Initiation Of Thromboprophylaxis Research Articles

Prevalence and clinical value of autoantibodies directed against lysobisphosphatidic acid in antiphospholipid syndrome.

To assess the prevalence and clinical significance of autoantibodies against lysobisphophatidic acid (aLBPA) in patients with antiphospholipid syndrome (APS). We conducted a retrospective analysis involving 91 patients with persistent conventional antiphospholipid antibodies (aPL): 60 patients with at least one clinical event of APS (symptomatic group) and 31 without (asymptomatic group), as well as 33 aPL-negative controls. Detection of aLBPA in serum samples was performed using an enzyme-linked immunosorbent assay (ELISA) specifically designed for this study. The prevalence of aLBPA is significantly higher in patients with persistent aPL than that of the control group (p< 0.0001). Among patients with persistent aPL, our findings reveal a significantly higher prevalence of aLBPA in asymptomatic patients compared with their symptomatic counterparts (p= 0.027). Notably, patients positive for IgG aPL alone demonstrated a greater likelihood of presenting clinical events suggestive of APS. The combined assay of aLBPA and conventional aPL could be used to stratify patients with persistent aPL. This combined approach could serve as a valuable tool in the management of this complex autoimmune disease, particularly in guiding decisions regarding the initiation of primary thromboprophylaxis in asymptomatic patients with persistent aPL.

Enhancing thromboprophylaxis after colorectal cancer surgery in China: Bridging the gap between evidence and implementation through pathway optimization.

The CRC-VTE trial conducted in China revealed a significant occurrence of venous thromboembolism (VTE) in patients following colorectal cancer (CRC) surgery, raising concerns about implementing thromboprophylaxis measures. The present study aimed to identify and analyze inappropriate aspects of current thromboprophylaxis practices. This study performed an analysis of the CRC-VTE trial, a prospective multicenter study that enrolled 1836 patients who underwent CRC surgery. The primary objective was to identify independent risk factors for VTE after CRC surgery using multivariate logistic regression analysis. Furthermore, among the cases in which VTE occurred, the appropriateness of thromboprophylaxis was assessed based on several factors, including pharmacologic prophylaxis, time to initiate prophylaxis, drug selection, drug dosage, and duration of pharmacologic prophylaxis. Based on the analysis of the current state of thromboprophylaxis and relevant clinical guidelines, a modified Delphi method was used to develop a clinical pathway for VTE prophylaxis after CRC surgery. In this analysis of 1836 patients, 205 (11.2%) were diagnosed with VTE during follow-up. The multifactorial analysis identified several independent risk factors for VTE, including age (≥70 years), female sex, varicose veins in the lower extremities, intraoperative blood transfusion, and the duration of immobilization exceeding 24 h. None of the patients diagnosed with VTE in the CRC trial received adequate thromboprophylaxis. The main reasons for this inappropriate practice were the omission of thromboprophylaxis, delayed initiation, and insufficient duration of thromboprophylaxis. We developed a specialized clinical pathway for thromboprophylaxis after CRC surgery to address these issues. This study offers a comprehensive nationwide evaluation of existing thromboprophylaxis practices in patients after CRC surgery in China. A specialized clinical pathway was developed to address the identified gaps and improve the quality of care. This clinical pathway incorporates explicit, tailored, detailed recommendations for thromboprophylaxis after CRC surgery.

Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization.

To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients. TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown. Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017 to 2019 American College of Surgeons Trauma Quality Improvement Project data sets. Cases with <24-hour length of stay and other serious injuries were excluded. Venous thromboembolism (VTE) included deep venous thrombosis and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses. Of 1550 patients, 1370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P <0.001) and 48 hours (13.2% vs 8.4%, P =0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3% vs 3.3%, P =0.025). In the 180 patients with hepatic surgery before angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P <0.001), and 72 hours (37% vs 14%, P =0.001). Moreover, deep venous thrombosis was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023). This is the first study to address the timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48 to 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE. Level III-retrospective cohort study.

Venous thromboembolism in patients with pancreatic adenocarcinoma: Disease burden and initiation of ambulatory thromboprophylaxis

Background/ObjectivesAmbulatory thromboprophylaxis (AT) in patients with pancreatic adenocarcinoma (PAC) reduces venous thromboembolism (VTE) risk and is recommended for patients receiving systemic chemotherapy. We evaluated VTE rates, severity, timing, and risk factors in PAC patients as well as AT rates and initiation times. MethodsPatients diagnosed with PAC were included. Data collected included patient demographics, medical history, PAC diagnosis, development of VTE, AT, and bleeding episodes. VTE was defined as a DVT or a PE. Patients were classified as receiving AT for VTE prevention if they received a prescription for outpatient anticoagulation. ResultsThe cohort included 243 PAC patients. VTE occurred in 24 %. Overall, 52 % developing VTE were hospitalized and 5 % died as a result of the VTE. Of those who developed VTE 50 % were diagnosed within the first 2 months of PAC diagnosis. Univariate predictors of elevated VTE risk included an elevated Onkotev score, metastasis at diagnosis, male gender and not receiving AT. Multivariate predictors of elevated VTE risk included male gender (P = 0.014) and not receiving AT (P = 0.001). Overall, 30 % of patients received AT. The median time from diagnosis to initiation of AT was 43 days. Major bleeding occurred in 5.8 %. Patients receiving AT were not at a significantly increased risk of major bleeding (p = 0.5). Patients with intestinal tumor invasion were at significantly increased risk of major bleeding (P = 0.021). ConclusionVTE risk is significant and morbid in PAC patients. AT rates are low, and initiation is often delayed. Therapeutic endoscopists diagnosing PAC may be helpful in AT initiation.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BackgroundThromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. MethodsAll blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. ResultsIn 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58–0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20–1.81]). ConclusionThis national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

The Role of KRAS Mutation in Colorectal Cancer-Associated Thrombosis

Venous thromboembolic events (VTE) are common in patients with colorectal cancer (CRC) and represent a significant contributor to morbidity and mortality. Risk stratification is paramount in deciding the initiation of thromboprophylaxis and is calculated using scores that include tumor location, laboratory values, patient clinical characteristics, and tumor burden. Commonly used risk scores do not include the presence of molecular aberrations as a variable. This retrospective study aims to confirm the link between KRAS-activating mutations and the development of VTE in CRC. A total of 166 patients were included in this study. They were split into two cohorts based on KRAS mutational status. We evaluated the frequency and mean time to VTE development stratified by the presence of KRAS mutations. Patients with mutant KRAS had an odds ratio (OR) of 2.758 for VTE compared to KRAS wild-type patients, with an increased risk of thrombosis being maintained in KRAS mutant patients even after adjusting for other known VTE risk factors. Taking into account the results of this study, KRAS mutation represents an independent risk factor for VTE.

Evaluation of Clinical Risk Factors and Thrombosis-Related Biomarkers in Newly Diagnosed Patients with Multiple Myeloma at Risk for Cancer-Associated Thrombosis. the Observational Roadmat-CAT-MM Study

Background: Hypercoagulability is a common blood alteration in newly diagnosed chemotherapy naïve patients with multiple myeloma. Multiple myeloma (MM) figures among malignancies that significantly increase the risk of venous thromboembolism (VTE). The rate of VTE is higher at the time of diagnosis and during the first months following initiation of first line therapy; approximately 10% of newly diagnosed MM (NDMM) will develop a VTE. Despite adequate thromboprophylaxis as per guidelines, the risk of residual VTE is not eliminated and remains as high as 12%. The optimization of VTE prevention in patients with MM is an unmet need. The exact mechanism of the increased risk of VTE is not yet fully understood. The identification of the procoagulant potential of cancer cells, which is related principally to tissue factor (TF) expression, attracts particular interest. Aim: We conducted a longitudinal prospective observational study, to explore the relationship of MM with cellular and plasma hypercoagulability as well as tissue factor positive microparticles, aiming to identify the most relevant biomarkers, which could be used in a Risk Assessment Model (RAM) for VTE in combination with clinical risk factors. Methods: Newly diagnosed patients (182) with multiple myeloma (NDMM) were prospectively enrolled. Patients were followed up for 12 months and the primary end-point was symptomatic objectively confirmed VTE. Patients were risk stratified and received thromboprophylaxis (none, aspirin on low molecular weight heparin (LMWH) based on previously published recommendations by the IMWG and EMN. Prior to treatment initiation and thromboprophylaxis initiation baseline biomarkers were obtained: Thrombin generation (TGT) in citrated PPP was assessed with the Thrombogram-Thrombinoscope® assay using PPP-reagent® 5 pm TF by Diagnostica Stago. The levels of P-Selectin and heparanase in plasma were measured with ELISA Kit (Cusabio Biotech and R&amp;D Systems respectively). The procoagulant phospholipids clotting time was measured with STA-Procoag-PPL®, Levels of Factor VIIa were measured by Staclot VIIa-rTF®, D-Dimers (DDi) by Liatest D-Di (Diagnostica Stago, France), and Tissue Factor activity (TFa) by specific clotting based home test. TF expression MPC-derived microparticles (MPC-dMPs) were detected using a Zymuphen MP-TF activity kit (Hyphen BioMed, Neuville sur Oise, France). These were compared against values in a population of healthy individuals (n=30). Results: The distribution of patients enrolled in the study is as follows: Median age was 67 years (36-86) and 52% of the population was male. Median time to follow up was 7 months (1-12 months). The control group (30 healthy individuals). The overall rate of symptomatic VTE during follow-up was 11.5% (n = 21 patients). Eleven out of 21 events (52%) occurred within 3 months from treatment initiation. Six of these patients did not receive any thromboprophylaxis; six patients were on aspirin at the time of the event and three were on LMWH.At inclusion, patients showed significantly increased levels of TFa, FVIIa, D-Dimers and FM, and significantly shorter Procoag-PPL® as compared to the group of healthy individuals. Levels of P-selectin and TM were significantly lower in patients as compared to healthy individuals. The levels of heparanase were not significantly different in the group of patients as compared to the healthy individuals. Overall thrombin generation was attenuated in patients compared to healthy individuals. Lag-time and ttPeak were significantly increased and Peak, MRI, and ETP were significantly lower as compared to the control group, MP-TF activity measured in NDMM significantly increased 1.46± 0.38 pg/mL compared to control subjects 0.19 ± 0.05 pg/mL (Table 1). Multivariate logistic regression analysis demonstrated that ETP, Procoag-PPL® and MP-TF were independently associated with VTE occurrence. (Table 2) Conclusion: The prospective ROADMAP-CAT-MM study demonstrates the presence of pronounced cellular hypercoagulability in newly diagnosed chemotherapy naïve patients with MM characterized by decreased Procoag-PPL® clotting time, enhanced endothelial cell activation, and exhausted thrombin generation. The Procoag-PPL clotting time and the ETP and MP-TF were found to be independently associated with the risk of VTE and can be prospectively incorporated into a RAM for VTE in MM.

The Association Between the Timing of Initiation of Pharmacologic Venous Thromboembolism Prophylaxis with Outcomes in Burns Patients.

Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Guidelines regarding thromboprophylaxis in burn patients are unclear. This study aims to compare the outcomes of early versus late thromboprophylaxis initiation in burn patients. In this 3-year analysis of 2017-2019 ACS-TQIP, adult(18-64years) burn patients were identified after applying inclusion/exclusion criteria and stratified based on timing of initiation of VTE prophylaxis: Early(<24 hours of admission); Late(>24 hours). Outcomes were deep venous thrombosis(DVT), pulmonary embolism(PE), unplanned return to operating room (OR), unplanned intensive care unit (ICU) admission, post-prophylaxis packed red blood cells (PRBC) transfusion, and mortality. Nine thousand two hundred and seventy-two patients were identified. Overall, median age was 41years, 71.5% were male, and median[IQR] injury severity score was 3[1-8]. 53% had second-degree burns, and 80% had less than 40% of total body surface area affected. Median time to thromboprophylaxis initiation was 11[6-20.6]hours. Overall VTE rate was 0.9% (DVT-0.7%, PE-0.2%). On univariable analysis, early prophylaxis group had lower rates of DVT(0.6% vs 1.1%, P = .025), and PE(0.1% vs 0.6%, P < .001). On multivariable regression, late prophylaxis was associated with 1.8 times higher odds of DVT (aOR = 1.8, 95% CI = 1.04-3.11, P = .03), 4.8 times higher odds of PE(aOR = 4.8, 95% CI = 1.9-11.9, P < .001), and 2 times higher odds of unplanned ICU admission(aOR = 2.1, 95% CI = 1.4-3.1, P < .001). Furthermore, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion(aOR = 1.1, 95% CI = 0.8-1.4, P = .4), and mortality(aOR = 0.68, 95% CI = 0.4-1.1, P = .13). Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population.

707 Comparing VTE Prophylaxis Strategies in Thermal Injuries: Don't Get Burned by Heparin!

Abstract Introduction Burn patients are at high risk of venous thromboembolism (VTE) as well as bleeding complications, thus choosing the best option for thromboprophylaxis can be challenging. Previous studies have analyzed the preferred antithrombotic agent in trauma patients, but this has not been established in burns. We hypothesize that low molecular weight heparin (LMWH) is associated with better outcomes than unfractionated heparin. Methods The Trauma Quality Improvement Project (TQIP) dataset was used to identify all patients with second- or third-degree burns that were administered VTE prophylaxis. Cases with missing data, &amp;lt; 24-hour hospital length of stay, other serious traumatic injuries (any AIS &amp;gt;3), interhospital transfer, history of kidney disease, or pre-hospital history of anticoagulant use were excluded. Bleeding complications were defined as hemorrhage control surgery, embolization procedures, or blood transfusion occurring after the initiation of thromboprophylaxis, consistent with other studies analyzing bleeding complications in TQIP. Rates of VTE and bleeding complications were compared between those who received heparin versus LMWH. Propensity score matching was performed to control for age, total body surface area percent (TBSA%) burned, and ICU admission (Table 1). Results The analysis included 9,857 patients (69% male). Median age was 50 (34-62) years. LWMH was associated with fewer complications including pulmonary embolism, any VTE, and bleeding (Table 2). Initiation of thromboprophylaxis within 24 hours of arrival was associated with a lower risk of VTE (1.0% vs 2.1%, p&amp;lt; 0.001) without showing a significant difference in bleeding complications (6.4% vs 7.2%, p=0.206). Conclusions This propensity score matched analysis of nearly ten thousand burn patients has demonstrated that low molecular weight heparin is associated with reduced risk of VTE and bleeding compared to heparin. Initiation of thromboprophylaxis within 24 hours is linked to lower rates of VTE. In burn patients without contraindications, thromboprophylaxis with LMWH should be started within 24 hours. Applicability of Research to Practice Venous thromboembolism is an important complication in burn patients, which may negatively impact patient outcomes. These patients regularly receive DVT prophylaxis and it is important for their care team to be able to select the proper agents.

289 The Timing of Pharmacologic Venous Thromboembolism Prophylaxis Initiation for Burn Patients with Concomitant Trauma

Abstract Introduction Hospitalized burn patients are at increased risk for venous thromboembolism (VTE). Clinical guidelines regarding thromboprophylaxis in burn patients with concomitant trauma are unclear. We aimed to compare the outcomes of early versus late thromboprophylaxis initiation for burn patients with concomitant trauma. Methods A 3-year analysis of 2017-2019 TQIP. We identified all adult burn patients with concomitant trauma who received thromboprophylaxis. We excluded patients that had severe TBI (Head AIS &amp;gt; 2), were transferred, those that died &amp;lt; 24 hours of admission and those that underwent hemorrhage control surgery. Patients were stratified based on the timing of initiation of postoperative thromboprophylaxis: Early (&amp;lt; 24 hours of admission) versus Late ( &amp;gt;24 hours). Multivariate regression analyses were performed. Outcome measures were odds of deep venous thrombosis (DVT), pulmonary embolism (PE), unplanned return to OR, unplanned ICU admission, post-prophylaxis PRBC transfusion and in-hospital mortality. Results 9,272 trauma patients with concomitant burns who received thromboprophylaxis were identified. Overall, mean age was 41.3 ± 13.4 years, 71.5% were male, and median ISS was 3 [1-8]. 53% had second degree burns, and 39% had more than 10% of total body surface area affected. Median time to thromboprophylaxis initiation was 11 [6-20.6] hours. On multivariate regression, patients who received thromboprophylaxis after 24 hours of admission had 1.8 times higher odds of developing DVT (aOR=1.8, 95% CI=1.04-3.11, p=0.03), 4.8 times higher odds of developing PE (aOR=4.8, 95% CI=1.9-11.9, p&amp;lt;.001), 2 times higher odds of unplanned ICU admission (aOR=2.1, 95% CI=1.4-3.1, p&amp;lt;0.001), and nonsignificant increase in the odds of unplanned return to OR (aOR=2, 95% CI=0.96-4.31, p=0.06). Further, early thromboprophylaxis was not associated with increased odds of post-prophylaxis PRBC transfusion (aOR=1.1, 95% CI=0.8-1.4, p=0.4), and in-hospital mortality (aOR=0.68, 95%CI=0.4-1.1, p=0.13) compared to patients who received late thromboprophylaxis. Conclusions Early VTE prophylaxis in burn patients is associated with decreased rates of DVT and PE, without increasing the risk of bleeding and mortality. VTE prophylaxis may be initiated within 24 hours of admission to reduce VTE in this high-risk patient population. Applicability of Research to Practice This work will guide the timing of initiation of venous thromboembolism prophylaxis in burn patients with concomitant trauma

Effect of timing of perioperative chemical thromboprophylaxis on thromboembolic, bleeding, and other complications during and after antireflux surgery: multicentre cohort study

Although guidelines recommend the use of perioperative chemical thromboprophylaxis for antireflux surgery, the optimal timing for its initiation is unknown. The aim of this study was to investigate whether perioperative timing of chemical thromboprophylaxis affects bleeding, symptomatic venous thromboembolism, and complication rates in patients undergoing antireflux surgery. This study involved analysis of prospectively maintained databases and medical records of all elective antireflux surgeries in 36 hospitals across Australia over 10 years. Overall, chemical thromboprophylaxis was given early (before surgery or intraoperatively) in 1099 (25.6 per cent) patients, and after surgery in 3202 (74.4 per cent) patients, with comparable exposure doses between the two groups. Symptomatic venous thromboembolism risk was unrelated to chemical thromboprophylaxis timing (0.5 versus 0.6 per cent for early and postoperative chemical thromboprophylaxis respectively (odds ratio (OR) 0.97, 95 per cent c.i. 0.41 to 2.47, P = 1.000). Postoperative bleeding developed in 34 (0.8 per cent) patients, and 781 intraoperative adverse events were identified in 544 (12.6 per cent) patients. Both intraoperative bleeding and complications were associated with significantly higher postoperative morbidity affecting multiple organ systems. Importantly, compared with postoperative chemical thromboprophylaxis, early administration increased the risk of postoperative bleeding ((1.5 versus 0.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 2.94, 95 per cent c.i. 1.48 to 5.84, P = 0.002)) and intraoperative adverse events ((16.1 versus 11.5 per cent for early and postoperative chemical thromboprophylaxis respectively (OR 1.48, 95 per cent c.i. 1.22 to 1.80, P < 0.001)), as well as independently predicted their occurrences. Intraoperative adverse events and bleeding that occur during and after antireflux surgery are associated with significant morbidity. Compared with postoperative chemical thromboprophylaxis, early initiation of chemical thromboprophylaxis confers a significantly higher risk of intraoperative bleeding complications, without appreciable additional protection from symptomatic venous thromboembolism. Therefore, postoperative chemical thromboprophylaxis should be recommended for patients undergoing antireflux surgery.

Renal transplant and hemostasis: early postoperative changes in recipients and donors

BackgroundThe benefit of administering pharmacologic thromboprophylaxis following renal transplantation remains uncertain. ObjectivesTo compare hemostatic parameters before and after renal transplant surgery in both recipients and their donors at predetermined time points. MethodsBlood samples were collected at baseline (T1), immediately after surgery (T2), and at 24 hours after surgery (T3) in both recipients and donors and at 72 (T4) and 120 hours (T5) from recipients only. Assays included in vitro thrombin generation, factor VIII (FVIIIc) activity, von Willebrand factor (VWF) antigen, D-dimer, antithrombin activity, prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes, and plasminogen activator inhibitor-1 (PAI-1) antigen. ResultsFifty-two patients (28 recipients and 24 donors) were enrolled. Both donors and recipients had increased FVIIIc, VWF, F1 + 2, D-dimer, and PAI immediately after surgery but reduced antithrombin. Mixed-model analysis showed that the magnitude of change over time (between T1 and T3) for FVIIIc (mean estimated difference [MED], 72; 95% CI, 41-102; P < .0001), VWF (MED, 89; 95% CI, 35-142; P = .001), F1 + 2 (MED, 283; 95% CI, 144-422; P < .0001), thrombin-antithrombin complexes (MED, 3.5; 95% CI, 1.9-5.1; P < .0001), D-dimer (MED, 2.2; 95% CI, 1.0-3.3; P < .0001), PAI-1 (MED, 9.2; 95% CI, 3.4-14.9; P = .002), and time to peak thrombin generation (MED, 1.5; 95% CI, 0.35-2.7; P = .01) was more significant in recipients than in donors. ConclusionPersistence of a hypercoagulable state was more prominent in recipients after 24 hours despite recovery in renal function and initiation of thromboprophylaxis.

Data linkage of two national databases: Lessons learned from linking the Dutch Arthroplasty Register with the Dutch Foundation for Pharmaceutical Statistics.

To provide guidance on data linkage in case of non-unique identifiers, we present a case study linking the Dutch Foundation for Pharmaceutical Statistics and Dutch Arthroplasty Register to investigate opioid prescriptions before/after arthroplasty. Deterministic data linkage was used. Records were linked on: sex, birthyear, postcode, surgery date, or thromboprophylaxis initiation as a proxy for the surgery date. Different postcodes were used, depending on availability: patient postcode (available from 2013 onwards), hospital postcode with codes for physicians/hospitals, and hospital postcode with catchment area. Linkage was assessed in several groups: linked arthroplasties, linked on patient postcode, linked on patient postcode, and low-molecular-weight heparin(LWMH). Linkage quality was assessed by checking prescriptions after death, antibiotics after revision for infection, and presence of multiple prostheses. Representativeness was assessed by comparing the patient-postcode-LMWH group with the remaining arthroplasties. External validation was performed by comparing our opioid prescription rates with those derived from datasets from Statistics Netherlands. We linked 317,899 arthroplasties on patient postcode/hospital postcode(48%). Linkage on the hospital postcode appeared insufficient. Linkage uncertainty ranged from roughly 30% in all arthroplasties to 10-21% in the patient-postcode-LMWH-group. This subset resulted in 166.357(42%) linked arthroplasties after 2013 with somewhat younger age, fewer females, and more often osteoarthritis than other indications compared to the other arthroplasties. External validation showed similar increases in opioid prescription rates. After identifier selection, checking data availability and internal validity, assessing representativeness, and externally validating our results we found sufficient linkage quality in the patient-postcode-LMWH-group, which consisted of around 42% of the arthroplasties performed after 2013.

Implementing guidelines for risk-stratified thromboprophylaxis among gynecologic oncology patients: A quality improvement initiative

Objective(s)Risk-stratified thromboprophylaxis is recommended for oncology patients with a Khorana risk score (KS) ≥ 2 receiving cancer-directed therapy. We describe a quality improvement (QI) initiative designed to increase adherence to thromboprophylaxis guidelines for patients with gynecologic malignancies initiating outpatient treatment. MethodsProvider awareness and documentation of venous thromboembolism (VTE) risk assessment and thromboprophylaxis eligibility were identified as key QI drivers. Starting May 2021, a KS calculator and thromboprophylaxis algorithm were incorporated into outpatient documentation templates. Patients with gynecologic malignancies initiating outpatient therapy from January – December 2021 were eligible. The primary process measure was the percentage of patients with KS eligibility documented each month during the baseline (Jan – Apr) versus implementation (May – Dec) periods. Rate of appropriate thromboprophylaxis initiation and incidence of VTE served as outcome measures. Incidence of adverse bleeding events served as the balancing measure. Results337 patients accounted for the initiation of 383 treatment regimens, including 128 in the baseline period and 255 in the implementation period. KS documentation increased significantly between the baseline and implementation periods (7% vs 62.4%, p < 0.001). 73 of the 177 eligible patients (46.2%; 166 unique patients) had appropriate documentation; of these, 57 initiated thromboprophylaxis. There was no difference in VTE rates or adverse bleeding events between eligible patients who initiated thromboprophylaxis compared with those who did not (12.3% vs 15.6%; p = 0.65 and 7.0% vs 8.2%; p = 1.0, respectively). Conclusion(s)This QI initiative resulted in greater adherence to risk-stratified thromboprophylaxis guidelines. No bleeding signals were identified. Studies addressing cost, medication adherence, and long-term outcomes are necessary.

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.

Implementation of a pharmacological prophylaxis bundle to prevent obstetric-associated venous thromboembolism.

Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population. This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home. An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Timing and choice of systemic anticoagulation in the setting of extremity arterial injury repair.

The role of perioperative anticoagulation in the setting of peripheral arterial injury remains unclear. We hypothesized that early initiation of anticoagulation is associated with a reduced amputation rate without increasing bleeding complications. Using the 2016-2019 ACS-TQIP database, adult patients with upper and lower extremity vascular injuries who underwent open arterial repair and received anticoagulation were included. Patients were divided into two groups: (1) early venous thromboembolism prophylaxis (≤ 24h) and (2) late prophylaxis (> 24h) following arterial repair. The primary outcomes were the rates of limb amputation and bleeding complications. Multivariable logistic regression was used to estimate the impact of timing and type of anticoagulation on the rates of limb amputation and bleeding complications. 4379 patients were included, and 83.9% were males. 68.1% of patients received early anticoagulation, whereas 31.9% received late thromboprophylaxis. Low-molecular-weight heparin (LMWH) was used in 62.0% of patients, and unfractionated heparin (UFH) was administered in 34.3% of patients. Multivariable analysis showed that late initiation of thromboprophylaxis (OR = 1.69 [1.16-2.45], p = 0.006) and use of UFH (OR = 2.61 [1.80-3.79], p < 0.001) were associated with increased rate of amputation. Early initiation of anticoagulation (OR = 2.16 [1.63-2.85], p < 0.001) was associated with increased risk of bleeding complications requiring blood transfusions. Similarly, the use of UFH was associated with a higher rate of bleeding events compared to LWMH (OR = 2.61, [1.80-3.79], p < 0.001). Patients with the operative repair of arterial injuries receiving early perioperative anticoagulation demonstrated an improved limb salvage outcome than those who received late thromboprophylaxis. Our data also suggest that early initiation of prophylaxis may be associated with increased bleeding risk, which may be attenuated using LMWH compared to UFH.

THE RELATIONSHIP BETWEEN FERRITIN LEVEL AND THROMBOSIS IN PATIENTS WITH DIFFUSE LARGE B-CELL LYMPHOMA

Cancer is a well-known condition associated with its treatment and follow-up and increases the risk of thrombosis. As with solid tumors, the risk of venous thromboembolism (VTE) is quite high in lymphomas, especially high-grade B-cell lymphomas. Diffuse large B-cell lymphoma (DLBCL) patients are the most important part of this group. The aim of our study is to determine the effect of ferritin level at the time of diagnosis on thrombosis in DLBCL patients. In this retrospective study, 133 patients who applied to SBU Dışkapı Yıldırım Beyazıt Training and Research Hospital Hematology clinic and were diagnosed with DLBCL were included in this retrospective study. Demographic characteristics, disease-related findings, presence of central venous catheter and laboratory results of the patients were recorded. The median age of the patients included in the study was 63.13±14.85 years. There were 67 female and 66 male patients, stage 1-2: 54 patients, stage 3-4: 79 patients at the time of diagnosis. Thrombosis was observed in 16 of the patients. Median ferritin levels were 357.42 ug/L and 253.07 ug/L, respectively, between the group with and without thrombosis (p:0.026). The ferritin value, which was examined for the presence of thrombosis, was determined as 227 ug/L as a result of the ROC analysis. In the logistic regression analysis, the risk of developing thrombosis was 6.1 times higher in those with a ferritin level ≥227 ug/L. Hyperferritinemia may be an independent risk factor for the development of thrombosis in DLBCL patients. In case of hyperferritinemia in patients, initiation of thromboprophylaxis may be an appropriate approach.

Preferences and Practices of Brazilian Orthopedists for Thromboprophylaxis Techniques in Total Knee Arthroplasty: Survey Among Members of the Brazilian Society of Knee Surgery (SBCJ).

Objective The present study describes the preferences and current practices of a sample of knee surgeons in Brazil regarding thromboprophylaxis in total knee arthroplasty (TKA). Method In the present internet survey, surgeons from the Brazilian Knee Surgery Society (SBCJ, in the Portuguese acronym) voluntarily answered an anonymous questionnaire including time of personal surgical experience, perceptions about the best thromboprophylaxis options, and actual practices in their work environment. Results From December 2020 to January 2021, 243 participants answered the questionnaire. All, except for 3 (1.2%), reported using thromboprophylaxis, and most (76%) combined pharmacological and mechanical techniques. The most prescribed drug was enoxaparin (87%), which changed to rivaroxaban (65%) after discharge. The time of thromboprophylaxis initiation varied according to the length of training of the knee surgeon ( p ≤ 0.03), and their preferences and practices differed according to the Brazilian region ( p < 0.05) and the health system in which the surgeons work (public or private sector; p = 0.024). The option for mechanical thromboprophylaxis also depended on the training time of the surgeon. Conclusion Thromboprophylaxis preferences and practices in TKA are diverse across Brazilian regions and health systems (public or private sectors). Given the lack of a national clinical guideline, most orthopedists follow either their hospital guidelines or none. The mechanical prophylaxis method and the little use of aspirin are the points that most diverge from international guidelines and practices.

Coagulation Abnormalities and Management in Hospitalized Pediatric Patients With COVID-19.

Background:The incidence and severity of coagulation abnormalities have not been extensively studied in pediatric populations with coronavirus disease 2019 (COVID-19). Moreover, their association with an increased risk for thromboembolic events remains unclear, and there is a lack of evidence for optimal prophylactic antithrombotic management. The aim of our study was to present our experience in evaluation, management, and long-term outcomes of coagulation abnormalities in pediatric hospitalized patients with COVID-19.Methods:A prospective study was performed in all children hospitalized for COVID-19 during a 6-month period focusing on patients’ coagulation abnormalities, the normalization of the coagulation profile with or without anticoagulation prophylaxis and the clinical outcome of the disease.Results:Two hundred twenty-three patients (median age: 11.4 months) were enrolled in the study. Coagulation abnormalities were detected in 92.4% of patients with increased D-dimer levels to be the most common abnormality detected in 84.3% of patients. Prophylactic anticoagulation was initiated only in 7 (3.1%) selected patients with severe COVID-19 and at least 2 risk factors for venous thromboembolism (VTE) and in all patients with previous history of VTE. Follow-up coagulation profile in 85 patients showed that changes over time had a tendency towards normalization irrespectively of the initiation of anticoagulant thromboprophylaxis. No thrombotic complications were observed 3 months upon discharge.Conclusions:Although abnormal findings in coagulation profile were very common, they were not associated with risk for VTE even in severe cases. A trend of normalization early in the course of the disease was observed regardless of the use of anticoagulant thromboprophylaxis.