Kooistra, Hilde A. M.

Meijer, Karina

van Schouwenburg, Inge M.

Veeger, Nic J. G. M.

English

Dissertations of the University of Groningen

   University of GroningenCatheter-directed thrombolysis for acute deep vein thrombosisvan Schouwenburg, Inge M.; Kooistra, Hilde A. M.; Veeger, Nic J. G. M.; Meijer, KarinaPublished in:LANCETIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2012Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Schouwenburg, I. M., Kooistra, H. A. M., Veeger, N. J. G. M., & Meijer, K. (2012). Catheter-directedthrombolysis for acute deep vein thrombosis. LANCET, 379(9828), 1785-1786.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 11-10-2022Correspondencewww.thelancet.com   Vol 379   May 12, 2012 1785Submissions should be made via our electronic submission system at http://ees.elsevier.com/thelancet/HR’s “data” are marked Private and Confi dential. Some things must be believed. To question them is heresy.We hope to report back on our Head’s one-to-one interview with himself. After all, we have his word, and that of College senior management, that the restructuring is proceeding with complete fairness and transparency. Perhaps he’ll use a mirror?We declare that we have no confl icts of interest.John F Allen, *Fanis Missirlisf.missirlis@qmul.ac.ukSchool of Biological and Chemical Sciences, Queen Mary University of London, London E1 4NS, UK (JFA, FM); and Departamento de Fisiología, Biofísica y Neurociencias, CINVESTAV-IPN, Mexico City, México (FM)1 Horton R. Offl  ine: Bullying at Barts. Lancet 2012; 379: 1086.2 Horton R. Offl  ine: Under a tree in Geneva. Lancet 2012; 379: 1182.3 Horton R. Offl  ine: The bent and twisted. Lancet 2012; 379: 1284.4 Allen JF. Research and how to promote it in a university. Future Med Chem 2012; 2: 15–20.5 McDonald S. Bullying at Barts. Lancet 2012; 379: 1483.Queen Mary: nobody expects the Spanish InquisitionThree timely Offl  ine columns by Richard Horton1–3 describe a mindless managerial rampage spreading through Queen Mary University of London, UK. Barts and The London, Queen Mary’s School of Medicine and Dentistry, has declared distinguished medical researchers to be at risk of redundancy.1 Queen Mary’s School of Biological and Chemical Sciences now follows suit.2,3 As we write, colleagues declared to be “at risk” just 2 weeks ago are summoned individually to closed audiences with the Head of School, attended by members of the ironically named “Human Resources” (HR) department. If targeted individuals fail to appease the inquisitor, they will be sacked. Other staff  members are earmarked for demotion, with replacement “Teaching and Scholarship” contracts that will oblige them to desist from independent research.But, one might ask, is it not high time to weed out slackers? It might help if one had any way of knowing who they are. Sadly, the “restructuring” hits exactly the wrong targets in many cases, and leaves unproductive academics unscathed. The reason is simple—the Head of School and HR have neither interest in, nor understanding of, individuals’ research, still less their research potential. This slaughter of the talented relies entirely on a carefully designed set of retrospective counts of the uncountable. These are labelled research “metrics”.Are we here engaged in special pleading? Actually, no.4 Our school has a reputation, envied worldwide, for research by individuals now for the chop. Their retrospective crimes, committed between 2008 and 2011, include too few publications as a “signifi cant” author in high-impact journals, and below-average external funding. Where the baseline of research income derived from the Higher Education Funding Council for England has disappeared, no-one seems to know. So, we are looking at the end of the road for unique and internationally leading-edge Queen Mary research. Among many outstanding projects we stand to lose are: sociogenomics of mole rats, the only eusocial mammals, and a model, incidentally, for the endocrinology of bullying; genetics of circadian rhythms and iron homoeostasis from experiments on fruit-fl ies; imaging of neural activity in zebrafi sh—a paradigm for vertebrate development; and heterogeneous catalytic oxidation and carbon–carbon coupling in inorganic chemical synthesis. The list is long. Alas, there are no boxes to tick for advances in knowledge and understanding—no metrics for science itself.Over in the Medical and Dental School, the grand inquisitor is identifi ed as the Dean for Research, whose own research credentials are, naturally, unavailable for scrutiny.1 Never mind, we now have the assurance from his colleague that “Each and every faculty member of the college was assessed in this process and from my own personal point of view it was done fairly...”5 Who needs evidence in the face of such assurance? “Consequently, to pick him out for criticism in this disgraceful manner is quite iniquitous”.5 Yet the Dean managed to pick out others—for oblivion, not just criticism. And he got it wrong.1The same double standard follows, now, in our School of Biological and Chemical Sciences. For example, one of the “metrics” for research output at professorial level is to have published at least two papers in journals with impact factors of 7 or more. This is ludicrous, of course—a triumph of vanity as sensible as selecting athletes on the basis of their brand of track suit. But let us follow this “metric” for a moment. How does the Head of School fair? Zero, actually. He fails. Just consult Web of Science. Take care though, the result is classifi ed information. Catheter-directed thrombolysis for acute deep vein thrombosisTone Enden and colleagues’ random-ised trial of catheter-directed throm-bolysis (CDT) in patients with high proximal deep vein thrombosis (Jan 7, p 31)1 is well designed and the results have been eagerly awaited. However, we feel that caution is recommended in assigning the 14·4% absolute reduc tion in the risk of post-thrombotic syndrome in patients on CDT to thrombolysis.Besides additional treatment, CDT patients were more compliant with wearing compression stockings than were patients who did not receive CDT. Although the diff erence in compliance of 11·8% is not signifi cant, it is relevant. Daily use of compression stockings reduces the risk of post-thrombotic syndrome by 50%.2,3 On the basis of this number and Published OnlineMay 4, 2012DOI:10.1016/S0140-6736(12)60697-7Science Photo Library Correspondence1786 www.thelancet.com   Vol 379   May 12, 2012other indirect costs associated with the longer hospital stay necessary.We declare that we have no confl icts of interest.*Saurav Chatterjee, Abhishek Sharmasauravchatterjeemd@gmail.comMaimonides Medical Center, Brooklyn, NY 11220, USA1 Enden T, Haig Y, Kløw NE, et al, on behalf of the CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2012; 379: 31–38.2 Watson LI, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev 2004; 4: CD002783.3 Arnesen H, Hoiseth A, Ly B. Streptokinase or heparin in the treatment of deep vein thrombosis: follow-up results of  a prospective study. Acta Medica Scand 1982; 211: 65–68.4 Vedantham S. Endovascular procedures in the management of DVT. Hematology Am Soc Hematol Educ Program 2011; 2011: 156–61.5 Bergqvist D, Jendteg S, Johansen L, Persson U, Odegaard K. Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden. Ann Intern Med 1997; 126: 454–57.the incidence of post-thrombotic syndrome in Enden and colleagues’ study, we calculate an expected absolute risk reduction in CDT patients of 4%, owing to better compliance with compression stocking use.Furthermore, more CDT patients than non-CDT patients had good-quality anticoagulant treat ment at both follow-up points. Oral anti-coagulant treatment that achieves an international normalised ratio within the therapeutic range reduces the risk of post-thrombotic syndrome by 63% compared with patients who spend more than 50% of time beneath the therapeutic range.4 Unfortunately, time in therapeutic range was not reported in Enden and colleagues’ trial and was not accounted for in examining the eff ect of CDT on post-thrombotic syndrome.The CDT strategy, with its more intense treatment and hospital admission, does seem to improve out-come. However, this might not be the eff ect of additional thrombolysis. Instead, it could be due to more intense initial patient support, which results in more awareness of the relevance of treatment compliance. We feel that taking treatment compliance into account is important before coming to conclusions about the eff ect of thrombolysis on post-thrombotic syndrome and before exposing patients to costly and invasive procedures.We declare that we have no confl icts of interest.Inge M van Schouwenburg, Hilde A M Kooistra, Nic J G M Veeger, *Karina Meijerk.meijer@umcg.nlDivision of Hemostasis and Thrombosis, Department of Hematology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, Netherlands (IMvS, HAMK, NJGMV, KM); and Trial Coordination Center, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands (NJGMV)1 Enden T, Haig Y, KlØw NE, et al, on behalf of the CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet 2012; 379: 31–38.2 Brandjes DP, Buller HR, Heijboer H, et al. Randomised trial of eff ect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349: 759–62.3 Prandoni P, Lensing AW, Prins MH, et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med 2004; 141: 249–56.4 van Dongen CJ, Prandoni P, Frulla M, Marchiori A, Prins MH, Hutten BA. Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome. J Thromb Haemost 2005; 3: 939–42. Tone Enden and colleagues, in their CaVenT trial,1 explore the interesting hypothesis of catheter-directed thrombolysis (CDT) in the prevention of post-thrombotic syn drome. We have several comments. In the Intro duction section, reference to the updated Cochrane review2 as sug gesting a benefi t of systemic thrombolysis in prevention of post-thrombotic syndrome comes with the caveat that the only study with a Jadad score of greater than 3 showed no benefi t.3The CaVenT trial was done in four specialised centres, and hence the outcomes might be very diff erent elsewhere. Additionally there might have been a learning curve for optimum results with CDT; hence it would be interesting to have a comparison of those who entered the trial earlier versus those who entered later.Enden and colleagues do not present the bleeding rates (if any) for the control group, and hence a number needed to harm is not available. Also, the rate of stent placement and its association with outcomes would have been interesting, especially in view of scant evidence available on the topic.4The limitations of the open-label design might have manifested with an obvious greater adherence to oral anticoagulation in the CDT group at 6 months. Finally, Enden and col-leagues imply a cost eff ectiveness with CDT, citing the cost associated with post-thrombotic syndrome;5 however, it would be interesting to assess the expense associated with CDT and Authors’ replyBoth sets of correspondents raise an issue about whether the noted absolute reduction in post-thrombotic syndrome of 14·4% in patients treated with additional catheter-directed thrombolysis (CDT) could be attri-buted to the thrombolytic treatment alone, since a higher proportion of these patients reported daily wear of elastic com pression stockings and had international normal ised ratios within the therapeutic range.We agree that the non-signifi cant tendency to better compliance could be attributable to the inherent risk of bias of this open-label randomised controlled trial, and relevance to the noted eff ect size cannot be ruled out. However, we think the eff ect on post-thrombotic syndrome cannot be simplifi ed as suggested by Inge van Schouwenburg and colleagues. First, the two landmark studies on the use of elastic com pression stockings1,2 reported on patients with any level of proximal deep vein thrombosis (DVT) from the popliteal vein and up, whereas our patients had a high proximal 

Catheter-directed thrombolysis for acute deep vein thrombosis

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Catheter-directed thrombolysis for acute deep vein thrombosis

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