Previous History Of Pulmonary Embolism Research Articles

Robotic-assisted hiatal hernia repair and pulmonary embolism: an institution-based retrospective cohort study.

Hiatal hernia (HH) is an abnormal protrusion of components of the abdominal viscera through the esophageal hiatus. The laparoscopic approach is the gold standard for repair with the robotic technique now gaining wide acceptance. Pulmonary embolism (PE) is a well-known post-operative complication but its incidence following robotically assisted HH repairs is not well known. This study provides a descriptive analysis of three patients who developed PE after robotic repairs of their HHs. The incidence of PE in the studied cohort was 2.7% (3 of 112) with a male preponderance (66.7%). The mean age of the patients was 55.3years with a mean BMI of 32.2kg/m2. The average duration of surgery was 4.2h with sizes of the diaphragmatic defects ranging from 3 to 6cm. Confirmatory PE diagnosis was made with a chest CT angiogram and the mean length of hospital stay was 4days. PE although rare, is a preventable cause of in-patient mortality and morbidity with implications on healthcare costs and hospital resource use. The Caprini model provides a guide to pre-operative patient risk stratification and PE prevention, and the patients in this study were in the moderate to high-risk groups. Risk factors common to all patients were: age > 40years, BMI > 30kg/m2 and duration of surgery > 2h with one of the patients having a previous history of PE. There are no established PE chemoprophylaxis guidelines for robotic HH repairs and in this cohort, heparin was commenced 6-8h post-operatively. Thus, there is a need for a consensus chemoprophylaxis guideline in this subset of surgical patients. PE following robotic HH repair is associated with prolonged hospital stay and increased healthcare costs. Guidelines for effective pre-operative chemoprophylaxis for these repairs are needed to optimize patient outcomes.

Relationship between CHA2DS2-VASc and CHADS2 scores with pulmonary hypertension in patients with acute pulmonary embolism.

Pulmonary hypertension (PH) is the most important prognostic factor after acute pulmonary embolism (PE). Therefore, determination of patients who will develop PH after acute PE is crucial. The aim of the present study was to evaluate the predictive value of the CHADS2 and CHA2DS2-VASc scores for PH in patients with acute PE. Seventy-nine adults who presented with acute PE, had an admission systolic pulmonary artery pressure (sPAP) measured on echocardiogram and no previous history of PE, were retrospectively identified from the computerized database. 31 patients who had sPAP ≤ 40 mm Hg were categorized as a "normal pulmonary pressure" group, whereas 48 patients who had sPAP > 40 mm Hg were categorized as a "PH" group. SPAP was > 40 mm Hg in 48 patients (60.8%), with a mean sPAP of 60.9 ± 16.1 mm Hg (median = 60, min-max = 41-100 mm Hg). In multivariate logistic regression models adjusted for CHADS2 and CHA2DS2-VASc score components, only age was found to be related with the development of PH. SPAP was weakly positively correlated with CHADS2 (p = 0.047; r = 0.224) and CHA2DS2-VASc (p = 0.023; r = 0.256) scores. SPAP values were increasing with the severity of the scores. Both CHADS2 and CHA2DS2-VASc scores could be useful in the determination of which patients should be closely followed up in order to prevent the development of PH after acute PE.

A Phase I Study of 177 lu-DOTA-HH1 (Betalutin) Radioimmunotherapy for Patients with Relapsed CD37+ Non-Hodgkin’s B Cell Lymphoma

Background and aim: The CD37 antigen is expressed at high levels predominantly by normal B cells and the majority of malignant B-cell lymphomas. Hence, this surface antigen represents an interesting therapeutic target for treatment of B-cell non-Hodgkin lymphomas (NHL). 177Lu-DOTA-HH1 (Betalutin™) is a novel anti-CD37 radioimmunoconjugate currently under clinical development. Betalutin™ consists of the β-emitting isotope Lutetium-177 (t/2 = 6.7 days) chelated to DOTA (a chemical linker) which is conjugated to the murine mAb HH1. Betalutin™ is delivered in a ready-to-use formulation at the study centers. Pre-clinical studies have demonstrated significant anti-tumor activity; both ex vivo and in models of human B-cell lymphomas in mice. Based on these results, a phase I study has been initiated in order to determine the maximum tolerated dose (MTD), overall safety and to explore tumor response.Methods: Patients with relapsed incurable CD37+ NHL of follicular grade I-IIIA, marginal zone, mantle cell, lymphoplasmacytic and small lymphocytic lymphomas with < 25% bone marrow infiltration and with platelet counts ≥ 150 x109/l were eligible for inclusion in the study. In order to deplete normal B cells patients first received a pre-treatment consisting of single infusions of rituximab (375 mg/m2) on day 1 and day 8. On day 29 the patients received a pre-dose infusion of HH1 (50 mg, cold CD37 antibody) followed by the radioimmunoconjugate 177Lu-DOTA-HH1administered as a 10 minute iv bolus. A 3 x 3 dose escalation design was used with 10 MBq/kg as the starting level. Patients were assessed for distribution of radioactivity by gamma camera wholebody scans and SPECT/CT. Clinical response was studied by 18F-FDG PET/CT, CT and bone marrow specimens. Evaluation of response was performed according to the NCI criteria of 1999 and 2007. Adverse events were monitored and scored in agreement with the NCI Common Terminology Criteria for Adverse Events (CTCAE) for toxicity grading.Results: A total often patients (9 follicular lymphoma,1 mantle cell lymphoma) have been treated according to protocol since the study was initiated in December 2012. The median number of prior therapies were 2 (range 1-7) and four out of ten patients had previously not responded to or progressed during treatment with rituximab as single agent. Serious adverse events were reported for four patients. Two patients developed thrombocytopenia requiring platelet transfusions and one of these patients had epistaxis. Another patient with a previous history of pulmonary embolism (PI) presented with pneumonia and PI. The fourth SAE was a transient case of atrial fibrillation, unlikely to be related to the study drug. Apart from these events, the most common toxicities were hematological, as expected with median time to nadir for platelets and neutrophils of 39 days and 48 days, respectively. Dose-limiting toxicity (DLT) was observed in all three patients treated at dose level 2 (20 MBq/kg), with grade III/IV neutropenia and/or thrombocytopenia, all reversible. However, no patients developed neutropenic fever. Based on the assumption that MTD is 15 MBq/kg, three patients are currently in follow-up after treatment at this dose level. With regard to efficacy, clinical responses have been observed at both dose level 1 (10 MBq/kg) and 2 (20 MBq/kg). At level 10 MBq/kg, two out of four patients had partial remissions, one had stable disease and one progressed. At level 20 MBq/kg two out of three patients obtained a complete remission and one had a partial remission. At dose level 15 MBq/kg efficacy results are pending. The first patient treated in this study has now been in stable remission with an observation time of 18 months.Conclusion:177Lu-DOTA-HH1 in a single dose ready-to-use formulation has a favorable safety profile, mostly with hematological toxicities as expected. DLT was observed at dose level 20 MBq/kg, and dose level 15 MBq/kg is currently predicted to be the MTD for the phase II part of this trial. Complete and partial responses have been observed so far, hence, 177Lu-DOTA-HH1 targeting the CD37 antigen is a promising new candidate against NHL. DisclosuresKolstad:Nordic Nanovector: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Dahle:Nordic Nanovector AS: Employment, Equity Ownership, Patents & Royalties. Bruland:Nordic Nanovector AS: Consultancy, Equity Ownership, Honoraria, Membership on an entity’s Board of Directors or advisory committees. Bolstad:Nordic Nanovector AS: Employment, Equity Ownership. Larsen:Nordic Nanovector AS: Consultancy, Equity Ownership, Membership on an entity’s Board of Directors or advisory committees, Patents & Royalties. Alfheim:Nordic Nanovector as: Employment, Equity Ownership. Holte:Nordic Nanovector AS: Membership on an entity’s Board of Directors or advisory committees.

Pulmonary artery re-thrombosis following interruption of anti-thrombotic therapy for bilateral carpal tunnel release surgery: An update of current protocols

In the perioperative period, patients who are under anti-thrombotic therapy should be managed with care, although there is no clear consensus on this matter. For hand surgery, several authors have advocated no interruption of the anti-thrombotic therapy, but the choice differs between institutes according to protocols and surgeons' preference. We report a case of massive pulmonary embolism after stopping warfarin for carpal tunnel release in a patient with a previous history of pulmonary embolism. Although the patient recovered after thrombolytic therapy and intensive care unit (ICU) care, this case has struck the authors as a valuable lesson. In managing anti-thrombotic therapy, we should weigh the risks and benefits of the patients carefully before making a decision.

Clinical and Laboratory Factors Associated With the Severity of Proliferative Sickle Cell Retinopathy in Patients With Sickle Cell Hemoglobin C (SC) and Homozygous Sickle Cell (SS) Disease

Proliferative sickle cell retinopathy (PSCR) is the most frequent vision-threatening complication of sickle cell disease (SCD). We investigated the relationship between the severity of sickle cell retinopathy in heterozygous (SC) or homozygous (SS) adult SCD patients and the clinical and laboratory data obtained during visits to a national SCD referral center. This retrospective longitudinal analysis included 942 SCD patients (313 patients with SC and 629 with SS disease) with ophthalmologic evaluations who were followed over a 19-year period by a multidisciplinary team in a referral center. PSCR was graded using the Goldberg classification. We identified patient and SCD characteristics associated with sickle cell retinopathy severity using multinomial logistic-regression models. Multivariate analysis associated severe PSCR forms (stages III-V) with older age (p=0.032), pulmonary involvement (documented pulmonary hypertension with pulmonary arterial pressure≥40 mm Hg, restrictive syndrome>20%, or previous history of pulmonary embolism diagnosed by vascular imaging) (p=0.029), deafness or tinnitus (p=0.026), and no history of osteomyelitis (p=0.013) for SC patients; and with older age (p<0.001), male sex (p=0.003), and acute pyelonephritis (p=0.04) for SS patients. The model of severe PSCR versus no PSCR showed good calibration and discrimination for SC and SS patients. Awareness of the clinical and laboratory factors significantly associated with severe PSCR in patients with SC or SS SCD may contribute to improved preventive strategies.

Evaluation of right ventricular function in patients with a previous episode of pulmonary embolism using tissue Doppler imaging

New echocardiographic techniques including tricuspid annular plane systolic excursion (TAPSE) and pulsed tissue Doppler imaging (TDI) of the right ventricular wall have been assessed to better define right ventricular dysfunction (RVD) during the acute phase of pulmonary embolism (PE) in patients without significant tricuspidal insufficiency. Their application in patients with a previous history of PE may provide a better estimation of the incidence and clinical significance of long-term functional impairment of the right ventricle. In a case-control study, we compared the prevalence of RVD in a cohort of consecutive patients with previous PE and in age and sex-matched controls without PE. Exclusion criteria were moderate-severe left heart failure, moderate-severe mitral valve regurgitation, severe tricuspid insufficiency, or other causes of chronic pulmonary hypertension. Systolic and diastolic right ventricular functions were evaluated by measuring TAPSE and TDI of the right ventricular wall. Twenty-five patients with a previous first episode of PE and 25 controls were enrolled. Mean value of TAPSE was similar between patients with previous PE and controls (2.58 ± 0.33 and 2.53 ± 0.35 cm, P = ns). In patients with PE, the mean value of E″/A″ was significantly lower than in controls (0.89 ± 0.24 vs. 1.30 ± 0.39, P < 0.001), with 14 out of 25 cases having diastolic dysfunction as compared to only 3 out of 25 controls (P < 0.002). A high proportion of patients with previous PE have echocardiographic signs of RV diastolic dysfunction 6 months after the acute phase, even in the absence of symptoms, and in the presence of normal pulmonary pressures.

The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients

We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253). Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures.

Post Discharge Prophylactic Anticoagulation in Gastric Bypass Patient—How Safe?

It is becoming an increasingly common practice to discharge gastric bypass (GBP) patients on prophylactic anticoagulation. This is because pulmonary embolism (PE) is a common cause of mortality postoperatively. This study was undertaken to: (1) determine the incidence of major bleeding in GBP patients discharged on prophylactic low molecular weight heparin (LMWH)-enoxaparin and, (2) correlate the bleeding risk to the dose used. Retrospective chart review of all open GBP operation from June 2004 to August 2005. One hundred and twenty seven patients were sent home on LMWH for 2 weeks. Body mass index (BMI) > or =50 kg/m(2) with chronic venous stasis and/or obstructive sleep apnea, previous history of PE or deep vein thrombosis (DVT) or BMI > or =60 kg/m(2). The study group was divided into two subgroups: 40 mg twice daily (bid) and 60 mg bid LMWH. Statistical analysis was done with the chi-square. The primary outcome measure was major bleeding; defined as bleeding during the period of LMWH use associated with symptomatic decrease in hematocrit (HCT), necessitating stopping LMWH administration before the end of the study period (2 weeks), bleeding-related readmission, blood transfusion, or intervention. Excluded were patients on warfarin or treated with therapeutic LMWH. The groups were similarly matched for age, body mass index, and risk factors. No episode of major bleeding after discharge occurred in either group. The use of low molecular weight heparin for prophylactic anticoagulation after open gastric bypass is not associated with risk of major bleeding.