Analysis of risk factors for deep vein thrombosis after spinal infection surgery and construction of a nomogram preoperative prediction model

Objective

To investigate the differences in postoperative deep venous thrombosis (DVT) between patients with spinal infection and those with non-infected spinal disease; to construct a clinical prediction model using patients' preoperative clinical information and routine laboratory indicators to predict the likelihood of DVT after surgery.

Method

According to the inclusion criteria, 314 cases of spinal infection (SINF) and 314 cases of non-infected spinal disease (NSINF) were collected from January 1, 2016 to December 31, 2021 at Xiangya Hospital, Central South University, and the differences between the two groups in terms of postoperative DVT were analyzed by chi-square test. The spinal infection cases were divided into a thrombotic group (DVT) and a non-thrombotic group (NDVT) according to whether they developed DVT after surgery. Pre-operative clinical information and routine laboratory indicators of patients in the DVT and NDVT groups were used to compare the differences between groups for each variable, and variables with predictive significance were screened out by least absolute shrinkage and operator selection (LASSO) regression analysis, and a predictive model and nomogram of postoperative DVT was established using multi-factor logistic regression, with a Hosmer- Lemeshow goodness-of-fit test was used to plot the calibration curve of the model, and the predictive effect of the model was evaluated by the area under the ROC curve (AUC).

Result

The incidence of postoperative DVT in patients with spinal infection was 28%, significantly higher than 16% in the NSINF group, and statistically different from the NSINF group (P < 0.000). Five predictor variables for postoperative DVT in patients with spinal infection were screened by LASSO regression, and plotted as a nomogram. Calibration curves showed that the model was a good fit. The AUC of the predicted model was 0.8457 in the training cohort and 0.7917 in the validation cohort.

Conclusion

In this study, a nomogram prediction model was developed for predicting postoperative DVT in patients with spinal infection. The nomogram included five preoperative predictor variables, which would effectively predict the likelihood of DVT after spinal infection and may have greater clinical value for the treatment and prevention of postoperative DVT.

Efficacy and safety of fondaparinux in preventing venous thromboembolism in Chinese cancer patients: a single-arm, multicenter, retrospective study

Objective

Fondaparinux is a synthetic anticoagulant for the prevention of venous thromboembolism (VTE), and its administration in Chinese cancer patients is rarely reported. This study aimed to assess the efficacy and safety of fondaparinux in preventing VTE in Chinese cancer patients.

Methods

A total of 224 cancer patients who received fondaparinux treatment were reviewed in this single-arm, multicenter, retrospective study. Meanwhile, VTE, bleeding, death, and adverse events of those patients in the hospital and at 1 month after treatment (M1) were retrieved, respectively.

Results

The in-hospital VTE rate was 0.45% and there was no (0.00%) VTE occurrence at M1. The in-hospital bleeding rate was 2.68%, among which the major bleeding rate was 2.23% and the minor bleeding rate was 0.45%. Moreover, the bleeding rate at M1 was 0.90%, among which both the major and minor bleeding rates were 0.45%. The in-hospital death rate was 0.45% and the death rate at M1 was 0.90%. Furthermore, the total rate of adverse events was 14.73%, including nausea and vomiting (3.13%), gastrointestinal reactions (2.23%), and reduced white blood cells (1.34%).

Conclusion

Fondaparinux could effectively prevent VTE with low bleeding risk and acceptable tolerance in cancer patients.

Pathological Analysis and Clinical Evolution After Radiological Removal of Retrievable Vena Cava Filters

Objective

Retrievable inferior vena cava filters (IVCF) have been developed because permanent filters have been associated with an increased risk of recurrent deep venous thrombosis. There is no data on the interactions of IVCF with the inferior vena cava (intrafilter thrombi, insertion through the venous wall) even though this may alter the course after retrieval of the IVCF.

Methods

A review of 85 consecutive patients undergoing retrieval of IVCF placed at a single center was performed from January 1, 2010 and December 31, 2014. Inferior vena cava filter were examined for presence of intrafilter thrombus at time of retrieval. Filter position and presence of intraluminal thrombus were examined. Patient outcomes, including recurrence of deep vein thrombosis (DVT) and death, were captured at 3 month followup.

Results

Eighty five patients were identified, with intrafilter thrombi found in 69 (81%) patients and venous wall fragments found in 75 (88%) patients. However, their presence was not associated with an increased risk of recurrent venous thromboembolism (VTE) or death during follow up.

Conclusions

Intrafilter thrombi and venous wall fragments are frequently found in removed IVCF but are not associated with a worse prognosis. They may not modify the therapeutic management of patients.

ERO1-PDI Redox Signaling in Health and Disease

Significance: Protein disulfide isomerase (PDI) and endoplasmic reticulum oxidoreductase 1 (ERO1) are crucial for oxidative protein folding in the endoplasmic reticulum (ER). These enzymes are frequently overexpressed and secreted, and they contribute to the pathology of neurodegenerative, cardiovascular, and metabolic diseases. Recent Advances: Tissue-specific knockout mouse models and pharmacologic inhibitors have been developed to advance our understanding of the cell-specific functions of PDI and ERO1. In addition to their roles in protecting cells from the unfolded protein response and oxidative stress, recent studies have revealed that PDI and ERO1 also function outside of the cells. Critical Issues: Despite the well-known contributions of PDI and ERO1 to specific disease pathology, the detailed molecular and cellular mechanisms underlying these activities remain to be elucidated. Further, although PDI and ERO1 inhibitors have been identified, the results from previous studies require careful evaluation, as many of these agents are not selective and may have significant cytotoxicity. Future Directions: The functions of PDI and ERO1 in the ER have been extensively studied. Additional studies will be required to define their functions outside the ER.

Risk Factors and Anticoagulation Therapy in Patients With Isolated Distal Deep Vein Thrombosis in the Early Post-operative Period After Thoracic Surgery

Background: Isolated distal deep vein thrombosis (IDDVT) accounts for ~50% of all patients diagnosed with deep venous thrombosis (DVT), but the diagnosis and optimal management of IDDVT remains unclear and controversial. The aim of this study was to explore potential risk factors and predictors of IDDVT, and to evaluate different strategies of anticoagulation therapy.

Methods: A total of 310 consecutive patients after thoracic surgery, who underwent whole-leg ultrasonography as well as routine measurements of D-dimer levels before and after surgery were evaluated. The general clinical data, anticoagulant therapy, pre- and postoperative D-dimer levels were collected. Differences between IDDVT, DVT and non-DVT groups were calculated. Logistic regression analysis was used to analyze risk factors of postoperative IDDVT.

Results: Age and postoperative D-dimer levels were significantly higher in IDDVT group than in non DVT group (p = 0.0053 and p < 0.001, respectively). Logistic regression analysis showed that postoperative D-dimer level was a significant independent predictor of IDDVT even when adjusted for age and operation method (p = 0.0003). There were no significant side effects associated with both full-dose and half-dose anticoagulation regimens. Half-dose therapy was associated with a significant decrease in the requirement for anticoagulation medications after discharge (p = 0.0002).

Conclusion: Age and D-dimer levels after surgery are strong predictors of IDDVT following thoracic surgery. Half-dose therapeutic anticoagulation has the same efficiency in preventing IDDVT progression, is not associated with any additional risks of adverse effects compared to a full-dose regimen, and may be adopted for treating IDDVT patients after thoracic surgery.

Obesity is strongly and independently associated with a higher prevalence of pulmonary embolism

BACKGROUND

Obesity is associated with many cardiovascular risk factors. This study aimed to evaluate the independent association between obesity and pulmonary embolism.

METHODS

We used the International Classification of Diseases, Ninth Revision, Codes for obesity and pulmonary embolism from the Nationwide Inpatient Sample database. We randomly selected the 1992 and 2002 databases, which are 10 years apart, as the two independent population samples. We performed uni- and multivariate analyses to evaluate any association between obesity and pulmonary embolism.

RESULTS

The 1992 database consisted of a total of 6,195,744 patients. Obesity was present in 93,568 patients. Pulmonary embolism occurred in 0.7% of obese patients vs. 0.3% of the control population (odds ratio [OR], 2.32; 95% confidence interval [CI] 2.2-2.4; p<0.0001). The 2002 database consisted of a total of 299,010 obese patients. Pulmonary embolism occurred in 0.9% of obese patients vs. 0.4% of the control population (OR, 2.36; 95% CI, 2.19-2.41; p<0.0001). After adjusting for age and many risk factors, obesity remained strongly associated with pulmonary embolism (for 1992, OR, 2.1; 95% CI, 2.0-2.3; p<0.0001 and for 2002, OR, 2.2; 95% CI, 2.1-2.3; p<0.0001).

CONCLUSION

Obesity has been consistently associated with pulmonary embolism over the years studied using a large inpatient database. This association has been persistent over a period of 10 years and is consistent with the negative effects of obesity on the cardiopulmonary system.

Effect of a new inhibitor of factor Xa zifaxaban, on thrombosis in the inferior vena cava in rabbits

In recent years, oral factor Xa inhibitors have become a research focus as anticoagulant drugs. Zifaxaban is the first oral FXa inhibitor to enter clinical trials in China. The aim of this study was to determine the inhibitory effect of zifaxaban on thrombosisthrough a model ofinferior vena cava (IVC) thrombosis in rabbits. IVC thrombosis model was established by electrical injury and stenosis, and zifaxaban was administered (p.o.) for 5 consecutive days, then coagulation indicators and bleeding were observed. The results showed that zifaxaban had obvious inhibitory effects on FXa, and had a significant inhibitory effect on IVC thrombosis induced by electrical damage and stenosis. The effect of zifaxaban was similar to that of rivaroxaban, but the bleeding side-effects of zifaxaban were less severe than those of rivaroxaban. Zifaxaban could prolong the prothrombin time and activated partial thromboplastin time of plasma similar to that of other oral FXa inhibitors. Zifaxaban had a significant inhibitory effect on FXa, but it had no obvious effect on other coagulation factors, major anticoagulant factors or fibrinolytic indices. Our results suggest that zifaxaban had specific inhibitory effects on FXa and inhibited IVC thrombosis in rabbits with its hemorrhagic effect was less than that of rivaroxaban. Zifaxaban is ecpected to be developed as a new drug for the prevention of deep venous thrombosis, providing more medication options for patients with such disease, more research is required to support it in the future.

Femoral versus jugular access for Denali Vena Cava Filter placement: Analysis of fluoroscopic time, filter tilt and retrieval outcomes

PURPOSE

To analyze relevant metrics involved in Denali Vena Cava Filter placement via different venous access sites.

MATERIALS AND METHODS

Patients with Denali filters inserted between March 2017 and February 2018 were retrospectively analyzed. Pre-procedural and pre-retrieval computed tomography (CT) were reviewed. We compared inferior vena cava (IVC) diameter, filter tilt angle, filter tip IVC wall abutment, fluoroscopy time, and retrieval outcomes by venous access site. Filter tip abutment/limb penetration and procedure-related complications were investigated.

RESULTS

Seventy-eight patients had successfully-placed Denali filters. Seventy-one of 78 (91%) patients had both pre-procedural and pre-retrieval CT. The majority (35 [49%]) were placed via the right femoral vein (left femoral vein: 22 [31%]; right internal jugular vein: 14 [20%]). The jugular approach involved a longer fluoroscopy time (mean 117 ± 37 s [s]) than the right and left femoral approaches (mean 64 ± 21 s, mean 67 ± 15 s, respectively [p < 0.05]). Filter tilt and filter tip abutment were not significantly different between the 3 access routes. Filter tip abutment and limb penetration were observed in 8/71 (11%) and 2/71 (3%) patients, respectively. Filter retrieval was attempted in 68 of 78 (87%) cases, and all filters were successfully retrieved. One filter arm fractured during advanced retrieval; no other procedure related complications were recorded.

CONCLUSIONS

Both femoral venous approaches can be safely used for placement of the Denali filter. Femoral venous access involved a shorter fluoroscopy time without any differences in filter tilt and filter tip abutment compared to transjugular access.

Filter tilting and retrievability of the Celect and Denali inferior vena cava filters using propensity score-matching analysis

Purpose

To assess the filter tilting and outcomes of the Celect and Denali inferior vena cava (IVC) filters by using a propensity score-matching analysis.

Materials and methods

From January 2009 to November 2017, 181 Celect and 58 Denali filters were inserted in our institution. To assess filter tilt, filter tip abutment or penetration of the IVC wall, and retrieval outcome, independent variables, including age, sex, IVC long diameter, IVC angulation, and proximity of the filter to renal vein insertion, were entered in the propensity model. Comparative analyses were performed before and after propensity score-matching analysis.

Results

Thirty-one patients were enrolled in each group for the final propensity score-matching analysis. The mean filter indwelling time was not significantly different between the groups (26 ± 22 days in Celect and 27 ± 23 days in Denali). After propensity score adjustment, the mean degree of filter tilt was higher in the Celect group (9.5° ± 7.4° vs 5.6° ± 6.7°). Filter tip abutment or penetration of the IVC wall was more common in the Celect group (39% [12/31, abutment: 12, penetration: 0] vs 13% [4/31, abutment: 3, penetration: 1]). The retrieval outcomes were not significantly different before and after propensity score adjustment in both filters.

Conclusion

The Denali IVC filter showed less tilt and low rate of filter tip abutment to the IVC wall after propensity score-matching analysis. The retrieval rate was not significantly different in the short-term filter indwelling setting. More large-scale, long-term follow-up studies are needed to verify these results.

The risk of deep vein thrombosis in total joint patients compared to orthopaedic trauma patients: Need for new prevention guidelines

BACKGROUND

The development of Deep Vein Thrombosis (DVT) is a major concern following orthopaedic surgery. No study has yet to compare the rate and risk factors for DVT between total joint and orthopaedic trauma patients. To evaluate if DVT prophylaxis for trauma should differ from total joints, we explored the rate and risk factors for DVT between both cohorts.

METHODS

Using a CPT code search from 2005 to 2013 in the ACS-NSQIP database, 150,657 orthopaedic total joint patients and 44,594 orthopaedic trauma patients were identified. DVT complications, patient demographics, preoperative comorbidities, and surgical characteristics were collected for each patient. A chi-squared test was used to compare the risk factors for DVT between orthopaedic trauma and total joint patients. A multivariable logistic regression model was built to adjust for comorbidities for each cohort.

RESULTS

The rate of DVT diagnosis in the total joint population was 0.8% (N = 1186) and 0.98% (N = 432) in the orthopaedic trauma population (p = 0.57). After controlling for individual comorbidities, dyspnea, peripheral vascular disease, and renal failure were significant risk factors for DVT in total joint patients (p < 0.05), whereas age, ascites and steroid use were significant risk factors for DVT in orthopaedic trauma patients (p < 0.05).

CONCLUSIONS

Historically, the risks for DVT in total joints have been emphasized, yet based on our results, the incidence of DVT is the same for orthopaedic trauma. However, the risk factors varied. It is therefore important to consider specialty-specific DVT prophylaxis for orthopaedic trauma patients in order to improve care and reduce postoperative complications.

Adipose tissue location and contribution to postinjury hypercoagulability

OBJECTIVES

Obesity is associated with a hypercoagulable state at baseline and following injury. The anatomic location of adipose deposition may influence the type of thrombotic event, with visceral adipose tissue (VAT) associated with arterial thrombosis and subcutaneous adipose tissue (SAT) predisposing to venous thrombosis. We sought to determine whether adipose tissue amount and location correlated with measures of coagulation.

METHODS

All adult Level I trauma activations at our institution between January 2013 and August 2014 who underwent admission abdominal computed tomography scan and had admission rotational thromboelastometry measurements were included. Patients were excluded for history of anticoagulant use and known coagulopathy/hypercoagulable state. Admission computed tomography was used to obtain cross-sectional VAT and SAT areas at the umbilicus utilizing a novel software system; VAT and SAT measurements were associated with markers of coagulation utilizing Spearman correlation and stepwise linear regression with significance set at p < 0.05.

RESULTS

Two hundred forty-two patients met inclusion and exclusion criteria. Sixty-nine percent of patients sustained blunt injury, 79% were male, mean age was 40 years, 25% were obese or morbidly obese, and mean Injury Severity Scale score was 17. Seventeen percent of patients had acute deep venous thrombosis or pulmonary embolism during hospitalization. Neither SAT nor VAT correlated with prothrombin time, international normalized ratio, or partial thromboplastin time. Subcutaneous adipose tissue correlated positively with platelet count. Visceral adipose tissue and SAT correlated negatively with clot formation time and positively with TEM fibrinogen, α angle, maximum clot firmness, and lysis at 30 minutes; stronger correlations and greater significance were seen between SAT and these measures except for lysis at 30 minutes. Stepwise linear regression confirmed significant relationships between SAT and clot formation time, AA, and maximum clot firmness; VAT showed a significant relationship with TEM fibrinogen.

CONCLUSIONS

Increased adipose tissue correlates with relative hypercoagulability following trauma. Subcutaneous adipose tissue shows a stronger relationship with functional measures of coagulation, suggesting that SAT may be associated with hemorrhage resistance and hypercoagulability after injury.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Edoxaban: A Review in Deep Vein Thrombosis and Pulmonary Embolism

Edoxaban (Lixiana, Savaysa) is an oral, direct factor Xa inhibitor which has recently been approved for use in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) [collectively, venous thromboembolism (VTE)] and for the prevention of recurrent VTE. This article reviews the pharmacological properties of edoxaban as well as its tolerability and therapeutic efficacy in the treatment and prevention of recurrent VTE events. As demonstrated in the pivotal Hokusai-VTE phase III trial, once-daily edoxaban after initial treatment with heparin was non-inferior to standard therapy with heparin/warfarin in preventing recurrent VTE events and was associated with a significantly lower risk of clinically relevant bleeding than the traditional therapy. Edoxaban shares the advantages of other direct oral anticoagulants (DOACs) over traditional therapies, including the lack of requirement for routine coagulation monitoring, a rapid onset and offset of action, and few drug-drug interactions. It offers the convenience of once-daily dosing, can be taken without regard to food and allows for a dose reduction in patients with certain clinical features, such as moderate renal impairment or low body weight. In conclusion, edoxaban represents an effective and potentially safer alternative to traditional vitamin K antagonist therapy for the treatment and prevention of recurrent VTE. Its recent approval expands the range of DOAC agents for recurrent VTE, further facilitating treatment individualization.

Real-Time Label-Free Embolus Detection Using In Vivo Photoacoustic Flow Cytometry

Thromboembolic events are one of the world's leading causes of death among patients. Embolus or clot formations have several etiologies including paraneoplastic, post-surgery, cauterization, transplantation, or extracorporeal circuits. Despite its medical significance, little progress has been made in early embolus detection, screening and control. The aim of our study is to test the utility of the in vivo photoacoustic (PA) flow cytometry (PAFC) technique for non-invasive embolus detection in real-time. Using in vivo PAFC, emboli were non-invasively monitored in the bloodstream of two different mouse models. The tumor-free mouse model consisted of two groups, one in which the limbs were clamped to produce vessel stasis (7 procedures), and one where the mice underwent surgery (7 procedures). The melanoma-bearing mouse model also consisted of two groups, one in which the implanted tumor underwent compression (8 procedures), and one where a surgical excision of the implanted tumor was performed (8 procedures). We demonstrated that the PAFC can detect a single embolus, and has the ability to distinguish between erythrocyte-rich (red) and leukocyte/platelet-rich (white) emboli in small vessels. We show that, in tumor-bearing mice, the level of circulating emboli was increased compared to tumor-free mice (p = 0.0013). The number of circulating emboli temporarily increased in the tumor-free control mice during vessel stasis (p = 0.033) and after surgical excisions (signed-rank p = 0.031). Similar observations were noted during tumor compression (p = 0.013) and after tumor excisions (p = 0.012). For the first time, it was possible to detect unlabeled emboli in vivo non-invasively, and to confirm the presence of pigmented tumor cells within circulating emboli. The insight on embolus dynamics during cancer progression and medical procedures highlight the clinical potential of PAFC for early detection of cancer and surgery-induced emboli to prevent the fatal thromboembolic complications by well-timed therapy.

Comparison of the efficacy and safety of low molecular weight heparins for venous thromboembolism prophylaxis in medically ill patients

OBJECTIVE

To conduct a systematic review and mixed-treatment comparison (MTC) meta-analysis to compare the efficacy and safety of low molecular weight heparins (LMWHs) for venous thromboembolism (VTE) prophylaxis in hospitalized medically ill patients. As a secondary objective we compared all therapies within the network to each other.

METHODS

We conducted a systematic literature search for randomized trials that evaluated pharmacologic VTE prophylaxis in hospitalized medically ill patients. We conducted a traditional meta-analysis for all pairwise comparisons using a random effects model, reporting relative risks (RRs) and 95% confidence intervals for each outcome. To determine the relative efficacy and safety of included therapies we conducted a MTC meta-analysis using a Bayesian framework, reporting odds ratios (OR) and 95% credible intervals.

RESULTS

Twenty trials met inclusion criteria. Enoxaparin, dalteparin, nadroparin and certoparin were the LMWHs evaluated although none in direct comparative trials. Upon MTC, the relative efficacy of all LMWHs was similar in preventing mortality and VTE as well as in the odds of major and minor bleeding. Dalteparin was not included in the network to evaluate deep vein thrombosis (DVT) and pulmonary embolism (PE) due to lack of reported data and the remaining LMWHs were found to be similar in relative efficacy in preventing these outcomes.

LIMITATIONS

Traditional meta-analysis was not possible for many drug comparisons made within the MTC. Heterogeneity was observed in several of the traditional meta-analyses although this may be an inherent limitation of the studied population. Overall rarity of events contributed to imprecise estimates demonstrated by the wide confidence intervals.

CONCLUSIONS

Enoxaparin, dalteparin, nadroparin and certoparin are similar in relative efficacy for the prevention of mortality and VTE and in the odds of major or minor bleeding while enoxaparin, nadroparin and certoparin are similar in relative efficacy for the prevention of PE and DVT in hospitalized medical patients.

Vena caval thrombosis after trauma to the liver

Thrombosis of the inferior vena cava due to compression of the inferior vena cava by a hepatic haematoma is seemingly rare. We present a case of a 56-year-old female with a hepatic haematoma after blunt trauma that caused this type of compression. The constriction resulted in the formation of an inferior vena cava thrombus, and considering the contraindication to anticoagulation, we placed a retrievable inferior vena cava filter under standard fluoroscopy. This case stresses the need for systematic investigation of the abdomen, especially after a blunt trauma, which can cause compression of the inferior vena cava. Furthermore, inferior vena cava thrombosis should be considered in patients with compression of the inferior vena cava due to hepatic haematoma.

Symptomatic venous thrombo-embolism in low-energy isolated fractures in hospitalised patients

INTRODUCTION

In the prevention of venous thrombo-embolic events (VTEs) in isolated low-energy fracture patients, management guidelines are conflicting and prior literature is lacking. We aimed to determine the incidence and factors associated with the development of symptomatic VTE in this patient cohort.

MATERIALS AND METHODS

To identify patients with isolated, low-energy fractures, we studied billing records from all admissions to our tertiary care orthopaedic hospital from 2007 to 2009. We used International Classification of Diseases, 9th Revision codes to identify patients who developed deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during their hospital admission or within 90 days of discharge. We also collected data on socio-demographics, type of injury, fracture treatment, co-morbidities and anticoagulation therapy at time of admission. This study was a retrospective review of a database.

RESULTS

In total, 1701 admissions fit our criteria. Average patient age was 64.27 years and 64.4% were female. There were 479 (28.2%) upper extremity fractures and 1222 (71.8%) lower extremity fractures. Incidence of clinically significant VTE was 1.4%. Of the 24 patients with 25 documented VTE, there were 13 DVTs and 12 PEs, including 2 fatal PEs (0.012%). Nineteen VTEs occurred in association with lower extremity fractures and six with upper extremity fractures; 74% of patients were chemoprophylaxed. Patients with VTE had an average age of 69.5 years and an average body mass index (BMI) of 28 kgm(-2). Logistical regression analysis found female sex (p = 0.05) and elevated BMI (p = 0.003) to be the only significant predictors of VTE.

CONCLUSIONS

Clinically significant VTE among patients who sustained isolated, low-energy fractures was found to be low in the setting of standard VTE prophylaxis. Our incidence was consistent with that of patients undergoing total hip arthroplasty. Female sex and increased BMI were statistically significant predictors of VTE.

Optimizing Transition of Care Through the Facilitation of a Pharmacist-Managed Deep Vein Thrombosis Treatment Program

A pharmacist-managed deep vein thrombosis (DVT) treatment program was put into operation at Jackson Memorial Hospital in Miami, Florida to provide appropriate transition of care to the outpatient setting for patients diagnosed with DVT. A postgraduate year 1 pharmacy practice resident partnered with a clinical pharmacist to establish and implement the DVT pilot program in the emergency department (ED). Once contacted, the pharmacy resident or the clinical pharmacist communicated with the ED physician and made recommendations regarding appropriate anticoagulation. The pharmacist met with the patient to obtain informed consent and provide counseling regarding the anticoagulants. A timely outpatient appointment at the pharmacy-managed warfarin clinic was arranged for the patient and contact information was exchanged between the patient and the pharmacist. On average, patients enrolled in the DVT program from the ED were released 18.29 hours (±7.06) following the time of arrival. Following release from the hospital, 91% of patients attended their outpatient follow-up appointment at the warfarin clinic. Since the initiation of the DVT program, 1 patient experienced a recurrent DVT and major bleed during their treatment course. Due to successful implementation of this pharmacist-managed DVT program in the ED, the services were subsequently extended to inpatients with DVT.

[Risk of deep venous thrombosis during an air flight: prevention and counselling at the counter]

Worldwide air traffic reaches about 2.3 billion passengers per year. The increasing number of persons at thrombo-embolic risk, together with potentially severe or fatal complications of deep venous thrombosis, suggests community pharmacists can give basic preventive advice to persons identified as at risk.

Perioperative implications of surgery in elderly patients with hip fractures: an evidence-based review

Hip fracture is a major cause of morbidity, mortality and loss of independence for the elderly. Surgical fixation of the fractured hip remains the standard of care to allow for early mobilisation and a return to independence. Operative management in this population carries its own set of problems. The altered physiological state of the older person, often coupled with significant comorbidity, can present challenges for the anaesthetist, the surgeon and the rest of the perioperative team. This article provides an evidence-based review of the important perioperative factors associated with hip fractures in the older person and their management.