Automated versus Manual Data Extraction of the Padua Prediction Score for Venous Thromboembolism Risk in Hospitalized Older Adults

OBJECTIVE

Venous thromboembolism (VTE) prophylaxis is an important consideration for hospitalized older adults, and the Padua Prediction Score (PPS) is a risk prediction tool used to prioritize patient selection. We developed an automated PPS (APPS) algorithm using electronic health record (EHR) data. This study examines the accuracy of APPS and its individual components versus manual data extraction.

METHODS

This is a retrospective cohort study of hospitalized general internal medicine patients, aged 70 and over. Fourteen clinical variables were collected to determine their PPS; APPS used EHR data exports from health system databases, and a trained abstractor performed manual chart abstractions. We calculated sensitivity and specificity of the APPS, using manual PPS as the gold standard for classifying risk category (low vs. high). We also examined performance characteristics of the APPS for individual variables.

RESULTS

PPS was calculated by both methods on 311 individuals. The mean PPS was 3.6 (standard deviation, 1.8) for manual abstraction and 2.8 (1.4) for APPS. In detecting patients at high risk for VTE, the sensitivity and specificity of the APPS algorithm were 46 and 94%, respectively. The sensitivity for APPS was poor (range: 6-34%) for detecting acute conditions (i.e., acute myocardial infarction), moderate (range: 52-74%) for chronic conditions (i.e., heart failure), and excellent (range: 94-98%) for conditions of obesity and restricted mobility. Specificity of the automated extraction method for each PPS variable was > 87%.

CONCLUSION

APPS as a stand-alone tool was suboptimal for classifying risk of VTE occurrence. The APPS accurately identified high risk patients (true positives), but lower scores were considered indeterminate.

[Hormonal contraception and vascular risk]

Hormonal contraception and vascular risk. Since the early 1960, it has been well documented that combined hormonal contraceptives (CHC) increase the risk of venous thromboembolism diseases (VTE) and arterial diseases, even if it is an uncommon disease before menopause. Vascular risk is the most important determinant of the benefit/ risk profile of hormonal contraceptive. The most recent pills are associated with a higher risk of VTE than second- generation pill. CHC increase the risk of arterial disease (myocardial infarction or ischemic stroke), especially in women at high vascular risk. This increase does not depend on the generation of CHC. A meticulous research of vascular risk factors, including familial history of VTE, is recommended before prescription. It allows to adapt the contraceptive strategy for every woman according to the bene- fit/risk profile. In context of high vascular risk, low doses of both oral progestin contraceptives and intrauterine levonorgestrel could be safe with respect to VTE risk.

[Anticoagulants: current topics]

Despite the introduction of direct oral anticoagulants (DOAC), the need for more effective and safer antithrombotic strategies exists. Recently, the findings stating that the contact system is important for thrombus formation has identified factor XI as a potential target for new anticoagulants. Approximately 20-30% of patients who develop venous thromboembolism (VTE) also have cancer. To date, the drugs primarily used in the treatment of VTE are heparin in the acute phase and warfarin in the chronic phase. Recently, a large-scale international clinical trial, which examined the composite outcomes of VTE recurrence and major bleeding in cancer patients, found that edoxaban, a direct factor Xa inhibitor, is not inferior to low-molecular-weight heparin. The study also showed that DOACs have a promising potential to prove therapeutically effective in future studies. Anticoagulants are associated with a severe side effect, bleeding, which makes emergency neutralization an important concern. Four-factor prothrombin complex concentrate can be used to reverse the effect of warfarin and could also be effective as a neutralizing agent in patients having received DOACs. Moreover, more specific reversing agents include the approved human monoclonal antibody fragment idarucizumab for reversing the effects of dabigatran.

Venous thromboembolism

Venous thromboembolism frequently occurs in patients with inflammatory bowel diseases (IBD) in western as well as Japan because of the alterations of congealing fibrinogenolysis system due to the refractory enteritis. Aging, disease activity, colorectal lesions, admission, central venous catheter and operations are risk factors for the development of venous thromboembolism. Aggressive treatments including preventive and therapeutic anti-coagulation are recommended in western countries. In Japan, it is needed to establish a consensus concerning the therapeutic strategy for venous thromboembolism in IBD patients.

Medical problems in pregnancy

The prevalence of medical problems in pregnancy is increasing because of a complex interplay between demographic and lifestyle factors, and developments in modern medicine. Maternal mortality and morbidity resulting from treatable medical conditions, such as venous thromboembolism, epilepsy and autoimmune disease, have not decreased in recent years. This is despite a marked decrease in overall maternal mortality. It is vital that all physicians acquire a basic knowledge and understanding of medical problems in pregnancy. This includes prepregnancy measures such as counselling and optimisation of medical therapy, as well as multidisciplinary management throughout pregnancy and the postpartum period. Prompt recognition and treatment of acute and chronic illness is of clear benefit, and most drugs and many radiological investigations may be used in pregnancy.

[Venous thromboembolism in critically ill patients: analysis of the main age-related risk factors and definition of specific scores.]

INTRODUCTION

Venous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke and and the most common preventable cause of hospital-related death. Several studies have demonstrated a significant reduction of fatal pulmonary embolism attributed to the introduction of thromboprophylactic measures and changes in hospital practices. However, the influence of some demographical variables, especially age, has largely been under appreciated.

METHODS

Using the date of the TEVere study, we have studied 187 patients with VTE and 350 case-control, and we proceeded to analyze the major risk factors for venous thromboembolism, separately for three age groups (≤60 years, 60-75 years, >75 years). Patients came from the departments of internal medicine and emergency medicine for 21 hospitals. In this subgroup, we have examined the main risk factors for the individual classes of age and have proposed, through a logistic regression analysis, 3 different types of scores, specific for each age class. We then compared the individual scores obtained with the Kucher's score.

RESULTS

It was found that in the class of patients with a lower age of 60, the main risk factors found to be estrogen-progestagen treatment (p=0.004) and family history of VTE (p=0.047), while in older patients (>75 years) the main risk factors were immobilization (p=0.005) and chronic venous insufficiency (p=0.001). In common for the three classes the presence of an evolutionary malignancy and previous episodes of VTE. Through the ROC curve analysis, it was found that the results for the three proposed scores improved sensitivity compared to Kucher's score. However our results showed that the only score of the intermediate class showed a statistically significant difference for prediction of the thromboembolic risk (p=0.0264 (AUROC 0.7946; 95% CI, 0.75 to 0.80, AUROC 0.7042; 95% CI, 0.68. to 0.72).

DISCUSSION

Our study emphasizes the importance of carrying a correct stratification, which also consider the patient's age and therefore the concomitant pathologies. In fact, although the age of the patient cannot be considered as the only criterion to start the thromboprophylaxis, as highlighted in literature, you need to consider each individual patient, with its own peculiarities.

CONCLUSION

This study showed the difficulty in identifying the key risk factors that are responsible for thromboembolic disease and has emerged the opportunity to be evaluated by larger studies, the use of specific scores by age groups.

[ANMCO position paper: Use of new oral anticoagulants for the treatment and prevention of pulmonary thromboembolism]

The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including 1) their mechanism of action, pharmacodynamics and pharmacokinetics; 2) the use in the acute phase with the "double drug single dose" approach or with "single drug double dose"; 3) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; 4) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance >30 ml/min), the elderly (>75 years); 5) they propose a possible laboratory clinical pathway for follow-up; 6) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.

Exploring sub-optimal use of an electronic risk assessment tool for venous thromboembolism

International guidelines and consensus groups recommend using a risk assessment tool (RAT) to assess Venous Thromboembolism (VTE) risk prior to the prescription of prophylaxis. We set out to examine how an electronic RAT was being used (i.e. if by the right clinician, at the right time, for the right purpose) and to identify factors influencing utilization of the RAT. A sample of 112 risk assessments was audited and 12 prescribers were interviewed. The RAT was used as intended in only 40 (35.7%) cases (i.e. completed by a doctor within 24 h of admission, prior to the prescription of prophylaxis). We identified several reasons for sub-optimal use of the RAT, including beliefs about the need for a RAT, poor awareness of the tool, and poor RAT design. If a user-centred approach had been adopted, it is likely that a RAT would not have been implemented or that problematic design issues would have been identified.

Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature.

ELIGIBILITY CRITERIA

Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE.

DATA EXTRACTION

Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers.

DATA ANALYSIS

Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy.

RESULTS

We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate).

CONCLUSIONS

We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.

Revascularization Of Late-Presenting Acute Limb Ischaemia And Limb Salvage

BACKGROUND

Late-presenting acute limb ischaemia represents a challenging vascular emergency. The purpose of this study was to evaluate the outcome in patients following revascularization and management of existing or impending reperfusion injury of ischaemic limbs over a 12-year period (2002-2014).

METHODS

Routine procedural codes were used to label consecutive patients admitted 72 hours following onset of symptoms for surgical revascularization of an acutely ischaemic limb. Data collected included demography, clinical presentation, synchronous morbidities, procedural specifics and outcomes of surgical management of all patients.

RESULTS

The study sample included 206 patients, (117 male and 89 female, average age =49.4±14.6 years) presenting with a diagnosis of acute limb ischemia. The most frequent cause of acute thromboembolic limbs was cardiac disease (n=148). Femoral artery exploration with embolectomy was the most common procedure and was used for aortic, iliac, infrainguinal and distal occlusion. Thirty-four patients required additional vascular surgery due to failure of revascularization by embolectomy. Fasciotomy was performed in 45.6% of cases for existing or impending compartment syndrome when the patient presented very late. Surgical site infection occurred in 8.25% of cases, repeat embolectomy was required in 10.68% of cases; amputation in 13.1% and mortality was 5.8%. Predictors of morbidity and mortality included age of the patient, time of presentation and specific comorbidities. The 5-year amputation-free and survival estimate was 80%.

CONCLUSIONS

Our study suggests that late revascularization of acute leg ischaemia improves blood supply to the limb, thereby reducing the number of amputations. The results suggest that revascularization is clinically warranted, even one week following the onset of acute ischaemia. Additional surgical procedures including fasciotomy further reduce the morbidity and mortality.