Importance: Before elective surgery, direct oral anticoagulants (DOACs) are discontinued following a standardized protocol. However, this could result in insufficient lowering of DOAC levels that could increase bleeding risk.
Objective: To estimate the proportion of patients with elevated DOAC levels at the time of elective surgery, evaluate factors associated with DOAC levels, and examine associated blood loss.
Design, setting, and participants: This cohort study (DOAC Level Prior to Incision [DALI]) assessed adult patients prescribed a DOAC (apixaban, dabigatran, or rivaroxaban) for any indication and at any dose, undergoing an elective procedure requiring DOAC interruption between May 27, 2018, and February 25, 2024, at 2 Dutch hospitals.
Exposure: Standardized interruption protocol (1 day before moderate- and 2 days before high bleeding-risk procedures) with interruption adjustments for the patient's kidney function.
Main outcomes and measures: Blood was drawn immediately before surgery to determine DOAC levels (by liquid chromatography-mass spectrometry). Proportions of preoperative DOAC levels of 30 ng/mL or higher and their 95% CIs were estimated, stratified by DOAC type and surgical bleeding risk. Factors associated with DOAC levels were identified through multivariable linear regression. Surgical blood loss and 30-day postoperative complications were described according to DOAC concentrations.
Results: The study was terminated after including 257 patients (100 receiving apixaban, 100 receiving rivaroxaban, and 57 receiving dabigatran due to the slow inclusion rate of those receiving dabigatran; median [IQR] age, 72 [66-78] years; 173 male [67%]); 212 patients (82%) underwent a high bleeding-risk operation. Preprocedural DOAC levels were 30 ng/mL or higher in 7.6% (95% CI, 4.9%-11.6%) of patients. Dabigatran and rivaroxaban had similar proportions, whereas 13.1% (95% CI, 7.8%-21.2%) of patients treated with apixaban had levels of 30 ng/mL or higher. Treatment with apixaban, decreased kidney function, and a shorter interruption time were associated with higher levels. Surgical blood loss (median [range], 0 [0-4250] mL) was not associated with DOAC levels. Twelve patients (4.7%; 95% CI, 2.7%-8.0%), who all had DOAC levels less than 30 ng/mL, experienced major bleeding.
Conclusions and relevance: In this cohort study, most patients following the current protocol had DOAC levels less than 30 ng/mL, although the proportion of patients with elevated levels was higher for apixaban. Preoperative DOAC levels were not associated with blood loss during surgery.
Importance: Current colorectal surveillance guidelines emphasize adenoma characteristics but overlook temporal, racial, and sex-based heterogeneity in recurrence risk, a gap that limits equitable and personalized care.
Objective: To evaluate the associations of demographic factors, obesity, and adenoma features with recurrence risk over time in a large longitudinal surveillance cohort.
Design, setting, and participants: This retrospective cohort study included adults who underwent their first colonoscopic polypectomy between January 1990 and July 2024 at a tertiary medical center.
Exposures: Demographic variables included race and ethnicity, sex, obesity (body mass index >30), family history of colorectal cancer (CRC) or polyps, and age at adenoma onset (<50 vs ≥50 years). Adenoma features included histology, size, number, and dysplasia.
Main outcomes and measures: The primary outcome was recurrence-free survival, defined as time from initial polypectomy to histologically confirmed recurrence. Time-varying coefficient Cox models were fitted to handle the nonconstant associations of exposure over the follow-up time. The follow-up time was categorized into 3 periods (less than 5 years, 5 to 10 years, and 10 or more years). The heterogeneity of exposure associations across the 3 follow-up periods was assessed with likelihood ratio tests.
Results: Among 59 667 patients (mean [SD] age, 60 years [11.2]; 29 401 [49.3%] female; 1007 [1.7%] Asian and Pacific Islander, 646 [1.1%] Hispanic, 5972 [10.0%] non-Hispanic Black, and 52 042 [87.2%] non-Hispanic White; median [IQR] follow-up, 4 [1-9] years), 17 596 (29.5%) experienced overall recurrence within 5 years. High-grade dysplasia demonstrated the largest early phase association (adjusted hazard ratio [aHR], 4.00; 95% CI, 3.56-4.50) with complete midterm and late attenuation, while villous histology exhibited biphasic patterns with early elevation (aHR, 2.89; 95% CI, 2.63-3.18) and late-phase (>10 years) reemergence (aHR, 2.71; 95% CI, 2.15-3.41). Obesity conferred persistent risk across all surveillance intervals (early: aHR, 1.16; 95% CI, 1.11-1.21; late: aHR, 1.22; 95% CI, 1.09-1.35). Female patients with high-risk adenomas exhibited marked late-term (>10 years) elevation exceeding male patients (female patients: aHR, 1.73; 95% CI, 1.43-2.08 vs male patients: aHR, 1.29; 95% CI, 1.06-1.58).
Conclusions and relevance: Both histopathologic features and demographic factors demonstrated distinct time-dependent patterns in adenoma recurrence, underscoring the need for surveillance strategies that account for temporal variation and population-specific risk profiles.
Importance: Respiratory syncytial virus (RSV) may trigger cardiorespiratory events in adults.
Objective: To assess the risk of cardiorespiratory events in the 180 days following RSV-related hospitalization compared with a control period in adults.
Design, setting, and participants: This self-controlled case series study had an observation period from January 1, 2017, through March 31, 2024. Data were obtained from the deidentified Optum Market Clarity Dataset, including RSV-related hospitalization and associated outcomes, which were identified based on diagnosis codes. Adults with 1 or more RSV-related hospitalizations and 1 or more cardiorespiratory events (myocardial infarction [MI], stroke, chronic obstructive pulmonary disease [COPD] exacerbation, congestive heart failure [CHF] exacerbation, and arrhythmia) were included.
Exposure: RSV-related hospitalization.
Main outcomes and measures: A conditional Poisson regression model was fitted to compare the incidence of cardiorespiratory events during the risk period (ie, ≤180 days after RSV-related hospital index date) and control periods (ie, >21 days before or >180 days after the index date). Incidence rate ratios (IRRs) and 95% CIs were estimated and adjusted for time-varying covariates.
Results: A total of 11 887 patients (mean [SD] age, 69.4 [15.5] years; 7303 females [61.4%]) with RSV-related hospitalization were included. An increased risk was associated with each cardiorespiratory event during the first 14 days following RSV-related hospitalization, with the highest IRR estimates observed in the initial 7 days. For MI, the IRRs were 8.7 (95% CI, 6.7-11.2) during days 1 to 7, decreasing to 5.2 (95% CI, 3.7-7.2) during days 8 to 14 and 2.6 (95% CI, 1.6-4.3) during days 15 to 21. For stroke, the IRRs were 7.4 (95% CI, 5.5-10.1), 5.9 (95% CI, 4.2-8.3), and 3.7 (95% CI, 2.3-5.9) during the first 3 weeks with a similar pattern for CHF exacerbation (12.5 [95% CI, 10.5-14.8], 4.1 [95% CI, 3.1-5.5], and 2.4 [95% CI, 1.6-3.6], respectively). For COPD exacerbation and arrhythmia, the IRRs decreased during the first 3 weeks from 23.1 (95% CI, 20.2-26.5) through day 7 to 1.3 (95% CI, 0.8-2.4) during days 15 to 21 and from 16.5 (95% CI, 14.5-18.7) to 1.6 (95% CI, 1.1-2.5), respectively.
Conclusions and relevance: This study demonstrated that RSV, similar to influenza and SARS-CoV-2, was associated with an increased risk of cardiorespiratory events 2 weeks following RSV-related hospitalization, and some conditions had significant risk elevations up to 180 days after admission. The findings reinforce the need to increase RSV immunization in adults.
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