Factors Associated with Venous Thromboembolism Development in Patients with Traumatic Brain Injury.

BACKGROUND: Venous thromboembolic (VTE) events are a major concern in trauma and intensive care, with the prothrombotic state caused by traumatic brain injury (TBI) increasing the risk in affected patients. We sought to identify critical demographic and clinical variables and determine their influence on subsequent VTE development in patients with TBI. METHODS: This was a cross-sectional study with data retrospectively collected from 818 patients with TBI admitted to a level I trauma center in 2015-2020 and placed on VTE prophylaxis. RESULTS: The overall VTE incidence was 9.1% (7.6% deep vein thrombosis, 3.2% pulmonary embolism, 1.7% both). The median time to diagnosis was 7 days (interquartile range 4-11) for deep vein thrombosis and 5 days (interquartile range 3-12) for pulmonary embolism. Compared with those who did not develop VTE, patients who developed VTE were younger (44 vs. 54 years, p = 0.02), had more severe injury (Glasgow Coma Scale 7.5 vs. 14, p = 0.002, Injury Severity Score 27 vs. 21, p < 0.001), were more likely to have experienced polytrauma (55.4% vs. 34.0%, p < 0.001), more often required neurosurgical intervention (45.9% vs. 30.5%, p = 0.007), more frequently missed ≥ 1 dose of VTE prophylaxis (39.2% vs. 28.4%, p = 0.04), and were more likely to have had a history of VTE (14.9% vs. 6.5%, p = 0.008). Univariate analysis demonstrated that 4-6 total missed doses predicted the highest VTE risk (odds ratio 4.08, 95% confidence interval 1.53-10.86, p = 0.005). CONCLUSIONS: Our study highlights patient-specific factors that are associated with VTE development in a cohort of patients with TBI. Although many of these are unmodifiable patient characteristics, a threshold of four missed doses of chemoprophylaxis may be particularly important in this critical patient population because it can be controlled by the care team. Development of intrainstitutional protocols and tools within the electronic medical record to avoid missed doses, particularly among patients who require operative interventions, may result in decreasing the likelihood of future VTE formation.

Consolidation regimens in primary central nervous system lymphoma: a single-center retrospective cohort evaluating survival outcomes and cost-benefit analysis.

ABSTRACT: PURPOSE: Optimal treatment for primary central nervous system lymphoma (PCNSL) comprises polychemotherapy induction with high-dose methotrexate followed by consolidation therapy, but there is no standard treatment regimen because of a lack of comparative trials examining efficacy or relative value. We performed a retrospective outcome and relative cost analysis on consolidation regimens to gain perspective on how cost and benefit can be weighed in medical decisions for patients with PCNSL. METHODS: Patients with newly diagnosed PCNSL who completed consolidation at our institution from July 1, 2012, to March 1, 2019, were included. Patients completed etoposide/cytarabine (EA), high-dose cytarabine (HIDAC), or high-dose chemotherapy with autologous stem-cell rescue (HDC-ASCR) as consolidation regimen. Data were collected from the electronic medical record and our institution's Value Driven Outcomes tool. Survival was analyzed as date of diagnosis to last known date of survival. RESULTS: Of the 22 patients included in the study, 12 completed the EA regimen, 4 completed HDC-ASCR, and 6 completed HIDAC. Facility and pharmacy costs contributed most to the cost of each treatment. HDC-ASCR treatment was 50× the cost of the cheapest treatment, HIDAC. Outcomes were numerically superior with HDC-ASCR and HIDAC compared with EA (2-year progression-free survival 100% vs. 100% vs. 63.6%, respectively, p = 0.1915). CONCLUSION: This small retrospective cost-benefit analysis provides evidence that HDC-ASCR may be a superior treatment for PCNSL but at a higher cost than other consolidation regimens. HIDAC may increase value for patients, including elderly patients, who are not appropriate candidates for HDC-ASCR when compared with EA.