'Body on the line': experiences of tackle injury in women's rugby union - a grounded theory study.

OBJECTIVES: Tackle-related injuries account for up to 67% of all match injuries in women's rugby union. The perspective of women players on tackle injury can help key stakeholders understand psychosocial determinants of tackle injury risk and prevention. We aimed to capture psychosocial processes that explain tackle injury experiences and behaviours in women's rugby union. METHODS: We conducted a qualitative study using a grounded theory approach. Adult women players, with at least 1-year senior level experience, were recruited from Europe, South Africa and Canada between December 2021 and March 2022. Data were collected through semistructured interviews and analysed in line with grounded theory coding procedures. RESULTS: Twenty-one players, aged 20-48 years with a mean 10.6 years of rugby playing experience, participated. In our analysis, we identified three categories central to participants' experiences of tackle injury: (1) embodied understandings of tackle injury, (2) gender and tackle injury risk and (3) influences on tackle injury behaviours. Participants reported a sense of fear in their experience of tackling but felt that tackle injuries were an inevitable part of the game. Tackle injury was described based on performance limitations. Tackle injury risks and behaviours were influenced by gendered factors perpetuated by relations, practices and structures within the playing context of women's rugby union. CONCLUSION: Women's tackle injury experiences were intertwined with the day-to-day realities of marginalisation and under preparedness. Grounded in the voices of women, we have provided recommendations for key stakeholders to support tackle injury prevention in women's rugby.

Eptacog Beta for Bleeding Treatment and Prevention in Congenital Hemophilia A and B With Inhibitors: A Review of Clinical Data and Implications for Clinical Practice.

OBJECTIVE: To review the pharmacology, dosing and administration, safety, clinical efficacy, and role of eptacog beta in the treatment of congenital hemophilia with inhibitors. DATA SOURCES: A literature search of PubMed (1966 to August 2021) was conducted using the keywords eptacog beta, recombinant FVII, and hemophilia. STUDY SELECTION AND DATA EXTRACTION: All relevant published articles and prescribing information on eptacog beta for the treatment of congenital hemophilia with inhibitors were reviewed. DATA SYNTHESIS: Eptacog beta is a novel recombinant activated factor VII (rVIIa) product that demonstrated efficacy in controlling bleeding and associated pain in patients with hemophilia A or B with inhibitors. Eptacog beta has limited Food and Drug Administration-approved and off-label indications compared with other bypassing agents (BPAs; activated prothrombin complex concentrates [aPCC; eptacog alfa]). Eptacog beta costs less than eptacog alfa, but still more than aPCCs. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review provides insight into the role of eptacog beta for treatment of congenital hemophilia with inhibitors and reviews important health system formulary considerations for available BPAs. CONCLUSIONS: Eptacog beta is more cost-effective than eptacog alfa and, as such, may become the preferred rVIIa formulary product. However, eptacog alfa availability remains necessary for the treatment of disorders where eptacog beta has limited data. aPCC should remain the first-line BPA for the treatment of bleeding in patients with inhibitors with no contraindications to use because of its equivocal efficacy and safety and in light of the magnitude of cost savings associated with this strategy.

Physical and Technical Demands and Preparatory Strategies in Female Field Collision Sports: A Scoping Review.

Women's participation in field collision sports is growing worldwide. Scoping reviews provide an overview of scientific literature in a developing area to support practitioners, policy, and research priorities. Our aim is to explore published research and synthesise information on the physical and technical demands and preparation strategies of female field collision sports. We searched four databases and identified relevant published studies. Data were extracted to form (1) a numerical analysis and (2) thematic summary. Of 2318 records identified, 43 studies met the inclusion criteria. Physical demands were the most highly investigated (n+=+24), followed by technical demands (n+= 18), tactical considerations (n+=+8) and preparatory strategies (n=1). The key themes embody a holistic model contributing to both performance and injury prevention outcomes in the context of female field collision sports. Findings suggest a gender data gap across all themes and a low evidence base to inform those preparing female athletes for match demands. Given the physical and technical differences in match-demands the review findings do not support the generalisation of male-derived training data to female athletes. To support key stakeholders working within female field collision sports there is a need to increase the visibility of female athletes in the literature.

Reduced ADAMTS13 activity during TTP remission is associated with stroke in TTP survivors.

With timely and effective treatment, most patients with thrombotic thrombocytopenic purpura (TTP) survive the acute TTP episode. In addition to the risk of relapse, TTP survivors have higher all-cause mortality than the general population and increased rates of chronic morbidities, including hypertension, depression, and mild cognitive impairment. We conducted this retrospective-prospective cohort study to determine the incidence and prevalence of stroke after recovery from acute TTP and to test the hypothesis that lower ADAMTS13 activity after recovery from TTP is associated with an increased risk of stroke during remission. Of 170 consecutive patients treated for TTP at The Johns Hopkins Hospital from 1995 through 2018, 14 (8.2%) died during the index episode and 19 were observed for less than 1 month after recovery. Of the remaining 137 patients, 18 (13.1%) developed stroke unrelated to an acute TTP episode over a median observation period of 3.08 years, which is fivefold higher than the expected prevalence of 2.6% from an age- and sex-matched reference population (P = .002). ADAMTS13 activity during remission was measured in 52 patients and was >70% in 44.2%, 40% to 70% in 23.1%, 10% to 39% in 25%, and <10% in 7.7%. Stroke after recovery from acute TTP occurred in 0% (0 of 22) of patients with normal remission ADAMTS13 activity (>70%) and in 27.6% (8 of 29) of patients with low ADAMTS13 activity (≤70%; P = .007). In conclusion, stroke is common after recovery from TTP and is associated with reduced ADAMTS13 activity during remission.

Reduced sensitivity of PLASMIC and French scores for the diagnosis of thrombotic thrombocytopenic purpura in older individuals.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder characterized by thrombocytopenia, microangiopathic hemolysis, and ischemic organ failure. The PLASMIC and French TTP scores can help guide clinical decisions when ADAMTS13 testing is not immediately available. Older individuals often present atypically, but the impact of age on these tools is not known. STUDY DESIGN AND METHODS: We calculated the sensitivity and specificity of the PLASMIC and French TTP scores in patients enrolled in the Johns Hopkins thrombotic microangiopathy (TMA) registry. RESULTS: Of 257 patients with TMA enrolled in the registry, we excluded patients less than 18 years of age (n = 19), with prior TMA (n = 81) or who initially presented at another hospital (n = 25). The remaining 132 patients (75 with TTP and 57 with other TMA) were analyzed. Sensitivity of a French score of 2 decreased with age and was 72.2%, 61.5%, and 46.2% for ages 18 to 39, 40 to 59, and ≥ 60 years old, respectively. A PLASMIC score ≥ 5 had higher sensitivity than the French score but this also decreased with age; sensitivity was 91.4% (95% confidence interval [CI], 76.9-98.2), 78.3% (95% CI, 56.3-92.5), and 76.9% (95% CI, 46.2-95.0) for patients 18 to 39, 40 to 59, and ≥ 60 years old, respectively. Older patients had higher platelet counts and serum creatinine than the youngest group, contributing to the loss in sensitivity. CONCLUSION: The PLASMIC and French TTP scores have reduced sensitivity at age ≥ 60 years and are less reliable in identifying TTP in older patients. A high index of suspicion and availability of rapid ADAMTS13 assays is required to correctly diagnose all patients with TTP.

Treating low back pain in athletes: a systematic review with meta-analysis.

OBJECTIVE: To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement. DATA SOURCES: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS). RESULTS: Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments. CONCLUSIONS: While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis.

OBJECTIVES: We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching. ELIGIBILITY CRITERIA: Studies evaluating prevalence of LBP in adult athletes across all sports. RESULTS: Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport. CONCLUSION: LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Antidepressant Use and Incident Urinary Incontinence: A Literature Review.

OBJECTIVE: To review available data examining antidepressant use and incident urinary incontinence (UI). DATA SOURCES: PubMed was used to conduct the literature search for this review. In the primary search, the term "antidepressive agents" was searched as a medical subject heading, a pharmacological action, and a keyword phrase. This choice was made so that any relevant articles would include complete results for antidepressive agents. "Antidepressive agents" was combined with the key phrase "drug-induced urinary incontinence" to complete this primary search. STUDY SELECTION: Relevant articles published in English and examining human subjects were included. DATA EXTRACTION: The study authors determined appropriateness of articles for inclusion, focusing on those examining antidepressant-associated UI. DATA SYNTHESIS: This literature review identified three cohort studies and 11 case reports examining various associations between antidepressant use and incident UI. CONCLUSION: All 11 case reports and 1 cohort study reviewed suggest an association between antidepressant use and incident UI. It remains unclear which drugs are most problematic and which patients are at greatest risk, and more data are needed to confirm an association, especially in older adults. Comprehensive medication reviews should be employed by pharmacists to identify potential medication-related causes of UI.

Are we tackle ready? Cross-sectional video analysis of match tackle characteristics in elite women's Rugby Union.

The tackle contest is the most common and most injurious match contact event in rugby and is an indicator of performance. Tackle Ready is World Rugby's tackle technique education program. Limited research has characterized the tackle contest in women's rugby. The purpose of this study is to: (1) identify the match situational characteristics, ball-carrier and tackler technical actions demonstrated in elite women's Rugby Union and (2) to determine the extent to which Tackle Ready recommended tackle techniques were exhibited. Technical characteristics for 1500 tackle events in the 2022-2023 Women's Six Nations Championship were visually assessed according to a predefined coding framework and the Tackle Ready program. Tackles lacked full completion (0.2%) of the 22 coded Tackle Ready techniques with 47% of the recommended techniques demonstrated in each tackle on average (range 15%-98%). A high proportion of tackles involved two defenders (48%), approaching ball-carriers from the side (38%) or oblique angles (39%), in an upright position (30%), and with initial contact made with the arm (51%). Incorrect pre-contact head positioning and head placement upon contact accounted for 50% and 15% of tackles, respectively, and there was a mean of 14 (95% CI 11-18) head and neck contacts to a tackler and 18 (95% CI 14-22) head and neck contacts to a ball-carrier per game. Targeted interventions to encourage adoption of recommended techniques are needed to reduce tackle-related injury risk in women's rugby. This study provides valuable context for future discussion across law enforcement, coach education and gender-specific tackle coaching in the women's game.

Paving the path for injury prevention in rugby-7s: A systematic review and meta-analysis.

This review and meta-analysis aimed to describe the current rugby-7s injury epidemiological literature by examining injury data from both sexes, all levels of play, and their associated risk factors. Studies published up until March 2024 were included. These studies were retrieved from six databases using search terms related to rugby-7s or sevens, tackle, collision, collision sport, injury, athlete, incidence rate, mechanism, and risk factor. Only peer-reviewed original studies using prospective or retrospective cohort designs with a clearly defined rugby-7s sample were considered. Included studies needed to report one injury outcome variable. Non-English and qualitative studies; reviews, conference papers, and abstracts were excluded. Twenty studies were included. The meta-analysis used the DerSimonian-Laird continuous random-effects method to calculate the pooled estimated means and 95% confidence interval. The estimated mean injury incidence rate for men was 108.5/1000 player-hours (95% CI: 85.9-131.0) and 76.1/1000 player-hours (95% CI: 48.7-103.5) for women. The estimated mean severity for men was 33.9 days (95% CI: 20.7-47.0) and 44.2 days (95% CI: 32.1-56.3) for women. Significantly more match injuries occurred in the second half of matches, were acute, located at the lower limb, diagnosed as joint/ligament, and resulted from being tackled. Fatigue, player fitness, and previous injuries were associated with an increased risk of injury. There were no statistically significant differences between women's and men's injury profiles. However, the inherent cultural and gendered factors which divide the two sports should not be ignored. The findings from this review will help pave the way forward beyond the foundational stages of injury prevention research in rugby-7s.

"It's always the bare minimum" - A qualitative study of players' experiences of tackle coaching in women's rugby union.

OBJECTIVES: Tackle coaching forms a cornerstone of training in rugby and is designed to enhance performance and mitigate tackle injury. The athlete voice can help key stakeholders understand the psychosocial determinants that shape skill development in relation to tackle coaching. We aimed to capture player experiences of tackle coaching in women's rugby union. DESIGN: Qualitative study using the grounded theory approach. METHODS: Current women rugby union players, with at least 1-year senior level experience, were recruited from Europe, Africa and North America between December 2021 and March 2022 to participate in the study. Data were collected through semi-structured interviews and analysed in line with grounded theory coding procedures. RESULTS: The 21 players were aged 20-48 years with a mean 10.6 years of rugby playing experience. Analysis revealed that the experiences of tackle coaching that shaped women's tackle skill development and sense of preparedness ranged from constraining to empowering, and gender was a pivotal influence in creating meaning. Participants expected and accepted the bare minimum in tackle coaching as the price that they had to pay for inclusion in rugby. CONCLUSIONS: Participants' experiences of tackle coaching were entangled in inequitable club structures and cultures where men's rugby is the norm. Empowering tackle coaching in women's rugby union must be bespoke to the given context and the needs of women players. The recommendations offered in this paper encourage discussion as to how best to empower women's tackle development in rugby.

The Impact of an Antithrombotic Stewardship Program on Heparin-Induced Thrombocytopenia Management.

Background: An antithrombotic stewardship program was implemented to reduce IV DTI use and increase fondaparinux and direct oral anticoagulant (DOAC) use for suspected or confirmed Heparin-induced thrombocytopenia (HIT). Objectives: This study evaluated the impact of an antithrombotic stewardship program on IV DTI utilization in patients with HIT. Methods: A retrospective analysis of adults receiving IV DTIs or fondaparinux from July 2016 to July 2017 (pre-stewardship) and October 2017 to July 2019 (post-stewardship) was conducted. Results: The median duration of IV DTI administration was not significantly different in HIT-negative patients between the pre- and post-stewardship cohorts (1.6 days (25th percentile (p25), 75th percentile (p75): .5, 3.3) vs 1.7 days (p25, p75: .9, 3.9), P = .31). The median duration of IV DTI administration in HIT-positive patients was 9.9 days (p25, p75: 7.6, 21.0) pre-stewardship and 7.3 days (p25, p75: 4.8, 16.5) post-stewardship (P = .18). For HIT-positive patients, the time from HIT diagnosis to discharge was 12.8 days (p25, p75: 8.9, 24.9) and 9.2 days (p25, p75: 4.0, 18.1) in the pre- and post-stewardship cohorts, respectively (P = .07). Fondaparinux and DOAC prescribing rates were 40.7% and 62.2% in the pre- and post-stewardship cohorts, respectively (P = .09). The percentage of patients with no contraindications to IV DTI alternatives receiving these agents increased from 31.2% to 78.6% (P = .01) following stewardship implementation. Conclusions: Intravenous DTI alternative utilization increased significantly after stewardship implementation. Stewardship implementation was associated with a non-statistically significant trend towards decreased IV DTI utilization and decreased length of stay for HIT-positive patients.

Cardiovascular risk and systemic inflammation in male professional rugby: a cross-sectional study.

Objective: To investigate cardiovascular risk factors' prevalence and association with systemic inflammation in professional male rugby players (RP). Methods: A cross-sectional investigation of 46 professional male RP (26.1±4.1 years) cardiovascular risk factors were compared by position. Inflammatory markers were compared with healthy controls (n=13) and patients with rheumatoid arthritis (RA) (n=10). Results: Twenty-six per cent of RP had no risk factors, 49% had 1-2 cardiovascular risk factors and 25% had 3-4 risk factors. Forwards had greater body fat (p<0.001), visceral fat (p<0.001), glucose (p=0.025), and C reactive protein (CRP) (p=0.023) compared with backs. RP demonstrated more favourable lipid and glucose profiles than reference values for the general population. Most RP (n=28, 61%) had elevated blood pressure (≥140/90 mm Hg). RP had higher vascular adhesion molecule-1 (VCAM-1) (p=0.004) and intracellular adhesion molecule-1 (ICAM-1) (p=0.002) than healthy controls. RP had lower CRP than patients with RA (p=0.009), while one-third (n=15) displayed equivalent ICAM-1 and VCAM-1 levels. Multivariate clustering and principal component analysis biplots revealed higher triglycerides, inflammatory markers, and worse body composition were associated with forwards. Conclusions: Despite athletic status, most of this rugby cohort had at least one cardiovascular risk factor. Concomitantly, these RP demonstrated increased levels of inflammation, with one-third, primarily forwards, displaying equivalent levels to patients with inflammatory disease. Further studies are needed to unravel the prognostic implications of increased inflammation in RP because unchecked, chronic inflammation may lead to increased cardiovascular disease risk.

Comparison of Clinical Scoring Tools to Predict Heparin-Induced Thrombocytopenia in Cardiac Surgery.

The 4Ts and HIT-Expert Probability (HEP) scoring tools for heparin-induced thrombocytopenia (HIT) have not been validated in cardiac surgery patients, and the reported sensitivity and specificity of the Post-Cardiopulmonary Bypass (CPB) scoring tool vary widely in the 2 available analyses. It remains unclear which of the available scoring tools most accurately predicts HIT in this population. Forty-nine HIT-positive patients who underwent on-pump cardiac surgery within a 6-year period were loosely matched to 98 HIT-negative patients in a 1:2 case-control design. The 4Ts, HEP, and CPB scores were calculated for each patient. Sensitivity and specificity of each tool were calculated using standard cut-offs. The Youden method was utilized to determine optimal cut-offs within receiver operating characteristic (ROC) curves of each score, after which sensitivities and specificities were recalculated. Using standard cut-offs, the sensitivities for the CPB, HEP, and 4Ts scores were 100%, 93.9%, and 69.4%, respectively. Specificities were 51%, 49%, and 71.4%, respectively. The AUC of the scoring tool ROC curves were 0.961 for the CPB score, 0.773 for the HEP score, and 0.805 for the 4Ts score. Using the Youden method-derived optimal cut-off of  ≥3 points on the CPB score, sensitivity remained 100% with improved specificity to 88.9%. The CPB score is the preferred HIT clinical scoring tool in adult cardiac surgery patients, whereas the 4Ts score performed less effectively. A cut-off of ≥ 3 points on the CPB score could increase specificity while preserving high sensitivity, which should be validated in a prospective evaluation.

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis for patients with COVID-19: March 2022 update on the use of anticoagulation in critically ill patients.

BACKGROUND: COVID-19-related critical illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for patients with COVID-19. METHODS: ASH formed a multidisciplinary guideline panel, including 3 patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline development process, including performing systematic evidence reviews (up to January 2022). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the GRADE approach to assess evidence and make recommendations, which were subject to public comment. This is an update to guidelines published in February 2021 and May 2021 as part of the living phase of these guidelines. RESULTS: The panel made 1 additional recommendation: a conditional recommendation for the use of prophylactic-intensity over therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of thrombotic and bleeding risk. CONCLUSIONS: This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation for patients with COVID-19-related critical illness.

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: January 2022 update on the use of therapeutic-intensity anticoagulation in acutely ill patients.

BACKGROUND: COVID-19-related acute illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE: These evidence-based guidelines from the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in making decisions about the use of anticoagulation in patients with COVID-19. METHODS: ASH formed a multidisciplinary guideline panel that included patient representatives and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process and performed systematic evidence reviews (through November 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. This is an update to guidelines published in February 2021 as part of the living phase of these guidelines. RESULTS: The panel made one additional recommendation. The panel issued a conditional recommendation in favor of therapeutic-intensity over prophylactic-intensity anticoagulation in patients with COVID-19-related acute illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of risk of thrombosis and bleeding. The panel also noted that heparin (unfractionated or low molecular weight) may be preferred because of a preponderance of evidence with this class of anticoagulants. CONCLUSION: This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation in patients with COVID-19-related acute illness.

American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: July 2021 update on postdischarge thromboprophylaxis.

BACKGROUND: COVID-19-related acute illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis in patients with COVID-19 who do not have confirmed or suspected VTE. METHODS: ASH formed a multidisciplinary guideline panel, including 3 patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including performing systematic evidence reviews (up to March 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the grading of recommendations assessment, development, and evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 1 additional recommendation. The panel issued a conditional recommendation against the use of outpatient anticoagulant prophylaxis in patients with COVID-19 who are discharged from the hospital and who do not have suspected or confirmed VTE or another indication for anticoagulation. CONCLUSIONS: This recommendation was based on very low certainty in the evidence, underscoring the need for high-quality randomized controlled trials assessing the role of postdischarge thromboprophylaxis. Other key research priorities include better evidence on assessing risk of thrombosis and bleeding outcomes in patients with COVID-19 after hospital discharge.

Continuous-infusion von Willebrand factor concentrate is effective for the management of acquired von Willebrand disease.

Acquired von Willebrand disease (aVWD) is a rare disorder associated with a reduction in von Willebrand factor (VWF) activity, leading to increased bleeding risk. Monoclonal gammopathy of undetermined significance (MGUS) is the most common cause of lymphoproliferative disorder-associated aVWD and is caused by accelerated clearance of circulating VWF. Standard VWF replacement protocols for congenital VWD based on intermittent bolus dosing are typically less effective for aVWD because of antibody-mediated clearance. Intermittent bolus dosing of VWF concentrates often leads to inadequate peak response and profoundly shortened VWF half-life in aVWD. Intravenous immune globulin (IVIG) has demonstrated efficacy in aVWD; however, treatment effect is delayed up to 4 days, limiting its efficacy in acutely bleeding patients. We report the successful use of continuous-infusion VWF concentrate (with or without concomitant IVIG) in 3 patients with MGUS-associated aVWD who had demonstrated an inadequate response to bolus dosing. VWF concentrate doses required in this cohort were higher than typical doses for bleeding treatment in congenital VWD. This report illustrates that continuous-infusion VWF concentrate administration with or without intravenous immunoglobulin rapidly achieves target ristocetin cofactor activity and provides adequate hemostasis in aVWD associated with immunoglobulin G MGUS.