Lower Rate Of Venous Thromboembolism Research Articles

Aspirin is Not for Everyone: Discharge to Non-home Facilities After Total Hip and Knee Arthroplasty Increases Risk of Venous Thromboembolism

BackgroundPatients discharged to non-home facilities (NHD) after total hip arthroplasty (THA) and total knee (TKA) arthroplasty experience higher rates of adverse events and may require more aggressive venous thromboembolism (VTE) chemoprophylaxis. Our aim was to compare the rates of VTE in NHD patients and those discharged home (HD) after THA/TKA. Our secondary aim was to determine VTE rates within HD and NHD groups when stratified by chemoprophylactic regimen. MethodsA retrospective cohort of primary THA and TKA patients were stratified into HD and NHD, then allocated into groups by chemoprophylactic regimen on discharge: aspirin alone (AA), more aggressive (MA) chemoprophylaxis, and other regimens (other). The primary outcome was VTE. Rates of VTE in HD and NHD patients, as well as AA and MA regimens, were analyzed using a generalized linear regression model. ResultsSix thousand three hundred seventy-nine patients were included with 1.03% experiencing VTE. HD had lower rates of VTE compared to NHD (0.83% vs 2.17%, P < .001). AA had similar rates of VTE compared to MA (0.99% vs 1.08%, P = .82). NHD patients had a lower VTE rate with MA vs AA prophylaxis (1.47% vs 3.83%, P = .016). HD patients treated with AA vs MA had no difference in VTE rates (0.76% vs 0.96%, P = .761). ConclusionsNHD patients have higher rates of VTE than HD patients. However, NHD patients have significantly lower rates of VTE on MA chemoprophylaxis compared to those on AA. Providers should consider prescribing MA VTE chemoprophylaxis for NHD patients. Prospective, randomized studies are necessary to confirm these recommendations.

The Influence of Patient Characteristics and Social Determinants of Health on Postoperative Complications Following Achilles Tendon Rupture.

The influence of social determinants of health (SDH) on postoperative complications has been investigated in several studies, although correlation with Achilles tendon rupture (ATR) repair remains uninvestigated. SDH encompasses several factors, including insurance status and area-based measurements, including the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), which ranks neighborhoods by social disadvantage. This study investigated the correlation between patient demographics, SDH, and complications following ATR repair. A retrospective cohort study was conducted on 521 patients who presented with acute ATR and met the inclusion criteria, including age ≥18 years, a minimum of 30-day follow-up, and repair within 28 days of rupture. We reviewed patient demographics, time to surgery (TTS), and postoperative complications, including venous thromboembolism (VTE), rerupture, surgical site infection (SSI), wound dehiscence, and sural nerve injury. SDH variables included race, smoking status, insurance status, level of education, ADI, and SVI. Univariate regression tested the correlation between complications and SDH indicators. Significant variables (P < .05) were included in a multivariate regression. Sixty-eight complications occurred in 59 patients (11.3%). Multivariate regression showed that a higher ADI, that is, socially deprived individuals, was associated with lower rates of VTE (OR = 0.41, P = .04). Higher body mass index (BMI) was associated with rerupture (OR = 8.73, P < .01). Male patients had lower rates of wound dehiscence (OR = 0.31, P = .03) and VTE (OR = 0.32, P = .02) compared with women. Longer TTS correlated with sural nerve injuries (OR = 2.23, P < .01) and shorter TTS with reruptures (OR = 0.02, P = .02). Some measures of SDH were associated with postoperative complications. Gender also may have an effect, with male sex associated with lower rates of wound dehiscence and VTE. BMI was associated with higher rates of reruptures and overall general complications. Level IV, case series.

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

IntroductionOptimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads...

Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease

AbstractHospitalized patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE). We aimed to evaluate the effectiveness and safety of prophylactic anticoagulation compared with no anticoagulation in hospitalized patients with IBD. We conducted a retrospective cohort study using a hospital-based database. We included patients with IBD who had a length of hospital stay ≥2 days between 1 January 2016 and 31 December 2019. We excluded patients who had other indications for anticoagulation, users of direct oral anticoagulants, warfarin, therapeutic-intensity heparin, and patients admitted for surgery. We defined exposure to prophylactic anticoagulation using charge codes. The primary effectiveness outcome was VTE. The primary safety outcome was bleeding. We used propensity score matching to reduce potential differences between users and nonusers of anticoagulants and Cox proportional-hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). The analysis included 56 194 matched patients with IBD (users of anticoagulants, n = 28 097; nonusers, n = 28 097). In the matched sample, prophylactic use of anticoagulants (vs no use) was associated with a lower rate of VTE (HR, 0.62; 95% CI, 0.41-0.94) and with no difference in the rate of bleeding (HR, 1.05; 95% CI, 0.87-1.26). In this study of hospitalized patients with IBD, prophylactic use of heparin was associated with a lower rate of VTE without increasing bleeding risk compared with no anticoagulation. Our results suggest potential benefits of prophylactic anticoagulation to reduce the burden of VTE in hospitalized patients with IBD.

Management of catheter-related upper extremity deep vein thrombosis in patients with cancer: a systematic review and meta-analysis

BackgroundPatients with cancer commonly require a central venous catheter, which is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent occurrence, the optimal anticoagulation management and outcomes for patients with cancer and catheter-related upper extremity deep vein thrombosis (DVT) are unclear. ObjectiveWe performed a systematic review and meta-analysis to evaluate the rates of recurrent VTE and bleeding in patients with cancer and catheter-related upper extremity DVT. MethodsWe searched MEDLINE, Embase, Scopus, and CENTRAL from inception to June 2, 2023. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding. The incidence rates (with 95% CI) of outcomes were pooled using random effects model. ResultsWe included 29 studies (N = 2,836), among which 5 were prospective. The duration of follow-up and anticoagulation varied considerably. The main long-term anticoagulant used was low molecular weight heparin, followed by direct oral anticoagulants. The pooled 3-month recurrent VTE rate from 14 studies (N = 1,128) was 0.56% (95% CI, 0.10%-3.01%; I2 = 0%). The pooled 3-month major bleeding rate from 10 studies (N = 834) was 2.34% (95% CI, 1.14%-4.76%; I2 = 0%). We were unable to pool event rates beyond 3 months, given high heterogeneity. All studies had serious risk of bias. ConclusionsOur study demonstrated a relatively low rate of recurrent VTE and moderate rate of major bleeding events within the first 3 months in patients with cancer and catheter-related upper extremity DVT. However, there was significant heterogeneity in the management and reporting after 3 months.

Management of Catheter-Related Upper Extremity Deep Vein Thrombosis in Patients with Cancer: A Systematic Review and Meta-Analysis

Background: Patients with cancer commonly require a central venous catheter (CVC) for delivery of cancer therapies and/or supportive care. The presence of a CVC is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent occurrence, the optimal anticoagulation management and outcomes for patients with cancer and catheter-related upper extremity deep vein thrombosis (DVT) are unclear. Objective: We performed a systematic review and meta-analysis to evaluate the rates of recurrent VTE and bleeding complications in patients with cancer and catheter-related upper extremity DVT. Methods: We searched MEDLINE, Embase, Scopus, and CENTRAL (Cochrane) from inception to June 2, 2023. We aimed to include randomized controlled trials (RCTs) (if any), prospective and retrospective cohort studies, and case-control studies (including ≥ 10 patients) evaluating adult patients with cancer and catheter-related upper extremity DVT. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding as defined by individual studies. Secondary outcomes included clinically relevant non-major bleeding, total bleeding events, and all-cause mortality. By using R software (version 4.0.3), the incidence rates (with 95% confidence interval [CI]) of recurrent VTE and bleeding outcomes at different time points were pooled using random effects model. Results: After screening 4,264 records, we included 29 studies (N=2,848 patients) in the systematic review. There were no RCTs, 5 prospective cohort studies (including 260 patients), and 24 retrospective cohort studies. Most studies had modest sample size (N&amp;lt;100). Overall from 24 studies with reported tumor types, the most common malignancy was hematological malignancy (50.4%), followed by gastrointestinal (13.6%), breast (10.2%), and lung (5.5%) cancers. The median or mean follow-up duration varied widely from 1 to 20 months. Duration of anticoagulation also varied considerably with median or mean duration of 20 days to 6 months. The main long-term anticoagulant used was low-molecular-weight heparin (58.1%), followed by direct oral anticoagulants (24.3%). Only two studies (N=87 patients) specifically reported the management and associated outcomes after catheter removal. Thirteen studies (N=1105 patients) reported a 3-month recurrent VTE rate, with the pooled rate of 1% (95% CI 0-3%, I 2 = 0%) (Figure 1). Nine studies (N=811 patients) reported a 3-month major bleeding rate, with the pooled rate of 2% (95% CI 1-5%, I 2 = 0%) (Figure 2). We were unable to pool event rates beyond 3 months given high degree of heterogeneity in the follow-up duration, bleeding definition, and duration of anticoagulation. Conclusions: Our systematic review and meta-analysis demonstrated relatively low rates of recurrent VTE and major bleeding events within the first 3 months in patients with cancer and catheter-related upper extremity DVT. However, there was significant heterogeneity in the management and reporting after 3 months, and available data are poor to guide treatment strategies and duration of anticoagulation. The optimal management after catheter removal was also unclear. Future large prospective studies are needed.

Thrombocytopenia and venous thromboembolic events after BNT162b2, CoronaVac, ChAdOx1 vaccines and SARS-CoV-2 infection: a self-controlled case series study

This study assessed the association between COVID-19 vaccines, SARS-CoV-2 infection and the risk of thrombocytopenia and venous thromboembolism (VTE). This self-controlled case series study used hospital records between 1st February 2021 and 28th February 2022 linked to the national immunisation registry and COVID-19 surveillance data in Malaysia. Conditional Poisson regression was used to estimate incidence rate ratios (IRR) of events in the risk period (day 1–21 post-exposure) relative to control period with the corresponding 95% confidence interval (CI) adjusted for calendar period. We found no significant increased risk of thrombocytopenia in 1–21 days following BNT162b2, CoronaVac and ChAdOx1 vaccines while the risk was increased following SARS-CoV-2 infection (IRR 15.52, 95% CI 13.38–18.00). Similarly, vaccination with BNT162b2, CoronaVac, or ChAdOx1 was not associated with an increased risk of VTE during the 1–21 days risk period. SARS-CoV-2 infection was associated with increased risk of VTE (IRR 39.84, 95% CI 27.45–32.44). Our findings showed low event rates of thrombocytopenia and VTE following booster vaccination with comparable safety profiles between those who received homologous and heterologous booster combinations. Our findings showed the risk of thrombocytopenia and VTE was not increased after COVID-19 vaccination while the risks were substantially higher after SARS-CoV-2 infection.

The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review.

Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods.

DNA Liquid Biopsies for Cancer-Associated Venous Thromboembolism Prediction

Introduction Cancer-associated venous thromboembolism (VTE) is a major source of oncologic cost, morbidity and mortality. Identifying an optimal population for prophylactic anticoagulation is challenging and adds to clinician overhead. Circulating tumor (ct)DNA sequencing assays (“liquid biopsies”) are increasingly deployed in clinic, with multiple US FDA approvals for matching to molecularly targeted therapy. Preliminary data suggest that cell-free (cf)DNA, which is also measured as part of liquid biopsies and may consist of tumor or wild-type DNA, is thrombogenic due to its association with neutrophil extracellular traps. However, clinical validation of cfDNA for VTE prediction is lacking. ctDNA detection is associated with aggressive tumor biology and worse survival; however, whether it is associated with VTE is unknown. To address these gaps, we studied the clinical utility of ctDNA and cfDNA from liquid biopsies for predicting VTE. Methods We conducted an observational study in two cohorts: 1) Patients with any cancer type at Memorial Sloan Kettering Cancer Center (MSK, New York USA), an academic medical center, with plasma ctDNA sequencing using MSK-ACCESS, a NY State-approved, 129-gene assay (N=4,141). 2) A nonoverlapping cohort of patients at MSK or GenesisCare (Sydney, Australia), a community oncology setting, with stage IV or recurrent non-small cell lung cancer and ctDNA sequencing using a separate commercial assay (Agilent ctDx Lung, N=463). We studied the independent contribution of ctDNA, cfDNA and related variables for predicting VTE using Cox proportional hazards. We studied the potential utility of DNA liquid biopsies for predicting VTE within six months using machine learning models, comparing their dynamic area under the receiver operating curve, precision, and recall to those of the Khorana score, the most widely implemented risk metric. We tested the impact of ongoing anticoagulation for non-VTE indications on future VTE in patients with and without detectable ctDNA using nonrandomized, real-world evidence. Results ctDNA detection was associated with an increased risk of VTE in a dose-dependent manner (Figure 1). This association was observed across assays and treatment sites and regardless of genomic subtype. ctDNA was associated with VTE risk in non-small cell lung, breast, pancreatic, prostate, and less represented cancers as well as melanoma but not in bladder, hepatobiliary, or colorectal cancer. By contrast, cfDNA concentration was associated with VTE risk in all cancer types. In multivariate analysis, ctDNA detection, cfDNA concentration, Khorana score, chemotherapy treatment within 30 days, and number of organ sites of metastasis were all independently associated with VTE. In a cohort of patients with treatment naive lung adenocarcinoma with segmented positron emission tomography scans, ctDNA was an independent predictor of VTE after controlling for metabolic tumor volume. A random survival forest machine learning model to predict VTE within six months of plasma draw using liquid biopsy data (i.e. cfDNA and ctDNA levels as well as genomic content), cancer type, and chemotherapy receipt (“LB+”) outperformed the Khorana score in 5-fold cross-validation and was similarly superior in the external lung cohort (Table 1). The superiority of the model was observed in patients treated or not treated with chemotherapy. Additional clinical and radiologic data, including demographics, metastatic sites of disease, and Khorana score components (“All”), did not improve the ctDNA assay-based LB+ model. Patients with anticoagulation had lower VTE rates if ctDNA was detectable (adjusted HR 0.54, 95%CI 0.33-0.87) but not if ctDNA was undetectable. Conclusion In patients with cancer, ctDNA and cfDNA are independent biomarkers for VTE. Risk models incorporating liquid biopsy data are feasible in academic or community settings and, if prospectively validated, would provide a means of VTE risk stratification at scale.

Correlation Between Statin Use and Symptomatic Venous Thromboembolism Incidence in Patients With Ankle Fracture: A Machine Learning Approach.

Identifying factors that correlate with the incidence of venous thromboembolism (VTE) has the potential to improve VTE prevention and positively influence decision-making regarding prophylaxis. In this study, we aimed to investigate the correlation between statin consumption and the incidence of VTE in patients who sustained an ankle fracture. In this retrospective, case-controlled study, cases were those who developed VTE and controls were those who had no VTE, and the ratio was 1:4. Patients' demographics, history of hyperlipidemia, and reported statins use were obtained. A random forest classifier (RFC) model was used to predict whether statin consumers were at risk of VTE after ankle fracture regardless of VTE prophylaxis administration based on statin consumption, body mass index (BMI), age, and biological sex. Of the 1175 patients with ankle fractures, 238 had confirmed VTE (case group), and 937 had no symptomatic VTE (control group; ratio 1:4). Fifty (21%) cases and 407 (43%) controls were on a statin. Statin users had a significantly lower incidence of VTE after ankle fracture, odds ratio (OR) = 0.35, 95% CI: 0.25, 0.49, P < .001. Our model showed an area under the receiving operator curve (AUROC) of 78%, a sensitivity of 73%, and a specificity of 83% in predicting the risk of VTE. The importance of the predictors of VTE, other than the use of statins (model importance = 0.1), were age (model importance of 0.72), BMI (model importance of 0.24), and biological sex (model importance of 0.02). Statins were significantly associated with a lower rate of VTE in our population of patients who sustained an ankle fracture. 3.

The Financial Burden of Aspirin versus Oral Factor Xa Inhibitors for Thromboprophylaxis Following Total Knee Arthroplasty

BackgroundAspirin and oral factor Xa inhibitor thromboprophylaxis regimens are associated with similarly low rates of venous thromboembolism following total knee arthroplasty (TKA). However, the rate of prosthetic joint infection (PJI) is lower with aspirin use. This study aimed to compare the cost differential between aspirin and factor Xa inhibitor thromboprophylaxis with respect to PJI management. MethodsWe used previously published rates of PJI following aspirin and factor Xa inhibitor thromboprophylaxis in primary TKA patients at a single, large institution. Prices for individual drugs were obtained from our hospital’s pharmacy service. The cost of PJI included that of 2-stage septic revision, with or without the cost of 1-year follow-up. National data were obtained to determine annual projected TKA volume. ResultsThe per-patient costs associated with a 28-day course of aspirin versus factor Xa inhibitor thromboprophylaxis were $17.36 and $3,784.20, respectively. Including cost of follow-up, per-patient costs for a 28-day course of aspirin versus factor Xa inhibitors increased to $73,358.76 and $77,125.60, respectively. The weighted average per-patient costs for a 28-day course were $237.38 and $4,370.93, respectively. The annual cost difference could amount to over $14.1 billion in the United States by 2040. ConclusionsThe per-patient cost associated with factor Xa inhibitor thromboprophylaxis is as much as 1,980.6% higher than that of an aspirin regimen due to increased costs of primary treatment, differential PJI rates, and high costs of management. In an era of value-based care, the use of aspirin is associated with major cost advantages.

Venous thromboembolism prevention in cancer care: implementation strategies to address underuse

BackgroundEvidenced-based interventions have been developed to prevent venous thromboembolism (VTE) in ambulatory patients with cancer, including VTE-risk assessment for all patients and targeted primary thromboprophylaxis for high-risk patients. Despite supportive evidence and recommendations, oncologists rarely assess VTE risk or provide primary prophylaxis. Our previous work identified barriers and facilitators to using VTE prevention interventions in oncology practice. ObjectivesTo identify potential strategies that address the identified barriers and leverage facilitators to achieve successful implementation of evidence-based interventions for VTE prevention in oncology practice. MethodsWe used the Implementation Research Logic Model, an implementation science framework, to map the relationships among barriers and facilitators, feasible and effective implementation strategies, and implementation and clinical outcomes that will be used to evaluate the implementation strategies. ResultsWe identified 12 discrete implementation strategies (eg, conducting clinician education and training and staged implementation scale-up) that address barriers and leverage facilitators through their mechanisms of action (eg, increased clinician awareness of evidence and targeting the highest effectiveness). We identified key implementation (eg, penetration, adoption, acceptability, fidelity, appropriateness, and sustainability), system (eg, integration of VTE-risk assessment into clinical workflow), and clinical (eg, lower VTE rates) outcomes targeted by the selected strategies. ConclusionUsing the Implementation Research Logic Model framework and building on our knowledge of barriers and facilitators, we identified implementation strategies and important outcomes to evaluate these strategies. We will use these results to test and measure the strategies to improve the uptake of evidence-based recommendations for VTE prevention in oncology practice.

Thrombophilia gene mutations predict venous thromboembolism in ambulatory cancer patients receiving chemotherapy

BackgroundInherited thrombophilia and cancer both independently increase the risk of venous thromboembolism (VTE). However, whether the increased VTE risk associated with inherited thrombophilia exists in cancer patients is less clear. ObjectivesOur objective was to determine the influence of inherited thrombophilia on VTE and bleeding risk in moderate-to-high-risk ambulatory cancer patients receiving chemotherapy. MethodsWe conducted a post hoc analysis using blood samples from patients enrolled in the AVERT trial to determine if previously recognized thrombophilia gene mutations (prothrombin factor [F] II G20210A, FXI, fibrinogen gamma, serpin family A member 10, FV K858R, FXIII, FV Leiden [FVL], and ABO blood) were associated with VTE or bleeding during the 7-months after starting chemotherapy. Logistic regression was used to compare heterozygous and homozygous mutations (combined) to wild-type. VTE rates, bleeding rates, and risk differences for mutations stratified by prophylactic anticoagulation use were calculated. ResultsOf the 447 patients, there were 39 VTE and 39 bleeding events. The odds of VTE were significantly increased with FVL mutation and non-O blood type (odds ratio [OR]: 5.2; 95% CI: 1.9-14.7 and OR: 2.7; 95% CI: 1.2-6.1, respectively). The use of anticoagulation prophylaxis resulted in complete protection in FVL patients, whereas those not receiving anticoagulation had a VTE rate of 119 per 100 patient-years. Lower VTE rates were also observed in non-O blood type patients taking prophylactic anticoagulation. No other thrombophilia genes tested were significantly associated with VTE or bleeding. ConclusionOur results indicate that FVL mutation and ABO blood type may be important VTE predictors in cancer patients starting chemotherapy.

Inadequate Venous Thromboembolism Chemoprophylaxis Is Associated With Higher Venous Thromboembolism Rates Among Trauma Patients With Epidurals

IntroductionGuidelines encourage higher doses of low molecular weight heparin (LMWH) for prophylaxis in trauma patients. The risks of LMWH must be considered for patients who require an epidural catheter. We compared adequate and inadequate prophylaxis to determine if venous thromboembolism (VTE) and complication rates differed among patients with epidural catheters. MethodsTrauma patients who required an epidural catheter between 2012 and 2019 were reviewed for VTE and epidural-related complications. Adequate dosing was defined as enoxaparin 30 mg or 40 mg twice daily. Inadequate dosing was defined as unfractionated heparin subcutaneously or enoxaparin once daily. ResultsOver the 8-y study period, 113 trauma patients required an epidural catheter of which 64.6% were males with a mean age of 55.8 y and injury severity score of 14. Epidural catheters were associated with 11 (9.7%) patients developing an acute deep vein thrombosis (DVT) and 2 (1.8%) patients with an acute pulmonary embolism. Those patients who received adequate doses of enoxaparin were less likely to have any VTE or DVT. Complications associated with epidural catheters were not dependent on the type of pharmacological prophylaxis. ConclusionsGiven the high VTE rate observed in trauma patients who required an epidural catheter, along with the low complication rate that was observed independent of the type of pharmacological prophylaxis given, the data indicate that current efforts for higher doses of LMWH appear to be safe and associated with a lower VTE rate.

Outcomes in infants with unprovoked venous thromboembolism: A retrospective cohort study

BackgroundAlthough children aged <1 year have a relatively high rate of venous thromboembolism (VTE) compared to older children, most have additional prothrombotic risk factors. Unprovoked VTE is rare, and little is known about this population, particularly the risk of recurrent VTE. ObjectivesWe aimed to determine the rate of recurrent VTE in infants with prior unprovoked VTE and evaluate long-term, end-organ outcomes for infants with renal and intracranial vein thrombosis. MethodsInfants <1 year of age with an unprovoked VTE between 2003 and 2021 at a single institution were included. Time to recurrent event and anticoagulation duration were summarized using the Kaplan-Meier estimator. Neurologic outcomes were summarized with the pediatric stroke outcome measure for infants with cerebral sinovenous, medullary, or cortical vein thrombosis. Kidney outcomes were summarized with estimated glomerular filtration rates for infants with renal vein thrombosis. Anticoagulation was summarized. ResultsForty infants with intracranial, renal, portal, and extremity VTE met the inclusion criteria and were followed for a median of 4.7 years (IQR, 2.1-8.5). Most VTE events occurred during the first month of life. There was 1 recurrent event in 237 person-years of follow-up (incidence rate, 4 per 1000 [95% CI, 0.6-29.9] person-years). In outpatient follow-up, 40% of infants with intracranial thrombosis met criteria for moderate or severe neurologic outcomes and two-thirds of infants with a prior renal vein thrombosis had abnormal kidney function (estimated glomerular filtration rate < 90 mL/min/1.73 m2). ConclusionThere is a low rate of recurrent VTE but significant end-organ morbidity in infants with unprovoked VTE.

Occurrence rates and risk factors of in-hospital venous thromboembolism, major bleeding, and death in patients receiving fondaparinux after orthopedic surgery or trauma surgery

AimFondaparinux is a synthetic anticoagulant that inhibits thrombosis by suppressing factor Xa. The efficacy of fondaparinux for orthopedic surgeries has been revealed by several foreign studies; however, relevant evidence in Chinese patients is lacking. This study intended to investigate the occurrence rate and risk factors of in-hospital venous thromboembolism (VTE), major bleeding, and death in patients receiving fondaparinux after orthopedic surgery or trauma surgery.MethodsTotally, 1258 patients who received fondaparinux after orthopedic surgery or trauma surgery were retrospectively enrolled. Meanwhile, in-hospital VTE, major bleeding, and death were obtained for assessment. Besides, adverse events were recorded.ResultsThe occurrence rates of in-hospital VTE, major bleeding, and death were 2.5%, 21.8%, and 0.0%, respectively. The multivariate logistic regression analysis revealed that only age (> 60 years vs. ≤ 60 years) (odd ratios (OR) = 3.380, P = 0.013) was independently correlated with increased risk of in-hospital VTE. Additionally, osteoarthritis diagnosis (OR = 3.826, P < 0.001), femoral head necrosis diagnosis (OR = 1.809, P = 0.034), hip replacement (vs. internal fracture fixation) (OR = 2.199, P = 0.007), knee replacement (vs. internal fracture fixation) (OR = 2.781, P = 0.002), and serum creatinine (abnormal vs. normal) (OR = 1.677, P = 0.012) were independently linked to a higher risk of in-hospital major bleeding. Moreover, the common adverse events included pain (56.6%), wound bleeding (23.0%), increased drainage (5.2%), etc.ConclusionFondaparinux realizes low occurrence rates of in-hospital VTE and major bleeding with tolerable adverse events in patients receiving orthopedic surgery or trauma surgery.

Low-Dose Heparin Infusion as Venous Thromboembolism Chemoprophylaxis in Patients With Blunt Cerebrovascular Injury

IntroductionBlunt cerebrovascular injury (BCVI) can result in devastating stroke. Because of operative inaccessibility, the most common treatment for BCVI is aspirin or a low-dose systemic heparin infusion. While it is assumed that low dose heparin infusion imparts venous thromboembolism (VTE) prophylaxis, this has not been evaluated in the BCVI population. The purpose of this study was to evaluate VTE rates in patients receiving low-dose heparin infusion as treatment for BCVI. MethodsPatients diagnosed with BCVI between 2014 and 2018 were reviewed for initiation of low-dose systemic heparin treatment. VTE was defined as a deep vein thrombosis or pulmonary embolism. BCVI patients without systemic heparin treatment were compared to BCVI patients with heparin treatment for overall VTE rates. Comparisons were also made to injured patients without a BCVI in our Trauma Activation Protocol (TAP) database. ResultsDuring the 5-year study period, 265 patients were identified with a BCVI. The majority (61%) were men with a median injury severity score (ISS) 22 (interquartile range [IQR]:14-33). Of these patients, 146 (55.1%) received a heparin infusion to treat BCVI. VTE was identified in eight of these patients (5.5%). Compared to TAP patients (n = 1020) who received standard dosing of VTE chemoprophylaxis, there was no difference in VTE rates compared to BCVI patients who were started on a low dose heparin infusion (3% versus 5.5%, P = 0.16). Area under the receiver operating characteristics (AUROC) was used to evaluate the predictive power of time to initiation of heparin infusion (AUC = 0.64 95% CI 0.42-0.85, P = 0.2) and time to reaching PTT goal (AUC = 0.52 95% CI 0.27-0.77, P = 0.83) as a predictor VTE events. ConclusionsLow dose heparin infusion is frequently used as an initial treatment of BCVI. In injured patients with BCVI, a low dose heparin infusion is associated with a low rate of VTE, comparable to injured patients without BCVI that received standard VTE chemoprophylaxis.

Direct Oral Anticoagulants versus Vitamin K Antagonists in Individuals Aged 80 Years and Older: An Overview in 2021.

Two main types of oral anticoagulants are available in France: vitamin K antagonists (VKA) and, more recently, direct oral anticoagulants (DOAC). The benefit−risk profile appears to be favorable for DOAC, which is as effective as VKA but safer (fewer cases of severe and cerebral bleeding). In a study in 2017, we observed that older adults did not seem to receive the same modalities of oral anticoagulants as younger individuals for various reasons. To assess anticoagulation prescribing practices over time, we repeated this cross-sectional study by comparing very old individuals taking DOAC to those taking VKA. Ambulatory individuals aged 80 years and older were included. They were affiliated with the Mutualité Sociale Agricole of Burgundy and were refunded for a medical prescription of oral anticoagulation in March 2021. The demographic characteristics, registered chronic diseases (RCD), number and types of prescribed drugs, and mortality of the DOAC group and the VKA group were compared. A total of 4275 subjects were included in the study: 67.44% (2883) received DOAC and 32.56% (1392) received VKA. The two groups were similar in age. In the DOAC group, there were more women (54.98% vs. 46.98%) (p < 0.001), fewer RCD (91.47% vs. 93.68%) (p = 0.014), and lower rates of venous thromboembolism (2.53% vs. 6.75%) (p < 0.001), severe heart failure (56.50% vs. 68.03%) (p < 0.001), and severe kidney diseases (1.38% vs. 3.59%) (p < 0.001), but there were more subjects with Alzheimer’s disease (7.49% vs. 4.31%) (p = 0.001). Individuals in the DOAC group had fewer prescriptions of furosemide (48.53% vs. 55.75%) (p < 0.001) and fibrates (2.32% vs. 3.88%) (p = 0.044). They also had more prescriptions of proton pump inhibitors (43.95% vs. 39.44%) (p = 0.006) and antirheumatics (1.60% vs. 0.65%) (p = 0.009) than those in the VKA group. There was no difference in mortality. This study revealed that prescribing practices for DOAC have changed over time.

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost

Background: Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. Hypothesis: Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. Study Design: Economic and decision analysis; Level of evidence, 3. Methods: The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A “break-even” analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. Results: The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. Conclusion: Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.

Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis

IntroductionTrauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation. MethodsA systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation. ResultsTwelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12). ConclusionsBased on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.