1
|
Westra BL, Whittenburg L, Lytle KS, Tokareva I, Umberfield EE, Leverette M, Buchleiter R, Johnson S, Jobman L. Clinical Knowledge Model for the Prevention of Healthcare-Associated Venous Thromboembolism. Comput Inform Nurs 2024; 42:144-150. [PMID: 38241731 DOI: 10.1097/cin.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
Knowledge models inform organizational behavior through the logical association of documentation processes, definitions, data elements, and value sets. The development of a well-designed knowledge model allows for the reuse of electronic health record data to promote efficiency in practice, data interoperability, and the extensibility of data to new capabilities or functionality such as clinical decision support, quality improvement, and research. The purpose of this article is to describe the development and validation of a knowledge model for healthcare-associated venous thromboembolism prevention. The team used FloMap, an Internet-based survey resource, to compare metadata from six healthcare organizations to an initial draft model. The team used consensus decision-making over time to compare survey results. The resulting model included seven panels, 41 questions, and 231 values. A second validation step included completion of an Internet-based survey with 26 staff nurse respondents representing 15 healthcare organizations, two electronic health record vendors, and one academic institution. The final knowledge model contained nine Logical Observation Identifiers Names and Codes panels, 32 concepts, and 195 values representing an additional six panels (groupings), 15 concepts (questions), and the specification of 195 values (answers). The final model is useful for consistent documentation to demonstrate the contribution of nursing practice to the prevention of venous thromboembolism.
Collapse
Affiliation(s)
- Bonnie L Westra
- Author Affiliations: School of Nursing, University of Minnesota, Minneapolis (Dr Westra); Health Informatics, Washington, DC (Dr Whittenburg); Health System Nursing and Duke Health Technology Systems, Duke University Health System, Durham, NC (Dr Lytle); Center for Healthcare Policy and Research, Sacramento, CA (Ms Tokareva); Division of Nursing Research, Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN (Dr Umberfield); University of Minnesota, Minneapolis, MN (Ms Leverette); Clinical Data and Analytics, HCA Healthcare, Nashville, TN (Ms Buchleiter); University of Minnesota, Institute for Health Informatics, Minneapolis (Dr Johnson); and Association of Perioperative Registered Nurses, Denver, CO (Mr Jobman)
| | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Cochran RL, Ghoshhajra BB, Hedgire SS. Body and Extremity MR Venography: Technique, Clinical Applications, and Advances. Magn Reson Imaging Clin N Am 2023; 31:413-431. [PMID: 37414469 DOI: 10.1016/j.mric.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.
Collapse
Affiliation(s)
- Rory L Cochran
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Brian B Ghoshhajra
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Sandeep S Hedgire
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
3
|
Samuel S, Li W, Dunn K, Cortes J, Nguyen T, Moussa D, Kumar A, Dao T, Beeson J, Choi HA, McCullough LD. Unfractionated heparin versus enoxaparin for venous thromboembolism prophylaxis in intensive care units: a propensity score adjusted analysis. J Thromb Thrombolysis 2023; 55:617-625. [PMID: 37029256 DOI: 10.1007/s11239-023-02795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/09/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in hospitalized patients. Pharmacologic prophylaxis is used in order to reduce the risk of VTE events. The main purpose of this study is to compare the prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients admitted to the intensive care unit (ICU) who received unfractionated heparin (UFH) versus enoxaparin as VTE prophylaxis. Mortality was evaluated as a secondary outcome. This was a Propensity Score Adjusted Analysis. Patients admitted to neurology, surgical, or medical ICUs and screened with venous doppler ultrasonography or computed tomography angiography for detection of VTE were included in the analysis. We identified 2228 patients in the cohort, 1836 (82.4%) patients received UFH and 392 (17.6%) patients received enoxaparin. Propensity score matching yielded a well-balanced cohort of 950 (74% UFH, 26% enoxaparin) patients. After matching, there was no difference in prevalence of DVT (RR 1.05; 95% CI 0.67-1.64, p = 0.85) and PE (RR 0.76; 95% CI, 0.44-1.30, p = 0.31). No significant differences in location and severity of DVT and PE between the two groups were detected. Hospital and intensive care unit stay was similar between the two groups. Unfractionated heparin was associated with a higher rate of mortality, (HR 2.04; 95% CI, 1.13-3.70; p = 0.019). The use of UFH as VTE prophylaxis in ICU patients was associated with a similar prevalence of DVT and PE compared with enoxaparin, and the site and degree of occlusion were similar. However, a higher mortality rate was seen in the UFH group.
Collapse
Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, Houston, TX, 77030, USA.
| | - Wen Li
- Department of Internal Medicine, The University of Texas McGovern Medical School at Houston, Houston, USA
| | - Koren Dunn
- College of Pharmacy, Texas A&M University, College Station, USA
| | - Jennifer Cortes
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, Houston, TX, 77030, USA
| | - Thuy Nguyen
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, Houston, TX, 77030, USA
| | - Daniel Moussa
- College of Pharmacy, Univerity of Houston, Houston, USA
| | - Abhay Kumar
- Department of Neurosurgery, The University of Texas McGovern Medical School at Houston, Houston, USA
| | - Thanh Dao
- Department of Comparative Analytics, Memorial Hermann-Texas Medical Center, Houston, USA
| | - James Beeson
- Department of Diagnostic Ultrasound, Memorial Hermann-Texas Medical Center, Houston, USA
| | - H Alex Choi
- Department of Neurosurgery, The University of Texas McGovern Medical School at Houston, Houston, USA
| | - Louise D McCullough
- Department of Neurology, Memorial Hermann-Texas Medical Center, Houston, USA
| |
Collapse
|
4
|
Clapham RE, Roberts LN. A systematic approach to venous thromboembolism prevention: a focus on UK experience. Res Pract Thromb Haemost 2022; 7:100030. [PMID: 36760776 PMCID: PMC9903667 DOI: 10.1016/j.rpth.2022.100030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 01/23/2023] Open
Abstract
Venous thromboembolism (VTE) remains a leading cause of preventable morbidity and mortality associated with hospitalization. Despite evidence that providing appropriate thromboprophylaxis to those at risk of VTE in hospital, recent data suggest that the delivery of thromboprophylaxis remains suboptimal across the globe, with a lack of standardization in approach to VTE prevention. This review considers the role of VTE risk assessment and interventions to improve the implementation of the VTE prevention pathway and highlights the systematic approach to VTE prevention adopted in England and its impact. Finally, the critical areas for further research and the emerging data presented during the 2022 ISTH annual congress in London, UK, are summarized.
Collapse
Affiliation(s)
- Rachel E. Clapham
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK,School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK,Correspondence Lara N. Roberts, King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK. @LaraNRoberts1
| |
Collapse
|
5
|
Thrombophilia and Pregnancy. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2020-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Leading cause of death in pregnant women still remains venous thromboembolism, with an incidence of 1.4 to 4.9 per 100,000 pregnancies. A special group of inherited and acquired coagulation disorders associated with a susceptibility to thrombosis is thrombophilia. Physiological changes during the pregnancy also contribute to the occurrence thromboembolic diseases (VTE) in pregnancy. Total rate of venous thromboembolism is 100 per 100,000 pregnancies and 200 per 100,000 births. Etiopathogenesis of obstetric complications in thrombophilia is not clearly defined, which is one of the reasons for the occasional failure of therapy. In pregnancies with hereditary thrombophilia the oxidative stress is considered to be a cause of complications, similar to preeclampsia. Based on the findings so far, additional research should clarify questions regarding the anticoagulants role in pregnancy loss prevention. In this paper, we analyze the effect of the screening on pregnancy outcomes, consider the justification for the use of anticoagulation therapy in difficult situations, discuss about previous knowledge in the field and argue the use of new specific protocols. In short, we address the justification for prescribing anticoagulants and evaluation of their effect within thrombophilia therapeutic strategies.
Collapse
|
6
|
Hisatake S, Ikeda T, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Rivaroxaban Treatment for Patients With Unprovoked or Provoked Venous Thromboembolism ― Subanalysis of the J’xactly Study ―. Circ Rep 2022; 4:490-498. [PMID: 36304427 PMCID: PMC9535131 DOI: 10.1253/circrep.cr-22-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022] Open
Abstract
Background: The efficacy and safety of direct oral anticoagulants (DOACs) in patients with unprovoked venous thromboembolism (VTE) remain unclear. Methods and Results: In this subanalysis of the J’xactly study, a multicenter prospective observational study, we evaluated the safety and effectiveness of rivaroxaban in patients with acute VTE according to unprovoked (n=388) or provoked (n=557) VTE status. Median follow-up was 21.2 months. Compared with patients in the provoked group, patients in the unprovoked group were younger, less likely to be female, and had higher body weight. The incidence of symptomatic VTE recurrence was significantly higher in the unprovoked than provoked VTE group (3.54% vs. 1.77% per patient-year; P=0.032). There was no significant difference in the incidence of major bleeding events between rivaroxaban-treated patients with unprovoked and provoked VTE (2.31% vs. 3.75% per patient-year; P=0.289). Although the proportion of patients with a body mass index (BMI) ≥25 kg/m2
who were non-users of antiplatelet agents was higher in the unprovoked VTE group, there was no interaction effect (BMI: 4.58% vs. 1.55% per patient-year [P=0.040; P for interaction=0.361]; concomitant antiplatelet agent non-users: 3.65% vs. 1.72% per patient-year [P=0.028; P for interaction=0.627]). Conclusions: This subanalysis suggests the safety and effectiveness of rivaroxaban in patients with unprovoked VTE. In such patients, DOAC discontinuation should be considered carefully, particularly in those not using antiplatelet agents and those with a high BMI.
Collapse
Affiliation(s)
- Shinji Hisatake
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital
| | | | | | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine
| | | | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | | | | |
Collapse
|
7
|
Farag A, Fielding J, Catanzano T. Role of Dual-energy Computed Tomography in Diagnosis of Acute Pulmonary Emboli, a Review. Semin Ultrasound CT MR 2022; 43:333-343. [PMID: 35738818 DOI: 10.1053/j.sult.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Prompt diagnosis of pulmonary embolism is essential to avert morbidity and mortality. There are a number of diagnostic options for identification of a pulmonary embolism, including laboratory and imaging investigations. While computed tomography pulmonary angiography (CTPA) has largely supplanted nuclear medicine ventilation/perfusion studies, there remain significant limitations in the optimal performance of CTPA. Dual-energy computed tomography has the ability to overcome many of the limitations of standard of care CTPA, including rescue of poor contrast boluses and the ability to evaluate pulmonary perfusion defects.
Collapse
Affiliation(s)
- Ahmed Farag
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Jordan Fielding
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA
| | - Tara Catanzano
- Department of Radiology, UMass Chan Medical School-Baystate, Springfield, MA.
| |
Collapse
|
8
|
Xue Z, Tu W, Gao J, Dong Z, Yuan J, Lang J. Optimal preoperative timing for prevention of deep vein thrombosis (DVT) in patients over 60 years of age with intertrochanteric fractures. Eur J Trauma Emerg Surg 2022; 48:4197-4203. [PMID: 35445814 DOI: 10.1007/s00068-022-01969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the incidence and risk factors of preoperative DVT in elderly patients with intertrochanteric fracture of the femur and determine the optimal preoperative time. METHODS Electronic medical records of 358 patients over 60 years of age with intertrochanteric fractures from May 1, 2016, to May 1, 2019, were retrospectively analyzed. The preoperative group was divided into DVT and non-DVT. Univariate analysis was used for preliminary comparison, and multivariate logistic regression analysis was used to identify independent risk factors associated with DVT development. ROC curve was drawn to analyze the specificity and sensitivity of risk factors for DVT diagnosis. The diagnostic value of the model was analyzed by the ROC curve of multivariable combined diagnosis. RESULTS A total of 358 patients who met the criteria were enrolled. The total prevalence of DVT before surgery was 8.38%. Multivariate logistic regression analysis showed that smoking status, preoperative time, albumin (ALB), D-dimer level, diabetes mellitus, and hypertension were independent risk factors for preoperative DVT. Preoperative time has the best sensitivity and specificity for diagnosing the occurrence of preoperative DVT. The ROC curve analysis model of multivariable combined diagnosis has a better diagnostic value. CONCLUSIONS In this study, elderly patients with intertrochanteric femur fracture had a higher incidence of deep vein thrombosis before surgery. Early identification of DVT-related risk factors may contribute to individualized risk assessment and preventing adverse outcomes in patients with intertrochanteric fractures.
Collapse
Affiliation(s)
- ZhiQiang Xue
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - WangJie Tu
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JianQing Gao
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - ZeTao Dong
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JianDong Yuan
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JunZhe Lang
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China.
| |
Collapse
|
9
|
Akamine A, Takahira N, Kuroiwa M, Tomizawa A, Atsuda K. Venous thromboembolism risk factors and usefulness of a risk scoring system in lower limb orthopedic surgery: A case-control study in Japan. Medicine (Baltimore) 2022; 101:e28622. [PMID: 35089199 PMCID: PMC8797501 DOI: 10.1097/md.0000000000028622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/27/2021] [Indexed: 01/05/2023] Open
Abstract
We previously developed a computerized clinical decision support system based on national consensus guidelines and previous studies. This system was used to assess the risk of venous thromboembolism. In this study, we examined the risk factors for venous thromboembolism in patients who underwent lower limb orthopedic surgery using our risk scoring system, to investigate the association between the total risk score and the occurrence of venous thromboembolism.We retrospectively evaluated the records of 649 patients who underwent lower limb orthopedic surgery at a tertiary care center in Japan between January 2015 and August 2018. Venous thromboembolism was confirmed using ultrasonography or computed tomography angiography. The computerized clinical decision support system was used throughout the hospitalization period. Independent risk factors for postoperative venous thromboembolism were identified using logistic regression analysis.Age (≥68 years) was significantly associated with an increased risk of venous thromboembolism (adjusted odds ratio: 1.06, 95% confidence interval: 1.03-1.09; P < 0.001). Furthermore, the Cochran-Armitage trend test revealed a significant positive correlation between the total risk score and the occurrence of venous thromboembolism (P < 0.001).Our risk scoring system may be used preoperatively to determine the need for venous thromboembolism prophylaxis. This study suggests that age (≥68 years) may be a risk factor for venous thromboembolism after lower limb orthopedic surgery. Additional studies are needed to validate these results.
Collapse
Affiliation(s)
- Akihiko Akamine
- Orthopedic Surgery, Clinical Medicine, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Kanagawa, Japan
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
| | - Naonobu Takahira
- Orthopedic Surgery, Clinical Medicine, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Kanagawa, Japan
- Physical Therapy Course, Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Masayuki Kuroiwa
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Atsushi Tomizawa
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
| | - Koichirou Atsuda
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, Japan
- Research and Education Center for Clinical Pharmacy, Division of Clinical Pharmacy, Laboratory of Pharmacy Practice and Science 1, Kitasato University School of Pharmacy, Tokyo, Japan
| |
Collapse
|
10
|
Arasappa A, Kumar N, Anto M, Manoharan GV, Selvanathan D. Cost-effective treatment for deep-vein thrombosis in rural tertiary care hospital. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_23_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
11
|
Hou J, Wang W, Cai H, Chen J, Chen B, Shen Z, Tang Y, Li J, Liu S, Mei Y, Wang J, Lu S. Patients with right lower extremity deep vein thrombosis have a higher risk of symptomatic pulmonary embolism: a retrospective study of 1585 patients. Ann Vasc Surg 2021; 81:240-248. [PMID: 34748950 DOI: 10.1016/j.avsg.2021.08.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/20/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the risk for pulmonary embolism (PE) and explore the relationship between the site of thrombosis and PE in patients with acute lower extremity deep vein thrombosis (DVT). METHODS 1585 hospitalized patients first diagnosed with acute lower extremity DVT were investigated retrospectively. The patients were divided into two groups: the non-PE group (Group 1) and the PE group (Group 2). Then, Group 2 was divided into two subgroups: asymptomatic pulmonary embolism (asPE, Group 2a) and symptomatic pulmonary embolism (sPE, Group 2b). Kaplan-Meier curves and logistic regression analysis were used to explore the relevant risk factors for PE. RESULTS Among 1585 patients, 458 patients suffered from PE, accounting for 28.9%. 102 (22.3%) of them had the typical clinical manifestations of PE and were defined as sPE, and the remaining 356 (77.7%) patients were classified as asPE. Patients with proximal lower extremity DVT were significantly more predominant in the PE group than in the non-PE group (92.8% vs. 86.2%, p<0.001). Moreover, in Group 2, patients with typical PE manifestations showed a higher proportion of patients with right lower extremity DVT than left lower extremity DVT (26.7% vs. 17.7%, P=0.035), and bilateral lower extremity DVT than unilateral DVT (44.1% vs. 20.5%, p<0.001). By multivariate analysis, alcohol consumption (OR, 1.824; 95% CI, 1.194-2.787; p=0.005), heart failure (OR, 2.345; 95% CI, 1.560-3.526; p<0.001), proximal DVT (OR, 2.096; 95% CI,1.407-3.123; p<0.001) were independent risk factors for PE. CONCLUSION Patients with proximal acute lower extremity DVT were more likely to suffer from PE than those with distal DVT. Patients with right acute lower extremity DVT had a higher risk of sPE than patients with left acute lower extremity DVT. Alcohol consumption and heart failure were associated with the occurrence of PE in patients with acute lower extremity DVT.
Collapse
Affiliation(s)
- Jiaxuan Hou
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Weiyi Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Hui Cai
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Jinxing Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Bingyi Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Zekun Shen
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Yanan Tang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Jiayan Li
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Shuang Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Yifan Mei
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China
| | - Jichang Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China.
| | - Shaoying Lu
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, Shaanxi Province, 710061, P.R. China.
| |
Collapse
|
12
|
Aboagye JK, Haut ER, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Holzmueller CG, Lau BD. Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2011-2019. [PMID: 33879395 DOI: 10.1016/j.jsurg.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN Prospective cohort study. SETTING The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
Collapse
Affiliation(s)
- Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Nursing, The Johns Hopkins Hospital; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science; Division of Health Sciences Informatics; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
13
|
Hypercoagulable State in COPD-A Comprehensive Literature Review. Diagnostics (Basel) 2021; 11:diagnostics11081447. [PMID: 34441381 PMCID: PMC8394684 DOI: 10.3390/diagnostics11081447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/01/2021] [Accepted: 08/07/2021] [Indexed: 01/18/2023] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory disease with multisystemic manifestations. Studies either held on stable disease patients or during exacerbations have demonstrated that COPD is strongly related to venous thromboembolism and cardiovascular events. The aim of the present review of the literature was to provide an in-depth overview regarding the alterations of coagulation factors and prothrombotic changes generated in patients with stable COPD and during COPD exacerbations.
Collapse
|
14
|
Rognoni C, Lugli M, Maleti O, Tarricone R. Clinical guidelines versus current clinical practice for the management of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2021; 9:1334-1344.e1. [PMID: 33744498 DOI: 10.1016/j.jvsv.2021.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/28/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is one of the major health problems worldwide with potentially serious outcomes related to mortality and morbidity. We provide a current view on how patients with DVT are managed in routine practice compared with the recommendations of published clinical guidelines. METHODS A literature review was conducted on studies reporting diagnostic and treatment patterns for acute DVT. Four dimensions were evaluated to compare the differences between clinical practice and clinical guidelines recommendations: diagnostic pathway, prescription of pharmacologic treatment and related duration, and prescription of compression therapy. For each aspect, the agreement with the corresponding guideline has been estimated as a percentage ranging from 0% (no agreement) to 100% (full agreement). RESULTS Sixteen studies reported clinical practices in 10 countries. Among them, Japan showed the highest agreement with guidelines, followed by the UK and Switzerland. Hong Kong showed the highest agreement with diagnosis guidelines, Spain for drug treatment, UK for treatment duration, and France for compression therapy. Conversely, Germany reported a complete disagreement with guidelines for diagnosis, followed by low agreement level by UK and Italy, and Switzerland reported a lower agreement level with prescription of compression therapy. CONCLUSIONS The implementation of clinical guidelines for the management of patients with DVT varies among countries from strict adherence to a complete lack of adherence. In this context, registries may be a useful tool to analyze clinical practice and produce findings that may be generalizable across populations.
Collapse
Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy.
| | - Marzia Lugli
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery - Cardiovascular Department, Hesperia Hospital, Modena, Italy
| | - Oscar Maleti
- National Reference Training Center in Phlebology (NRTCP), Vascular Surgery - Cardiovascular Department, Hesperia Hospital, Modena, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Milan, Italy; Department of Social and Political Sciences, Bocconi University, Milan, Italy
| |
Collapse
|
15
|
Bisch S, Findley R, Ince C, Nardell M, Nelson G. Efficacy of pre-operative pharmacologic thromboprophylaxis on incidence of venous thromboembolism following major gynecologic and gynecologic oncology surgery: a systematic review and meta-analysis. Int J Gynecol Cancer 2021; 31:257-264. [PMID: 33214216 PMCID: PMC7854514 DOI: 10.1136/ijgc-2020-001991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Steven Bisch
- Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Rachelle Findley
- Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Christina Ince
- Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Maria Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregg Nelson
- Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| |
Collapse
|
16
|
Prevention, diagnosis, and management of venous thromboembolism in the critically ill surgical and trauma patient. Curr Opin Crit Care 2021; 26:640-647. [PMID: 33027148 DOI: 10.1097/mcc.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
17
|
Abstract
IMPORTANCE Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. OBSERVATIONS PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. CONCLUSIONS AND RELEVANCE Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.
Collapse
Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
18
|
Factors to Consider When Evaluating Rates of Pharmacologic Venous Thromboembolism Prophylaxis Administration Among Trauma Patients. J Healthc Qual 2020; 42:304-314. [DOI: 10.1097/jhq.0000000000000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Wulfert CH, von Schassen C, Becker P, Porst R, Rost W, Heidelmann LM. [Pharmacological prophylaxis of thromboembolism in daily clinical practice: Evaluation of the clinical decision-making process]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 156-157:33-39. [PMID: 33023840 DOI: 10.1016/j.zefq.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Chris-Henrik Wulfert
- Klinik für Allgemein- und Viszeralchirurgie Bundeswehrkrankenhaus, Hamburg, Deutschland
| | | | - Pascal Becker
- Klinik für Urologie Bundeswehrkrankenhaus, Hamburg, Deutschland
| | - Rolf Porst
- Unabhängiger Beraterdependent Research Consultant, vorher GESIS - Leibniz-Institut für Sozialwissenschaften, Mannheim, Deutschland
| | - Wilm Rost
- Klinik für Allgemein- und Viszeralchirurgie Bundeswehrkrankenhaus, Hamburg, Deutschland
| | - Lena M Heidelmann
- Klinik für Allgemein- und Viszeralchirurgie Bundeswehrkrankenhaus, Hamburg, Deutschland.
| |
Collapse
|
20
|
Wang Q, Ding J, Yang R. The venous thromboembolism prophylaxis in patients receiving thoracic surgery: A systematic review. Asia Pac J Clin Oncol 2020; 17:e142-e152. [PMID: 33009716 DOI: 10.1111/ajco.13386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Qin Wang
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
| | - Jiefang Ding
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
| | - Rusong Yang
- Department of Thoracic Surgery, The Affiliated Brain Hospital of Nanjing Medical University (South Branch, Nanjing Chest Hospital), Nanjing, China
| |
Collapse
|
21
|
Papakonstantinou PE, Tsioufis C, Konstantinidis D, Iliakis P, Leontsinis I, Tousoulis D. Anticoagulation in Deep Venous Thrombosis: Current Trends in the Era of Non- Vitamin K Antagonists Oral Anticoagulants. Curr Pharm Des 2020; 26:2692-2702. [DOI: 10.2174/1381612826666200420150517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022]
Abstract
:
Anticoagulation therapy is the cornerstone of treatment in acute vein thrombosis (DVT) and it aims to
reduce symptoms, thrombus extension, DVT recurrences, and mortality. The treatment for DVT depends on its
anatomical extent, among other factors. Anticoagulation therapy for proximal DVT is clearly recommended (at
least for 3 months), while AT for isolated distal DVT should be considered, especially in the presence of high
thromboembolic risk factors. The optimal anticoagulant and duration of therapy are determined by the clinical
assessment, taking into account the thromboembolic and bleeding risk in each patient in a case-by-case decision
making. Non-Vitamin K antagonists oral anticoagulants (NOACs) were a revolution in the anticoagulation management
of DVT. Nowadays, NOACs are considered as first-line therapy in the anticoagulation therapy for DVT
and are recommended as the preferred anticoagulant agents by most scientific societies. NOACs offer a simple
route of administration (oral agents), a rapid onset-offset of their action along with a good efficacy and safety
profile in comparison with Vitamin K Antagonists (VKAs). However, there are issues about their efficacy and
safety profile in specific populations with high thromboembolic and bleeding risks, such as renal failure patients,
active-cancer patients, and pregnant women, in which VKAs and heparins were the standard care of treatment.
Since the available data are promising for the use of NOACs in end-stage chronic kidney disease and cancer
patients, several ongoing randomized trials are currently trying to solve that issues and give evidence about the
safety and efficacy of NOACs in these populations.
Collapse
Affiliation(s)
- Panteleimon E. Papakonstantinou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitris Konstantinidis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Panagiotis Iliakis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Ioannis Leontsinis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| |
Collapse
|
22
|
Castaldi M, George G, Turner P, McNelis J. NSQIP Impacts Patient Experience. J Patient Exp 2020; 7:89-95. [PMID: 32128376 PMCID: PMC7036676 DOI: 10.1177/2374373518817081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
National Quality Improvement Project (NSQIP) semiannual reports (SARs) revealed high observed to expected ratios for venous thromboembolic events (VTEs) on the surgical service. Press Ganey scores identified an area of particular weakness in shared decision-making in patient care. Patients reported little to no participation in shared decision-making. A performance improvement project was developed with a 2-fold objective: decrease the percentages of patients sustaining VTE through adequate screening and prophylaxis (VTEP) and to engage patients in shared decision-making to accept VTEP through enhanced patient-centered discussions and education on the risks and benefits of VTEP. A clinical pathway was developed to implement VTEP using a standardized risk assessment tool. Patient-centered discussion introduced VTEP and impact on perioperative safety. Results included telephone survey, NSQIP SARs, and Press Ganey patient experience survey. Using NSQIP data and a pathway developed for both VTE risk assessment and patient engagement, the authors observe immediate improvements in patient experience and decreased rates of VTE.
Collapse
Affiliation(s)
- Maria Castaldi
- Jacobi Medical Center, Bronx, NY, USA.,Westchester Medical Center, Valhalla, NY, USA
| | | | | | | |
Collapse
|
23
|
Mahlab-Guri K, Otman MS, Replianski N, Rosenberg-Bezalel S, Rabinovich I, Sthoeger Z. Venous thromboembolism prophylaxis in patients hospitalized in medical wards: A real life experience. Medicine (Baltimore) 2020; 99:e19127. [PMID: 32049830 PMCID: PMC7035063 DOI: 10.1097/md.0000000000019127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in acutely ill patients hospitalized in medical departments. Thromboprophylaxis with anticoagulants was shown to be safe and effective in medical patients with high risk to develop VTE. Despite guidelines recommendations, the rate of thromboprophylaxis in those patients is low. The objective of the study was to evaluate the rate of VTE risk assessment in routine medical department practice, the rate of eligible patients for thromboprophylaxis, the rate of patients who received thromboprophylaxis, and their outcome.Medical records of consecutive patients (3000 at 2013, 1000 at 2018) hospitalized in medical department were reviewed, retrospectively, for demographic, clinical characteristics, thromboprophylaxis treatment with enoxaparin and outcome (up to 90 days following discharge). Padua score was used for VTE risk assessment. VTE diagnosis was based on clinical suspicion.The mean patient's age (52.6% females) was 67.95 ± 21.56 years. 21% were eligible for thromboprophylaxis. Routine VTE risk assessment rate increased significantly following its incorporation into quality parameters, but the rate of treated patients was low (22% at 2013; 46% at 2018). The patients who received thromophylaxis were sicker compared to eligible patients without thromboprophylaxis. The rate of symptomatic VTE was low (0.24%; 0.12% and 0.55% for low and high VTE risk, respectively). Thromboprophylaxis did not have significant effect on the low number of VTE events. No major bleeding was observed.Major efforts are still needed to increase the rate of thromboprophylaxis in all eligible medical patients according to the guidelines recommendations.
Collapse
Affiliation(s)
- Keren Mahlab-Guri
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Monged Shaher Otman
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Natalia Replianski
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Shira Rosenberg-Bezalel
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Irina Rabinovich
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Zev Sthoeger
- Kaplan Medical Center, Rehovot
- Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| |
Collapse
|
24
|
A prospective study of the adequacy in the tromboprofilaxis in patients admitted in a short-stay unit. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
25
|
Tsai CJ, Lee CY. Comparative outcomes of catheter-directed thrombolysis plus rivaroxaban vs rivaroxaban alone in patients with acute iliofemoral deep vein thrombosis. J Chin Med Assoc 2019; 82:902-908. [PMID: 31567881 DOI: 10.1097/jcma.0000000000000206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Since novel oral anticoagulants (NOACs) have been introduced in the past decade, the first option of deep vein thrombosis (DVT) treatment is toward NOACs. However, aggressive and early thrombus removal strategy is widely used for treating acute iliofemoral DVT. Consequently, optimal treatment duration, efficacy, and safety of rivaroxaban alone or in combination with catheter-directed intrathrombus thrombolysis (CDT) in acute iliofemoral DVT patients should be investigated. METHODS Patients with recent acute iliofemoral DVT treated with combined CDT-rivaroxaban (CDT) or rivaroxaban alone (control) were followed for mean (standard deviation) of 25.7 (2.5) months. DVT evolution, treatment efficacy and safety, and predisposing factors for patency and postthrombotic syndrome (PTS) development were analyzed through duplex ultrasonography, plethysmography, venography, and computed tomographic venography. RESULTS 43.2%, 64.9%, 75.7%, and 72.2% of the CDT patients showed complete patency at 3, 6, 12, and 24 months of treatment compared with the control patients having 8.5%, 36.2%, 55.3%, and 57.4% of cumulative patency at 3, 6, 12, and 24 months, respectively (p = 0.001, 0.017, 0.088, and 0.081, respectively). The p value of the log-rank test comparing patency rates of the two groups was 0.009. The median (interquartile range, IQR) Villalta scores at 24 months were 3 (2-5) and 6 (4-8) in CDT and control patients, respectively (p = 0·001). PTS and bleeding events during therapy were, respectively, found in 35.1% and 63.8% (p = 0.017) and in 27% and 17% of CDT and control patients (p = 0.4). The Kaplan-Meier curve analysis of cumulative patency at 24 months for 6 months of rivaroxaban treatment was significant (p = 0.016). CONCLUSION Treatment therapy and treatment duration with rivaroxaban alone or in combination with CDT are potentially associated with vein patency at 24 months, and a 6-month lysis rate and obstructive vein can influence PTS development. A larger randomized trial is warranted to confirm these findings.
Collapse
Affiliation(s)
- Chia Ju Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chiu-Yang Lee
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan, ROC
| |
Collapse
|
26
|
Identification of Chinese Hospitalized Patients' Risk Profile for Venous Thromboembolism (DissolVE1): A Study Protocol of a Non-Interventional Registry Study. Adv Ther 2019; 36:2180-2190. [PMID: 31140121 DOI: 10.1007/s12325-019-00987-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a frequent cause of hospitalization, mortality, and long-term adverse consequence among medical and surgical inpatients. The current study is performed to identify the prophylaxis of patients with VTE risk within the 6 weeks prior to the diagnosis of VTE, and the treatment pattern during 3 months after VTE diagnosis in Chinese patients hospitalized for surgeries or medical illness. METHODS This multicenter, non-interventional, observational registry plans to enroll 1200 patients from 40 centers in China. The study will retrospectively collect data from patients' hospitalization record within 6 weeks of VTE diagnosis and prospectively follow-up patients for 3 months (in four visits). The primary outcome is to determine the percentage of patients receiving adequate prophylaxis in patients hospitalized within 6 weeks before VTE diagnosis and treatment pattern within 3 months after VTE diagnosis. Important secondary endpoints include determining patients with risk of VTE in the hospital setting, risk factors for VTE, and cost analysis of VTE treatment. EXPECTED OUTCOMES The findings will determine the characteristics of VTE, its treatment practices, cost of treatment, and quality of life in patients; this information may help in building diagnostic and prophylaxis strategies for VTE in China. TRIAL REGISTRATION The study is registered in the Venous Thromboembolism Registry in China with study number DIREGL07581. FUNDING Sanofi China.
Collapse
|
27
|
Das D, Pramanik M. Combined ultrasound and photoacoustic imaging of blood clot during microbubble-assisted sonothrombolysis. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-8. [PMID: 31342692 PMCID: PMC7005573 DOI: 10.1117/1.jbo.24.12.121902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/12/2019] [Indexed: 05/06/2023]
Abstract
Blockage of healthy blood vessels by blood clots can lead to serious or even life-threatening complications. The use of a combined ultrasound (US) and photoacoustic (PA) imaging was explored for blood clot monitoring during microbubble-assisted sonothrombolysis. PA imaging is an emerging hybrid imaging modality that has garnered the attention of the biomedical imaging community in recent years. It enables the study of the composition of a blood clot due to its sensitivity toward optical absorption. Here, in vitro imaging of the side of a blood clot facing the microbubbles was done over time. The US and PA signal-to-noise (SNR) ratio value changes during microbubble-assisted sonothrombolysis were studied for two different local environments: blood clot in deionized water and blood clot in blood. In the first case, US and PA SNR values increased by 4.6% and reduced by 20.8%, respectively after 30 min of sonothrombolysis treatment. After 10 min of sonothrombolysis treatment of the blood clot in blood, the US and PA SNR values increased by 7.7% and 38.3%, respectively. The US and PA SNR value changes were recorded in response to its local environment. This technique can be used to determine the final composition of the blood clot which may, in turn, help in the administration of clot-dissolving drugs.
Collapse
Affiliation(s)
- Dhiman Das
- Nanyang Technological University, School of Chemical and Biomedical Engineering, Singapore
| | - Manojit Pramanik
- Nanyang Technological University, School of Chemical and Biomedical Engineering, Singapore
- Address all correspondence to Manojit Pramanik, E-mail:
| |
Collapse
|
28
|
Cole JL, Stark JE. A facility mandate for pharmacist assessment improves venous thromboembolism outcomes. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jennifer L. Cole
- Department of Pharmacy Veterans Healthcare System of the Ozarks Fayetteville Arkansas
| | - Jennifer E. Stark
- Department of Pharmacy Veterans Healthcare System of the Ozarks Fayetteville Arkansas
| |
Collapse
|
29
|
Abstract
Venous thromboembolism (VTE), referring to both deep vein thrombosis and pulmonary embolism, is a leading cause of death in the developed world during pregnancy. This increased risk is attributed to the Virchow triad, inherited thrombophilias, along with other standard risk factors, and continues for up to 6 to 12 weeks postpartum. During the peripartum period, women should be risk stratified and preventive measures should be initiated based on their risk. Diagnostic tests and treatment strategies commonly used in VTE differ in pregnancy. An understanding of these differences is imperative to diagnose with confidence and to treat appropriately.
Collapse
Affiliation(s)
- Christopher Deeb Dado
- Pulmonary and Critical Care Fellowship, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903, USA
| | - Andrew Tobias Levinson
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 164 Summit Avenue, Providence, RI 02904, USA
| | - Ghada Bourjeily
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, 146 West River Street, Suite 11C, Providence, RI 02904, USA.
| |
Collapse
|
30
|
Betrixaban: Safely Reducing Venous Thromboembolic Events with Extended Prophylaxis. Am J Med 2019; 132:307-311. [PMID: 30201249 DOI: 10.1016/j.amjmed.2018.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 11/23/2022]
Abstract
Although venous thromboembolism prophylaxis of acute medically ill patients is commonly employed, a percentage of high-risk patients still have venous thromboembolic events within 30 days of discharge. Research over the last several years has attempted to identify characteristics of these high-risk patients to facilitate provision of extended prophylaxis and venous thromboembolic event reduction; however, extended prophylaxis has been associated with a significant increase in the risk for major bleeding until recently. Betrixaban, a new oral direct Xa inhibitor with once-daily dosing and limited renal elimination, significantly reduces the risk of venous thromboembolism without increasing the risk for major bleeding. Consequently, betrixaban is the only anticoagulant approved by the Food and Drug Administration for preventing venous thromboembolism with extended prophylaxis in acute medically ill patients.
Collapse
|
31
|
Sullivan M, Eusebio ID, Haigh K, Panti JP, Omari A, Hang JR. Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery. Foot Ankle Int 2019; 40:330-335. [PMID: 30577712 DOI: 10.1177/1071100718807889] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The evidence regarding the prevalence of deep vein thrombosis (DVT) after foot and ankle surgery in elective patients that need to be 6 weeks non-weight bearing postoperatively is incomplete and has limitations. METHODS: The prevalence of DVT in 114 procedures involving the hindfoot and midfoot was determined using ultrasonographic surveillance at 2 and 6 weeks after surgery. RESULTS: The prevalence of DVT was observed to be 25.4%. The majority (68.9%) of DVTs were diagnosed at the ultrasonographic scan performed 2 weeks postoperatively. The remainder (31.1%) of DVTs were diagnosed at the 6-week postoperative ultrasonographic scan. At least 75% of the patients who had early and late DVT had no clinical symptoms or signs of DVT. The prevalence of DVT in clinically detectable patients was 6%. The average age of patients with early DVT was 62.2 years, significantly higher compared to those who had no DVT. The mean tourniquet time for patients with early DVT was 68.1 minutes, significantly higher compared to those without DVT. All DVTs detected were distal to the popliteal vein. CONCLUSIONS: The prevalence of clinically silent DVT was significantly higher than was previously thought. We believe this increased rate is directly attributable to the use of ultrasonographic surveillance postsurgery both at 2 and 6 weeks. The risk of DVT continued after the 2-week visit, and 30% of the DVTs were detected at the ultrasonographic scan at 6 weeks. LEVEL OF EVIDENCE: Level II, prospective cohort.
Collapse
Affiliation(s)
- Martin Sullivan
- 1 St. Vincent's Foot and Ankle Department, St Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| | - Ilian Dominiq Eusebio
- 1 St. Vincent's Foot and Ankle Department, St Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| | - Kristin Haigh
- 1 St. Vincent's Foot and Ankle Department, St Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| | - Juan Paulo Panti
- 1 St. Vincent's Foot and Ankle Department, St Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| | - Abdullah Omari
- 2 St Vincent's Vascular Laboratory, St. Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| | - Jacqueline R Hang
- 1 St. Vincent's Foot and Ankle Department, St Vincent's Clinic, Darlinghurst, Sydney, New South Wales, Australia
| |
Collapse
|
32
|
Miano TA, Abelian G, Seamon MJ, Chreiman K, Reilly PM, Martin ND. Whose Benchmark Is Right? Validating Venous Thromboembolism Events Between Trauma Registries and Hospital Administrative Databases. J Am Coll Surg 2019; 228:752-759.e3. [PMID: 30772443 DOI: 10.1016/j.jamcollsurg.2019.02.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) events are tracked in trauma registries and by administrative data sets. Both databases are used to assess outcomes, despite having varying processes for data capture. STUDY DESIGN This study was performed at an urban, university-based, Level I trauma center from 2004 to 2014. Retrospective review of the trauma registry and the hospital's administrative database was performed querying for all VTEs. Each VTE was then validated through manual chart review. Confirmed events were those with radiographic evidence of VTE by ultrasound, CT, and/or ventilation-perfusion scan. Sensitivity, specificity, and predictive values were calculated and compared between databases. RESULTS There were 19,353 trauma patients admitted during the study period; 656 VTEs were identified in the registry and 890 were identified via administrative data; 527 potential events were identified by both databases; 129 events were only in registry; and 363 were only found in the administrative database. We confirmed 636 of 656 events in registry (positive predictive value, 97%; 95% CI, 95.6% to 98.3%) vs 815 of 890 events in administrative data (positive predictive value, 91.6%; 95% CI, 89.75% to 93.4%; p < 0.001). Sensitivity was higher for administrative (87.2% vs 68.0%; p < 0.001), as 299 confirmed VTE events were not in the registry. Differences between the 2 databases were diminished when the analysis excluded untreated events and those present on admission. Twenty-three percent of validated deep vein thrombosis events in the registry were upper extremity events. CONCLUSIONS The trauma registry showed higher specificity and lower sensitivity compared with administrative data. The low false-positive rate of the trauma registry supports its validity in VTE outcomes research. Additional investigation is needed to evaluate the relevance of the variable sensitivity, likely due to definitional differences. Supplementation of trauma registry data with administrative data can strengthen its completeness.
Collapse
Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Grigor Abelian
- Department of Clinical Pharmacology and Pharmacometrics, Bristol-Myers Squibb, Philadelphia, PA
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kristen Chreiman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
33
|
Abstract
Gynecologic surgery offers unique challenges, as pelvic surgery places patients at an increased risk of venous thromboembolism (VTE). Prevention of VTE is a goal of patients, policy makers, and surgeons. In this review, we address the current research and recommendations for VTE prophylaxis.
Collapse
|
34
|
Venous Thromboembolism in Minimally Invasive Gynecologic Surgery: A Systematic Review. J Minim Invasive Gynecol 2019; 26:186-196. [DOI: 10.1016/j.jmig.2018.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 01/05/2023]
|
35
|
Carroll BJ, Piazza G. Hypercoagulable states in arterial and venous thrombosis: When, how, and who to test? Vasc Med 2018; 23:388-399. [PMID: 30045685 DOI: 10.1177/1358863x18755927] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evaluation for underlying hypercoagulable states in patients with thrombosis is a frequent clinical conundrum. Testing for thrombophilias is often reflexively performed without strategic approach nor clear appreciation of the clinical implications of such results. Guidelines vary in the appropriate utilization of thrombophilia testing. In this review, we discuss the more commonly encountered inherited and acquired thrombophilias, their association with initial and recurrent venous thromboembolism, arterial thromboembolism, and role in women's health. We suggest an approach to thrombophilia testing guided by the clinical presentation, suspected pathophysiology, and an understanding of how such results may affect patient care.
Collapse
Affiliation(s)
- Brett J Carroll
- 1 Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- 2 Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
36
|
Thirukumaran CP, Glance LG, Rosenthal MB, Temkin‐Greener H, Balkissoon R, Mesfin A, Li Y. Impact of Medicare's Nonpayment Program on Venous Thromboembolism Following Hip and Knee Replacements. Health Serv Res 2018; 53:4381-4402. [PMID: 30022482 PMCID: PMC6232432 DOI: 10.1111/1475-6773.13013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program. DATA SOURCES State Inpatient Database for New York (NY) from 2005 to 2013. STUDY DESIGN The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects. PRINCIPAL FINDINGS A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals. CONCLUSION Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued.
Collapse
Affiliation(s)
| | | | - Meredith B. Rosenthal
- Department of Health Policy and ManagementHarvard T. H. Chan School of Public HealthBostonMA
| | | | | | - Addisu Mesfin
- Department of OrthopaedicsUniversity of RochesterRochesterNY
| | - Yue Li
- Department of Public Health SciencesUniversity of RochesterRochesterNY
| |
Collapse
|
37
|
Albertsen IE, Nielsen PB, Søgaard M, Goldhaber SZ, Overvad TF, Rasmussen LH, Larsen TB. Risk of Recurrent Venous Thromboembolism: A Danish Nationwide Cohort Study. Am J Med 2018; 131:1067-1074.e4. [PMID: 30266273 DOI: 10.1016/j.amjmed.2018.04.042] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 04/20/2018] [Accepted: 04/20/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE In this study, we aimed to estimate recurrence risk after incident venous thromboembolism, stratified according to unprovoked, provoked, and cancer-related venous thromboembolism in a prospective cohort of inpatients and outpatients receiving routine care. METHODS We linked nationwide Danish health registries to identify all patients with incident venous thromboembolism from January 2000 through December 2015. Rates of recurrence were calculated and Cox regression was used to compute hazard ratios (HRs) with 95% confidence intervals (CIs) by incident venous thromboembolism type after adjusting for coexisting risk factors. RESULTS The study included 73,993 patients with incident venous thromboembolism (54.1% females; mean age, 62.3 years). At 6-month follow-up, rates per 100 person-years were 6.80, 6.92, and 9.06 for provoked, unprovoked, and cancer-related venous thromboembolism, respectively. At 10-year follow-up, corresponding rates were 2.22, 2.84, and 3.70, respectively. Additionally, at 6-month follow-up, hazard rates of recurrence were comparable for patients with unprovoked venous thromboembolism 1.01 (95% CI, 0.92-1.11) and provoked. At 10-year follow-up, unprovoked venous thromboembolism (HR, 1.17; 95% CI, 1.12-1.23) and cancer-related venous thromboembolism (HR, 1.21; 95% CI, 1.12-1.32) were associated with higher risk of recurrence compared with that found in provoked venous thromboembolism. CONCLUSIONS In this nationwide cohort, patients with cancer-related venous thromboembolism had the highest risk of recurrence. At 6-month follow-up, there were similar risks of recurrence for patients with unprovoked and provoked venous thromboembolism. At 10-year follow-up, recurrence risks were similar for patients with unprovoked venous thromboembolism and patients with cancer-related venous thromboembolism. High recurrence risks in all categories indicate that further research is needed to optimize duration of extended anticoagulation for these patients.
Collapse
Affiliation(s)
- Ida Ehlers Albertsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA..
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | - Samuel Zachary Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
| | | | | | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| |
Collapse
|
38
|
Chendrasekhar A, Aleti S. Venous thromboembolism risk assessments on trauma patients has suboptimal interobserver reliability among inexperienced clinicians (fourth-year medical students). Int J Gen Med 2018; 11:225-231. [PMID: 29950883 PMCID: PMC6012549 DOI: 10.2147/ijgm.s162025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Venous thromboembolic disease is a major cause of morbidity and mortality in hospitalized patients worldwide. The objective of this study is to compare interobserver reliability for qualitative and quantitative venous thromboembolism (VTE) risk assessments in hospitalized trauma patients. Methods We conducted a retrospective medical record review of 40 randomly selected trauma patients admitted to a 448-bed urban level-I trauma center from January 2013 to January 2014. Interclass correlation coefficient (ICC) was calculated based on a two-way mixed model. The sample was equally distributed between patients admitted to the floor and the intensive care unit (ICU). Eight fourth-year medical students performed the risk assessments by the medical record. Two forms for risk assessment were used: a qualitative screening and a quantitative screening. The composite of intraobserver and interobserver variabilities was determined. Results The ICC for qualitative VTE risk assessments was 0.845 and for quantitative VTE risk assessment was 0.628. Conclusion To optimize accuracy of VTE risk stratification and appropriate prophylaxis, medical students and first-year residents should be formally trained to perform quantitative assessments.
Collapse
Affiliation(s)
- Akella Chendrasekhar
- State University of New York Downstate, Brooklyn, NY, USA.,Department of Surgery, Richmond University Medical Center, Staten Island, NY, USA
| | - Sireesha Aleti
- Department of Surgery, Richmond University Medical Center, Staten Island, NY, USA
| |
Collapse
|
39
|
The Impact of Epidural Analgesia on the Rate of Thromboembolism without Chemical Thromboprophylaxis in Major Oncologic Surgery. Am Surg 2018. [DOI: 10.1177/000313481808400631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with abdominopelvic cancers are at increased risk of venous thromboembolism (VTE) due to their malignancy. We evaluated outcomes and the rate of VTE in patients undergoing abdominopelvic surgery for malignancy with preoperative epidural analgesia without postoperative chemical VTE prophylaxis. A retrospective review between 2009 and 2015 identified 285 patients with malignancy who underwent abdominopelvic surgery by a single surgeon (AWS). Lower extremity venous duplex scans (VDS) were performed preoperatively and before discharge. Demographics, procedures, and VTE outcomes were reviewed. The median age was 66 years. The average operative time was 315 minutes. All patients ambulated on postoperative day (POD) one or two. Epidural catheters (ECs) were removed on postoperative day four or five. No patient received VTE prophylaxis while an epidural catheter was in place. Preoperative lower extremity VDS revealed above-knee deep vein thrombosis (DVT) in seven patients (2.5%). Postoperative lower extremity VDS revealed acute DVT in 24 patients (8.4%): nine (3.2%) above-knee and 15 (5.2%) below-knee. The nine patients with above-knee DVT were anticoagulated after epidural removal. No patient developed a pulmonary embolism. Our data suggest that patients undergoing major open operations with epidural analgesia have low rates of DVT and may obviate the need for chemical prophylaxis. However, larger studies are required to determine the overall effects of epidural analgesia on the development of DVTs postoperatively.
Collapse
|
40
|
Guidelines' risk assessment recommendations for venous thromboembolism prophylaxis: A comparison and implementability appraisal. Thromb Res 2018; 168:5-13. [PMID: 29864630 DOI: 10.1016/j.thromres.2018.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/02/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) prophylaxis guidelines for non-surgical patients recommend VTE- and bleeding risk assessment to guide prophylactic strategies. These recommendations differ between guidelines and implementation is suboptimal. Assessing a guideline's implementability characteristics helps predicting the ease of implementation and reveals barriers. OBJECTIVES We aimed to compare guidelines' risk assessment recommendations and critically appraise the implementability characteristics. MATERIAL AND METHODS Two guidelines, one from the American College of Chest Physicians and one from the National Institute for Health and Care Excellence were selected for comparison. Risk assessment methods and subsequent prophylactic recommendations were compared. Eight experts then appraised the guideline recommendations on intrinsic implementability characteristics using the GuideLine Implementability Appraisal (GLIA) instrument. GLIA identifies barriers and facilitators for guideline implementation in nine dimensions. RESULTS Eleven out of 20 individual VTE-risk factors and 2 out of 19 individual bleeding-risk factors used, were present in both guidelines. Additionally, a high VTE- or bleeding risk was defined differently between the two guidelines. The GLIA appraisal identified implementation barriers within all recommendations analyzed. On content level, barriers were identified in recommendations addressing bleeding risk assessment, mechanical prophylaxis and critical care patients. On implementability level, barriers were identified in decidability, flexibility, effect on process of care and computability dimensions. CONCLUSION Depending on the guideline used, VTE-prophylaxis will most likely be provided to different non-surgical patient populations, primarily due to discordance in bleeding risk assessment. Revising the recommendations, taking into account the most apparent implementation barriers, should be considered. However, insufficient evidence to support the recommendations currently complicates this.
Collapse
|
41
|
Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
| |
Collapse
|
42
|
Cave B, Hough A, Dobesh PP. Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients. Pharmacotherapy 2018. [PMID: 29543384 DOI: 10.1002/phar.2102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Brandon Cave
- Fort Loudoun Medical Center; Lenoir City Tennessee
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center; West Palm Beach Florida
| | - Paul P. Dobesh
- College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
| |
Collapse
|
43
|
Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
| |
Collapse
|
44
|
Lau BD, Streiff MB, Pronovost PJ, Haut ER. Venous Thromboembolism Quality Measures Fail to Accurately Measure Quality. Circulation 2018; 137:1278-1284. [DOI: 10.1161/circulationaha.116.026897] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients’ risk for VTE and prescribe therapy appropriate for each patient’s risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.
Collapse
Affiliation(s)
- Brandyn D. Lau
- Russell H. Morgan Department of Radiology and Radiological Science (B.D.L.)
- Division of Health Sciences Informatics (B.D.L.)
- Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.)
- Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)
| | - Michael B. Streiff
- Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.)
- Department of Medicine (M.B.S.)
- Department of Pathology (M.B.S.)
| | - Peter J. Pronovost
- Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.)
- Department of Anesthesiology and Critical Care Medicine (P.J.P., E.R.H.)
- Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)
| | - Elliott R. Haut
- Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.)
- Department of Anesthesiology and Critical Care Medicine (P.J.P., E.R.H.)
- Department of Surgery (E.R.H.)
- Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)
| |
Collapse
|
45
|
Zhou H, Hu Y, Li X, Wang L, Wang M, Xiao J, Yi Q. Assessment of the Risk of Venous Thromboembolism in Medical Inpatients using the Padua Prediction Score and Caprini Risk Assessment Model. J Atheroscler Thromb 2018. [PMID: 29540637 PMCID: PMC6224205 DOI: 10.5551/jat.43653] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: The optimal risk assessment model (RAM) to stratify the risk of venous thromboembolism (VTE) in medical inpatients is not known. We examined and compared how well the Padua Prediction Score (PPS) and the Caprini RAM stratify VTE risk in medical inpatients. Methods: We undertook a retrospective case-control study among medical inpatients admitted to a large general hospital in China during a 4-year period. In total, 902 cases were confirmed to have VTE during hospitalization and 902 controls were selected randomly to match cases by medical service. Results: The VTE risk increased significantly with an increase of the cumulative PPS or Caprini RAM score. A PPS and Caprini RAM “high risk” classification was, respectively, associated with a 5.01-fold and 4.10-fold increased VTE risk. However, the Caprini RAM could identify 84.3% of the VTE cases to receive prophylaxis according to American College of Chest Physicians guidelines, whereas the PPS could only identify 49.1% of the VTE cases. In the medical inpatients studied, five risk factors seen more frequently in VTE cases than in controls in the Caprini RAM were not included in the PPS. The Caprini RAM risk levels were linked almost perfectly to in-hospital and 6-month mortality. Conclusions: Both the PPS and Caprini RAM can be used to stratify the VTE risk in medical inpatients effectively, but the Caprini RAM may be considered as the first choice in a general hospital because of its incorporation of comprehensive risk factors, higher sensitivity to identify patients who may benefit from prophylaxis, and potential for prediction of mortality.
Collapse
Affiliation(s)
- Haixia Zhou
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| | - Yuehong Hu
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| | - Xiaoqian Li
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| | - Lan Wang
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| | - Maoyun Wang
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| | - Jun Xiao
- Intensive Care Unit, West China Hospital, Sichuan University
| | - Qun Yi
- Department of Respiratory and Critical Medicine, West China Hospital, Sichuan University
| |
Collapse
|
46
|
Ye F, Stalvey C, Khuddus MA, Winchester DE, Toklu HZ, Mazza JJ, Yale SH. A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients. J Thromb Thrombolysis 2018; 44:94-103. [PMID: 28484939 DOI: 10.1007/s11239-017-1501-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.
Collapse
Affiliation(s)
- Fan Ye
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA.,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA
| | - Carolyn Stalvey
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Matheen A Khuddus
- North Florida Regional Medical Center, The Cardiac and Vascular Institute, Gainesville, FL, 32605, USA
| | - David E Winchester
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Hale Z Toklu
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA
| | - Joseph J Mazza
- Marshfield Clinic Research Foundation, Marshfield, WI, 54449, USA
| | - Steven H Yale
- Department of Medicine and Graduate Medical Education, North Florida Regional Medical Center, Gainesville, FL, 32605, USA. .,College of Medicine, University of Central Florida, Orlando, FL, 32827, USA. .,Department of Internal Medicine, North Florida Regional Medical Center, 6500 Newberry Road, Gainesville, FL, 32614, USA.
| |
Collapse
|
47
|
Farrow NE, Aboagye JK, Lau BD, Najjar P, Orgill DP, Popoola VO, Kraus PS, Hobson DB, Shaffer DL, Safar B, Gearhart S, Efron JE, Streiff MB, Haut ER. The role of extended/outpatient venous thromboembolism prophylaxis after abdominal surgery for cancer or inflammatory bowel disease. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2018. [DOI: 10.1177/1356262217753427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Current guidelines recommend in-hospital venous thromboembolism prophylaxis for many patients and extended/outpatient prophylaxis in high-risk patients undergoing abdomino-pelvic surgery for cancer. Despite these guidelines, extended venous thromboembolism prophylaxis is not used uniformly at all institutions. This study aimed to evaluate the impact of postdischarge prophylaxis practices at two academic medical centers on the rate of postdischarge venous thromboembolism. Methods We retrospectively analyzed data from the Brigham and Women’s Hospital and the Johns Hopkins Hospital’s American College of Surgeons, National Surgical Quality Improvement Program registries from 1 August 2014 to 30 June 2015. Brigham and Women’s Hospital patients received four weeks supply of extended/outpatient venous thromboembolism prophylaxis, while Johns Hopkins Hospital patients did not. We determined the proportion of patients in each cohort that developed venous thromboembolism within 30 days of surgery. Results Four hundred and eighty-nine patients underwent abdominal surgery for cancer and inflammatory bowel disease; 181 (37.0%) patients from Brigham and Women’s Hospital and 308 (63.0%) patients from Johns Hopkins Hospital. Fourteen patients developed postoperative venous thromboembolism. Seven patients developed in-hospital venous thromboembolism and seven developed venous thromboembolism postdischarge. All postdischarge venous thromboembolism occurred in the Johns Hopkins group, and this difference was statistically significant (p = 0.0498). There was no difference in postdischarge bleeding rates between the groups. Conclusions Extended prophylaxis likely prevents postdischarge venous thromboembolism after major abdominal surgery without an increased risk of bleeding.
Collapse
Affiliation(s)
- Norma E Farrow
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan K Aboagye
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Brandyn D Lau
- Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
| | - Peter Najjar
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Dennis P Orgill
- Department of Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Victor O Popoola
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Peggy S Kraus
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Deborah B Hobson
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Dauryne L Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Susan Gearhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Jonathan E Efron
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Michael B Streiff
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Medicine, Johns Hopkins University, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
- The Armstrong Institute for Patient Safety, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, USA
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University, The Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, USA
| |
Collapse
|
48
|
Holdsworth M, Welch S, Borrego M, Spyropoulos A, Mahan C. Deep-vein thrombosis: A United States cost model for a preventable and costly adverse event. Thromb Haemost 2017; 106:405-15. [DOI: 10.1160/th11-02-0132] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 05/19/2011] [Indexed: 11/05/2022]
Abstract
SummaryPreventable venous thromboembolism (VTE) and “appropriate” type, dose, and duration of prophylaxis are emerging concepts. Contemporary definitions by key quality organisations, including the World Health Organization, have shifted towards “preventable” VTE being considered an adverse event or adverse drug event. A decision tree and cost model were developed to estimate the United States health care costs for total deep-vein thrombosis (DVT), total hospital-acquired DVT, and total “preventable” DVT. Annual cost ranges were obtained in 2010 US dollars for total ($7.5 to $39.5 billion), hospital-acquired ($5 to $26.5billion), and preventable ($2.5 to $19.5 billion) DVT costs. When the sensitivity analysis was applied – taking into consideration higher incidence rates and costs – annual US total, hospital-acquired, and “preventable” DVT costs ranged from $9.8 to $52 billion, $6.8 to $36 billion, and $3.4 to $27 billion, respectively.
Collapse
|
49
|
Douce D, McClure LA, Lutsey P, Cushman M, Zakai NA. Outpatient Treatment of Deep Vein Thrombosis in the United States: The Reasons for Geographic and Racial Differences in Stroke Study. J Hosp Med 2017; 12:826-830. [PMID: 28991948 PMCID: PMC6246775 DOI: 10.12788/jhm.2831] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the uptake of outpatient DVT treatment in the United States and understand how comorbidities and socioeconomic conditions impact the decision to treat as an outpatient. DESIGN/SETTING The Reasons for Geographic and Racial Differences in Stroke cohort study recruited 30,329 participants between 2003 and 2007. DVT events were ascertained through 2011. MEASUREMENTS Multivariable logistic regression was used to determine the correlates of outpatient treatment of DVT accounting for age, sex, race, education, income, urban or rural residence, and region of residence. RESULTS Of 379 venous thromboembolism events, 141 participants had a DVT without diagnosed pulmonary embolism and that did not occur during hospitalization. Overall, 28% (39 of 141) of participants with DVT were treated as outpatients. In a multivariable model, the odds ratio for outpatient versus inpatient DVT treatment was 4.16 (95% confidence interval [CI], 1.25-13.79) for urban versus rural dwellers, 3.29 (95% CI, 1.30-8.30) for white versus black patients, 2.41 (95% CI, 1.06-5.47) for women versus men, and 1.90 (95% CI, 1.19-3.02) for every 10 years younger in age. Living outside the southeastern United States and having higher education and income were not statistically significantly associated with outpatient treatment. CONCLUSIONS Despite known safety and efficacy, only 28% of participants with DVT received outpatient treatment. This study highlights populations in which efforts could be made to reduce hospital admissions.
Collapse
Affiliation(s)
- Daniel Douce
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
| | - Leslie A. McClure
- Department of epidemiology and biostatistics, Dornsife School of Public Health, Drexel University, Philedelphia, PA
| | - Pamela Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Mary Cushman
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
- Department of Pathology, University of Vermont College of Medicine, Burlington VT
| | - Neil A. Zakai
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT
- Department of Pathology, University of Vermont College of Medicine, Burlington VT
| |
Collapse
|
50
|
Alotaibi HK, Abo el-Fetoh NM, MenwerAlanazi A, Alanazi OA, Alanazi AB, Alhowaish MA, Alzahrani HSB, Alshammari MA, ALrashidi RF, Alblowi TM, Alqahtani SJ, Almaashi FS. Deep venous thrombosis among diabetic patients in King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia. Electron Physician 2017; 9:5185-5190. [PMID: 29038695 PMCID: PMC5633211 DOI: 10.19082/5185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 08/23/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Deep venous thrombosis (DVT) is a major cause of morbidity and mortality among hospitalized patients worldwide and, simultaneously, the most preventable. Studies revealed several risk factors of deep venous thrombosis in hospitalized patients. OBJECTIVE to identify frequency and factors associated with occurrence of deep venous thrombosis among diabetic patients referred to King Abdulaziz University (KAU) Hospital, Jeddah, Kingdom of Saudi Arabia. METHODS This cross-sectional hospital-based study was conducted from June to December, 2016. All diabetic patients referred to the hospital departments and who were suspected to have deep venous thrombosis (DVT) and subjected to Doppler examination were included in the study. A questionnaire was designed to obtain data about deep venous thrombosis frequency among participants and factors associated with the development of deep venous thrombosis among them. Data was collected through face to face interviews with patients included in the study. We used SPSS version 16 for data analysis through descriptive statistics and Chi-square test. RESULTS DVT was detected in 14.7 % of the examined patients. There were significant and positive associations between age and DVT (X2=10.13, p=0.03) and between ischemic heart disease and DVT (X2=1.628, p=0.043) with the development of deep venous thrombosis among the studied patients. On the other hand, gender, other comorbidities, history of previous DVT, being bed ridden and using orthopedic casting were not significantly associated with the occurrence of deep venous thrombosis among the participants. CONCLUSION DVT development rate among the participants was 14.7 %. Aging was significantly associated with DVT occurrence. Most of the studied factors and comorbidities had no significant role in DVT development among participants and only ischemic heart disease was significantly associated with DVT development.
Collapse
Affiliation(s)
- Hanan Khalid Alotaibi
- Intern, Faculty of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
| | - Nagah Mohamed Abo el-Fetoh
- Associate professor, Community Medicine Department, Faculty of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
| | - Aseel MenwerAlanazi
- Intern, Faculty of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
| | - Omar Ayed Alanazi
- Intern, Faculty of Medicine, Northern Border University, Arar, Kingdom of Saudi Arabia
| | | | | | | | | | | | | | | | - Fatin Salem Almaashi
- Medical Intern, Faculty of Medicine, Hail University, Hail, Kingdom of Saudi Arabia
| |
Collapse
|