The incidence of deep vein thrombosis detected by routine surveillance ultrasound in neurosurgery patients receiving dual modality prophylaxis.

The optimal method of thromboprophylaxis and the value of screening ultrasonography for detection of deep venous thrombosis (DVT) in neurosurgery patients remains unclear. The goal of this study was to determine the incidence of DVT in neurosurgical patients who, by hospital protocol, receive surveillance ultrasonography of the lower extremities twice weekly, in addition to prophylaxis with unfractionated heparin and external pneumatic compression sleeves. A retrospective review of 7,298 ultrasound studies carried out on 2,593 patients over 4 years at a university neurosurgical hospital was conducted. There was a 7.4% incidence of proximal lower extremity DVT and a 9.7% total incidence including distal DVT. A greater number of distal DVTs were detected with the implementation of whole-leg ultrasonography in the last 2 years of observation. Chart review of 237 patients diagnosed with DVT demonstrated an admitting diagnosis of subarachnoid hemorrhage in nearly half of the patients. The median hospital length of stay for DVT patients was 18 days. Institutional control data demonstrated non-ruptured aneurysm and cerebrovascular anomalies to be the leading reason for admission, followed closely by subarachnoid hemorrhage. The hospital protocol of biweekly screening ultrasound and dual modality prophylaxis for neurosurgery patients resulted in a proximal DVT incidence consistent with that demonstrated by previous studies of standardized dual modality prophylaxis, and higher than that demonstrated in previous studies that employed ultrasound screening protocols

The Impact of Community Use of Novel Oral Anticoagulants on an Academic Medical Center

Warfarin has been a mainstay of therapy for treatment and prevention of venous thromboembolic disease (VTED) and prevention of stroke and systemic embolism for over 50 years. Recent FDA approval of several novel oral anticoagulants has offered more extensive treatment options for management of these disease states. The availability of the novel anticoagulants offers an attractive alternative to warfarin therapy for patients due to their convenience of use. In comparison to warfarin, dabigatran, rivaroxaban and apixaban offer: - a fixed dosage regimen - a relatively small potential drug interaction profile - minimal laboratory monitoring - little to no dietary restrictions. Although these agents offer a relatively fixed dose regimen, dosage adjustment is required in moderate renal dysfunction, and use is contraindicated in severe renal dysfunction. Currently there are no specific reversal agents in the event of a nov- el anticoagulant associated bleed. These concerns led to the development of an anticoagulation stewardship program at our institution to monitor and guide the usage of these agents

Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism

Introduction: Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial due to variable outcomes. This review investigates patient outcomes following surgical embolectomy for acute PE. Methods: Electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review. Results: Mean patient age was 56.3 [95% CI 52.5; 60.1] years and 50% [46; 55] were male. 82% had right ventricular dysfunction [62; 93], 80% [67; 89] had unstable hemodynamics, and 9% [5; 16] experienced cardiac arrest. Massive PE and submassive PE were present in 83% of patients [43; 97] and 13% [2; 56], respectively. Before embolectomy, 33% of patients [14; 60] underwent systemic thrombolysis and 14% [8; 24] catheter embolectomy. Preoperatively, 47% of patients were ventilated [26; 70] and 36% had percutaneous cardiopulmonary support [11; 71]. Mean operative time and mean cardiopulmonary bypass time were 170 [101; 239] and 56 [42; 70] minutes, respectively. Intraoperative mortality was 4% [2; 8]. Mean hospital and ICU stay were 10 [6; 14] and 2 [1; 3] days, respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from preoperative (sPAP 57.8 mmHg [53; 62.7]) to postoperative period (sPAP 31.3 mmHg [24.9; 37.8]), p \u3c0.01). In-hospital mortality was 16% [12; 21]. Overall survival at five years was 73% [64; 81]. Discussion: Surgical embolectomy is an acceptable treatment option with favorable outcomes

Ethanol and Cognition: Indirect Effects, Neurotoxicity and Neuroprotection: A Review

Ethanol affects cognition in a number of ways. Indirect effects include intoxication, withdrawal, brain trauma, central nervous system infection, hypoglycemia, hepatic failure, and Marchiafava-Bignami disease. Nutritional deficiency can cause pellagra and Wernicke-Korsakoff disorder. Additionally, ethanol is a direct neurotoxin and in sufficient dosage can cause lasting dementia. However, ethanol also has neuroprotectant properties and in low-to-moderate dosage reduces the risk of dementia, including Alzheimer type. In fetuses ethanol is teratogenic, and whether there exists a safe dose during pregnancy is uncertain and controversial

The New Oral Anticoagulants for the Treatment of Venous Thromboembolism: A New Paradigm Shift in Antithrombotic Therapy

Background: Several novel oral anticoagulants have been studied for the prevention and treatment of venous thromboembolism (VTE) in different patient populations. Clinicians will increasingly encounter scenarios in which they must choose among these and conventional anticoagulants for the treatment of this potentially fatal condition. Objective: To review the results of Phase III clinical trials that investigated the novel oral anticoagulants for the treatment of deep vein thrombosis and pulmonary embolism. Potential advantages and disadvantages of these anticoagulant agents with respect to each other and conventional therapy will also be explored through a case-based approach. Methods: A literature search in PubMed was conducted that identified Phase III clinical trials investigating the novel oral anticoagulant agents for the treatment of VTE. Results: The new oral anticoagulant agents have been shown to be as safe and effective for the treatment of VTE as conventional therapies. Conclusions: These novel, oral anticoagulant agents are legitimate options for the treatment of VTE. A careful assessment of a patient׳s comorbidities, medication use, and laboratory results should be undertaken before prescribing the new oral anticoagulant agents for patients with VTE

CATCHem Before They Fall Through the Cracks: Implementation of a Comprehensive Atherosclerosis Treatment Collaborative Health System Transition of Care Multidisciplinary Clinic

Introduction: Peripheral Artery Disease (PAD) is a common atherosclerotic cardiovascular (CV) disease that increases the risk for fatal and non-fatal CV events. Guidelines for the treatment of PAD recommend that in addition to necessary revascularization, general CV prevention with optimal medical therapy is of utmost importance and management is recommended to be multidisciplinary. While the prevalence of PAD in various practices is high, physician awareness of the PAD diagnosis is relatively low and the pharmacological component of preventative CV care is often underutilized resulting in patients receiving less intensive treatment. With new pharmacological agents, including advances in antithrombotic therapy, contributing to the best medical practice in the treatment of PAD, the role of the pharmacist in the multidisciplinary team is becoming more vital and has documented success in improving patient outcomes. Methods: The CATCHem (Comprehensive Atherosclerosis Treatment Collaborative Health System) program consists of multiple disciplines that specialize in the management of various facets of atherosclerotic disease. The objective of this study is to assess the development of a pharmacist-led component of CATCHem on patient outcomes and to describe the processes required in the implementation of the program. The pharmacist will be responsible for enrolling and tracking patients, ensuring glycemic, hypertensive, and lipid control measures in addition to monitoring the use of low-dose rivaroxaban in the appropriate patients. Results: The models, algorithms, tracking system and order sets will be described once developed and implemented. Conclusions: Patient outcomes, results and conclusions will be defined after implementation. Findings are to be presented

Role of Target Specific Oral Anticoagulation After Operative Management of Venous Thoracic Outlet Syndrome

Background: The purpose of this study is to review the efficacy of Target Specific Oral Anticoagulants (TSOAC) versus vitamin K antagonist (VKA) for post-surgical anticoagulation in patient with primary subclavian vein thrombosis. Rivaroxaban, a factor Xa inhibitor, was the first TSOAC approved by the FDA in 2012 for the treatment and prevention of deep vein thrombosis. However, the efficacy and safety of TSOAC for prevention of recurrent deep vein thrombosis after revascularization of upper extremity compression syndromes is largely unknown.https://jdc.jefferson.edu/surgeryposters/1001/thumbnail.jp

Apixaban Discontinuation Prior To Major Surgery: Results From A Prospective Single Center Study

Primary Objective Estimate the proportion of patients who achieve a plasma apixaban concentration of/mL following at least 48 hours of discontinuation prior to surgery or invasive procedure Secondary Objective Perioperative and follow up arterial or venous thromboembolic events, major bleeding, clinically significant non-major bleeding complications. Correlation of apixaban anti-Factor Xa (FXa) activity and plasma apixaban concentrations at pre-admission and prior to surgeryhttps://jdc.jefferson.edu/petposters/1006/thumbnail.jp

Apixaban Discontinuation for Invasive Or major Surgical procedures (ADIOS): A prospective cohort study.

Background Apixaban pharmacokinetic properties and some clinical reports suggest cessation 48 hours prior to surgery is safe, but this has not been demonstrated in a naturalistic setting. We sought to measure the residual apixaban exposure in patients who had apixaban held as part of standard of care peri-operative management. Methods This was a prospective, observational study of patients in whom apixaban plasma concentration and anti-Xa activity were measured while at steady state apixaban dosing and again immediately prior to surgery. Clinical management of cessation and resumption of apixaban was at the discretion of the treating physician. Results One hundred and eleven patients provided paired blood samples. Ninety four percent (104/111) patients had measured apixaban concentrations of \u3c 30 ng/mL. Only one patient had a value \u3e 50 ng/mL. The median time between the self-reported last dose and pre-surgery blood sampling was 76 hours (range 32 – 158) for those who achieved concentrations \u3c 30 ng/mL and 59 hours (range 49 – 86) for those \u3e 30 ng/mL. Measured anti-Xa activity correlated well with apixaban exposure. Clinically significant non-major bleeding was reported in one patient at 1-week post-surgery. There was one venous thromboembolic event and one stroke in the peri-operative period. Conclusion In a naturalistic setting with a heterogeneous patient population, apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure. (NCT02935751