Cost-effectiveness of extended prophylaxis with fondaparinux compared with low molecular weight heparin against venous thromboembolism in patients undergoing hip fracture surgery

A model was developed to estimate costs and clinical effectiveness of fondaparinux compared with enoxaparin after hip fracture surgery in Sweden. Outcomes and costs of venous thromboembolism (VTE)-related care from a health care perspective were incorporated, with symptomatic deep-vein thrombosis and pulmonary embolism, recurrent VTE, post-thrombotic syndrome, major haemorrhage and all-cause death being included. Event probabilities were derived from fondaparinux clinical trial data and published data. VTE-related resource use and associated costs as well as costs of prophylaxis were based on local Swedish data. Extended prophylaxis with fondaparinux could avoid an additional 28 symptomatic VTE per 1,000 patients compared with extended prophylaxis with enoxaparin in hip fracture surgery patients. Although the prophylaxis costs were higher in the fondaparinux group, these were offset by the lower costs associated with treating fewer VTE, which thus indicates that extended fondaparinux prophylaxis is the dominant alternative when compared with enoxaparin in hip fracture surgery.      

Risk-assessment algorithm and recommendations for venous thromboembolism prophylaxis in medical patients

The risk for venous thromboembolism (VTE) in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis.

Purpose

To perform a systematic review about VTE risk factors (RFs) in hospitalized medical patients and generate recommendations (RECs) for prophylaxis that can be implemented into practice.

Data sources

A multidisciplinary group of experts from 12 Brazilian Medical Societies searched MEDLINE, Cochrane, and LILACS.

Study selection

Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner. A risk-assessment algorithm was created based on the results of the review.

Data synthesis

Several VTE RFs have enough evidence to support RECs for prophylaxis in hospitalized medical patients (eg, increasing age, heart failure, and stroke). Other factors are considered adjuncts of risk (eg, varices, obesity, and infections). According to the algorithm, hospitalized medical patients ≥40 years-old with decreased mobility, and ≥1 RFs should receive chemoprophylaxis with heparin, provided they don’t have contraindications. High prophylactic doses of unfractionated heparin or low-molecular-weight-heparin must be administered and maintained for 6–14 days.

Conclusions

A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients.     

Cost-effectiveness of fondaparinux vs. enoxaparin as venous thromboembolism prophylaxis in Sweden

Deep-vein thrombosis and pulmonary embolism are important causes of morbidity and mortality among patients undergoing major surgery. Fondaparinux is a new antithrombotic agent for use in prophylaxis, and this study compared its cost and effect vs. enoxaparin as prophylactic treatment in patients undergoing total knee replacement, total hip replacement, or hip-fracture surgery in Sweden. The analyses were based on a simulation model. Swedish data on cost for deep-vein thrombosis and pulmonary embolism were obtained from a large sample of patients undergoing major orthopedic surgery. The relative risk reduction for treatment with fondaparinux was estimated from results of four recently published clinical trials. The base case analyses showed that fondaparinux was cost saving and more effective than enoxaparin after total knee replacement and hip-fracture surgery and had costs per prevented venous thromboembolism of about €239 after total hip replacement. Fondaparinux is thus more cost-effective than enoxaparin as prophylactic treatment in patients undergoing major surgery in Sweden.     

低分子肝素对脓毒症患者预后及出血风险的Meta分析

目的系统评价低分子肝素(LMWH)对脓毒症患者预后及出血风险的影响。方法计算机检索英文数据库Cochrane Library Databases、PubMed、Embase,中文数据库维普全文电子期刊数据库、万方期刊数据库、中国知网数据库(CNKI)、中国生物医学文献数据库,检索时间为1995年1月—2017年9月,主题为LMWH治疗脓毒症的随机对照临床研究。按照纳入与排除标准筛选文献,提取数据并进行质量评价,使用RevMan5.3软件进行Meta分析。结果最终纳入19项研究,共1 016例患者。19项研究对比了28天病死率,发现LMWH可降低脓毒症患者28天病死率[RR=0.52,95%CI(0.43~0.63),P0.001];亚组分析纳入2项研究,发现LMWH可降低脓毒症合并急性肺损伤患者28天病死率[RR=0.40,95%CI(0.21~0.75),P=0.004];4项研究对比了重症监护病房(ICU)住院时间,发现LMWH对脓毒症患者ICU住院时间无明显影响[MD=-0.84,95%CI(-1.95~0.26),P=0.14];15项研究对比了LMWH对APACHEⅡ评分,发现LMWH可降低脓毒症患者7 d后APACHEⅡ评分[MD=-0.64,95%CI(-0.93~0.34),P=0.00];4项研究对比了LMWH对弥散性血管内凝血(DIC)发生率的影响,发现LMWH可降低脓毒症患者DIC的发生率[RR=0.34,95%CI(0.18~0.67),P=0.002];12项研究对比了LMWH对出血的影响,发现LMWH可增加脓毒症患者出血风险[RR=2.74,95%CI(1.60~4.71),P=0.00]。结论 LMWH可降低脓毒症患者28天病死率、改善预后,但增加出血发生率。     

低分子量肝素对胸外科高龄患者术后凝血功能影响的临床研究

目的 对比研究胸外科高龄患者术后凝血功能变化及低分子量肝素的临床干预效果.方法 选取2007年9月至2009年12月接受开胸手术的96例高龄患者,用随机数字表法分为对照组54例和试验组42例(术后第1～7天皮下注射低分子量肝素).观察两组患者术前和术后凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、血小板(Plt)、D-二聚体(D-D)、纤维蛋白原(Fib)以及抗-Xa活性等凝血功能指标的变化及临床表现,同时观察糖尿病对手术前后凝血功能指标的影响.结果 试验组和对照组术前的各项凝血功能指标比较差异无统计学意义(P＞0.05).术后各时间点对照组PT延长,Fib、D-D升高,与术前比较差异有统计学意义(P＜0.05).术后各时间点对照组的Fib、D-D较试验组升高(P＜0.05).试验组术后各时间点抗-Xa活性较术前逐渐升高(P＜0.05),与对照组比较差异有统计学意义(P＜0.05).糖尿病对术后凝血功能的变化无明显影响.对照组出现1例肺血栓栓塞症,试验组无一例出现静脉血栓栓塞症及出血等不良反应.结论 胸外科高龄患者术后血液处于高凝状态,容易出现静脉血栓栓塞症,术后早期给予适量低分子量肝素预防性治疗,有利于改善高凝状态并有较好的安全性.     

A case-control study of seated immobility at work as a risk factor for venous thromboembolism

OBJECTIVE: To determine the relative risk of prolonged seated immobility at work in patients with a deep vein thrombosis (DVT) or pulmonary embolism (PE). DESIGN: A case-control study: cases and controls completed an interviewer-administered questionnaire to obtain information on risk factors for venous thromboembolism (VTE), including prolonged seated immobility at work. Univariate and multivariate logistic regression was used to determine the association between predicted variables and the probability of being a case or control. PARTICIPANTS: Cases were patients<65 years old attending the Wellington Hospital Outpatient VTE Clinic following hospital discharge for DVT and/or PE. Controls were patients<65 years old admitted to the Coronary Care Unit at Wellington Hospital. SETTING: The Wellington Hospital Outpatient VTE Clinic and Coronary Care Unit. MAIN OUTCOME MEASURES: Odds ratio of VTE for prolonged seated immobility. RESULTS: There were 97 cases (53 DVT, 29 PE, 15 DVT and PE), and 106 controls. In the multivariate analysis the odds ratio of VTE for prolonged seated immobility at work was 1.8 (95% CI 0.71-4.8). The maximum number of hours seated at work was associated with VTE, with the risk increasing by 10% per hour longer seated (odds ratio 1.1, 95% CI 1.0-1.2). The maximum number of hours seated at work without getting up was associated with VTE, with the risk increasing by 20% per hour longer seated (odds ratio 1.2, 95% CI 0.96-1.6). CONCLUSIONS: This study provides preliminary evidence that prolonged seated immobility at work may represent a risk factor for VTE.     

低分子肝素对尘肺肺心病患者血液流变学及临床疗效研究

目的 探讨低分子肝素对尘肺肺心病患者血液流变学及临床疗效的作用.方法 60例尘肺肺心病患者,随机分为治疗组(31例)和对照组(29例).对照组按常规方法治疗,治疗组在常规治疗基础上加用低分子肝素针,观察2组临床疗效、肺功能[1秒用力呼气容积( FEV1)、用力肺活量(FVC)、FEV1/FVC]、肺动脉平均压(mPAP)、血液流变学(全血黏度、红细胞压积、纤维蛋白原)等指标的变化.结果 低分子肝素能缓解尘肺肺心病患者临床症状,改善肺功能和血液高凝,降低肺动脉高压;治疗后2组的治疗有效率、FEV1、FVC、FEV1/FVC、mPAP及全血黏度、红细胞压积、纤维蛋白原指标比较,差异均有统计学意义(P＜0.05).结论 低分子肝素对肺心病肺动脉高压患者具有良好的治疗作用.     

Unexpected hospital-acquired bacteraemia in patients at low risk of bloodstream infection: the role of a heparin drip

Following a cluster of cases of unexpected hospital-acquired bacteraemia suspected to be related to an intravenous (iv) heparin drip, all cases of hospital-acquired primary bloodstream infection (BSI) in patients at low risk of bacteraemia were analysed over a four-year period. Ninety-six bacteraemic patients (6%) from 1618 episodes of hospital-acquired bacteraemia had a peripheral iv line as the only risk factor. These patients were divided into two groups: 60 patients with phlebitis and 36 without local signs of inflammation. Baseline features of the two groups were comparable, but in univariate and multivariate analysis, a significant association was found between iv heparin use, predominance of Gram-negative organisms (especially Klebsiella, Serratia and Enterobacter species), and absence of phlebitis. In spite of clear statistical association, however, the means by which the heparin solution became contaminated with Gram-negative organisms remained unknown. Following implementation of infection control methods concerning heparin handling, no more cases occurred. Unexpected hospital-acquired Gram-negative bacteraemia in patients with peripheral iv lines should prompt investigation of potential infusate-related infection, especially in patients without phlebitis and those receiving iv heparin.     

Low molecular weight heparin in the symptomatic treatment of chronic venous insufficiency. Controlled double blind study vs calcium heparin

Ninety patients suffering from chronic venous insufficiency were submitted to subcutaneous treatment with calcium heparin in fixed doses (5000 I.U. t.i.d.) or with different doses of a low molecular weight heparin fraction 7,500 AXaU/day or 15,000 AXaU/day) for thirty days with a double blind random design. On days 0, 15 and 30, clinical parameters were assessed (edema, painfulness, cutaneous trophic lesions, paresthesia) and laboratory tests carried out (fibrinogenemia, plasma viscosity, euglobin lysis time, general tolerance parameters); at the beginning and at the end of the study the plethysmographic indexes of maximum venous flow and venous capacitance were evaluated. Treatment with 15,000 AXaU, of low molecular weight heparin caused modifications of the clinical and instrumental parameters which were on the whole better than those caused by heparin calcium t.i.d. throughout the study. The administration of 7,500 AXaU of low molecular weight heparin was practically equivalent to the control treatment at the end of the study, although at the intermediate assessment it was slightly less effective despite the fact that it had produced significant modifications with respect to the basal values. Treatment with low molecular weight heparin, with both doses used, produced fewer side effects than the reference drug.     

Choosing the right heparin prophylaxis strategy in medical patients at risk for developing VTE: an evidence-based approach

Many acutely ill medical patients are at significant risk for developing venous thromboembolism (VTE) during hospitalization. Venous thromboembolism risk arises from both the presenting clinical condition as well as predisposing risk factors, such as advanced age. Thromboprophylaxis is underprescribed in these patients. Thrombotic risk assessment could encourage the prescribing of thromboprophylaxis and, therefore, improve patient protection against VTE. Current guidelines from the American College of Chest Physicians and the International Union of Angiology (IUA) recommend thromboprophylaxis with low-dose unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH), or fondaparinux for acutely ill medical patients with VTE risk factors. However, the optimal dose regimen for UFH is unclear. The 2006 evidence-based guidelines from the IUA recommend a 3-times-daily dose regimen for UFH. However, UFH is usually administered twice daily despite a lack of evidence for the superiority of this regimen. Both heparin-induced thrombocytopenia and bleeding are associated with UFH, and to a lesser degree with alternative anticoagulants, such as the LMWHs. If utilized, an appropriate prophylaxis regimen in medical patients can reduce the risk of VTE and its burden.     

低分子肝素联合艾灸对复发性流产患者妊娠结局的影响

目的探讨低分子肝素联合艾灸疗法对复发性流产患者妊娠结局的影响。方法选取符合诊断标准的患者56例,分为对照组和观察组,各28例,对照组给予常规低分子肝素治疗及护理,观察组在其基础上给予低分子肝素联合艾灸疗法,从妊娠结局、出血程度、疼痛及满意度评价等方面对治疗效果进行比较。结果观察组与对照组比较,观察组活产率92. 86%,高于对照组85. 71%,二者数据差异具有显著性(P <0. 05);观察组未出血率为92. 86%,高于对照组75. 00%,P <0. 05,具有显著性差异。同时,观察组VAS评分(2. 72±0. 74)低于对照组(3. 67±0. 93),满意度为96. 43%,高于对照组85. 71%,两组结果均具有显著性差异(P <0. 05)。结论低分子肝素联合艾灸疗法较单一肝素对复发性流产患者的治疗效果以及改善妊娠结局方面临床效果明显,值得进一步推广使用。     

脑卒中患者静脉血栓栓塞症风险预测模型的构建及验证

目的  构建并验证脑卒中患者发生静脉血栓栓塞症(venous thromboembolism, VTE)的风险预测模型,为脑卒中患者VTE的预防控制提供科学依据。方法  研究对象为河南省脑卒中队列的675例脑卒中患者,按7∶3随机划分为训练集(473例)和测试集(202例)。使用随机森林算法筛选变量、logistic回归模型分析方法构建模型,并绘制列线图。通过受试者工作特征曲线下面积(area under curve, AUC)、Hosmer-Lemeshow检验等评价模型的预测效能,使用决策曲线分析(decision curve analysis, DCA)评估模型的临床使用价值;并采用五折交叉验证对模型进行内部验证。结果  最终纳入模型的预测因子为年龄、住院天数、日常生活活动能力(activity of daily living, ADL)、肌力、尿酸(uric acid, UA)、D-二聚体、纤维蛋白原(fibrinogen, Fib)和总胆固醇(total cholesterol, TC)。模型在训练集中的Hosmer-Lemeshow检验P=0.872,AUC=0.924(95% CI: 0.898~0.950);测试集Hosmer-Lemeshow检验P=0.597,AUC=0.902(95% CI: 0.852~0.951)。DCA曲线表明,模型在训练集和测试集中均具有较高的临床净获益。五折交叉内部验证结果显示,模型在训练集和测试集中的平均AUC分别为0.913和0.929。结论  该研究构建的脑卒中患者VTE风险预测模型能有效预测VTE的发生,可为高风险患者早期识别和预防性治疗提供参考。     

Aspirin prophylaxis in patients at low risk for cardiovascular disease: a systematic review of all-cause mortality

OBJECTIVE: We investigated whether aspirin reduces all-cause mortality in low-risk patients. STUDY DESIGN: We systematically reviewed studies of aspirin for primary prevention to measure total mortality. We included all clinical trials, cohort studies, and case control studies that assessed primary prevention, included low-risk subjects, and measured total mortality. The quality of studies was evaluated with a standard scale. DATA SOURCES: MEDLINE, the Cochrane Library, and the Internet were systematically searched for studies with the key terms primary, prevention, aspirin, myocardial infarction, stroke, and mortality. Reference lists of identified trials and reviews also were examined. POPULATION: Active members in the Indiana Academy of Family Physicians 2000-2001 membership database (N = 1328). OUTCOMES MEASURED: Primary outcomes were myocardial infarction, stroke, and mortality. RESULTS: Three primary prevention studies met our criteria. Two clinical trials, the United States Physicians Health Study and British Doctors Study, demonstrated no significant decrease in mortality in the aspirin group alone or when results from the 2 studies were combined. The United States Physicians Health Study showed a lower rate of myocardial infarction (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.47-0.71). In the Nurses Health Study, a cohort study, taking aspirin at any dose was associated with higher rates of myocardial infarction (OR, 2.34; CI, 1.92-2.86), stroke (OR, 1.84; CI, 1.39-2.44), and all-cause mortality (OR, 1.83; CI, 1.57-2.14). CONCLUSIONS: There is currently no evidence to recommend for or against the use of aspirin to decrease mortality in low-risk individuals.     

低分子肝素钙联合奥拉西坦对血管性认知功能障碍的效果

目的探讨低分子肝素钙联合奥拉西坦对血管性认知功能障碍的效果。方法 100例血管性认知障碍患者随机分为对照组32例,奥拉西坦组34例,联合组34例,对照组给予常规治疗+安慰剂治疗,奥拉西坦组在常规治疗的基础上,给予奥拉西坦,联合组在常规治疗的基础上,给予奥拉西坦与低分子肝素钙,疗程为2个月。运用简易智力状态检查量表(MMSE)和日常生活能力量表(ADL)评价效果。结果 2个月后联合组MMSE和ADL评分值提高(P<0.01)。结论低分子肝素钙联合奥拉西坦可以显著改善血管性认知障碍患者的认知功能。     

极低出生体质量儿PICC相关血流感染的危险因素

目的 探讨经外周静脉置入中心静脉导管(PICC)的极低出生体质量儿(VLBWI)发生导管相关血流感染(CRBSI)的危险因素。方法 选取郑州大学第三附属医院2019年1月—2021年11月入住新生儿重症监护病房(NICU)的PICC置管VLBWI。回顾性分析VLBWI的临床资料,采用病例对照研究的方法,以发生CRBSI者为病例组,未发生CRBSI者为对照组,采用单因素和logistic回归分析CRBSI的危险因素。结果 共有61例PICC置管VLBWI发生CRBSI,总置管时间26 521 d, CRBSI发病率为2.3‰。VLBWI发生CRBSI的感染病原菌主要为表皮葡萄球菌(23.0%)、肺炎克雷伯菌(19.7%)、黏质沙雷菌(14.8%)。logistic回归分析表明,出生体质量<1 000 g(OR=2.254)、机械通气(OR=2.168)、置管时日龄≤7 d(OR=2.534)、PICC留置时间≥21 d(OR=2.200)是VLBWI发生CRBSI的独立危险因素,一次穿刺成功(OR=0.378)是保护性因素。结论 对于VLBWI,尤其是出生体质量<1 000 ...     

Maternal pregravid weight, age, and smoking status as risk factors for low birth weight births.

The Illinois Department of Public Health, in cooperation with the Centers for Disease Control (CDC), monitors trends in the prevalence of prenatal risk factors that are major predictors of infant mortality and low birth weight (LBW). Analyzed data from CDC are available to the department annually. During 1988, a total of 26,767 records of Illinois women giving birth were submitted to CDC. These surveillance data support the fact that women older than 30 years who smoke and enter pregnancy underweight are at greatest risk of delivering LBW babies. Overall, 13.9 percent of underweight smokers had LBW infants compared with 8 percent of underweight nonsmokers. Prevalence of LBW among underweight and smoking women older than 34 years was much higher (29.6 percent) than among those between ages 30 and 34 (15.2 percent). The prevalence of LBW decreased as the pregravid weight increased among normal weight smokers (10 percent) and overweight smokers (8.6 percent).