Broadening the Categories of Patients Eligible for Extended Venous Thromboembolism Treatment.

Traditionally, venous thromboembolism (VTE) resulting from major transient risk factors (e.g., surgery or trauma) or a major persistent risk factor such as cancer, has been defined as being provoked, whereas unprovoked VTE encompasses events without an identifiable cause. These categorizations influence anticoagulant treatment duration; unlike VTE provoked by major transient risk factors, extended anticoagulation beyond 3 months is advised for patients with cancer or unprovoked VTE due to risk persistence after treatment cessation. However, some patients with VTE provoked by minor transient or minor persistent risk factors may also be candidates for extended anticoagulation therapy due to the continuing risk of recurrence. In patients who require extended therapy, vitamin K antagonists (VKAs) are effective but are associated with an increased risk of bleeding and various treatment burdens (e.g., anticoagulation monitoring and dose adjustment). Evaluations of extended VTE treatment with the less-burdensome direct oral anticoagulants such as apixaban, dabigatran, edoxaban, and rivaroxaban show that they are at least as safe and effective as VKAs in a broad range of patients. In addition, apixaban and rivaroxaban offer more than one dosing option, allowing tailoring of treatment to the patient's specific risk factor profile. Analysis of more granular definitions for risk factor groupings has also yielded vital information on the most appropriate strategies for the treatment of patients with specific risk factors, highlighting that extended anticoagulation treatment may benefit those with minor transient and persistent environmental and nonenvironmental risk factors who commonly receive shorter-duration therapy

International Courts & Judicial Affairs

This chapter reviews some of the most significant developments made by international courts and tribunals in 2020. I. International Court of Justice As of the time of writing (November 2020), this year, the International Court of Justice (Court) has rendered one order on provisional measures, two judgments on appeals from decisions of the International Civil Aviation Organization (ICAO) Council, and two orders relating to expert evidence

Mechanical thrombectomy with a novel device: initial clinical experience with the ANA thrombectomy device

Mechanical thrombectomy; New device; StrokeTrombectomia mecànica; Nou dispositiu; IctusTrombectomía mecánica; Nuevo dispositivo; IctusIntroduction The ANA™ (Anaconda Biomed) thrombectomy system is a novel stroke thrombectomy device comprising a self-expanding funnel designed to reduce clot fragmentation by locally restricting flow while becoming as wide as the lodging artery. Once deployed, ANA allows distal aspiration in combination with a stentretriever (SR) to mobilize the clot into the funnel where it remains copped during extraction. We investigate safety and efficacy of ANA™ in a first-in-man study. Methods Prospective data was collected on 35 consecutive patients treated as first line with ANA™ at a single centre. Outcome measures included per-pass reperfusion scores, symptomatic intracerebral hemorrhage (sICH), NIHSS at day 5, and mRS at 90 days. Results Median NIHSS was 12(9−18). Sites of primary occlusion were: 5 ICA, 15 M1-MCA, 15 M2-MCA. Primary performance endpoint, mTICI 2b-3 within 3 passes without rescue therapy was achieved in 91.4% (n = 32) of patients; rate of complete recanalization (mTICI 2c-3) was 65.7%. First pass complete recanalization rate was 42.9%, and median number of ANA passes 1(IQR: 1−2). In 17.1% (n = 6) rescue treatment was used; median number of rescue passes was 2(1–7), leading to a final mTICI2b-3rate of 94.3% (n = 33). There were no device related serious adverse events, and rate of sICH was 5.7% (n = 2). At 5 days median NIHSS was 1 (IQR 1−6) and 90 days mRS 0−2 was achieved in 60% of patients. Conclusions In this initial clinical experience, the ANA™ device achieved a high rate of complete recanalization with a good safety profile and favourable 90 days clinical outcomes.The study was funded by Anaconda Biomed S.L

Evaluating the cost-utility of a direct transfer to angiosuite protocol within 6 h of symptom onset in suspected large vessel occlusion patients

Catalonia healthcare; Cost-utility; Large vessel occlusionSanitat de Catalunya; Cost-utilitat; Oclusió de grans vasosSanidad de Cataluña; Coste-utilidad; Oclusión de grandes vasosIntroduction A direct transfer to angiosuite (DTAS) protocol has shown to be effective and safe by shortening in-hospital workflows and encouraging long-term outcome benefits. To implement DTAS at a new facility, a large organizational effort is necessary. We performed a cost-utility analysis and budget impact analysis (BIA) of the operation of a new angiosuite, primarily dedicated to stroke patients, that allows facilities to approximate the cost implications of utilizing a DTAS pathway. Methods Sixty-one patients who underwent endovascular treatment (EVT) following DTAS were matched for baseline variables to 117 patients who underwent a conventional imaging protocol at a hospital in Catalonia, Spain. An economic model, based on actual data from these patients, was developed to assess the short- and long-term clinical and economic implications of DTAS. In the BIA, the DTAS scenario was gradually implemented for 20% of patients each year until reaching a plateau at 80% of patients in the DTAS pathway. Initial investment and additional organizational costs, €4 million, were taken into consideration to compare the budget impact of the DTAS scenario with no organizational changes over five years. Results DTAS was associated with better patient functional independence rates (mRS 0–2: 50.9% vs. 41.0%) and a quality-adjusted life-years gain of 0.82 per patient. Despite the additional initial investment, DTAS development was associated with an estimated 10.2% reduction (€14.7 million) of the total costs (€144.5 million). Cost savings were mainly due to long-term associated costs related to patient disability (€13.2 million). Limitations The study relies on data obtained from a single-center, and therefore it may be difficult to generalize the findings Conclusions Our economic model predicts that the implementation of a DTAS program is cost-effective compared with no organizational changes. Our model also predicts better clinical outcomes for patients in terms of functional independence and quality-adjusted life years.This study was sponsored by Medtronic

The Lectin-like Domain of Thrombomodulin Confers Protection from Neutrophil-mediated Tissue Damage by Suppressing Adhesion Molecule Expression via Nuclear Factor κB and Mitogen-activated Protein Kinase Pathways

Thrombomodulin (TM) is a vascular endothelial cell (EC) receptor that is a cofactor for thrombin-mediated activation of the anticoagulant protein C. The extracellular NH2-terminal domain of TM has homology to C-type lectins that are involved in immune regulation. Using transgenic mice that lack this structure (TMLeD/LeD), we show that the lectin-like domain of TM interferes with polymorphonuclear leukocyte (PMN) adhesion to ECs by intercellular adhesion molecule 1–dependent and –independent pathways through the suppression of extracellular signal–regulated kinase (ERK)1/2 activation. TMLeD/LeD mice have reduced survival after endotoxin exposure, accumulate more PMNs in their lungs, and develop larger infarcts after myocardial ischemia/reperfusion. The recombinant lectin-like domain of TM suppresses PMN adhesion to ECs, diminishes cytokine-induced increase in nuclear factor κB and activation of ERK1/2, and rescues ECs from serum starvation, findings that may explain why plasma levels of soluble TM are inversely correlated with cardiovascular disease. These data suggest that TM has antiinflammatory properties in addition to its role in coagulation and fibrinolysis

Multiphase CT Angiography Improves Prediction of Intracerebral Hemorrhage Expansion

Angiography; Intracerebral hemorrhage; PredictionAngiografía; Hemorragia intracerebral; PredicciónAngiografia; Hemorràgia intracerebral; PrediccióPurpose To determine the prevalence of the spot sign and the accuracy of using the spot sign to predict intracerebral hemorrhage (ICH) expansion with standardized multiphase computed tomographic (CT) angiography. Materials and Methods This prospective observational cohort study included 123 consecutive patients with acute ICH (onset 33% or >6 mL) at 24 hours. Associations between the presence of the spot sign and substantial hematoma expansion were assessed by using the Pearson χ2 test. Results The later the phase of CT angiography, the higher the frequency of the spot sign. The spot sign was seen in 29.3% of patients in phase 1, 43.1% of patients in phase 2, and 46.3% of patients in phase 3 (P B > C > D > no spot sign (P = .002). Conclusion Multiphase CT angiography can help differentiate among different forms of spot sign presentation and can help stratify patients at risk for hematoma expansion. The more arterial the spot sign pattern, the greater the frequency and extent of expansion