European expert consensus recommendations on the primary care use of direct oral anticoagulants in patients with venous thromboembolism.

BACKGROUND: Direct oral anticoagulants for the treatment of venous thromboembolism are supported by robust clinical trial evidence. Despite published guidance, general practitioners are faced with increasingly complex decisions and implementation remains sub-optimal in certain real-world scenarios. METHODS: A two stage formal consensus exercise was performed to formulate consensus statements and a summary guide, facilitating optimal management of direct oral anticoagulants in venous thromboembolism patients by generalist physicians across Europe. An online questionnaire distributed to a broad panel (Phase 1), followed by a virtual panel discussion by an expert group (Phase 2) were conducted. Phase 1 statements covered nine management domains, and were developed via a literature review and expert steering committee. Participants rated statements by their level of agreement. Phase 1 responses were collated and analysed prior to discussion and iterative refinement in Phase 2. RESULTS: In total 56 participants from across Europe responded to Phase 1. The majority had experience working as general practitioners. Consensus indicated that direct oral anticoagulants are the treatment of choice for managing patients with venous thromboembolism, at initiation and for extended treatment, with a review at three to six months to re-assess treatment effect and risk profile. Direct oral anticoagulant choice should be based on individual patient factors and include shared treatment choice between clinicians and patients; the only sub-group of patients requiring specific guidance are those with cancer. CONCLUSION: Results demonstrate an appreciation of best practices, but highlight challenges in clinical practice. The patient pathway and consensus recommendations provided, aim to highlight key considerations for general practice decision making, and aid optimal venous thromboembolism treatment.

Low CD49d expression in newly diagnosed chronic lymphocytic leukaemia may be associated with high-risk features and reduced treatment-free-intervals.

This study was carried out to assess the prognostic power of low CD49d expression (≥10%) in newly diagnosed CLL patients using a previously described cohort. Eighty-five patients were included. Median age at diagnosis; 70 years (43-88); CD49d was expressed in 33/85 (38.8%); 23/33 (69.7%) at ≥30% referred to as 'HiCD49d' and 10/33 (30.3%) between 10 and 30% with a bimodal pattern on scatterplot analysis referred to as 'LoCD49d'. Eleven patients (12.9%) presented as Binet stage B, of whom 8 (72.7%) were CD49d+ (HiCD49d 7/8; LoCD49d 1/8). Seven of 81 patients (8.6%) were NOTCH1 mutated and all were CD49d+ (p ≤ .01). IgVH analysis was performed on 29 (87.8%) of the CD49d+ cases, of whom 21 (72.4%) were unmutated and 8 (27.6%) were mutated. CD38+/CD49d+ accounted for 11/20 (55%) (CD38+/HiCD49D: 9/11; CD38+/LoCD49D: 2/11). At 42 months, treatment had been initiated in 18/85 (21%) patients, of these 10/33 (30.3%) were CD49d+ versus 8/52 (15.4%) of the CD49d- group. The median treatment free interval for the CD49d+ group was 11 months (HiCD49d; 14.5 months, LoCD49d; 11 months) compared to 21.5 months for the CD49d- group. These findings suggest that the predictive value of CD49d expression is retained at expression levels down to 10%.

Inpatient outcomes for hospitalized older adults with rhinovirus.

BackgroundRhinoviruses account for many cases of the "common cold" and infection is often self-limiting. As such, there is a lack of data regarding the inpatient outcomes of individuals hospitalized with rhinovirus infection. Given the generalized poorer prognosis of elderly admitted with respiratory viral infections, we assessed the mortality rate of general medical patients admitted with rhinovirus infection along with the major risk factors associated to mortality. MethodsWe performed a retrospective chart review of patients admitted to our clinical teaching ward from December 2013 to June 2017. ResultsOverall, 12.5% of patients admitted with rhinovirus infection died within 90 days of admission. The median age of admitted patients was 70 years-old. In univariable analysis, age (OR 1.05; 95% confidence interval (CI) 1.01-1.09) and the need for oxygen at presentation (OR 3.23; 95% CI 1.06-9.86) were associated with death while obstructive pulmonary disease or asthma (OR 0.10; 95% CI 0.01-0.81) was associated with survival. In the multivariable model, age (aOR 1.04; 95% CI 1.00-1.09) and obstructive lung disease (aOR 0.09 95%CI 0.01-0.73) remained significant whereas the requirement for oxygen at presentation did not (aOR 2.78; 95% CI 0.84-9.23). ConclusionOur study reveals that rhinovirus is an important cause of both morbidity and mortality in the elderly and further highlights the need for studies of potentially effective treatment options. In the meantime, we suggest that rigorous respiratory hygiene measures and quality older adult care should be practiced when caring for at-risk adults.