Obstetrical and Peri-Operative Management of Patients with Factor XI Deficiency - a Retrospective Observational Study

Abstract Introduction Factor XI deficiency (FXI) is an autosomally inherited injury-related bleeding disorder. Although relatively rare worldwide, it is common amongst Ashkenazi and Iraqi Jewish ancestry with a heterozygosity rate as high as 8 to 9%. FXI deficiency does not provoke spontaneous bleeding; however, it predisposes to a potential risk of life-threatening bleeding at childbirth or surgery. Unfortunately, data regarding obstetrical and perioperative management of this condition is scarce, with less than 500 cases reviewed in the last 20 years. Therefore, this study aimed to expand this database and identify factors associated with increased bleeding risk. Methods We performed a retrospective chart review of patients (pts) with FXI deficiency who underwent childbirth or other surgical procedures between August 2011 to April 2021 within the Mount Sinai Health System in New York City. Data on age, sex, ethnicity, genotype, family or personal history of bleeding, type of anesthesia, estimated blood loss, peri-procedural bleeding complication, and type and timing of blood product or hemostatic agent administered in the peri-operative period were collected. Prior history of bleeding was defined as 1 or more of the following: easy bruisability, epistaxis, heavy menstrual bleeding, bleeding related to dental, surgical or obstetrical procedure. The paired t-test was used to compare the initial and subsequent FXI levels measured during pregnancy. We performed logistic regression to test the association between historical, laboratory, and procedural variables with the bleeding endpoint (defined as acute postpartum or postoperative hemorrhage or any bleeding warranting non-prophylactic administration of packed red blood cells, fresh frozen plasma [FFP], or tranexamic acid). Receiver operative characteristic (ROC) curve was plotted for FXI levels to identify the cutoff for optimal sensitivity and specificity. Analyses were performed using SPSS software. Results We identified 198 pts who underwent 252 procedures in total- including 143 vaginal deliveries, 64 C-sections and 45 other surgical procedures. Mean age was 36 years with 94% females, and ~70% were Ashkenazi Jews. c.403G>T p.E135X (42%) and c.901T>C p.F301L (44.8%) were the most common genotypes identified. 38 out of 252 procedures resulted in bleeding complications. In multivariable logistic regression, both prior history of bleeding (odds ratio (OR) 8.97, p=0.02) and lower FXI levels ( OR 1.03 per U/dL increase, p=0.05) were independently associated with the bleeding endpoint. Family history of bleeding, ethnicity, genotype, pre-procedural PTT and platelet levels were not associated with bleeding risk. There were no cases of epidural or spinal hematomas associated with neuraxial anesthesia in our cohort. Mean FXI level for pts receiving neuraxial anesthesia was 50 U/dl (3-118 U/dl). Five pts who had a negative bleeding history despite surgical challenges received neuraxial anesthesia at FXI level <10 U/dl without any complications (only 1/5 received prophylactic FFP). Mean FXI level for pts receiving prophylactic FFP was 25.6 U/dl (range 1-71 U/dl). 8 out of 21 (38%) pts suffered a bleeding complication despite prophylactic FFP use. ROC analyzing FXI levels as a risk factor for the bleeding endpoint resulted in an AUC of 0.605 with specificity of 96%, 94%, 91%, 83%, 49% and sensitivity of 11%, 12%, 19%, 35%, 65% respectively for cut-off values of 10, 20, 30, 40 and 50 U/dl. Of note, there was no significant variation in FXI levels during pregnancy [mean first measurement was 49.7 U/dl vs final measurement of 48.3 U/dl, p=0.3]. Conclusions Personal history of bleeding is the strongest predictor of perioperative or obstetrical bleeding in pts with FXI deficiency. Higher FXI levels correlate with a slightly lower but statistically significant odds of surgical bleeding. Although a FXI level cut-off of 40 U/dl may predict bleeding risk with reasonable specificity (83%), it lacks sensitivity and must be interpreted in the context of personal bleeding history. FXI levels remain stable during pregnancy and repeat measurements may not be necessary. Neuraxial anesthesia appears to be safe to use in this cohort. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

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High Risk of One-year Stroke Recurrence in Patients with Younger Age and Prior History of Ischemic Stroke

Current Neurovascular Research ◽

10.2174/1567202616666190618164528 ◽

2019 ◽

Vol 16 (3) ◽

pp. 250-257 ◽

Cited By ~ 1

Author(s):

Jiann-Der Lee ◽

Ya-Han Hu ◽

Meng Lee ◽

Yen-Chu Huang ◽

Ya-Wen Kuo ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Multivariate Logistic Regression Analysis ◽

Stroke Recurrence ◽

Prior History ◽

Multivariate Logistic Regression ◽

Cart Analysis ◽

Younger Age ◽

History Of ◽

One Year

Background and Purpose: Recurrent ischemic strokes increase the risk of disability and mortality. The role of conventional risk factors in recurrent strokes may change due to increased awareness of prevention strategies. The aim of this study was to explore the potential risk factors besides conventional ones which may help to affect the advances in future preventive concepts associated with one-year stroke recurrence (OSR). Methods: We analyzed 6,632 adult patients with ischemic stroke. Differences in clinical characteristics between patients with and without OSR were analyzed using multivariate logistic regression and classification and regression tree (CART) analyses. Results: Among the study population, 525 patients (7.9%) had OSR. Multivariate logistic regression analysis revealed that male sex (OR 1.243, 95% CI 1.025 – 1.506), age (OR 1.015, 95% CI 1.007 - 1.023), and a prior history of ischemic stroke (OR 1.331, 95% CI 1.096 – 1.615) were major factors associated with OSR. CART analysis further identified age and a prior history of ischemic stroke were important factors for OSR when classified the patients into three subgroups (with risks of OSR of 8.8%, 3.8%, and 12.5% for patients aged > 57.5 years, ≤ 57.5 years/with no prior history of ischemic stroke, and ≤ 57.5 years/with a prior history of ischemic stroke, respectively). Conclusions: Male sex, age, and a prior history of ischemic stroke could increase the risk of OSR by multivariate logistic regression analysis, and CART analysis further demonstrated that patients with a younger age (≤ 57.5 years) and a prior history of ischemic stroke had the highest risk of OSR.

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Assessment of pain and postoperative nausea and vomiting and their association in the early postoperative period: an observational study from Palestine

BMC Surgery ◽

10.1186/s12893-021-01172-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Reem M. Elsaid ◽

Ashraqat S. Namrouti ◽

Ahmad M. Samara ◽

Wael Sadaqa ◽

Sa’ed H. Zyoud

Keyword(s):

Logistic Regression ◽

Observational Study ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Binary Logistic Regression ◽

Nausea And Vomiting ◽

Prior History ◽

Factors Associated ◽

Duration Of Surgery ◽

History Of

Abstract Background Postoperative nausea and vomiting (PONV) and postoperative pain (POP) are most commonly experienced in the early hours after surgery. Many studies have reported high rates of PONV and POP, and have identified factors that could predict the development of these complications. This study aimed to evaluate the relationship between PONV and POP, and to identify some factors associated with these symptoms. Methods This was a prospective, multicentre, observational study performed at An-Najah National University Hospital and Rafidia Governmental Hospital, the major surgical hospitals in northern Palestine, from October 2019 to February 2020. A data collection form, adapted from multiple previous studies, was used to evaluate factors associated with PONV and POP in patients undergoing elective surgery. Patients were interviewed during the first 24 h following surgery. Multiple binary logistic regression was applied to determine factors that were significantly associated with the occurrence of PONV. Results Of the 211 patients included, nausea occurred in 43.1%, vomiting in 17.5%, and PONV in 45.5%. Multiple binary logistic regression analysis, using PONV as a dependent variable, showed that only patients with a history of PONV [odds ratio (OR) = 2.28; 95% confidence interval (CI) = 1.03–5.01; p = 0.041] and POP (OR = 2.41; 95% CI = 1.17–4.97; p = 0.018) were significantly associated with the occurrence of PONV. Most participants (74.4%) reported experiencing pain at some point during the first 24 h following surgery. Additionally, the type and duration of surgery were significantly associated with POP (p-values were 0.002 and 0.006, respectively). Conclusions PONV and POP are common complications in our surgical patients. Factors associated with PONV include a prior history of PONV and POP. Patients at risk should be identified, the proper formulation of PONV protocols should be considered, and appropriate management plans should be implemented to improve patients’ outcomes.

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A Practical Approach to Pediatric Patients Referred With an Abnormal Coagulation Profile

Archives of Pathology & Laboratory Medicine ◽

10.5858/2005-129-1011-apatpp ◽

2005 ◽

Vol 129 (8) ◽

pp. 1011-1016 ◽

Cited By ~ 1

Author(s):

Monica Acosta ◽

Rachel Edwards ◽

E. Ian Jaffe ◽

Donald L. Yee ◽

Donald H. Mahoney ◽

...

Keyword(s):

Family History ◽

Positive Family History ◽

Laboratory Data ◽

Bleeding Risk ◽

Personal History ◽

Retrospective Case ◽

Laboratory Assessment ◽

Repeat Testing ◽

Effective Manner ◽

History Of

Abstract Context.—Workup for prolonged prothrombin time (PT) and activated partial thromboplastin time (PTT) is a frequent referral to a Hematology and Coagulation Laboratory. Although the workup should be performed in a timely and cost-effective manner, the complete laboratory assessment of the coagulation state has not been standardized. Objective.—To determine which clinical and laboratory data are most predictive of a coagulopathy and to formulate the most efficient strategy to reach a diagnosis in patients referred for abnormal coagulation profiles. Design.—Retrospective case review. Medical records of 251 patients referred for prolonged PT and/or PTT to our Hematology Service between June 1995 and December 2002 were reviewed. Results.—The study included 135 males and 116 females with a mean age of 7.0 years. A personal history of bleeding was reported in 137 patients, and a family history of bleeding was reported in 116 patients. Fifty-one patients (20%) had a coagulopathy (ie, a bleeding risk). Factors predictive of a bleeding risk were a positive family history of bleeding (P < .001) and a positive personal history of bleeding (P = .001). Of 170 patients with findings of normal PT and PTT values on repeat testing, 14 were subsequently diagnosed with a coagulopathy. Two of these patients reported no positive personal or family history of bleeding. Conclusions.—Coagulopathy was identified in 20% of the children referred for abnormal PT and/or PTT. In the absence of a personal or family history of bleeding, a normal PT and/or PTT on repeat testing has a negative predictive value of more than 95%.

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THE MAGNETIC RESONANCE IMAGING OF THE LUMBAR SPINE IN OUT-PATIENTS WITH LOW BACK PAIN

Journal of Musculoskeletal Research ◽

10.1142/s0218957701000611 ◽

2001 ◽

Vol 05 (04) ◽

pp. 261-267 ◽

Cited By ~ 1

Author(s):

BOHUA CHEN ◽

STEVE LAVENDER ◽

GUNNAR B. J. ANDERSSON

Keyword(s):

Logistic Regression ◽

Medical Center ◽

Lumbar Disc ◽

Statistical Significance ◽

White Collar ◽

Individual Characteristics ◽

Blue Collar ◽

Prior History ◽

Spine Pathology ◽

History Of

This paper aims to estimate the prevalence rates of MRI change in LBP out-patients and to determine the relationship between abnormalities in an MRI and personal and occupational factors. The MRI records were obtained from 200 out-patients with LBP (114 males and 86 females) who received a diagnostic MRI at St. Luke's Medical Center. The mean and standard deviation of this sample's age were 43.8 years and 14.8 years, respectively. Based on the MRI, each lumbar disc was scored as normal or degenerated. Bulging and herniated were also recorded. Each patient completed a short questionnaire that included the measures of height, weight, age, and present occupation and any history of "heavy manual labor". Occupations were grouped into white collar sedentary, white collar professional, blue collar exposed to prolonged sitting and vibration, blue collar exposed to heavy, unemployed or retired, and homemaker. Chi-square tests were used to determine the statistical significance of these trends. A multiple logistic regression was used to develop a predictive model of spine pathology based on a subject's individual characteristics and occupational classification. Normal discs were found in 26% of the patients and degenerated discs in 47.5%. There were bulging/herniated disks in 26.5%. In men who were younger than 29 years, 50% had herniated disks, and 50% were normal. Three fourth of the women in the same age group showed normal discs. Forty-three percent of the subjects reported a history of performing heavy labor. Using the logistic regression model there were two variables predictive of observable MRI pathology: age and prior history of heavy labor. The analysis indicated that an older individual who had a history and heavy labor was more likely to show one or more pathological model discs in an MRI scan.

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Surgical procedures in patients on aspirin. Literature Review

Hellenic Archives of Oral and Maxillofacial Surgery ◽

10.54936/haoms2225772 ◽

2021 ◽

pp. 57-72

Author(s):

Stella Papamimikou ◽

◽

Nikolaos Kolomvos ◽

Nadia Theologie-Lygidakis

Keyword(s):

Surgical Procedures ◽

Bleeding Risk ◽

Chronic Medication ◽

Antiplatelet Medication ◽

Anticoagulant Drugs ◽

History Of ◽

Inflammatory Drugs ◽

The Common ◽

Anti Inflammatory ◽

Prosthetic Surgery

Aspirin is referred to as the original of the common non-steroid anti-inflammatory drugs and is used as a comparison measure to new ones. Aspirin, whose active ingredient is acetylsalicylic acid, combines strong antipyretic, analgesic, anti-inflammatory and anti-coagulant action. For the latter, aspirin is administered on an ongoing basis to patients for the prevention of cardiovascular events or recurrence of cerebral throm- bosis and therapeutically to patients with a history of heart attack or ischemic stroke. Taking aspirin as an anticoagulant chronic medication concerns dentists es- pecially when it comes to surgical procedures as it is likely to cause increased bleeding perioperatively. The management of the patient on aspirin varies depending on the reason aspirin is administered and its dosage, the co-administration of other antiplatelet or anticoagulant drugs and the severity of the surgical procedure itself. An interruption of antiplatelet medication is decided after assessing the above-mentioned criteria and con- sulting the patient’s physician. Additionally, in cases of increased bleeding risk like complex extractions, pre- prosthetic surgery, periodontal surgery, the procedure needs to be performed as atraumatically as possible and be accompanied by local haemostatic measures.

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The greater use of flavoured snus among ever-smokers versus never-smokers in Norway

Harm Reduction Journal ◽

10.1186/s12954-020-00419-7 ◽

2020 ◽

Vol 17 (1) ◽

Author(s):

Tord Finne Vedoy ◽

Karl Erik Lund

Keyword(s):

Logistic Regression ◽

Confidence Intervals ◽

Real World ◽

Logistic Regression Model ◽

Smoking Status ◽

Prior History ◽

Age Group ◽

Health Authorities ◽

History Of ◽

Never Smokers

Abstract Background Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status. Methods Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked “Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model. Results Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44–.46), highest among daily (.51, 95% CI .47–.54) and former daily smokers (.50, 95% CI .48–.52), and lowest among never (.41, 95% CI .39–.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38–.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65–.69) compared to males (p = .35, 95% CI .34–.36), highest among the youngest age group, 15–24 years (p = .58, 95% CI .56–.60) and decreased with increasing age. Conclusion Regulation that would ban or limit flavoured snus use may affect smokers—an at risk population—more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.

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P672Ischemic and bleeding risk after an acute coronary syndrome in patients with prior history of cancer treated with dual antiplatelet therapy

European Heart Journal ◽

10.1093/eurheartj/ehz747.0278 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

I Munoz Pousa ◽

S Raposeiras Roubin ◽

E Abu-Assi ◽

S Manzano Fernandez ◽

F D'Ascenzo ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Bleeding Risk ◽

Prior History ◽

Patients With Cancer ◽

Coronary Syndrome ◽

History Of ◽

History Of Cancer

Abstract Introduction Very few patients with history of cancer are included in clinical trials. With this study from real-life patients, we try to analyze the ischemic and bleeding risk of patients with history of cancer who were treated with dual antiplatelet therapy (DAPT) after an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without previous history of recent cancer. The impact of prior cancer in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. All events occurred with DAPT, as follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 1,661 have prior history of cancer (6.4%). Patients with cancer were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with cancer in comparison with the rest of the population (14.5% vs 22.4%, p<0.001). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), and 640 AMI (2.5%) and 685 MB (2.6%) were reported. The unadjusted cumulative incidences of AMI and MB were higher in patients with prior cancer (5.1 and 5.2 per 100 patients/year, respectively) than in those with prior cancer (2.4 and 2.6 per 100 patients/year, respectively). After propensity-score matching, we obtained two matched groups of 1,656 patients. Patients with prior cancer showed a significant higher risk of AMI (sHR 1.44, 95% CI 1.01–2.04, p=0.044), but not higher risk of MB (sHR 1.21, 95% CI 0.88–1.68, p=0.248), in comparison with those without prior cancer. Conclusions In ACS patients discharged with DAPT after PCI, prior history of cancer is an independent factor of higher ischemic risk – in terms of AMI, but it is not an independent predictor of increased hemorrhagic risk.

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Prior History of Venous Thromboembolism Is a Significant Risk Factor for Recurrence of Thrombosis after Cancer Diagnosis

Blood ◽

10.1182/blood-2020-141961 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 32-33

Author(s):

Sargam Kapoor ◽

Aman Opneja ◽

Jahnavi Gollamudi ◽

Lalitha V. Nayak

Keyword(s):

Cancer Diagnosis ◽

Factor V Leiden ◽

Personal History ◽

Prior History ◽

Cancer Type ◽

Patients With Cancer ◽

History Of ◽

Diagnosis Of Cancer ◽

Recurrent Vte ◽

The Impact

Introduction: The risk of venous thromboembolism (VTE) is increased in patients with cancer and contributes to significant morbidity, treatment delays and mortality. The Khorana score is the most well-validated VTE risk prediction tool that guides use of prophylactic anticoagulation in patients with cancer. The Khorana score includes cancer type, body mass index (BMI), hemoglobin, platelet count and leukocyte count but not a prior history of VTE which may increase the risk of recurrent VTE. Scant published data have suggested that a personal history of VTE increases the risk of VTE recurrence by 2 to 7-fold after cancer diagnosis. In this study, we examine the impact of history of VTE on VTE recurrence in a large cohort of patients with cancer. Methods: We performed a retrospective cohort study of patients diagnosed with cancer using aggregated de-identified data from electronic medical record of >300 major hospitals in US (IBM Watson Explorys). Patients with a personal history of VTE (deep vein thrombosis and/ or pulmonary embolism) more than one year prior to the diagnosis of cancer were included. Within this cohort, patients who developed recurrent VTE within 180 days of diagnosis of cancer were identified. The primary end-point was the incidence of cancer associated VTE (CVTE) in patients with prior history of VTE as compared to patients without history of VTE. Baseline characteristics including age, race, gender, BMI, prothrombotic mutations (Factor V Leiden, prothrombin gene 20210A mutation), antineoplastic agent use, cancer type and laboratory values (as included in Khorana risk score) were compared in all patients. Results: A total of 4,159,400 patients with a diagnosis of cancer were included. Of these, 138,820 patients (3.3%) had a history of VTE >1 year prior to being diagnosed with cancer. The incidence of CVTE at 180 days was 10-fold higher in those with prior history of VTE compared to those without (36.9% vs 3.66%; OR 15.4, 95% CI 15.22-15.6, P value <0.0001). While the inherent risk of CVTE varied based on cancer type (highest risk of 10.5% in pancreatic cancer), the risk of recurrent VTE in patients with prior VTE history is magnified to a similar degree across all cancer types as shown in Figure 1. Baseline characteristics including age, race, gender and cancer type distribution were similar in all groups, as shown in Table 1. Factor V Leiden mutation or activated protein C resistance (FVL/APC) was more prevalent in patients with prior history of VTE and subsequent CVTE (3%) as compared to all patients with CVTE regardless of history (1%), as shown in Table 1. A higher BMI was noted in patients with prior history of VTE (49% and 71% respectively in patients with and without CVTE) as compared to 41% in all patients with CVTE. Greater use of antineoplastic agents (41%) was noted in the group of patients with prior history of VTE and subsequent CVTE as compared to patients with prior VTE but no CVTE (36%). Conclusion: Our study highlights that a prior personal history of VTE >1 year before cancer diagnosis significantly increases the risk of cancer associated VTE independently, regardless of other established risk factors for VTE suggesting that this group of patients, especially those undergoing anti-cancer treatment may benefit from prophylactic anticoagulation. Increased incidence of FVL/ APC in patients with prior history of VTE and recurrent CVTE may reflect increased testing for prothrombotic mutations in this cohort. Our ongoing efforts include examining the effect of addition of history of VTE to the Khorana score. Finally, large prospective observational studies would be key to assess the impact of history of VTE on cancer thrombosis. Disclosures No relevant conflicts of interest to declare.

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Improving Hematology Clinic Access for Patients with Cancer-Associated Thrombosis

Blood ◽

10.1182/blood-2021-151152 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 1885-1885

Author(s):

Karlyn A. Martin ◽

Caroline Laub ◽

Lindsey Kalhagen ◽

Iwona Boska ◽

Mark Attilio ◽

...

Keyword(s):

Drug Interactions ◽

Process Improvement ◽

Bleeding Risk ◽

Advisory Board ◽

Prior History ◽

First Year ◽

Tumor Type ◽

History Of ◽

Cancer Associated Thrombosis

Abstract Background : Venous thromboembolism (VTE) is a common consequence for patients with malignancy, and adversely impacts quality of life, morbidity and mortality. While historically low-molecular weight heparin (LMWH) was considered standard of care for treatment of cancer-associated thrombosis (CAT), more recent data support the safety and efficacy of direct oral anticoagulants (DOACs). However, management of CAT remains complex, and a national shortage of non-malignant hematologists limits access to thrombosis experts. Our non-malignant hematology group developed a pilot program to expedite referrals for oncology patients with CAT to aid in management and selection of appropriate therapies. Methods: With guidance from the Process Improvement team at Northwestern Medicine, the Cancer-Associated Thrombosis clinic was established in April 2020. Information about the clinic was disseminated via administrative meetings and e-mails from the clinical practice director. Patients were referred from the Robert H. Lurie Comprehensive Cancer Center for either: (1) newly diagnosed ("acute") venous thromboembolic event (VTE) that could be managed in an outpatient setting, or (2) "ongoing management" of an established VTE diagnosis. We aimed to see acute referrals within 24 business hours and ongoing management referrals within 2 weeks. Patients were seen initially by an advanced practice provider, with case discussion with an attending non-malignant hematologist and pharmacist review for anticoagulant eligibility and teaching. Patients were to be scheduled for follow-up with an attending hematologist within 3 months. Decision-making regarding anticoagulant choice was based on perceived bleeding risk, tumor type, drug interactions, and patient preferences. Herein we report our experience during the first year (April 2020-April 2021) of the CAT clinic. Results Sixty-three patients were seen in the first year, of whom 59% were women, with a median age of 63 years (range 30-90 years). 20.6% of patients had a prior history of VTE, and 6.3% had a prior history of bleeding. Tumor types from nine oncology sites were represented, of which gastrointestinal (33.3%); gynecological (22.2%); hematological malignancies (14.2%), and breast (7.9%) were the most common. Among 18 patients (28.5%) referred for acute VTE, the median time to appointment was 0 days, and among 45 patients (71.4%) referred for ongoing VTE management, the median time to appointment was 10 days. The most common VTE was pulmonary embolism (PE) (25.4%), followed by proximal deep vein thrombosis (DVT) (20.6%), concurrent PE and DVT (14.3%) and upper extremity DVT (11.1%). Additionally, 7.9% of thrombotic events involved splanchnic vein and 4.8% cerebral veins (1 isolated, 2 together with DVT and/or PE). DOACs were recommended in 29 (46%) of patients (19 apixaban, 9 rivaroxaban, 1 edoxaban), whereas enoxaparin was advised in 28 patients (44.4%). Four patients were advised to discontinue anticoagulation and 1 was advised to continue warfarin given prior DOAC failure and preference for an oral anticoagulant. Of 28 patients advised to use enoxaparin over a DOAC, the most common reasons included perceived bleeding risk/tumor type (50%), DOAC failure (21.4%), and drug-drug interactions (17.8%). Thirteen patients (21%) switched to a different anticoagulant (7 to a DOAC) in follow-up after the initial recommendation. Thirty-seven patients (59.7%) had a follow-up visit in the CAT clinic. During follow-up, 5 patients (7.9%) experienced recurrent or progressive VTE, and 7 (11.1%) patients had bleeding events. Fifteen patients (24.2%) died during follow-up. Conclusions The aim of this process improvement project was to improve access and assist with anticoagulant choice and management of CAT. Compared to a historical 3 month wait time for non-malignant hematology appointments at our institution, most acute CAT patients were scheduled within 24 hours, and patients requiring ongoing management were seen within 10 days. While DOACs are increasingly prescribed for treatment of CAT, we found that DOACs were not our recommended anticoagulant in over half of patients referred to our clinic, largely due to perceived risk of bleeding/tumor type. This highlights the complexity of management of CAT, and demonstrates the benefit of dedicated thrombosis expertise to aid in management of CAT. Disclosures Martin: Janssen: Research Funding; Penumbra: Other: Scientific Advisory Board. Kalhagen: Harborside: Other: Consulting; Incyte: Speakers Bureau. Zakarija: Bayer: Other: Consultancy Advisory Board. Stein: Pharmassentia: Other: Advisory Board and Steering Committee; Constellation Pharmaceuticals: Other: Advisory Board x 1.

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Incorporation of Evidence Based Guidelines on Bleeding Risk Assessment PRIOR to Ent Surgery into Practice: Real Time Experience

Blood ◽

10.1182/blood-2018-99-118193 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4714-4714

Author(s):

Nada Al-Marhoobi ◽

Manar Maktoom ◽

Fatma Bulushi ◽

Mohamed Ebrahim Mohamed Ebrahim Elshinawy ◽

Hanan Nazir ◽

...

Keyword(s):

Bleeding Risk ◽

Bleeding Tendency ◽

Invasive Procedures ◽

Coagulation Profile ◽

Awareness Campaigns ◽

Laboratory Test Results ◽

Coagulation Testing ◽

History Of ◽

British Committee ◽

Bleeding History

Abstract Background: In spite of guidelines recommending the no need for coagulation profile prior to ENT surgeries when challenging history of bleeding is negative, yet surgeons still practice it. Cost and delaying surgeries are major issues faced when insignificant abnormalities are found in the coagulation profile results. In 2008, British Committee for Standards of Hematology has published guidelines (1) on assessing the bleeding risk prior to surgeries or invasive procedures, which stated that the indication for sending a coagulation profile is best based on the bleeding history of the patient. Aim: This study aimed to measure unbiased estimate of hemostatic outcomes in ENT surgeries in relation to coagulation testing. Methods: All patients who underwent ENT surgeries from three tertiary hospitals during the period from 1st July 2016 to 1st January 2017 were enrolled in the study. The retrieved data included gender, age, type of surgery, results of coagulation blood test (if done), other laboratory test results (complete blood count, biochemical profile, etc.), postoperative bleeds, how it was managed, need for blood transfusion and whether the patient required another surgery to stop the bleeding or not. Patients with known bleeding history or previous coagulation derangement were excluded from the study. The primary outcome was post-operative bleeding. Results: The study included data from 730 patients who underwent ENT surgical procedures. They were 432 males and 298 females. Their mean age was 19.6 + 16.92 year. Out the 730 patients, 372 patients were interviewed for a challenging bleeding history alone (group 1) and 358 were interviewed plus a pre-operative coagulation profile check (Group 2). Total of fourteen patients (1.9 %) developed postoperative bleeding. None of them was due to abnormal bleeding tendency and they didn't require any hemostatic support. Six of them bled early (primary hemorrhage) while at the hospital due to surgical reasons (surgical site bleed that required suturing). Eight patients had delayed postoperative bleeds, after being discharged (due to eating hard food/Trauma). Only total of four patients had major bleeds, requiring surgical intervention. Conclusion: Despite guidelines recommending not doing coagulation testing prior to surgeries, many local surgeons still consider preoperative coagulation testing as a standard practice to evaluate the patients bleeding risk prior to any surgical procedure. This has resulted in unnecessary delays in surgeries (reaching up to a year in many patients) besides the parents/patients anxiety and additional total cost. We recommend awareness campaigns for surgeons and adhering to guidelines of taking detailed hemostatic history. Reference: Chee YL1, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504. Keywords: Coagulation testing, Bleeding History, Surgery Disclosures No relevant conflicts of interest to declare.

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