Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy.

Introduction/Objective Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods We conducted a retrospective study including all participants (age 50-74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March-August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy.

Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients.

Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.

Clinical care pathway for the evaluation of patients with suspected VITT after ChAdOx1 nCoV-19 vaccination.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare complication after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) adenoviral vector vaccination. In British Columbia (BC), Canada, a provincial clinical care pathway was developed to guide clinicians in evaluating for VITT among patients who present with thrombocytopenia or thrombosis symptoms within 4 to 28 days after adenoviral vector vaccine exposure. All patients had enzyme-linked immunosorbent assay (ELISA) testing for platelet factor 4 (PF4) antibodies, and all cases with positive PF4-ELISA or d-dimer levels ≥2.0 mg/L fibrinogen equivalent units (FEU) had further testing for platelet-activating PF4 antibodies using a modified serotonin release assay (SRA). Between 1 May and 30 June 2021, 37% of 68 patients investigated for VITT had thrombosis, but only 3 had VITT confirmed by PF4-ELISA and SRA. Platelet counts, d-dimer levels, and ELISA optical density values were significantly different between those with and without VITT. Three patients had thrombocytopenia and thrombosis with d-dimer levels >4.0 mg/L FEU but had negative PF4-ELISA and SRA results. Patients with VITT were treated successfully with IV immunoglobulin, nonheparin anticoagulants, and corticosteroids. Our pathway demonstrated that thrombosis is common among patients investigated for VITT and that PF4-ELISA testing is necessary to confirm VITT in those presenting with thrombosis and thrombocytopenia.

Reducing emergency department visits in patients with deep vein thrombosis: introducing a standardised outpatient treatment pathway.

Deep vein thrombosis (DVT) is an acute medical condition that requires urgent diagnosis and treatment to prevent significant morbidity and mortality. Patients with DVT frequently present to the emergency department (ED) because the necessary diagnostic investigations and medical treatment for successful outpatient management are not readily accessible in the outpatient clinics. A collaborative quality improvement project was undertaken to implement and evaluate a standardised outpatient treatment pathway designed to direct patients with a newly diagnosed DVT from the ultrasound department to the thrombosis clinic, where guideline-based management for DVT can be accomplished without ED visits. During the baseline period (1 February 2017 to 31 January 2019), the number of ED visits for DVT was 383 with an average of 16 visits per month. During the intervention period (1 February 2019 to 31 January 2020), the number of ED visits for DVT was 106 with an average of 8.8 visits per month. This represents almost a 50% reduction in the average ED visits during the intervention period. A standardised outpatient treatment pathway can significantly reduce the number of ED visits in patients with DVT, potentially improving patient care and reducing ED overcrowding.

Preventability of 28-Day Hospital Readmissions in General Internal Medicine Patients: A Retrospective Analysis at a Quaternary Hospital.

BACKGROUND: Unplanned hospital readmissions are associated with increased patient mortality and health care costs, yet only a fraction are likely to be preventable. This study's objective was to identify preventable hospital readmissions of general internal medicine patients, and their common causes. METHODS: Patients who were discharged from the general internal medicine teaching service and readmitted to hospital within 28 days for 24 hours or more were recruited to the study; they were identified via the hospital electronic medical record system. Data were gathered via structured review of hospital charts/electronic medical records, along with standardized patient interviews. Unique to our study, a multidisciplinary panel of physicians, nurses, and hospital administrators adjudicated preventability and identified common causes of readmission. RESULTS: Fifty-five hospital readmissions were identified; 53% were adjudicated to be preventable. There was no difference in any variable analyzed between preventable and nonpreventable readmissions. The most common causes of preventable readmissions were inadequate coordination of community services upon discharge, insufficient clinical postdischarge follow-up, and suboptimal end-of-life care. CONCLUSION: This study identified a higher proportion of preventable 28-day hospital readmissions when compared with prior research. Increased involvement of palliative care during initial hospitalization for appropriate conditions and improvements in care after discharge may reduce preventable hospital readmissions.

Residual pulmonary embolism as a predictor for recurrence after a first unprovoked episode: Results from the REVERSE cohort study.

BACKGROUND: The optimal duration of oral anticoagulant therapy after a first, unprovoked venous thromboembolism is controversial due to tightly balanced risks and benefits of indefinite anticoagulation. Risk stratification tools may assist in decision making. OBJECTIVES: We sought to determine the relationship between residual pulmonary embolism assessed by baseline ventilation-perfusion scan after completion of 5-7months of oral anticoagulant therapy and the risk of recurrent venous thromboembolism in patients with the first episode of unprovoked pulmonary embolism. METHODS: We conducted a multicentre prospective cohort study of participants with a first, unprovoked venous thromboembolism enrolled after the completion of 5-7months of oral anticoagulation therapy. The participants completed a mean 18-month follow-up. Participants with pulmonary embolism had baseline ventilation-perfusion scan before discontinuation of oral anticoagulant therapy and the percentage of vascular obstruction on baseline ventilation-perfusion scan was determined. During follow-up after discontinuation of oral anticoagulant therapy, all episodes of suspected recurrent venous thromboembolism were independently adjudicated with reference to baseline imaging. MEASUREMENTS AND MAIN RESULTS: During follow-up, 24 of 239 (10.0%) participants with an index event of isolated pulmonary embolism or pulmonary embolism associated with deep vein thrombosis and central assessment of percentage of vascular obstruction on baseline ventilation-perfusion scan had confirmed recurrent venous thromboembolism. As compared to participants with no residual pulmonary embolism on baseline ventilation-perfusion scan, the hazard ratio for recurrent venous thromboembolism was 2.0 (95% CI 0.5-7.3) for participants with percentage of vascular obstruction of 0.1%-4.9%, 2.1 (95% CI 0.5-7.8) for participants with percentage vascular obstruction of 5.0%-9.9% and 5.3 (95% CI 1.8-15.4) for participants with percentage vascular obstruction greater than or equal to 10%. CONCLUSIONS: Residual pulmonary embolism assessed by pulmonary vascular obstruction on baseline ventilation-perfusion performed after 5-7months of oral anticoagulant therapy for the first episode of unprovoked pulmonary embolism was associated with a statistically significant higher risk of subsequent recurrent venous thromboembolism. Percentage of pulmonary vascular obstruction assessment by ventilation-perfusion scans maybe a useful tool to help guide the duration of oral anticoagulant therapy after a first unprovoked pulmonary embolism. TRIAL REGISTRATION: Registered at www.clinicaltrials.gov identifier: NCT00261014.

Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies.

Pulmonary embolism (PE) is one of the leading causes of maternal mortality despite a low incidence of PE during pregnancy. Several challenges surround the diagnosis of PE in pregnant women and the existing clinical guidelines provide weak recommendations on selecting the appropriate investigations for suspected PE in pregnancy. The purpose of this narrative review is to compare and contrast the recommendations of current clinical guidelines and review the evidence underpinning the recommendations on the evaluation of suspected PE in pregnancy. Consensus and controversies, knowledge gaps and areas requiring further research will be highlighted.

Catastrophic antiphospholipid syndrome presenting with pulmonary hemorrhage: case report.

This is a case report of catastrophic antiphospholipid syndrome (APLS) involving the rare manifestation of pulmonary hemorrhage. This rare variant of APLS is frequently life threatening despite medical therapy. The pathogenesis of pulmonary hemorrhage in catastrophic APLS remains incompletely understood. The optimal approach to managing pulmonary hemorrhage in the setting of catastrophic APLS is still unclear, however this case report demonstrates the success of combination therapy with anticoagulation, corticosteroids and plasma exchange.