Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study

Nursing in mechanical prevention of venous thromboembolism in surgical patients

OBJECTIVE

This theoretical study aims to discuss the role of nurses in the mechanical prevention of venous thromboembolism in surgical patients.

METHOD

The study considered the updated versions of the main international guidelines and reviews on the topic. Non-pharmacological measures to prevent venous thromboembolism in surgical patients and the role of nurses are discussed.

RESULTS

It is important that surgical nurses include in their activities risk of assessments for venous thromboembolism and non-pharmacological prophylactic measures, based on scientific evidence and well-designed institutional protocols.

CONCLUSION

Among the mechanical measures, the use of graduated compression stockings and intermittent pneumatic compression should be ensured by nurses.

Achieving Noise Reduction With a Novel Lower Limb External Mechanical Compression System

Hospitals are one of the noisiest public environments in the United States, and hospital noise is associated with disrupted sleep. This study provides insights into the noise levels produced by three commonly used medical devices for mechanical deep vein thrombosis prophylaxis: the VenaFlow Elite System, the Kendall SCD Compression System, and the ArjoHuntleigh Flowtron. Noise levels produced were compared with a novel device, the RF Health MAC™ system, which was designed to provide improved comfort and noise reduction. Results suggest that future innovation in mechanical deep vein thrombosis prophylaxis should include efforts to reduce noise during operation.

Cancer-Associated Thrombosis: A New Light on an Old Story

Cancer-associated thrombosis (CAT) is a rising and significant phenomenon, becoming the second leading cause of death in cancer patients. Pathophysiology of CAT differs from thrombosis in the non-cancer population. There are additional risk factors for thrombosis specific to cancer including cancer type, histology, and treatment, such as chemotherapy. Recently developed scoring systems use these risk factors to stratify the degree of risk and encourage thromboprophylaxis in intermediate- to high-risk patients. Anticoagulation is safely used for prophylaxis and treatment of CAT. Both of these have largely been with low-molecular-weight heparin (LMWH), rather than the vitamin K antagonist (VKA); however, there has been increasing evidence for direct oral anticoagulant (DOAC) use. Consequently, international guidelines have also adapted to recommend the role of DOACs in CAT. Using DOACs is a turning point for CAT, but further research is warranted for their long-term risk profile. This review will discuss mechanisms, risk factors, prophylaxis and management of CAT, including both LMWH and DOACs. There will also be a comparison of current international guidelines and how they reflect the growing evidence base.

Bleeding risk assessment for venous thromboembolism prophylaxis

Venous thromboembolism (VTE) is one of the main preventable causes of morbidity and mortality in hospitalized patients and fatal pulmonary embolism (PE) may be its first manifestation. Several national and international guidelines recommend using risk assessment models for prescription of VTE prophylaxis in hospitalized patients. Despite evidence and guidelines supporting VTE prevention, use of VTE prophylaxis in hospitalized patients remains suboptimal, which may be because of low awareness of the benefits of VTE prophylaxis, but might also reflect fear of bleeding complications in these patients, since this constitutes one of the main reasons for underutilization of thromboprophylaxis worldwide. Bleeding risk assessment is therefore necessary for adequate prophylaxis prescription and should be carried out concurrently with assessment of the risk of thrombosis. The purpose of this review is to highlight the importance of jointly assessing risk of VTE and risk of bleeding in hospitalized patients.

Safety and effectiveness of thromboprophylaxis use in hospitalized elderly medical patients at a Saudi tertiary care center

Introduction

Appropriate prescribing of thromboprophylaxis according to guidelines' recommendations can heighten over- or underutilization risk. The study intended to evaluate the safety and effectiveness of appropriate/inappropriate thromboprophylaxis use among hospitalized elderly medical patients.

Methods

A retrospective observational cohort study was conducted, including patients who were ≥60 years old, hospitalized for an acute medical illness that required hospitalization in a medical ward for >48 h, and received thromboprophylaxis. Against the American College of Chest Physicians guidelines, the thromboprophylaxis use appropriateness was assessed.

Results

A total of 370 patients met the inclusion criteria, in 71.9% of whom thromboprophylaxis use was appropriate. The mean age of the included patients was 75 years (±9.1), and 72.4% of them were at high risk of venous thromboembolism (VTE), and almost all these patients received appropriate thromboprophylaxis. The occurrence of bleeding was significantly higher in the appropriate use group during hospitalization than the inappropriate use group (11.7% vs. 2.9%, p = 0.009); the majority of these bleeding events were classified as major. There were no differences in VTE events during hospitalization or 90 days all-cause mortality between the two groups.

Conclusion

The study demonstrates high prescribers' compliance with recommendations in high-risk patients. In patients at low risk for VTE, the overutilization of thromboprophylaxis did not increase their bleeding risk. This study suggests that the benefits of thromboprophylaxis in elderly patients, regardless of their VTE risk, may outweigh the risk of bleeding.

[Pharmacological Thromboprophylaxis in Acutely Ill Hospitalized Medical Patients]

Venous thromboembolic events (VTE) occur in approximately 50% of cases during or following hospitalization; VTE are a major cause of morbidity and mortality. Thromboprophylaxis for 6 to 14 days with heparins or fondaparinux has been demonstrated to be effective in VTE prevention in patients hospitalized for acute medical illnesses and reduced mobility. Nevertheless, the level of recommendation has been gradually downgraded as the benefit has been mainly demonstrated on the basis of systematic imaging diagnosed events. Direct oral anticoagulants have been assessed only as an extended prophylaxis, and are currently not recommended in medical thromboprophylaxis. Assessing the risk of VTE and bleeding in medical patients is complex. VTE and bleeding risk assessment scores were constructed but have not been validated. In order to improve the adequacy of prescriptions for thromboprophylaxis, the impact of different interventions has been the subject of several studies but these yielded varying results. The aim of this review is to analyze the indications for thromboprophylaxis in a medical setting with the latest available data.

Reduced expression of annexin A2 is associated with impaired cell surface fibrinolysis and venous thromboembolism

Reduced plasma fibrinolysis has been identified as a potential risk factor for venous thromboembolism (VTE), but the role of cell surface fibrinolysis in VTE is unknown. The annexin A2/S100A10 complex serves as a coreceptor for plasminogen and tissue plasminogen activator (tPA), augmenting plasmin generation by 60-fold on the endothelial cell surface. Several studies in both mice and humans support the concept that A2 regulates fibrin homeostasis and intravascular thrombosis in vivo. Here, we examined A2 protein expression and function in 115 adult subjects with VTE and 87 healthy controls. Using peripheral blood mononuclear cells as a surrogate for endothelial cells, we found a 41% mean decrease in cell surface tPA-dependent fibrinolytic activity in subjects who had a positive personal and family history of VTE but tested negative for known inherited thrombophilias (ITs). A2 protein was reduced on average by 70% and messenger RNA levels by 30%, but neither decrease correlated with anticoagulant therapy. Neither cell A2 protein nor cell surface plasmin generation correlated with plasma-based clot lysis times, suggesting that the plasma and cell surface fibrinolytic systems operate independently of one another. These data suggest that reduced expression of annexin A2 protein is associated with cell surface hypofibrinolysis and may represent a novel risk factor for IT.

Clinical characteristics and risk factors for symptomatic venous thromboembolism in hospitalized COVID-19 patients: A multicenter retrospective study

BACKGROUND

High incidence of asymptomatic venous thromboembolism (VTE) has been observed in severe COVID-19 patients, but the characteristics of symptomatic VTE in general COVID-19 patients have not been described.

OBJECTIVES

To comprehensively explore the prevalence and reliable risk prediction for VTE in COVID-19 patients.

METHODS/RESULTS

This retrospective study enrolled all COVID-19 patients with a subsequent VTE in 16 centers in China from January 1 to March 31, 2020. A total of 2779 patients were confirmed with COVID-19. In comparison to 23,434 non-COVID-19 medical inpatients, the odds ratios (ORs) for developing symptomatic VTE in severe and non-severe hospitalized COVID-19 patients were 5.94 (95% confidence interval [CI] 3.91-10.09) and 2.79 (95% CI 1.43-5.60), respectively. When 104 VTE cases and 208 non-VTE cases were compared, pulmonary embolism cases had a higher rate for in-hospital death (OR 6.74, 95% CI 2.18-20.81). VTE developed at a median of 21 days (interquartile range 13.25-31) since onset. Independent factors for VTE were advancing age, cancer, longer interval from symptom onset to admission, lower fibrinogen and higher D-dimer on admission, and D-dimer increment (DI) ≥1.5-fold; of these, DI ≥1.5-fold had the most significant association (OR 14.18, 95% CI 6.25-32.18, p = 2.23 × 10-10 ). A novel model consisting of three simple coagulation variables (fibrinogen and D-dimer levels on admission, and DI ≥1.5-fold) showed good prediction for symptomatic VTE (area under the curve 0.865, 95% CI 0.822-0.907, sensitivity 0.930, specificity 0.710).

CONCLUSIONS

There is an excess risk of VTE in hospitalized COVID-19 patients. This novel model can aid early identification of patients who are at high risk for VTE.

A multifaceted clinical decision support intervention to improve adherence to thromboprophylaxis guidelines

Background Venous thromboembolism is a potentially fatal complication of hospitalisation, affecting approximately 3% of non-surgical patients. Administration of low molecular weight heparins to the appropriate patients adequately decreases venous thromboembolism incidence, but guideline adherence is notoriously low. Objective To determine the effect of a multifaceted intervention on thromboprophylaxis guideline adherence. The secondary objective was to study the effect on guideline adherence specifically in patients with a high venous thromboembolism risk. As an exploratory objective, we determined how many venous thromboembolisms may be prevented. Setting A Dutch general teaching hospital. Method A prospective study with a pre- and post-intervention measurement was conducted. A multifaceted intervention, consisting of Clinical Decision Support software, a mobile phone application, monitoring of duplicate anticoagulants and training, was implemented. Guideline adherence was assessed by calculating the Padua prediction and Improve bleeding score for each patient. The number of preventable venous thromboembolisms was calculated using the incidences of venous thromboembolism in patients with and without adequate thromboprophylaxis and extrapolated to the annual number of admitted patients. Main outcome measure Adherence to thromboprophylaxis guidelines in pre- and post-intervention measurements. Results 170 patients were included: 85 in both control and intervention group. The intervention significantly increased guideline adherence from 49.4 to 82.4% (OR 4.78; 95%CI 2.37–9.63). Guideline adherence in the patient group with a high venous thromboembolism risk also increased significantly from 54.5 to 84.3% (OR 2.46; 95%CI 1.31–4.62), resulting in the potential prevention of ± 261 venous thromboembolisms per year. Conclusions Our multifaceted intervention significantly increased thromboprophylaxis guideline adherence.

A retrospective study on the effectiveness of Artificial Intelligence-based Clinical Decision Support System (AI-CDSS) to improve the incidence of hospital-related venous thromboembolism (VTE)

Background

Artificial intelligence technology is widely used in the medical industry. Our retrospective study evaluated the effectiveness of an AI-CDSS in improving the incidence of hospital-related VTE and the impact of anticoagulant drug use.

Methods

This study collected relevant data on adult patients over 18 years of age who are not discharged 24 hours, from January to July 2019 and from January to July 2020, the VTE high-risk department of Ruijin Hospital. Before and after using AI-CDSS, the incidence of hospital-related VTE and using anticoagulants were analyzed.

Results

Between January to July 2019 and January to July 2020, 3,565 and 4,423 adult patients over 18 years old were hospitalized in our hospital and were designed as a control group and intervention group, respectively (7,988 in total). Both groups had similar baseline characteristics. There were 4,716 (59.03%) male patients, the mean age was 60.43±13.09 years, and the mean stay was 7.56±7.76 days. More than half of the patients (4,605, 57.58%) came from the respiratory. VTE events during hospitalization occurred in 41 patients; overall, 5.13/1,000 (41 episodes in 7,988 patients). Compared with the control group, before implementing AI-CDSS, the rate of VTE during hospitalization was reduced from 5.89/1,000 (21 episodes in 3,565 patients) to 4.75/1,000 patients (20 episodes in 4,423 patients) (relative reduction of 19.35%) in the intervention group. The use rate of anticoagulant drugs was increased from 19.97% (712/3,565) in the control group to 22.88% (1,012/4,423) in intervention group [P<0.01, odds ratio (OR): 1.19, 95 percent confidence interval (95% CI) (1.07-1.32)], (relative 14.57% increase). Poisson's regression results showed that department, age ≥75 years [OR: 3.09, 95% Cl (1.45-6.33)], duration of hospitalization [OR: 1.04, 95% CI (1.03-1.05)], heart failure [OR: 5.13, 95% CI (1.74-13.54)] and renal failure [OR: 3.60, 95% CI (0.90-11.34)] were high-risk factors for VTE events.

Conclusions

Implementing AI-CDSS can help clinicians identify hospitalized patients at increased VTE risk, take effective preventive measures, and improve clinicians' compliance with the American College of Chest Physicians (ACCP) guidelines.

Venous thromboembolism in Asia and worldwide: Emerging insights from GARFIELD-VTE

BACKGROUND

Although epidemiological studies report a lower risk of venous thromboembolism (VTE) than in the Western world, VTE rates in Asia may be underestimated. Furthermore, it is uncertain whether VTE outcomes differ in Asia and the rest of the world (ROW).

METHODS

GARFIELD-VTE is a global, prospective, non-interventional study of real-world treatment practices. In this study, we compared baseline characteristics, treatment patterns, and 12-month outcomes in Asia and ROW.

RESULTS

Of the 10,684 enrolled patients, 1822 (17.1%) were Asian (China n = 420, Hong Kong n = 98, Japan n = 148, Malaysia n = 244, South Korea n = 343, Taiwan n = 232, Thailand n = 337). Compared with ROW patients, those from Asia were more often female (57.4% vs. 48.0%), non-smokers (74.0% vs. 58.9%) and had a lower BMI (24.8 kg/m² vs. 29.1 kg/m²). Asian patients were more likely to be managed in the hospital (86.9% vs. 70.4%) and to have active cancer (19.8% vs. 8.1%) or a history of cancer (19.1% vs. 12.0%). Asian patients received no anticoagulation more frequently than ROW patients (6.5% vs. 2.1%). Over 12-months follow-up, the rate of all-cause mortality (per 100 person-years [95% confidence interval]) was higher in Asians (15.2 [13.4-17.3] vs. 5.9 [5.4-6.5]). Adjusted hazard ratios indicated a higher risk of all-cause mortality in Asian patients than the ROW (1.32 [1.08-1.62]). The frequencies of major bleeding and recurrent VTE were similar.

CONCLUSION

Asian patients have different risk profiles, treatment patterns and a higher risk of mortality compared with the ROW.

Rivaroxaban versus aspirin in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery: a meta-analysis

Objective

To evaluates the efficacy and safety of rivaroxaban versus aspirin in prevention of venous thromboembolism (VTE) following total hip (THA) or knee arthroplasty (TKA) or hip fracture surgery.

Methods

Major databases were systematically searched for all relevant studies published in English up to October 2020. The meta-analysis was conducted using RevMan 5.3 software.

Results

In total, 7 studies were retrieved which contained 5133 patients. Among these patients, 2605 patients (50.8%) received rivaroxaban, whereas 2528 patients (49.2%) received aspirin. There were no statistical difference between aspirin and rivaroxaban for reducing VTE (RR = 0.75, 95% CI 0.50–1.11, I² = 36%, p = 0.15), major bleeding (RR = 0.94, 95% CI 0.45–2.37, I² = 21%, p = 0.95), and all-cause mortality (RR = 0.88, 95% CI 0.12–6.44, I² = 0%, p = 0.90) between the two groups. Compared with aspirin, rivaroxaban significantly increased nonmajor bleeding (RR = 1.29, 95% CI 1.05–1.58, I² = 0%, p = 0.02).

Conclusion

There was no significant difference between aspirin and rivaroxaban in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery. Aspirin may be an effective, safe, convenient, and cheap alternative for prevention of VTE. Further large randomized studies are required to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02274-z.

A cross-sectional, multicenter, observational study to assess the prophylaxis of venous thromboembolism in Lebanese and Jordanian hospitals

Background

There is a growing body of evidence showing substantial underuse of appropriate venous thromboembolism (VTE) prophylaxis in patients at risk. In the present study, our goal was to assess the current practices in the use rate of VTE prophylaxis among hospitalized patients in Jordan and Lebanon.

Methods

A cross-sectional, multicenter, observational study was conducted on 40 centers across Lebanon and Jordan. We included patients who were admitted to the participating hospitals for the treatment of a serious medical or surgical illness. The patients’ records were screened for the fulfillment of inclusion/exclusion criteria during a single assessment visit. The proportion of medical and surgical patients who were at risk of VTE and the thrombo-prophylactic measures employed by physicians for these patients were assessed according to the American College of Chest Physicians (ACCP 2016) guidelines.

Results

The present study included 704 patients (400 from Jordan and 304 from Lebanon) with a mean age of 54.9 ± 17.5 years. Almost 59% of the patients received prophylaxis treatment in form of pharmacological anticoagulant prophylaxis and/or mechanical prophylaxis. Low molecular weight heparin was the most commonly used anticoagulant for VTE prophylaxis in 366 out of the total 704 (51.9%) patients in the analysis cohort. Two hundred and sixteen patients (52, 95% confidence interval [47.1–56.9%]) received appropriate prophylactic agents out of 415 patients who were eligible for prophylaxis according to the ACCP 2016 guidelines. On the other hand, 199 (72.1, 95% confidence interval [66.4–77.3%) patients received prophylaxis out of 276 ineligible patients. The rate of compliance to guidelines showed wide variations according to the type of hospital, specialty, and the patients’ age. The multivariate logistic regression analysis showed that only age was a significant predictor of appropriate VTE prophylaxis (odds ratio [OR] 1.05, P < 0.001).

Conclusion

The rates of the appropriate use of VTE prophylaxis are low in Lebanon and Jordan. There is a lack of compliance to guidelines for VTE prophylaxis use for hospitalized patients in both countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-021-00261-2.

Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism remains a significant complication following major gynecologic surgery. Evidence is lacking on whether it is beneficial to give pharmacologic thromboprophylaxis pre-operatively. The aim of this meta-analysis was to assess the role of pre-operative pharmacologic thromboprophylaxis in preventing post-operative venous thromboembolism.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials were searched to find randomized controlled, cohort, and case-control trials comparing pre-operative pharmacologic thromboprophylaxis to no prophylaxis, mechanical prophylaxis, or only post-operative pharmacologic thromboprophylaxis for open and minimally invasive major gynecologic surgery (benign and malignant conditions). Two authors independently assessed abstracts, full-text articles, and methodological quality. Data were extracted and pooled using ORs for random effects meta-analysis. Heterogeneity was explored using forest plots, Q-statistic, and I2 statistics. Planned subgroup analysis of use of sequential compression devices, equivalent versus non-equivalent post-operative prophylaxis, cancer diagnosis, and methodological quality were performed.

RESULTS

Some 503 unique studies were found, and 16 studies (28 806 patients) were included in the systematic review. Twelve studies (14 273 patients) were included in the meta-analysis. The OR for incidence of post-operative venous thromboembolism was 0.59 (95% CI 0.39, 0.89), favoring pre-operative pharmacologic thromboembolism prophylaxis compared with no pre-operative pharmacologic prophylaxis (Q=13.80, I2=20.30). In studies where post-operative care was equivalent between groups, the OR for venous thromboembolism was 0.56 (95% CI 0.22, 1.40). Pre-operative pharmacologic prophylaxis demonstrated greatest benefit when utilized with both intra-operative and post-operative sequential compression devices (OR 0.43, 95% CI 0.30, 0.64) compared with when no sequential compression devices were utilized (OR 1.27, 95% CI 0.63, 2.56). When looking at only studies determined to be of high quality, the results no longer reached significance (OR 0.73, 95% CI 0.36, 1.46).

CONCLUSIONS

Pre-operative pharmacologic thromboprophylaxis decreases the odds of venous thromboembolism in the peri-operative period for major gynecologic oncology surgery by approximately 40%. It remains unclear whether this benefit is present in benign and minor procedures. Adequately powered studies are needed.

Ethnic differences in thromboprophylaxis for COVID-19 patients: should they be considered?

Thromboembolic events contribute to morbidity and mortality in coronavirus disease 2019 (COVID-19). As a result, thromboprophylaxis using low-molecular-weight heparin (LMWH) is universally recommended for hospitalized patients based on multiple guidelines. However, ethnic differences with respect to thrombogenicity have been reported and the incidence of thromboembolic events is considered to be lower in the Asian population. Despite the importance of thromboprophylaxis, bleeding is also a side effect that should be considered. We examine the data relating to potential ethnic differences in thrombosis and bleeding in COVID-19. Although sufficient data is not yet available, current evidence does not oppose routine anticoagulant use and thromboprophylaxis using a standard dose of LMWH for admitted patients regardless of ethnicity based on our review.

Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries

New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.

Prevention, diagnosis, and management of venous thromboembolism in the critically ill surgical and trauma patient

PURPOSE OF REVIEW

Venous thromboembolism (VTE), which encompasses deep vein thrombosis and pulmonary embolism, is common among trauma patients and critically ill surgical patients admitted to the ICU. Critical care surgical patients are at an extremely high risk for VTE and the related morbidity and mortality associated with it. The present review aims to provide an overview of the importance of identifying risk factors, prescribing effective prohylaxis, accurate diagnosis, and timely appropriate treatment for trauma and critically ill surgical patients with VTE in the ICU.

RECENT FINDINGS

VTE is a healthcare burden among critically ill surgical patients that is mostly preventable through adherence to prophylactic protocols that aim to recognize VTE risk factors while simultaneously providing guidance to appropriate timing and administration prophylaxis regimens. Newer pharmacologic therapies for prophylaxis and treatment, diagnostic modalities, and indications for therapy of VTE have continued to evolve.

SUMMARY

Critical care surgical and trauma patients represent a population that are at a heightened risk for VTE and associated complications. Appropriate screening, prevention strategies, accurate diagnosis, and timely administration of appropriate treatment must be utilized to reduce morbidity and mortality.

Understanding the andromeda strain - The role of cytokine release, coagulopathy and antithrombin III in SARS-CoV2 critical illness

As the current coronavirus pandemic continues and cases of COVID-19 critical illness rise, physicians and scientists across the globe are working to understand and study its pathophysiology. Part of the pathology of this illness may result from its prothrombotic potential as witnessed from derangements in coagulation and thrombotic complications reported in observational studies performed in China and Europe to findings of microthrombosis upon autopsy analysis of patients who succumbed to COVID-19. Multiple organizations, including the American Society of Hematology (ASH), recommend the routine use of prophylactic heparin to temper the thrombotic complications of this illness given its mortality benefit in severe COVID-19 infections. Reductions in circulating levels of Antithrombin III (AT), the primary mediator of heparin's action, is present in cases of coronavirus related critical illness. AT's use as a prognostic marker, an important effector of heparin resistance, and a potential therapeutic target for COVID-19 remains to be explored.

Do Inpatients Receive Risk-Based Prophylactic Treatment for Thrombotic Events?

BACKGROUND

Current guidelines recommend risk-based use of prophylaxis for preventing medical inpatients from venous thromboembolism (VTE). Little is known about the current prescription practice, and even less whether differences between subspecialists like cardiologists, usually treating patients with thrombotic or thromboembolic diseases, and gastroenterologists, treating more patients with gastrointestinal bleeding complications, exist.

METHODS

We performed a retrospective chart review of patients on cardiology and gastroenterology wards of our university hospital. Patients with a clear indication for anticoagulation and contraindication against antithrombotic treatment were excluded. A total of 450 patients per specialty were included. Quantitative risk assessment models were used to determine the risk of a VTE (Padua Prediction Score (PPS), IMPROVE Score) and bleeding (IMPROVE-Bleeding and HAS-BLED Score).

RESULTS

The overall rate of VTE prophylaxis was high in both patient populations. Significant more low-risk cardiology compared to gastroenterology patients received drug-based prophylaxis. Furthermore, crucial discrepancies were found in the way individual patients would be classified based on PPS and IMPROVE Score. Finally, not the risk category but the length of hospital stay was best at predicting which patient received prophylaxis.

Application of AI and IoT in Clinical Medicine: Summary and Challenges

The application of artificial intelligence (AI) technology in the medical field has experienced a long history of development. In turn, some long-standing points and challenges in the medical field have also prompted diverse research teams to continue to explore AI in depth. With the development of advanced technologies such as the Internet of Things (IoT), cloud computing, big data, and 5G mobile networks, AI technology has been more widely adopted in the medical field. In addition, the in-depth integration of AI and IoT technology enables the gradual improvement of medical diagnosis and treatment capabilities so as to provide services to the public in a more effective way. In this work, we examine the technical basis of IoT, cloud computing, big data analysis and machine learning involved in clinical medicine, combined with concepts of specific algorithms such as activity recognition, behavior recognition, anomaly detection, assistant decision-making system, to describe the scenario-based applications of remote diagnosis and treatment collaboration, neonatal intensive care unit, cardiology intensive care unit, emergency first aid, venous thromboembolism, monitoring nursing, image-assisted diagnosis, etc. We also systematically summarize the application of AI and IoT in clinical medicine, analyze the main challenges thereof, and comment on the trends and future developments in this field.

Underuse of medical thromboprophylaxis in mobile elderly inpatients: The SWITCO65+ cohort

BACKGROUND

Hospital-associated venous thromboembolism (HA-VTE) can be prevented by pharmacologic thromboprophylaxis. Thrombotic risk assessment models (RAMs) are essential tools to improve inadequately prescribed thromboprophylaxis. Among cases of HA-VTE, our study objectives are to explore the classifications of available thrombosis RAMs, the adequacy of thromboprophylaxis and risk factors for inadequate thromboprophylaxis.

METHODS

We identified cases of HA-VTE occurring during medical hospitalizations within a multicenter Swiss venous thromboembolism (VTE) cohort (2009-2013). We calculated the proportion of VTE cases deemed at high risk with 4 VTE RAMs (Geneva, Simplified Geneva, Padua, and Improve) and the adequacy of administered pharmacologic thromboprophylaxis, and explored risk factors for underprescription of thromboprophylaxis in high-risk inpatients.

RESULTS

Among 66 medical inpatients with HA-VTE, 60.6% had pulmonary embolism. The sensitivities of the Geneva, Simplified Geneva, Padua, and Improve RAMs were 86.4%, 80.3%, 72.7%, and 57.6%, respectively. The proportion of inadequate thromboprophylaxis was high, as 62.5%-71.1% of high-risk inpatients had not received it. Among the high-risk group according to the Simplified Geneva RAM, absence of immobilization was the only variable significantly associated with an inadequate use of thromboprophylaxis (odds ratio, 3.59; 95% confidence interval, 1.08-11.88).

CONCLUSIONS

We found a dramatically high proportion of inadequate medical thromboprophylaxis among inpatients who suffered from HA-VTE. This reinforces the need for global and local quality-improvement efforts to promote adequate use of thromboprophylaxis in elderly inpatients. Mobility may favor the underuse of thromboprophylaxis, and clinicians should stay alert to other thrombotic risk factors in mobile inpatients.

Development of a Risk Model for Pediatric Hospital-Acquired Thrombosis: A Report from the Children's Hospital-Acquired Thrombosis Consortium

OBJECTIVE

To identify pertinent clinical variables discernible on the day of hospital admission that can be used to assess risk for hospital-acquired venous thromboembolism (HA-VTE) in children.

STUDY DESIGN

The Children's Hospital-Acquired Thrombosis Registry is a multi-institutional registry for all hospitalized participants aged 0-21 years diagnosed with a HA-VTE and non-VTE controls. A risk assessment model (RAM) for the development of HA-VTE using demographic and clinical VTE risk factors present at hospital admission was derived using weighted logistic regression and the least absolute shrinkage and selection (Lasso) procedure. The models were internally validated using 5-fold cross-validation. Discrimination and calibration were assessed using area under the receiver operating characteristic curve and Hosmer-Lemeshow goodness of fit, respectively.

RESULTS

Clinical data from 728 cases with HA-VTE and 839 non-VTE controls, admitted between January 2012 and December 2016, were abstracted. Statistically significant RAM elements included age <1 year and 10-22 years, cancer, congenital heart disease, other high-risk conditions (inflammatory/autoimmune disease, blood-related disorder, protein-losing state, total parental nutrition dependence, thrombophilia/personal history of VTE), recent hospitalization, immobility, platelet count >350 K/μL, central venous catheter, recent surgery, steroids, and mechanical ventilation. The area under the receiver operating characteristic curve was 0.78 (95% CI 0.76-0.80).

CONCLUSIONS

Once externally validated, this RAM will identify those who are at low-risk as well as the greatest-risk groups of hospitalized children for investigation of prophylactic strategies in future clinical trials.

Improving compliance of risk assessment and nonpharmacological interventions for deep venous thrombosis prevention in a respiratory ICU: a best practice implementation project

OBJECTIVES

To increase the compliance with deep venous thrombosis (DVT) nonpharmacologic prophylaxis best practice recommendations while ensuring appropriate and structured nonpharmacologic prophylaxis for patients in the respiratory ICU.

BACKGROUND

DVT is a major problem for patients, with those who are critically ill representing a high-risk population for developing the condition. Nonpharmacologic prophylaxis is considered an effective intervention. However, the application of such interventions in practice has not been optimal to date.

METHODS

The current project was conducted in a respiratory ICU of a tertiary hospital. Audit criteria were developed on the basis of an evidence summary developed by the Joanna Briggs Institute, whereby the institute's Practical Application of Clinical Evidence System program to facilitate an audit and feedback cycle was utilized as an implementation framework. Baseline and follow-up audits on nonpharmacological DVT prophylaxis were conducted for 35 patients against five evidence-based recommendations. In addition, the nurses' knowledge and attitude regarding DVT prophylaxis were investigated both prior to and postimplementation.

RESULTS

In the baseline audit, compliance with the five evidence-based audit criteria was less than 15%. After the implementation of strategies including education, person-centered care, financial and human-resource support, there was a significant improvement in all the audit criteria. In addition, improvements in the nurses' knowledge and attitude regarding DVT prophylaxis were reported. The rate of discharged patients due to a deterioration of their condition decreased from 31.4 to 5.7% in the follow-up cycle. One DVT patient occurred in the baseline data, whereas no new incidences of DVT were found in the follow-up data.

CONCLUSION

The project not only improved nurses' knowledge and attitude regarding DVT prevention, but also remarkably improved the implementation of nonpharmacological DVT prophylaxis. The application of evidence-based nonpharmacological DVT prophylaxis may improve patients' outcomes in the ICU.

Venous Thromboembolism Prophylaxis in Acute Medically Ill Patients: A Retrospective Cohort Study

OBJECTIVE

Current guidelines recommend pharmacologic prophylaxis for medical patients at high risk for venous thromboembolism. We aimed to assess the benefit and safety of venous thromboembolism prophylaxis in acutely ill medical patients hospitalized.

METHODS

We prepared a retrospective cohort study in a tertiary hospital in Israel with patients hospitalized in medical departments with an admission lasting more than 48 hours during 2014-2017.

PRIMARY OUTCOME

30-day mortality.

SECONDARY OUTCOMES

90-day incidence of pulmonary embolism, symptomatic deep vein thrombosis, and major bleeding. Propensity-weighted logistic multivariate analysis was performed.

RESULTS

A total of 18,890 patient-unique episodes were included in the analysis. Of them, 3206 (17.0%) received prophylaxis. A total of 1309 (6.9%) died, 540/3206 (16.8%) of those who received venous thromboembolism prophylaxis and 769/15,864 (4.9%) of those who did not. Prophylaxis was not associated with a reduction in mortality, multivariable-adjusted odds ratio propensity-weighted (OR) 0.99 (95% confidence interval [CI], 0.84-1.14). One hundred forty-two patients (0.7%) developed venous thromboembolism, 44/3206 (1.4%) of those who received prophylaxis and 98/15,864 (0.6%) of those who did not. Prophylaxis was not associated with reduction in venous thromboembolism in the whole cohort, multivariable-adjusted propensity-weighted OR 1.09 (95% CI, 0.52-2.29). Prophylaxis was associated with an increase in major bleeding (multivariable-adjusted propensity-weighted OR 1.24; 95% CI, 1.04-1.48).

CONCLUSION

The current practice of routinely administering venous thromboembolism prophylaxis to medically ill patients considered at high risk for thrombosis resulted in a high risk for bleeding without a clear clinical benefit, and should be reassessed.

The importante of profilaxis in venous thromboembolism

During the coronavirus pandemic, there has been much discussion worldwide about the prophylaxis of venous thromboembolism (VTE) in hospitalized patients or not. After the pandemic is over or minimized, we must keep this in mind as one of the most critical tasks to be done, during and after hospitalization, regardless of the case.

Prescribing patterns and outcomes of venous thromboembolism prophylaxis in hospitalized medical and cancer patients: Observations from the Ottawa Hospital

Guidelines suggest broad use of pharmacologic prophylaxis to prevent venous thromboembolism (VTE) in hospitalized medical patients, however little 'real-world' data exists to support this. Our goal was to describe the use of thromboprophylaxis among general medical and cancer patients admitted to hospital, compare VTE and bleeding outcomes according to use of thromboprophylaxis, and to determine what variables influence prescribing patterns and outcomes. Patients admitted to the general medical and oncology services at The Ottawa Hospital between 2010 and 2015 were retrospectively reviewed and classified according to whether they received initial, delayed, or no pharmacologic thromboprophylaxis during their first hospitalization. Patients with an alternate indication for anticoagulation or those admitted with a bleeding event were excluded from analysis. The primary efficacy outcome was any symptomatic VTE during index hospitalization or within 90 days of discharge, and the primary safety outcome was clinically relevant bleeding during the index hospitalization. 17,262 patients were included in our final analysis. General medical patients selected to receive no, initial, or delayed thromboprophylaxis had 0.4%, 0.7%, and 2.4% rates of VTE; and 0.2%, 0.7%, and 1.5% rates of clinically relevant bleeding complications, respectively. Cancer patients had significantly higher rates of VTE: 3.3%, 3.9%, and 5.0%; and 0.9%, 0.7%, and 3.0% rates of clinically relevant bleeding among those selected to receive no, initial, or delayed thromboprophylaxis, respectively. Overall, our study suggests that broad use of pharmacologic thromboprophylaxis may be unnecessary in select low-risk general medical patients and may be less effective in cancer patients in whom new studies are indicated.

Validation of the IMPROVE bleeding risk score in Chinese medical patients during hospitalization: Findings from the dissolve-2 study

Background

Venous thromboembolism (VTE) prophylaxis remains suboptimal in China due to the bleeding risk associated with pharmacologic prophylaxis. We used data from the DissolVE-2 study to report the risk factors for bleeding and validated the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS).

Methods

In-hospital major bleeding incidence in medical patients from the DissolVE-2 study were assessed by Kaplan-Meier method. Risk factors associated with clinically relevant bleeding (CRB) were analysed using Cox regression model. Sensitivity, specificity, positive predictive value, negative predictive value and receiver-operating characteristic (ROC) curve was used to compute the diagnostic accuracy of IMPROVE BRS in the study cohort.

Findings

Of the 6623 medical patients, 5076 patients with all relevant clinical details were included for the validation cohort. Overall, 127 CRB events (38 major and 89 clinically relevant non-major bleeding events) occurred in this cohort, with a cumulative incidence rate of 2.6% (95% confidence interval [CI], 2.3–3.4). Application of IMPROVE BRS revealed significantly higher hazards of CRB (hazard ratio [HR]: 7.17, 95% CI, 5.05–10.18) and major bleeding (HR: 13.95, 95% CI, 7.28–26.73) in patients with IMPROVE BRS ≥7. Comparison of predictive parameters revealed higher sensitivity (44.1 vs 35.9) and positive predictive value (10.9 vs 2.6) for CRB in our study than the IMPROVE study, which was substantiated by the area under the curve (0.73, p<0.0001) from the ROC curve analysis.

Interpretation

IMPROVE BRS is a simple model for estimating bleeding risk in Chinese medical patients and could be used in conjunction with VTE risk assessment models to decide prophylactic treatment for VTE.

Funding

This study and the additional data analysis were funded by Sanofi (Beijing) Pharmaceutical Co, Ltd by the Fund of The National Key Research and Development Program of China [Grant 2016YFC0905600] and by CAMS Innovation Fund for Medical Sciences (CIFMS) (No.2018-I2M-1–003)

Venous Thromboembolism Risk and Thromboprophylaxis Assessment in Surgical Patients Based on Caprini Risk Assessment Model

PURPOSE

Venous thromboembolism (VTE) is the most common preventable cause of hospitalization-associated mortality. In the absence of optimal prophylaxis and depending on the type of surgery and patient-related factors, the risk of developing VTE increases by 10% to 50%. We aimed to assess VTE risk and thromboprophylaxis among surgical patients hospitalized at surgical wards of Tikur Anbessa Specialized Hospital (TASH). Addis Ababa, Ethiopia.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted from September 1, 2018 to February 28, 2019. Data were collected using a pretested observational checklist which is prepared based on the VTE Caprini risk assessment model. Then, the collected data were checked for completeness and finally entered and analyzed using Statistical Package for Social Sciences (SPSS) version 25.

RESULTS

Out of 155 admitted patients, almost equal numbers of males (49.68%) and females (50.32%) participated in the study with a mean age of 41.87±16.84 and an age range of 13 to 89 years. Undergoing major surgery, resting in bed for more than 3 days and having acute infections (including pneumonia) were the most frequently seen VTE risk factors. Most of the study participants (135, 87.10%) were at risk of developing VTE (>1 Caprini risk score), and 47.11% were in the highest risk category (≥5 Caprini score). The maximum and minimum total risk scores were 19 and 1, respectively with a mean score of 4.53±2.31. Among patients who were at risk of developing VTE and eligible for thromboprophylaxis, only 17.78% received thromboprophylaxis and two ineligible patients received prophylaxis. Parental unfractionated heparin twice or three times per day was the most widely used thromboprophylaxis regimen. A total of 29 (18.71%) patients had one or more contraindication(s) for thromboprophylaxis and three of them took prophylaxis despite the contraindications. Only 3 (1.93%) patients admitted to surgical wards developed VTE during hospitalization.

CONCLUSION

As per the Caprini risk assessment model, the majority of surgical patients treated at TASH were at risk of developing VTE. However, thromboprophylaxis was underutilized. The incidence of VTE was 1.93% in our study.

University Teaching Trauma Centers: Decreased Mortality but Increased Complications

BACKGROUND

Teaching hospitals are often regarded as excellent institutions with significant resources and prominent academic faculty. However, the involvement of trainees may contribute to higher rates of complications. Conflicting reports exist regarding outcomes between teaching and nonteaching hospitals, and the difference among trauma centers is unknown. We hypothesized that university teaching trauma centers (UTTCs) and nonteaching trauma centers (NTTCs) would have a similar risk of complications and mortality.

METHODS

We queried the Trauma Quality Improvement Program (2010-2016) for adults treated at UTTCs or NTTCs. A multivariable logistic regression analysis was performed to evaluate the risk of mortality and in-hospital complications, such as respiratory complications (RCs), venous thromboembolisms (VTEs), and infectious complications (ICs).

RESULTS

From 895,896 patients, 765,802 (85%) were treated at UTTCs and 130,094 (15%) at NTTCs. After adjusting for covariates, UTTCs were associated with an increased risk of RCs (odds ratio (OR) 1.33, confidence interval (CI) 1.28-1.37, P < 0.001), VTEs (OR 1.17, CI 1.12-1.23, P < 0.001), and ICs (OR 1.56, CI 1.49-1.64, P < 0.001). However, UTTCs were associated with decreased mortality (OR 0.96, CI 0.93-0.99, P = 0.008) compared with NTTCs.

CONCLUSIONS

Our study demonstrates increased associated risks of RCs, VTEs, and ICs, yet a decreased associated risk of in-hospital mortality for UTTCs when compared with NTTCs. Future studies are needed to identify the underlying causative factors behind these differences.

Is guideline-driven prophylaxis for venous thromboembolism common practice in the South African private hospital setting?

Background

Prophylactic venous thromboembolism (VTE) strategies have the greatest impact on patient outcomes. Both global and local guidelines support VTE prophylaxis for hospitalised patients. However, studies have reported that these measures are routinely under-prescribed. This study evaluated prescribing patterns of VTE prophylaxis in one of the largest South African (SA) private hospital groups.

Methods

A quantitative, retrospective analysis of the hospital group’s patient database was conducted for patients admitted between 01 September 2015 and 31 August 2016. Those younger than 18 years with trauma or suffering from contraindications to anticoagulation were excluded. Additionally, patients with warfarin billed were also excluded as they possibly required therapeutic anticoagulation. Included prophylactic measures were compared with published SA guidelines by abstracting prophylaxis type and dosing, according to corresponding individual patients’ VTE risk ratings.

Results

Amongst the 373 020 patients included as the study population, 77% required prophylaxis. Of these, 38.36% (n = 85 486) received guideline-appropriate prophylactic measures during their hospital stay. Patients in whom prophylaxis was indicated, only 24.56% (n = 42 715) complied with the SA guidelines. The most commonly used prophylactic measures were enoxaparin (89.09%) and fondaparinux (2.68%). Prophylactic measures differed per speciality, with the most compliant amongst intensivists. A low uptake of the risk assessment model use (n = 222 860, 59.75%) was, however, reported for this data set.

Conclusion

Less than 24.56% of patients who required prophylaxis received guideline-appropriate interventions. Further studies should focus on understanding differences in practice and improving acceptance and application of guideline-driven care.

[Pharmacological prophylaxis of thromboembolism in daily clinical practice: Evaluation of the clinical decision-making process]

BACKGROUND

Considering the amount of national and international scientific evidence regarding the use of anticoagulants in the periprocedural prevention of thromboembolism, the decision-making process when prescribing anticoagulants is complex. Due to frequent prescriptions for inpatients, the topic is of high significance. This decision-making process in our hospital is the main focus of the study.

METHODS

In a standardised survey, a target group of physicians was asked about their decision-making process with regard to the prescription of anticoagulants in the periprocedural period. For this study a questionnaire was developed consisting of 12 survey questions. Data from 130 participants was collected and analysed.

RESULTS

Generally, there was a high level of agreement on the importance of venous thromboembolism prophylaxis. Significant differences exist between medical specialities. A gap between scientific evidence and clinical practice among the respondents could be identified. The decision-making process when prescribing anticoagulants was not documented by the physicians.

CONCLUSIONS

A combined approach consisting of structured documentation with electronic decision support in combination with standardised treatment methods and educational measures can be a useful solution.

The venous thromboembolism prophylaxis in patients receiving thoracic surgery: A systematic review

OBJECTIVES

Venous thromboembolism (VTE) is a significant and preventable cause of mortality and morbidity in thoracic surgery. It usually deep venous thromboembolism (DVT) and pulmonary thromboembolism (PE). We conducted this article to perform a systematic review on prophylaxis of perioperative VTE in patients undergoing thoracic surgery especially lung surgery and esophageal surgery and to identify potential areas for future research.

METHODS

The systematic review we conducted included studies of patients undergoing thoracic surgery especially lung surgery and esophageal surgery RESULTS: The study identified 2621 references. Finally, 22 trials with a total of 9072 patients were included. Only six studies declared that they continued a follow-up after the discharge of the patients. (range: 1-3 months); three studies reported on major bleeding events as an outcome measure, and the incidence varied from 0.8% to 1.6%. Total 346 VTEs occurred, and the overall mean risk of VTE was estimated at 3.8% (range: 0.77-27%).

CONCLUSIONS

The evidence for using thromboprophylaxis in thoracic surgery is limited and controversial, predominantly based on clinical consensus. Future research is needed to focus on identifying risk of VTE and providing sufficient evidence with high quality to support clinical strategies concerning the prophylaxis for VTE.

Prophylaxis of venous thromboembolism in medical patients

Venous thromboembolism (VTE) is a prevalent and serious complication in hospitalized medical patients. Pulmonary embolism is the most common preventable cause of hospital death. VTE extends hospitalization, with a higher resource consumption and an increase in healthcare costs. Risk factors for VTE include intrinsic factors and those related to hospitalization. It is important to know and to identify these factors at the moment of hospital admission and during the course of disease. VTE prophylaxis has demonstrated to be an efficient and effective action. Its implementation reduces life-threatening pulmonary embolism, symptomatic deep vein thrombosis and death rate three months after discharge. An individual and detailed assessment of prophylaxis risk-benefit is a priority. In our country, low molecular weight heparins are still the first option for VTE pharmacological prophylaxis. In those patients at high risk of bleeding or in whom anticoagulation is contraindicated mechanical methods could be used.

Factors Influencing Prescribers' Decision for Extending Venous Thromboembolism Prophylaxis in the Medical Patient Population following Hospitalization

Introduction  Venous thromboembolism (VTE) prophylaxis during hospitalization has clearly defined metrics for risk stratification and practice policy employed to ensure processes of adherence. However, acceptance for practice or even the level and timeline of risk is less clear during the immediate time after hospitalization. With emerging new oral anticoagulant agents, data are available that may influence prescribing in the outpatient setting following hospitalization. A survey was created to determine the level of acceptance or influences for practice surrounding continuation of anticoagulation following hospitalization.

Methods  This study was designed as a single-center survey of hospitalist and family medicine physician to assess influences to the physician's impression for risk of VTE prophylaxis and knowledge of therapy options.

Results  Physicians reported depending heavily on medical center protocols for determining anticoagulation at hospital discharge. Prescribing postdischarge anticoagulation was reported to be affected by lack of comfort with prescribing oral medications and concerns with risk of bleeding for all types of anticoagulation outweighing the perceived benefit. Additionally, the decision whether to prescribe these medications at discharge was reported to be related to perceived cost and other patient barriers such as concerns over route of administration.

Conclusion  Concerns for bleeding were an influence and likely resulted in shorter duration for VTE prophylaxis being prescribed posthospitalization.

Trends of venous thromboembolism risk before and after diagnosis of gout: a general population-based study

OBJECTIVE

To estimate the overall risk and the temporal trend of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolism (PE) before and after gout diagnosis in an incident gout cohort compared with the general population.

METHODS

We conducted a matched cohort study using a province-wide population-based administrative health database in Canada. We calculated incidence rates (IRs) and multivariable adjusted hazard ratios (HRs) for the risk of VTE, DVT and PE before and after gout diagnosis.

RESULTS

Among 130 708 incident individuals with gout (64% male, mean age 59 years), 2071 developed VTE, 1377 developed DVT and 1012 developed PE. IRs per 1000 person-years for gout were 2.63, 1.74 and 1.28 compared with 2.03, 1.28 and 1.06 for non-gout, respectively. The fully adjusted HRs (95% CI) for VTE, DVT and PE were 1.22 (1.13, 1.32), 1.28 (1.17, 1.41) and 1.16 (1.05, 1.29). For the pre-gout period, the fully adjusted HRs (95% CI) were 1.51 (1.38, 1.64), 1.55 (1.40, 1.72) and 1.47 (1.31, 1.66) for VTE, DVT and PE. During the third, second and first years preceding gout, the fully adjusted HRs for VTE were 1.44, 1.56 and 1.62. During the first, second, third, fourth and fifth years after gout, the fully adjusted HRs were 1.63, 1.29, 1.33, 1.28 and 1.22. Similar trends were also seen for DVT and PE.

CONCLUSION

Increased risks of VTE, DVT and PE were found both before and after gout diagnosis. The risk increased gradually before gout, peaking in the year prior to diagnosis, and then progressively declined. Gout-associated inflammation may contribute to venous thrombosis risk.

Early positive fluid balance is predictive for venous thromboembolism in critically ill surgical patients

BACKGROUND

Positive fluid balance (FB) in the intensive care unit (ICU) may be a marker for increased venous thromboembolism (VTE) risk. We hypothesized that an early positive fluid balance (FB) would be associated with increased VTE occurrence.

METHODS

A single-center retrospective review of surgical ICU patients was conducted from May 2011 to December 2014. Patients with a VTE were compared to those who did not develop a VTE (NVTE).

RESULTS

There were 619 patients analyzed with 77 (12.4%) diagnosed with a VTE; these patients had longer ventilator days (12.3 vs. 5.0 days, p < 0.01) and ICU stays (10.3 vs. 6.4 days, p < 0.01), and were more likely to have a net FB ≥ 4L over the first three days (62% vs. 44%, p < 0.01). A FB ≥ 4L over the first three ICU days was an independent predictor of VTE (AOR 1.74, p = 0.04).

CONCLUSION

Patients with an early positive FB are more likely to develop a VTE.

Two novel risk factors for postoperative venous thromboembolism: A reconsideration of standard risk assessment and prophylaxis

BACKGROUND

Postoperative venous thromboembolism (VTE) is usually preventable with adequate prophylaxis. In an institutional study, patients with emergency operations (EO), multiple operations (MO), and perioperative sepsis (PS) were more likely to develop VTE despite standard prophylaxis.

METHODS

General surgery patients in the NSQIP database from 2011 to 2014 were stratified into VTE and non-VTE groups, and statistical analyses were performed.

RESULTS

Among 1,610,086 patients, 13,673 (0.8%) were diagnosed with VTE. The VTE odds ratios for patients with EO, MO and PS were 1.4 (95%CI:1.3-1.5), 1.9 (95%CI:1.7-2.0), and 2.4 (95%CI:2.2-2.5), respectively. VTE odds ratios increased with concurrence of two factors (EO+PS: 2.0 (95%CI:1.9-2.2)) (EO+MO: 2.3 (95%CI:1.9-2.7)) (MO+PS: 2.5 (95%CI:2.2-2.7)) and further still for patients with all three factors (2.7, 95%CI:2.4-3.0).

CONCLUSION

General surgery patients with EO, MO, or PS have a greater likelihood of developing postoperative VTE. These factors are not necessarily captured in contemporary risk assessment models that guide chemoprophylaxis, and so these high-risk patients may receive insufficient prophylaxis.

Assessing the Risk for Development of Deep Vein Thrombosis among Chinese Patients using the 2010 Caprini Risk Assessment Model: A Prospective Multicenter Study

AIM

We sought to validate the 2010 Caprini risk assessment model (RAM) in risk stratification for deep vein thrombosis (DVT) prophylaxis among Chinese bedridden patients.

METHODS

We performed a prospective study in 25 hospitals in China over 9 months. Patients were risk-stratified using the 2010 Caprini RAM.

RESULTS

We included a total 24,524 patients. Fresh DVT was found in 221 patients, with overall incidence of DVT 0.9%. We found a correlation of DVT incidence with Caprini score according to risk stratification (χ2 =196.308, P＜0.001). Patients in the low-risk and moderate-risk groups had DVT incidence ＜0.5%. More than half of patients with DVT were in the highest risk group. Compared with the low-risk group, risk was 2.10-fold greater in the moderate-risk group, 3.34-fold greater in the high-risk group, and 16.12-fold greater in the highest-risk group with Caprini scores ≥ 9. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval, 0.71-0.78; P＜0.01) for all patients. A Caprini score of ≥ 5 points was considered the criterion of a reliably increased risk of DVT in surgical patients with standard thromboprophylaxis. Predicting DVT using a cumulative risk score ≥ 4 is recommended for nonsurgical patients.

CONCLUSIONS

Our study suggested that the 2010 Caprini RAM can be effectively used to stratify hospitalized Chinese patients into DVT risk categories, based on individual risk factors. Classification of the highest risk levels using a cumulative risk score ≥ 4 and ≥ 5 provides significantly greater clinical information in nonsurgical and surgical patients, respectively.

Post-operative oral chemoprophylaxis in patients undergoing hip arthroscopy mitigates VTE risk with a low side-effect profile

Hip arthroscopy (HA) has increased exponentially over the last decade. A recent systematic review found that the risk of venous thromboembolism (VTE) is 2%. This was higher than previous reports which may have underestimated the true incidence of VTE in HA. Thus, protocols to mediate VTE may be more necessary than previously thought. The aim of this article is to present a VTE prevention protocol and evaluate its subsequent efficacy. This is a prospective study of 880 consecutive HA cases. All patients were treated according to a predetermined VTE protocol which classified patients as high (≥1 risk factors) or low (no risk factors) risk for post-operative VTE. In high-risk patients, the protocol followed that of low-risk patients but additionally included rivaroxaban for 2 weeks post-operatively. The incidence of VTE was recorded and analysed in this study. A total of 880 HA cases at an average age of 35.4 years were evaluated, with 76.6% (n = 674) undergoing labral repair and concomitant cam and/or pincer resection, 17.2% (n = 151) of cases for isolated labral tear repaired, and 6.1% (n = 55) classified as other. The overall incidence of VTE was 0.45%. The incidence of VTE was 1.2% and 0.16% in high- and low-risk groups, respectively. Oral VTE prophylaxis was not associated with post-operative complications. This study demonstrated a lower rate of VTE in both risk groups. It highlights the value of a predetermined risk-adjusted protocol to VTE prophylaxis. Rivaroxaban prophylaxis is safe and efficacious in HA with a low associated morbidity.

Multidisciplinary, patient-centred approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital

Hospital-acquired venous thromboembolism (VTE) accounts for an estimated 25 000 preventable deaths per annum in the UK and is associated with significant healthcare costs. The National Institute for Health and Care Excellence guidelines on the prevention of VTE in hospitalised patients highlight the clinical and cost-effectiveness of VTE prevention strategies. A multidisciplinary quality improvement team (MD QIT) based in a district general hospital sought to improve compliance with VTE prophylaxis prescription to greater than 85% of patients within a 3-month time frame. Quality improvement methodology was adopted over three cycles of the project. Interventions included the introduction of a 'VTE sticker' to prompt risk assessment; educational material for medical staff and allied healthcare professionals; and patient information raising the awareness of the importance of VTE prophylaxis. Implementation of these measures resulted in significant and sustained improvements in rates of risk assessment within 24 hours of admission to hospital from 51% compliance to 94% compliance after cycle 2 of the project. Improvements were also observed in medication dose adjustment for the patient weight from 69% to 100% compliance. Dose adjustments for renal function showed similar trends with compliance with guidelines improving from 80% to 100%. These results were then replicated in a different clinical environment. In conclusion, this project exemplifies the benefits of MD QITs in terms of producing sustainable and replicable improvements in clinical practice and in relation to meeting approved standards of care for VTE risk assessment and prescription. It has been demonstrated that the use of educational material in combination with a standardised risk assessment tool, the 'VTE sticker', significantly improved clinical practice in the context of a general medical environment.

Venous thromboembolism prevention compliance: A multidisciplinary educational approach utilizing NSQIP best practice guidelines

BACKGROUND

Review of our institutional National Surgical Quality Improvement Project (NSQIP) data found higher rate of Venous Thromboembolic Events (VTE) (2.5% vs. 1.1%). Compared to the national benchmark. Our goal was to identify opportunities for quality improvement.

METHODS

We compared NSQIP general surgery data from January 2015-December 2016 (period 1) to January 2017-December 2018 (period 2). A multidisciplinary committee was developed and patient centered education implemented to enhance VTE compliance.

RESULTS

Over 50% of all the patients who developed VTE were non-compliant with chemical prophylaxis. The majority of non-compliance was due to pain. During period 1 there were 12 VTEs in 482 cases, while in period two, 18 VTEs in 2347 cases (2.5% vs. 0.8%; RR 2.3, 95% CI 1.5-3.7, p < 0.001). Missed chemical prophylaxis decreased from 50 to 17 per week after the intervention.

CONCLUSION

A multidisciplinary, patient centered approach to increase VTE prevention decreases VTE rates to below a comparable benchmark.

Incidence of Venous Thromboembolism, Risk Factors and Prophylaxis in Hospitalized Patients in the South West Region of Cameroon

Background

Venous thromboembolism (VTE) is a serious complication in hospitalized patients. It is associated with considerable morbidity and mortality. Therefore, its prevention is of great importance. There is paucity of data on the incidence of VTE in hospitalized patients in Cameroon. The aim of this study was to determine the incidence of symptomatic VTE, its risk factors and the proportion of patients at risk that receive thromboprophylaxis in patients hospitalized in the medical and surgical units in two hospitals in the South West Region of Cameroon.

Methods

A prospective study was performed in the medical and surgical units from January to March 2018. All consecutive eligible patients admitted for at least 3 days were included. Patient profile and risk factors were recorded. Patients were followed and evaluated for signs and symptoms of VTE until discharge from hospital. Suspected VTE was confirmed using compression ultrasonography and computed tomography.

Results

A total of 314 patients were included of which 58.7% were females. The mean age was 46±17.9 years. Patients aged <40 years represented 42% of the study population. Three cases of symptomatic VTE were recorded. The incidence of symptomatic VTE was 1% (95% CI: 0.3-2.8%). The prevalence of VTE risk was 93.6% with 32.5% being at high risk. The risk was 94.6% in medical patients and 92.8% in surgical patients. Among the patients at risk, only 32.5% received thromboprophylaxis. Thromboprophylaxis was significantly higher in surgical patients compared to medical patients (45.2% versus 18.7%; p<0.0001).

Conclusion

The incidence of VTE in hospitalized medical and surgical patients appeared low but likely underestimated considering the high prevalence of patients at risk of VTE coupled with the underutilization of thromboprophylaxis. Clinicians should assess risk of VTE in conjunction with the clinical situation to determine the most appropriate type of prophylaxis as well as the duration of prophylaxis for VTE.

Novel approaches to facilitate the implementation of guidelines in the ICU

The effective implementation of evidence-based recommendations in routine intensive care unit (ICU) practice is challenging. Barriers related to the proposed recommendations, local contexts and processes can make the adoption of evidence-based practices difficult, contributing to healthcare inefficiency and worse patient and family outcomes. This review discusses the common barriers to guideline implementation in critical care settings, explores how implementation science provides an important framework for guiding implementation interventions, and discusses some specific and proven implementation strategies to improve adherence to evidence-based practices in the ICU.

Low venous thromboembolism incidence in high risk medical patients in an Israeli hospital. Can risk assessment be extrapolated to different populations?

BACKGROUND

Guidelines recommend venous thromboembolism (VTE) prophylaxis in hospitalized medical patients with Padua prediction score (PPS) ≥4 points. This recommendation is based on the high risk of symptomatic VTE observed among these patients in the Italian PPS derivation study, and the fivefold risk reduction with VTE-prophylaxis. This study aims to assess the incidence of VTE in high risk medical patients in a medium sized hospital in Israel.

METHOD

In this retrospective cohort study, data was collected of all medical patients hospitalized between January and June 2014. Patients were classified into low and high risk groups according to their PPS score, and according to whether they received anticoagulant thromboprophylaxis for VTE. Patients were further randomly selected to compare high risk patients that did or did not receive anticoagulant thromboprophylaxis. We further compared VTE incidence in high and low risk patients not treated with thromboprophylaxis. A search was conducted for diagnoses of venous thromboembolism and death during hospitalization and the following 90 days.

RESULTS

568 high risk patients (PPS ≥4 points) were included, 284 treated with prophylactic anticoagulation and 284 not. There were no VTE events in either group. There was no difference in mortality. A total of 642 non anticoagulated patients were randomly selected, 474 low risk and 168 high risk. There were no VTE events in either group.

CONCLUSIONS

The risk of VTE appears to be very low in our study, suggesting that among medical patients with PPS ≥4, the risk of VTE may differ dramatically between populations.

[Prevention of thromboembolic disease in elderly patients admitted to medical wards]

OBJECTIVES

To determine the suitability of the prevention of thromboembolic disease in elderly patients admitted to medical departments, as well as some associated factors, such as the measures required in order to improve quality and safety.

PATIENTS AND METHODS

A retrospective study in a tertiary level hospital that included elderly patients that were admitted to medical departments. A simple, non-proportional, randomised sample was used, stratified by department. The risk was measured using the Padua prediction model and the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) adjusting depending on the number of discharges. A Lot Quality Assurance Sampling (LQAS) plan was used with three levels, good, (standard 95%, threshold 70%), acceptable (standard 95%, threshold 50%), and not acceptable.

RESULTS

A total of 72 cases from 8 departments were evaluated. Just over half (51.4%) of patients had a high risk of thromboembolic disease (Padua≥4), and 23.6% of bleeding (IMPROVE≥7). Besides the advanced age, the adjusted scores were particularly due to cancer (22%) and reduced mobility (19%) for Padua, and male gender (13%) and renal failure (12%) for IMPROVE. The adjusted overall suitability was 57.5% (95%CI: ±19.0%). The OR for suitable conduct on not starting medication, 1.56 (95%CI: 1.07-2.26). The suitability by department was not uniform: all the lots were acceptable, in 3 with level "good" and in 5 with "acceptable".

CONCLUSIONS

The suitability of thromboembolic prophylaxis in the study hospital maintains acceptable levels, although not homogeneous. There is an opportunity for improvement that must be taken. The data obtained may help in deciding interventions, with LQAS being useful to optimise the evaluation effort.

Venous thromboembolism in SARS-CoV-2 patients: only a problem in ventilated ICU patients, or is there more to it?

Venous thromboembolism (VTE) is a well-known complication in hospitalised patients [1–5]. Risk factors include older age, obesity, immobilisation, active malignancy, systemic inflammatory response syndrome (SIRS), (major) surgery, thrombophilia and a history of thromboembolism [2, 5]. In 1884, Rudolph Virchow first described the underlying pathophysiological mechanisms, which consist of endothelial cell dysfunction/inflammation, low blood flow and blood hypercoagulability. Current guidelines recommend the use of thromboprophylaxis in acutely ill medical patients who are at high risk for VTE (Padua score ≥4, IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) score ≥2) [6]. However, in medical practice, less than half of the patients at risk receive adequate thromboprophylaxis [4].

Insidious venous thromboembolism (VTE) is mainly a problem in ICU-ventilated SARS-CoV-2 patients, while patients in the general ward, treated with thromboprophylaxis (0.5 mg·kg−1), had a low incidence of insidious VTE https://bit.ly/2Yl8jft

Surgical venous thromboembolism prophylaxis: clinical practice update

BACKGROUND

Perioperative medicine continues to evolve as new literature emerges. This article provides an update on prevention of venous thromboembolism (VTE) in surgical patients.

METHODS

We reviewed articles on VTE prevention in surgical patients published in peer-reviewed journals since the publication of 2012 ACCP guidelines on VTE prevention in surgical patients.

RESULTS

Methods of VTE prophylaxis include aggressive ambulation, mechanical prophylaxis, and pharmacological prophylaxis. In non-orthopedic surgery, the overall approach remains assessment of thrombosis risk with the recommendation to use a risk assessment tool such as the modified Caprini score. Low molecular weight heparin (LMWH) appears to be more effective than unfractionated heparin (UFH) for VTE prophylaxis in non-orthopedic surgery. For orthopedic surgery, recent studies now recognize aspirin as an option for VTE prophylaxis after total hip arthroplasty, total knee arthroplasty, and hip fracture surgery. Extended prophylaxis with LMWH reduces the risk of symptomatic VTE in high risk abdominal and pelvic cancer surgery without an appreciable increase in risk of bleeding and decreased symptomatic VTE in major orthopedic surgery but with more minor but not major bleeding. Prophylactic Inferior vena cava (IVC) filter placement or surveillance compression ultrasonography is not recommended in management or detection of VTE in surgical patients.

CONCLUSIONS

This article aims to provide insight into data from last several years which has potential to change clinical practices in perioperative setting.