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Nissar SM, Kuchay AA, Mir TH, Goud LN, Latief M. Direct Oral Anticoagulants in Nephrotic Syndrome: Our Experience and Literature Review. Indian J Nephrol 2024; 34:169-171. [PMID: 38680998 PMCID: PMC11044691 DOI: 10.4103/ijn.ijn_317_22] [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: 09/21/2022] [Accepted: 11/02/2022] [Indexed: 05/01/2024] Open
Abstract
Nephrotic syndrome (NS) is one of the common presentations of kidney diseases both in children and adults. NS patients, particularly those with membranous nephropathy, have increased risk of thromboembolic events. Heparin and vitamin K antagonists (VKAs) continue to be commonly used as prophylactic and therapeutic agents, given the experience of use of these agents in NS and nonrenal indications of anticoagulation. The use of direct oral anticoagulants (DOACs) in NS is reported in some case series, conference abstracts, and a few small studies. We report our experience of using DOACs in 11 patients of NS with severe hypoalbuminemia. Out of 11, one patient required change of anticoagulation from DOACs to VKA and the rest of them did well with DOACs. There were no bleeding episodes in our study. We suggest larger studies to be carried out to better understand the use of these agents in NS.
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Affiliation(s)
- Syed M. Nissar
- Nephrology Division, Super Specialty Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Abid A. Kuchay
- Nephrology Division, Super Specialty Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - Tajamul H. Mir
- Nephrology Division, Super Specialty Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
| | - L. Naresh Goud
- Cancer Research, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - Muzamil Latief
- Nephrology Division, Super Specialty Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
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2
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Lin S, Alepuz A, Tritsch T, Schwartz G. Deep Vein Thrombosis Prophylaxis in Orthopedic Surgery. Cureus 2024; 16:e53726. [PMID: 38455781 PMCID: PMC10919879 DOI: 10.7759/cureus.53726] [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: 12/12/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Deep vein thrombosis (DVT) is a complex and multifactorial process arising from a variety of factors, including recent surgical procedures, traumatic events, and periods of prolonged immobility. The extended period of stasis post-orthopedic surgery places patients at a notably high risk of developing DVT, and DVT-related pulmonary embolism (PE) ranks as the third most common cause of death in orthopedic surgery patients. This review examines the multifaceted risk factors contributing to the development of DVT in orthopedic patients. Additionally, it addresses the importance of DVT prophylaxis in orthopedic settings, the efficacy and safety of various prophylactic methods encompassing both mechanical and pharmacological approaches, and the economic dimensions of DVT prophylaxis, including scrutiny of cost-effectiveness and the exploration of strategies for optimization.
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Affiliation(s)
- Shu Lin
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Adrian Alepuz
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Tara Tritsch
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Gary Schwartz
- Orthopedic Surgery, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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Bakhsh E. The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review. J Clin Med 2023; 12:7009. [PMID: 38002623 PMCID: PMC10672497 DOI: 10.3390/jcm12227009] [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: 10/08/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods.
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Affiliation(s)
- Ebtisam Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia
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4
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Baldari L, Boni L, Giuliani B, Cassinotti E. Porto-spleno-mesenteric venous thrombosis after elective splenectomy: a retrospective cohort study. Front Immunol 2023; 14:1216283. [PMID: 37928557 PMCID: PMC10625444 DOI: 10.3389/fimmu.2023.1216283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Background Elective splenectomy is the main treatment for a wide range of haematological diseases. Porto-spleno-mesenteric venous thrombosis represents one of the most severe complications of this procedure. The aim of this study was to evaluate risk factors associated with development of porto-spleno-mesenteric venous thrombosis after elective splenectomy. Methods All cases of elective splenectomy carried out from April 1st 2017 to January 31st 2023 were included in this single centre retrospective cohort study. Patients' demographics and perioperative data were analysed and correlated with the incidence of postoperative thrombosis. All patients underwent postoperative doppler ultrasound screening for thrombosis. Analysis was performed using SPSS 28, with p-value < 0.05 considered significant. Results Twenty-two patients (10 women, 12 men) underwent splenectomy during the study period. Indications were: immune thrombocytopenia (n: 6), myeloproliferative disorder (n: 6), hereditary spherocytosis (n: 4), thalassemia (n: 1), lymphoma (n: 1), leukaemia (n: 1), other malignancies (n: 3). Six patients developed porto-spleno-mesenteric venous thrombosis and only 2 of them were symptomatic. Patients were treated with anticoagulation therapy with complete resolution. Analysis identified three main factors associated with thrombosis: spleen diameter (p = 0.03), myeloproliferative disorder (p = 0.02), intraoperative platelet transfusion (p = 0.002) and intraoperative red blood cells transfusion (p = 0.009). Conclusion Standardized postoperative screening allows prompt diagnosis and treatment of porto-spleno-mesenteric venous thrombosis even in asymptomatic cases. Patient with splenomegaly and affected by myeloproliferative disorder have a greater risk to develop this complication.
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Affiliation(s)
- Ludovica Baldari
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Boni
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunitá, Univeristy of Milan, Milan, Italy
| | - Beatrice Giuliani
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Cassinotti
- Department of General and Minimally-Invasive Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunitá, Univeristy of Milan, Milan, Italy
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Metoyer GT, Ali Asgar J, D'Adamo CR, Wolf JH, Katlic M, Svoboda S, Mavanur A. The modified frailty index predicts postoperative venous thromboembolism incidence better than older age in colorectal surgery patients. Am J Surg 2023:S0002-9610(23)00440-3. [PMID: 37802702 DOI: 10.1016/j.amjsurg.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 10/08/2023]
Affiliation(s)
- Garyn T Metoyer
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA.
| | - Juzer Ali Asgar
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA; University of Medicine and Health Sciences, 275 7th Ave 26th Floor, New York, NY, 10001, USA.
| | - Christopher R D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Center for Integrative Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA.
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA; Department of Surgery, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA.
| | - Mark Katlic
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA; Department of Surgery, George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA.
| | - Shane Svoboda
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA.
| | - Arun Mavanur
- Department of Surgery, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA; Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA.
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Zeng M, Wu Z. An Evidenced-Based Review of the Prevention of Venous Thromboembolism in Traumatic Patients with Intermittent Pneumatic Compression Devices. Emerg Med Int 2023; 2023:2116496. [PMID: 37583590 PMCID: PMC10425255 DOI: 10.1155/2023/2116496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/16/2023] [Accepted: 07/29/2023] [Indexed: 08/17/2023] Open
Abstract
Objective To search, evaluate, and summarize the best evidence of intermittent pneumatic compression devices to prevent venous thromboembolism in trauma patients. Method Evidence retrieval was conducted from top to bottom according to the "6S" evidence model, including guidelines, clinical decision making, evidence summary, expert consensus, and systematic reviews. The retrieval time limit was from the establishment of the database to August 31, 2022. Two researchers independently evaluated the quality of the literature, extracted evidence, and summarized evidence. Results A total of 140 studies were obtained in the literature retrieval, and 50 studies were obtained after rechecking and reading the title and abstract. After combining the inclusion and exclusion criteria, 19 studies were finally included. Among them, there were 12 guidelines, 1 clinical decision making, 1 evidence summary, 1 expert consensus, and 4 systematic reviews. The 27 best pieces of evidence were summarized from the four dimensions of pretreatment evaluation, contraindications and applicable conditions, treatment strategies, training, and patient education. Conclusion This study summarized the evidence of using an intermittent pneumatic compression device to prevent venous thromboembolism in trauma patients and provided the basis for scientific and effective standardized management of mechanical thromboembolism prevention. When applying evidence, it is necessary to combine clinical practice and patient wishes and select evidence pertinent to improving the effectiveness of intermittent pneumatic compression devices in preventing venous thromboembolism. In addition, compliance with the clinical application of IPC is relatively low, so we should start from two aspects before the application of evidence. We should not only increase the number of IPCs but also strengthen the training of VTE prevention knowledge and practical skills of medical staff to provide good health education for patients and their families to improve compliance with the clinical application of IPC.
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Affiliation(s)
- Meng Zeng
- Department of Orthopedics, West China Hospital, Sichuan University, 37 GuoXue Alley, Chengdu 610041, Sichuan, China
| | - Zhoupeng Wu
- Department of Vascular Surgery, West China Hospital, Sichuan University, 37 GuoXue Alley, Chengdu 610041, Sichuan, China
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Poulos CM, Althoff AL, Scott RB, Wakefield D, Lewis R. A novel scoring system for identifying patients at risk for venous thromboembolism undergoing diverticular resection: an American College of Surgeons-National Surgical Quality Improvement Program Study. Surg Endosc 2022; 36:8415-8420. [PMID: 35229213 DOI: 10.1007/s00464-022-09129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
Following colorectal surgery, venous thromboembolism (VTE) is a serious complication occurring at an estimated incidence of 2-4%. There is a significant body of literature stratifying risk of VTE in specific populations undergoing colorectal resection for cancer or inflammatory bowel disease. There has been little research characterizing patients undergoing colorectal surgery for other indications, e.g. diverticulitis. We hypothesize that there exists a subgroup of patients with identifiable risk factors undergoing resection for diverticulitis that has relatively higher risks for VTE. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Project database from 2006 to 2017 who underwent colorectal resection for diverticulitis. Patients with a primary indication for resection other than diverticulitis were excluded. Multivariate logistic regression modeling was conducted to determine the risk of VTE for each independent variable. A novel scoring system was developed and a receiver-operating-characteristic curve was generated. The rate of VTE was 1.49%. An 7-point scoring system was developed using identified significant variables. Patients scoring ≥ 6 on the developed scoring scale had a 3.12% risk of 30-day VTE development. A simple scoring system based on identified significant risk factors was specifically developed to predict the risk of VTE in patients undergoing diverticular colorectal resection. These patients are at significantly higher risk and may justify increased vigilance regarding VTE events, similar to patients undergoing colorectal resection for cancer or inflammatory bowel disease.
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Affiliation(s)
- Constantine M Poulos
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA.
| | - Ashley L Althoff
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA
| | - Rachel B Scott
- Colon and Rectal Surgeons of Greater Hartford, Bloomfield, CT, 06002, USA
| | - Dorothy Wakefield
- Department of Surgery, University of Connecticut Health Center, Farmington, CT, 06030, USA
| | - Robert Lewis
- Colon and Rectal Surgeons of Greater Hartford, Bloomfield, CT, 06002, USA
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8
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Lott N, Robb F, Nolan E, Attia J, Reeves P, Gani J, Smith S. Efficacy of intermittent compression devices for thromboembolic prophylaxis in major abdominal surgery: a systematic review and meta-analysis. ANZ J Surg 2022; 92:2926-2934. [PMID: 36259216 PMCID: PMC9828528 DOI: 10.1111/ans.18101] [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: 03/01/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The benefits of mechanical prophylaxis for the prevention of venous thromboembolism (VTE) in abdominal and pelvic surgery are uncertain, with different guidelines stating that graduated compression stockings (GCS) and intermittent pneumatic compression devices (IPCDs) can be used either alone or in combination. To review the efficacy of IPCDs in preventing VTE following abdominal and pelvic surgery. METHODS A systematic review was conducted, identifying relevant literature reporting clinical trials conducted in abdominopelvic surgery, comparing the effect of IPCDs alone or in combination with no prophylaxis, GCS and chemical prophylaxis. The review identified studies reported from 1966 to 2022 in Medline, Embase, PubMed and Cochrane databases for randomized controlled trials. RESULTS Thirteen RCTs involving 1914 participants were identified. IPCDs were superior to placebo (OR VTE 0.39; 95% CI 0.20-0.76) but not superior to other forms of prophylaxis (OR 0.83; 95% CI 0.30-2.27) or to GCS alone (OR 0.9; 95% CI 0.24-3.36). The addition of IPCDs to GCS compared with GCS alone was beneficial (OR 0.45; 95% CI 0.23-0.91) as was the addition of IPCDs to standard perioperative chemoprophylaxis (OR 0.25; 95% CI 0.09-0.74). The overall quality and reliability of trials were low, with high risk of bias. CONCLUSIONS IPCDs are more effective than placebo in reducing VTE rates but are not more effective than other forms of thrombo-prophylaxis (chemical or mechanical) following abdominal and pelvic surgery. There is poor quality evidence to suggest that they might have a role as additional prophylaxis when combined with GCS and chemical prophylaxis.
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Affiliation(s)
- Natalie Lott
- Surgical ServicesJohn Hunter HospitalNewcastleNew South WalesAustralia,Hunter Surgical Clinical Research UnitJohn Hunter HospitalNewcastleNew South WalesAustralia,School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Felicity Robb
- School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia,Hunter Medical Research InstituteKookaburra CircuitNew Lambton HeightsNew South WalesAustralia
| | - Erin Nolan
- School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia,Hunter Medical Research InstituteKookaburra CircuitNew Lambton HeightsNew South WalesAustralia
| | - John Attia
- School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia,Hunter Medical Research InstituteKookaburra CircuitNew Lambton HeightsNew South WalesAustralia
| | - Penny Reeves
- School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia,Hunter Medical Research InstituteKookaburra CircuitNew Lambton HeightsNew South WalesAustralia
| | - Jon Gani
- Hunter Surgical Clinical Research UnitJohn Hunter HospitalNewcastleNew South WalesAustralia,School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Stephen Smith
- Hunter Surgical Clinical Research UnitJohn Hunter HospitalNewcastleNew South WalesAustralia,School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia
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What is the value of preoperative prophylactic heparin in reducing venous thromboembolism in major non-cardiac thoracic surgery? Am J Surg 2022; 224:1086-1089. [DOI: 10.1016/j.amjsurg.2022.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/02/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022]
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Rastogi R, Lattimore CM, Mehaffey JH, Turrentine FE, Maitland HS, Zaydfudim VM. Electronic Health Record Risk-Stratification Tool Reduces Venous Thromboembolism Events in Surgical Patients. Surg Open Sci 2022; 9:34-40. [PMID: 35620709 PMCID: PMC9127397 DOI: 10.1016/j.sopen.2022.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background Venous thromboembolism is a preventable cause of morbidity and mortality after surgery. To ensure that patients receive appropriate venous thromboembolism chemoprophylaxis, a nonmandatory risk-stratification tool based on patient clinical condition was implemented through the electronic health record to stratify patient risk and recommend chemoprophylaxis. We hypothesized that implementing this tool would reduce postoperative venous thromboembolism events in general surgery as well as across all surgical services. Methods All adult patients undergoing inpatient surgical operations (January 2012–December 2019) at a single quaternary care center and Level 1 trauma center were abstracted from institutional electronic health record database and stratified into patients admitted before and after venous thromboembolism risk-stratification tool implementation. Bivariable analyses compared venous thromboembolism chemoprophylaxis prescription and venous thromboembolism events with implementation and screening among all surgical patients as well as in general surgery patient subset. Results A total of 64,377 adults underwent operations: 27,819 preimplementation and 36,558 postimplementation. A significant reduction in venous thromboembolism events occurred from pre- to post-tool implementation for all cases (0.77% vs 0.47%, P < .001). General surgery patients (n = 15,723) had a significant increase in chemoprophylaxis prescription (81.9% vs 86.0%, P < .001) and a significant reduction in venous thromboembolism events (1.41% vs 0.59%, P < .001). After tool implementation, use of extended postdischarge chemoprophylaxis was greater among general surgery patient subset than the entire patient cohort (46.7% vs 29.6%, P < .001). Conclusion The integration of a nonmandatory electronic health record risk-stratification tool was associated with a significant reduction in venous thromboembolism events. Extended chemoprophylaxis was prescribed in nearly half of general surgery patients at very high risk for postdischarge events. Implementing an electronic VTE risk-stratification tool reduced surgical VTE events. Even as a nonmandatory tool, risk stratification led to overall fewer VTE events. Postoperative VTE events were reduced by 39% after the tool was integrated in EHR. With the tool, general surgery had 58% less VTE events and improved prophylaxis use.
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Affiliation(s)
- Radhika Rastogi
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Courtney M. Lattimore
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - J. Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - Hillary S. Maitland
- Department of Medicine, Hematology/Oncology, University of Virginia, Charlottesville, VA 22908
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
- Corresponding author at: Division of Surgical Oncology, Department of Surgery, PO Box 800709, Charlottesville, VA, 22908-0709. Tel.: + 1-434-924-2839; fax: + 1 434-982-4778. @vz_surgery
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12
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Incidence and Outcomes of Pulmonary Embolism among Hospitalized COVID-19 Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147645. [PMID: 34300096 PMCID: PMC8307735 DOI: 10.3390/ijerph18147645] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Patients with COVID-19 may be at high risk for thrombotic complications due to excess inflammatory response and stasis of blood flow. This study aims to assess the incidence of pulmonary embolism among hospitalized patients with COVID-19, risk factors, and the impact on survival. METHODS A retrospective case-control study was conducted at Al-Noor Specialist Hospital in Saudi Arabia between 15 March 2020 and 15 June 2020. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and confirmed diagnosis of pulmonary embolism by Computed Tomography pulmonary angiogram (CTPA) formed the case group. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and without confirmed diagnose of pulmonary embolism formed the control group. Logistic regression analysis was used to identify predictors of pulmonary embolism and survival. RESULTS A total of 159 patients participated were included in the study, of which 51 were the cases (patients with pulmonary embolism) and 108 patients formed the control group (patients without pulmonary embolism). The incidence of PE among those hospitalized was around 32%. Smoking history, low level of oxygen saturation, and higher D-dimer values were important risk factors that were associated with a higher risk of developing PE (p < 0.05). Higher respiratory rate was associated with higher odds of death, and decreased the possibility of survival among hospitalized patients with PE. CONCLUSIONS Pulmonary embolism is common among hospitalized patients with COVID-19. Preventive measures should be considered for hospitalized patients with smoking history, low level of oxygen saturation, high D-dimer values, and high respiratory rate.
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13
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Ellenbogen Y, Power RG, Martyniuk A, Engels PT, Sharma SV, Kasper EM. Pharmacoprophylaxis for Venous Thromboembolism in Spinal Surgery: A Systematic Review and Meta-analysis. World Neurosurg 2021; 150:e144-e154. [PMID: 33684581 DOI: 10.1016/j.wneu.2021.02.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a significant contributor to postoperative morbidity and mortality. Prophylactic regimens for VTE involve mechanical prophylaxis and pharmacoprophylaxis. This systematic review and meta-analysis aimed to determine the efficacy and safety of pharmacoprophylaxis in comparison with any nonpharmacoprophylaxis regimen for the prevention of postoperative VTE in patients undergoing spinal surgery. METHODS MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ICRCTN were searched for comparative studies including both pharmacoprophylaxis and nonpharmacoprophylaxis post spinal surgery. The primary outcome was the incidence of VTE within the postoperative hospitalized period. Secondary outcomes included the incidence of spinal epidural hematoma, significant bleeding events, and other adverse events associated with VTE. The data was pooled using random-effects models of meta-analysis and relative risk (RR) was calculated. RESULTS Four retrospective and 3 randomized controlled trials representing a total of 8373 patients were included. Overall, there was a significant decrease in postoperative deep venous thrombosis with pharmacoprophylaxis versus nonpharmacoprophylaxis (RR 0.42, 95% confidence interval 0.21-0.86, P = 0.02, I2 = 0%); however, there were no significant differences between the groups in the incidences of VTE (RR 0.31, 95% confidence interval 0.12-0.81, P = 0.02, I2 = 0%). The incidences of spinal epidural hematoma and significant bleeding events were rare and comparable in both groups. CONCLUSIONS This systematic review and meta-analysis found a potential benefit with pharmacoprophylaxis post spinal surgery in the prevention of deep venous thrombosis. However, there is a need for future randomized controlled trials to investigate the efficacy and safety of pharmacoprophylaxis in spinal surgery across various spinal procedures.
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Affiliation(s)
- Yosef Ellenbogen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert G Power
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay V Sharma
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
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Waxman MJ, Griffin D, Sercy E, Bar-Or D. Compliance with American College of Chest Physicians (ACCP) recommendations for thromboembolic prophylaxis in the intensive care unit: a level I trauma center experience. Patient Saf Surg 2021; 15:13. [PMID: 33766093 PMCID: PMC7993448 DOI: 10.1186/s13037-021-00288-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/16/2021] [Indexed: 12/21/2022] Open
Abstract
Background Recommendations are for nearly universal venous thromboembolism (VTE) prophylaxis in critically ill hospitalized patients because of their well-recognized risks. In those intensive care units (ICUs) where patient care is more uniformly directed, it may be expected that VTE prophylaxis would more closely follow this standard over units that are less uniform, such as open-model ICUs. Methods This was a retrospective cohort study on all patients aged 18+ admitted to an open ICU between 6/1/2017 and 5/31/2018. Patients were excluded if they had instructions to receive comfort measures only or required therapeutic anticoagulant administration. Prophylaxis administration practices, including administration of mechanical and/or pharmacologic prophylaxis and delayed (≥48 h post-ICU admission) initiation of pharmacologic prophylaxis, were compared between patients admitted to the ICU by the trauma service versus other departments. Root causes for opting out of pharmacological prophylaxis were documented and compared between the two study groups. Results One-hundred two study participants were admitted by the trauma service, and 98 were from a non-trauma service. Mechanical (98% trauma vs. 99% non-trauma, P = 0.99) and pharmacologic (54% vs. 44%, P = 0.16) prophylaxis rates were similar between the two admission groups. The median time from ICU admission to pharmacologic prophylaxis initiation was 53 h for the trauma service and 10 h for the non–trauma services (P ≤ 0.01). In regression analyses, trauma-service admission (odds ratio (OR) = 2.88, 95% confidence interval (CI) 1.21–6.83) and increasing ICU length of stay (OR = 1.13, 95% CI 1.05–1.21) were independently associated with pharmacologic prophylaxis use. Trauma-service admission (OR = 8.30, 95% CI 2.18–31.56) and increasing hospital length of stay (OR = 1.15, 95% CI 1.03–1.28) were independently associated with delayed prophylaxis initiation. Conclusions Overall, the receipt of VTE prophylaxis of any type was close to 100%, due to the nearly universal use of mechanical compression devices among ICU patients in this study. However, when examining pharmacologic prophylaxis specifically, the rate was considerably lower than is currently recommended: 54% among the trauma services and 44% among non-trauma services.
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Affiliation(s)
- Michael J Waxman
- Medical-Surgical Intensive Care Unit and Progressive Care Unit, Research Medical Center, Kansas City, MO, USA
| | - Daniel Griffin
- Pulmonary and Critical Care, University of Missouri School of Medicine, Kansas City, MO, USA
| | - Erica Sercy
- Trauma Research Department, Research Medical Center, Kansas City, MO, USA
| | - David Bar-Or
- Trauma Research Department, Research Medical Center, Kansas City, MO, USA. .,Injury Outcomes Network and Trauma Research LLC, 501 E. Hampden Avenue, Room 4-454, Englewood, Colorado, 80113, USA.
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Ryan L, Mataraso S, Siefkas A, Pellegrini E, Barnes G, Green-Saxena A, Hoffman J, Calvert J, Das R. A Machine Learning Approach to Predict Deep Venous Thrombosis Among Hospitalized Patients. Clin Appl Thromb Hemost 2021; 27:1076029621991185. [PMID: 33625875 PMCID: PMC7907939 DOI: 10.1177/1076029621991185] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Deep venous thrombosis (DVT) is associated with significant morbidity, mortality, and increased healthcare costs. Standard scoring systems for DVT risk stratification often provide insufficient stratification of hospitalized patients and are unable to accurately predict which inpatients are most likely to present with DVT. There is a continued need for tools which can predict DVT in hospitalized patients. We performed a retrospective study on a database collected from a large academic hospital, comprised of 99,237 total general ward or ICU patients, 2,378 of whom experienced a DVT during their hospital stay. Gradient boosted machine learning algorithms were developed to predict a patient's risk of developing DVT at 12- and 24-hour windows prior to onset. The primary outcome of interest was diagnosis of in-hospital DVT. The machine learning predictors obtained AUROCs of 0.83 and 0.85 for DVT risk prediction on hospitalized patients at 12- and 24-hour windows, respectively. At both 12 and 24 hours before DVT onset, the most important features for prediction of DVT were cancer history, VTE history, and internal normalized ratio (INR). Improved risk stratification may prevent unnecessary invasive testing in patients for whom DVT cannot be ruled out using existing methods. Improved risk stratification may also allow for more targeted use of prophylactic anticoagulants, as well as earlier diagnosis and treatment, preventing the development of pulmonary emboli and other sequelae of DVT.
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16
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Venous Thromboembolism Prophylaxis and Thrombotic Risk Stratification in the Varicose Veins Surgery-Prospective Observational Study. J Clin Med 2020; 9:jcm9123970. [PMID: 33297575 PMCID: PMC7762368 DOI: 10.3390/jcm9123970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background: An invasive phlebological treatment is still not free from complications such as thrombosis. As in other surgical populations, not only the treatment modality, but also patient condition-related venous thromboembolism (VTE) risk factors matter. The current protocols used in varicose vein surgery centers are based mostly on individual risk assessment as well as on an implementation and extrapolation of general surgery VTE prophylaxis guidelines. In the presented study, the efficacy of routine VTE pharmacological thromboprophylaxis in patients undergoing saphenous varicose vein surgery was prospectively evaluated. In the result assessment, VTE risk factor evaluation and Caprini score results were included; however, due to the limited size of the projected study group, as well as expected limited deep vein thrombosis (DVT) prevalence in this clinical scenario, it was not possible to perform the validation of the Caprini model efficacy in the projected study model. Methods: In the study, 141 patients undergoing saphenous vein stripping and miniphlebectomy in spinal anesthesia were included. In all of the patients, VTE risk factors (including Caprini score evaluation) were assessed, and the routine thromboprophylaxis with enoxaparin 40 mg for 10 days was used. The venous ultrasounds were undertaken before the surgery and on the 10th and 30th day after surgery. The study endpoint was the presence of symptomatic or asymptomatic DVT confirmed in the imaging study. The study safety endpoint was major bleeding occurrence intraoperatively or within 30 days after surgery. Results: The presence of a postoperative DVT was diagnosed in five cases (3.5%) In all of these cases, only distal DVT was confirmed. Despite extensive saphenous varicose vein surgery with stripping and miniphlebectomy performed in nontumescent but spinal anesthesia, no proximal lower leg episode was diagnosed. Three out of five DVT cases were diagnosed on day 10 postoperative control, while a further two were confirmed in the ultrasound examination performed 30 days after procedure. No clinically documented pulmonaly embolism (PE) as well as no bleeding episodes were noticed. Among the factors related to the statistically significant higher DVT occurrence, the results of the Caprini score were identified with odds ratio (OR) = 2.04 (95% CI = (0.998; 4.18)). Another factor that became statistically significant in terms of the higher postoperative DVT prevalence was the reported Venous Clinical Severity Score (VCSS) results (OR = 1.98; 95% CI (1.19; 3.26)). In the multiple logistic regression analysis, the patient age (OR = 0.86; 95% CI (0.75–0.99)), Caprini score evaluation results (OR = 4.04; 95% CI (1.26–12.9)) and VCSS results (OR = 2.4; 95% CI (1.23–4.7)) were of statistical significance as predictors for postoperative DVT occurrence, with a p value of 0.029 for age, and p = 0.017 and p = 0.009 for Caprini score results and VCSS results, respectively. Due to the confirmed limited number of the DVT events in our study cohort, as well as the descriptive and explorative nature of the achieved results, the final clinical potential and significance of the identified parameters, including Caprini score rate and VCSS rate, should be interpreted with caution and studied in the further trials in these clinical settings. Conclusion: All the patients undergoing varicose vein surgery should undergo VTE risk evaluation based on the individual assessment. In VTE risk evaluation, patient and surgical procedure characteristics based on the factors included into the Caprini score but also on specific chronic venous disease-related factors should be taken into consideration. Further studies are needed to propose an objective and validated VTE risk assessment model, as well as a validated antithrombotic prophylaxis protocol in this particular patient group.
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17
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Trends in venous thromboembolism prophylaxis in gynecologic surgery for benign and malignant indications. Arch Gynecol Obstet 2020; 302:935-945. [PMID: 32728922 DOI: 10.1007/s00404-020-05678-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of perioperative morbidity and mortality. We analyzed the trends in use of VTE prophylaxis over time in women undergoing hysterectomy for both benign and malignant indications. METHODS The Premier Database was used to identify women who underwent hysterectomy from 2011 to 2017. Women were stratified by indication for surgery (benign or malignant) and route of hysterectomy. VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination (mechanical and pharmacologic). Trends in use of prophylaxis over time were analyzed. Multivariate models were developed to examine predictors of use of prophylaxis. RESULTS Among 920,477 patients identified, 579,824 (63.0%) received VTE prophylaxis, including 15.4% who received pharmacologic, 34.5% who received mechanical, and 13.1% who received combination prophylaxis. Overall use of prophylaxis declined annually from 68.1% in 2011 to 56.7% in 2017 (P < 0.001). Among patients with cancer, the use of prophylaxis declined from 84.5% in 2011 to 78.6% in 2017 (P < 0.001). A similar trend was noted among women with benign conditions, with rates of prophylaxis declining from 66.2 to 53.3% (P < 0.001). Additionally, use of prophylaxis declined for patients undergoing MIS hysterectomy from 65.4% in 2011 to 53.3% in 2017, and from 73.1 to 66.7% in patients who underwent abdominal hysterectomy. Among patients with cancer, rates of pharmacologic and combined prophylaxis was 70.9% in 2011 and 69.7% in 2017. However, among women with benign conditions, the rates of pharmacologic and combined prophylaxis rose from 19.4% in 2011 to 25.6% in 2017 (P < 0.001). Despite these changes in prophylaxis rates and methods, there was no significant change in the rate of VTE between 2011 and 2017 (P = 0.06). CONCLUSION Despite the lack of change in guidelines for VTE prophylaxis in gynecologic surgery, the overall rates of prophylaxis decreased over time independent of the indication or route of surgery. The rates of thromboembolic events did not significantly increase in response to the decreased use of VTE prophylaxis.
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18
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Fong ZV, Sell NM, Fernandez-Del Castillo C, Del Carmen G, Ferrone CR, Chang DC, Warshaw AL, Polk HC, Lillemoe KD, Qadan M. Does preoperative pharmacologic prophylaxis reduce the rate of venous thromboembolism in pancreatectomy patients? HPB (Oxford) 2020; 22:1020-1024. [PMID: 31732463 DOI: 10.1016/j.hpb.2019.10.2437] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/05/2019] [Accepted: 10/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether the risk of venous thromboembolism (VTE) may be reduced by preoperative administration of prophylactic heparin is unknown. We hypothesized that timing of heparin administration does not significantly alter the incidence of VTE in pancreatic surgery. METHODS An analysis was conducted using data from Massachusetts General Hospital's National Surgical Quality Improvement Program from 2012 to 2017. All patients admitted for elective pancreatic resection were included. The primary outcome was development of VTE. Multivariable regression was performed, adjusting for patient demographics and various clinical factors. RESULTS In total, 1448 patients were analyzed, of whom 1062 received preoperative heparin (73.3%). Overall, 36 (2.5%) patients developed VTE. On unadjusted analysis, there was no statistically significant difference between patients who received preoperative heparin compared with those who did not (2.6% vs. 1.3%, respectively; p = 0.079). On adjusted analysis, there was an association with increased VTE rates among patients who received preoperative heparin (OR 2.93, 95% CI 1.10-7.81; p = 0.031). CONCLUSION There was an association between preoperative heparin administration and increased incidence of VTE on adjusted analysis, possibly reflecting appropriate surgical judgment in patient selection for prophylaxis. These data question the inclusion of preoperative VTE pharmacologic prophylaxis as a reliable quality indicator.
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Affiliation(s)
- Zhi V Fong
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Naomi M Sell
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | | | - Gabriel Del Carmen
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Hiram C Polk
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
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Culbert MH, Hamidi M, Zeeshan M, Hanna K, Romero A, Joseph B, O'Keeffe T. Retrospective Analysis of Low-Molecular-Weight Heparin and Unfractionated Heparin in Pediatric Trauma Patients: A Comparative Analysis. J Surg Res 2020; 249:121-129. [DOI: 10.1016/j.jss.2019.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/28/2019] [Accepted: 11/03/2019] [Indexed: 11/28/2022]
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20
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Kirby KF, Good B. From Education to Practice: Incorporating Quality Improvement Projects Into a Baccalaureate Nursing Curriculum. AORN J 2020; 111:527-535. [PMID: 32343377 DOI: 10.1002/aorn.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The accelerated pace of change in health care and the call for a radical transformation in prelicensure nursing education will require changes in baccalaureate nursing programs to ensure nurses are adequately prepared for practice. At one Midwestern university, academic nurse educators developed an innovative multilevel interprofessional and intradisciplinary education opportunity using a Lean Healthcare quality improvement (QI) process to improve systems, strengthen academic-practice partnerships, and bridge the education-to-practice gap. During one 16-week semester, one group of sophomore and junior clinical nursing students worked collaboratively with personnel at a local health care organization on a QI project on sequential compression devices. The students identified practice barriers related to sequential compression device compliance when medication prophylaxis was contraindicated. Using a Lean QI framework, the students developed and implemented a comprehensive, evidence-based venous thromboembolism prophylaxis policy, including tools and strategies for educating employees and patients.
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MESH Headings
- Curriculum/standards
- Curriculum/trends
- Education, Nursing, Baccalaureate/methods
- Education, Nursing, Baccalaureate/standards
- Education, Nursing, Baccalaureate/trends
- Evidence-Based Nursing/methods
- Humans
- Quality Improvement
- Schools, Nursing/organization & administration
- Schools, Nursing/trends
- Translational Research, Biomedical/instrumentation
- Translational Research, Biomedical/methods
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21
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Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review. J Trauma Acute Care Surg 2019; 88:522-535. [DOI: 10.1097/ta.0000000000002538] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Venous Thromboembolism Prediction in Postoperative Urogynecology Patients: The Utility of Risk Assessment Tools. Female Pelvic Med Reconstr Surg 2019; 26:e27-e32. [PMID: 31651538 DOI: 10.1097/spv.0000000000000780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the utility of risk assessment tools (Rogers and Caprini Score models) in predicting venous thromboembolism (VTE) in a urogynecology patient population. METHODS All surgical patients underwent a procedure in the operating room with 1 of 7 female pelvic medicine and reconstructive surgery.Attendings from January 1 to December 31, 2015, were investigated. Rogers and Caprini Scores were calculated for each patient as well as the occurrence of any VTE in the 30 days after surgery. Patients were then grouped into risk categories based on the American College of Chest Physicians guidelines. RESULTS A total of 783 patients were identified and included in this study. The average patient age was 58 years (range = 18-89 years). The average operative time was 109 minutes (range = 4-491 minutes). Most patients obtained a Rogers Score of 5 (32%) and a Caprini Score of 4 (34%). Based on Caprini scoring, the American College of Chest Physicians category distribution was as follows: 10% low risk, 61% moderate risk, and 29% high risk. Based on Rogers scoring, this distribution was as follows: 96.8% very low risk, 3.1% low risk, and 0.1% moderate risk. Two VTE events were identified in the cohort. Overall, the incidence of VTE was 0.26%. CONCLUSIONS The standard VTE risk assessment tools grade urogynecology patients very differently. Although the Caprini Scale seems to appropriately differentiate individual patient VTE risk, the Rogers Scale does not adequately stratify this risk, thus potentially limiting its use within this population.
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J B, J A, T M, G P, I Ž, L K, J R, M A. A case report of pulmonary embolism during electroconvulsive therapy and its further application after somatic stabilization. Brain Stimul 2019; 13:250-252. [PMID: 31558373 DOI: 10.1016/j.brs.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/02/2019] [Accepted: 09/17/2019] [Indexed: 10/26/2022] Open
Abstract
We describe a case of a 49-year-old, male, Caucasian, pharmaco-resistant patient with a recurrent major depressive disorder, who developed acute pulmonary embolism during a course of inpatient right-unilateral ultra-brief electroconvulsive therapy. After the stabilization of his somatic condition, we were able to safely continue with further ECT applications until his mood normalized and he was able to return to his normal life outside the hospital. Case reports on this topic are scarce - our article demonstrates that electroconvulsive treatment, with proper precautionary measures (anti-aggregative or anti-coagulation prophylaxis) is safe and can be administered without unnecessary delay.
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Affiliation(s)
- Buday J
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic.
| | - Albrecht J
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Mareš T
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Podgorná G
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Žukov I
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Kališová L
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Raboch J
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Anders M
- Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
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Cronin M, Dengler N, Krauss ES, Segal A, Wei N, Daly M, Mota F, Caprini JA. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost 2019; 25:1076029619838052. [PMID: 30939900 PMCID: PMC6714938 DOI: 10.1177/1076029619838052] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The Caprini risk assessment model (RAM) has been validated in over 250 000 patients in
more than 100 clinical trials worldwide. Ultimately, appropriate treatment options are
dependent on precise completion of the Caprini RAM. As the numerical score increases, the
clinical venous thromboembolism rate rises exponentially in every patient group where it
has been properly tested. The 2013 Caprini RAM was completed by specially trained medical
students via review of the presurgical assessment history, medical clearances, and medical
consults. The Caprini RAM was completed for every participant both preoperatively and
predischarge to ensure that any changes in the patient’s postoperative course were
captured by the tool. This process led to the development of completion guidelines to
ensure consistency and accuracy of scoring. The 2013 Caprini scoring system provides a
consistent, thorough, and efficacious method for risk stratification and selection of
prophylaxis for the prevention of venous thrombosis.
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Affiliation(s)
- MaryAnne Cronin
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Nancy Dengler
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Eugene S Krauss
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Ayal Segal
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Nicole Wei
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Madison Daly
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Frank Mota
- 1 Department of Orthopaedic Surgery, Syosset Hospital, Syosset, NY, USA
| | - Joseph A Caprini
- 2 Emeritus, NorthShore University HealthSystem, Evanston, IL, USA.,3 University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Amirsadri M, Mousavi S, Karimipour A. The cost-effectiveness and cost-utility analysis of the use of enoxaparin compared with heparin for venous thromboembolism prophylaxis in medical inpatients in Iran. ACTA ACUST UNITED AC 2019; 27:627-634. [PMID: 31368091 DOI: 10.1007/s40199-019-00292-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/22/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Moderate to high risk medical inpatients are at increased risk of Venous Thromboembolism (VTE). The present study aims to investigate the cost-effectiveness and cost-utility of using Enoxaparin compared to Heparin in VTE prophylaxis in medical inpatients, from Iranian payer's perspective. METHODS Decision tree modeling technique was used to evaluate cost-effectiveness and cost-utility of the compared interventions. The main considered outcomes were Life Years Gained (LYG) for Cost-Effectiveness Analysis (CEA) and Quality-Adjusted Life Years (QALY) for Cost-Utility Analysis (CUA). Costs and consequences of the interventions were evaluated for a three-month period and reported as Incremental Cost-Effectiveness Ratios (ICERs). One-way and Probabilistic Sensitivity Analysis (PSA) were conducted to evaluate the robustness of the model due to uncertainty in the input data. RESULTS In base case scenario (i.e. public tariff), incremental cost was $10.32, and incremental QALY and incremental LYG were 0.0001 and 0.0002 per patients respectively. Base case ICERs were 60,376 USD/QALY and 71,077 USD/LYG per patient. The results of the sensitivity analysis showed the robustness of the model. CONCLUSION As the estimated ICER per QALY is more than three times the reported Gross Domestic Product (GDP) per capita by world bank for Iran in 2017 ($5415), the use of Enoxaparin for VTE prophylaxis in medical in patients doesn't seem to be a cost-effective intervention compared to the use of Heparin in Iran.
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Affiliation(s)
- Mohammadreza Amirsadri
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Hezar jarib Street, Isfahan, 81746-73461, Iran. .,Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Sarah Mousavi
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Hezar jarib Street, Isfahan, 81746-73461, Iran
| | - Ali Karimipour
- School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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Knotts TL, Mousa SA. Anticoagulation in Venous Thromboembolism Prophylaxis in Medically Ill Patients: Potential Impact of NOACs. Am J Cardiovasc Drugs 2019; 19:365-376. [PMID: 30809772 DOI: 10.1007/s40256-019-00329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
While substantial evidence supports the use of standard-duration injectable anticoagulants for venous thromboembolism (VTE) prophylaxis, consensus is mixed about which agents may be preferred in acutely ill patients with ongoing need of VTE prophylaxis past the first 10-day duration of hospital stay and post-discharge. Non-vitamin K antagonist oral anticoagulants (NOACs) provide Factor Xa inhibition to prevent the thrombin generation essential in thromboembolism development, but evidence for the efficacy and safety of most NOACs is conflicting regarding extended-duration prophylaxis. Enoxaparin, a preferred injectable anticoagulant in standard-duration VTE prophylaxis, has shown an increased risk of major bleeding events when used in extended-duration prophylaxis, which outweighs its benefit. Rivaroxaban has demonstrated efficacy in extended-duration prophylaxis, but both rivaroxaban and apixaban have shown increased risks of major bleeding. Betrixaban remains the only NOAC approved in the USA for extended-duration VTE prophylaxis, and it demonstrates efficacy, with fewer adverse effects than other NOACs. This review evaluates the appropriateness of different NOAC agents compared with current therapies for the extended-duration VTE prophylaxis setting in medically ill populations.
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Affiliation(s)
- Tara L Knotts
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive, Rensselaer, NY, 12144, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive, Rensselaer, NY, 12144, USA.
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Emoto S, Nozawa H, Kawai K, Hata K, Tanaka T, Shuno Y, Nishikawa T, Sasaki K, Kaneko M, Hiyoshi M, Murono K, Ishihara S. Venous thromboembolism in colorectal surgery: Incidence, risk factors, and prophylaxis. Asian J Surg 2019; 42:863-873. [PMID: 30683604 DOI: 10.1016/j.asjsur.2018.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023] Open
Abstract
Colorectal surgery is associated with a high risk of perioperative venous thromboembolism (VTE), and this risk is especially high following colorectal cancer resection and surgery for inflammatory bowel disease. Previous analyses of large databases have reported the incidence of postoperative VTE in this population to be approximately 1.1%-2.5%. Therefore, to minimize this risk, patients should be offered appropriate prophylaxis, which may involve a combination of mechanical and pharmacologic prophylaxis with low-dose unfractionated heparin or low molecular weight heparin as recommended by several guidelines. Prior to initiation of treatment, appropriate risk stratification should be performed according to the patients' basic and disease-related as well as procedure-related risk factors, and post-operative factors. Furthermore, a risk-benefit calculation that takes into account patients' VTE and bleeding risk should be performed prior to starting pharmacologic prophylaxis and to help determine the duration of treatment.
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Affiliation(s)
- Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Yasutaka Shuno
- Department of Surgical Oncology, The University of Tokyo, Japan
| | | | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Manabu Kaneko
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Masaya Hiyoshi
- Department of Surgical Oncology, The University of Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, Japan
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Keyes GR, Singer R, Iverson RE, Nahai F. Incidence and Predictors of Venous Thromboembolism in Abdominoplasty. Aesthet Surg J 2018; 38:162-173. [PMID: 29117339 DOI: 10.1093/asj/sjx154] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/27/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The prevention of venous thromboembolism (VTE) is a high priority in aesthetic surgery. Abdominoplasty is the aesthetic procedure most commonly associated with VTE, yet the mechanisms for the development of VTE associated with this procedure are unclear. OBJECTIVES The purpose of this study was to analyze the incidence and predictors of VTE in patients undergoing abdominoplasty procedures in outpatient surgery centers using data from the Internet Based Quality Assurance Program (IBQAP). METHODS IBQAP data from 2001 to 2011 were queried retrospectively to identify abdominoplasty cases and VTE cases. Patient- and procedure-specific variables were analyzed to identify potential predictors of VTE in abdominoplasty. RESULTS Among all outpatient aesthetic surgery cases entered from 2001 to 2011, 414 resulted in VTE, representing a VTE incidence of 0.02%. Of these, 240 (58%) occurred in abdominoplasty cases. Predictors of VTE were age greater than 40 years and BMI greater than 25 kg/m2. Patient sex, duration of anesthesia and surgery, type of anesthesia, type of additional procedure, and number of procedures did not appear to influence the risk of VTE. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which would not be an indication for chemoprophylaxis according to current recommendations. CONCLUSIONS Many factors must be considered when determining the true incidence of VTE in abdominoplasty. Research is needed to discover the reason abdominoplasty carries a greater risk compared with other aesthetic surgery procedures so that appropriate steps can be taken to prevent its occurrence and improve the safety of the procedure.
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Affiliation(s)
- Geoffrey R Keyes
- Clinical Associate Professor of Surgery, Division of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert Singer
- Clinical Professor of Plastic Surgery (Voluntary), The University of California, San Diego (UCSD), San Diego, CA
| | - Ronald E Iverson
- Adjunct Clinical Professor of Plastic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Foad Nahai
- Jurkiewicz Chair in Plastic Surgery and Professor of Plastic Surgery, Emory University School of Medicine, Atlanta, GA; and is Editor-in-Chief of Aesthetic Surgery Journal
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29
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Fuji T, Fujita S, Kimura T, Ibusuki K, Abe K, Tachibana S, Nakamura M. Clinical benefit of graduated compression stockings for prevention of venous thromboembolism after total knee arthroplasty: post hoc analysis of a phase 3 clinical study of edoxaban. Thromb J 2016; 14:13. [PMID: 27284271 PMCID: PMC4899917 DOI: 10.1186/s12959-016-0087-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/25/2016] [Indexed: 11/13/2022] Open
Abstract
Background Guidelines from the Japanese Circulation Society recommend prophylaxis with anticoagulation plus intermittent pneumatic compression or graduated compression stockings (GCS) among patients at the highest risk for developing venous thromboembolism (VTE). However, the benefits of concomitant GCS use for patients undergoing total knee arthroplasty (TKA) and receiving anticoagulation remain unknown. In this study, the efficacy of GCS plus anticoagulation compared with anticoagulation alone was evaluated among patients undergoing TKA. Methods This study is a post hoc analysis of a previously reported phase 3 trial involving patients undergoing TKA. In the primary study, which permitted the use of GCS for mechanical prophylaxis, patients were randomized to receive edoxaban 30 mg once daily or enoxaparin 20 mg twice daily for 11 to 14 days following TKA. The primary endpoint was the incidence of VTE, a composite of symptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE), and asymptomatic DVT. Treatment comparisons were performed using the chi-square test, and the 95 % confidence intervals were calculated. Results Among patients receiving edoxaban, the incidence of VTE was 3.8 and 5.8 % for patients with and without GCS, respectively. For patients receiving enoxaparin, VTE incidence was 8.4 and 20.8 % among those with and without GCS, respectively. Overall, VTE incidence was 6.0 and 13.0 % for anticoagulated patients with and without GCS mechanical prophylaxis, respectively. No deaths or symptomatic PE were reported during this study. Conclusions Although the incidence of VTE was >2-fold lower among patients receiving anticoagulation plus GCS compared with those receiving anticoagulation alone, statistical significance was not achieved. Further studies are required to confirm the findings of this preliminary analysis. Trial registration ClinicalTrials.gov Identifier: NCT01181102
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Affiliation(s)
- Takeshi Fuji
- Department of Orthopedic Surgery, Japan Community Healthcare Organization Osaka Hospital, 4-2-78 Fukushima, Fukushima-ku, Osaka 553-0003 Japan
| | - Satoru Fujita
- Department of Orthopedic Surgery, Takarazuka Daiichi Hospital, 19-5 Kogetsu-cho, Takarazuka, 665-0832 Japan
| | - Tetsuya Kimura
- Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426 Japan
| | - Kei Ibusuki
- Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426 Japan
| | - Kenji Abe
- Clinical Data and Biostatistics Department, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa-ku, Tokyo, 140-8710 Japan
| | - Shintaro Tachibana
- Department of Orthopedic Surgery, Mishuku Hospital, 5-33-12 Shimomeguro, Meguro-ku, Tokyo, 153-0051 Japan
| | - Mashio Nakamura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Tsu, 514-8507 Mie Japan
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Bilgi K, Muthusamy A, Subair M, Srinivasan S, Kumar A, Ravi R, Kumar R, Sureshkumar S, Mahalakshmy T, Kundra P, Kate V. Assessing the risk for development of Venous Thromboembolism (VTE) in surgical patients using Adapted Caprini scoring system. Int J Surg 2016; 30:68-73. [PMID: 27109201 DOI: 10.1016/j.ijsu.2016.04.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 11/19/2022]
Abstract
AIM To determine the incidence, morbidity and mortality due to Venous Thromboembolism (VTE) in surgical patients, and to assess the validity and reliability of Adapted Caprini scoring in risk stratification for VTE prophylaxis. METHODOLOGY This was a prospective observational study in a tertiary care hospital of South India on patients who underwent both elective and emergency surgeries over a period of 9 months. An Adapted Caprini score was devised which included only the clinical criteria. The patients were scored by two persons independently at admission and followed up till the 30th post-operative day and primary and secondary end points were statistically analyzed. RESULTS Three hundred and one patients were included and the overall incidence of VTE at 30 days was 7.3%. The risk of developing VTE was found to be significantly higher among the >8 score group as compared to 3-4 group (OR = 153.5, p < 0.001), or the 5-6 group (OR = 52.9, p < 0.001) or the 7-8 group (OR = 2.3, p = 0.002). Patients with a score of 7-8 were more likely to develop VTE as compared to 3-4 group (OR = 67.5, p < 0.001) or the 5-6 group (OR = 23.2, p < 0.001). CONCLUSION The risk of developing VTE is less significant in the 5-6 score group compared to 7-8 or more score group. Further stratification of the highest risk groups is recommended to provide appropriate prophylaxis only to the patients with high scores, thereby reducing complications due to VTE prophylaxis.
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Affiliation(s)
- Kanchan Bilgi
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Anitha Muthusamy
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Mohsina Subair
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Sanjeev Srinivasan
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Arun Kumar
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Ramya Ravi
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Ranjith Kumar
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Sathasivam Sureshkumar
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - T Mahalakshmy
- Department of Social and Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Pankaj Kundra
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India
| | - Vikram Kate
- Departments of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006, India.
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Abstract
Thrombosis in inflammatory bowel disease (IBD) is an increasingly noted extraintestinal manifestation with high morbidity and mortality. While controlling the activity of the disease with the appropriate therapy, thromboembolism prophylaxis should be applied to all patients. All common risk factors for thromboembolism are also valid for patients with IBD; however, it is clear that uncontrolled disease and hospitalization are major disease-specific risk factors for venous thromboembolism in patients with IBD. Pharmacological thromboprophylaxis with currently available anticoagulants does not increase the risk of further bleeding in patients with IBD with mild-to-moderate bleeding. In severe bleeding or with increased risk of further bleeding due to other comorbid conditions, thromboprophylaxy with mechanical methods should be the treatment option. Whether thrombosis is the cause or the result of intestinal inflammation remains to be elucidated, and other issues in the etiology, such as the role of intestinal flora in thrombosis pathogenesis, will be the subject of future studies.
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Automated objective surgical skill assessment in the operating room from unstructured tool motion in septoplasty. Int J Comput Assist Radiol Surg 2015; 10:981-91. [PMID: 25895080 DOI: 10.1007/s11548-015-1194-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
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Improving outcomes and cost-effectiveness of colorectal surgery. J Gastrointest Surg 2014; 18:1944-56. [PMID: 25205538 DOI: 10.1007/s11605-014-2643-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Abstract
In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.
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