Transition of care for pediatric and adult patients with venous thromboembolism: A National Quality Improvement Project from the American Thrombosis and Hemostasis Network (ATHN).

BACKGROUND: Transition of care (TOC) for management of anticoagulation from inpatient to outpatient setting for patients with acute venous thromboembolism (VTE) poses serious safety concerns. We implemented a national quality improvement educational initiative to address this issue. METHODS: Pediatric and adult patients admitted for their first VTE were prospectively enrolled at 16 centers from January 2016 to December 2018. Patient demographics, VTE diagnosis, risk factors, and treatment characteristics were collected. There were two phases: pre-intervention (PI) and quality intervention (QI). The PI phase assessed the quality and patient understanding and satisfaction of anticoagulation instructions given at hospital discharge and adherence to these instructions via a patient and/or caregiver feedback questionnaire (PFQ) and a patient knowledge questionnaire (PKQ) at 30 days. The QI phase provided patient and/or caregiver enhanced education regarding anticoagulation therapy and VTE at hospital discharge using a comprehensive discharge instruction module and a phone call follow-up at one week. Patient and/or caregiver knowledge at 7 and 30 days was assessed with the same PFQ and PKQ and compared to the PI baseline measures. RESULTS: Of the 409 study patients, 210 (51%) were adults, 218 (53%) females, and 316 (77%) White. Deep vein thrombosis (62.8%) and pulmonary embolism (47.9%) were the most common VTE in children and adults, respectively. Day 30 PFQ scores were significantly higher in the QI phase compared to the PI phase by 11% (p < 0.01). Day 30 PKQ demonstrated enhanced teaching (93.7% vs. 83.5%, p-value 0.004) and disease recognition (89.6% vs. 84.6% p = 0.03) in the QI phase than the PI phase. CONCLUSION: Comprehensive VTE discharge instructions followed by a 1-week post-discharge phone call strengthen patient and caregiver knowledge, satisfaction of education given and care provided, and disease recognition.

Predictors of non-adherence to prescribed prophylactic clotting-factor treatment regimens among adolescent and young adults with a bleeding disorder.

INTRODUCTION: Adherence to clotting-factor treatment regimens, especially among adolescents and young adults (AYAs), is under-researched. AIM: We determined factors associated with better adherence to prophylaxis. METHODS: From April through December 2012, a convenience sample of AYA (aged 13-25 years) persons with haemophilia or von Willebrand disease (VWD) completed an online survey that assessed adherence to prescribed prophylactic treatment regimens [Validated Haemophilia Regimen Treatment Adherence Scale (VERITAS)-Pro]. Logistic regression analysis assessed demographic and clinical factors related to non-adherence (VERITAS-Pro≥57). RESULTS: Seventy-three prophylactically treating AYAs participated. Of which, 88%, 8% and 4% had haemophilia A, B and VWD respectively. Almost all (90%) had severe disease and 58% had never developed an inhibitor. Most were aged 13-17 years (56%), white (78%), non-Hispanic (88%), never married (94%) and had some type of health insurance (96%). Median VERITAS-Pro score was 48 (range = 25-78) and 22 (30%) participants were non-adherent to prophylaxis (VERITAS-Pro≥57). Final logistic regression modelling suggested that, compared to those aged 13-17 years, participants aged 18-25 years were 6.2 (95% CI: 1.8-21.0; P < 0.01) times more likely to be non-adherent. Compared to respondents whose mother had at least a Bachelor's degree, respondents whose mother did not were 3.8 (95% CI: 1.0-14.3; P = 0.05) times more likely to be non-adherent. CONCLUSIONS: Results suggest that adherence efforts should be especially targeted to young adults as they transition from adolescence (i.e. parental supervision) and assume primary responsibility for their bleeding disorder care. Healthcare providers should be mindful of AYAs whose mothers have less formal education and ensure that adequate time and resources are dedicated to family adherence education.

Better adherence to prescribed treatment regimen is related to less chronic pain among adolescents and young adults with moderate or severe haemophilia.

Little data exist, especially for adolescent and young adult (AYA) persons with haemophilia (PWH), about the relationship between adherence to prescribed treatment regimen and chronic pain. We examined this relationship among PWH (moderate or severe) aged 13-25 via cross-sectional survey. Adherence was assessed using the Validated Hemophilia Regimen Treatment Adherence Scale (VERITAS)-Pro and VERITAS-PRN for prophylactic and on-demand participants respectively. VERITAS scores range from 24 (most adherent) to 120 (least adherent). Chronic pain was measured using the FPS-R and was dichotomized as high for FPS-R scores ≥4 and low for <4. Logistic regression models were constructed to assess factors associated with having high (vs. low) chronic pain. Of 80 AYA respondents (79 men), most had severe disease (91%), infused prophylactically (86%) and had haemophilia A (91%). Fifty-one per cent were aged 13-17 and most were white (76%), non-Hispanic (88%) and never married (93%). Chronic pain was reported as high for 35% of respondents. Mean VERITAS-Pro scores for those with high and low chronic pain were 53.6 ± 12.3 vs. 47.4 ± 12.9, P = 0.05. VERITAS-PRN scores were similar across chronic pain status. Logistic regression revealed that for each 10-point reduction (i.e. increase in adherence) in the combined VERITAS (Pro and PRN) and VERITAS-Pro scores there was a 35% (OR = 0.65; 95% CI = 0.44, 0.96; P = 0.03) and 39% (OR = 0.61; 95%CI = 0.39, 0.96; P = 0.03) reduction in odds of having high chronic pain respectively. Among AYA PWHs, better adherence was associated with significantly lower odds of having high chronic pain. Moreover, non-whites were >4 times as likely as whites to report high chronic pain.

Current prescription of prophylactic factor infusions and perceived adherence for children and adolescents with haemophilia: a survey of haemophilia healthcare professionals in the United States.

The primary goal of prophylaxis in patients with severe haemophilia is to convert the phenotype from severe to moderate and to prevent the development of chronic arthropathy. Prior studies have demonstrated that prophylaxis decreases episodes of joint bleeds and chronic arthropathy. Effectiveness depends on prescription of prophylaxis and adherence to the prescribed regimen. The aim of this study was to determine if prescription of prophylaxis for children with haemophilia and perceptions of adherence to prophylaxis have changed since publication of the Joint Outcome Study (JOS). A questionnaire was sent, in electronic and written formats, to health professionals who provide care to children with haemophilia at US haemophilia treatment centres (HTCs). The response rate was 56 of 128 (44%) of the targeted HTCs. There were a few missing data and denominators are provided. All responses agreed with the results of the JOS and 30/55 (55%) reported the JOS increased their prescription of prophylaxis. Nineteen of 56 (34%) physicians or HTC staff reported that they had not prescribed prophylaxis within the last year due to concerns about adherence, and 19/56 (34%) reported they had stopped prophylaxis due to concerns about adherence within the last year. Predicted adherence decreased with increasing age. Prescription of prophylaxis appears to be increasing since publication of the JOS. Strategies to improve adherence may increase the likelihood of physician prescription of prophylaxis and make prophylaxis easier to implement for individual patients, thereby improving the clinical outcome of children and adults with haemophilia.

Operative intervention for carotid restenosis is safe and effective.

Carotid stenting has been proposed as an alternative to reoperative carotid endarterectomy (rCEA) for recurrent carotid stenosis. The purpose of this study is to prove the safety, effectiveness and durability of reoperation in long term follow up of 18 years in a community hospital setting. From March 1988 to April 2005 80 patients, 46 men and 34 women (mean age: 64.1 years) underwent a total of 83 operations. Symptomatic recurrent stenosis (>70%) was the indication in 32, asymptomatic high-grade stenosis (>80%) in 49, intimal flap in one and fibromuscular dysplasia (F.M.D), in one. The initial operation was carotid endarterectomy with primary closure in 60 and prosthetic patch in 23. The mean recurrences were at 23.3 months in 33 with myointimal hyperplasia, 105.4 months in 29 with recurrent atherosclerosis, 61.4 months in 19 with both hyperplasia and atherosclerosis, 2 months in one with intimal flap and 8 months in one with F.M.D bands. Reoperation utilized primary closure (3), vein patch (14), prosthetic patch (55), Gore-Tex interposition grafts (7), vein interposition grafts (3) and intraoperative dilation (1). No perioperative strokes or deaths occurred. One patient died from cardiac complications following combined rCEA and coronary artery bypass grafting. Operative morbidity consisted of reversible nerve injury (5), irreversible recurrent laryngeal nerve injury (1) and hematoma requiring evacuation (3). During follow up (3-153 months; mean: 50.9) carotid occlusion resulted in mild ipsilateral stroke in one patient, and one non-hemispheric stroke. There were 26 late deaths due to all causes, one due to CVA. Eight patients required reoperation (mean 53.4 months). Seven of these were hypertensive. Kaplan-Meier analysis of long-term follow up shows relatively high stroke free rates; at 153 months (12.75 years) the hemispheric stroke free rate was 98.67% and the all-stroke free rate was 95.85%. The survival estimate following redo surgery was 69.97% at 5 years and 40.23% at 10 years. We found that individuals on statin therapy (p-value=0.0042), and those on combination of statin and aspirin (p-value=0.0320), had significantly increased interval between primary and secondary operation. Increased age was correlated to a decreased time to redo surgery (p-value=<0.0001). We conclude that reoperation for recurrent carotid stenosis using standard vascular techniques is safe, effective, durable and cost effective. It should continue to be the mainstay of treatment when secondary intervention is required. Statins have a salutary effect on durability of the procedure and should be used when indicated.

Serotonin transporter function, but not expression, is dependent on brain-derived neurotrophic factor (BDNF): in vivo studies in BDNF-deficient mice.

In the present study, we used high-speed chronoamperometry to examine serotonin (5-HT) transporter (5-HTT) function in vivo in 2-, 5-, and 10-month-old brain-derived neurotrophic factor (BDNF)+/- mice. The rate of clearance of exogenously applied 5-HT was measured in CA3 region of hippocampus. In 2-month-old mice, the rate of 5-HT clearance did not differ between BDNF+/+ and BDNF+/- mice. In BDNF+/+ mice, 5-HT clearance rate (Tc) increased markedly with age. In contrast, Tc remained relatively static in BDNF+/- mice across 2-, 5-, and 10-month age groups. At 5 months of age, female BDNF+/+ mice had a lower maximal velocity (Vmax) for 5-HT clearance than male BDNF+/+ mice. There was a similar trend in 5-month-old BDNF+/- mice, but this did not reach statistical significance. There was an age-dependent increase in KT value for 5-HT clearance (i.e., decreased in vivo affinity of 5-HTT), but no significant effect of genotype or gender. 5-HTT density, as measured by [3H]cyanoimipramine binding, was not different between BDNF+/+ and BDNF+/- mice, although there was a significant increase in 5-HTT binding with age. The selective 5-HT reuptake inhibitor fluvoxamine (50 and 100 pmol) significantly decreased 5-HT clearance in BDNF+/+ mice, but not in BDNF+/- mice. Our data suggest that the profoundly reduced ability of 5- and 10-month-old BDNF+/- mice to clear 5-HT is not because of a decrease in the total number of 5-HTTs, but may be due to functional deficits in the 5-HTT, e.g., in the machinery/signaling required for insertion of 5-HTTs into the plasma membrane and/or activation of the 5-HTT once it is positioned to take up 5-HT from extracellular fluid.

Characteristic retinal atrophy with secondary "inverse" optic atrophy identifies vigabatrin toxicity in children.

OBJECTIVE: To describe the clinical pattern of retinal atrophy in children caused by the anticonvulsant vigabatrin. DESIGN: An interventional case series report. PARTICIPANTS: One hundred thirty-eight patients, mainly infants, were evaluated regularly for evidence of possible vigabatrin toxicity in the Eye and Neurology clinics at the Hospital for Sick Children, Toronto. METHOD: Sequential clinical and electroretinographic (International Society for Clinical Electrophysiology of Vision standards) evaluations every 6 months. MAIN OUTCOME MEASURES: Presence of recognizable retinal and optic atrophy in the presence of abnormal electroretinogram (ERG) and other clinical findings. RESULTS: Three children being treated for seizures with vigabatrin showed definite clinical findings of peripheral retinal nerve fiber layer atrophy, with relative sparing of the central or macular portion of the retina and relative nasal optic nerve atrophic changes. Some macular wrinkling was evident in 1 case. Progressive ERG changes showing decreased responses, especially the 30-Hz flicker response, supported the presence of decreased retinal function. CONCLUSIONS: A recognizable and characteristic form of peripheral retinal atrophy and nasal or "inverse" optic disc atrophy can occur in a small number of children being treated with vigabatrin. The changes in superficial light reflexes of the retina in children facilitate the clinical recognition of nerve fiber layer atrophy. The macula is relatively spared, although superficial retinal light reflexes indicating wrinkling of the innermost retina suggest early macular toxicity as well. Because these changes are accompanied by electrophysiologic evidence of retinal dysfunction, discontinuation of vigabatrin should be strongly considered.

Contralateral effects of unilateral resistance training: a meta-analysis.

It is often claimed that strength training of one limb increases the strength of the contralateral limb, but this has not been demonstrated consistently, particularly in well-controlled studies. The aim was to quantitatively combine the results of other studies on the effects of unilateral training on contralateral strength in humans to provide an answer to this physiological question. We analyzed all randomized controlled studies of voluntary unilateral resistance training that used training intensities of at least 50% of maximal voluntary strength for a minimum of 2 wk. Studies were identified by computerized and hand searches of the literature. Data on changes in strength of contralateral and control limbs were extracted and statistically pooled in a meta-analysis. This approach allows conclusions to be based on a statistically meaningful sample size, which might be difficult to achieve in other ways. Seventeen studies met the inclusion criteria, and 13 provided enough data for statistical pooling. The contralateral effects of strength training reported in individual studies varied from -2.7 to 21.6% of initial strength. The pooled estimate of the effect of unilateral resistance training on the maximal voluntary strength of the contralateral limb was 7.8% (95% confidence interval: 4.1-11.6%). This was 35.1% (95% confidence interval: 20.9-49.3%) of the effect on the trained limb. Pooling of all available data shows that unilateral strength training produces modest increases in contralateral strength.

Passive moment about the hip in straight leg raising.

OBJECTIVE: The purpose of this examine is to study the load-deformation characteristics of the hip in straight leg raising. DESIGN: An experimental study in which passive moment about the hip was determined as a function of hip angle. BACKGROUND: Straight leg raising is widely employed in clinical examination, and there is little information on its mechanical characteristics. METHODS: Fourteen healthy volunteers were recruited for this study. Three trials of straight leg raise tests were performed while subjects lay supine on a plinth that was fitted with load cells. An electrogoniometer was employed to measure hip flexion during the test. Resistive moment at the hip was determined using a dynamic biomechanical model. RESULTS: The present experimental method was shown to be highly reliable. The moment-angle curves of all subjects were shown to follow an exponential function. CONCLUSION: Stiffness and strain energy of posterior hip tissues could be derived from the moment-angle curves. Evaluation of such elastic properties is clinically important as they may be altered with injuries of the tissues. RELEVANCE: Clinically, contracture of hamstring muscles and other posterior hip tissues is evaluated by measuring the available range of hip flexion in straight leg raising. However, this does not provide any information on the elastic properties of the tissues. The present study reports a reliable method of evaluating such properties.

Axillobifemoral bypass: elective versus emergent operation.

Axillobifemoral bypass (AxBFB) is considered an inferior operation because of comparatively poor long-term results. One factor that has not been considered in the literature is whether or not the operation is performed electively or for acute ischemia (< 24 hours duration). This may be a more important predictor of poor results than previously recognized. During the last 10 years, we have performed 59 AxBFB. In Group A, 41 patients (mean age 71) underwent elective AxBFB and in Group B, 18 patients (mean age 65) had emergency AxBFB. Indications for surgery in Group A were limb-threatening ischemia (30), infected aortic graft (5), and severe claudication (6); in Group B, indications for surgery were acute limb ischemia (16), and aortoduodenal fistula (2). Primary patency (p < 0.002), limb salvage (p < 0.002), and survival (p < 0.03) were significantly better in Group A versus Group B. We conclude that an AxBFB performed electively provides satisfactory palliation of severe vascular disease in high-risk patients. The indications for operation and timing of the operation may explain the widely disparate clinical results reported in the literature.

Long-term follow-up of bypasses to the brachial artery across the shoulder joint.

BACKGROUND: Most atherosclerotic lesions in the subclavian artery are successfully treated with carotid to subclavian bypass. The need to bypass to the brachial artery (BA) is rare. We reviewed our experience with this bypass. METHODS: Over a 10-year period, we have performed 13 bypasses to the BA originating from an artery proximal to the shoulder joint. In this retrospective study, the demographic and clinical risk factors were evaluated. Long-term results were analyzed. RESULTS: Thirteen operations were performed in 10 patients, aged 47 to 80 years. The operations were carried out for acute severe ischemia in 1 limb, effort discomfort in 9, and rest pain in 3 limbs. Donor arteries were axillary (7), carotid (4), and subclavian (2). All bypasses were to the BA proximal to the elbow joints. Life-table analysis showed 100% patency in the first 3 years and 88% at 7 years. There were 2 deaths in follow-up. Average preoperative brachial to brachial index was 0.59 and postoperative index was 1.1. In patients with bilateral occlusions, mean preoperative brachial artery pressure was 62 mm Hg, which improved to 142 mm Hg postoperatively. There were no neurological complications and no 30-day mortality. CONCLUSIONS: Bypass across the shoulder joint to the BA using expanded polytetrafluoroethylene (ePTFE) or vein is a safe operation with excellent long-term patency. The carotid artery can be used as a donor vessel without complications. Hypertension and female gender appear to be risk factors for extensive disease in proximal upper extremity arteries.

Vascular operations in nonagenarians.

This is a retrospective study describing our experience with vascular surgical procedures performed in patients 90 years of age or older. Thirty-four procedures, including major and minor vascular reconstruction and amputation, were performed in 20 patients. The 30-day mortality rate was 6% for planned surgical procedures. The 24-month survival rate was 82% for elective major revascularizations and limb salvage was 80% in these patients. We believe that vascular reconstruction can be carried out with acceptable morbidity and mortality when the operations are planned and the patients have been chosen carefully.

Health and activity after intensive care.

All patients discharged from a general intensive care unit over a 4.5 year period were sent a questionnaire 3 months after discharge which investigated aspects of their health and physical abilities. Replies were compared on the basis of age, diagnosis and sickness severity on admission. Five hundred and four questionnaires were analysed. Overall, 47% of patients described their health as good/very good, 42% as fair and 11% as poor/very poor. Activity level, compared to that before their admission, was unchanged in 59%, worse in 33% and improved in 8% of patients. There were no differences in health status or changes in activity with age, diagnosis or severity of sickness. Patients aged 76 years or older were more likely to perceive their health as 'better than average' than younger patients (p < 0.01). Eight percent of patients would be unwilling to undergo intensive care again. An unacceptable health status after intensive care cannot be predicted in any group of patients.

Improvement in suction catheter efficiency and safety in arterial operations.

The Blood Shield is a new device which has been developed to attach easily to the tip of a conventional suction catheter. Two experiments were performed to determine if the Blood Shield could limit the degree of splash which occurs during vascular graft flushing and whether it could increase the efficiency of a standard suction tip in collecting shed blood for autotransfusion. The results of the experiments indicate that the Blood Shield, when added to a conventional suction catheter, diminishes the amount of spray which may occur during anastomotic flushing. Secondly, it more effectively collects blood from a flushed anastomosis or arteriotomy in comparison with a suction catheter alone.

Aortoiliac bypass in a renal transplant patient using a new technique.

There are only 18 patients described in the English literature who had a preexisting renal transplant and underwent aortic surgery for aortoiliac occlusive disease. We describe an additional patient who was treated with a new technique using a Sundt shunt and a GraftAssist. This technique provides antegrade flow and minimal ischemic time and avoids exploration of arteries not involved in the anastomosis.

Routine completion study during carotid endarterectomy is not necessary.

The results of many studies have suggested the need for a completion study during carotid endarterectomy (CE). This paper describes our experience not routinely using completion studies. We retrospectively reviewed the charts of 417 patients who underwent 455 CEs. Demographic features, risk factors, ipsilateral neurologic events during the first 30 days, and mortality data were identified. There were 14 neurologic events and 4 deaths. No technical defects were found in 13 patients; 1 patient did not have exploratory surgery after an occlusion. Long-term follow-up shows 10 of the 14 arteries are open. Two patients were lost to follow-up, 1 patient died, and 1 artery was not explored. We conclude that CE may be carried out without routinely using a completion study, with an acceptable postoperative neurologic complication rate. Careful technique is mandatory.

Effect of metoclopramide on renal vascular resistance index and renal function in patients receiving a low-dose infusion of dopamine.

Metoclopramide is a dopamine receptor antagonist and, in large doses, has been shown to reverse the increase in renal blood flow, the diuresis and the natriuresis produced by a low-dose infusion of dopamine. We gave a single i.v. dose of metoclopramide 10 mg to 21 patients on an intensive care unit who were haemodynamically stable and receiving dopamine 3 micrograms kg-1 min-1. Renal vascular resistance index, measured by duplex Doppler ultrasonography, did not change after metoclopramide. Renal function, measured by creatinine and osmolar clearance, natriuresis, kaliuresis and excretion fractions of sodium and potassium did not change after metoclopramide. We conclude that normal doses of metoclopramide (< 0.2 mg kg-1) do not antagonize the renal effects of a low-dose infusion of dopamine in critically ill patients.

Adolescents and AIDS: knowledge and attitude.

Ninth- and tenth-grade adolescents' AIDS knowledge and attitude were assessed before and after a mandated AIDS education program. A control group of adolescents not exposed to the education program was included. As a result of the AIDS education, knowledge gains were indicated for the girls, but not for the boys. Both boys and girls gained in tolerance for AIDS victims. In turn, for the boys, but not for the girls, the knowledge gained had a direct effect on increasing tolerance toward AIDS victims. A plateau effect with regard to knowledge about AIDS is indicated. Gender differences and implications for future research on adolescents and AIDS education are discussed.