Introduction: While several risk stratification tools have been developed to predict the risk of recurrence in patients with an unprovoked venous thromboembolism (VTE), only 1 in 4 patients are categorized as low-risk. Rather than a one-time measure, serial D-dimer assessment holds promise to enhance the prediction of VTE recurrence after oral anticoagulant (OAC) cessation.Methods: Using the REVERSE cohort, we compared VTE recurrence among patients with normal D-dimer levels (<490 ng/mL among males under age 70, <500 ng/mL in others) at OAC cessation and 1-month follow-up, to those with an elevated D-dimer level at either timepoint. We also evaluated VTE recurrence based on absolute increase in D-dimer levels between the two timepoints (e.g., Delta D-dimer) according to quartiles.Results: Among 214 patients with serial D-dimer levels measured at OAC cessation and 1-month follow-up, an elevated D-dimer level at either timepoint was associated with a numerically higher risk of recurrent VTE than patients with normal D-dimer levels at both timepoints (6.9 % vs. 4.2 % per year, hazard ratio 1.6; 95 % CI 0.9-2.7). Among women with <2 HERDOO2 criteria, a normal D-dimer level at both timepoints predicted a very low risk of recurrent VTE during follow-up (0.8 % per year, 95 % CI 0.1-2.8). Irrespective of baseline value, recurrent VTE risk was only 3 % per year (95 % CI 1.4-5.6) among patients in the lowest Delta D-dimer quartile.Conclusion: Serial normal D-dimer levels have the potential to identify patients at a low risk of recurrent VTE. In addition, Delta D-dimer, irrespective of its elevation above cutoff threshold, may predict recurrent VTE.

Despite guideline recommendations for long-term anticoagulation after the first diagnosis of unprovoked venous thromboembolism (VTE), benefits and harms associated with this approach remain unclear among older adults at risk of non VTE-related mortality. While death is a competing event to recurrent VTE, competing risk methods have not been used in determining VTE recurrence rates following anticoagulant discontinuation in unprovoked VTE. We sought to evaluate the risk of recurrent VTE by age strata among patients with first unprovoked VTE after anticoagulant cessation, accounting for all-cause mortality as a competing risk.

Nitrogen exports from landscapes can contribute to the eutrophication of surface waters. The most common form of N studied in prior runoff research has been nitrate, although ammoniacal and organic forms of N are also considered important causes of eutrophication. The relative abundance of each N form in runoff from turfgrasses has not been widely reported. The objective of this study was to quantify dissolved inorganic N (DIN) and dissolved organic N (DON) exports in runoff from St. Augustinegrass [Stenotaphrum secundatum (Walt.) Kuntze] turf over a 2-yr period in College Station, TX. Treatments were arranged as a randomized complete block design having eight combinations of irrigation (100, 75, or 50% of estimated turfgrass water requirements) and fertility level (0, 88, and 176 kg N ha(-1) yr(-1)). Runoff from 31 rainfall events and one excess irrigation event were used to estimate annual and seasonal DIN and DON exports. Nitrate-N concentration was typically below 5 mg L-1, but peaks in excess of 20 mg L-1 were measured during late winter in one year. Aside from this atypical peak, the largest portion of total dissolved N (TDN) was DON, whereas NH4-N was typically the smallest portion. Increasing fertilizer rates typically amplified each form of N in runoff, but NO3-N was the most responsive to N rate, with corresponding reductions in the DON/TDN ratio and increases in the nitrate/ammonium ratio. Nitrate-N may be the best indicator for fate of anthropogenic N inputs, but studies focusing only on NO3-N are likely underreporting N exports.

BACKGROUND:Obesity is associated with a higher incidence of atrial fibrillation (AF). Weight reduction improves outcomes in patients known to have AF. OBJECTIVE:The purpose of this study was to compare the incidence of heart failure (HF) or first-time AF hospitalization in obese patients undergoing bariatric surgery (BAS) vs other abdominal surgeries. METHODS:A retrospective cohort study was conducted using linked hospital discharge records from 1994-2014. Obese patients without known AF or atrial flutter (AFL) who had undergone abdominal hernia or laparoscopic cholecystectomy surgery were identified for each case that underwent BAS (2:1). Clinical outcomes were HF, first-time hospitalization for AF, AFL, gastrointestinal bleeding (GIB), and ischemic or hemorrhagic stroke. Outcomes were analyzed using conditional proportional hazard modeling accounting for the competing risk of death, adjusting for demographics and comorbidities. RESULTS:There were 1581 BAS cases and 3162 controls (48% age <50 years; 60% white; 79% female; mean CHA2DS2VASc score 1.6 ± 1.2) with follow-up of 66 months. Compared to controls, BAS cases had a significantly lower risk of new-onset AF (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.54-0.93) or HF (HR 0.74; 95% CI 0.60-0.91) but a higher risk of GIB (HR 2.1; 95% CI 1.5-3.0), with no differences in AFL, ischemic stroke, or hemorrhagic stroke. Reduction in AF improved as follow-up increased beyond 60 months. CONCLUSION:In patients undergoing BAS, the risk of either HF or AF was reduced by ∼29% but with greater risk of GIB. The findings support the hypothesis that weight loss reduces the long-term risk of HF or incident AF hospitalization.

Introduction: The epidemiology of isolated distal deep-vein-thrombosis (d-DVT) in the calf among cancer patients is not well defined, particularly the incidence and effect on development of recurrent VTE (rVTE) and overall survival.

Background: Ablation for atrial fibrillation (AF) is superior to medical therapy for rhythm control. We compared stroke and mortality among patients undergoing ablation for AF to matched controls in a large multiethnic population. Methods: Using discharge and surgical records from California nonfederal hospitals, we identified patients who had ablation and principal diagnosis of AF with at least 1 prior hospitalization for AF. We excluded cases with valve disease, open maze, other arrhythmias, or implantable devices. Matched controls were selected based on years of AF diagnosis, age, sex, and being alive the same number of days from the initial AF encounter to the ablation date. Clinical outcomes, including mortality, ischemic stroke, or hemorrhagic stroke, were assessed using a weighted proportional hazard model, adjusting for demographics, prior admissions with AF before the ablation, calendar year, and presence of chronic comorbidities. Results: There were 4169 ablation cases and 4169 weighted-matched controls; 39% percent of the ablation group was >65 years, 72% men, 84% white; mean follow-up was up to 3.6±0.9 years. In adjusted models, ablation was associated with significantly lower mortality (per patient-years) 0.9% versus 1.9%, hazard ratio=0.59 ( P <0.0001; confidence interval: 0.45–0.77); ischemic stroke (>30 days post-ablation ≤5 years), 0.37% versus 0.59%, hazard ratio=0.68 ( P =0.04; confidence interval: 0.47–0.97); hemorrhagic stroke 0.11% versus 0.35%, hazard ratio=0.36 ( P =0.001; confidence interval: 0.20–0.64) compared with controls. Conclusions: In this large population-based study of hospitalized patients with nonvalvular AF, ablation was associated with lower mortality, ischemic stroke, and hemorrhagic stroke compared with controls.

Making a definitive diagnosis of heparin-induced thrombocytopenia (HIT) can be problematic. A prompt platelet rise following treatment has been proposed as a “post-test” criterion for diagnosis. However, the platelet response following discontinuation of heparin and initiation of a recommended alternative anticoagulant remains largely undefined and unstudied. This study aimed to characterize platelet response to initial treatment in patients with a low, intermediate, or high likelihood of having HIT. This was a multicenter retrospective cohort study. Patients were over 18 years in age, underwent serologic testing for HIT, and received alternative anticoagulation treatment for HIT. Classification of each patient’s likelihood of having HIT was based on an empiric, pre-hoc combination of the 4T score and serology results. The primary outcome for this study was a platelet count response after initiation of direct thrombin inhibitor (DTI) or fondaparinux therapy within 48 h. 124 patients were analyzed. The sensitivity and specificity of having an immediate platelet rise of at least 10,000/µL by day 2 after starting treatment among high-likelihood for HIT patients were 0.71 (95% CI 0.55–0.84) and 0.64 (95% CI 0.5–0.76), respectively. The negative predictive value of no platelet rise was 75.5% (95% CI 0.61–0.86). A prompt platelet count rise may be appropriate to consider along with other known criteria for the clinical diagnosis of HIT. The rise should be immediate following discontinuation of heparin and initiation of recommended treatment, with an upward rise within 48 h.

Proper management of turfgrass systems is critical for reducing the risk of nutrient loss and protecting urban surface waters. In the southern United States, irrigation can be the most significant management practice regulating the biogeochemical and hydrological cycles of turfgrass systems. A turfgrass runoff research facility was used to assess the effects of deficit irrigation and fertilizer applications on turfgrass canopy cover and nitrate-N (NO-N) exports in runoff from St. Augustinegrass [Stenotaphrum secundatum (Walt.) Kuntze] turf over a 2-yr period. Treatments were arranged as a randomized complete block design having eight combinations of irrigation (100, 75, or 50% of estimated turfgrass water requirements) and fertility level (0, 88, and 176 kg N ha yr). Runoff from 31 rainfall events and one irrigation excess event were used to estimate annual and seasonal NO-N exports. The majority of annual NO-N exports occurred during the late winter and spring. Deficit irrigation reduced summer and early autumn runoff volumes. Lower summer and autumn runoff volumes (from deficit irrigation) coincided with reduced NO-N exports from runoff during Year 1. Deficit irrigation combined with fertilizer applications increased runoff [NO-N] in Year 2, suggesting that the previous year's export reduction contributed to higher N accumulation in the system and thus a higher N loss potential. These findings suggest that deficit irrigation can be a tool for reducing seasonal nutrient exports from St. Augustinegrass lawns so long as fertilizer inputs are moderate.

The study assessed 12-month chronic pain (CP)-related health care utilization and costs among chronic noncancer pain (CNCP) patients who initiated various long-term opioid treatments. Treatments included monotherapy with long-acting opioids (mono-LAOs), monotherapy with short-acting opioids (mono-SAOs), both LAOs and SAOs (combination), and opioid therapy initiated with SAO or LAO and switched to the other class (switch). Using MarketScan((R)) claims databases (2006-2012), we identified CNCP patients with >= 90 days opioid supply after pain diagnosis and continuous enrollment 12 months before pain diagnosis (baseline period) and 12 months after opioid start (post-index period). Outcomes included CP-related health care utilization and costs. Among CNCP patients (n=21,203), the cohort distribution was 74% mono-SAOs, 22% combination, 2% mono-LAOs, and 2% switch. During follow-up, the average daily morphine equivalent dose was highest in mono-LAO patients (96.4 mg) compared with combination patients (89.8 mg), switch patients (64.3 mg), and mono-SAO patients (36.2 mg). After adjusting for baseline differences, the mono-LAO cohort had lower total CP-related costs ($4,933) compared with the mono-SAO ($8,604), switch ($10,470), and combination ($15,190) cohorts (all: P<0.05). Mono-LAO patients had greater CP-related prescription costs but lower medical costs than the other cohorts during the follow-up period, including lower CP-related hospitalizations (1% vs 11%-20%), emergency department visits (4% vs 11%-18%), and diagnostic radiology use (21% vs 54%-61%) (all: P<0.001). Use of pain-related medications and other treatment modalities was also significantly lower in the mono-LAO cohort relative to the other cohorts. CNCP patients using long-term monotherapy with LAOs had the lowest CP-related total health care costs in the 12 months after opioid initiation compared with mono-SAO, switch, or combination patients despite higher opioid daily doses and higher prescription costs. Future research accounting for severity and duration of pain would aid in determining the optimal long-term opioid regimen for CNCP patients.

IMPORTANCE:Deep vein thrombosis (DVT) isolated to the calf veins (distal to the popliteal vein) is frequently detected with duplex ultrasonography and may result in proximal thrombosis or pulmonary embolism (PE).OBJECTIVE:To evaluate whether therapeutic anticoagulation is associated with a decreased risk for proximal DVT or PE after diagnosis of an isolated calf DVT.DESIGN, SETTING, AND PARTICIPANTS:All adult patients with ultrasonographic detection of an isolated calf DVT from January 1, 2010, to December 31, 2013, at the Vascular Laboratory of the University of California, Davis, Medical Center were included. Patients already receiving therapeutic anticoagulation and those with a chronic calf DVT, a contraindication to anticoagulation, prior venous thromboembolism within 180 days, or diagnosis of a PE suspected at the time of calf DVT diagnosis were excluded. Data were analyzed from August 18, 2015, to February 14, 2016.EXPOSURES:Intention to administer therapeutic anticoagulation.MAIN OUTCOMES AND MEASURES:Proximal DVT or PE within 180 days of the diagnosis of the isolated calf DVT.RESULTS:From 14 056 lower-extremity venous duplex studies, we identified 697 patients with an isolated calf DVT and excluded 313 of these. The remaining 384 patients were available for analysis (222 men [57.8%]; 162 women [42.2%]; mean [SD] age, 60 [16] years). The calf DVT involved an axial vein (anterior tibial, posterior tibial, or peroneal) in 243 patients (63.2%) and a muscular branch (soleus or gastrocnemius) in 215 (56.0%). Physicians attempted to administer therapeutic anticoagulation in 243 patients (63.3%), leaving 141 control participants. Proximal DVT occurred in 7 controls (5.0%) and 4 anticoagulation recipients (1.6%); PE, in 6 controls (4.3%) and 4 anticoagulation recipients (1.6%). Therapeutic anticoagulation was associated with a decreased risk for proximal DVT or PE at 180 days (odds ratio [OR], 0.34; 95% CI, 0.14-0.83) but an increased risk for bleeding (OR, 4.35; 95% CI, 1.27-14.9), findings that persisted after adjustment for confounding factors (ORs, 0.33 [95% CI, 0.12-0.87] and 4.87 [95% CI, 1.37-17.3], respectively) and sensitivity analyses.CONCLUSIONS AND RELEVANCE:Rates of proximal DVT or PE are low after isolated calf DVT. Therapeutic anticoagulation is associated with a reduction of these outcomes but an increase in bleeding.

Venous thromboembolism (VTE) is categorized by the U.S. Surgeon General as a major public health problem. VTE is relatively common and associated with reduced survival and substantial health-care costs, and recurs frequently. VTE is a complex (multifactorial) disease, involving interactions between acquired or inherited predispositions to thrombosis and VTE risk factors, including increasing patient age and obesity, hospitalization for surgery or acute illness, nursing-home confinement, active cancer, trauma or fracture, immobility or leg paresis, superficial vein thrombosis, and, in women, pregnancy and puerperium, oral contraception, and hormone therapy. Although independent VTE risk factors and predictors of VTE recurrence have been identified, and effective primary and secondary prophylaxis is available, the occurrence of VTE seems to be relatively constant, or even increasing.

BackgroundGlobal Activity Limitation Indicator (GALI) measures disability in terms of participation restriction.It lies at the basis of the European indicator Healthy Life Years (HLY).The objective of this paper is to review validity and reliability studies of GALI.Methods Expert consultation and database searches (Pubmed, Google Scholar, using keywords ''GALI (excluding name)'' and ''Global activity limitation'') identified 9 manuscripts.Studies were grouped by scope (national vs. international scope) and objectives: (1) association studies linking GALI to other disability measures (both objective and self-reported measures), (2) outcome studies linking GALI to mortality or health care use, and (3) reliability studies.Results There were 4 association studies.Two of them use international data, one of which uses objective measures.There was 1 health care expenditure study and 3 mortality studies (1 international).One reliability study looked at national data only.None of the studies indicated a validity failure.The international association studies concluded that GALI effectively captures limitations as measured by objective and selfreported measures and that this is valid for different countries.GALI is a good predictor of mortality.Its predictive power is linked to the severity of the limitations and decreases over time (10 years).GALI was an important predictor of health care expenditure even after adjustment for chronic conditions.The weighted Kappa as reliability measure was 0.68. ConclusionsEvidence provided by a first (limited) set of different validation exercises suggests that (1) GALI, as global measure of participation restriction, is an instrument with sufficient validity and reliability, (2) GALI has an added value over complex measures of health and disability, as well as over general measures of health such as self-rated health.Further (inter)national validity and reliability studies are needed given the international use of GALI.