<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_448"
                     title="Inflammatory Bowel Disease Linked to Dangerous VT (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Gastroenterology/InflammatoryBowelDisease/tb/18362?impressionId=1265786775477"
                     
      &lt;p&gt;Patients with active inflammatory bowel disease (IBD) could be at far greater risk for potentially deadly blood clots than doctors previously thought, a new British study found.&lt;/p&gt;
&lt;p&gt;Nonhospitalized patients with active IBD are 16 times more likely to suffer venous thromboembolism than the general population, with an occurrence rate of 6.4 per 1,000 person-years (HR 15.8, 95% CI 9.8 to 25.5, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), according to an online report in the Feb. 9 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The authors concluded that such patients could benefit from preventative treatment to prevent blood clotting.&lt;/p&gt;
&lt;p&gt;&quot;Despite the low absolute risks during nonhospitalised periods, these results suggest that active inflammatory bowel disease in ambulatory patients might be a far greater risk factor for venous thromboembolism than previously recognised,&quot; Matthew J. Grainge, MD, of the University of Nottingham, and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Patients with venous thromboembolism in the leg have a short term-mortality rate of about 6%, increasing as high as 20% when the clot has circulated to the lung.&lt;/p&gt;
&lt;p&gt;Researchers believe that infection and inflammation, such as occur in IBD, predispose patients to this life-threatening condition, and those with inflammatory bowel disease seem to be at particular risk.&lt;/p&gt;
&lt;p&gt;Grainge and colleagues used records from the U.K. General Practice Research Database from November 1987 through July 2001, to match 13,756 patients with IBD against 71,672 controls without the disease.&lt;/p&gt;
&lt;p&gt;Of the subjects, 139 patients and 165 controls developed a blood clot during the study period.&lt;/p&gt;
&lt;p&gt;Their results agreed with previous studies indicating that patients hospitalized for IBD are at high risk for venous thromboembolism. However, the new study also found the danger extends to nonhospitalized IBD patients, particularly during a flare-up.&lt;/p&gt;
&lt;p&gt;Overall, the researchers reported, patients with IBD had three times as much risk of an embolism as controls (HR 3.4, 95% CI 2.7 to 4.3; &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001) with an occurrence rate of 2.6 per 1,000 per person-years.&lt;/p&gt;
&lt;p&gt;During a flare-up, IBD patients were at dramatically greater risk.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study excluded patients likely to have received corticosteroids for chronic respiratory disease and rheumatoid arthritis, so the results may not reflect blood clotting rates in these populations.&lt;/p&gt;
&lt;p&gt;They also noted that they relied on anonymous patient records and were dependent on family doctors&apos; diagnoses of inflammatory bowel disease, flare-ups and venous thromboembolism.&lt;/p&gt;
&lt;p&gt;Despite the limitations of the study, they argued that research into ways to prevent embolism in IBD outpatients is warranted.&lt;/p&gt;
&lt;p&gt;&quot;We believe that the medical profession needs to recognise the increased risk in people with inflammatory bowel disease when assessing the likelihood of venous thromboembolism and to address the difficulty of reducing this risk in patients with a flare who are not admitted to hospital,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;They suggested that strategies used to prevent blood clots in hospitalized patients  --  courses of low molecular weight heparin or other newly available anticoagulants  --  might be also be used to prevent clots in nonhospitalized IBD patients experiencing a flare-up.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Geoffrey C. Nguyen, MD, and Erik L. Yeo, MD, of the University of Toronto, noted that &quot;the use of steroid prescriptions as a surrogate indicator of acute disease flare restricts the applicability of Grainge and colleagues&apos; findings to flares that are moderate to severe. Whether patients with mild flares are also at increased risk is not clear.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Recognition of venous thromboembolism might be increased during periods of frequent contact with doctors, such as during flares compared with during remission of inflammatory bowel disease, thus potentially introducing a bias in ascertainment of venous thromboembolism,&quot; they added.&lt;/p&gt;
&lt;p&gt;Nguyen and Yeo also argued that the clinical efficacy and cost-effectiveness of pharmacological prevention in patients with inflammatory bowel disease should be proven before it is routinely recommended during acute flares.&lt;/p&gt;
&lt;p&gt;However, they acknowledged that such evidence could be difficult to acquire, given the low numbers of nonhospitalized IBD patients who suffer venous thromboembolism.&lt;/p&gt;
&lt;p&gt;&quot;A pragmatic initial approach to reduction of the rates of morbidity and mortality resulting from venous thromboembolism in ambulatory patients with inflammatory bowel disease would be nonpharmacological thromboprophylaxis, including patients&apos; education and awareness of risk and signs and symptoms of venous thromboembolism, and use of support stockings,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Physicians should clinically assess for signs and symptoms of this embolism during visits for acute flare of inflammatory bowel disease.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the National Association for Colitis and Crohn&apos;s Disease.&lt;/p&gt;&lt;p&gt;The authors reported no financial conflicts of interest.&lt;/p&gt;&lt;p&gt;Nguyen reported serving on advisory boards for Schering-Plough, Canada, and Abbott Pharmaceuticals.&lt;/p&gt;&lt;p&gt;Yeo reported receiving an honorarium from sanofi-aventis.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_371"
                     title="Single Ultrasound for DVT May Suffice (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/VenousThrombosis/tb/18257?impressionId=1265786775477"
                     
      &lt;p&gt;For patients with suspected deep vein thrombosis, the risk of symptomatic venous thromboembolism after a single, negative whole-leg compression ultrasound examination is low, a meta-analysis showed.&lt;/p&gt;
&lt;p&gt;Pooled results from seven studies showed the risk to be just 0.57% (95% CI 0.25% to 0.89%) through three months of follow-up in patients who were not given anticoagulants, Scott Stevens, MD, of Intermountain Medical Center in Murray, Utah, and colleagues reported in the Feb. 3 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The researchers suggested that a repeated compression ultrasound evaluation to detect distal thrombi moving upward  --  recommended in clinical practice guidelines five to seven days after a negative finding  --  may not be necessary.&lt;/p&gt;
&lt;p&gt;&quot;The efficiency and convenience of whole-leg compression ultrasound as a single study is superior to that of repeated ... evaluations,&quot; the researchers concluded.&lt;/p&gt;
&lt;p&gt;However, an accompanying editorial by Robert McNutt, MD, PhD, of Rush University Medical Center in Chicago, and Edward Livingston, MD, of the University of Texas Southwestern Medical Center in Dallas, cautioned against basing clinical decisions on a meta-analysis.&lt;/p&gt;
&lt;p&gt;They pointed to the variation in event rates among the seven included studies, ranging from 0.24% to 1.95%. The highest rate was found in hospitalized patients, although most of the studies included ambulatory patients.&lt;/p&gt;
&lt;p&gt;&quot;So using this average probability [0.57%] for clinical decision making in some clinical contexts may do more harm than good,&quot; they wrote. &quot;Greater detail about individual patient scenarios is necessary to facilitate better application of the study results to individual patients.&quot;&lt;/p&gt;
&lt;p&gt;Although whole-leg compression ultrasound reliably identifies the presence or absence of deep vein thrombosis above the knee, its accuracy for thrombi below the knee is less certain, according to Stevens and colleagues.&lt;/p&gt;
&lt;p&gt;So guidelines have recommended repeating the examination after a negative finding to rule out the upward propagation of a distal thrombus.&lt;/p&gt;
&lt;p&gt;But only 1% to 2% of those repeat exams actually detect thrombus propagation.&lt;/p&gt;
&lt;p&gt;Thus, a single whole-leg compression ultrasound may reliably exclude both proximal and distal deep vein thrombosis, the authors said.&lt;/p&gt;
&lt;p&gt;They reviewed the literature to assess the risk of venous thromboembolism in patients with suspected lower extremity deep vein thrombosis who had a single, negative whole-leg compression ultrasound and who had not received anticoagulation treatments for 90 days.&lt;/p&gt;
&lt;p&gt;Seven studies were included  --  one randomized controlled trial and six prospective cohort studies  --  comprising 4,731 patients, mostly from the ambulatory setting.&lt;/p&gt;
&lt;p&gt;Through three months of follow-up, 0.7% of patients had either confirmed venous thromboembolism or suspected venous thromboembolism-related death. All nine who died were either acutely ill, hospitalized patients, or patients with advanced cancer.&lt;/p&gt;
&lt;p&gt;The risk of having an event during follow-up increased with greater pretest probability of having deep vein thrombosis  --  0.29% for low risk, 0.82% for moderate risk, and 2.49% for high risk.&lt;/p&gt;
&lt;p&gt;However, because of low patient numbers, the researchers wrote, &quot;using a single negative whole-leg compression ultrasound result as the sole diagnostic modality in patients with high pretest probability of deep vein thrombosis requires further study.&quot;&lt;/p&gt;
&lt;p&gt;The authors listed several limitations of the analysis: &lt;ul&gt; &lt;li&gt;The variability in ultrasound techniques between the included studies may limit the validity and generalizability of the findings.&lt;/li&gt; &lt;li&gt;The pretest probability of deep vein thrombosis was not assessed using a standardized clinical prediction rule by most studies.&lt;/li&gt; &lt;li&gt;The findings might have limited generalizability to pregnant women, patients with cancer, and inpatients, who were underrepresented in the studies.&lt;/li&gt; &lt;li&gt;Longer-term outcomes were not assessed.&lt;/li&gt; &lt;li&gt;The findings might have been affected by verification bias, because only patients with symptoms were evaluated for venous thromboembolism during follow-up.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Steven did not report any conflicts of interest. One of his co-authors reported receiving consulting fees from AGEN Biomedical, Janssen-Ortho, Boehringer-Ingelheim, sanofi-aventis, and AstraZeneca, and receiving speaker&apos;s fees from Pfizer, Leo Pharma, and sanofi-aventis.&lt;/p&gt;&lt;p&gt;The editorialists did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_1387"
                     title="Oral Factor Xa Inhibitor Prevents Postsurgical Thrombosis"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Cardiology/VenousThrombosis/tb/14058?impressionId=1265786775477"
                     
      WHEELING, W.Va., May 5 -- The investigational anticoagulant rivaroxaban (Xarelto), given after knee surgery, showed significantly better efficacy and equivalent safety compared with enoxaparin (Lovenox), researchers said.
              &lt;p&gt; 
              &lt;p&gt;Rates of a composite outcome measure -- comprising deep vein thrombosis, nonfatal pulmonary embolism, and all-cause mortality -- were 6.9% with rivaroxaban and 10.1% with enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.012), reported Alexander Turpie, M.D., of McMaster University in Hamilton, Ontario, and colleagues online in &lt;em&gt;The Lancet&lt;/em&gt;.
              &lt;p&gt; 
              &lt;p&gt;Major bleeding events were seen in 0.7% of rivaroxaban patients versus 0.3% of those taking enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.110), the researchers said.
              &lt;p&gt; 
              &lt;p&gt;The findings came in the fourth installment in the RECORD series of randomized trials involving rivaroxaban, an oral inhibitor of Factor Xa. Results from the trial were also presented last May at an orthopedics meeting, and pooled results from all four RECORD studies were reported in December at another meeting. (See &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ASHHematology/12123&quot; target=&quot;blank&quot;&gt;ASH: Investigational Drug Beats Enoxaparin for Post-Surgery Thrombosis Prevention&lt;/a&gt;)
              &lt;p&gt; 
              &lt;p&gt;All four studies demonstrated significantly lower rates of thrombotic events. The RECORD4 finding of nonsignificantly increased frequency of major bleeding events also mirrored those of the other trials in the series. (See &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/VenousThrombosis/9932&quot; target=&quot;blank&quot;&gt;Investigational Oral Anticoagulant Bests Enoxaparin After Orthopedic Surgery&lt;/a&gt;)
              &lt;p&gt; 
              &lt;p&gt;On the strength of the RECORD studies, the drug&apos;s manufacturers have filed a marketing application for rivaroxaban. An FDA advisory panel voted 15 to 2 in March to recommend approval for the drug. (See &lt;a href=&quot;http://www.medpagetoday.com/ProductAlert/Prescriptions/13353&quot; target=&quot;blank&quot;&gt;Panel Recommends Approval for Rivaroxaban&lt;/a&gt;)
              &lt;p&gt; 
              &lt;p&gt;In RECORD4, 3,148 patients undergoing knee arthroplasty were randomized to oral rivaroxaban at 10 mg once a day, beginning six to eight hours after surgery, or to subcutaneous enoxaparin at 30 mg twice a day starting 12 to 24 hours after surgery.
              &lt;p&gt; 
              &lt;p&gt;Individual efficacy outcomes in RECORD4 through day 17 after surgery did not show significant superiority for rivaroxaban compared with enoxaparin:
              &lt;p&gt; 
              &lt;ul&gt;
                &lt;li&gt;Major venous thromboembolism (intent-to-treat): 1.2% rivaroxaban, 2.0% enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.124)
                &lt;li&gt;Nonfatal pulmonary embolism: 0.3% rivaroxaban, 0.5% enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.525)
                 &lt;li&gt;Death: 0.1% rivaroxaban, 0.2% enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.745)
                  &lt;li&gt;Symptomatic venous thromboembolism: 0.7% rivaroxaban, 1.2% enoxaparin (&lt;em&gt;P&lt;/em&gt;=0.187)
                            &lt;/ul&gt;
                              &lt;p&gt; 
                              &lt;p&gt;Small numbers of these outcomes appeared to account for the lack of significance. There were only 35 cases of major embolic events, 12 nonfatal pulmonary embolisms, and five deaths in the study.
                              &lt;p&gt; 
                              &lt;p&gt;Likewise, there were few major bleeds among participants -- a total of 14 (10 with rivaroxaban, four with enoxaparin) from the start of treatment to two days after the last dose.
                              &lt;p&gt; 
                              &lt;p&gt;&quot;Major&quot; bleeding included events leading to reoperation or transfusion, bleeding into a critical organ, or resulting in measurable reduction in hemoglobin levels.
                              &lt;p&gt; 
                              &lt;p&gt;Less significant bleeding events occurred in 39 rivaroxaban patients and 30 in the enoxaparin group.
                              &lt;p&gt; 
                              &lt;p&gt;Other adverse events occurred at similar rates in the two groups. Counts of all serious adverse events occurring during treatment were 114 with rivaroxaban and 134 with enoxaparin.
                              &lt;p&gt; 
                              &lt;p&gt;Knee outcomes were not specifically assessed in the study.
                              &lt;p&gt; 
                              &lt;p&gt;Dr. Turpie and colleagues said the best time to begin rivaroxaban therapy was still uncertain.
                              &lt;p&gt; 
                              &lt;p&gt;&quot;Earlier postoperative initiation of prophylaxis is probably more effective than is delayed administration after surgery,&quot; they said. &quot;However, earlier administration can also result in increased risk of early postoperative bleeding.&quot;
                              &lt;p&gt; 
                              &lt;p&gt;They said additional investigation was needed to settle the issue.
                              &lt;p&gt; 
                              &lt;p&gt;In an accompanying editorial, Richard C. Becker, M.D., of Duke University said the trial highlighted the value of venous thromboembolism prophylaxis following orthopedic surgery.
                              &lt;p&gt; 
                              &lt;p&gt;&quot;The long-term consequences of venous thromboembolism are being increasingly recognized and defined with clarity,&quot; he wrote.
                              &lt;p&gt; 
                              &lt;p&gt;&quot;Clear progress has been achieved, and oral drug-delivery platforms could represent a vital step forward,&quot; he added.
                              &lt;p&gt; 
                              &lt;p&gt;But he also pointed out that the pathobiology of disease and &quot;widely translatable management strategies&quot; remain worthy targets of research.
                              &lt;p&gt; 
                              &lt;p&gt; 
                              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The study was funded by Bayer-Schering and Johnson &amp; Johnson.
                              &lt;p&gt; 
                              &lt;p&gt;Several authors of the study were employees of Bayer-Schering and all other authors received honoraria from the company. Dr. Becker reported no potential conflicts of interest.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
                           
    </recommendedItem>
    <recommendedItem id="20090101_3_976"
                     title="WTC: No Standard for Thrombosis Prevention in Living Liver Donors"
                     score="-0.006"
                     href="