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Background Aims Methods Content Conclusions Catheter‐related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life‐threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non‐catheter related upper extremity or lower extremity deep venous thromboses.This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.The management of CRT is still challenging with constant need for updated evidence to support tailored approaches. [ABSTRACT FROM AUTHOR]

Background: Limited prospective data exist about the clinical relevance of frailty in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) receiving direct oral anticoagulants (DOACs). The aim of this study was to evaluate whether frailty phenotype identifies DOAC‐treated patients at higher risk of adverse clinical outcomes. Methods: Consecutive, adult outpatients treated with DOACs for AF or VTE were prospectively enrolled. Patients were classified as frail, pre‐frail, or non‐frail according to frailty phenotype. Study outcomes were clinically relevant bleeding, including major and clinically relevant non‐major bleeding, arterial and venous thromboembolism, and all‐cause mortality. Results: 236 patients (median age 78 years, 44% females) were included, of whom 156 (66%) had AF and 80 (34%) VTE. Ninety‐eight (41%) patients were frail, 115 (49%) pre‐frail, and 23 (10%) non‐frail. Inappropriately high or low dose DOAC was used in 33% of frail and in 20% of non‐frail or pre‐frail patients. Over a median follow‐up of 304 days, the incidence of clinically relevant bleeding, thromboembolism, and mortality were 20%, 4%, 9% in frail, and 10%, 3%, and 2% in pre‐frail, respectively, while no study outcome occurred among non‐frail patients. Risk ratios (95% confidence intervals) for these outcomes in frail versus pre‐frail and non‐frail patients were respectively 2.5 (1.8, 3.7), 1.9 (0.9, 4.0), and 6.3 (2.9, 13.6). Conclusion: In a prospective cohort of ambulatory patients receiving DOAC treatment for AF or VTE, frailty phenotype identified patients at higher risk of bleeding and all‐cause mortality. Frailty assessment could be valuable to guide targeted interventions potentially improving patient prognosis. [ABSTRACT FROM AUTHOR]

Summary: Cancer‐associated venous thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with cancer. Treatment of cancer‐associated VTE comes with a heightened risk of anticoagulant‐related bleeding that differs by choice of anticoagulant as well as by patient‐ and disease‐specific risk factors. Available data from randomized controlled trials and observational studies in cancer‐associated VTE suggest that direct oral anticoagulants are effective, continuing anticoagulation beyond six months is indicated in those with active cancer and that patients who develop 'breakthrough' thrombotic events can be effectively treated. We review the evidence that addresses these key clinical questions and offer pragmatic approaches in individualizing care. While significant investigative efforts over the past decade have made impactful advances, future research is needed to better define the factors that contribute to anticoagulant‐related bleeding and VTE recurrence, in order to aid clinical decision‐making that improves the care of patients with cancer‐associated VTE. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall‐related fractures in community‐dwelling older persons. Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) evaluating the effectiveness of fall prevention interventions in community‐dwelling adults aged ≥65 years, from inception until February 27, 2019. Two large RCTs (published in 2020 after the search closed) were included in post hoc analyses. Pairwise meta‐analysis and network meta‐analysis (NMA) were conducted. Results: NMA including 192 studies revealed that the following single interventions, compared with usual care, were associated with reductions in number of fallers: exercise (risk ratio [RR] 0.83; 95% confidence interval [CI] 0.77–0.89) and quality improvement strategies (e.g., patient education) (RR 0.90; 95% CI 0.83–0.98). Exercise as a single intervention was associated with a reduction in falls rate (RR 0.79; 95% CI 0.73–0.86). Common components of multiple interventions significantly associated with a reduction in number of fallers and falls rate were exercise, assistive technology, environmental assessment and modifications, quality improvement strategies, and basic falls risk assessment (e.g., medication review). Multifactorial interventions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80–0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89–1.01). The following single interventions, compared with usual care, were associated with reductions in number of fall‐related fractures: basic falls risk assessment (RR 0.60; 95% CI 0.39–0.94) and exercise (RR 0.62; 95% CI 0.42–0.90). Conclusions: In keeping with Tricco et al. (2017), several single and multiple fall prevention interventions are associated with fewer falls. In addition to Tricco, we observe a benefit at the NMA‐level of some single interventions on preventing fall‐related fractures. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy of medication review as an isolated intervention and with several co‐interventions for preventing hospital readmissions in older adults. Methods: Ovid MEDLINE, Embase, The Cochrane Central Register of Controlled Trials and CINAHL were searched for randomized controlled trials evaluating the effectiveness of medication review interventions with or without co‐interventions to prevent hospital readmissions in hospitalized or recently discharged adults aged ≥65, until September 13, 2019. Included outcomes were "at least one all‐cause hospital readmission within 30 days and at any time after discharge from the index admission." Results: Twenty‐five studies met the inclusion criteria. Of these, 11 studies (7,318 participants) contributed to the network meta‐analysis (NMA) on all‐cause hospital readmission within 30 days. Medication review in combination with (a) medication reconciliation and patient education (risk ratio (RR) 0.45; 95% confidence interval (CI) 0.26–0.80) and (b) medication reconciliation, patient education, professional education and transitional care (RR 0.64; 95% CI 0.49–0.84) were associated with a lower risk of all‐cause hospital readmission compared to usual care. Medication review in isolation did not significantly influence hospital readmissions (RR 1.06; 95% CI 0.45–2.51). The NMA on all‐cause hospital readmission at any time included 24 studies (11,677 participants). Medication review combined with medication reconciliation, patient education, professional education and transitional care resulted in a reduction of hospital readmissions (RR 0.82; 95% CI 0.74–0.91) compared to usual care. The quality of the studies included in this systematic review raised some concerns, mainly regarding allocation concealment, blinding and contamination. Conclusion: Medication review in combination with medication reconciliation, patient education, professional education and transitional care, was associated with a lower risk of hospital readmissions compared to usual care. An effect of medication review without co‐interventions was not demonstrated. Trials of higher quality are needed in this field. [ABSTRACT FROM AUTHOR]

Aims: Acute heart failure (AHF) represents a frequent cause of hospitalization and is associated with significant mortality among elderly patients. Risk assessment models like the prognostic nutritional index (PNI) have been proposed to stratify the risk of death and identify patients requiring more intensive levels of care. We evaluated the predictive value of PNI for in‐hospital and overall mortality in a cohort of consecutive elderly patients hospitalized for AHF. Methods and results: Prognostic nutritional index, laboratory, and clinical parameters were collected upon admission. PNI values were calculated from albumin concentration and lymphocyte count and reported on a continuous scale with lower values indicating worse prognosis. The primary outcome was overall all‐cause mortality defined as death from any cause occurring during hospitalization up to 6 months after discharge. Cox proportional regression analysis was used to calculate hazard ratios (HRs) and the relative 95% confidence intervals (CIs). The study population included 344 patients (median age 84 years, range 65 to 101). During a median follow‐up of 158 days (range 2 to 180 days), 75 patients (21.8%) died of whom 28 (8.1%) died during hospitalization. The median PNI was 34 (range 17 to 55). In univariable analysis, PNI was inversely associated with overall mortality (HR 0.90; 95% CI, 0.87 to 0.94) and in‐hospital mortality (HR 0.91; 95% CI, 0.85 to 0.98). In multivariable analysis, PNI remained a significant predictor of overall mortality (HR 0.93; 95% CI, 0.89 to 0.98) after adjustment for age, anaemia, NT‐proBNP values, and bedridden status. PNI values ≤34 were associated with a two‐fold higher risk of overall mortality (HR 2.54; 95% CI, 1.52 to 4.24) and three‐fold higher risk of in‐hospital mortality (HR 3.37; 95% CI, 1.14 to 9.95). Conclusions: Low PNI values are associated with short‐term and long‐term mortality among elderly patients hospitalized for acute decompensated heart failure. Future studies are warranted to confirm these findings and evaluate the use of PNI to guide therapeutic decisions. [ABSTRACT FROM AUTHOR]

Aim To assess the prevalence of vascular dementia, mixed dementia and Alzheimer's disease in patients with atrial fibrillation, and to evaluate the accuracy of the Hachinski ischemic score for these subtypes of dementia. Methods A nested case-control study was carried out. A total of 103 of 784 consecutive patients evaluated for cognitive status at the Ambulatory Geriatric Clinic had a diagnosis of atrial fibrillation. Controls without atrial fibrillation were randomly selected from the remaining 681 patients using a 1:2 matching for sex, age and education. Results The prevalence of vascular dementia was twofold in patients with atrial fibrillation compared with controls (21.4% vs 10.7%, P = 0.024). Alzheimer's disease was also more frequent in the group with atrial fibrillation (12.6% vs 7.3%, P = 0.046), whereas mixed dementia had a similar distribution. The Hachinski ischemic score poorly discriminated between dementia subtypes, with misclassification rates between 46% (95% CI 28-66) and 70% (95% CI 55-83). In patients with atrial fibrillation, these rates ranged from 55% (95% CI 32-77) to 69% (95% CI 39-91%). In patients in whom the diagnosis of dementia was excluded, the Hachinski ischemic score suggested the presence of vascular dementia in 11% and mixed dementia in 30%. Conclusions Vascular dementia and Alzheimer's disease, but not mixed dementia, are more prevalent in patients with atrial fibrillation. The discriminative accuracy of the Hachinski ischemic score for dementia subtypes in atrial fibrillation is poor, with a significant proportion of misclassifications. Geriatr Gerontol Int 2015; 15: 770-777. [ABSTRACT FROM AUTHOR]

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Polycythemia vera (PV) is a chronic myeloproliferative disorder whose major morbidity and mortality are thrombohaemorragic events and progression to acute leukaemia or myelofibrosis. Whether the haematocrit and platelet count predict such complications remains unclear. The European Collaboration on Low-dose Aspirin in Polycythemia Vera prospective study included 1638 PV patients. A total of 164 deaths (10%), 145 (8·85%) major thrombosis and 226 (13·8%) total thrombosis were encountered during 4393 person-years follow-up (median 2·8 years). In time-dependent multivariable analysis, a haematocrit in the evaluable range of 40–55% was neither associated with the occurrence of thrombotic events, mortality nor with haematological progression in the studied population. The haematocrit of patients in the highest and lowest deciles at baseline was maintained within a narrow interval of haematocrit values ranging from 40% to 47% throughout follow-up. High platelet count was associated with a lower progression rate to acute leukaemia/myelofibrosis, whereas it had no significant relationship with thrombotic events or mortality. Our findings do not suggest that the range of haematocrit (<55%) and platelet counts (<600 × 109/l) we encountered in our population had an impact on the outcome of PV patients treated by current therapeutic strategies. [ABSTRACT FROM AUTHOR]

The article presents images of a rare case of superior vena cava (SVC) syndrome caused by a large intracardiac non-Hodgkin lymphoma in a 75-year-old woman. A hypo-dense aspect of the SVC was shown during the angiographic computed tomography phase, suggestive of occlusion. Cardiac surgery was performed including the removal of the tumor and pericardial reconstruction.