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Joseph A Caprini

Publications and source records attributed to Joseph A Caprini.

16 recordsLinked to original sources
PubMed2007

Results of the national pilot screening program for venous disease by the American Venous Forum.

OBJECTIVE: This report describes the pilot of a free comprehensive national screening program for venous disease. METHODS: The screening process consisted of a venous thromboembolism (VTE) risk assessment, abbreviated duplex examination for venous obstruction and reflux, inspection for signs of chronic venous insufficiency (CVI), and an exit interview. Physicians coordinating the screenings were members of the American Venous Forum. RESULTS: Seventeen institutions screened 476 people (mean, 28 per site; range, 6 to 71). Mean age was 60 years (range, 40 to 91 years), with 78% women and 68% with a body mass index of > or =25. If placed in a situation conducive for VTE, 22 participants (5%) were low risk, 87 (18%) were moderate risk, 186 (39%) were high risk, and 179 (38%) were at very high risk. In 26 people (6%), one or more segments had venous obstruction, and 190 (40%) had one or more segments of venous reflux in the lower extremities. Varicose veins were present in 32%, edema without skin changes in 11%, skin changes attributable to venous disease in 8%, and healed or active venous stasis ulcer in 1.3% (CEAP classification 2, 3, 4, 5, and 6, respectively). Increasing age and increasing deep venous thrombosis risk score significantly correlated with increasing clinical classification, r = 0.09, P = .04, and r = 0.16, P = .0004, respectively. Those participants with reflux in one or more segments were significantly more likely to have a higher clinical classification compared with those with no reflux (P = .0001). CONCLUSION: The first comprehensive national screening for venous disease was performed. Participants were informed of their risk for VTE if placed in a situation conducive to VTE, screened for evidence of obstruction, reflux, and CVI, and empowered to share their results with their primary care provider.

Adult↗
PubMed2006

Venous thromboembolism following major orthopedic surgery: what is the risk after discharge?

Guidelines recommend thromboprophylaxis for at least 10 days to prevent venous thromboembolism in patients undergoing high-risk orthopedic surgery, such as total hip arthroplasty (THA) or total knee arthroplasty (TKA). Furthermore, the recently updated ACCP guidelines also recommend extending the duration of thromboprophylaxis for 28 to 35 days following THA or hip fracture surgery as the risk for venous thromboembolism persists for up to 3 months after surgery. Extended-duration thromboprophylaxis (up to 6 weeks) with low-molecular-weight heparin is significantly more effective in preventing venous thromboembolism in orthopedic surgery patients than the recommended practice of at least 10 days. Extended-duration thromboprophylaxis may require risk stratification to identify high-risk patients. Current risk-assessment models have limitations and are not specific to orthopedic surgery patients; therefore, improvements may facilitate the use of extended-duration thromboprophylaxis in high-risk patients, thereby reducing the burden of venous thromboembolism.

Aftercare↗
PubMed2006

Compliance with antithrombotic guidelines.

Venous thromboembolism (VTE) remains a significant threat to public health despite the availability of effective and safe prophylactic measures and treatments. Guidelines based on randomized clinical trials are available to improve the management of thromboembolic disease. However, gaps exist between recommendations and clinical practice, and many patients are unnecessarily exposed to the risk of a deep vein thrombosis or potentially fatal pulmonary embolism. Barriers responsible for poor compliance with current antithrombotic guidelines include lack of familiarity with recommendations, overestimation of bleeding risk, underestimation of thrombotic risk, and logistical limitations of health care management systems. Improving compliance is a complex task, but successful initiatives rest upon improving thrombotic risk-assessment methods and facilitating appropriate prescribing of prophylaxis. Multifaceted, interdisciplinary strategies involving risk-assessment models, electronic reminders, and audit and feedback show the most potential to improve compliance with guidelines.

Fibrinolytic Agents↗
PubMed2005

Negative regulation of monocyte adhesion to arterial elastic laminae by signal regulatory protein alpha and Src homology 2 domain-containing protein-tyrosine phosphatase-1.

Elastic laminae are extracellular matrix constituents that not only contribute to the stability and elasticity of arteries but also play a role in regulating arterial morphogenesis and pathogenesis. We demonstrate here that an important function of arterial elastic laminae is to prevent monocyte adhesion, which is mediated by the inhibitory receptor signal regulatory protein (SIRP) alpha and Src homology 2 domain-containing protein-tyrosine phosphatase (SHP)-1. In a matrix-based arterial reconstruction model in vivo, elastic laminae were resistant to leukocyte adhesion and transmigration compared with the collagen-dominant arterial adventitia. The density of leukocytes within the elastic lamina-dominant media was about 58-70-fold lower than that within the adventitia from 1 to 30 days. An in vitro assay confirmed the inhibitory effect of elastic laminae on monocyte adhesion. The exposure of monocytes to elastic laminae induced activation of SIRP alpha, which in turn activated SHP-1. Elastic lamina degradation peptides extracted from arterial specimens could also activate SIRP alpha and SHP-1. The knockdown of SIRP alpha and SHP-1 by specific small interfering RNA diminished the inhibitory effect of elastic laminae, resulting in a significant increase in monocyte adhesion. These observations suggest that SIRP alpha and SHP-1 potentially mediate the inhibitory effect of elastic laminae on monocyte adhesion.

Animals↗
PubMed2005

Antithrombotic therapy practices in US hospitals in an era of practice guidelines.

BACKGROUND: Antithrombotic therapy is efficacious for the prevention of thromboembolic disease, but it necessitates careful risk-benefit assessment. METHODS: Antithrombotic therapy data were retrospectively collected from inpatient medical records at 38 US hospitals. Patients treated for atrial fibrillation, acute myocardial infarction, deep vein thrombosis, or pulmonary embolism and patients given prophylaxis for total knee replacement, total hip replacement, or hip fracture surgery between July 1, 2000, and June 30, 2003, were randomly selected. RESULTS: The medical records of 3778 patients (53.3% men) were included. The mean patient age was 66.1 years. Of patients with atrial fibrillation at high risk for stroke, only 54.7% received warfarin sodium, and 20.6% received neither aspirin nor warfarin. Of patients with acute myocardial infarction, only 75.5% received aspirin on hospital arrival. After orthopedic surgery procedures, only 85.6% of patients received prophylaxis with a parenteral anticoagulant agent or warfarin. In 49.4% of patients with deep vein thrombosis, pulmonary embolism, or both, unfractionated or low-molecular-weight heparin use was discontinued before an international normalized ratio of 2.0 or greater was achieved for 2 consecutive days. Patients with deep vein thrombosis or pulmonary embolism were rarely discharged from the hospital with bridge therapy (an injectable anticoagulant agent plus warfarin), although the length of hospitalization was significantly shorter than if discharged taking warfarin alone (4.0 vs 8.1 days; P < .001). CONCLUSIONS: A significant percentage of hospitalized patients do not receive adequate antithrombotic therapy for the primary and secondary prevention of thromboembolic disease.

Aged↗
PubMed2005

Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs.

OBJECTIVES: To assess the treatment of venous thromboembolism (VTE) in hospitalized patients enrolled in a national, multicenter database. METHODS: This was a retrospective, cohort study that randomly selected VTE patients from 38 academic/teaching, community, and Veterans Administration (VA) hospitals. The study included a physician survey component. The patients selected were those treated between January 2002 and June 2003 who had an ICD-9-CM code for pulmonary embolus (PE), deep vein thrombosis (DVT), or pregnancy-related PE or DVT. RESULTS: The study included 939 patients: 52.7% with DVT, 28.4% with PE, and 18.8% with PE and DVT. Mean age was 59.5 years. Risk factors included obesity (body mass index > 30) in 30.1%, history of VTE in 28.0%, malignancy in 27.4%, surgery in 21.1%, and immobility in 18.5%. Only 56.1% of patients were treated with low-molecular-weight heparin (LMWH). Bridging from LMWH or unfractionated heparin (UFH) to warfarin was completed during hospitalization in 486 (68.6%), but only 246 (50.6%) had an international normalized ratio (INR) > or = 2 for 48 hours before discontinuation of the injectable anticoagulant. Length of stay in patients discharged on bridge therapy was 4.0 +/- 3.7 days vs 8.1 +/- 5.8 days for patients discharged on warfarin therapy (P < .001). Ninety-two (10.1%) patients were discharged with neither oral nor injectable anticoagulation and had a mean duration of treatment of only 10.6 +/- 16.2 days. Of 245 physicians surveyed from participating hospitals, 84% and 53%, respectively, indicated that LMWH was their preferred agent for treatment of DVT and treatment of PE. With regard to warfarin, 30% did not believe it was necessary to have a therapeutic INR for > or = 2 days before discontinuing LMWH or UFH, and 27% responded that it was necessary to keep DVT patients in the hospital until they were therapeutic. CONCLUSIONS: In this cross-section of United States hospitals, lower than anticipated use of LMWH, insufficient bridging from UFH or LMWH to warfarin, and continuation of anticoagulation after hospitalization were all problems discovered with the treatment of VTE. Physician knowledge, attitudes, and beliefs are partially responsible for the gap between actual practice and international guidelines. These results suggest that hospitals should evaluate their adherence to international VTE treatment guidelines and develop strategies to optimize antithrombotic therapy.

Anticoagulants↗
PubMed2005

Fatal vascular outcomes following major orthopedic surgery.

Major orthopedic surgery is known to be associated with potentially serious arterial and venous vascular complications, although uncertainty exists about current event rates. Using electronic databases and investigator contact, we identified randomized and cohort studies reporting overall mortality and fatal vascular events. Where possible, studies reporting high autopsy rates (>60%) were examined. Pooled incidences were calculated from eligible studies. For Autopsy studies: Pooled overall mortality and fatal pulmonary embolism for patients undergoing elective hip and knee replacement without prophylaxis could not be calculated, while with prophylaxis they were 0.44% (95% confidence interval 0.02 to 0.87%) and 0.43% (0.01 to 0.85%). For patients undergoing hip fracture surgery, the corresponding rates without prophylaxis were 15.9% (14.5 to 17.3%) and 1.9% (1.4 to 2.4%). With prophylaxis, mortality and fatal pulmonary embolismrates were 8.5% (7.3 to 9.7%) and 1.0% (0.6 to 1.5%). Among Cohort studies: Pooled overall mortality and fatal pulmonary embolism for patients undergoing elective hip and knee replacement without prophylaxis were 0.93% (0.57 to 1.29%) and 0.36% (0.14 to 0.59%). For patients receiving prophylaxis (7 to 14 days), mortality and fatal pulmonary embolism were 0.57% (0.51 to 0.62%) and 0.18% (0.14 to 0.21%). Patients undergoing hip fracture surgery receiving prophylaxis hadmortality and fatal pulmonary embolismrates of 3.2% (2.8 to 3.6%) and 0.30% (0 to 0.61%). Vascular events contributed towards approximately 50% of all deaths with similar proportions due to ischemic heart disease, cardiac failure and pulmonary embolism. In conclusion, although prophylaxis results in a reduction in overall mortality and fatal pulmonary embolism, vascular events continue to be a common cause of mortality.

Autopsy↗
PubMed2004

Laboratory markers in the diagnosis of venous thromboembolism.

Selected blood tests may be useful in the diagnosis of venous thromboembolism (VTE), or in the identification of a congenital or acquired defect associated with the development of VTE. Several studies have shown the D-dimer assay to have a high negative predictive value but poor specificity when used in the detection of VTE. Yet in the emergency room setting, the D-dimer test may be useful if a detailed risk factor analysis for each patient is included in the diagnosis. The presence of such genetic thrombophilia markers as factor V Leiden, prothrombin 20210A mutation, and antiphospholipid antibodies significantly increases a patient's risk of a thrombotic event. The relative risk of thrombosis in factor V heterozygotes is at least 3 times higher than in the general population, whereas the increased risk of thrombosis in homozygotes is estimated to be 50- to 80-fold greater than those without the defect. Thromboembolic events are reported in approximately one third of antiphospholipid-positive patients. Other markers such as hyperhomocysteinemia and deficiencies of antithrombin, protein C, or protein S, when combined with the previous mutations, significantly increase a patient's risk of a thrombotic event. We feel that it is important to identify these ultra-high-risk patients to provide adequate counseling about the risk of thrombosis before elective surgical procedures. Often, lifelong anticoagulation may be needed as these patients and family members may need testing before taking birth control pills or hormonal replacement.

Antiphospholipid Syndrome↗
PubMed2003

Deep vein thrombosis: validation of a patient-reported leg symptom index.

INTRODUCTION: Deep vein thrombosis (DVT) is a serious health problem that affects more than 2 million people annually in the United States. Many of these patients develop asymptomatic DVT, but months to years later may experience symptomatic post-thrombotic syndrome (PTS). It is not known how many cases of PTS can be traced to "asymptomatic" DVT because venography is no longer routinely done and ultrasonography (US) may miss some asymptomatic clots. As a result, a clinical tool in addition to US to detect symptom emergence or exacerbation in patients after DVT would be of value. METHODS: Seventy-seven patients hospitalized with an acute DVT interviewed by telephone at 3-7 days, 30-40 days, and 12-months following discharge were included in this report. All were treated with a standard anticoagulation "Clinical Pathway Protocol" between April 1999 and January 2000. Using a 14-item Deep Vein Thrombosis Leg Symptom Index (DVT-LSI), patients were queried regarding leg pain, swelling, skin discoloration, cosmetic appearance, activity tolerance, emotional distress, and leg-related sleep problems. RESULTS: The DVT-LSI for each leg was reliable at all assessments, with instrument reliability (alpha coefficients) greater than 0.70 at all time points (range 0.71-0.87). DVT-LSI scores, and the percentage of patients exhibiting symptoms, were higher in the DVT-affected leg at all time points. Among patients with unilateral disease, symptom severity ratings were significantly worse for patients in the affected leg compared to the normal leg at all time points, with the exception of those with a right-leg DVT at 12 months. Patients with bilateral thrombi did not have different scores on one leg compared to the other. CONCLUSION: The DVT-LSI is useful in assessing symptomatic clinical outcomes in patients after diagnosis of DVT, and may represent a surrogate marker for DVT otherwise presumed to be asymptomatic.

Anticoagulants↗
PubMed2003

Calf deep venous thrombosis should be treated with anticoagulation.

A 50-year-old man with hypertension presents with a 2-day history of right calf swelling and pain. Venous duplex ultrasound reveals a right soleal vein thrombosis. He denies history of bleeding, renal disease, and symptoms suggestive of pulmonary embolism (PE). Physical examination is unrevealing except for calf tenderness, redness, warmth, and swelling. He is ambulatory. A decision is made to treat the calf deep venous thrombosis (DVT) with anticoagulation.

Anticoagulants↗
PubMed2003

The management and outcome of acute venous thromboembolism: a prospective registry including 4011 patients.

OBJECTIVE: To obtain a realistic overview of management and clinical outcomes of patients with venous thromboembolism (VTE) in Spain on the basis of data from a national multicenter registry. METHODS: A prospective registry was initiated in Spain in March 2001. Data were collected from patients with objectively confirmed deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and entered into the online registry by physicians who were responsible for the management of these patients. RESULTS: As of August 2002, 4011 patients with confirmed VTE were included in the registry: 60% with DVT, 23% with PE, and 17% with both DVT and PE. Diagnostic methods for VTE included compression ultrasonography (86%), venography (10%), V/Q lung scans (42%), computed tomography scan (28%), and pulmonary angiography (0.9%). D-dimer testing was performed in 61% of cases and was positive in 92% of patients with confirmed VTE. The majority of DVT (95%) were located in the lower extremities (82% proximal and 4% bilateral), while 4.8% were located in the upper extremities or neck veins. Most patients (90.5%) were admitted to hospital. In the acute phase, treatment consisted of low molecular weight heparin (LMWH) in 88%, unfractionated heparin (UFH) in 11%, and fibrinolysis in 0.8%. Cava filters were inserted in 2% of patients, mainly because of active bleeding (13%), increased hemorrhagic risk (38%), or recurrent VTE (29%). Absolute bed rest was recommended to 63% of patients. Secondary prevention of VTE included oral anticoagulants (75%) and LMWH (24.5%). Therapeutic compression stockings were prescribed to 53% of patients at the time of hospital discharge. Regarding the main clinical outcomes during an average (+/-SD) follow-up period of 156 +/- 95 days, 19% had adverse events: 12.5% of patients died, 5.5% had clinically confirmed VTE recurrence, and 9.8% suffered bleeding complications (44% with major bleeding). CONCLUSIONS: This prospective observational multicenter registry provides a large database reflecting the actual day-to-day clinical practice regarding VTE management in a European country. The most important findings were the increasing use of spiral computed tomography for PE diagnosis, the unexpectedly high proportion of patients admitted to hospital despite the use of LMWH in almost 90% of cases in the acute phase, and the utilization of LMWH for secondary prevention in almost 25% of cases. On the other hand, this large-scale prospective registry permits on-line consultation of high-risk situations to assess how difficult cases were treated and what their outcomes were. This will provide a most useful tool for the practicing physician responsible for the management of VTE patients.

Acute Disease↗
PubMed2003

Correlates of thrombin generation in patients with advanced prostate cancer.

Thrombin generation is increased in men with advanced prostate cancer. Thrombin has the ability to interact with, and affect the biology of, a variety of cell types including prostate cancer cell lines. We therefore looked for correlations between thrombin generation and other markers of disease activity in spot urine samples obtained from men with advanced prostate cancer. Excretion of part of the prothrombin activation peptide F(1+2) (called here iF2), interleukin-6 (IL-6), the bone turnover marker deoxypyridinoline (DpD), and vascular endothelial growth factor (VEGF) were quantitated in spot urine samples collected from 37 men with hormone-refractory prostate cancer. Following log transformation of the data, significant correlations were found by univariate analysis between the excretion of a marker of thrombin generation (iF2) and IL-6, DpD and VEGF, as well as between IL-6 and DpD or VEGF excretion. No correlation was found between any marker and serum PSA level. After multivariate analysis, a significant correlation remained between thrombin generation and IL-6 excretion. Analysis of a second urine specimen obtained from 19 of the subjects 1 to 7 months after the first also revealed a significant correlation between thrombin generation and IL-6, DpD, and VEGF excretion. These data provide evidence of a correlation between thrombin generation/coagulation system activation and IL-6 generation in patients with cancer. They provide a rationale for studying the effects of inhibitors of thrombin generation upon the biology of prostate cancer.

Amino Acids↗
PubMed2002

Thrombosis prophylaxis in orthopedic surgery: current clinical considerations.

Thrombosis prophylaxis in orthopedic surgery is an important consideration in order to avoid the morbidity and mortality of venous thromboembolism (VTE). Patients who do not receive prophylaxis, or receive inadequate prophylaxis, may be at risk for clinical or fatal pulmonary emboli, and a fatality, although rare, may be the first sign of a VTE. Although the surgeon may have corrected the patient's orthopedic problem, a symptomatic or asymptomatic venous thrombosis may become a new threat to the patient's quality of life. This problem places such patients at risk for recurrent VTE, as well as post-thrombotic syndrome, a progressive, lifelong disability. Methods of prophylaxis that prevent the most clots result in the fewest venous thromboembolic events, but no one method of prophylaxis is suitable for all patients. In order to select the appropriate modality, a careful risk assessment of each patient is necessary. Those at low or moderate risk levels do not require the same modalities that may be used in a patient with a previous history of thrombosis or with many risk factors. The purpose of this brief review is to examine the complications associated with venous thromboembolism and to discuss, in detail, the risk of thrombosis in orthopedic patients. In addition, thrombosis prophylaxis modalities are discussed and suggestions made based on current Chest Consensus Guidelines and FDA-approved products.

Humans↗
PubMedDate not supplied

Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States.

BACKGROUND: Estimates of the cost of long-term complications of a primary deep vein thrombosis (DVT), including the post-thrombotic syndrome (PTS) and recurrent venous thromboembolism (VTE), may be relevant for resource allocation decisions. OBJECTIVE: The objective of this study was to provide US cost estimates of the long-term complications of a primary DVT, which occurs in approximately 5% to 20% (with adequate thromboprophylaxis) and 50% (in the absence of thromboprophylaxis) of total hip replacement surgeries (THRS). METHODS: A literature-based model was used to project the excess long-term complication costs of DVT following THRS. The model simulated the natural history of DVT complications using published estimates of the incidence and prognosis of PTS and recurrent VTE. Each complication was assigned a cost obtained by multiplying the amount of resources used in its management by the unit price of these resources. RESULTS: The annual per-patient cost of each complication was as follows: mild-to-moderate PTS, 839 dollars in the first year and 341 dollars in subsequent years; severe PTS, 3817 dollars in the first year and 1677 dollars in subsequent years; DVT, 3798 dollars; and pulmonary embolism, 6604 dollars. The average discounted lifetime cost of DVT complications was estimated to be 3069 dollars (95% interval 2091 dollars-4279 dollars). CONCLUSIONS: The long-term complications of a primary DVT represent a significant economic burden. Preventing a DVT could arguably lead to substantial savings in long-term DVT complications.

Aged↗