Management of venous thromboembolism in pregnancy

Venous thromboembolism (VTE) in pregnancy, consisting of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major factor of maternal mortality. Several patient-specific risk factors along with the physiologic changes of pregnancy promote a state of hypercoagulability in pregnant women. Detailed assessment of all pregnant women can establish a risk profile that would guide clinical decisions, and balance potential therapeutic benefits with side effects. Differentiating between physiologic changes of pregnancy and symptoms of VTE can be challenging and warrants meticulous clinical evaluation. Timely and accurate diagnosis of VTE with proper imaging is essential for its management, and systemic anticoagulation remains the cornerstone of VTE prevention and therapy. Furthermore, advanced invasive treatment options such as inferior vena cava filters and thrombectomy can be considered for complex cases. Importantly, the risk of systemic anticoagulation should be balanced against the risk of VTE-associated morbidity and mortality for mother and fetus, and an informed decision should be made. In this review, we present an up-to-date overview of VTE management in pregnancy and the postpartum period. Keywords: Anticoagulants; Deep venous thrombosis; Pregnancy; Pulmonary embolism; Venous thromboembolism

Influence of ultra-low dose Aprotinin on thoracic surgical operations: a prospective randomized trial

<p>Abstract</p> <p>Background</p> <p>The blood saving effect of aprotinin has been well documented in cardiac surgery. In thoracic surgery, very few recent studies, using rather high doses of aprotinin, have shown a similar result. In a randomized prospective trial, we have tested the influence of aprotinin using an ultra-low dose drug regime.</p> <p>Methods</p> <p>Fifty-nine patients, mean age 58 ± 13.25 years (mean ± SD) undergoing general thoracic procedures were randomized into placebo (Group A) and treatment group (Group B). The group B (n = 29) received 500.000 IU of aprotinin after induction to anesthesia and a repeat dose immediately after chest closure. A detailed protocol with several laboratory parameters was recorded. Patients were transfused when perioperative Ht was less than 26%.</p> <p>Results</p> <p>The two groups were similar in terms of age, gender, diagnosis, pathology, co-morbidity and operations performed. The mean drainage of the first and second postoperative day in group B was significantly reduced (412.6 ± 199.2 vs. 764.3 ± 213.9 ml, p < 0.000, and 248.3 ± 178.5 vs. 455.0 ± 274.6, p < 0.001). Similarly, the need for fresh frozen plasma transfusion was lower in group B, p < 0.035. Both the operation time and the hospital stay were also less for group B but without reaching statistical significance (84.6 ± 35.2 vs 101.2 ± 52.45 min. and 5.8 ± 1.6 vs 7.2 ± 3.6 days respectively, p < 0.064). The overall transfusion rate did not differ significantly. No side effects of aprotinin were noted.</p> <p>Conclusion</p> <p>The perioperative ultra-low dose aprotinin administration was associated with a reduction of total blood losses and blood product requirements. We therefore consider the use of aprotinin safe and effective in major thoracic surgery.</p

The influence of formal and informal sales controls on customer-directed selling behaviors and sales unit effectiveness

Adaptive selling (AS) and customer-oriented selling (COS) constitute two key customer-directed selling behaviors for the success of the modern sales force. However, knowledge regarding the organizational factors that can induce salespeople to engage in those behaviors is strikingly limited. Against this background, we develop a comprehensive model that delineates the influences of formal and informal sales controls on AS and COS and, through them, on sales unit effectiveness. Based on a sample of sales managers in a major European Union country, we present new evidence that (a) formal and informal sales controls exert differential impact on salespeople's AS and COS behaviors; (b) AS directly and positively influences sales unit effectiveness; (c) COS affects sales unit effectiveness only indirectly, i.e. by fostering AS; and (d) outcome and cultural controls directly improve sales unit effectiveness. We conclude with a discussion of our findings for academics and practitioners

Sales Force Downsizing and Firm-Idiosyncratic Risk: The Contingent Role of Investors’ Screening and Firm’s Signaling Processes

Although sales force downsizing represents a challenging marketing resource change that can signal uncertainty about future firm performance, little is known about its impact on financial-market performance. Drawing from information economics, the authors address this knowledge gap by developing a comprehensive framework to (1) examine the impact of the size of a firm’s sales force downsizing on firm-idiosyncratic risk, (2) uncover investors’ screening processes that influence this relationship, and (3) identify firms’ mitigating signaling processes that can alleviate investor uncertainty linked to downsizing. The authors draw from several secondary sources to assemble a longitudinal data set of 314 U.S. public firms over 12 years and model their framework using a robust econometric approach. Findings show that larger sales force reductions are associated with greater firm-idiosyncratic risk. Furthermore, this increase in risk is amplified when firms face high levels of future competitive threats and lack transparency in financial reporting. However, chief executive officers can mitigate these deleterious moderating effects by signaling a commitment to growth (i.e., increasing advertising expenditures) and formally communicating an external strategic focus to Wall Street

Sales Force Downsizing and Firm-Idiosyncratic Risk: The Contingent Role of Investors’ Screening and Firm’s Signaling Processes

Although sales force downsizing represents a challenging marketing resource change that can signal uncertainty about future firm performance, little is known about its impact on financial-market performance. Drawing from information economics, the authors address this knowledge gap by developing a comprehensive framework to (1) examine the impact of the size of a firm’s sales force downsizing on firm-idiosyncratic risk, (2) uncover investors’ screening processes that influence this relationship, and (3) identify firms’ mitigating signaling processes that can alleviate investor uncertainty linked to downsizing. The authors draw from several secondary sources to assemble a longitudinal data set of 314 U.S. public firms over 12 years and model their framework using a robust econometric approach. Findings show that larger sales force reductions are associated with greater firm-idiosyncratic risk. Furthermore, this increase in risk is amplified when firms face high levels of future competitive threats and lack transparency in financial reporting. However, chief executive officers can mitigate these deleterious moderating effects by signaling a commitment to growth (i.e., increasing advertising expenditures) and formally communicating an external strategic focus to Wall Street

Expression of Immune System-Related Membrane Receptors CD40, RANK, BAFFR and LTβR is Associated with Clinical Outcome of Operated Non-Small-Cell Lung Cancer Patients

An increasing number of studies implicates the NF-&#954;B (Nuclear Factor of kappa light chain gene enhancer in B cells) alternative pathway in non-small-cell lung cancer (NSCLC). We assessed the clinical significance of CD40 (Tumor necrosis factor receptor superfamily member 5, TNFRSF5), BAFFR (B-cell activating factor receptor), RANK (Receptor activator of NF-&#954;B) and LT&#946;R (lymphotoxin &#946; receptor) receptors, which activate the alternative pathway of NF-&#954;B, in NSCLC. Evaluation of CD40, BAFFR, RANK and LT&#946;R expression was performed based on the Cancer Genome Atlas (TCGA) and the Genotype-Tissue Expression (GTEx) datasets, while protein expression was assessed by immunohistochemistry in specimens from 119 operated NSCLC patients. CD40 gene overexpression was correlated with improved five-year overall survival (OS) (p &lt; 0.001), while increased BAFFR and LT&#946;R mRNA levels were associated with worse OS in patients with adenocarcinomas (p &lt; 0.001 and p &lt; 0.001, respectively). Similarly, patients with adenocarcinomas exhibited a negative correlation between membranous BAFFR protein expression in carcinoma cells and three- and five-year survival (p = 0.021; HR, 4.977 and p = 0.030; HR, 3.358, respectively) as well as between BAFFR protein overexpression in cancer-associated fibroblasts (CAFs) and two-year survival (p = 0.036; HR, 1.983). Patients with increased LT&#946;R nuclear protein staining or stage II patients with lower cytoplasmic LT&#946;R protein expression had worse five-year OS (p = 0.039 and p = 0.008, respectively). Moreover, CD40 protein expression in tumor infiltrating lymphocytes (TILs) and CAFs was positively associated with metastatic spread while BAFFR protein expression in CAFs was negatively associated with bone metastasis (p = 0.041). Our data suggests that CD40, BAFFR, RANK and LT&#946;R play an important role in NSCLC and further supports the role of NF-&#954;B alternative pathway in NSCLC