Thromb Haemostasis
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Increasing the starting dose of enoxaparin results in the early achievement of therapeutic anti-factor Xa levels in children receiving enoxaparin which is critical for effective therapy and the reduction of venipunctures. The aim of this study was: i) to determine the enoxaparin dose required to achieve therapeutic anti-factor Xa levels in infants and children, and ii) to establish whether increasing the starting dose of enoxaparin influenced the time required to reach the therapeutic range and the number of venipunctures required for dose-adjustment, and iii) the radiographic outcome of the thrombosis, where applicable. A retrospective chart review of children who received enoxaparin was carried out at the Stollery Children's Hospital, Edmonton, Alberta, Canada. ⋯ Infants <3 months required an enoxaparin dose of 1.83 mg/kg, and those who received an increased initial enoxaparin dose resulted in faster attainment of therapeutic anti-factor Xa levels requiring significantly fewer venipunctures. Similarly, infants > or =3-12 months, 1-5 years, and 6-18 years, require enoxaparin 1.48 mg/kg, 1.23 mg/kg and 1.13 mg/kg, respectively, in order to achieve a therapeutic anti-factor Xa level. In conclusion, increasing the starting dose of enoxaparin may result in more rapid attainment of therapeutic range with fewer venipunctures, dose adjustments, and without an increase in adverse events.
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Multicenter Study
Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism.
The recently introduced simplified Wells rule for the exclusion of pulmonary embolism (PE) assigns only one point to the seven variables of the original Wells rule. This study was performed to independently validate the simplified Wells rule for the exclusion of PE. We retrospectively calculated the prevalence of PE in the "unlikely" probability categories of the original Wells (cut-off < or =4) and the simplified Wells rule (cut-off < or =1) in 922 consecutive patients with clinically suspected PE from a multicenter cohort study. ⋯ The proportions of patients in whom further tests could safely be withheld based on PE "unlikely" and a normal D-dimer test was 28% (95%CI, 25-31%) using the original and 26% (95%CI, 24-29%) using the simplified Wells rule. In this external retrospective validation study, the simplified Wells rule appeared to be safe and clinically useful, although prospective validation remains necessary. Simplification of the Wells rule may enhance the applicability.
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Randomized Controlled Trial
Venous thromboembolism in critically ill patients. Observations from a randomized trial in sepsis.
Venous thromboembolism (VTE) is a central concern in the intensive care unit (ICU). However, little is known about both current practices for VTE prevention in the ICU and the risk for VTE in persons with severe sepsis and septic shock. XPRESS was a randomized, double-blind, placebo-controlled trial of prophylactic heparin in patients with severe sepsis and higher disease severity who were treated with drotrecogin alfa (activated) (DAA). ⋯ Despite multiple guidelines, physicians do not uniformly prescribe VTE prophylaxis. Nonetheless, early VTE occurs even in persons given DAA. Most VTE in critically ill patients are clinically silent.
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The concept of 'Compensatory anti-inflammatory response syndrome' (CARS) was proposed in 1997 by Roger Bone (1941-1997) to qualify the consequences of the counter-regulatory mechanisms initiated to limit the overzealous inflammatory process in patients with infectious (sepsis) or non-infectious systemic inflammatory response syndrome (SIRS). One major consequence of CARS is the modification of the immune status that could favour the enhanced susceptibility of intensive care patients to nosocomial infections. Indeed, most animal 'two-hit' models illustrate an enhanced sensitivity to infection after a first insult. ⋯ However, this is rather a reprogramming of circulating leukocytes, since there is not a global defect of the immune cells functions. Furthermore, within tissues, leukocytes are rather primed or activated than immunosuppressed. Thus, CARS may be considered as an adapted compartmentalized response with the aim to silence some acute proinflammatory genes, and to maintain the possible expression of certain genes involved in the anti-infectious process.