The association of severe coronavirus disease 2019 (COVID-19) with an increased risk of venous thromboembolism (VTE) has resulted in specific guidelines for its prevention and management. The VTE ...risk appears highest in those with critical care admission. The need for postdischarge thromboprophylaxis remains controversial, which is reflected in conflicting expert guideline recommendations. Our local protocol provides thromboprophylaxis to COVID-19 patients during admission only. We report postdischarge VTE data from an ongoing quality improvement program incorporating root-cause analysis of hospital-associated VTE (HA-VTE). Following 1877 hospital discharges associated with COVID-19, 9 episodes of HA-VTE were diagnosed within 42 days, giving a postdischarge rate of 4.8 per 1000 discharges. Over 2019, following 18 159 discharges associated with a medical admission; there were 56 episodes of HA-VTE within 42 days (3.1 per 1000 discharges). The odds ratio for postdischarge HA-VTE associated with COVID-19 compared with 2019 was 1.6 (95% confidence interval, 0.77-3.1). COVID-19 hospitalization does not appear to increase the risk of postdischarge HA-VTE compared with hospitalization with other acute medical illness. Given that the risk-benefit ratio of postdischarge thromboprophylaxis remains uncertain, randomized controlled trials to evaluate the role of continuing thromboprophylaxis in COVID-19 patients following hospital discharge are required.
•The rate of symptomatic postdischarge VTE following hospitalization with COVID-19 is low.
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Abstract Context Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce ...recovery times. Objective To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. Evidence acquisition A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms “postoperative period,” “postoperative care,” “enhanced recovery after surgery,” “enhanced recovery,” “accelerated recovery,” “fast track recovery,” “recovery program,” “recovery pathway”, “ERAS,” and “urology” or “cystectomy” or “urologic surgery.” Evidence synthesis We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6 h and perioperative liquid–carbohydrate loading up to 2 h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. Conclusions ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. Patient summary This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.
Background
Emerging safety and efficacy data for rivaroxaban suggest traditional therapy and rivaroxaban are comparable in the morbidly obese. However, real‐world data that indicate pharmacokinetic ...(PK) parameters are comparable at the extremes of body size are lacking. The International Society of Thrombosis and Haemostasis Scientific and Standardisation Committee (ISTH SSC) suggests avoiding the use of direct oral anticoagulants (DOACs) in patients weighing >120 kg or with a body mass index >40 kg/m2 and gives no recommendation on the use of DOACs in those <50 kg.
Objectives
To generate a population PK model to understand the influence of bodyweight on rivaroxaban exposure from clinical practice data.
Method
Rivaroxaban plasma concentrations and patient characteristics were collated between 2013 and 2018 at King's College Hospital anticoagulation clinic. A population PK model was developed using a nonlinear mixed effects approach and then used to simulate rivaroxaban concentrations at the extremes of bodyweight.
Results
A robust population PK model derived from 913 patients weighing between 39 kg and 172 kg was developed. The model included data from n = 86 >120 kg, n = 74 BMI >40 kg/m2, and n = 30 <50 kg. A one‐compartment model with between‐subject variability on clearance and a proportional error model best described the data. Creatinine clearance calculated by Cockcroft‐Gault, with lean bodyweight as the weight descriptor in this equation, was the most significant covariate influencing rivaroxaban exposure.
Conclusions
Our work demonstrates rivaroxaban can be used at extremes of bodyweight provided renal function is satisfactory. We recommend that the ISTH SSC revises the current guidance with respect to rivaroxaban at extremes of body size.
Heavy menstrual bleeding on rivaroxaban Ferreira, Melanie; Barsam, Sarah; Patel, Jignesh P. ...
British journal of haematology,
April 2016, 2016-Apr, 2016-04-00, 20160401, Letnik:
173, Številka:
2
Journal Article
Background & Aims
Patients with liver disease often show profound abnormalities in their haemostatic system. Studies using thrombin generation demonstrate rebalanced coagulation in patients with ...chronic liver disease. Our aim was to evaluate the haemostatic profile in patients with acute liver injury/failure (ALI/ALF) compared with healthy controls.
Methods
Thrombin generation was measured in the presence and absence of thrombomodulin (TM) to activate protein C (PC) with endogenous thrombin potential (ETP; the area under the thrombin generation curve) a key parameter. Routine coagulation assays were also performed.
Results
Thirty two patients with ALI/ALF and 40 controls were recruited. Patients had grossly abnormal coagulation profiles with decreased pro‐ and anticoagulant factors compared with controls (P < 0.001 for all comparisons), except for median Factor VIII which was increased 247 U/dl interquartile range: 214–347 in patients compared with 120 U/dl 97–139; P < 0.001 in controls. Mean ETP was significantly lower in patients 886 nM.min (± 436) compared with controls 1596 nM.min (± 259; P < 0.001). However, when the assay was repeated with TM to activate PC, there was no significant difference in mean ETP + TM between patients and controls (632 ± 418 vs 709 ± 301 nM.min respectively; P = 0.666). Furthermore, the ETP ratio (ETP + TM/ETP) was significantly higher in patients 0.89 (0.60–0.97) compared with controls 0.48 (0.3–0.6; P = 0.002) and negatively correlated with PC (R = −0.487, P = 0.003) and Factor V (R = −0.431, P = 0.01).
Conclusion
ALI/ALF patients have normal ETP in the presence of TM. This supports rebalanced coagulation mediated by acquired PC resistance because of the reduction in PC, Factor V and concomitant increase in Factor VIII.
Background & objectives: India has been reporting the cases of coronavirus disease 2019 (COVID-19) since January 30, 2020. The Indian Council of Medical Research (ICMR) formulated and established ...laboratory surveillance for COVID-19. In this study, an analysis of the surveillance data was done to describe the testing performance and descriptive epidemiology of COVID-19 cases by time, place and person.
Methods: The data were extracted from January 22 to April 30, 2020. The frequencies of testing performance were described over time and by place. We described cases by time (epidemic curve by date of specimen collection; seven-day moving average), place (area map) and person (attack rate by age, sex and contact status), and trends were represented along with public health measures and events.
Results: Between January 22 and April 30, 2020, a total of 1,021,518 individuals were tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Testing increased from about 250 individuals per day in the beginning of March to 50,000 specimens per day by the end of April 2020. Overall, 40,184 (3.9%) tests were reported positive. The proportion of positive cases was highest among symptomatic and asymptomatic contacts, 2-3-fold higher than among those with severe acute respiratory infection, or those with an international travel history or healthcare workers. The attack rate (per million) by age was highest among those aged 50-69 yr (63.3) and was lowest among those under 10 yr (6.1). The attack rate was higher among males (41.6) than females (24.3). The secondary attack rate was 6.0 per cent. Overall, 99.0 per cent of 736 districts reported testing and 71.1 per cent reported COVID-19 cases.
Interpretation & conclusions: The coverage and frequency of ICMR's laboratory surveillance for SARS-CoV-2 improved over time. COVID-19 was reported from most parts of India, and the attack rate was more among men and the elderly and common among close contacts. Analysis of the data indicates that for further insight, additional surveillance tools and strategies at the national and sub-national levels are needed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Switching non-adherent patients prescribed anticoagulant treatment to a regime with less monitoring could lead to significant non-adherence. Health beliefs are known to influence medication ...adherence; however, the extent of this influence is unknown in patients switched from vitamin-K antagonists (VKAs) to direct oral anticoagulants (DOACs). This study aimed to determine adherence to long-term therapy in patients switched from VKAs to DOAC due to low time in therapeutic range (TTR) and if adherence is associated with health beliefs.
The Switching Study is a longitudinal observational cohort study following patients for at least 1-year. 254 patients anticoagulated with VKAs for stroke prevention in atrial fibrillation (AF) or secondary prevention of venous thromboembolism (VTE) and TTR < 50% were recruited from anticoagulation clinics at King's College Hospital, London, UK. All participants were switched to DOAC and had health beliefs measured at baseline with VKA, 1-month and 12-months after switching.
Of the 220 patients who completed 12-month follow-up 39% had sub-optimal adherence measured by self-report. 23% were non-adherent according to prescriptions issued. Increasing concerns about anticoagulation over time relative to beliefs about necessity was associated with lower self-reported adherence (OR = 0.902 95%C.I: 0.836, 0.974; p = 0.008). At baseline, believing that medications in general were overused in healthcare was negatively associated with adherence to DOAC (β = −1.5, 95%C.I: −2.7, −0.3; p = 0.013).
Although many patients who switched were adherent to therapy long-term, between 23 and 39% of patients exhibited sub-optimal adherence: these patients can be identified through their modifiable health beliefs at the time of switching.
•Adherence to DOAC therapy in up to one-third of patients is sub-optimal.•Patient's health beliefs can predict non-adherence and offer a modifiable target for clinicians in their consultations.•Increasing concerns about anticoagulation relative to beliefs about necessity are associated with lower rates of adherence.•Interventions targeting treatment and health beliefs should be tested, particularly with the growing use of DOAC therapy.
Electrocatalytic water splitting provides a sustainable method for storing intermittent energies, such as solar energy and wind, in the form of hydrogen fuel. However, the oxygen evolution reaction ...(OER), constituting the other half-cell reaction, is often considered the bottleneck in overall water splitting due to its slow kinetics. Therefore, it is crucial to develop efficient, cost-effective, and robust OER catalysts to enhance the water-splitting process. Transition-metal-based coordination polymers (CPs) serve as promising electrocatalysts due to their diverse chemical architectures paired with redox-active metal centers. Despite their potential, the rational use of CPs has faced obstacles including a lack of insights into their catalytic mechanisms, low conductivity, and morphology issues. Consequently, achieving success in this field requires the rational design of ligands and topological networks with the desired electronic structure. This study delves into the design and synthesis of three novel conjugated coordination polymers (CCPs) by leveraging the full conjugation of terpyridine-attached flexible tetraphenylethylene units as electron-rich linkers with various redox-active metal centers Co(II), Ni(II), and Zn(II). The self-assembly process is tuned for each CCP, resulting in two distinct morphologies: nanosheets and nanorings. The electrocatalytic OER performance efficiency is then correlated with factors such as the nanostructure morphology and redox-active metal centers in alkaline electrolytes. Notably, among the three morphologies studied, nanorings for each CCP exhibit a superior OER activity. Co(II)-integrated CCPs demonstrate a higher activity between the redox-active metal centers. Specifically, the Co(II) nanoring morphology displays exceptional catalytic activity for OER, with a lower overpotential of 347 mV at a current density of 10 mA cm–2 and small Tafel slopes of 115 mV dec–1. The long-term durability is demonstrated for at least 24 h at 1.57 V vs RHE during water splitting. This is presumably the first proof that links the importance of nanostructure morphologies to redox-active metal centers in improving the OER activity, and it may have implications for other transdisciplinary energy-related applications.
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