Near Real-time Natural Language Processing for the Extraction of Abdominal Aortic Aneurysm Diagnoses From Radiology Reports: Algorithm Development and Validation Study.

BACKGROUND: Management of abdominal aortic aneurysms (AAAs) requires serial imaging surveillance to evaluate the aneurysm dimension. Natural language processing (NLP) has been previously developed to retrospectively identify patients with AAA from electronic health records (EHRs). However, there are no reported studies that use NLP to identify patients with AAA in near real-time from radiology reports. OBJECTIVE: This study aims to develop and validate a rule-based NLP algorithm for near real-time automatic extraction of AAA diagnosis from radiology reports for case identification. METHODS: The AAA-NLP algorithm was developed and deployed to an EHR big data infrastructure for near real-time processing of radiology reports from May 1, 2019, to September 2020. NLP extracted named entities for AAA case identification and classified subjects as cases and controls. The reference standard to assess algorithm performance was a manual review of processed radiology reports by trained physicians following standardized criteria. Reviewers were blinded to the diagnosis of each subject. The AAA-NLP algorithm was refined in 3 successive iterations. For each iteration, the AAA-NLP algorithm was modified based on performance compared to the reference standard. RESULTS: A total of 360 reports were reviewed, of which 120 radiology reports were randomly selected for each iteration. At each iteration, the AAA-NLP algorithm performance improved. The algorithm identified AAA cases in near real-time with high positive predictive value (0.98), sensitivity (0.95), specificity (0.98), F1 score (0.97), and accuracy (0.97). CONCLUSIONS: Implementation of NLP for accurate identification of AAA cases from radiology reports with high performance in near real time is feasible. This NLP technique will support automated input for patient care and clinical decision support tools for the management of patients with AAA. .

Survival Implications of Thrombus Recurrence or Bleeding in Cancer Patients Receiving Anticoagulation for Venous Thromboembolism Treatment.

BACKGROUND: Study aims were to analyze prospectively collected data from patients with cancer-associated venous thromboembolism (VTE) to determine the impact of VTE recurrence and anticoagulant-related bleeding on all-cause mortality. PATIENTS/METHODS: Consecutive cancer patients with acute VTE treated with anticoagulants (March 1, 2013-November 30, 2021) were included in this analysis. Anticoagulant therapy-associated VTE recurrences, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were assessed for their impact on all-cause mortality outcomes. RESULTS: This study included 1,812 cancer patients with VTE. Of these, there were 97 (5.4%) with recurrent VTE, 98 (5.4%) with major, and 104 (5.7%) with CRNMB while receiving anticoagulants. Recurrent VTE (hazard ratio [HR]: 1.52; 95% confidence interval [CI]: 1.16-2.00; p = 0.0028), major bleeding (HR: 1.82; 95% CI: 1.41-2.31; p = 0.006), and CRNMB (HR; 1.38; 95% CI: 1.05-1.81; p = 0.018) each adversely influenced mortality outcomes. Deep vein thrombosis as the incident thrombotic event type was associated with VTE recurrence (HR: 1.78; 95% CI: 1.08-2.89; p = 0.02). Neither cancer type nor stage, chemotherapy, or Ottawa risk category influenced VTE recurrence. Higher body weights (HR: 1.01; 95% CI: 1.00-1.01; p = 0.005) were associated with increased major bleeding, while high Ottawa scores (HR: 0.66; 95% CI: 0.46-0.96; p = 0.03) and apixaban treatment (HR: 0.62; 95% CI: 0.45-0.84; p = 0.002) were associated with fewer major bleeding outcomes. CONCLUSION: Among cancer patients receiving anticoagulant therapy for VTE, adverse outcomes such as VTE recurrence, major bleeding, or CRNMB increase mortality risk by 40 to 80%. Identifying variables predicting these outcomes may help risk-stratify patients with poor prognosis.

Inpatient Management of Pulmonary Embolism: Clinical Characteristics and Mortality in a High-Volume Tertiary Care Center.

The optimal management strategy for submassive or intermediate risk pulmonary embolism (IRPE)-anticoagulation alone versus anticoagulation plus advanced therapies-remains in equipoise leading many institutions to create multidisciplinary PE response teams (PERTs) to guide therapy. Cause-specific mortality of IRPE has not been thoroughly examined, which is a meaningful outcome when examining the effect of specific interventions for PE. In this retrospective study, we reviewed all adult inpatient admissions between 8/1/2018 and 8/1/2019 with an encounter diagnosis of PE to study all cause and PE cause specific mortality as the primary outcomes and bleeding complications from therapies as a secondary outcome. There were 429 total inpatient admissions, of which 59.7% were IRPE. The IRPE 30-day all-cause mortality was 8.7% and PE cause-specific mortality was 0.79%. Treatment consisted of anticoagulation alone in 93.4% of cases. Advanced therapies-systemic thrombolysis, catheter directed thrombolysis, or mechanical thrombectomy, were performed in only six IRPE cases (2.3%). Decompensation of IRPE cases requiring higher level of care and/or rescue advanced therapy occurred in only five cases (2%). In-hospital major bleeding and clinically relevant non-major bleeding were more common in those receiving systemic thrombolysis (61.5%) compared to anticoagulation combined with other advanced therapies (11.7%). Despite the high overall acuity of PE cases at our institution, in-hospital all-cause mortality was low and cause-specific mortality for IRPE was rare. These data suggest the need to target other clinically meaningful outcomes when examining advanced therapies for IRPE.

Calf vein thrombosis outcomes comparing patients with and without cancer.

Distal or calf deep vein thrombosis (DVT) are said to have low rates of propagation, embolization, and recurrence. The objective of this study was to determine outcomes among cancer patients with calf DVT compared to those without cancer. Consecutive patients with ultrasound confirmed acute calf DVT (3/1/2013-8/10/2019) were assessed for venous thromboembolism (VTE) recurrence and bleeding outcomes compared by cancer status. There were 830 patients with isolated calf DVT; 243 with cancer and 587 without cancer. Cancer patients were older (65.9 ± 11.4 vs. 62.0 ± 15.9 years; p = 0.006), with less frequent recent hospitalization (31.7% vs. 48.0%; p < 0.001), surgery (30.0% vs. 38.0%; p = 0.03), or trauma (3.7% vs. 19.9%; p < 0.001). The four most common cancers included hematologic malignancies (20.6%), lung (11.5%), gastrointestinal (10.3%), and ovarian/GYN (9.1%). Nearly half of patients had metastatic disease (43.8%) and 57% were receiving chemotherapy. VTE recurrence rates were similar for patients with (7.1%) and without cancer (4.0%; p = 0.105). Major bleeding (6.3% vs. 2.3%; p = 0.007) were greater for cancer patients while clinical relevant non major bleeding rates did not differ (7.1% vs. 4.6%; p = 0.159). In this retrospective analysis, cancer patients with calf DVT have similar rates of VTE recurrence but higher major bleeding outcomes compared to patients without cancer.

Apixaban and dalteparin in active malignancy associated venous thromboembolism. The ADAM VTE Trial.

Currently, low molecular weight heparin (LMWH) is the guideline endorsed treatment of patients with cancer associated venous thromboembolism (VTE). While apixaban is approved for the treatment of acute VTE, there are limited data supporting its use in cancer patients. The rationale and design of this investigator initiated Phase IV, multicenter, randomized, open label, superiority trial assessing the safety of apixaban versus dalteparin for cancer associated VTE is provided (ADAM-VTE; NCT02585713). The main aim of the ADAM-VTE trial is to test the hypothesis that apixaban is associated with a significantly lower rate of major bleeding compared to dalteparin in the treatment of cancer patients with acute VTE. The primary safety outcome is rate of major bleeding. Secondary efficacy objective is to assess the rates of recurrent VTE or arterial thromboembolism. Cancer patients with acute VTE (n=300) are randomized to receive apixaban (10 mg twice daily for 7 days followed by 5 mg twice daily thereafter) or dalteparin (200 IU/Kg daily for 30 days followed by 150 IU/kg daily thereafter) for 6 months. Stratification factors used for randomization include cancer stage and cancer specific risk of venous thromboembolism using the Khorana score. Participating centers are chosen from the Academic and Community Cancer Research United (ACCRU) consortium comprised of 90 oncology practices in the United States and Canada. Based on the hypothesis to be tested, we anticipate that these trial results will provide evidence supporting apixaban as an effective treatment of cancer associated VTE at lower rates of major bleeding compared to LMWH.

Utilidad de la heparina como terapia anticoagulante puente en la fibrilación auricular: [revisión] / Usefulness of heparin as bridging anticoagulation therapy: [review]

La fibrilación auricular se asocia con un aumento de 5 a 6 veces en el riesgo de accidente cerebrovascular y como tal es la causa más común de cardioembolismo. La anticoagulación con warfarina reduce este riesgo en casi un 70%. Sin embargo, los pacientes con fibrilación auricular (FA) a menudo requieren la interrupción temporal de la warfarina debido a un procedimiento invasivo. Este escenario es un problema clínico frecuente, que afecta a casi 400.000 pacientes por año en Norteamérica. El uso de ®puentes¼ de tratamiento con heparina reduce el intervalo de tiempo sin anticoagulación y por tanto disminuye teóricamente el riesgo de eventos cardioembólicos cercanos al procedimiento. Sin embargo, no todos los pacientes requieren este tipo de terapia. Las condiciones que aumentan el riesgo de trombosis vinculado con el procedimiento en pacientes con fibrilación auricular incluyen las válvulas cardíacas mecánicas, el antecedente de embolia arterial o un accidente cerebrovascular previo, trombo intracardíaco conocido, y el alto puntaje compuesto CHADS2 (4 o más). Para los pacientes anticoagulados con FA de causa no valvular que requieren un procedimiento invasivo, se debe considerar la terapia con heparina como puente sólo en aquellos con mayor riesgo de tromboembolismo. El manejo clínico del paciente debe ser individualizado, manteniendo un equilibrio entre el riesgo específico del paciente y el riesgo específico del procedimiento, tanto para trombosis como para hemorragias.