ABSTRACT
BACKGROUND: Perioperative bridging with low-molecularweight heparins (LMWH) is applied to minimise the risk of thromboembolism (TE). Guidelines characterise patients at risk and strategies to be followed. We assessed guideline adherence in bridging episodes and identified possible risk factors for bleeding in a retrospective cohort study. METHODS: We searched the electronic patient data system of the Maastricht anticoagulation service, the Netherlands. We identified 181 patients on chronic anticoagulation who underwent surgery (222 procedures) and were bridged with LMWH. Guideline adherence was defined in terms of the relation between TE risk and the dose of LMWH administered, the bleeding risk of the procedure and the duration of postprocedural administration of LMWH. Logistic regression was used to identify risk factors for bleeding. RESULTS: Of all low TE risk patients (n=102), 84.3% were treated with therapeutic doses of LMWH. The median duration of postprocedural LMWH administration was eight days. The 30-day incidence of major bleeding in the entire group (n=222) was 11.3%. Two patients (0.90%) experienced a deep venous thrombosis. Creatinine clearance ≤40 ml/min (odds ratio (OR) 5.03, 95% confidence interval (CI) 1.25 to 20.26) and dental procedures (OR 3.32, 95% CI 1.22 to 9.04) were independent predictors for total bleeding. CONCLUSION: Guideline adherence was low, leading to prolonged bridging procedures, excess treatment of patients and high bleeding rates. The majority of patients had a low thromboembolic risk profile or underwent low-risk procedures. For patients with decreased creatinine clearance, reduced doses of LMWH should be considered to reduce bleeding risk.
Subject(s)
Anticoagulants/administration & dosage , Guideline Adherence , Hemorrhage/chemically induced , Heparin, Low-Molecular-Weight/administration & dosage , Perioperative Care/standards , Thromboembolism/prevention & control , Aged , Anticoagulants/adverse effects , Creatinine/blood , Creatinine/urine , Female , Hemorrhage/prevention & control , Heparin, Low-Molecular-Weight/adverse effects , Humans , Male , Middle Aged , Practice Guidelines as Topic , Risk FactorsABSTRACT
BACKGROUND: To date, only a few risk factors for pancreatic cancer have been established. We examined prospectively relations between several medical conditions and pancreatic cancer incidence. METHODS: In 1986, 120 852 participants completed a baseline questionnaire on cancer risk factors, including several self-reported physician diagnosed medical conditions. At baseline, a random subcohort of 5000 participants was selected using a case-cohort approach for analysis. After 16.3 years of follow-up, 448 pancreatic cancer cases (63% microscopically confirmed) were available for analysis. RESULTS: Diabetes mellitus type II and hepatitis were positively associated with pancreatic cancer risk (multivariable-adjusted hazard ratio: 1.79; 95% confidence interval: 1.12-2.87 and hazard ratio: 1.37; 95% confidence interval: 1.04-1.81, respectively). Furthermore, a positive trend in risk with increasing years of diagnosis of diabetes (P=0.004) and of hepatitis (P=0.02) was observed. However, an inverse association was observed between hypertension and pancreatic cancer risk, this was found among microscopically confirmed cases only (hazard ratio: 0.66; 95% confidence interval: 0.49-0.90), while years since diagnosis of hypertension significantly decreased cancer risk (P for trend=0.02). CONCLUSION: In this prospective study, a positive association was observed between self-reported physician diagnosed diabetes mellitus type II and hepatitis and pancreatic cancer risk, whereas an inverse association was observed with hypertension.
