Retrospective, multicenter analysis of the safety and effectiveness of direct oral anticoagulants for the treatment of venous thromboembolism in obesity.

BACKGROUND: Direct oral anticoagulants (DOACs) are the preferred treatment for venous thromboembolism (VTE). However, DOAC use in patients with a BMI greater than 40 kg/m2 has not been well studied despite the growing prevalence of obesity, and current literature is often underpowered. METHODS: This multicenter, retrospective, observational study evaluated patients 18 years and older who received DOACs for acute VTE treatment. Patients receiving DOACs for recurrent VTE or for failure of another agent were excluded. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding within 12 months (or one month after stopping anticoagulation therapy). A propensity score analysis was performed to balance patient characteristics and evaluate the primary endpoints by BMI group. Time-to-event outcomes were analyzed using weighted Kaplan-Meier curves. RESULTS: There were 165 patients with a BMI of at least 40 kg/m2 and 320 patients with a BMI less than 40 kg/m2. The majority received apixaban (373, 77%). Recurrent VTE occurred in 5 (3.0%) and 13 (4.1%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 0.66; 95% CI: 0.16-2.69). Major bleeding occurred in 5 (3.0%) and 15 (4.7%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 1.19; 95% CI: 0.36-3.92). CONCLUSION: There was no significant difference in VTE recurrence or major bleeding related to BMI among patients treated with DOACs. This study showed that DOACs may be a safe and effective VTE treatment option in patients with obesity.

Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit.

INTRODUCTION: Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population. METHODS: We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission. RESULTS: Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff. CONCLUSIONS: Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Assessment of web-based applications for ambulatory care rotations.

BACKGROUND: An interactive Web site was developed to supplement ambulatory care clinical rotations, optimize collaborative efforts of ambulatory care preceptors, and standardize the educational and evaluation experience. OBJECTIVE: To evaluate perceptions of residents and students using an interactive Web site for ambulatory care clinical pharmacy rotations. METHODS: An online anonymous survey comprised of 12 questions using a 5-point Likert scale (1-5, strongly disagree-strongly agree) and 4 open-ended questions was designed. Over a 3-year time frame, each student and resident rotating through the ambulatory care clinical rotation was instructed to complete the survey at the end of the rotation experience. Survey results were compiled and analyzed. RESULTS: Sixty-nine percent (18/26) of residents and 71% (54/76) of students completed the survey. Overall, the Web site was well accepted by all learners. Residents and students differed in opinion on a few aspects of the Web site; however, both appreciated the ease of accessibility and links to additional resources. Inoperable links and outdated quizzes were identified as major weaknesses. CONCLUSIONS: Perceptions of an interactive Web site used during ambulatory care clinical rotations were positive. The survey results reinforce the continued use of this teaching method and will enable preceptors to make appropriate adjustments for future learners.