Treatment of Venous Thrombosis with Intravenous Unfractionated Heparin Administered in the Hospital as Compared with Subcutaneous Low-Molecular-Weight Heparin Administered at Home. The Tasman Study Group
An intravenous course of standard (unfractionated) heparin with the dose adjusted to prolong the activated partial-thromboplastin time to a desired length is the standard initial in-hospital treatment for patients with deep-vein thrombosis, but fixed-dose subcutaneous low-molecular-weight heparin appears to be as effective and safe. Because the latter treatment can be given on an outpatient basis, we compared the two treatments in symptomatic outpatients with proximal-vein thrombosis but no signs of pulmonary embolism.
We randomly assigned patients to adjusted-dose intravenous standard heparin administered in the hospital (198 patients) or fixed-dose subcutaneous low-molecular-weight heparin administered at home, when feasible (202 patients). We compared the treatments with respect to recurrent venous thromboembolism, major bleeding, quality of life, and costs.
Seventeen of the 198 patients who received standard heparin (8.6 percent) and 14 of the 202 patients who received low-molecular-weight heparin (6.9 percent) had recurrent thromboembolism (difference, 1.7 percentage points; 95 percent confidence interval, -3.6 to 6.9). Major bleeding occurred in four patients assigned to standard heparin (2.0 percent) and one patient assigned to low-molecular-weight heparin (0.5 percent; difference, 1.5 percentage points; 95 percent confidence interval, -0.7 to 2.7). Quality of life improved in both groups. Physical activity and social functioning were better in the patients assigned to low-molecular-weight heparin. Among the patients in that group, 35 percent were never admitted to the hospital at all, and 40 percent were discharged early. This treatment was associated with a mean reduction in hospital days of 67 percent, ranging from 29 percent to 86 percent in the various study centers.
In patients with proximal-vein thrombosis, treatment with low-molecular-weight heparin at home is feasible, effective, and safe.
"The use of low molecular weight heparins (LMWHs) was investigated and implemented in DVT patients before it became standard practice in PE patients [6–8]. Likewise, whereas the ambulatory treatment of patients with DVT has been widespread for over a decade [9, 10], outpatient treatment of patients with PE at low risk of an adverse outcome has only been validated in the past years . Due to these differences in outcome and nuances in therapeutic approach, efficacy and safety outcomes may not be readily translatable from one group of VTE patients to another. "
[Show abstract][Hide abstract] ABSTRACT: With the advent of new oral anticoagulants (NOACs) for the treatment of deep-vein thrombosis (DVT) and/or pulmonary embolism (PE), a new era of oral anticoagulation for patients with venous thromboembolism (VTE) has begun. Rivaroxaban is the first NOAC to receive regulatory approval for the acute and continued treatment of DVT and PE, and for the secondary prevention of VTE. Here, the clinical trials of rivaroxaban in patients with VTE are reviewed, and the clinical use of rivaroxaban for patients with PE is discussed. Even though rivaroxaban will facilitate the therapeutic management of PE, its use in specific clinical situations needs further study.
Advances in Therapy 06/2013; 30(6). DOI:10.1007/s12325-013-0041-4 · 2.27 Impact Factor
"A study on technological innovations in surgery showed that as more patients were treated on an outpatient basis, fewer hospital beds were needed, and traditional operating rooms had to adapt to a greater turnover of patients. In addition, postoperative care is carried out in the community rather than in hospitals [2,4]. Also reduction of costs is mentioned as a result of substituting day care for clinical care [2-8]. "
[Show abstract][Hide abstract] ABSTRACT: Patient satisfaction is an important indicator of quality of care in hospitals. Reliable and valid instruments to measure clinical and outpatient satisfaction already exist. Recently hospitals have increasingly provided day care, i.e., admitting patients for one day without an overnight stay. This article describes the adaption of the 'Core questionnaire for the assessment of Patient Satisfaction' (COPS) for general Day care (COPS-D), and the subsequent validation of the COPS-D.
The clinical COPS was supplemented with items to cover two new dimensions: Pre-admission visit and Operation Room. It was sent to a sample of day care patients of five general Dutch hospitals to investigate dimensionality, acceptability, reliability, construct and external validity. Construct validity was established by correlating the dimensions of the COPS-D with patients' overall satisfaction.
The COPS-D was returned by 3802 patients (response 46%). Factor analysis confirmed its' structure: Pre-intake visit, Admission, Operation room, Nursing care, Medical care, Information, Autonomy and Discharge and aftercare (extraction communality 0.63-0.90). The internal consistency of the eight dimensions was good (α = 0.82-0.90); the item internal consistency corrected for overlap was satisfactory (>0.40); all inter-item correlations were higher than 0.45 but not too high (<0.90). The construct validity of all dimensions was good (r from 0.52-0.62, p < 0.01). The Information dimension had the strongest correlation with overall day care satisfaction.
The COPS-D is a reliable and valid instrument for measuring satisfaction with day care. It complements the model of measuring patient satisfaction with clinical and outpatient care given in hospitals. It also fulfils the conditions made while developing the clinical and outpatient COPS: a short, core instrument to screen patient satisfaction.
BMC Health Services Research 05/2012; 12(1):125. DOI:10.1186/1472-6963-12-125 · 1.71 Impact Factor
"In addition, several studies have demonstrated that LMWHs offer several advantages in terms of efficacy and safety in cancer patients     . The anticoagulant regimens used in these trials are reported in Table 1. "
[Show abstract][Hide abstract] ABSTRACT: Venous thromboembolism (VTE) is frequently encountered in patients with cancer. Cancer patients have an increased risk of VTE during the entire course of their disease, but this risk is particularly high during the first months after cancer diagnosis and during the advanced stage of disease. VTE is a relevant cause of morbidity and mortality in patients with cancer and has a significant impact on their quality of life. Since 50 years, heparin and vitamin K antagonists are the mainstay anticoagulants for the prevention and treatment of VTE. At present, the treatment of VTE in patients with cancer does not differ from that of other medical patients. However, patients with cancer still have unmet clinical needs with the currently available antithrombotic agents. These patients are known to be at two- to four-fold risk for both VTE recurrence and anticoagulant-related bleeding, despite adequate anticoagulation, in comparison to non cancer patients Several new antithrombotic drugs targeting activated factor X or activated thrombin have been developed in the last decades for treatment of VTE. Some of them seems to have a potential therapeutic value for VTE treatment in patients with cancer, but no randomized studies have been specifically conducted in cancer patients. Until data with these novel agents in the specific oncology setting will be available, their efficacy and safety for both prevention and treatment of VTE in cancer patients remains to be defined.
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