Derivation and validation of a novel bleeding risk score for elderly patients with venous thromboembolism on extended anticoagulation

2017 ◽  
Vol 117 (10) ◽  
pp. 1930-1936 ◽  
Author(s):  
Andreas Limacher ◽  
Marie Méan ◽  
Hans-Jürg Beer ◽  
Joseph Osterwalder ◽  
Beat Frauchiger ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Elderly Patients ◽  
Major Bleeding ◽  
Clinical Score ◽  
Low Risk ◽  
University Hospital ◽  
Moderate Risk ◽  
Internal Validation ◽  
Risk Of Bleeding

SummaryExisting clinical scores do not perform well in predicting bleeding in elderly patients with acute venous thromboembolism (VTE). We sought to derive an easy-to-use clinical score to help physicians identify elderly patients with VTE who are at high-risk of bleeding during extended anticoagulation (>3 months). Our derivation sample included 743 patients aged ≥65 years with VTE who were enrolled in a prospective multicenter cohort study. All patients received extended anticoagulation with vitamin K antagonists. We derived our score using competing risk regression, with the time to a first major bleeding up to 36 months of extended anticoagulation as the outcome, and 17 candidate variables as predictors. We used bootstrapping methods for internal validation. Sixty-six (9%) patients suffered major bleeding. The clinical score is based on seven clinical factors (previous bleeding, active cancer, low physical activity, anemia, thrombocytopenia, antiplatelet drugs/NSAIDs, and poor INR control). Overall, 48% of patients were classified as low-risk, 37% as moderate-risk, and 15% as high-risk of bleeding. The rate of major bleeding was 1.4 events in low-risk, 5.0 events in moderate-risk, and 12.2 events per 100 patientyears in high-risk patients. The c-statistic was 0.78 at 3 months and 0.71 at 36 months of extended anticoagulation. Model calibration was excellent (p=0.93). Internal validation showed similar results. This simple clinical score accurately identified elderly patients with VTE who are at high risk of major bleeding and who may not benefit from extended anticoagulation. Further validation of the score is important before its implementation into practice. The study is registered to https://clinicaltrials.gov as NCT00973596.This work was carried out at the Department of General Internal Medicine in the Bern University Hospital, Switzerland.

External validation of the VTE-BLEED score for predicting major bleeding in stable anticoagulated patients with venous thromboembolism

2017 ◽  
Vol 117 (06) ◽  
pp. 1164-1170 ◽  
Author(s):  
Frederikus A. Klok ◽  
Stefano Barco ◽  
Stavros V. Konstantinides
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Major Bleeding ◽  
External Validation ◽  
Chronic Phase ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Study Population

SummaryOne of the main determinants of establishing the optimal treatment duration of patients with venous thromboembolism (VTE) is the risk of major bleeding during long-term anticoagulant therapy. The 6-variable VTE-BLEED score was recently developed to enable estimation of this bleeding risk. This study aimed at externally validating VTE-BLEED. This was a post-hoc study of the randomised, double-blind, double-dummy, Hokusai-VTE study that compared edoxaban versus warfarin for treatment of VTE. VTE-BLEED was calculated in all 8,240 study patients. The numbers of adjudicated major bleeding events during ‘stable anticoagulation’, i. e. occurring after day 30, in patients with low (total score <2 points) and high risk of bleeding (total score ≥2 points) were compared for the overall study population, patients randomised to edoxaban or warfarin, and for important patient subcategories. During ‘stable’ anticoagulation, major bleeding occurred in 1.02% (40/3,903) and 0.82% (32/3,899) of patients treated with warfarin and edoxaban, respectively. For the overall study population, the risks of bleeding in the low and high risk groups were 0.51% and 2.03%, respectively, for an odds ratio (OR) of 4.04 (95% confidence interval [CI]: 2.51–6.48). ORs were 5.04 (95%CI: 2.62–9.69) and 3.09 (95%CI: 1.54–6.22) for warfarin and edoxaban, respectively. VTE-BLEED was consistently able to identify patients at a 2.5- to 11-fold higher bleeding risk across all the predefined subcategories, as well as for the treatment period between day 30 to day 180, and beyond day 180. In conclusion, patients identified as high risk by VTE-BLEED had a four-fold increased risk of bleeding during the chronic phase of treatment.Supplementary Material to this article is available online at www.thrombosis-online.com.

Risk Stratification for the Development of Venous Thromboembolism in Hospitalized Patients with Cancer

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4728-4728 ◽  
Author(s):  
Arabesque Parker ◽  
Erica A. Peterson ◽  
Agnes Y. Y. Lee ◽  
Carine de Wit ◽  
Marc Carrier ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Stratification ◽  
Board Of Directors ◽  
Cancer Patients ◽  
Major Bleeding ◽  
Research Funding ◽  
Low Risk ◽  
Advisory Committees ◽  
Risk Patients

Abstract Introduction: No method of venous thromboembolism (VTE) risk stratification exists for hospitalized cancer patients. The Khorana score is a validated tool in outpatients with cancer. The objective of this study was to assess the Khorana score for predicting development of VTE in cancer patients during admission to hospital. Methods: We conducted a retrospective analysis of data collected from healthcare records of consecutive, medically-ill cancer patients hospitalized between January and June 2010 in 3 academic medical centers in Canada. Objectively diagnosed symptomatic VTE during hospitalization, anticoagulant thromboprophylaxis (TP), and Khorana score variables were collected for every patient. Patients receiving therapeutic anticoagulation at admission, and those with incomplete data were excluded. The risk of VTE based on Khorana score category was evaluated using logistic regression. Continuous data were compared using a Student's t-test and expressed using the means and standard deviations. Categorical data were compared using the Pearson Chi-square test and were expressed as percentages. Statistical significance was defined as alpha less than 0.05. Results: 1398 patients were included. Mean age was 61.6 years, 51.2% were male, and mean BMI was 25.9 kg/m2. The most frequent tumor types were non-small cell lung carcinoma (12.7%) followed by lymphoma (10.9%). The median length of stay was 6 days (range 0-114 days). The most frequent reasons for hospitalization were chemotherapy (22.3%) followed by pain and palliation (21.4%). 34.5% received anticoagulant TP (n = 483/1398). The incidence of VTE was 2.9% (41/1398) overall, 5.4% (9/166) in high, 3.2% (26/817) in moderate, and 1.4% (6/415) in low Khorana score risk groups. High risk patients were significantly more likely than low risk patients to have VTE (p=0.016; OR 3.9, 95% CI 1.4-11.2). There was no difference in VTE incidence between patients who received anticoagulant TP and those who did not (3.5% vs 2.6%, p = 0.345). Patients with high risk Khorana score were more likely to receive anticoagulant TP than those with low risk Khorana score (46.4% vs. 23.9%, p <0.001, OR 2.8, 95% CI 1.9-4.0). Total incidence of major bleeding was 1.8% (25/1398). There was no difference in major bleeding between patients who received anticoagulant TP and those who did not (1.7% vs. 1.9%, p = 0.787). Conclusion: The Khorana score is predictive of VTE development in cancer patients who are hospitalized for medical illness and may be a useful tool for tailoring inpatient anticoagulant prophylaxis. Disclosures Lee: LEO: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Bristol Myers-Squibb: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria. Carrier:BMS: Research Funding; Leo Pharma: Research Funding. Wu:Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Leo Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

scholarly journals A dynamic model to estimate evolving risk of major bleeding after percutaneous coronary intervention

2021 ◽  
Author(s):  
Nathan C Hurley ◽  
Nihar Desai ◽  
Sanket Dhruva ◽  
Rohan Khera ◽  
Wade L Schulz ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Clinical Information ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Low Risk ◽  
Initial Model ◽  
Moderate Risk ◽  
Risk Of Bleeding ◽  
Percutaneous Coronary

Background: Bleeding is a common complication of percutaneous coronary intervention (PCI), leading to significant morbidity, mortality, and cost. While several risk models exist to predict post-PCI bleeding risk, however these existing models produce a single estimate of bleeding risk anchored at a single point in time. These models do not update the risk estimates as new clinical information emerges, despite the dynamic nature of risk. Objective: We sought to develop models that update estimates of patient risk of bleeding over time, enabling a dynamic estimate of risk that incorporates evolving clinical information, and to demonstrate updated predictive performance by incorporating this information. Methods: Using data available from the National Cardiovascular Data Registry (NCDR) CathPCI, we trained 6 different XGBoost tree-based machine learning models to estimate the risk of bleeding at key decision points: 1) choice of access site, 2) prescription of medication prior to PCI, and 3) the choice of closure device. Results: We included 2,868,808 PCIs; 2,314,446 (80.7%) prior to 2014 for training and 554,362 (19.3%) remaining for validation. Discrimination improved from an AUROC of 0.812 (95% Confidence Interval: 0.812-0.812) using only presentation variables to 0.845 (0.845-0.845) using all variables. Among 123,712 patients classified as low risk by the initial model, 14,441 were reclassified as moderate risk (1.4% experienced bleeds), while 723 patients were reclassified as high risk (12.5% experienced bleeds). Among 160,165 patients classified as high risk by the initial model, there were 40 patients reclassified to low risk (0% experienced bleeds), and 43,265 patients reclassified to moderate risk (2.5% experienced bleeds). Conclusion: Accounting for the time-varying nature of data and capturing the association between treatment decisions and changes in risk provide up-to-date information that may guide individualized care throughout a hospitalization.

Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry

2008 ◽  
Vol 100 (07) ◽  
pp. 26-31 ◽  
Author(s):  
Nuria Ruíz-Giménez ◽  
Carmen Suárez ◽  
Rocío González ◽  
José Nieto ◽  
José Todolí ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Anticoagulant Therapy ◽  
Major Bleeding ◽  
Low Risk ◽  
Ratio Test ◽  
Validation Sample ◽  
Bleeding Events ◽  
Increased Risk ◽  
Acute Venous Thromboembolism

SummaryA score that can accurately determine the risk of major bleeding during anticoagulant therapy may help to make decisions on anticoagulant use. RIETE is an ongoing registry of consecutive patients with acute venous thromboembolism (VTE). We composed a score to predict the risk for major bleeding within three months of anticoagulant therapy. Of 19,274 patients enrolled, 13,057 (67%) were randomly assigned to the derivation sample, 6,572 to the validation sample. In the derivation sample 314 (2.4%) patients bled (fatal bleeding, 105). On multivariate analysis, age >75 years, recent bleeding, cancer, creatinine levels >1.2 mg/dl, anemia, or pulmonary embolism at baseline were independently associated with an increased risk for major bleeding. A score was composed assigning 2 points to recent bleeding, 1.5 to abnormal creatinine levels or anemia, 1 point to the remaining variables. In the derivation sample 2,654 (20%) patients scored 0 points (low risk); 9,645 (74%) 1–4 points (intermediate); 758 (5.8%) >4 points (high risk). The incidences of major bleeding were: 0.3% (95% confidence interval [CI]: 0.1–0.6), 2.6% (95% CI: 2.3–2.9), and 7.3% (95% CI: 5.6–9.3), respectively. The likelihood ratio test was:0.14 (95% CI:0.07–0.27) for patients at low risk;2.96 (95% CI:2.18–4.02) for those at high risk. In the validation sample the incidence of major bleeding was:0.1%,2.8%,and 6.2%,respectively. In conclusion, a risk score based on six variables documented at entry can identify VTE patients at low, intermediate, or high risk for major bleeding during the first three months of therapy.

scholarly journals Conservative Management of Overanticoagulation in Patients With Low–Moderate Risk for Bleeding Complications

2018 ◽  
Vol 24 (8) ◽  
pp. 1255-1260 ◽  
Author(s):  
Elise Schapkaitz ◽  
Susan Louw ◽  
Jessica Friedman ◽  
Johanna Sithole ◽  
Mavis Masebe ◽  
...  
Keyword(s):  
Vitamin K ◽  
Major Bleeding ◽  
Conservative Management ◽  
Low Dose ◽  
Low Risk ◽  
Moderate Risk ◽  
Oral Vitamin ◽  
Risk Of Bleeding ◽  
Dose Oral

Despite long-standing experience with warfarin, anticoagulation clinic services are often confronted with the challenging clinical situation of patients with overanticoagulation. This requires repeat international normalized ratio (INR) monitoring and in some cases administration of vitamin K to minimize the risk of bleeding. A study was performed to determine the safety and efficacy of outpatient management in order to provide guidance on the management of patients with prolonged INRs. Patients on stable warfarin therapy for more than 1 month attending a dedicated academic hospital anticoagulation clinic who had an INR ≥5 were identified over a 1-year period. Follow-up INR results and outcomes were recorded for 30 days. One hundred and ninety-five episodes of overanticoagulation in 148 patients were identified. Patients were classified as low risk (n = 85, 57.4%) and moderate risk of bleeding (n = 63, 42.6%). The mean index INR was 7.22 (1.88). Management with low-dose oral vitamin K (n = 32, 16.4%) did not significantly result in a more rapid correction of the INR when compared to conservative management (n = 163, 83.6%; P = .103). Follow-up INR testing was performed at a mean of 11.1 (8.9) days from the index measurement. A mean of 1.6 (0.9) follow-up INR tests were performed per episode. During the 30-day follow-up, there was 1 (0.5%) episode of major bleeding and 1 (0.5%) death. The management of asymptomatic outpatients with overanticoagulation is associated with a low risk of major bleeding within 30 days. Conservative management of overanticoagulation is as effective as utilizing low-dose oral vitamin K.

scholarly journals Proposal for the use of echocardiography in bloodstream infections due to different streptococcal species

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sandra Chamat-Hedemand ◽  
Niels Eske Bruun ◽  
Lauge Østergaard ◽  
Magnus Arpi ◽  
Emil Fosbøl ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
High Risk ◽  
Blood Culture ◽  
Positive Blood Culture ◽  
Bloodstream Infections ◽  
Low Risk ◽  
Moderate Risk ◽  
Streptococcal Species ◽  
Very High

Abstract Background Infective endocarditis (IE) is diagnosed in 7–8% of streptococcal bloodstream infections (BSIs), yet it is unclear when to perform transthoracic (TTE) and transoesophageal echocardiography (TOE) according to different streptococcal species. The aim of this sub-study was to propose a flowchart for the use of echocardiography in streptococcal BSIs. Methods In a population-based setup, we investigated all patients admitted with streptococcal BSIs and crosslinked data with nationwide registries to identify comorbidities and concomitant hospitalization with IE. Streptococcal species were divided in four groups based on the crude risk of being diagnosed with IE (low-risk < 3%, moderate-risk 3–10%, high-risk 10–30% and very high-risk > 30%). Based on number of positive blood culture (BC) bottles and IE risk factors (prosthetic valve, previous IE, native valve disease, and cardiac device), we further stratified cases according to probability of concomitant IE diagnosis to create a flowchart suggesting TTE plus TOE (IE > 10%), TTE (IE 3–10%), or “wait & see” (IE < 3%). Results We included 6393 cases with streptococcal BSIs (mean age 68.1 years [SD 16.2], 52.8% men). BSIs with low-risk streptococci (S. pneumoniae, S. pyogenes, S. intermedius) are not initially recommended echocardiography, unless they have ≥3 positive BC bottles and an IE risk factor. Moderate-risk streptococci (S. agalactiae, S. anginosus, S. constellatus, S. dysgalactiae, S. salivarius, S. thermophilus) are guided to “wait & see” strategy if they neither have a risk factor nor ≥3 positive BC bottles, while a TTE is recommended if they have either ≥3 positive BC bottles or a risk factor. Further, a TTE and TOE are recommended if they present with both. High-risk streptococci (S. mitis/oralis, S. parasanguinis, G. adiacens) are directed to a TTE if they neither have a risk factor nor ≥3 positive BC bottles, but to TTE and TOE if they have either ≥3 positive BC bottles or a risk factor. Very high-risk streptococci (S. gordonii, S. gallolyticus, S. mutans, S. sanguinis) are guided directly to TTE and TOE due to a high baseline IE prevalence. Conclusion In addition to the clinical picture, this flowchart based on streptococcal species, number of positive blood culture bottles, and risk factors, can help guide the use of echocardiography in streptococcal bloodstream infections. Since echocardiography results are not available the findings should be confirmed prospectively with the use of systematic echocardiography.

scholarly journals SARS-CoV-2 Seroprevalence in Healthcare Workers in Germany: A Follow-Up Study

2021 ◽  
Vol 18 (9) ◽  
pp. 4540
Author(s):  
Johannes Korth ◽  
Benjamin Wilde ◽  
Sebastian Dolff ◽  
Jasmin Frisch ◽  
Michael Jahn ◽  
...  
Keyword(s):  
High Risk ◽  
Healthcare Workers ◽  
Risk Group ◽  
Close Contact ◽  
Virus Transmission ◽  
High Risk Group ◽  
Low Risk ◽  
University Hospital ◽  
Intermediate Risk ◽  
Igg Antibody

SARS-CoV-2 is a worldwide challenge for the medical sector. Healthcare workers (HCW) are a cohort vulnerable to SARS-CoV-2 infection due to frequent and close contact with COVID-19 patients. However, they are also well trained and equipped with protective gear. The SARS-CoV-2 IgG antibody status was assessed at three different time points in 450 HCW of the University Hospital Essen in Germany. HCW were stratified according to contact frequencies with COVID-19 patients in (I) a high-risk group with daily contacts with known COVID-19 patients (n = 338), (II) an intermediate-risk group with daily contacts with non-COVID-19 patients (n = 78), and (III) a low-risk group without patient contacts (n = 34). The overall seroprevalence increased from 2.2% in March–May to 4.0% in June–July to 5.1% in October–December. The SARS-CoV-2 IgG detection rate was not significantly different between the high-risk group (1.8%; 3.8%; 5.5%), the intermediate-risk group (5.1%; 6.3%; 6.1%), and the low-risk group (0%, 0%, 0%). The overall SARS-CoV-2 seroprevalence remained low in HCW in western Germany one year after the outbreak of COVID-19 in Germany, and hygiene standards seemed to be effective in preventing patient-to-staff virus transmission.

scholarly journals Infiltration and sealing for managing non-cavitated proximal lesions: a systematic review and meta-analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yuanyuan Chen ◽  
Dongru Chen ◽  
Huancai Lin
Keyword(s):  
Systematic Review ◽  
High Risk ◽  
Meta Analysis ◽  
Low Risk ◽  
Caries Risk ◽  
Moderate Risk ◽  
Risk Levels ◽  
Non Invasive ◽  
Randomised Controlled ◽  
Caries Lesions

Abstract Background Infiltration and sealing are micro-invasive treatments for arresting proximal non-cavitated caries lesions; however, their efficacies under different conditions remain unknown. This systematic review and meta-analysis aimed to evaluate the caries-arresting effectiveness of infiltration and sealing and to further analyse their efficacies across different dentition types and caries risk levels. Methods Six electronic databases were searched for published literature, and references were manually searched. Split-mouth randomised controlled trials (RCTs) to compare the effectiveness between infiltration/sealing and non-invasive treatments in proximal lesions were included. The primary outcome was obtained from radiographical readings. Results In total, 1033 citations were identified, and 17 RCTs (22 articles) were included. Infiltration and sealing reduced the odds of lesion progression (infiltration vs. non-invasive: OR = 0.21, 95% CI 0.15–0.30; sealing vs. placebo: OR = 0.27, 95% CI 0.18–0.42). For both the primary and permanent dentitions, infiltration and sealing were more effective than non-invasive treatments (primary dentition: OR = 0.30, 95% CI 0.20–0.45; permanent dentition: OR = 0.20, 95% CI 0.14–0.28). The overall effects of infiltration and sealing were significantly different from the control effects based on different caries risk levels (OR = 0.20, 95% CI 0.14–0.28). Except for caries risk at moderate levels (moderate risk: OR = 0.32, 95% CI 0.01–8.27), there were significant differences between micro-invasive and non-invasive treatments (low risk: OR = 0.24, 95% CI 0.08–0.72; low to moderate risk: OR = 0.38, 95% CI 0.18–0.81; moderate to high risk: OR = 0.17, 95% CI 0.10–0.29; and high risk: OR = 0.14, 95% CI 0.07–0.28). Except for caries risk at moderate levels (moderate risk: OR = 0.32, 95% CI 0.01–8.27), infiltration was superior (low risk: OR = 0.24, 95% CI 0.08–0.72; low to moderate risk: OR = 0.38, 95% CI 0.18–0.81; moderate to high risk: OR = 0.20, 95% CI 0.10–0.39; and high risk: OR = 0.14, 95% CI 0.05–0.37). Conclusion Infiltration and sealing were more efficacious than non-invasive treatments for halting non-cavitated proximal lesions.

scholarly journals Assessment of risk of developing diabetes using Indian diabetes risk score in the urban field practice area of Rajarajeswari Medical College and Hospital, Bangalore

2019 ◽  
Vol 7 (1) ◽  
pp. 170
Author(s):  
Nazia N. Shaik ◽  
Swapna M. Jaswanth ◽  
Shashikala Manjunatha
Keyword(s):  
At Risk ◽  
High Risk ◽  
Risk Score ◽  
Diabetes Risk ◽  
Low Risk ◽  
Risk Category ◽  
Moderate Risk ◽  
Medical College ◽  
Field Practice ◽  
Diabetes Risk Score

Background: Diabetes is one of the largest global health emergencies of the 21st century. As per International Federation of Diabetes some 425 million people worldwide are estimated to have diabetes. The prevalence is higher in urban versus rural (10.2% vs 6.9%). India had 72.9 million people living with diabetes of which, 57.9% remained undiagnosed as per the 2017 data. The objectives of the present study were to identify subjects who at risk of developing Diabetes by using Indian diabetes risk score (IDRS) in the Urban field practice area of Rajarajeswari Medical College and Hospital (RRMCH).Methods: A cross sectional study was conducted using a Standard questionnaire of IDRS on 150 individuals aged ≥20 years residing in the Urban field practice area of RRMCH. The subjects with score <30, 30-50, >or =60 were categorized as having low risk, moderate risk and high risk for developing diabetes type-2 respectively.Results: Out of total 150 participants, 36 (24%) were in high-risk category (IDRS≥60), the majority of participants 61 (41%) were in the moderate-risk category (IDRS 30–50) and 53 (35%) participants were found to be at low-risk (<30) for diabetes. Statistical significant asssociation was found between IDRS and gender, literacy status, body mass index (p<0.0000l).Conclusions: It is essential to implement IDRS which is a simple tool for identifying subjects who are at risk for developing diabetes so that proper intervention can be carried out at the earliest to reduce the burden of diabetes.

Sign in / Sign up

Export Citation Format

Share Document