View a list of our frequently asked questions
We have to absolutely report this treatment. The rationale is that we have to document all relevant medication regardless of the reason it was given … we are not just collecting VTE treatment in the CRF. We would be a missing a crucial part of this patients medical management if we omitted capturing this treatment with a NOAC.
ACTS English version can be used by patients where it has been validated.
Patients should have at least 2 weeks of treatment before they complete the baseline questionnaire. It would be preferable to ask the patient to complete the questionnaire when they have completed 4 weeks of treatment or as close to this as possible. If the patient complete the questionnaire after more than 4 weeks of treatment, then the data may not represent baseline data.
Patients should have at least 2 weeks of treatment before they complete the baseline questionnaire. It would be preferable to ask the patient to complete the questionnaire when they have completed 4 weeks of treatment or as close to this as possible. If the patient complete the questionnaire after more than 4 weeks of treatment, then the data may not represent baseline data.
Let me know if we need further clarification
Below is not quite right – popliteal is considered proximal:
Proximal is popliteal, femoral, iliac;
Isolated distal has no proximal component and is below the popliteal – typically there are 3 calf veins – anterior tibial, posterior tibial and peroneal.
Separately, another area of confusion that sometimes comes up – the femoral is sometimes called the superficial femoral vein. The unwary think (not unreasonably!) that it is a superficial vein – however, that is not the case, it is a deep vein and therefore the patient has a DVT rather than superficial vein thrombosis.
Ventilation scan without perfusion scan is inadequate to diagnose PE. The tick box in the CRF reads "Lung Scan (Ventilation Perfusion Scan)" and this means that both is required to show the ventilation/perfusion mismatch which is the objective criterion to confirm PE.
If the patient received treatment based on this diagnosis the answer is "yes"
No. Swollen leg plus increase of D-Dimer is not adequate to diagnose DVT
Duplex scanning is covered by ultrasound
For example, Heart failure NYHA class III or IV, Active cancer (e.g. admitted for chemotherapy or for treatment of a complication of the active cancer), Acute ischemic stroke, Acute infectious and inflammatory diseases, including acute rheumatic diseases, Acute respiratory insufficiency.
Yes, this should be entered
If the patient returns at month 3 to give consent, the data for the patient between diagnosis and 30 days post diagnosis should be entered for baseline, the data between 1 month and 3 months should be entered for month 3. Patients should only complete the questionnaires once they have given consent. Therefore, if the patient only gives informed consent at month 3, the patient should only complete month 3 questionnaire. The baseline questionnaire will be considered as missing for data analysis.
The sites should enter this as DVT and PE in the CRF
Any data collected after the milestone date should be entered for the next milestone
As the haematoma had been preexisting before diagnosis and treatment we shall not capture this as bleeding
"We are capturing all hospitalisations. The current list of options are:
Recurring VTE Episode Bleeding
Stroke
Diagnostic procedure/ routine check up Complication of VTE Cancer
Cardiac
Surgery/Other Intervention Other
Unknown
If the sites are reporting the lab results in a different units, then these will have to be converted by the site before entering the data into the system. It will be good if all sites use the same conversion.
fall in haemoglobin of 2 g/dl or more between two consecutive measurements regardless the time in between
It is all data collected between the last milestone and the current milestone which needs to be entered. So at month three, the site will need to record data collected any time between baseline and month 3.
Yes if these data are collected in CRF, we will need these to be recorded in the Medical Chart as source data.
If the question is if we need to collect information about the patient’s hospitalisation data (ie date when they went into hospital, whether it was planned or not), then we do not need this information prior to the date of diagnosis.
If the question is about hospitalisation as a risk factor for VTE, then we will need to collect this data during the past 3 months of diagnosis.
It is possible to have multiple sites of involvement. We need to capture and record the largest and most severe.
These multiple small bilateral pulmonary emboli may fall in the category "sub-segmental".
As per the CRF, for mixed medical treatment fund, the options are
o all cost covered by medical insurance
o partial costs covered by medical insurance
o all cost covered by medical insurance
If the patient’s treatment is funded by both sector, then the site should select “partial costs covered by medical insurance”.
Patient should be followed up according to the protocol even though he has now joined an interventional study
The site should follow up with the patient's GP to obtain any clinical data. Patients questionnaires can be omitted if patients are unable to complete them
The follow up visits in protocol are not any additional measures, these are as per a routine VTE practice. If a patient is signing off ICF and agreeing to participate then as per below they agree to come for FU visits and in some cases they can be contacted by the physician.
As per ICF – “As part of the study your doctor will provide information on your health. They will collect this by reviewing your medical history from your medical records. Some information about your progress will be provided from your medical records at certain time points. This will be firstly at diagnosis and up to 30 days after your diagnosis and then at 1, 3, 6, 12, 24, and 36 month intervals following your diagnosis. We will follow your progress for a minimum of 3 years. In case you haven’t visited your doctor between two of these time points, your doctor or a delegate from
1. As the IRB of each site has approved the ICF the site is bound to follow the ICF procedure, which requests their follow up by phone in exceptional cases
2. On the other hand we will also be instructing sites to check medical records but in some countries the sites do not have access to medical records of patients directly and in those cases the only way for site is to phone patients.
3. Also the sites might need to FU with patients on phone for questionnaires or any other events
The bottom line is if a patient cannot come for fu visit then for any missing data the site is bound to contact them to obtain required information per protocol.
These patients can be enrolled as long as the patient records are accessible upon request from the PI to the treating physician/medical care.
Per section 4.3 of the protocol –
In case no patient data or patient visits have been recorded in the patient’s medical records at the site (i.e. a patient has not been seen by his treating physician) during the months following the last data entry, a follow-up phone contact will be made by the site and documented to verify that all events are being captured and patients are not lost to follow up.
Even though the patients are not due to be seen by the investigators, the sites should contact the patients by phone to follow up the patients and to obtain information for the CRF.
We are also interested to capture other thromboembolis events such as arterial and cardiac thrombosis although these are different pathophysiologies. We also capture other types of thromboembolic events in GARFIELD AF since both studies are anticoagulation registries
Even though the patients are not due to be seen by the investigators, the sites should contact the patients by phone to follow up the patients and to obtain information for the CRF.
No - because thrombosis has been developed due to a stent.
So just so we can answer correctly the question is: are VTE events that are diagnosed and treated following surgery e.g. post hip surgery or post varicose vein surgery included in the registry? If that is the question then yes they are included.
GARFIELD-VTE is a non-interventional registry and therefore, we cannot require that personal patient visits take place at predefined time intervals unless the examination is required by the disease or doctor’s routine treatment. Therefore, we translated the seven clinical signs originally to be assessed by the physician into patient language and included these questions in the patient questionnaire. However, doctors who see the patients at 3, 6, 12 months anyhow are more than welcome to also answer these question based on patient visits. Thus, the minimum requirement of follow up visits is limited in the protocol to the end of the study period or the last patient visit if the patient drops off before month 36.
I’d not recommend to enrol the patient because this is special or unusual site thrombosis and would need be kept separate from statistics. The jugular vein is not part of the deep venous system and in particular, if jugular vein thrombosis is due to lymphoma, i.e. compression from external site, the effectiveness of anticoagulation or thrombolytic treatment cannot be fully assessed as the external compression of the vein will remain.
I think she should stay in the registry and should continue follow-up according to protocol. But perhaps we can flag the patient in the system in order to re-discuss the case before the data base will be locked before final statistics in the future.
No. We cannot include patients who may already have reached the endpoint of follow-up before enrolment. The patient has already developed chronic thromboembolism and this may already be on its way to development of the full picture of CTEPH.
Only when this treatment is completed and a new acute VTE event occurs after anticoagulation had been completed.
No, the patient should not be enrolled.
If superficial vein thrombosis that has reached the perforated veins in the calf, the patient should not be included. However, thrombi that have grown via the sapheno-popliteal- or sapheno-femoral junction into the deep venous system should be included.
Should be included if treated
No. It is attributed to the location of the thrombosis above confluence. Patients with thrombus in a vein related anatomically to the deep, but located below the popliteal vein can be included if treated
Patients to be included must have an event of acute VTE which requires treatment. If this event has been detected from screening for cancer (e.g. incidental PE detected by CT examination) and the investigator decides to treat this PE, the patient should be included.
Life expectancy should not be an exclusion criteria
No. Patients who have not started any treatment are not be enrolled in GARFIELD-VTE
GARFIELD-VTE does not enroll patients without acute VTE. If this patient hasn’t had another acute event requiring treatment, the patient only diagnosed with chronic pulmonary thromboembolism, caused by Pulmonary Hypertension, and pulmonary heart disease should not be enrolled.
Mesenteric artery thrombosis is not VTE and therefore, it does not qualify for enrollment in GARFIELD-VTE.
I assume this patient is treated because of DVT in the left superficial femoral vein and thus, the patient is a candidate for GARFIEld-VTE
PS: Of note, the superficial femoral vein is part of deep venous system. The name "superficial" may be misleading.
The patient is not eligible for GARFIELD-VTE
If the patient is still receiving anticoagulation therapy for secondary prevention of a previous event (even if this was six years ago in 2010) the patient should not be included
Obviously, for this patient treatment of the previous event had not been completed but only interrupted due to surgery. Thus, the patient should not be enrolled.
I do not see a contraindication for this patient to be included in GARFIELD-VTE although this patient is a challenging special case. The treatment options for this patient are limited because this patient requires dual antiplatelet therapy for secondary prevention of ACS and therefore, the bleeding risk is markedly increased for any chosen type of anticoagulation therapy. It may happen that the investigator will not use regular conventional standard anticoagulation or NOAC therapy according to labelling but will individualise therapy according to the special circumstances of the patient. We may face difficulties to statistically group this patient at the end. Thus, I think the patient can be included although he/she would not be an ideal candidate.
Patient should be followed up according to the protocol even though he has now joined an interventional study
I think the patient can be enrolled although the history of the patient is not very clear.
This belongs to the group of unusual site thrombosis and venous thrombosis in unusual sites are rare and heterogenous manifestations of venous thromboembolism (VTE). These uncommon diseases are each characterized by peculiar pathophysiological and clinical features, mainly reflecting the different characteristics of the organs of origin. Moreover, the relative frequency and importance of risk factors associated with their development may be different compared to those of the classical manifestations of VTE, such as deep vein thrombosis of the lower limbs or pulmonary embolism. Therefore, the patient should not be included
If there was no objectively confirmed VTE event, the patient should be withdrawn. Clinical symptoms without confirmed diagnosis do not qualify for enrollment in GARFIELD VTE.
It is correct that DVT and PE are the same entity of disease and in cases where PE is diagnosed shortly after the diagnosis of DVT, it may be difficult to distinguish between "DVT plus PE" as qualifying diagnosis for enrollment or "DVT" as qualifying diagnosis and PE as recurrent VTE event. We discussed the definition of recurrent VTE during the steering committee meeting in London since we were aware about the uncertainties related to the discrimination of "same event" and "recurrent event" in the early treatment phase. This relates in particular to patients with DVT diagnosed first and PE diagnosed shortly thereafter. The main question is if the patient had new clinical symptoms which triggered the diagnosis PE. In case the diagnostic examination of PE was done without clinical symptoms of PE, this would qualify the patient to enter the study with "DVT plus PE". Recurrent VTE has been defined as "onset of new symptoms diagnostically confirmed". In brief, "new clinical symptoms = recurrent event". "No new clinical symptoms = same event".
If this was a symptomatic thrombosis and the patient gets treatment for this event, then patient should be included. Of course, the patient also needs to agree for the long-term follow up
No
This patient should not be included in GARFIELD-VTE since the history of this case may be too special due to the filter implantation, advanced cancer with probably quite limited life expectancy, bleeding under rivaroxaban and probably due to this, the anticoagulation of the first event was prematurely discontinued
The patient can remain in the study and be followed up for remaining part of the study
The patient can be enrolled in both studies
It is at the discretion of the investigator to decide whether the patient should be included or not into the study based on the inclusion and exclusion criteria. If the investigator decides that the patient is eligible, then a 'responsible person' representing the patient should also sign the informed consent. It is also at the discretion of the investigator to decide whether the patient is able to answer the questionnaires.
As per protocol, the assessment of eligibility has to be completed within 30 days of diagnosis. If assessment of eligibility was done at 30 days after diagnosis, but patient is only returning 3 months after diagnosis to give informed consent, the patient can still be enrolled. However, no data can be entered into the eCRF until consent is given. Since this is an observational study, we are not interfering with the patient’s routine practice.
Depending on the provoking factors. Refer to protocol section 6.2.5
Life expectancy should not be an exclusion criteria
Life expectancy should not be an exclusion criteria
If this is non-interventional as described, the patient can be enrolled in GARFIELD-VTE
Superficial vein thrombosis and femoral arterial thrombosis are completely different anatomic entities and both cannot be included in GARFIELD VTE
Post-op VTE events are eligible for inclusion in GARFIELD VTE as long as the diagnosis of VTE has been objectively confirmed
It is not necessary to obtain patient’s consent within 30 days. However, no data can be entered into the eCRF until consent is given. Since this is an observational study, we are not interfering with the patient’s routine practice. Therefore, the recommendation is to get the consent of the patients at the next vis
If life expectancy is short due to concomitant diseases, e.g. cancer we should not include the patient. In the protocol we only have as exclusion criterion "Patients for whom long-term follow up is not envisaged within the enrolling hospital or the associated primary care physician".
Patient not eligible because this is not DVT but superficial vein thrombosis.
Any patient who has finished therapy for a previous VTE event and requires therapy for another event (including events at the same site of the previous one) can be included in GARFIELD VTE regardless the duration of the treatment pause between the two episodes.
As long as the patient is still under anticoagulation treatment, this would be "recurrent VTE" although this occurred in the contralateral leg. This is not a new event. Hospitalisation would be due to VTE related thrombosis as mentioned in section 6.2.15 of the protocol
Subclavian thrombosis not catheter related is eligible
Only if the patient is treated
If a patient with incidental PE or subsegmental clots is treated, he/she can be included. If the patient is not treated he/she cannot be included
HIV is not a reason for exclusion. With modern types of medications their average life expectancy can be quite long
The patient should be excluded
No, the patient should not be enrolled.
Only when this treatment is completed and a new acute VTE event occurs after anticoagulation had been completed.
Patients with Budd-Chiari syndrome should not be enrolled in the study
A patient with advanced malignant disease which may also mechanically affect the deep venous system. I would recommend not to include the patient since the patient needs very individualised treatment
Yes, we collect information about any AC treatment.
The site should report the AC treatment to the eCRFs regardless of the reason it was given as we have to document all AC treatment and not only the treatment given for VTE in order to fully document patient’s medical management.
However this is only true if the patient underwent superficial thrombophlebitis during the follow up period. If this was a Baseline event and the patient didn’t have DVT then they may not be eligible for the study. Please clarify with the site.
This assessment is an unscheduled assessment and could be conducted at any time point.
So apart from the patients who are due for the 36 month milestone, any patients at any time point of their participation could be contacted and asked about their PTS symptoms.
This includes:
1) patients that had their 36M visit in the past without having the Physician’s Evaluation of PTS using the Villalta scale. You can contact these patients and complete the unscheduled patient’s assessment instead in order to fully complete the follow-up of the patient,
2) patients that didn’t manage to complete the scheduled 24M Villalta questionnaire and they are willing to go through the assessment over the phone.
This “unscheduled” Villalta doesn’t replace the scheduled Villalta assessments but it is an supplementary option when it is not feasible to conduct the scheduled assessments.
This was caused by an EDC upgrade and can be corrected by marking questionnaires as 'Not done'.
To avoid data loss you are advised to mark as ‘not known’ what is not completed. However, it is known that the questionnaire for the other limb was not completed because there was no thrombosis. In any case, ‘not known’ is still more accurate than ‘0’, describing the situation much better.
Throughout the study the patients were allowed to complete the questionnaires at any time point. The Milestones were only indicative. We provided a rough timeframe of around 1 month before and after each Milestone to complete each questionnaire, however we also invited the patients to fill in the questionnaires at any time point as long as they provided the date of completion.
The study protocol allows this flexibility. In paragraph 4.3, page 22 it says “the study protocol does not dictate follow-up frequency or timing”, “…data will be collected approximately at Baseline, 3, 6, 12, 24 and 36 months after diagnosis through review of patient notes and medical records. These time points will be used as markers for collection of all data from the preceding period.”
We are just repeating the same instructions for 36M Milestone as for previous Milestones.
Until the closure of each site, they will have the opportunity to collect and enter patients’ data on the database.
Please note that one of sites’ responsibilities for the 36-month follow up is the PTS evaluation using the Villalta scale so in order to fully complete the assigned responsibilities we are kindly asking them to complete the unscheduled patient’s assessment if they were not able to conduct the physical assessment using the Physician’s questionnaire. If this is not yet feasible, they can always mark the relevant form as Not Done.
Please advise the site to enter INR values only for VKA patients. For these patients all INR readings are required.
We will most likely keep both names in the publication as they have still contributed to the study.
The site should leave the Cancer event in the event folder and select the NO option in the relevant question of the Milestone form (Has there been a cancer event since the last milestone).
Not only doctors, other medical staff can make the call as well.
Not really. The site will enter patients’ responses to the new form of patients’ Villalta that will be added on ClinPal at the end of July and it will be titled “Unscheduled patients’ assessment of PTS symptoms according to the Villalta scale”. This form will be exactly the same as the form you know and will have two parts for left and right leg respectively.
Regarding the 36M Villalta, they need to mark as not done.
The 36M Villalta (or Physician’s Evaluation of PTS using Clinical sings from Villalta Scale) cannot be performed over the phone. Only patients’ version of Villalta.
They need to use the new form to enter patients’ responses. The new form will have the ratings of the patients’ Villalta.
Yes, old PIs will also be included in publications as they have contributed to the study. Sub-Is will generally not be listed unless they have a signed contract.
The site doesn't have to enter this PE event since it occurred after the 36M follow up period. Generally speaking the Stats team will truncate follow up in their programs at 3 years so you don't need to worry if a site enters an event after the 3 years follow-up period.
The Physician’s PTS (Villalta) should be completed by the person appointed for the patient’s routine care and should be done in person. However, an unscheduled Patients Villalta can be done via phone call (instead of performing Physicians’ Villalta or in addition to performing the Physicians’ PTS (Villalta)). The patient Villalta can be performed by anyone delegated this task as it is a patient reported outcome and the person taking the information is only transcribing what the patient is reporting.
No, if the 36M physicians PTS (Villalta) cannot be done in person, then instead, the site should try to do a telephonic assesment using Patients Villalta (not the Physicians Villalta). This 36M Patients Villalta (done over the phone) should be entered in Clinpal in the “Patient Reported Outcomes” folder as an “unscheduled patients assessment of PTS symptoms according to Villata Scale”.
The sites should relock the folders after they enter the new data, not you (Site manager) or ClinPal.
The site needs to add the missing value and not to replace the value already entered. By clicking the plus button on the right side, a new row appears where they can enter the missing value.
Firstly please do not advise the sites to send their ISF to the Sponsor after the expiration of the archiving period. This applies to all VTE sites. No ISFs should be sent back to the sponsor.
Secondly, the sites need to follow GCP and local regulatory requirements.
The VTE protocol states in section 10.4 that “The PI will retain all essential documents associated with the Registry according to local regulations” and the CTA doesn’t state any specific requirements for archiving.
Therefore the sites need to follow GCP and local regulatory requirements. About documents destruction, this is something the sites need to decide after the expiration of the 2-year archiving period.
The difference is that the care setting questions in the Milestones ask for the facility that the patient was followed up at that Milestone and not the site that participates in VTE and it is common that these two are not the same as we are not asking the sites to invite the patients to their facility during follow-up.
Yes if you are able to answer on behalf of the PI regarding the speciality of the site that would be great.
Yes you are correct, if the site does not admit any patients for overnight care then “Outpatient setting” should be selected.
We are not able to provide patient data files to sites before the database is locked, the data is extracted from our vendor’s database and converted into a usable/readable format. The database lock will take place when all study sites are closed out.
We’d like to provide further instructions on how to copy patients’ responses from the Physician’s to Patient’s Villalta when the assessment of the clinical signs was made by the patients (with no interpretation by the site, scenario No1 below).
In particular, the score ratings of the two Villalta versions are not the same. Physician’s Villalta is using the None/Mild/Moderate/Severe rating while the Patient’s Villalta is using a scale from 0 to 10 to assess the severity of the PTS signs and symptoms.
If the sites find it difficult to convert the one rating into the other, please let them know that the equivalence between the two scores is the following:
Physician's Villalta score None (0)
Patient’s Villalta score 0
Mild (1)
1 2 3
Moderate (2)
4 5 6 7
Severe (3)
8 9 10
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