Patients with a first episode of idiopathic venous thromboembolism should be treated with anticoagulant agents for longer than three months.

The novel coronavirus disease of 2019 (COVID-19) pandemic, as declared by the World Health Organization, is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). 1,2 Cardiovascular disease and, in particular, venous thromboembolism (VTE), has emerged as an important consideration in the management of hospitalized patients with COVID-19. The diagnosis of VTE using standardized objective testing is problematic in these patients, given the risk of infecting non-COVID-19 hospitalized patients and hospital personnel, coupled with the usual challenges of performing diagnostic testing in critically ill patients.Early reports suggest a high incidence of VTE in hospitalized COVID-19 patients, particularly those with severe illness, that is similar to the high VTE rates observed in patients with other viral pneumonias, including severe acute respiratory syndrome

The number of drugs reported to interact with warfarin continues to expand. While most reports are of poor quality and present potentially misleading conclusions, the consistency of reports of interactions with azole antibiotics, macrolides, quinolones, nonsteroidal anti-inflammatory drugs, including selective cyclooxygenase-2 inhibitors, selective serotonin reuptake inhibitors, omeprazole, lipid-lowering agents, amiodarone, and fluorouracil, suggests that coadministration with warfarin should be avoided or closely monitored. More systematic study of warfarin drug interactions in patients is urgently needed.

Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]CMAJ 2007;176(8 suppl): S1-13 This is a summary of the full document, which consists of this summary as well as 26 chapters on specific aspects of obesity prevention and management.The full document can be found at www.cmaj.ca/cgi/content/full/176/8/S1/DC1.O besity is now reaching epidemic proportions in both developed and developing countries and is affecting not only adults but also children and adolescents. Over the last 20 years, obesity has become the most prevalent nutritional problem in the world, eclipsing undernutrition and infectious disease as the most significant contributor to ill health and mortality. It is a key risk factor for many chronic and noncommunicable diseases.In Canada, the prevalence of overweight and obesity has increased over recent decades among both children and adults in all areas of the country. According to the most recent estimates from the 2004 Canadian Community Health Survey, 1 59% of the adult population is overweight (i.e., body mass index [BMI] ≥ 25 kg/m 2 ) and 1 in 4 (23%) is obese (i.e., BMI ≥ 30 kg/m 2 ). The sheer numbers of people who are overweight and obese highlight a pressing public health problem that shows no signs of improving in the near future. What is more alarming is the problem of obesity among children and adolescents in Canada, which is advancing at an even more rapid pace than obesity among adults. In 2004, 1 in 4 (26%) Canadian children and adolescents aged 2-17 years was overweight. The obesity rate has increased dramatically in the last 15 years: from 2% to 10% among boys and from 2% to 9% among girls.1,2 This increase is cause for concern, since there is a tendency for obese children to remain obese as adults. Moreover, obesity-related health problems are now occurring at a much earlier age and continue to progress into adulthood. Given the recent temporal obesity trends among children and youth, the prevalence of obesity among adults will likely continue to increase as the current generation of children enters adulthood.Obesity should no longer be viewed as a cosmetic or body-image issue. There is compelling evidence that overweight people are at increased risk of a variety of health problems, including type 2 diabetes, hypertension, dyslipidemia, coronary artery disease, stroke, osteoarthritis and certain forms of cancers. It has recently been estimated that about 1 in 10 premature deaths among Canadian adults 20-64 years of age is directly attributable to overweight and obesity. In addition to affecting personal health, the increased health risks translate into an increased burden on the health care system. The cost of obesity in Canada has been conservatively estimated to be $2 billion a year or 2.4% of total health care expenditures in 1997.3 Thus, the continuing epidemic of obesity in Canada is exacting a high toll on the health of the population.The cause of obesity is complex and multifactorial. Within the context of environm...

BACKGROUND It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding. METHODS We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding. RESULTS In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], −0.6 to 0.8; P = 0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P = 0.005 for superiority). CONCLUSIONS In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.)

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Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.

BackgroundVenous thromboembolism (VTE) is a common preventable cause of mortality in hospitalized medical patients. Despite rigorous randomized trials generating strong recommendations for anticoagulant use to prevent VTE, nearly 40% of medical patients receive inappropriate thromboprophylaxis. Knowledge-translation strategies are needed to bridge this gap.MethodsWe conducted a 16-week pilot cluster randomized controlled trial (RCT) to determine the proportion of medical patients that were appropriately managed for thromboprophylaxis (according to the American College of Chest Physician guidelines) within 24 hours of admission, through the use of a multicomponent knowledge-translation intervention. Our primary goal was to determine the feasibility of conducting this study on a larger scale. The intervention comprised clinician education, a paper-based VTE risk assessment algorithm, printed physicians’ orders, and audit and feedback sessions. Medical wards at six hospitals (representing clusters) in Ontario, Canada were included; three were randomized to the multicomponent intervention and three to usual care (i.e., no active strategies for thromboprophylaxis in place). Blinding was not used.ResultsA total of 2,611 patients (1,154 in the intervention and 1,457 in the control group) were eligible and included in the analysis. This multicomponent intervention did not lead to a significant difference in appropriate VTE prophylaxis rates between intervention and control hospitals (appropriate management rate odds ratio = 0.80; 95% confidence interval: 0.50, 1.28; p = 0.36; intra-class correlation coefficient: 0.022), and thus was not considered feasible. Major barriers to effective knowledge translation were poor attendance by clinical staff at education and feedback sessions, difficulty locating preprinted orders, and lack of involvement by clinical and administrative leaders. We identified several factors that may increase uptake of a VTE prophylaxis strategy, including local champions, support from clinical and administrative leaders, mandatory use, and a simple, clinically relevant risk assessment tool.ConclusionsHospitals allocated to our multicomponent intervention did not have a higher rate of medical inpatients appropriately managed for thromboprophylaxis than did hospitals that were not allocated to this strategy.