scholarly journals Patterns of Venous Thromboembolism Prophylaxis during Inpatient Treatment of Acute Leukemia: Results of a North American Web-Based Survey

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4455-4455
Author(s):  
Eun-Ju Lee ◽  
B. Douglas Smith ◽  
Jessica W Merrey ◽  
Alfred I Lee ◽  
Nikolai A. Podoltsev ◽  
...  
Keyword(s):  
Platelet Count ◽  
Venous Thromboembolism ◽  
Acute Leukemia ◽  
Research Funding ◽  
Practice Patterns ◽  
Evidence Based ◽  
Web Based ◽  
Vte Prophylaxis ◽  
Pharmacologic Prophylaxis ◽  
Evidence Based Guidelines

Abstract On behalf of the ECOG-ACRIN Cancer Research Group Background: Venous thromboembolism (VTE) occurs in 2-12% of patients with acute leukemia (AL) despite disease and therapy-associated thrombocytopenia, and can be associated with significant morbidity and mortality. Due to limited high-quality studies, there are no evidence-based guidelines for VTE prophylaxis in this patient population. Based on our experience and the lack of consensus guidelines, we hypothesized that there would be a wide range in provider practice regarding methods of VTE prevention in patients with AL. To determine the current individual practices in North America, we devised a web-based survey of VTE prophylaxis practice among clinicians caring for patients with AL. Methods: An anonymous 19 question web-based survey, approved by the Johns Hopkins Institutional Review Board, was distributed by email to members of the ECOG-ACRIN Cancer Research Group on 10/22/14. Four reminders were sent at two-week intervals with the survey closing on 12/8/14. Results: Of the total 215 respondents, 64 were excluded for the following reasons: 52 did not directly manage medical care of AL patients, 3 referred AL patients to other centers, 5 left blank responses to all questions regarding VTE prophylaxis, 1 was a duplicate entry, and 3 described their position as support or office staff. One hundred fifty-one responses were eligible for analysis, with a response rate of 20.9% among physicians who treated leukemias. One hundred forty-seven were from the United States and 4 from Canada, representing 88 different institutions and 37 states or provinces. Overall, 47% and 45% of providers reported using pharmacologic VTE prophylaxis during induction and consolidation phases, respectively. Among the providers using pharmacologic prophylaxis, 60% designated 50,000/μL as the platelet count threshold below which they would hold prophylaxis and 26% used a platelet count of 30,000/μL. Fewer providers chose a platelet count of 20,000/μL (4%), 75,000/μL (4%), and 100,000/μL (2%). Lastly, 2% held prophylactic anticoagulation only in the setting of an active bleed and 2% reported variable thresholds. Approximately 15% of providers did not utilize any VTE prophylaxis while 36% used mechanical methods and ambulation. Among providers who did not recommend pharmacologic prophylaxis, the most commonly cited reasons were the perceived high risk of bleeding (51%), absence of data supporting use (38%), and perceived low risk of VTE (11%). Conclusions: These results demonstrate wide variation in clinician practice regarding VTE prevention in hospitalized AL patients during induction and consolidation therapy. Our findings emphasize the need to develop standardized, evidence-based guidelines in this at-risk population. VTE: venous thromboembolism, AL: acute leukemia, SC: subcutaneous, TED: thromboembolic deterrant stockings, SCD: sequential compression device Figure 1. Practice patterns of VTE prophylaxis for AL patients during induction and consolidation therapies Figure 1. Practice patterns of VTE prophylaxis for AL patients during induction and consolidation therapies Disclosures Barbarotta: Celgene, BMS, Novartis: Speakers Bureau. Prebet:CELGENE: Research Funding. Gore:Celgene: Consultancy, Honoraria, Research Funding.

scholarly journals Practical considerations in prevention and treatment of venous thromboembolism in hospitalized patients with COVID-19

2020 ◽  
Vol 77 (21) ◽  
pp. 1739-1745 ◽  
Author(s):  
Kelly Smith ◽  
Kristin C Krajewski ◽  
Michael P Krajewski
Keyword(s):  
Venous Thromboembolism ◽  
Oral Anticoagulant Therapy ◽  
Hospitalized Patients ◽  
Clinical Equipoise ◽  
Evidence Based ◽  
Vte Prophylaxis ◽  
Treatment And Prevention ◽  
Agent Selection ◽  
Evidence Based Guidelines ◽  
D Dimer

Abstract Purpose There are increasing reports in the literature of high rates of coagulopathy and venous thromboembolism (VTE) among hospitalized patients with coronavirus disease 2019 (COVID-19). Understanding of these abnormalities is continually evolving, but these conditions may pose a risk to patients with COVID-19 beyond the risk typically seen in critically ill patients. Summary There are currently no widely accepted evidence-based guidelines regarding specifics related to treatment and prevention of COVID-19–related coagulopathies. Areas of management requiring clinical equipoise include agent selection and dosing, continuation vs interruption of home oral anticoagulant therapy during hospital admission, and postdischarge VTE prophylaxis. Clinicians may wish to consider use of a stratified, 3-tiered approach of low-intensity anticoagulation, intermediate-intensity anticoagulation, and therapeutic-dose anticoagulation. Patients can be categorized by tier depending on their risk factors for VTE, acuity of illness, and laboratory values such as D-dimer level. Conclusion Practical guidance on anticoagulation considerations and dosing suggestions are provided to assist clinicians faced with challenging anticoagulation-related situations in caring for hospitalized patients with COVID-19 until formal evidence-based guidelines become available.

Influence of Perceived Risk Factors for Bleeding on Venous Thromboembolism Prophylaxis Practices in Acutely Ill Medical Patients: Findings from IMPROVE.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 917-917
Author(s):  
Manuel Monreal ◽  
Rainer B. Zotz ◽  
Hervé Decousus ◽  
Beng H. Chong ◽  
Geno Merli ◽  
...  
Keyword(s):  
Risk Factors ◽  
Platelet Count ◽  
Venous Thromboembolism ◽  
Hepatic Failure ◽  
Perceived Risk ◽  
Medical Illness ◽  
Cumulative Number ◽  
Medical Patients ◽  
Vte Prophylaxis ◽  
Pharmacologic Prophylaxis

Abstract Background Acutely ill medical patients at risk for venous thromboembolism (VTE) should receive VTE prophylaxis. However, factors perceived by physicians to increase patients’ risk of bleeding may influence VTE prophylaxis practices. In this analysis from The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE), we examined whether perceived risk factors for bleeding had a significant influence on physicians’ prescribing of in-hospital prophylaxis in acutely ill medical patients. Methods Patients aged ≥18 years and hospitalized ≥3 days with an acute medical illness have been enrolled consecutively since July 2002. Risk factors considered were: severe renal failure, known bleeding disorder, hemorrhagic stroke, thrombocytopenia, bacterial endocarditis, active gastroduodenal ulcer, NSAID use, hepatic failure, age, immobility and alcoholism. Factors associated with different prescription rates of prophylaxis compared with rates in patients without these factors were identified and included in a multiple logistic regression model (significance at p<0.05). Results Up to 31 March 2005, 6946 patients were enrolled in 49 hospitals in 12 countries. Pharmacologic prophylaxis was received by 42%, 25%, 16%, and 14% of patients with a platelet count at admission >100, 50–100, 20–50 and <20x109/L, respectively (p<0.0001), and 43%, 39%, 30% and 32% of patients with none, 1, 2 and 3 risk factors for bleeding (p<0.0001). Factors independently associated with a lower/higher prescription rate of heparin-based prophylaxis compared with the risk in patients without these factors are shown in the Table. Conclusions The likelihood that hospitalized acutely ill medical patients receive in-hospital pharmacologic prophylaxis decreases as their platelet count at admission decreases, or their cumulative number of perceived risk factors for bleeding increases. Further studies are needed to determine whether the changes in prophylaxis practices observed in this study are justified. Table. Factors Independently Associated with a Higher/lower Rate of Heparin-based VTE Prophylaxis Factor Odds Ratio 95% Confidence Interval Age (per 10-year increase) 1.19 1.66–1.22 Immobility (per 10-day increase) 1.03 1.02–1.05 Alcoholism 0.62 0.46–0.83 Thrombocytopenia 0.60 0.48–0.74 Active duodenal ulcer 0.36 0.26–0.52 Hepatic failure 0.34 0.21–0.54

scholarly journals Incidence, Management and Outcomes of Arterial and Venous Thromboembolism after Chimeric Antigen Receptor Modified T Cells for B-Cell Lymphoma and Multiple Myeloma

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 7-7
Author(s):  
Anna L. Parks ◽  
Swetha Kambhampati ◽  
Bita Fakhri ◽  
Charalambos Andreadis ◽  
Lissa Gray ◽  
...  
Keyword(s):  
Risk Factors ◽  
Multiple Myeloma ◽  
T Cells ◽  
Venous Thromboembolism ◽  
B Cell ◽  
Research Funding ◽  
Vte Prophylaxis ◽  
Therapeutic Anticoagulation ◽  
Car T ◽  
History Of

Introduction: Chimeric antigen receptor modified T Cell (CAR-T) therapy is a rapidly developing treatment for patients with relapsed/refractory (R/R) B-cell non-Hodgkin lymphoma (NHL) or multiple myeloma (MM). Although this population is at high risk for thrombosis, there are few data about rates of venous thromboembolism (VTE) and arterial thromboembolism (ATE) with CAR-T. Additionally, treatment with anticoagulation is complicated because of the prevalence of thrombocytopenia following CAR-T. Our goal was to determine the incidence, associated risk factors, management and outcomes of VTE and ATE in the 60 days following CAR-T therapy. Methods: We performed a single-center, retrospective cohort study of all patients who received inpatient CAR-T cells at UCSF Medical Center between January 2018 and May 2020 for R/R NHL or MM as standard-of-care or on a clinical trial. The outcomes of incident VTE and ATE were identified by ICD-10 codes and medical record review. Patient characteristics, pre-existing thrombosis risk factors, laboratory results, medications, and major or clinically relevant non-major bleeding or recurrent thrombotic complications were obtained through chart review. We used descriptive statistics to delineate risk factors, incidence, management and outcomes of thrombotic events. Results: Ninety-one patients who underwent CAR-T therapy were included in the analysis, 37 with NHL and 54 with MM. For NHL, mean age was 63 (range 38-82), and 41% were women. For MM, mean age was 62 (range 33-77), and 50% were women. Patients with NHL were treated with either investigational or Federal Drug Administration-approved CD19-directed therapies, and patients with MM were treated with a variety of investigational B-cell maturation antigen-directed (BCMA) therapies. For thrombotic risk factors, 13% of patients with NHL had a history of VTE, 3% had a history of ATE, 27% had a BMI ≥30, 59% had a recent procedure including central venous catheter (CVC) placement, 14% had an intensive care unit (ICU) stay, and 22% had an infectious complication in the 30 days pre- or post-CAR-T. Forty-one percent of patients with NHL had neurotoxicity of any grade, and 59% had CRS of any grade. At 30 days, 57% had a complete response, 41% had a partial response, 3% had stable disease. For MM, 6% of patients had a pre-existing history of VTE, 2% had a history of ATE, 19% had a BMI ≥30, 96% had a recent procedure, 11% had an ICU stay and 19% had an infection. Seventeen percent had neurotoxicity, and 85% had CRS. Thirty-two percent of patients with NHL and 48% with MM received pharmacologic VTE prophylaxis while undergoing CAR-T. For those who did not receive VTE prophylaxis, thrombocytopenia was the reason for holding prophylaxis, which occurred in 51% and 50% of NHL and MM patients, respectively. In the 60 days post-CAR-T, 4 (11%) patients with NHL were diagnosed with VTE-3 pulmonary embolism (PE) and 1 lower extremity deep vein thrombosis (DVT) associated with a previously placed inferior vena cava filter. Four (7%) patients with MM were diagnosed with VTE-1 PE and 3 upper extremity DVTs associated with CVCs. Five out of these 8 (63%) patients had symptomatic VTE, while the remainder were incidental on PETCT. Mean time from CAR-T infusion to VTE diagnosis was 20 days (range 6-39 days). There were no documented ATEs. Six out of 8 (75%) were treated with therapeutic anticoagulation. Of those who were anticoagulated, 4 patients received direct oral anticoagulants and 2 received low-molecular-weight-heparin. Duration was 3 months in 3 patients, 11 days in 1, 150 days in 1, and indefinitely in 1 with atrial fibrillation. Among all 8 patients with VTE, there were no bleeding events or recurrent thromboses regardless of whether or not they received anticoagulation. Discussion: In this cohort of patients with R/R NHL or MM who received either CD19- or BCMA-directed therapies, almost 1 in 10 developed VTE in the 60 days post-CAR-T. This occurred in the context of a high prevalence of risk factors for thrombosis and low rates of pharmacologic prophylaxis. Among those who developed VTE, the majority were treated with therapeutic anticoagulation for at least 3 months, without documented bleeding or recurrent VTE. Our findings provide crucial information on a common complication that can inform patients, clinicians and researchers and should be expanded upon in larger, prospective studies to identify optimal preventive and therapeutic strategies. Disclosures Fakhri: University of California San Francisco: Current Employment. Andreadis:Jazz Pharmaceuticals: Honoraria; Karyopharm: Honoraria; Incyte: Consultancy; Merck: Research Funding; Gilead/Kite: Consultancy; Novartis: Research Funding; BMS/Celgene/Juno: Honoraria, Research Funding; Genentech: Consultancy, Current equity holder in publicly-traded company. Wong:Janssen: Research Funding; Amgen: Consultancy; Roche: Research Funding; Fortis: Research Funding; Sanofi: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Research Funding; GSK: Research Funding. Shah:BMS, Janssen, Bluebird Bio, Sutro Biopharma, Teneobio, Poseida, Nektar: Research Funding; GSK, Amgen, Indapta Therapeutics, Sanofi, BMS, CareDx, Kite, Karyopharm: Consultancy.

Temporal trends in pharmacologic prophylaxis for venous thromboembolism after hip and knee replacement in older adults

2020 ◽  
Vol 25 (5) ◽  
pp. 450-459
Author(s):  
Darae Ko ◽  
Alok Kapoor ◽  
Adam J Rose ◽  
Amresh D Hanchate ◽  
Donald Miller ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Adverse Events ◽  
Knee Replacement ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Temporal Trends ◽  
Major Hemorrhage ◽  
Vte Prophylaxis ◽  
Physician Review ◽  
Pharmacologic Prophylaxis

Trends in prescription for venous thromboembolism (VTE) prophylaxis following total hip (THR) and knee replacement (TKR) since the approval of direct oral anticoagulants (DOACs) and the 2012 guideline endorsement of aspirin are unknown, as are the risks of adverse events. We examined practice patterns in the prescription of prophylaxis agents and the risk of adverse events during the in-hospital period (the ‘in-hospital sample’) and 90 days following discharge (the ‘discharge sample’) among adults aged ⩾ 65 undergoing THR and TKR in community hospitals in the Institute for Health Metrics database over a 30-month period during 2011 to 2013. Eligible medications included fondaparinux, DOACs, low molecular weight heparin (LMWH), other heparin products, warfarin, and aspirin. Outcomes were validated by physician review of source documents: VTE, major hemorrhage, cardiovascular events, and death. The in-hospital and the discharge samples included 10,503 and 5722 adults from 65 hospitals nationwide, respectively (mean age 73, 74 years; 61%, 63% women). Pharmacologic prophylaxis was near universal during the in-hospital period (93%) and at discharge (99%). DOAC use increased substantially and was the prophylaxis of choice for nearly a quarter (in-hospital) and a third (discharge) of the patients. Aspirin was the sole discharge prophylactic agent for 17% and 19% of patients undergoing THR and TKR, respectively. Warfarin remained the prophylaxis agent of choice for patients aged 80 years and older. The overall risk of adverse events was low, at less than 1% for both the in-hospital and discharge outcomes. The low number of adverse events precluded statistical comparison of prophylaxis regimens.

Head and Neck Microsurgeon Practice Patterns and Perceptions Regarding Venous Thromboembolism Prophylaxis

2020 ◽  
Vol 36 (08) ◽  
pp. 549-555
Author(s):  
Kaushik P. Venkatesh ◽  
Shoshana W. Ambani ◽  
Aris R.L. Arakelians ◽  
Jonas T. Johnson ◽  
Mario G. Solari
Keyword(s):  
United States ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Head And Neck ◽  
Free Flap ◽  
Practice Patterns ◽  
The United States ◽  
Bleeding Events ◽  
Vte Prophylaxis ◽  
Prophylactic Anticoagulation

Abstract Background Patients undergoing head and neck (H&N) microvascular reconstruction comprise a population at high risk for venous thromboembolism (VTE). Free flap and VTE thromboprophylaxis may coincide but tend to vary from surgeon to surgeon. This study identifies VTE prophylaxis patterns and perceptions among H&N microsurgeons in the United States. Methods An online survey on VTE prophylaxis practice patterns and perceptions was emailed to 172 H&N microsurgeons in the United States using an anonymous link. Results There were 74 respondents (43% response rate). These surgeons completed residencies in otolaryngology (59%), plastic surgery (31%), and oral maxillofacial surgery (7%). Most underwent fellowship training (95%) and have practiced at an academic center (97%) for at least 6 years (58%), performing an average of 42 ± 31 H&N free flap cases per year (range = 1–190). Most adhered to general VTE prophylaxis guidelines (69%) while 11% did not and 20% were unsure. Nearly all surgeons (99%) would provide prophylactic anticoagulation, mostly in the form of subcutaneous heparin (51%) or enoxaparin (44%); 64% additionally used aspirin, while 4% used aspirin alone. The majority of surgeons (68%) reported having postoperative VTE complications, with six surgeons (8%) reporting patient deaths due to pulmonary embolism. A third of the surgeons have encountered VTE prophylaxis-related adverse bleeding events, but most still believe that chemoprophylaxis is important for VTE prevention (92%). While 35% of surgeons were satisfied with their current practice, most would find it helpful to have official prophylactic anticoagulation guidelines specific to H&N free flap cases. Conclusion The majority of microsurgeons experienced postoperative VTE complications after H&N free flap reconstruction despite the routine use of prophylactic anticoagulation. Though bleeding events are a concern, most surgeons believe chemoprophylaxis is important for VTE prevention and would welcome official guidelines specific to this high-risk population.

Venous Thromboembolism in Abdominoplasty Patients: A Study of Incidence and Prophylaxis Recommendations

2007 ◽  
Vol 24 (2) ◽  
pp. 66-79 ◽  
Author(s):  
Samir Pancholi ◽  
Angelo Cuzalina
Keyword(s):  
Venous Thromboembolism ◽  
Cosmetic Surgery ◽  
Mechanical Prophylaxis ◽  
Specific Data ◽  
Cosmetic Procedure ◽  
Vte Prophylaxis ◽  
Vein Thrombosis ◽  
Pharmacologic Prophylaxis ◽  
Incidence Analysis ◽  
Deep Vein

Introduction: Pulmonary embolism (PE) and deep vein thrombosis (DVT) comprise venous thromboembolism (VTE). VTE is the most common preventable cause of death in postsurgical hospitalized patients. The literature consistently defines prophylaxis as being integral to avoiding VTE. No study, however, specifically addresses this with abdominoplasty, a high-VTE-risk cosmetic procedure. This study aims to fill this void by providing specific data on VTE incidence and, through comprehensive literature review, providing specific abdominoplasty prophylaxis recommendations. Methods: A retrospective review of 267 patients undergoing abdominoplasty between January 2000 and June 2006 at a fully accredited outpatient surgical facility was performed to assess symptomatic VTE incidence. Analysis reviewed VTE risk factors and current prophylaxis practice. A review of current cosmetic, plastic, and general surgery prophylaxis measures in the literature was performed and correlated with the authors' practice to develop abdominoplasty-specific VTE prophylaxis recommendations. Results: Four of 267 abdominoplasty patients (1.5%) developed VTE (all DVT). None of the 97 patients undergoing abdominoplasty alone developed DVT. Four of 170 abdominoplasty patients undergoing additional cosmetic procedures developed DVTs (23%). Of these, 3 had liposuction and 1 had simultaneous breast augmentation/mastopexy. All patients underwent general anesthesia, received mechanical prophylaxis, and were encouraged to ambulate the morning after surgery. Conclusions: VTE is a real and preventable issue in patient safety. Cosmetic surgery patients frequently are treated with inconsistent and less aggressive VTE prophylaxis than similar noncosmetic surgery patients owing to scant relevant data and/or concerns of problematic bleeding. The authors present abdominoplasty-specific DVT and PE rates of 1.5% and 0%, respectively, when mechanical prophylaxis is used. Although the results mirror those in the literature, the demand for optimal VTE prevention led the authors to increase their current prophylaxis regimen to a higher standard. They soundly use and present a VTE prophylaxis protocol for abdominoplasty patients that includes mechanical as well as pharmacologic prophylaxis.

Pharmacologic Prophylaxis for Venous Thromboembolism Among Hospitalized Patients with Acute Medical Illness: An Electronic Medical Records Study

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2074-2074
Author(s):  
Marc B Rosenman ◽  
Xianchen Liu ◽  
Hemant Phatak ◽  
Amy Qi ◽  
Evgenia Teal ◽  
...  
Keyword(s):  
Research Funding ◽  
Primary Diagnosis ◽  
Medical Illness ◽  
Vte Prophylaxis ◽  
The Past ◽  
Neurologic Disorders ◽  
Treatment Dose ◽  
Primary Hospital ◽  
Pharmacologic Prophylaxis ◽  
History Of

Abstract Abstract 2074 Introduction: Patients hospitalized with acute medical illness have an elevated risk of venous thromboembolism (VTE). ACCP guidelines list various risk factors including active cancer, congestive heart failure (CHF), respiratory failure, chronic obstructive pulmonary disease (COPD), sepsis, advanced age, history of VTE and immobility. These guidelines also recommend prophylactic anticoagulation using fondaparinux, low molecular-weight heparin, or low-dose unfractionated heparin. This study examined pharmacologic prophylaxis against VTE among hospitalized medically ill patients and assessed demographic and clinical correlates related to VTE prophylaxis. Methods: A retrospective observational study was conducted with electronic medical records (EMR) in a large Midwestern U.S. public hospital and its network of outpatient clinics between 1999 and 2010. Patients >=40 years old were included if they were hospitalized with a primary diagnosis (ICD-9 code) of CHF, pneumonia, cancer, stroke, infectious diseases, sepsis, severe respiratory disorders (including COPD, asthma, and acute respiratory failure), inflammatory bowel disease (IBD), or neurologic disorders, or were hospitalized for VTE within the year before the index admission. Each patient's first qualifying hospitalization during the 12-year period was included in the analysis. Patients were excluded if the length of stay was <3 days, the primary diagnosis was VTE, if a hospital diagnosis of VTE was given in the past 30 days, or if IV heparin or a treatment dose of subcutaneous (SC) heparin (>15,000 units/day) or enoxaparin (>40 mg/day) was started within one day of admission. Patients treated with warfarin (and not heparin or enoxaparin) were also excluded. Fondaparinux was not on the formulary. Prophylaxis was defined as present if the first dose (during the hospital stay) of anticoagulation with SC heparin or enoxaparin was lower than the treatment dose levels defined above. All IV heparin was considered to be at treatment-level doses. SC heparin records with missing doses were considered to be at prophylaxis-level doses. Logistic regression was used to examine factors associated with VTE prophylaxis. Results: Of 13,029 patients eligible for the study, mean age was 58.6 years; 51% were women; 47% were white, 47% African-American, 6% other; 58% had public healthcare coverage, 15% commercial insurance, 27% self-pay. Among patients with a BMI stored in the EMR, 44% were obese, 23% overweight, and 28% normal. There was a history of cigarette smoking in 44% and atrial fibrillation in 8%. The primary hospital diagnoses were infectious diseases 21.2%, cancer 19.9%, severe respiratory disorders 14.5%, pneumonia 12.7%, CHF 12.2%, stroke 9.6%, sepsis 8.9%, IBD <1%, neurologic disorders <1%, and other <1%. Mean length of stay was 7.8 days (median 5 days). The overall prophylaxis rate was 22.1% (14.8% for 1999–2002, 22.0% for 2003–2006, 28.5% for 2007–2010), including 11.8% with enoxaparin and 10.3% with SC heparin. Multivariable logistic regression showed that VTE prophylaxis was significantly associated with year of hospitalization (OR=2.2 for ‘07-’10, OR=1.7 for ‘03-’06 vs. ‘99-’02, P<.001), SC heparin in the 30 days before admission (OR=1.6, p=0.02), aspirin use (OR=1.4, p<.0001), a primary hospital diagnosis of sepsis (OR=1.4, p<.0001), self-pay status (OR=1.2 vs. commercial insurance, p=0.01), and age (for 10 year increments, OR=1.07, p=0.001). The following factors were associated with reduced likelihood of VTE prophylaxis: smoking (OR=0.9, p=.005), alcohol use (OR=0.9, p=.04), warfarin in the past 30 days (OR=0.5, p=0.02), and a primary diagnosis of stroke (OR=0.7, p<0.0001), infectious disease (OR=0.7, p<.0001), or IBD (OR=0.3, p=.003). Conclusion: Pharmacologic VTE prophylaxis has increased significantly over the past 12 years but is still largely underused in patients hospitalized with acute medical illness. Multiple demographic, behavioral and clinical factors are associated with VTE prophylaxis during hospitalization. Further research is needed to examine if VTE prophylaxis is associated with reduced VTE risk and healthcare utilization. Disclosures: Rosenman: Bristol-Myers Squibb: Research Funding; Pfizer: Research Funding. Liu:Pfizer: Employment. Phatak:Bristol-Myers Squibb: Employment. Qi:Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding. Teal:Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding. Nisi:Pfizer: Research Funding; Bristol-Myers Squibb: Research Funding. Liu:Pfizer: Employment, Equity Ownership. Ramacciotti:Bristol-Myers Squibb: Employment.

Influence Of Updated ASH Guidelines On Practice Patterns In Management Of Newly Diagnosed Childhood ITP, 2007-2012

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 772-772
Author(s):  
Corinna L. Schultz ◽  
Michele P Lambert
Keyword(s):  
United States ◽  
Platelet Count ◽  
Research Funding ◽  
Chart Review ◽  
Practice Patterns ◽  
The United States ◽  
Pharmacologic Treatment ◽  
Newly Diagnosed ◽  
Alternative Diagnosis ◽  
Younger Age

Abstract Background Treatment recommendations for childhood Immune Thrombocytopenia (ITP) in the United States have been a subject of much debate. In early 2011, the American Society of Hematology (ASH) updated their guidelines, recommending that children with ITP be managed with observation alone when there is mild or no bleeding symptoms regardless of platelet count, reserving hospitalization and pharmacologic treatment for those with significant bleeding. The objective of this study was to better understand the impact these recommendations have had on practice patterns at a large, urban, pediatric tertiary care hospital in the United States. Methods We examined data from patients aged 0-17 with newly diagnosed ITP seen in inpatient and outpatient locations at the Children's Hospital of Philadelphia (CHOP) between January 1, 2007 and December 31, 2012. A cohort was developed by querying the hospital data system for all patients treated 2007-2012 using the ICD-9 code for ITP (287.31). Chart review was used to exclude patients with alternative diagnosis for thrombocytopenia, diagnosis prior to the time of interest, and initial treatment elsewhere. We compared management strategies at diagnosis and retreatment rates in the first 6 months after the initial diagnosis. The primary outcome, management at diagnosis, was analyzed by logistic regression and chi square analysis. Results 502 unique patients were identified. After chart review, an evaluable cohort of 313 patients with newly diagnosed ITP remained. The most common reasons for elimination were an alternative diagnosis (n=41), diagnosis in a previous year (n=68), and initial treatment at another hospital (n=69). Of those with an alternative diagnosis, Evan's syndrome (n=8) and ALPS (n=5) were the most common reasons for elimination. New diagnoses per year ranged from 34-51 in 2007-2009 and 60-63 in 2010-2012. The mean platelet count and age at diagnosis were 16.9 x10^9/l and 6.22 years old, respectively. Distribution was skewed toward lower platelet count and younger age. Overall, 19.5% of patients were noted to have bleeding symptoms beyond bruising or petechiae. The most common bleeding symptoms at presentation were epistaxis (n=25), wet purpura (n=20), gastrointestinal bleeding (n=5), hematuria (n=4), and menstrual bleeding (n=4). Intracranial hemorrhage was rare (n=2, 0.6%). Overall, 55% of patients were managed with pharmacologic treatment at diagnosis. Of those treated, 98% were treated with IVIG. Additionally, the proportion of patients observed at diagnosis rose significantly during this time period from 34% of patients in 2007-2010 to 49.2% in 2011 (p<.02) and 72% in 2012 (p<0.001). Via logistic regression, younger age, lower platelet count, and year of diagnosis were significantly associated with increased odds of pharmacologic treatment. During 2010-2012, 21% of patients were also treated within 0.25-6 months after diagnosis, with no significant difference by year or initial management (p>0.5). The majority treated after diagnosis were due to “low platelet counts” (n=14), bruising/wet purpura (n=6), or parental anxiety/activity level (n=3). One child, initially treated with IVIG, presented with ICH secondary to trauma 1.5 months after diagnosis. Conclusions Over time, a significantly increased proportion of patients were observed at diagnosis. Though we cannot prove causation, this change demonstrates a strong association between timing of ASH recommendations and increase in observation rates. As we increased the proportion of children being observed at diagnosis we did not see an increase in the proportion of children receiving treatment or those with significant bleeding symptoms in the following 6 months. Additionally, we found that 37% of patients originally identified via ICD-9 code did not meet our criteria for evaluation of ‘newly diagnosed ITP'. As there is a greater shift to observing patients, along with the development of outpatient infusion services, inpatient databases could become skewed in regard to ITP. Because of this, caution should be utilized in using ICD-9 code alone to identify new diagnoses, especially when chart review is not accessible. Future studies will be able to identify the changing national trend in admission and management and whether adoption of ASH guidelines is widespread. Disclosures: Lambert: Amgen: Research Funding; Nestle: Consultancy; GSK: Research Funding.

scholarly journals Dietitians' perceptions and experience of blenderised feeds for paediatric tube-feeding

2016 ◽  
Vol 102 (2) ◽  
pp. 152-156 ◽  
Author(s):  
Janis Armstrong ◽  
Elaine Buchanan ◽  
Hazel Duncan ◽  
Kathleen Ross ◽  
Konstantinos Gerasimidis
Keyword(s):  
Clinical Practice ◽  
Tube Feeding ◽  
Infection Risk ◽  
Previous Experience ◽  
Evidence Based ◽  
Web Based ◽  
Commercial Feeds ◽  
Evidence Based Guidelines ◽  
Professional Guidelines

ObjectiveThere is an emerging interest in the use of blenderised food for tube-feeding (BFTF). This survey explored paediatric dietitians' perceptions and experiences of BFTF use.DesignA web-based questionnaire was distributed to the Paediatric group of the British Dietetic Association. The survey captured dietitians' personal opinions and experience supporting children on BFTF, and the perceptions of carers.ResultsOf the 77 respondents, 19 were aware of professional guidelines and 63 had never received training on BFTF. Thirty-four would not recommend BFTF and 11 would advise against its use; yet 43 would recommend it to supplement commercial feeds. Fifty-seven would change their perception about BFTF if there were evidence-based guidelines. Forty-four would feel confident to support a patient using BFTF. Forty-three had previous experience supporting a patient with BFTF. The main concerns perceived by dietitians, pertinent to the use of BFTF, were nutritional inadequacy (n=71), tube blockages (n=64) and increased infection risk (n=59) but these were significantly higher than those experienced by themselves in clinical practice (p<0.001 for all three). A reduction in reflux and vomiting and increased carer involvement were the main perceived and observed benefits by both dietitians and carers.ConclusionsThe use of these feeds for tube-fed children is increasingly being seen as a viable choice. Dietitians experienced significantly fewer issues with the use of BFTF in clinical practice compared with their self-reported apprehensions in the survey. Well-controlled studies are now needed to objectively assess the benefits, risks, costs and practicality of BFTF.

The National Practice Patterns of Venous Thromboembolism Prophylaxis Post-Cardiothoracic Surgery

2016 ◽  
Vol 30 (4) ◽  
pp. 394-399 ◽  
Author(s):  
Sheena E. Mathew ◽  
Craig J. Beavers ◽  
Elizabeth McNeely
Keyword(s):  
Venous Thromboembolism ◽  
Artery Bypass ◽  
Bypass Graft ◽  
The United States ◽  
Cardiothoracic Surgery ◽  
Thromboembolism Prophylaxis ◽  
Vte Prophylaxis ◽  
Multicenter Survey ◽  
Pharmacologic Prophylaxis ◽  
Chemical Prophylaxis

Background: The rates of venous thromboembolism (VTE) post-cardiothoracic surgery are not well understood. The american college of chest physicians (CHEST) guidelines report weak recommendations for starting VTE prophylaxis post-cardiothoracic surgery. It is suspected that due to the increase in bleed risk, postsurgery initiation of pharmacologic VTE prophylaxis is limited. Objective: The study sought to investigate the use of VTE prevention in US hospitals performing cardiac surgery and the use of mechanical/chemical prophylaxis postoperatively. Methods: This is a multicenter survey distributed to cardiac hospitals in the United States. The survey was distributed through 3 separate listservs. Data were analyzed utilizing descriptive statistics. Results: The majority of the hospitals were academic and/or community and completed coronary artery bypass graft (CABG), valve replacement (mitral/aortic/tricuspid), and aortic repair. It was common for hospitals to start mechanical and pharmacologic prophylaxis post-cardiothoracic surgery on postoperative day (POD) 1 to 2. The anticoagulation most commonly used consisted of unfractionated heparin. Conclusions: The majority of the institutions are initiating therapy POD 1 to 2 with both mechanical and chemical prophylaxis. The full impact of early initiation of VTE prophylaxis is unknown, and more studies are needed to assess the true risks/benefits of these practices.

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