger of future respiratory deterioration in COVID-19 patients

227: Factors associated with women's adherence to postpartum thromboprophylaxis: a prospective cohort study

Postpartum low-molecular-weight heparin (LMWH) thromboprophylaxis is indicated for a substantial proportion of women. We assessed women's adherence to postpartum thromboprophylaxis and the factors associated with adherence. This prospective cohort study was conducted at a university hospital during 2018. Parturients for whom a recommendation for LMWH prophylaxis was given at discharge from the maternity ward were contacted at the end of the recommended post-discharge course of LMWH, and were invited to participate in a telephone survey. The main outcome measures were optimal (>80%) and suboptimal adherence (< 80%) to LMWH administration, reasons for nonadherence, and views regarding LMWH, as assessed by an adapted Beliefs about Medication Questionnaire. Overall, 250 women completed the questionnaire. The median recommended duration of post-discharge LMWH was 7 [5-8] days. Suboptimal adherence was reported by 82 (32.8%); 45 (18.0%) women did not administer any LMWH dose following discharge and only 147 (58.8%) completed the full LMWH course. In multivariate analysis, optimal adherence was positively associated with patients' perceptions of the necessity of LMWH (odds ratio [95% CI]: 3.50 (2.12, 9.53), P=0.002) and of the adequacy of explanation given prior to discharge regarding LMWH technical administration (odds ratio [95% CI]: 5.0 (2.33, 11.11), P< 0.001). Nearly one-third of women prescribed postpartum LMWH thromboprophylaxis reported suboptimal adherence. Patients' perceptions of the necessity of the treatment and their opinion of the adequacy of explanation regarding LMWH technical administration were identified as predictors of treatment compliance, and thus represent potential areas for improvement.

Predictability of the Caprini Risk Assessment Model for Postoperative Venous Thromboembolism may be Increased by Global Test of Haemostasis

Introduction - Postoperative venous thromboembolism (VTE) is still a challenge. Standard preventive protocol, that includes elastic compression stockings and low-molecular-weight heparin (LMWH) injection, may be not equally effective in different patients at high risk. Previously it has been shown that patients with 11 and more Caprini scores have a dramatically increased risk of VTE at the background of elastic compression and LMWH injections. The way to improve such situation is to understand, why standard prophylaxis does not work properly in some individuals. To achieve this goal may be used modern global tests of hemostasis. The aim of this study was to compare predictability for postoperative deep vein thrombosis (DVT) of the classic Caprini 2005 RAM and its modified version, considering the results of TD test in surgical patients at high risk. Methods - This was a prospective observational clinical study involving 80 patients (33 men and 47 women, mean age - 73,9±7,2 years), undergoing major (79 cases) or minor (1 case) surgery for colorectal cancer. Patients were at high risk of postoperative venous thromboembolism: 5-15 Caprini scores (mean - 9,9±2,0) and received combined prophylaxis: anti-embolic above-knee compression stockings and LMWH injections (enoxaparin 40 mg once daily) until discharge. LMWH was administered in a fixed hour according to the time of blood shambling for TD. Before and after the surgery (0 day, 5-7 day and 1 month) duplex ultrasound was performed to detect postoperative DVT. Results - DVT was found in 21 of 80 patients (26.3%; 95% CI: 17,9-36,8%) at 5-7 day after surgery. No new venous thromboembolism events were detected at 1 month. Regression analysis and ROC-curve showed a significant predictability of Caprini scores for DVT (p<0,0001, S=0,839±0,045). Analysis of ROC-curve coordinates showed a cut-off point of 11 scores, which with the sensitivity of 76.2% and a specificity of 74.6% predicted DVT. The results of TD test showed significant hypercoagulation at the background of LMWH administration in patients with DVT. Regression analysis and ROC-curves demonstrated that TD parameters as stationary velocity of clot growth, measured at 2 hours after surgery (Vst), and initial velocity of clot growth, measured 24 hours after the LMWH injection (Vin), had the greatest predictability for postoperative DVT: S=0,764 ± 0,109, p=0,049 and S=0,946±0,047, p=0,001, respectively. The cut-off points for DVT prediction with high sensitivity/specificity appeared to be Vst>32,5 (normal range 20-29) μm/min and Vin>64,5 (normal range 36-56) μm/min. Identified thresholds for TD parameters have been integrated into Caprini RAM under the item "other congenital or acquired thrombophilia" (score of 3). Total Caprini scores were recalculated in patients who had one or both TD parameters exceeded the cut-off, followed by re-analysis of the ROC-curves. It was found that the Caprini RAM with integrated Vin>64,5 μm/min characterized by the highest predictability for DVT (S=0,876±0,038, p<0,0001) and increased cut-off up to 12 scores with sensitivity of 85,7% and specificity of 72.9%. Conclusion - The integration of TD parameters into Caprini RAM allows increasing predictability for postoperative DVT.

Factors associated with women’s adherence to postpartum thromboprophylaxis

Postpartum low-molecular-weight heparin (LMWH) thromboprophylaxis is indicated for a substantial proportion of women. We assessed women's adherence to postpartum thromboprophylaxis and the factors associated with adherence. This retrospective cohort study was conducted at a university hospital during 2018. Parturients for whom a recommendation for LMWH prophylaxis was given at discharge from the maternity ward were contacted at the end of the recommended post-discharge course of LMWH, and were invited to participate in a telephone survey. The main outcome measures were optimal (> 80%) and suboptimal adherence (< 80%) to LMWH administration, reasons for nonadherence, and views regarding LMWH, as assessed by an adapted Beliefs about Medication Questionnaire. Overall, 250 women completed the questionnaire. The median recommended duration of post-discharge LMWH was 7 [5-8] days. Suboptimal adherence was reported by 82 (32.8%); 45 (18.0%) women did not administer any LMWH dose following discharge and only 147 (58.8%) completed the full LMWH course. In multivariate analysis, patients' perceptions of the necessity of LMWH [odds ratio (95% CI): 3.50 (2.12, 9.53), P = 0.002] and of the adequacy of the explanation given prior to discharge regarding LMWH technical administration [odds ratio (95% CI): 5.0 (2.33, 11.11), P < 0.001] were positively associated with optimal adherence. Nearly one-third of women prescribed postpartum LMWH thromboprophylaxis reported suboptimal adherence. Patients' perceptions of the necessity of the treatment and their opinion of the adequacy of explanation regarding LMWH technical administration were identified as predictors of treatment compliance, and thus represent potential areas for improvement.