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Wang L. Venous Thrombus. THE ORIGIN AND ONSET OF THROMBUS DISEASE 2018. [PMCID: PMC7120794 DOI: 10.1007/978-981-10-7344-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Venous thromboembolism (VTE) includes pulmonary thromboembolism (PE) and deep venous thrombosis (DVT). Both belonging to thrombus, acute arterial thrombus is white thrombus, while acute venous thrombus is red thrombus. What does the pathological difference mean? Venous thrombosis can autolyze, while arterial thrombosis cannot. For VTE patients, oral anticoagulants are usually recommended for 3, 6, or 12 months and occasionally lifelong, but the course cannot be determined. Furthermore, even with standard anticoagulation therapy and INR, some patients still develop chronic thromboembolic pulmonary hypertension (CTEPH). Thus, the physicians are extremely puzzled about anticoagulant usage. Proposed risk factors for VTE include advanced age, infection, malignancy, autoimmune disease, surgery, trauma, pregnancy, long trip syndrome, family history, AMI, heart failure, and so on. Relevant risk factors are increasing over time. Risk factors are derived from the summary of evidence-based medicine. Although these factors are found to be associated with venous thrombosis, the intrinsic factors have not been well elucidated.
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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.
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Geahchan N, Basile M, Tohmeh M. Venous thromboembolism prophylaxis in patients undergoing abdominal and pelvic cancer surgery: adherence and compliance to ACCP guidelines in DIONYS registry. SPRINGERPLUS 2016; 5:1541. [PMID: 27652114 PMCID: PMC5020030 DOI: 10.1186/s40064-016-3057-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 05/30/2016] [Indexed: 11/14/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major health care problem resulting in significant mortality, morbidity and increase in medical expenses. Patients with malignant diseases represent a high risk population for VTE. The American College of Chest Physicians (ACCP) proposed, since 1986, prophylaxis guidelines that are unequally respected in surgical practice. METHODS DIONYS is a multinational, longitudinal and non-interventional registry including patients having undergone abdominal or pelvic surgery for cancer in Latin America, Africa and the Middle East. Patients were evaluated with regard to VTE prophylaxis, during three consecutive visits, for their adherence to ACCP 2008 guidelines. Data were collected on type and duration of VTE prophylaxis, adherence to guidelines, and compliance with prescriptions, complications and possible reasons for omission of prophylaxis. RESULTS Between 2011 and June 2012, 921 adult patients were included and divided into abdominal (435), pelvic (390) and combined abdominal and pelvic surgery (96), 65.4 % being females. VTE prophylaxis was prescribed to 90 % of patients during hospitalization and to 28.3 % after hospital discharge. Prescriptions adhered to ACCP guidelines in 73.9 % of patients during hospitalization and 18.9 % after discharge. The reason of non-adherence was mainly the clinical judgment by the physician that the patient did not need a prophylaxis. The most commonly prescribed type of prophylaxis was pharmacological (low molecular weight heparin). CONCLUSION A wide gap exists between VTE prophylaxis in daily practice and the ACCP 2008 guidelines, in abdominal and pelvic cancer surgery. A better awareness of surgeons is probably the best guarantee for improvement of VTE prophylaxis in surgical wards.
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Affiliation(s)
- Negib Geahchan
- Faculty of Medicine, Saint Joseph University, Damascus street, Riad El Solh, P.O.Box 11-5076, Beirut, 1107 2180 Lebanon
| | - Melkart Basile
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Maroon Tohmeh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - on behalf of the DIONYS registry
- Faculty of Medicine, Saint Joseph University, Damascus street, Riad El Solh, P.O.Box 11-5076, Beirut, 1107 2180 Lebanon
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Abstract
OBJECTIVES An elevated maximal amplitude (mA) value with rapid thrombelastography on admission can identify general trauma patients with an increased risk of venous thromboembolic events (VTEs). We hypothesized that (1) the risk of VTE traditionally assigned to injury lies specifically in those who sustain major orthopaedic trauma and (2) an elevated admission mA value could be used to identify patients with major orthopaedic injuries at risk for VTE during initial hospital admission. DESIGN Retrospective. SETTING University level 1 trauma center. PATIENTS/PARTICIPANTS Consecutive trauma patients admitted to an urban level 1 trauma center between September 2009 and February 2011 who met the criteria for level 1 trauma activation and who were between 18 and 85 years of age were included in our study group. Two groups were created, one whose extremity abbreviated injury severity score was 2 or greater (ORTHO) and the other whose extremity abbreviated injury severity score was <2 (non-ORTHO). MAIN OUTCOME MEASUREMENTS Pulmonary emboli were confirmed by computed tomography angiography, and deep vein thromboses were confirmed by venous duplex. Univariate analyses were conducted and followed by purposeful regression analysis. RESULTS Of note, 1818 patients met the inclusion criteria (310 ORTHO and 1508 non-ORTHO). Despite more hypocoagulable r-TEG values on arrival (alpha angle 71 vs. 73 and mA 62 vs. 64, both P < 0.05), ORTHO patients had higher rates of VTE (6.5% vs. 2.7%, P < 0.001). Stepwise regression generated 4 values to predict development of VTE (age, male gender, white race, and ORTHO). After controlling for these variables, admission mA values ≥65 (odds ratio 3.66) and ≥72 (odds ratio 6.70) were independent predictors of VTEs during hospitalization. CONCLUSIONS Admission rapid thrombelastography mA values can identify patients with major orthopaedic trauma injuries who present with an increased risk of in-hospital deep vein thromboses and pulmonary embolism with a 3.6-fold and 6.7-fold increased risk for mA values ≥65 and ≥72, respectively. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Changes in the incidence, case fatality rate, and characteristics of symptomatic perioperative pulmonary thromboembolism in Japan: Results of the 2002-2011 Japanese Society of Anesthesiologists Perioperative Pulmonary Thromboembolism (JSA-PTE) Study. J Anesth 2014; 29:433-441. [PMID: 25412800 DOI: 10.1007/s00540-014-1939-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/18/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to examine the incidence, case fatality rate, and characteristics of perioperative symptomatic pulmonary thromboembolism (PS-PTE) throughout Japan. METHODS From 2002 to 2011, confidential questionnaires were mailed annually to all Japanese Society of Anesthesiologists-certified training hospitals for data collection to determine the incidence and case fatality rate of PS-PTE patients. Data from 10,537 institutions in which a total of 11,786,489 surgeries had been performed were analyzed using the Mann-Whitney and Chi-square tests. RESULTS In total, 3,667 PS-PTE cases were identified. The average incidence of PS-PTE was 3.1 (2.2-4.8) per 10,000 surgeries, and the average case fatality rate was 17.9% (12.9-28.8%). The incidence of PS-PTE began to significantly decrease in 2004 compared with that of 2002 (0.0036 vs. 0.0044%: p < 0.01). The case fatality rate temporarily increased toward 2005 (17.9 to 28.8%); however, it gradually decreased since 2008 (15.7%) and was the lowest (12.9%) in 2011. Regarding the trends in prophylaxis, the rate of mechanical prophylaxis increased significantly in 2003 compared with that of 2002 (59.5 vs. 35.0%: p < 0.01), and almost plateaued (73.1-83.1%) after 2004. Furthermore, the rate of pharmacological prophylaxis started increasing in 2008 (17.6%) and reached around 30% after 2009 (28.8-30.2%). CONCLUSIONS The results of our 10-year survey study show that the incidence of PS-PTE decreased significantly since 2004, and the case fatality rate seemed to show a downward trend since 2008. Major changes in the distribution of prophylaxis in PS-PTE patients were observed.
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LV WEI, DUAN QIANGLIN, WANG LEMIN, GONG ZHU, YANG FAN, SONG YANLI. Expression of B-cell-associated genes in peripheral blood mononuclear cells of patients with symptomatic pulmonary embolism. Mol Med Rep 2014; 11:2299-305. [DOI: 10.3892/mmr.2014.2978] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 10/24/2014] [Indexed: 11/06/2022] Open
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Lv W, Wang L, Duan Q, Gong Z, Yang F, Song H, Song Y. Characteristics of the complement system gene expression deficiency in patients with symptomatic pulmonary embolism. Thromb Res 2013; 132:e54-7. [PMID: 23726092 PMCID: PMC7112067 DOI: 10.1016/j.thromres.2013.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 04/19/2013] [Accepted: 04/29/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a disease with a high mortality and morbidity rate, and the pathogenesis of PE remains still unclear. We aimed to investigate the gene expression differences of the complement system in peripheral blood mononuclear cells (PBMCs) from patients with symptomatic PE and controls. METHODS Twenty cases of PE patients and twenty sex and age matched controls were recruited into the study. Human cDNA microarray analysis was used to detect the gene expression difference of the complement system between the two groups. RESULTS 1). Expression of twenty-one genes encoding complement components was detected. In PE patients, expression of the genes encoding C1qα, C1qβ, C4b, C5 and Factor P was significantly greater (P<0.05) than controls, while C6, C7, C9, mannose-binding lectin (MBL) and mannan-binding lectin serine peptidase 1 (MASP1) mRNAs were lower (P<0.05) than controls. 2). Expression of seven genes encoding complement receptors was examined. In PE patients, CR1, integrin αM, integrin αX and C5aR mRNAs were significantly up-regulated (P<0.01) compared with controls. 3). Seven genes encoding complement regulators were examined. The mRNA expression of CD59 and CD55 was significantly up-regulated (P<0.05), whereas Factor I mRNA was significantly down-regulated (P<0.05) in PE patients than controls. CONCLUSIONS In PE patients, the mRNA expressions of complement components, receptors and regulators were unbalanced, suggesting dysfunction and/or deficiency of the complement system, which leads to decreased function of MAC-induced cell lysis in PE patients finally.
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Affiliation(s)
- Wei Lv
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Borzecki AM, Cowan AJ, Cevasco M, Shin MH, Shwartz M, Itani K, Rosen AK. Is development of postoperative venous thromboembolism related to thromboprophylaxis use? A case-control study in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2012; 38:348-58. [PMID: 22946252 DOI: 10.1016/s1553-7250(12)38045-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational studies continue to report thromboprophylaxis underuse for postoperative pulmonary embolism/deep vein thrombosis (pPE/DVT) despite the long-standing existence of prevention guidelines. However, data are limited on whether thromboprophylaxis use differs between patients developing pPE/DVT versus those who do not or on why prophylaxis is withheld. METHODS Administrative data (2002-2007) from 28 Veterans Health Administration hospitals were screened for discharges with (1) pPE/DVT as flagged by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator software and (2) pharmacoprophylaxis-recommended procedures, and the medical records were reviewed to ascertain true pPE/DVT cases. Controls were selected by matching cases by hospital, age, sex, diagnosis-related group, and predicted probability for developing pPE/DVT, and who underwent a pharmacoprophylaxis-recommended procedure. Records were assessed for "appropriate pharmacoprophylaxis use," defined primarily per American College of Chest Physicians (ACCP) guidelines, and reasons for anticoagulant nonuse. RESULTS The 116 case-control pairs were similar in terms of demographics, surgery type, ACCP risk category, and appropriate pharmacoprophylaxis rates overall. Of the highest-risk patients, respective pharmacoprophylaxis rates among cases and controls were 88% versus 92% among hip/knee replacements and 31% versus 48% among cancer patients. Of the cases and controls who did not receive appropriate pharmacoprophylaxis, only about 25% had documented contraindications. Reviewers identified contraindications in 14% of cases and 9% of controls. CONCLUSIONS Similarities in preventive pPE/DVT practice between cases and controls suggest that pPE/DVTs occur despite implementation of guideline-adherent practices.
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Affiliation(s)
- Ann M Borzecki
- US Department of Veterans Affairs, Center for Health Quality, Outcomes and Economic Research, Bedford VA Hospital, Bedford, Massachusetts, USA.
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Admission rapid thrombelastography predicts development of pulmonary embolism in trauma patients. J Trauma Acute Care Surg 2012; 72:1470-5; discussion 1475-7. [PMID: 22695409 DOI: 10.1097/ta.0b013e31824d56ad] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury leads to dramatic disturbances in coagulation with increased risk of bleeding followed by a hypercoagulable state. A comprehensive assessment of these coagulation abnormalities can be measured and described by thrombelastography. The purpose of this study was to identify whether admission rapid-thrombelastography (r-TEG) could identify patients at risk of developing pulmonary embolism (PE) during their hospital stay. METHODS Patients admitted between September 2009 to February 2011 who met criteria for our highest-level trauma activation and were transported directly from the scene were included in the study. PE defined as clinically suspected and computed tomography angiography confirmed PE. We evaluated r-TEG values with particular attention to the maximal amplitude (mA) parameter that is indicative of overall clot strength. Demographics, vital signs, injury severity, and r-TEG values were then evaluated. In addition to r-TEG values, gender and injury severity score (ISS) were chosen a priori for developing a multiple logistic regression model predicting development of PE. RESULTS r-TEG was obtained on 2,070 consecutive trauma activations. Of these, 2.5% (53) developed PE, 97.5% (2,017) did not develop PE. Patients in the PE group were older (median age, 41 vs. 33 years, p = 0.012) and more likely to be white (69% vs. 54%, p = 0.036). None of the patients in the PE group sustained penetrating injury (0% vs. 25% in the no-PE group, p < 0.001). The PE group also had admission higher mA values (66 vs. 63, p = 0.050) and higher ISS (median, 31 vs. 19, p = 0.002). When controlling for gender, race, age, and ISS, elevated mA at admission was an independent predictor of PE with an odds ratio of 3.5 for mA > 65 and 5.8 for mA > 72. CONCLUSION Admission r-TEG mA values can identify patients with an increased risk of in-hospital PE. Further studies are needed to determine whether alternative anticoagulation strategies should be used for these high-risk patients. LEVEL OF EVIDENCE Prognostic study, level III.
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Mahan CE, Borrego ME, Woersching AL, Federici R, Downey R, Tiongson J, Bieniarz MC, Cavanaugh BJ, Spyropoulos AC. Venous thromboembolism: annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates. Thromb Haemost 2012; 108:291-302. [PMID: 22739656 DOI: 10.1160/th12-03-0162] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/07/2012] [Indexed: 11/05/2022]
Abstract
Healthcare reform is upon the United States (US) healthcare system. Prioritisation of preventative efforts will guide necessary transitions within the US healthcare system. While annual deep-vein thrombosis (DVT) costs have recently been defined at the US national level, annual pulmonary embolism (PE) and venous thromboembolism (VTE) costs have not yet been defined. A decision tree and cost model were developed to estimate US health care costs for total PE, total hospital-acquired PE, and total hospital-acquired "preventable" PE. The previously published DVT cost model was modified, updated and combined with the PE cost model to elucidate the same three categories of costs for VTE. Direct and indirect costs were also delineated. For VTE in the base model, annual cost ranges in 2011 US dollars for total, hospital- acquired, and hospital-acquired "preventable" costs and were $13.5-$27.2, $9.0-$18.2, and $4.5-$14.2 billion, respectively. The first sensitivity analysis, with higher incidence rates and costs, demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $32.1-$69.3, $23.7-$51.5, and $11.9-$39.3 billion, respectively. The second sensitivity analysis with long-term attack rates (LTAR) for recurrent events and post-thrombotic syndrome and chronic pulmonary thromboembolic hypertension demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $15.4-$34.4, $10.3-$25.4, and $5.1-$19.1 billion, respectively. PE costs comprised a majority of the VTE costs. Prioritisation of effective VTE preventative strategies will reduce significant costs, morbidity and mortality within the US healthcare system. The cost models may be utilised to estimate other countries' costs or VTE-specific disease states.
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Affiliation(s)
- Charles E Mahan
- New Mexico Heart Institute, University of New Mexico College of Pharmacy, Albuquerque, New Mexico 87102, USA.
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Xie Y, Duan Q, Wang L, Gong Z, Wang Q, Song H, Wang H. Genomic characteristics of adhesion molecules in patients with symptomatic pulmonary embolism. Mol Med Rep 2012; 6:585-90. [PMID: 22684872 DOI: 10.3892/mmr.2012.940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 06/01/2012] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to identify the differences in the expression of cell adhesion molecule-related mRNAs between symptomatic pulmonary embolism (PE) and a control group, and to investigate the interactions among activated leukocytes, platelets and endothelial cells. Whole human gene chip was applied to detect the expression of cell adhesion molecule-related mRNAs in symptomatic PE and in the control group, and statistical analysis was performed. In patients with PE, the expression of the majority of integrin mRNAs located on leukocytes and platelets was significantly upregulated. The expression of mRNAs related to L-selectin and P-selectin glycoprotein ligand was significantly upregulated, while the expression of mRNA related to E-selectin was significantly downregulated. The expression of mRNAs related to classic cadherins and protocadherins was downregulated, and the expression of mRNAs related to vascular endothelial cadherin was significantly downregulated; the expression of mRNAs related to the immunoglobulin superfamily had no obvious difference between the 2 groups. In conclusion, we demonstrated that, in symptomatic PE patients, the adhesion of leukocytes and platelets was enhanced; the activation of endothelial cells was obviously weakened; the adherens junctions among endothelial cells were weakened, with the endothelium becoming more permeable.
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Affiliation(s)
- Yuan Xie
- Department of Cardiology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, PR China
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Gray J, Razmus I. Improving venous thromboembolism prevention processes and outcomes at a community hospital. Jt Comm J Qual Patient Saf 2012; 38:61-6. [PMID: 22372252 DOI: 10.1016/s1553-7250(12)38008-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a cause of significant morbidity and mortality in hospitalized patients in the United States. Quality improvement (QI) strategies to increase the rates of prophylaxis in patients at-risk for VTE have been shown to be successful. The development of a formal, active strategy addressing the prevention of VTE, as a written, institutionwide VTE prophylaxis policy, presents a challenge for hospitals METHODS In 2007 a multidisciplinary VTE committee was initiated to develop and implement a hospitalwide QI program to standardize VTE risk assessment and prophylaxis prescribing practices at Saint Francis Hospital (Tulsa, Oklahoma). The QI program included clinician education, VTE order set and electronic trigger implementation, and changes in mechanical prophylaxis usage. RESULTS The VTE prophylaxis order set was successfully piloted and implemented hospitalwide within three months of the project's initiation. Standardization of VTE prophylaxis practices across surgical and medical specialties was the key aim of this QI program. As a result, patient-related outcomes were also improved. The number of hospital-acquired VTE events decreased from 123 (0.39%) in 2008 to 99 (0.32%) in 2009 and 87 (0.27%) in 2010, and a reduction in the VTE rate between 2008 and 2010 of 31.6%. There was a significant decrease between 2008 and 2010 in the number of hospital-acquired VTE events (p = .035). CONCLUSIONS Keys to the success of this QI program included leveraging multidisciplinary VTE committee members, physician champions, multiple approaches to communication and education, and providing evidence to support the changes. Sharing the hospital's QI process may provide a model for other hospitals challenged with developing and sustaining positive outcomes in patients at risk for VTE.
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Duan Q, Gong Z, Song H, Wang L, Yang F, Lv W, Song Y. Symptomatic venous thromboembolism is a disease related to infection and immune dysfunction. Int J Med Sci 2012; 9:453-61. [PMID: 22859906 PMCID: PMC3410365 DOI: 10.7150/ijms.4453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Accepted: 07/16/2012] [Indexed: 11/08/2022] Open
Abstract
The characteristics of human genomics and cellular immune function between clinically symptomatic venous thromboembolism (VTE) and controls were systematically compared to explore the immunologic pathogenesis of VTE. Microarray assay showed the mRNA expressions of genes related to non-specific cellarer immune and cytokines were significantly down-regulated. Abnormal expressions of CD3+, CD4+, CD8+, NK marker CD16+56+, CD19 and aberrant CD4+/CD8+ ratio were detected in 54 among 56 patients. In PE patients, microarray assay revealed the imbalance in the expressions of genes related to the immune system. The expressions of genes related to non-specific immune cells and cytokines were markedly up-regulated and those associated with cellular immune were dramatically down-regulated. In VTE patients, cytological examination indicated the functions of NK cells were significantly compromised, and the antigen recognition and killing function of T cells markedly decreased. The consistence between genomic and cytological examination suggests the symptomatic VTE is closely associated with the infection and immune dysfunction.
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Affiliation(s)
- Qianglin Duan
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billingham R, Flum DR. Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery. J Am Coll Surg 2011; 213:596-603, 603.e1. [PMID: 21871823 DOI: 10.1016/j.jamcollsurg.2011.07.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 07/16/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND To determine the effectiveness of pharmacologic prophylaxis in preventing clinically relevant venous thromboembolic (VTE) events and deaths after surgery. The Surgical Care Improvement Project recommends that VTE pharmacologic prophylaxis be given within 24 hours of the operation. The bulk of evidence supporting this recommendation uses radiographic end points. STUDY DESIGN The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement initiative with data linked to hospital admission/discharge and vital status records. We compared the rates of death, clinically relevant VTE, and a composite adverse event (CAE) in the 90 days after elective, colon/rectal resections, based on receipt of pharmacologic prophylaxis (within 24 hours of surgery) at 36 Surgical Care and Outcomes Assessment Program hospitals (2005-2009). RESULTS Of 4,195 (mean age 61.1 ± 15.6 years; 54.1% women) patients, 56.5% received pharmacologic prophylaxis. Ninety-day death (2.5% vs 1.6%; p = 0.03), VTE (1.8% vs 1.1%; p = 0.04), and CAE (4.2% vs 2.5%; p = .002) were lower in those who received pharmacologic prophylaxis. After adjustment for patient and procedure characteristics, the odds were 36% lower for CAE (odds ratio = 0.64; 95% CI, 0.44-0.93) with pharmacologic prophylaxis. In any given quarter, hospitals where patients more often received pharmacologic prophylaxis (highest tertile of use) had the lowest rates of CAE (2.3% vs 3.6%; p = 0.05) compared with hospitals in the lowest tertile. CONCLUSIONS Using clinical end points, this study demonstrates the effectiveness of VTE pharmacologic prophylaxis in patients having elective colorectal surgery. Hospitals that used pharmacologic prophylaxis more often had the lowest rates of adverse events.
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Affiliation(s)
- Steve Kwon
- Department of Surgery, University of Washington, Seattle, WA, USA
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Dossett LA, Adams RC, Cotton BA. Unwarranted National Variation in the Use of Prophylactic Inferior Vena Cava Filters After Trauma: An Analysis of the National Trauma Databank. ACTA ACUST UNITED AC 2011; 70:1066-70; discussion 1070-1. [DOI: 10.1097/ta.0b013e31821282d5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Venous Thromboembolism Prophylaxis in Surgical Patients: Identifying a Patient Group to Maximize Performance Improvement. Jt Comm J Qual Patient Saf 2011; 37:178-83. [DOI: 10.1016/s1553-7250(11)37022-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. ACTA ACUST UNITED AC 2011; 70:141-6; discussion 147. [PMID: 21217492 DOI: 10.1097/ta.0b013e3182032f45] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Low-molecular-weight heparins (LMWHs) are effective in preventing thromboembolic complications after trauma. In the nonoperative management (NOM) of blunt solid abdominal organ injuries, the timing of the administration of LMWH remains controversial because of the unknown risk for bleeding. METHODS Retrospective study including patients aged 15 years or older who sustained blunt splenic, liver, and/or kidney injuries from January 2005 to December 2008. Patients were stratified according to the type and severity of organ injuries. NOM failure rates and blood transfusion requirements were compared between patients who got LMWH early (≤3 days), patients who got LMWH late (>3 days), and patients who did not receive LMWH. RESULTS Overall, 312 (63.8%) patients with solid organ injuries had NOM attempted. There were 154 splenic, 144 liver, and 65 kidney injuries (1.2 organs injured per patient). Forty-one patients (13.2%) received LMWH early, 70 patients (22.4%) received LMWH late, and 201 (64.4%) patients did not receive LMWH. The early LMWH group was less severely injured compared with the late LMWH group. However, the distribution of the risk factors for failure of NOM (high-grade injury, large amount of hemoperitoneum, and contrast extravasation) was similar between the three LMWH groups. Overall, 17 of 312 patients (5.4%) failed NOM (7.8% spleen, 2.1% liver, and 3.1% kidney). All but one failure occurred before LMWH administration. After adjustment for demographic differences, the overall blood transfusion requirements for the early LMWH group was significantly lower when compared with patients with late LMWH administration (3.0±5.3 units vs. 6.4±9.9 units; adjusted p=0.027). Pulmonary embolism and deep venous thrombosis occurred in four patients. The mortality rate for patients with splenic, liver, and kidney injuries was 3.2% and did not differ with LMWH application. CONCLUSION In patients with solid abdominal organ injuries undergoing NOM, early use of LMWH does not seem to increase failure rates or blood transfusion requirements.
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Skånér Y, Nilsson GH, Arrelöv B, Lindholm C, Hinas E, Wilteus AL, Alexanderson K. Use and usefulness of guidelines for sickness certification: results from a national survey of all general practitioners in Sweden. BMJ Open 2011; 1:e000303. [PMID: 22189350 PMCID: PMC3244659 DOI: 10.1136/bmjopen-2011-000303] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives Diagnoses-specific sickness certification guidelines were recently introduced in Sweden. The aim of this study was to investigate to which extent general practitioners (GPs) used these guidelines and how useful they found them, 1 year after introduction. Design A cross-sectional questionnaire study. A comprehensive questionnaire about sickness certification practices in 2008 was sent to all physicians living and working in Sweden (n=36 898, response rate 60.6%). In all, 19.7% (n=4394) of the responders worked as GPs. Setting Primary healthcare in all Sweden. Participants The participating GPs who had consultations concerning sickness certification at least a few times a year (n=4278, 97%). Main outcome measures Descriptive statistics and prevalence ratios for the 11 questionnaire items about the use and usefulness of the sickness certification guidelines. Results A majority (76.2%) of the GPs reported that they used the guidelines. In addition, 65.4% and 43.5% of those GPs reported that the guidelines had facilitated their contacts with patients and social insurance officers, respectively. The guidelines also helped nearly one-third (31.5%) of the GPs to develop their competence and improve the quality of their management of sickness certification consultations (33.5%). About half experienced some problems when using the guidelines and 43.7% wanted better competence in using them. A larger proportion of non-specialists and of GPs with fewer sickness certification consultations had benefitted from the guidelines. Conclusions The national sickness certification guidelines implemented in Sweden were widely used by GPs already a year after introduction. Also, the GPs consider the guidelines useful in several respects, for example, in patient contacts and for competence development.
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Affiliation(s)
- Ylva Skånér
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar H Nilsson
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Britt Arrelöv
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Christina Lindholm
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Elin Hinas
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Löfgren Wilteus
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Alexanderson
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
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Venous thromboembolism: what is preventing achievement of performance measures and consensus guidelines? J Cardiovasc Nurs 2010; 24:S14-9. [PMID: 19858961 DOI: 10.1097/jcn.0b013e3181b85c7b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Venous thromboembolism (VTE) is a major cause of death and disability throughout the world. Evidenced-based guidelines and performance measures aimed at prevention of VTE have existed for over a decade, yet VTE occurrence rate appears to be increasing. This increase may, in part, be due to more aggressive surveillance; however, noncompliance with guideline recommendations for prophylaxis is a concern. Several barriers have been identified as contributing to lack of guideline adherence including lack of supportive systems, lack of individual responsibility for implementation, lack of acceptance, perceived lack of need in some clinical areas, no oversight or incentives, and conflicting guideline recommendations. Distribution of guidelines to healthcare providers does not result in increased guideline adherence. Applying multiple process improvement strategies appears to increase guideline utilization and may help achieve improved patient outcomes and higher performance measures.
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Amin AN, Deitelzweig SB. Optimizing the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement. Jt Comm J Qual Patient Saf 2010; 35:558-64. [PMID: 19947332 DOI: 10.1016/s1553-7250(09)35076-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is associated with a substantial health care and economic burden, yet many VTE events are preventable. Despite the availability of evidence-based guidelines derailing effective thromboprophylaxis strategies, the underuse and inappropriate prescribing of VTE prophylaxis are common. Current national quality initiatives were reviewed to identify strategies that may help hospitals and health care professionals optimize current VTE prophylaxis practices. METHODS A computerized literature search was performed using PubMed and MEDLINE, and this was complemented by hand searches of relevant journals and Web sites to identify additional literature related to VTE prevention and quality improvement. FINDINGS Many organizations, including the Centers for Medicare & Medicaid Services, the National Quality Forum, the Joint Commission, and the Agency for Healthcare Research and Quality have developed performance measures, quality indicators, public reporting initiatives, incentive programs, and "negative reimbursement" that are designed to help improve VTE prevention. CONCLUSIONS It remains the responsibility of individual hospitals to identify specific areas in which they can improve their VTE prophylaxis rates to obtain positive results from the reporting initiatives and incentive programs. If performance measures are to be met, all hospital departments will need to implement effective VTE prevention policies, including early risk assessment, appropriate prophylaxis prescribing, monitoring, and follow-up. Multifaceted, integrated initiatives involving risk assessment tools, decision support, electronic alert systems, and hospitalwide education, with a mechanism for audit and feedback, may help ensure that all health care professionals comply with VTE-prevention policies and initiatives.
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Affiliation(s)
- Alpesh N Amin
- Department of Medicine, University of California, Irvine, USA.
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Caruana JA, Anain PM, Pham DT. The pulmonary embolism risk score system reduces the incidence and mortality of pulmonary embolism after gastric bypass. Surgery 2009; 146:678-83; discussion 683-5. [DOI: 10.1016/j.surg.2009.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 07/29/2009] [Indexed: 01/19/2023]
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McKean SC, Deitelzweig SB, Sasahara A, Michota F, Jacobson A. Assessing the risk of venous thromboembolism and identifying barriers to thromboprophylaxis in the hospitalized patient. J Hosp Med 2009; 4:S1-7. [PMID: 19830850 DOI: 10.1002/jhm.587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sylvia C McKean
- Academic Hospitalist Service, Brigham & Women's Hospital, Boston, MA 02115, USA.
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Implementation of Resident Work Hour Restrictions is Associated With a Reduction in Mortality and Provider-Related Complications on the Surgical Service. Ann Surg 2009; 250:316-21. [DOI: 10.1097/sla.0b013e3181ae332a] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sundt TM, Henrickson SE, Cima RR. Approaching process improvement from a human factors perspective: seeking leverage from a systems approach. Surgery 2008; 144:96-8. [DOI: 10.1016/j.surg.2008.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 04/14/2008] [Indexed: 10/21/2022]
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