Katherine Hurst

Quick reference guide to apixaban

Direct oral anticoagulants (DOACs) are being increasingly used in the clinical setting for patients at risk of venous thromboembolism (VTE) and/or stroke. These medications offer valued benefits for long-term use, including a fast onset of anticoagulation, fixed anticoagulation profile (and consequent prescription of specified doses) and no requirement for routine monitoring. Apixaban is a selective factor Xa inhibitor, approved for use in the prevention of stroke in patients with nonvalvular atrial fibrillation and in the prevention and treatment of acute VTE. Like many of the DOACs, it has a fast onset of action and works to deliver predictable coagulation results. Multiple randomized controlled trials including ARISTOTLE and AMPLIFY have shown apixaban to be noninferior to vitamin K antagonists in the prevention of stroke and VTE, with a good safety profile. This article aims to review the use of apixaban for the prevention and treatment of thromboembolic disease, highlighting the key study results that have led to its current licensing and use.

The Experience of Patients During the Clinical Management Pathway of Abdominal Aortic Aneurysms at a NHS Trust

Background: The epidemiology of abdominal aortic aneurysm (AAA) is changing. Outcomes for aortic surgery have improved. However, the accepted guideline for the management of AAAs has remained unchanged over the last 2 decades. We aimed to gain insight into the patients’ experience while they are managed under the traditional clinical pathway. Method: With the help of a patient focus group, we designed a survey to assess the patients’ perception of the disease and their experience during different stages of the AAA clinical care pathway (surveillance, perioperative care, postoperative follow-up). An invitation to participate in the survey was sent to all patients with AAA who were receiving care at the Oxford Regional Vascular Services Unit, part of the Oxford University Hospitals NHS Trust. Results: We received 194 responses from patients with AAA. One hundred seventy-seven were male, with a median age of 75 to 79 years. Just over a third had undergone surgery already, and the remaining 63% were either in surveillance or awaiting surgery. Their experience during the AAA management pathway was mostly positive. Of the issues that were most important to them in terms of their medical care, the provision of explanation and regularity of monitoring stood out as the most common considerations. Conclusion: Patients are generally satisfied with the care they received, but there is room for improvement. They have also highlighted key areas that are most important to them in terms of their medical care. These should guide the future direction for quality improvement and research.

Delays in the presentation to stroke services of patients with transient ischaemic attack and minor stroke

The UK National Institute for Health and Care Excellence (NICE) guidelines state that carotid endarterectomy should be scheduled within 2 weeks of symptoms. The recent National Stroke Strategy has reduced the time interval to 48u2009h. This study aimed to review the possible delays.

Risk impact of edoxaban in the management of stroke and venous thromboembolism

The new generation of target-specific oral anticoagulants is being prescribed for increasing numbers of patients at risk of stroke or venous thromboembolism (VTE). These drugs offer valuable benefits due to fast onset anticoagulation, a fixed anticoagulation effect (allowing administration of specified doses), and no requirement for routine monitoring. Edoxaban is a fast-acting oral anticoagulant, approved for use in the prevention of stroke in patients with nonvalvular atrial fibrillation (AF) and in the treatment of acute VTE. Like many of the new oral anticoagulants, it selectively inhibits factor Xa, in a concentration-dependent manner. Multiple Phase II clinical trials have shown edoxaban to be noninferior to vitamin K antagonists in the prevention of stroke and VTE, with a good safety profile. To date, the pivotal studies to endorse edoxaban’s clinical use have been ENGAGE AF-TIMI and Hokusai-VTE, both of which have compared its efficacy to standard warfarin treatment. This paper aims at reviewing the use of edoxaban in the management of stroke and thromboembolic disease, highlighting the key study results that have led to its current license.

Quick reference guide to apixaban [Corrigendum]

[This corrects the article on p. 263 in vol. 13, PMID: 28744136.].

Long-term follow-up results of patients undergoing transjugular coil embolisation

Dear Mr Dos Santos, We enjoyed your article entitled ‘Long-term results of transjugular coil embolisation for pelvic reflux – Results of the abolition of venous reflux at 6–8 years’. We read with great interest the results your study has highlighted, including the indication of good long-term results in patients following pelvic embolization. This is an interesting area of clinical practice with an impressive series of 28 patients. It is unfortunate that only 25% of the patients have long-term follow-up making broad conclusions difficult to justify. Within the 75% who were not followed up, many of the patients may have had positive outcomes, but it is also possible that they may not. Although 11/28 patients had good long-term outcomes from this surgery, only 39% of patients had complete elimination of reflux. In light of this, it is difficult to justify conclusions on the results, but efforts to follow-up the rest of the patients may be more meaningful.

Quick reference guide to the new oral anticoagulants

After the commissioning of new oral anticoagulants for the treatment and prevention of thrombosis, these medications are now widely used within clinical settings. Increasing numbers of patients present to the health services on anticoagulant medications, and it is therefore imperative for surgeons to be aware of the new therapeutic treatments available and how patients will benefit from such interventions. This review highlights the most pertinent learning points for surgeons regarding the indications, pharmacokinetics, and perioperative management of these new oral medications, as a quick reference guide.

Improving information availability in vascular surgical clinics. A service evaluation and improvement project.

Abstract This prospective service evaluation was designed to assess the availability of critical information required in vascular surgical clinics. All the data was collected via a repeated questionnaire, and the outcomes from each cycle were used to highlight where intervention was required to improve the surgical clinic experience. The first audit identified outpatient clinic deficiencies and allowed for problem analysis. Two Plan-Do-Check-Act (PDCA) cycles then were undertaken. Interventions following each cycle included consultant access to online duplex scans and secretarial access to referral letters. Results from the first cycle showed that approximately 20% of clinic appointments were missing information and only 30% of these issues were resolved during the clinic using a work around. Following the first intervention; the numbers of missing patient notes reduced to 4.3% (10.5%), and referral letters to 3.6% (4.6%). Although the numbers of missing duplex scan results increased to 6.5% (3.3%), the new system of online scan results allowed for all scans to be accessed during the clinic. Following results of a second PDCA cycle, vascular surgical secretaries were given access to ‘choose and book’, a database of GP referral letters. Post intervention, all missing referral letters (2%) could be accessed immediately within the clinic setting. Data driven interventions and repeated PDCA cycles can improve hospital systems for minimal cost. With an annual clinic turnaround of 2500 patients, these interventions can reduce clinic delays and potential harm caused by unavailable records for up to 500 patients a year.

Re: Primary care trust commissioning of varicose vein intervention--new guidance needed?

Dear Miss Griffin, Many congratulations for your detailed study on the national variability of commissioning in the treatment of varicose veins. Your data clearly present a ‘postcode lottery’ in both the selection of patients meeting the criteria for treatment and whether they receive endovenous laser therapy (ELT) or a surgical procedure. We agree that new NICE guidelines are imperative to assist primary care trusts in their referrals, but this should not lead to one national treatment for all. All patients with symptomatic varicose veins require an expert opinion from a consultant vascular surgeon. Decisions on those patients appropriate for treatment should be at this stage, along with planning for intervention. ELT is commonly used as first-line treatment, as it is not associated with potential surgical morbidity; however, at present, there are no long-term data on the outcomes of ELT. ELT also provides a poorer cosmetic result, often leading to further referrals and subsequent treatment. We agree with your recommendation for a first-line national decision in the commissioning of varicose vein surgery; however, commissioners should not be prescriptive in the treatment modality. Treatment should be at the discretion of a vascular specialist making the decision in partnership with the patient and taking into account the patient’s values, expectations and concerns.