Venous thromboembolism prophylaxis in medical patients: future perspectives

Venous thromboembolism is a common potentially life-threatening complication in acutely ill medical patients. Actually, over 70% fatal episodes of pulmonary embolism during hospitalization occur in non-surgical patients. In the absence of thromboprophylaxis, the incidence of venographically detected deep vein thrombosis is about 15% in medical patients and several trials and meta-analyses have clearly demonstrated the prophylactic role of unfractioned heparin and low-molecular-weight heparins. Although over the last years the knowledge of epidemiology, clinical features and prophylaxis in medical patients has significantly improved, there are still several relevant issues to investigate thoroughly. Scarce data are available on a simple way to stratify patients in order to identify those who should undergo prophylaxis and several studies clearly show that thromboprophylaxis in medical conditions is underused. Moreover, in comparison to surgical settings, very few randomized clinical trials on the efficacy of pharmacologic prophylaxis have been performed and no data at all have been published concerning mechanical prophylaxis in medical conditions. According to previous studies and results of very recently published trials, new data are available to tailor low molecular weight heparin optimal dose, whereas the optimal duration of prophylaxis in medical patients is still a matter of debate. Moreover, the possible role of the new antithrombotic drugs in the venous thromboembolism prevention in medical conditions and the optimal management of thromboprophylaxis in patients with ischaemic stroke have not been fully investigated. Although new evidence represents a significant improvement both in stratification of VTE risk and in decisions about the appropriate type and duration of prophylactic strategies in medical patients, additional data are still needed.     

Prevalence of factor V Leiden,FII G20210A,FXIII Val34Leu and MTHFR C677T polymorphisms in cancer patients with and without venous thrombosis

Venous thromboembolism (VTE) is a common complication in patients with malignant disease. In addition to well-established acquired risk factors for VTE, several genetic risk factors, mainly related to the haemostatic system, are known to influence thrombotic risk. However, the contribution of gene abnormalities to thrombotic tendency in cancer patients remains poorly explored. We performed a prospective study to evaluate the prevalence and clinical significance of four gene variations (factor V Leiden [FVL], factor II G20210A, factor XIII Val34Leu and MTHFR C677T) in cancer patients, with and without VTE. Enrolled were 211 unrelated and unselected patients (M/F ratio 0.5, mean age 57 years, range 12-91 years) with a diagnosis of cancer, admitted to two University Oncology Clinics in the city of S?o Paulo, Southeastern Brazil. After admission, all patients were evaluated for the presence of symptoms and signs of VTE. Sixty-four patients (30.3%) had an episode of deep venous thrombosis (DVT) or pulmonary embolism (PE), which has been objectively verified; 147 patients (69.7%) had no evidence of VTE. FVL was found with a frequency of 1.5% and 2.7% in the VTE and non-VTE group, respectively (odds ratio [OR] for VTE 0.6, 95% CI: 0.06-5.3). FII G20210A was found in 1.5% and 1.3% of thrombotic and nonthrombotic patients, respectively, yielding an OR of 1.2 (95% CI: 0.1-13.1). FXIII Val34Leu was detected in 29.6% of the thrombotic patients and in 28.5% of the non-thrombotic patients (OR 1.1, 95% CI: 0.5-2). MTHFR 677T was present in 53.1% and 60.5% of patients with and without thrombosis, respectively (OR 0.8, 95% CI: 0.4-1.4). The present data do not point to an association between the four polymorphisms here investigated and the risk of VTE in cancer patients.     

Incidence and risk factors of symptomatic venous thromboembolism related to implanted ports in cancer patients

Introduction

The true incidence of symptomatic implanted port related venous thromboembolism (VTE) in cancer patients is unclear and there is very limited data on its associated risk factors.

Materials and methods

We performed a retrospective cohort study of consecutive cancer outpatients who received an ultrasound guided implanted port insertion for the administration of chemotherapy. The primary outcome measure was symptomatic VTE. Univariable and multivariable logistic regression analyses were used to identify risk factors for symptomatic VTE.

Results

A total of 400 cancer patients with a newly inserted implanted port for deliverance of chemotherapy were included in the study. Median age was 58 years (range of 21 to 85 years) and 120 (30%) were males. Patients were followed for a median of 12 months and none received thrombophrophylaxis. Of the 400 patients included in the analysis, 34 patients (8.5%; 95% CI: 6.0 to 11.7%) had symptomatic VTE (16 DVTs, 16 PEs, and 2 with both). In the univariate analyses, metastatic disease, male gender and right sided implanted port insertion were significantly associated with the risk of VTE. In the multiple-variable analysis, male gender (OR 2.17, p = 0.04) and presence of metastases (OR 8.22, p < 0.01) were the two significant independent predictors of implanted port related VTE.

Conclusion

Symptomatic VTE is a frequent complication in cancer patients with implanted port receiving chemotherapy. Gender and presence of metastatic disease are independent risk factors for symptomatic VTE. Future trials assessing the role of thromboprophylaxis among these higher risk patients are needed.     

Chronic kidney disease in patients with cancer and its association with occurrence of venous thromboembolism and mortality

Introduction

The risk for occurrence of venous thromboembolism (VTE) in cancer patients has been the aim of numerous investigations. Chronic kidney disease (CKD) is a frequent comorbidity in cancer patients and has been found to be a risk factor for VTE in the general population. We investigated the association of CKD with VTE and mortality in cancer patients.

Methods

Patients were recruited into the prospective cohort study, Vienna Cancer and Thrombosis Study (CATS). CKD was estimated with equations for glomerular filtration rate (eGFR) based on serum creatinine by Modification of Diet in Renal Disease (MDRD), CKD Epidemiology collaboration (CKD-EPI) and Cockcroft-Gault equation (C-G). Patients were subsequently classified to stages of CKD according to the Kidney Diseases Outcomes Quality Initiative. Primary endpoint was occurrence of VTE and secondary endpoint was death.

Results

The cohort of 1100 patients was prospectively followed over a median of 723 days. CKD with an eGFR of under 90 ml/min was common with a prevalence of 71.1%, 67.0% or 51.5% of patients calculated with MDRD, CKD-EPI and C-G equations, respectively, but severe CKD (eGFR < 30 ml/min) was rare. Patients with a moderately decreased eGFR (90-60 ml/min/1.73 m²) based on CKD-EPI had a subdistribution hazard ratio of 0.68 (95% confidence interval 0.43-1.06). An association between CKD and occurrence of VTE or mortality could also not be shown with the other equations.

Conclusions

In our investigation of a large cohort of cancer patients with a high prevalence of CKD, a reduced eGFR was not an independent risk factor for occurrence of VTE or death.     

Identifying high-school dance students who will develop an eating disorder: A 1-year prospective study

This study examined the changes in eating disorder (ED) status over 1 year and identified risk factors for EDs among female dance students. In 2003, all students enrolled in each of the nation's 12 high schools with gifted dance programs participated in a two-phase survey. The same participants were invited to take part in a follow-up survey 1 year later. In all, 583 persons completed the phase 1 questionnaire survey, and 245 persons completed interviews twice at baseline and follow-up. Thirty-five females had a newly developed ED, and less than half of the ED cases found at baseline had recovered at follow-up. Being a grade 12 student carried a reduced risk of EDs, whereas higher baseline scores on the Bulimic Investigatory Test Edinburgh (BITE) increased risks of developing an ED after 1 year. A 10-item BITE questionnaire validly identified girl dance students who would develop EDs later in high school. EDs were more commonly developed during middle adolescence, and we suggest that prevention work against EDs begin in this period among the dance student population. The brief screening questionnaire might help detect intervention targets of a prevention program among adolescent dance students.     

Pharmacodynamics of low molecular weight heparin in patients undergoing bariatric surgery: A prospective, randomised study comparing two doses of parnaparin (BAFLUX STUDY)

Background

The optimal dose of low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE) after bariatric surgery remains controversial.

Aim

The aim of this study was to evaluate the pharmacodynamic parameters of two doses of the LMWH parnaparin administered to patients undergoing bariatric surgery.

Methods

Patients were enrolled in a multicentre, open label, pilot study and were randomised to receive 4250 IU/day [n = 36; 30 females; median age: 38 years (23-56); median BMI: 46.7 Kg/m² (36.5-58.8)] or 6400 IU/day [n = 30; 24 females; median age: 42 years (22-63); median BMI: 43.7 Kg/m² (36.1-64.1)] of parnaparin s.c. for 7-11 days. The pharmacodynamic effects of parnaparin were analysed by measuring the anti Factor Xa activity on day 0 (12 hours after the first parnaparin injection), day 4 and day 6 after surgery (before and 4 hours after parnaparin administration).

Results

In 98.3% of patients receiving 4250 IU/day the peak anti-Xa levels were in the range of 0.1-0.4 IU/ml. Higher anti-Xa levels were observed in patients receiving 6400 IU/day: in 62.3% of these patients the peak anti-Xa levels were greater than 0.4 IU/ml. The anti-Xa levels measured 4 hours after injection on days 4 and 6 were not statistically correlated with BMI for either dose of-parnaparin (p = 0.077 and p = 0.401 for 4250 or 6400 IU/day, respectively).

Conclusion

The dose of 4250 IU/day seems adequate to achieve prophylactic anti-Xa levels in morbid obese patients undergoing bariatric surgery. Conversely, most of the patients receiving 6.400 IU/day show anti-Xa levels higher than the recommended prophylactic values.     

Epidemiology and management of venous thromboembolism in patients with cancer

Cancer and its treatments are well-recognized risk factors for venous thromboembolism (VTE). Although the incidence of VTE in cancer patients is not well documented, there is evidence that the absolute risk depends on the tumor type, the stage or extent of the cancer, and treatment with antineoplastic agents. The most common cancer types seen in patients with thrombosis are breast, colorectal and lung, reflecting the prevalence of these malignancies in the general population. When the underlying prevalence is taken into account, cancers of the pancreas, ovary and brain are the most strongly associated with thrombotic complications. Although idiopathic thrombosis can be the first manifestation of an occult malignancy, extensive screening for cancer in these patients has not been shown to improve survival and is not warranted. Prophylaxis in patients undergoing major surgery for cancer with either unfractionated or low-molecular-weight heparin (LMWH) is strongly recommended, but prophylaxis in ambulatory medical oncology patients is not routinely indicated. Anticoagulant therapy remains the mainstay treatment of VTE in cancer patients and recent evidence shows that LMWH is effective and well tolerated for both initial therapy and secondary prophylaxis. Despite treatment, cancer patients with thrombosis have a poor prognosis. This is likely due to premature deaths from recurrent VTE and to the aggressive nature of the underlying cancer. Whether LMWH is capable of modifying tumour biology remains unanswered. Further research is needed to address the many clinical questions in the management of thrombosis in patients with cancer.     

Renal failure as a risk factor for venous thromboembolism in critically Ill patients: A cohort study

Rationale

The relationship between kidney function and venous thromboembolism (VTE) in critically ill patients is not well studied. The main objective of this study was to evaluate this relationship in patients admitted to a medical-surgical intensive care unit (ICU).

Methods

This was a retrospective study of 798 patients admitted to a tertiary-care ICU and prospectively followed for the development of clinically suspected and radiologically diagnosed deep venous thrombosis or pulmonary embolism. Patients were divided based on admission creatinine and dialysis history into five groups: normal kidney function, RIFLE classes R, I and F (combined = acute kidney injury [AKI]) and endstage renal disease (ESRD). We compared VTE prophylaxis practices and VTE incidence in these groups and evaluated renal failure as a VTE risk factor using multivariate Cox regression analysis.

Results

Of the 798 patients, 27.2% had AKI and 10.1% had ESRD. Unfractionated heparin use was similar in the five groups but enoxaparin use was less frequent in AKI (13.4%) and ESRD (3.8%) patients compared with patients with normal kidney function (39.0%). VTE occurred in 7.6% of patients with normal renal function, 7.8% AKI patients and 2.5% ESRD patients (p = 0.22). The adjusted hazard ratios for VTE compared to patients with normal kidney function were 0.35 (95% confidence interval [CI], 0.08-1.47) for RIFLE class R, 1.19 (95% CI, 0.83-1.70) for RIFLE class I, 0.82 (95% CI, 0.59-1.14) for RIFLE class F and 0.71 (95% CI, 0.49-1.02, p = 0.06) for ESRD.

Conclusions

Neither AKI nor ESRD was an independent risk factors for critically ill patients.     

Thrombolysis in hemodynamically stable patients with acute pulmonary embolism: A meta-analysis

Introduction

The role of thrombolysis in hemodynamically stable patients with acute pulmonary embolism (PE) remains controversial. We performed a meta-analysis of randomized trials to assess the effect of thrombolysis in these patients.

Materials and Methods

We searched MEDLINE and EMBASE for randomized studies comparing thrombolysis and heparin for the initial treatment of hemodynamically stable PE patients. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated. NNH to cause a major bleeding (MB) or an intracranial hemorrhage (ICH) and NNT to avoid one death were also calculated.

Results

Eleven studies (1833 patients) were included seven with rt-PA, three with tenecteplase and one with urokinase. Patients randomized to thrombolysis had a significant increased risk for MB (5.9% vs 1.9%; OR 2.83, 95% CI 1.68-4.76, I² 18.7%) and an increased risk for ICH (1.74% versus 0.6%; OR 2.36, 95% CI 0.98-5.71, I² 0%) and for fatal bleeding (1.3% versus 0.54%; OR 1.84, 95% CI 0.73-4.61, I² 0%). A not-significant reduction for all-cause death (1.74% vs 2.51%; OR 0.68, 95% CI 0.37-1.26, I² 0%) and a significant reduction for recurrent PE (1.1% vs 2.5%; OR 0.44, 95% CI 0.21-0.92, I² 0%) in favor of thrombolysis compared with heparin was found. NNH to cause a MB or an ICH were 27 and 91 patients, respectively. NNT to avoid one death was 125 patients.

Conclusions

Due to increased risk for MB and ICH with no evidence of reduction in mortality, thrombolysis should not be used for most normotensive PE patients.     

Self-reported family history in estimating the risk of hormone,surgery and cast related VTE in women

Background

Combined hormonal contraceptives, menopause hormone treatment and surgery/cast in orthopedic patients are important risk factors for venous thromboembolism (VTE) in women.

Objectives

To evaluate whether self-reported family history can be used for risk assessment concerning hormone and surgery /cast related VTE in women.

Patients/methods

1288 women 18–64 years with a first event of VTE and 1327 age-matched controls were included in a nation-wide population-based case–control study in Sweden. Odds ratios were calculated by comparing occurrence of VTE in women with and without a positive family history in combination with hormones or surgery/cast.

Results

The risk of hormone-associated VTE was doubled in women with a family history of VTE as compared to women with hormones and negative family history. The risk was more than tripled in women with surgery/cast and a positive family history, as compared to surgery/cast patients with negative family history. Women with a positive family history and combined hormonal contraceptive or menopause hormone treatment had an OR of 15.3 (95% CI 6.1–38) and 5.9 (95% CI 3.3–11) respectively compared to women without hormones or family history. The corresponding OR in women with surgery/cast and a positive family history was 67 (95% CI 21–213) compared to women without surgery/cast treatment and a negative family history.

Conclusion

Self-reported family history is associated with increased odds of developing VTE on combined hormonal contraceptives, menopause hormone treatment and in connection with surgery or plaster. We believe that assessing family history of VTE can be helpful in identifying high risk patients.     

High prevalence of recurrent thrombosis in subsets of cancer patients with isolated gonadal vein thrombosis: A single center retrospective study

Purpose

Cancer patients are a high-risk population for venous thromboembolism (VTE); the natural history of gonadal vein thrombosis (GVT) occurring in cancer patients is not well described in the medical literature.

Methods

Utilizing a software program the computerized tomographic scan reports of patients at a single cancer center from January 1, 2004 to June 30, 2011 were searched for the term GVT. Patients included in this analysis had a diagnosis of cancer, an isolated GVT (i.e. no evidence of thrombosis at another site), no symptoms referable to the GVT, and at least six months of follow-up information. All subsequent recurrent VTE events were confirmed by imaging studies.

Results

196 cancer patients with GVT were identified. The majority of patients in this analysis had metastatic disease (118, 61.2%) as well as active cancer (167, 85.2%). Twenty patients (10.8%) developed recurrent VTE (median follow-up 14.5 months); median time to recurrent VTEs was 5.5 months (range 0–19 months). When considering only patients with without a recent history of gynecologic surgery, VTE recurrence rates were 14.3%. Active cancer was the only risk factor significantly associated with recurrent VTE (P = 0.047).

Conclusions

Based upon the patient’s risk factors for VTE, treatment of an incidentally detected GVT in cancer patients with anticoagulation, as per guidelines for other VTE sites, may be indicated in certain high risk subgroups, especially those patients with active cancer who have not had prior pelvic surgery.     

石家庄市社区居民脑卒中危险因素调查分析

目的调查石家庄市部分社区40岁以上居民脑卒中高危人群分布及危险因素暴露情况,为建立脑卒中防控干预措施提供依据。方法采取随机抽样调查的方法对石家庄社区40岁及以上常住居民进行现场问卷调查、评估、分级,将调查数据进行统计分析。结果 2633居民接受了调查,其中有脑卒中低危1561人,中危638人,高危373人,排在前3位的危险因素分别是高血压(31.9%)、运动减少(21.5%)及肥胖(21.2%),男性居民吸烟率明显高于女性,而女性在血脂异常及运动减少者明显多于男性。结论高血压、运动减少和肥胖是脑卒中高危人群中主要的危险因素,应作为重点进行干预。     

Prolonged travel and venous thromboembolism findings from the RIETE registry

There is a lack of information on clinical risk factors for venous thromboembolism (VTE) development following prolonged traveling. Clinical characteristics and additional risk factors for VTE in travelers were analyzed in RIETE, an ongoing registry of patients with symptomatic, confirmed acute VTE. Of 26,172 patients enrolled in RIETE as of May 2009, 2% developed VTE in association with recent traveling. Travelers were ten years younger, had significantly more previous VTE events (20% vs. 16%; OR: 1.4; 95%CI: 1.1-1.7) and their body mass index (BMI) was 28.4 ± 5.1 vs. 27.7 ± 5.2 in other patients from the registry (P = 0.004). 115 (20%) of recent travelers had previous VTE compared to 16% among others patients (OR: 1.4; 95%CI: 1.1-1.7). Recent travelers used hormones significantly more frequently (8.7% vs. 3.7%; OR: 2.5; 95% CI: 1.8-3.3) and more often had a positive thrombophilia test (16% vs. 8.7%; OR: 2; 95%CI: 1.6-2.6). Travelers used LMWH prophylaxis significantly less frequently than other patients in the registry (2.4% vs. 13%; OR 0.2; 95%CI: 0.1-0.3). There were differences in VTE risk in professional drivers compared to passengers. The current study demonstrates four risk factors for VTE development after long traveling: high BMI, previous VTE, hormone use and thrombophilia. Studies of prophylactic antithrombotic therapy in high risk travelers are warranted.     

颅脑手术部位感染率及危险因素前瞻性研究

目的研究颅脑手术部位感染率及危险因素。方法采用前瞻性方法调查我院颅脑手术病人478例。结果我院颅脑手术部位感染率为3.1%;按美国疾控中心NNIS系统SSI危险因素评分分层得到的感染率分别是:0分者1.2%(4/344),1分者7.4%(9/121),2-3分者15.4%(2/13)。发生SSI的危险因素包括手术时间>4h、术后使用引流管、SSI危险因素评分>0分、本次手术前曾进行过颅脑手术。结论我院颅脑手术SSI发生率为3.1%;危险因素为手术时间>4h、术后使用引流管、SSI危险因素评分>0分、本次手术前曾进行过颅脑手术。     

Etiology and VTE risk factor distribution in patients with inferior vena cava thrombosis

Introduction

Inferior vena cava (IVC) thrombosis is a rare event and data detailing the underlying etiology are scarce.

Materials and methods

Therefore, we reviewed all available cases of IVC thrombosis consecutively registered in the MAISTHRO (MAin-ISar-THROmbosis) database and described the prevalence of VTE risk factors and other conditions contributing to IVC thrombosis development.

Results

53 patients (35 F, 18 M) with IVC thrombosis aged 12 to 79 years were identified. 40 patients (75.5%) developed thrombosis under the age of 45. Local problems, such as IVC anomalies or external venous compression, contributed to the development of thrombosis in 12 cases (22.6%). Lupus anticoagulants (10.9 vs. 2.3%, p = 0.013) and malignoma (17.0 vs. 6.4%, p = 0.023) were more prevalent in IVC thrombosis patients compared to 265 age and sex matched controls with isolated lower extremity DVT. No difference was identified with regard to inherited thrombophilia or other known VTE risk factors. Symptomatic pulmonary embolism (PE) occurred in 32.1% of IVC thrombosis patients compared to 15.2% of controls (p = 0.005).

Conclusions

Local problems such as IVC anomalies and external venous compression, malignancy and the presence of lupus anticoagulants contribute to the risk of IVC thrombosis. The risk of symptomatic pulmonary embolism in the acute setting is high.     

卒中后深静脉血栓形成调查及危险因素探讨

目的 调查卒中后急性期和随访期深静脉血栓形成(DVT)发生率,并探讨DVT发生的危险因素.方法 采用多中心、前瞻性研究设计.所有患者于发病后10～14 d进行双下肢静脉超声检查,出院后继续随访6个月.计算出卒中后急性期和随访期DVT发生率.通过比较卒中后并发DVT与卒中后无DVT的患者多种相关因素,筛选出卒中后DVT发生的危险因素.结果 卒中急性期DVT发生率为4.49%,其中有DVT症状者为51.6%,无症状者为48.4%;多因素Logistic分析显示:年龄(≥70岁,OR=1.63,95%CI 1.08～2.84)、卧床(OR=4.85,95%CI 2.65～9.68)、Wells评分≥2(OR=3.96,95%CI 1.86～7.86)、下肢NIHSS评分≥3分(OR=4.56,95%CI 2.07～8.85)、D-二聚体水平高(OR=3.45,95%CI 2.01～8.52)、Barthel指数(BI)评分低(OR=2.98,95%CI 1.52～6.47)、是否康复治疗(OR=1.82,95%CI 1.22～3.43)、是否抗凝治疗(OR=1.91,95%CI 1.34～4.92)是急性期卒中患者DVT发生的独立危险因素,其中康复治疗和抗凝治疗是保护因素;卒中随访期DVT发生率为1.51%,年龄(≥70岁,OR=1.82,95%CI 1.21～3.98)、出院后仍卧床(OR=5.12,95% CI 2.82～11.32)、出院时下肢NIHSS评分≥3分(OR=4.25,95%CI 2.11～7.87)、出院时BI评分低(OR=2.18,95%CI 1.18～6.23)、急性期有DVT(OR=3.81,95% CI 1.87～7.48)是随访期卒中患者DVT发生的独立危险因素.结论 卒中后DVT多发生于老年患者,48.4%DVT无症状,卒中患者发生DVT的独立危险因素多,对有上述危险因素卒中患者进行DVT监测和预防干预十分必要,康复治疗和抗凝治疗可能能降低DVT的发生.     

Adjuvant therapy with bemiparin in patients with limited-stage small cell lung cancer: Results from the ABEL study

Introduction

The haemostatic system plays an important role in the process of cancer development and spread. Anticoagulants, mainly low molecular weight heparins, could prolong survival in cancer patients, particularly in patients with lung cancer, beyond prevention of thromboembolic events.

Methods

In a multicenter, investigator-initiated, open-label, randomized, sequential study, 38 patients with newly-diagnosed, limited-stage small-cell lung cancer were randomized to receive standard chemoradiotherapy or the same therapy plus 3,500 IU daily of bemiparin for a maximum of 26 weeks. The primary outcome was progression-free survival.

Results

The study was terminated early due to slow recruitment. Median progression-free survival was 272 days with chemoradiotherapy alone and 410 days in the bemiparin group; hazard ratio, 2.58 (95% confidence interval [CI], 1.15-5.80); p = 0.022. Median overall survival was 345 days with chemoradiotherapy alone and 1133 days in the bemiparin group; hazard ratio, 2.96 (95% CI, 1.22-7.21); p = 0.017. The rate of tumor response was similar in both study arms. There was no significant between-group difference in the rates of major bleeding. Toxicity related with the experimental treatment was minimal.

Conclusion

The addition of bemiparin to first line therapy with chemoradiotherapy significantly increases survival in patients with newly-diagnosed, limited-stage small-cell lung cancer. (Funded by the Instituto Científico y Tecnológico, University of Navarra. ClinicalTrials.gov identifier: NCT00324558).     

Outcome of patients with splanchnic venous thrombosis presenting without overt MPN: A role for the JAK2 V617F mutation re-evaluation

Introduction

Although investigation for JAK2 V617F mutation is recommended in patients presenting with splanchnic venous thrombosis (SVT), no specific clinical advice is given to SVT patients presenting without myeloproliferative neoplasms (MPN) and JAK2 V617F mutation. In MPN-free SVT patients, to investigate the clinical outcome, the clinical impact of re-evaluation for the JAK2 V617F mutation, and relationships with the occurrence and time to diagnosis of MPN.

Materials and Methods

A cohort of non-cirrhotic SVT patients, enrolled at a single centre and prospectively analyzed.

Results

In 121 SVT patients prospectively followed from 1994 to 2012, a MPN was present in 28 (23.1%). Additional 13 patients (10.7%) showed only the JAK2 V617F mutation. During the follow-up, the JAK2 V617F mutation and/or MPN were identified in 8 patients (median time of development: 21 months, range 6-120), whereas 72 remained (MPN and JAK2 V617F)-free until the end of the observation.The mortality rate was higher among patients presenting with MPN and/or the JAK2 V617F mutation than in patients who developed later or remained disease-free (p = 0.032). The thrombosis-free survival was lower in patients with (p = 0.04) or developing later MPN and the JAK2 V617F mutation (p = 0.005) than in patients (MPN and JAK2 V617F)-free. The incidence of bleeding was similar among groups.

Conclusions

MPN with or without circulating positive clones for JAK2 V617F mutation can occur long after a SVT, identifying at risk patients for new thrombotic events. If confirmed in other studies, re-evaluation for JAK2 V617F mutation may be of help in early MPN detection and clinical management of SVT patients.     

Thromboprophylaxis following cesarean delivery: one site prospective pilot study to evaluate the application of a risk score model

Background

Venous thromboembolism (VTE) remains an important cause of maternal mortality and morbidity. Cesarean delivery (CD) is a known risk factor for VTE. Data from clinical trials of thomboprophylaxis following CD are lacking and current guidelines are based on experts opinion. Our aim was to assess the efficacy of a risk score model, established at our institution, in preventing CD-related VTE.

Methods

Before undergoing CD women received a risk score assessment based on age, weight, history of thrombosis, thrombophilia, immobility, parity and varicose vein. Women at moderate-high risk received pharmacological prophylaxis; all patients wore antithrombotic stockings. They had a visit before discharge and were advised to come back for visit and ultrasound if required. All received a follow-up phone call after three months.

Results

501 consecutive women were included in the study; 233 (46.5%), at low risk, had no pharmacological prophylaxis; one of them developed a symptomatic leg deep vein thrombosis (DVT); 268 (53.5%), at moderate-high risk, received enoxaparin and none of them developed VTE. Two were lost at follow up. The incidence of DVT was 1/499 (0.2%; 95%CI 0-1.1%). The differences in major and minor bleeding were not significant between women who received or not prophylaxis respectively (1/267 vs 1/232, p = 1 and 3/267 vs 1/232, p = 0.62).

Conclusions

The risk score model applied proved effective in avoiding pharmacological prophylaxis in almost half of women and safe, since the rate of failure resulted very low (0.2%, C.I.95 0-1.1%) and there were not significant differences in bleeding in the two groups.