Elderly Patients with Venous Thromboembolism: Insights from the RIETE Registry.

Venous thromboembolism (VTE) presents a notable healthcare burden, particularly among the elderly, who experience increased risks and more severe complications. This review aims to use the extensive data from the RIETE registry, a comprehensive database on consecutive patients with VTE. We examine the clinical features, therapeutic approaches, and patient outcomes of VTE in elderly patients, compared to younger patients, offering a comprehensive understanding of management challenges and emphasizing the need for strategies that accommodate the unique challenges of this population.

Applying Machine Learning for Prescriptive Support: A Use Case with Unfractionated Heparin in Intensive Care Units.

Continuous unfractionated heparin is widely used in intensive care, yet its complex pharmacokinetic properties complicate the determination of appropriate doses. To address this challenge, we developed machine learning models to predict over- and under-dosing, based on anti-Xa results, using a monocentric retrospective dataset. The random forest model achieved a mean AUROC of 0.80 [0.77-0.83], while the XGB model reached a mean AUROC of 0.80 [0.76-0.83]. Feature importance was employed to enhance the interpretability of the model, a critical factor for clinician acceptance. After prospective validation, machine learning models such as those developed in this study could be implemented within a computerized physician order entry (CPOE) as a clinical decision support system (CDSS).

Perinatal Injectable Opioid Agonist Therapy (iOAT) Administration: A Case Series.

OBJECTIVES: Untreated opioid use disorder (OUD) in pregnancy may lead to adverse outcomes for the individual and fetus. Injectable opioid agonist therapy (iOAT) is the highest intensity treatment for severe refractory OUD currently available; however, research on perinatal administration is limited. We present the first known case series of 13 pregnant or postpartum participants who received intravenous hydromorphone while admitted to the Families in Recovery (FIR) unit, an in-patient perinatal stabilization unit in Canada. METHODS: Patients who received iOAT at FIR between 2019 and 2022 were invited to participate. Prospectively enrolled participants completed a self-report sociodemographics and exposures survey. Medical/social backgrounds of participants at admission, iOAT and other opioid agonist therapy administration, and health/social outcomes of mother and infant at discharge were collected on all participants via retrospective maternal and infant medical chart review. RESULTS: Participants initiated iOAT while pregnant (n = 5) or postpartum (n = 8) and received iOAT for 23 days on average. At discharge, 8 participants underwent planned transition to community with infant in their care and a discharge plan including outpatient prescriptions, housing arrangements, follow-up appointments, and supportive programming. All infants received oral morphine after delivery and were discharged in good health. CONCLUSIONS: This is the first known case series of iOAT administration in the peripartum. The cases illustrate iOAT as an option that can achieve OUD stabilization in perinatal individuals to support patient engagement and retention in care.

Breastfeeding on Injectable Opioid Agonist Therapy: A Case Report.

BACKGROUND: Injectable opioid agonist therapy (iOAT) is the highest-intensity treatment currently available in Canada for individuals with severe opioid use disorder. However, there is limited data on iOAT administration in the perinatal period, with no research, practice guidelines, or known reports of breastfeeding on iOAT. This article presents the first known case of an individual breastfeeding on iOAT. CASE SUMMARY: We present a case of a pregnant 32-year-old woman from Canada with severe opioid use disorder, who stabilized with iOAT and chose to breastfeed her infant. She presented to hospital at 38 + 6 gestation in labor, unstable in her substance use disorder despite multiple interventions and was initiated on iOAT (intravenous hydromorphone) shortly after delivery. Before initiation of breastfeeding the infant was admitted to the neonatal intensive care unit for monitoring. On day 9 of life the infant received breastmilk for the first time, and was discharged from neonatal intensive care unit on day 12 of life with no clinical evidence of sedation or respiratory depression. The infant maintained mixed feeding and at 58 days of life was discharged in the mother and father's care, a healthy infant with stable vitals. DISCUSSION: This case suggests positive infant and maternal health and social outcomes for breastfeeding on iOAT. Further research on perinatal iOAT use and the pharmacokinetics of high-dose hydromorphone in breastmilk is required to inform clinical practice guidelines to safely support individuals and their infants who are impacted by substance use.

Impact of a pneumatic tube system transport on hemostasis parameters measurement: the experiment of Cochin universitary hospital (AP-HP, Paris, France).

Samples transported by pneumatic tube system are submitted to forces of acceleration and deceleration which can affect laboratory parameters. At Cochin hospital, majority of samples of hemostasis, except for platelets tests, are transported by pneumatic tube system. The objective of this study was to evaluate the impact of a pneumatic tube system (PTS) transport compared to hand-delivered transport on samples and to qualify Cochin hospital PTS according to requirements of standard ISO 15189. A bibliographical study was made and showed that pneumatic tube system particularly influences platelets tests. Four citrate tubes were collected in 5 healthy volunteers in the maternity: 2 tubes were transported by PTS and 2 others were hand-delivered to the laboratory. Five coagulation tests were analyzed: prothrombine time (PT), activated partial thromboplastin time (aPTT), factor (F) V, FVIII and platelet closure time with PFA-100TM collagen/epinephrine. For each volunteer, the results obtained by PTS and by hand-delivered transport were compared with formula usually used for biological analysis retake: 2.8 x standard deviation of reproductibility variation coefficient (SH GTA 01, COFRAC). This study did not show an impact of PTS on PT, aPTT, FV and FVIII. For PFA-100TM collagen/epinephrine, we noted an impact on 2/5 volunteers. These results, in agreement with the literature, led to the conclusion that Cochin hospital PTS is in compliance to transport samples for usual coagulation tests except platelet tests. This study allowed to issue French recommendations for PTS transport of hemostasis tubes qualification available on "Groupe français d'hémostase et thrombose" Web site.

Initiation of warfarin therapy in elderly medical inpatients: a safe and accurate regimen.

PURPOSE: Elderly patients are at high risk of over-anticoagulation when treated with warfarin, especially during treatment induction. We developed a simple low-dose regimen for starting warfarin therapy in elderly inpatients. The daily maintenance dosage is predicted from the international normalized ratio (INR) measured the day after the third daily intake of a 4-mg dose. We conducted a prospective multicenter study to evaluate the accuracy and safety of this regimen. METHODS: We studied 106 elderly (age >or=70 years) inpatients (mean [+/- SD] age, 85 +/- 6 years; range, 71 to 97 years) who had a target INR of 2.0 to 3.0. Accuracy in predicting the daily maintenance dose from INR value on day 3 was evaluated. RESULTS: The predicted daily maintenance warfarin dose (3.1 +/- 1.6 mg/d) correlated closely with the actual maintenance dose (3.2 +/- 1.7 mg/d; R(2) = 0.84). The predicted dose was equal to the actual dose in 77 patients (73%; 95% confidence interval [CI]: 64% to 81%) and within 1 mg in 101 patients (95%; 95% CI: 91% to 99%). The mean time needed to achieve a therapeutic INR was 6.7 +/- 3.3 days (median, 6.0 days); the mean time needed to achieve the maintenance dose was 9.2 +/- 4.5 days (median, 7.0 days). None of the patients had an INR >4.0 during this period. One fatal bleeding event was recorded in a patient with an INR in the therapeutic range. CONCLUSION: Our warfarin induction regimen was simple, safe, and accurate in predicting the daily maintenance warfarin dose in elderly hospitalized patients.

Safety profile of tinzaparin administered once daily at a standard curative dose in two hundred very elderly patients.

OBJECTIVES: Too few very elderly patients with an age-related renal impairment are included in clinical trials. We conducted a study in order to evaluate the safety profile of tinzaparin, a low molecular weight heparin (LMWH), given at a curative dose (175 IU/kg once daily) in very elderly patients treated for up to 30 days. SETTING: An 800-bed geriatric hospital. DESIGN: A 1-year prescribing study. PATIENTS: Consecutive in-patients older than age 70, whose creatinine clearance was above 20 ml/min, and requiring full anticoagulation with LMWH were included. MEASUREMENTS: Safety parameters (major bleeding/heparin-induced thrombocytopenia/death) were recorded. Plasma anti-Xa activity levels were regularly measured throughout the treatment period. RESULTS: Two-hundred in-patients, mean age 85.2 +/- 6.9 years (70 to 102), mean creatinine clearance 51.2 +/- 22.9 ml/min, were given tinzaparin. Six patients died during the treatment period: only one could be related to the anticoagulation treatment. Three major bleeding episodes (1.5%) were reported. Antithrombotic drug interactions likely contributed to the bleeding event in two of them. Heparin-induced thrombocytopenia was confirmed in two patients (1%). No correlation was found between anti-Xa activity and creatinine clearance or age. CONCLUSIONS: Tinzaparin can be used safely at a curative dose in very elderly patients as long as (i) the accurate bodyweight-adjusted dose is given; (ii) platelet counts and anti-Xa levels are regularly monitored and; (iii) the interaction with other antithrombotic drugs is correctly managed.

Placement of the VenaTech LP caval filter in the elderly: feasibility and clinical benefits of insertion via the arm.

PURPOSE: To evaluate routine use of access sites in the arm for percutaneous caval filter placement (PCFP) in elderly patients. Neck arthritis, patient anxiety, access site thrombosis or fecal/urinary incontinence complicating jugular or femoral access may require alternative access sites in this population. METHODS: Access via the right arm was chosen for PCFP (VenaTech LP). The indication for PCFP was deep vein thrombosis, a history of pulmonary embolism, and a contraindication to anticoagulant therapy. Ultrasound-guided puncture was performed after diameter measurement of the arm veins (ØAV). The filter was inserted with standard imaging procedures. Procedural difficulty was graded and compared with ØAV and the angle from the arm vein to the superior vena cava (alphaAV/SVC). RESULTS: Over 2 years, 16 patients (14 women, 2 men) with an average age of 90 years (range 79-97 years) were included in the study. The average ØAV value of the basilic or brachial veins was 4.2 mm (range 3.0-5.1 mm). The minimal ØAV for successful access was determined after the first 15 patients. No hematoma occurred at the puncture sites. The average alphaAV/SVC value was 62 degrees (range 29 degrees -90 degrees ). Arm access was possible in 12 of 16 patients (75%) with ØAV >or= 3.5 mm and alphaAV/SVC >or= 29 degrees . Every procedure via the arm was graded "easy" by the operator, regardless of angulation values. Femoral access was used in one case due to the impossibility of traversing the heart (patient no. 2), and jugular access was used in 3 of 16 (19%) patients due to puncture failure (patient no. 4), small ØAV (3 mm) (patient no. 6), and stenosis of the distal right subclavian vein (patient no.16), respectively. CONCLUSION: PCFP via the arm can be routinely accomplished in patients older than 75 years, provided ØAV >or= 3.5 mm, and alphaAV/SVC >or= 29 degrees .

Low molecular weight heparin treatment in elderly subjects with or without renal insufficiency: new insights between June 2002 and March 2004.

PURPOSE OF REVIEW: Low molecular weight heparin has become the treatment of choice for venous thromboembolism events and acute coronary syndromes. In contrast to unfractionated heparin, low molecular weight heparins are mainly excreted by the kidney. Thus, repeated administration of therapeutic doses of low molecular weight heparins may lead to overdosage and/or an accumulation effect in patients with renal impairment, such as the elderly. Moreover, older patients are often excluded from clinical trials. Little evidence is available to assess the risk/benefit ratio of low molecular weight heparins used at therapeutic dosages in elderly patients with or without renal insufficiency in normal clinical practice. RECENT FINDINGS: Pharmacovigilance data, case reports, and observational studies reporting major bleeding complications in the elderly highlight the potential risk of using low molecular weight heparins at therapeutic dosages in these patients. An evaluation of renal function is thus essential before therapy with low molecular weight heparins is begun. Moreover, multiple-dose pharmacokinetic studies in the elderly have shown that the pharmacokinetic response to impaired renal function, especially the risk of accumulation effect, may differ among preparations of low molecular weight heparins. SUMMARY: Three approaches to improve the safety of low molecular weight heparins in the elderly are discussed: (1) to replace low molecular weight heparin therapy with monitored unfractionated heparin therapy in cases of severe renal insufficiency, but comparative studies are necessary to clarify whether unfractionated heparin offers better safety in this setting; (2) to use initial reduced dosages in elderly patients with or without renal failure, but these regimens have to be validated for each low molecular weight heparin in terms of efficacy in controlled trials; and (3) to monitor anti-Xa activity to detect any overdosage and/or any accumulation effect of low molecular weight heparins.