Pharmacological methods of thromboprophylaxis

The burden of venous thromboembolism (VTE) in hospitalized patients is significant and often underestimated. In this article the rationale for thromboprophylaxis is reviewed and rates of VTE in different patient populations considered. The options for pharmacological methods of prophylaxis are outlined and the evidence for their use in specific patient groups is reviewed. Thromboprophylaxis is effective but currently underused. Strategies are being developed to remedy this situation including the development of national guidelines and intervention by the Department of Health.

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Venous Thromboembolism Prophylaxis Rates In Specific Patient Groups Using An Electonic Reminder Designed To Improve Compliance With ACCP Guidelines

10.1164/ajrccm-conference.2010.181.1_meetingabstracts.a1455 ◽

2010 ◽

Author(s):

Josh Mitchell ◽

Sarah Petteys ◽

Aaron B. Holley ◽

Jacob Collen ◽

Anita Shah

Keyword(s):

Venous Thromboembolism ◽

Thromboembolism Prophylaxis ◽

Specific Patient ◽

Venous Thromboembolism Prophylaxis ◽

Improve Compliance ◽

Patient Groups

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PP018 Clinical Risk Prediction Scores For Venous Thromboembolism In Hospitalized Patients

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462317002094 ◽

2017 ◽

Vol 33 (S1) ◽

pp. 76-76

Author(s):

Matthew Mitchell ◽

Nikhil Mull ◽

Todd Hecht ◽

Craig Umscheid

Keyword(s):

Venous Thromboembolism ◽

Risk Prediction ◽

External Validation ◽

Risk Of Bias ◽

Hospitalized Patients ◽

Surgical Patients ◽

Medical Patients ◽

National Guidelines ◽

Clinical Risk ◽

Increased Risk

INTRODUCTION:Risk prediction scores have been devised to identify patients at increased risk for Venous Thromboembolism (VTE) in different patient populations and settings. Guideline recommendations for VTE risk assessment vary greatly. We performed a systematic review to synthesize evidence on clinical risk prediction scores for VTE in hospitalized medical and surgical patients.METHODS:We systematically searched Medline, EMBASE, Cochrane, National Institute of Health and Care Excellence (NICE), National Guidelines Clearinghouse (NGC), and Guidelines International Network (GIN) databases up to March 2016. We included studies validating risk prediction scores for adult hospitalized patients. We excluded studies for any of the following reasons: non-English publication, conducted in non-OECD (Organisation for Economic Co-operation and Development) countries, validation cohorts focused solely on critical care patients, or scores developed for specific surgical or medical sub-specialty populations. We plotted receiver operating characteristic (ROC) curves of included studies and performed summary ROC meta-analyses for scores in which >1 external validation studies were combinable. Risk of bias was assessed qualitatively. We assessed the strength of the evidence base using Grading of Recommendations Assessment, Development and Evaluation (GRADE).RESULTS:We screened 110 primary studies and included 18 of those for analysis. There were seven studies of the Caprini score, three studies of the Padua score, two studies of the IMPROVE score; and one study each of the Arcelus, Geneva, Khorana, RAP, and Kucher scores . Strength of evidence was downgraded for study risk of bias because most studies disproportionately included patients at high risk of VTE. Our summary estimates of the performance of the three combinable scores at clinically-relevant thresholds are: Caprini score at a threshold of three in surgical patients – 96 percent sensitivity, 44 percent specificity; IMPROVE at a threshold of one in medical patients – 96 percent sensitivity, 20 percent specificity; and Padua at a threshold of 4–87 percent sensitivity and 58 percent specificity.CONCLUSIONS:There is moderate strength evidence for use of the Caprini score to predict VTE in surgical patients and for the Padua and IMPROVE scores in medical patients. Lower thresholds may be warranted to achieve sufficient sensitivity to identify low risk populations who may not require routine VTE prophylaxis. Studies making direct comparisons of risk prediction scores in similar patient populations are lacking and are necessary to ascertain which score is most effective.

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Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in at-risk patient groups: pregnancy, elderly and obese patients

Thrombosis Journal ◽

10.1186/s12959-019-0214-8 ◽

2019 ◽

Vol 17 (1) ◽

Cited By ~ 5

Author(s):

Benjamin Brenner ◽

Roopen Arya ◽

Jan Beyer-Westendorf ◽

James Douketis ◽

Russell Hull ◽

...

Keyword(s):

At Risk ◽

Venous Thromboembolism ◽

Pregnant Women ◽

Unmet Needs ◽

The Elderly ◽

Assessment Tools ◽

Obese Patients ◽

Specific Patient ◽

Prevention And Treatment ◽

Patient Groups

Abstract Background Venous thromboembolism (VTE) accounts for an estimated 900,000 cases per year in the US alone and constitutes a considerable burden on healthcare systems across the globe. Objective To understand why the burden is so high, qualitative and quantitative research was carried out to gain insights from experts, guidelines and published studies on the unmet clinical needs and therapeutic strategies in VTE prevention and treatment in three populations identified as being at increased risk of VTE and in whom VTE prevention and treatment were regarded as suboptimal: pregnant women, the elderly and obese patients. Methodology A gap analysis methodology was created to highlight unmet needs in VTE management and to discover the patient populations considered most at risk. A questionnaire was devised to guide qualitative interviews with 44 thrombosis and haemostasis experts, and a review of the literature on VTE in the specific patient groups from 2015 to 2017 was completed. This was followed by a Think Tank meeting where the results from the research were discussed. Results This review highlights the insights gained and examines in detail the unmet needs with regard to VTE risk-assessment tools, biomarkers, patient stratification methods, and anticoagulant and dosing regimens in pregnant women, the elderly and obese patients. Conclusions Specifically, in pregnant women at high risk of VTE, low-molecular-weight heparin (LMWH) is the therapy of choice, but it remains unclear how to use anticoagulants when VTE risk is intermediate. In elderly patients, evaluation of the benefit of VTE prophylaxis against the bleeding risk is particularly important, and a head-to-head comparison of efficacy and safety of LMWH versus direct oral anticoagulants is needed. Finally, in obese patients, lack of guidance on anticoagulant dose adjustment to body weight has emerged as a major obstacle in effective prophylaxis and treatment of VTE.

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Non-medical risk factors associated with postponing elective surgery: a prospective observational study

BMC Medical Ethics ◽

10.1186/s12910-021-00660-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Julia Becker ◽

Gerald Huschak ◽

Hannes-Caspar Petzold ◽

Volker Thieme ◽

Sebastian Stehr ◽

...

Keyword(s):

Elderly Patients ◽

Low Socioeconomic Status ◽

Elective Surgery ◽

Nursing Home Residents ◽

Hospital Staff ◽

Data Management System ◽

Electronic Patient Records ◽

Specific Patient ◽

Emergency Procedures ◽

Patient Groups

Abstract Background Operation room (OR) planning is a complex process, especially in large hospitals with high rates of unplanned emergency procedures. Postponing elective surgery in order to provide capacity for emergency operations is inevitable at times. Elderly patients, residents of nursing homes, women, patients with low socioeconomic status and ethnic minorities are at risk for undertreatment in other contexts, as suggested by reports in the medical literature. We hypothesized that specific patient groups could be at higher risk for having their elective surgery rescheduled for non-medical reasons. Methods In this single center, prospective observational trial, we analysed 2519 patients undergoing elective surgery from October 2018 to May 2019. A 14-item questionnaire was handed out to illicit patient details. Additional characteristics were collected using electronic patient records. Information on the timely performance of the scheduled surgery was obtained using the OR’s patient data management system. 6.45% of all planned procedures analysed were postponed. Association of specific variables with postponement rates were analysed using the Mann–Whitney U test and Fisher's exact test/χ2-test. Results Significantly higher rates of postponing elective surgery were found in elderly patients. No significant differences in postponing rates were found for the variables gender, nationality (Germany, EU, non-EU), native language, professional medical background and level of education. Significantly lower rescheduling rates were found in patients with ties to hospital staff and in patients with a private health insurer. Conclusions Elderly patients, retirees and nursing home residents seem to be at higher risk for having their elective surgery rescheduled. However, owing to the study design, causality could not be proven. Our findings raise concern about possible undertreatment of these patient groups and provide data on short-term postponement of elective surgery. Trial registration DRKS00015836. Retrospectively registered.

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Predictive Factors in Sacral Neuromodulation: A Systematic Review

Urologia Internationalis ◽

10.1159/000513937 ◽

2021 ◽

pp. 1-21

Author(s):

Ranjana Jairam ◽

Jamie Drossaerts ◽

Tom Marcelissen ◽

Gommert van Koeveringe ◽

Desiree Vrijens ◽

...

Keyword(s):

Systematic Review ◽

Predictive Factors ◽

Sacral Neuromodulation ◽

Level Of Evidence ◽

Specific Patient ◽

Detrusor Contractility ◽

Affective Symptoms ◽

Lower Success Rate ◽

Patient Groups ◽

Based Medicine

Introduction: Sacral neuromodulation (SNM) is an effective treatment in patients with overactive bladder syndrome or nonobstructive urinary retention when conservative treatment fails. Several factors that could impact outcome with SNM have been studied. This systematic review investigated these predictive factors and their relevance for clinical practice. Methods: Systematic review according to the PRISMA guidelines was conducted. This review is registered in the PROSPERO register (CRD42015016256). Results: Seventy-eight studies (of which 11 abstracts) were included. Females, younger patients, and a tined lead procedure tend to be predictive in successful SNM outcome. Factors that did not influence SNM outcome were prior back surgery, surgery for stress urinary incontinence, affective symptoms, and duration of complaints. Reduced detrusor contractility is associated with a lower success rate. The level of evidence of most studies (graded according to the Centre for Evidence-Based Medicine) was 3b. Conclusion: Even though this systematic review investigated predictive factors (gender, age, type of procedure, type of lead, and detrusor contractility), no general consensus on predictive factors could be made. Most studies are small, retrospective, and involve a heterogeneous population. Therefore, prospective research in larger specific patient groups remains necessary to find predictors of SNM outcome.

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Staphylococcus aureus ventilator-associated pneumonia in patients with COVID-19: clinical features and potential inference with lung dysbiosis

Critical Care ◽

10.1186/s13054-021-03623-4 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Gennaro De Pascale ◽

Flavio De Maio ◽

Simone Carelli ◽

Giulia De Angelis ◽

Margherita Cacaci ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Clinical Features ◽

Hospitalized Patients ◽

Fold Change ◽

Ventilator Associated Pneumonia ◽

Icu Mortality ◽

Unifrac Distance ◽

Saps Ii ◽

Medical Icus ◽

Patient Groups

Abstract Background Hospitalized patients with COVID-19 admitted to the intensive care unit (ICU) and requiring mechanical ventilation are at risk of ventilator-associated bacterial infections secondary to SARS-CoV-2 infection. Our study aimed to investigate clinical features of Staphylococcus aureus ventilator-associated pneumonia (SA-VAP) and, if bronchoalveolar lavage samples were available, lung bacterial community features in ICU patients with or without COVID-19. Methods We prospectively included hospitalized patients with COVID-19 across two medical ICUs of the Fondazione Policlinico Universitario A. Gemelli IRCCS (Rome, Italy), who developed SA-VAP between 20 March 2020 and 30 October 2020 (thereafter referred to as cases). After 1:2 matching based on the simplified acute physiology score II (SAPS II) and the sequential organ failure assessment (SOFA) score, cases were compared with SA-VAP patients without COVID-19 (controls). Clinical, microbiological, and lung microbiota data were analyzed. Results We studied two groups of patients (40 COVID-19 and 80 non-COVID-19). COVID-19 patients had a higher rate of late-onset (87.5% versus 63.8%; p = 0.01), methicillin-resistant (65.0% vs 27.5%; p < 0.01) or bacteremic (47.5% vs 6.3%; p < 0.01) infections compared with non-COVID-19 patients. No statistically significant differences between the patient groups were observed in ICU mortality (p = 0.12), clinical cure (p = 0.20) and microbiological eradication (p = 0.31). On multivariable logistic regression analysis, SAPS II and initial inappropriate antimicrobial therapy were independently associated with ICU mortality. Then, lung microbiota characterization in 10 COVID-19 and 16 non-COVID-19 patients revealed that the overall microbial community composition was significantly different between the patient groups (unweighted UniFrac distance, R2 0.15349; p < 0.01). Species diversity was lower in COVID-19 than in non COVID-19 patients (94.4 ± 44.9 vs 152.5 ± 41.8; p < 0.01). Interestingly, we found that S. aureus (log2 fold change, 29.5), Streptococcus anginosus subspecies anginosus (log2 fold change, 24.9), and Olsenella (log2 fold change, 25.7) were significantly enriched in the COVID-19 group compared to the non–COVID-19 group of SA-VAP patients. Conclusions In our study population, COVID-19 seemed to significantly affect microbiological and clinical features of SA-VAP as well as to be associated with a peculiar lung microbiota composition.

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Narrowing in on the True Rate of Venous Thromboembolism in Hospitalized Patients With COVID-19 Disease

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvbaha.120.314977 ◽

2020 ◽

Vol 40 (9) ◽

pp. 1958-1960 ◽

Cited By ~ 1

Author(s):

Deborah M. Siegal ◽

Peter L. Gross

Keyword(s):

Venous Thromboembolism ◽

Hospitalized Patients ◽

True Rate

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Assessment of the quality, content and perceived utility of local maternity guidelines in hospitals in England implementing the saving babies’ lives care bundle to reduce stillbirth

BMJ Open Quality ◽

10.1136/bmjoq-2019-000756 ◽

2020 ◽

Vol 9 (2) ◽

pp. e000756

Author(s):

Yu Zhen Lau ◽

Kate Widdows ◽

Stephen A Roberts ◽

Sheher Khizar ◽

Gillian L Stephen ◽

...

Keyword(s):

Clinical Practice ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Stakeholder Involvement ◽

Care Bundle ◽

Intrapartum Care ◽

National Guidelines ◽

Department Of Health ◽

The Uk

IntroductionThe UK Department of Health have targeted a reduction in stillbirth by 50% by 2025; to achieve this, the first version of the Saving Babies’ Lives Care Bundle (SBLCB) was developed by NHS England in 2016 to improve four key areas of antenatal and intrapartum care. Clinical practice guidelines are a key means by which quality improvement initiatives are disseminated to front-line staff.MethodsSeventy-five clinical practice guidelines covering the four areas of antenatal and intrapartum care in the first version of SBLCB were obtained from 19 maternity providers. The content and quality of guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Maternity health professionals in participating organisations were invited to participate in an anonymous survey to determine perceptions toward and experiences of the use of clinical practice guidelines using a series of Likert scales.ResultsUnit guidelines showed considerable variation in quality with median scores of 50%–58%. Only 4 (5.6%) guidelines were recommended for use in clinical practice without modifications, 54 (75.0%) were recommended for use subject to modifications and 12 (16.7%) were not recommended for use. The lowest scoring domains were ‘rigour of development’, ‘stakeholder involvement’ and ‘applicability’. A significant minority of unit guidelines omitted recommendations from national guidelines. The majority of staff believed that clinical practice guidelines standardised and improved the quality of care but over 30% had insufficient time to use them and 24% stated they were unable to implement recommendations.ConclusionTo successfully implement initiatives such as the SBLCB change is needed to local clinical practice guidelines to reduce variation in quality and to ensure they are consistent with national recommendations . In addition, to improve clinical practice, adequate time and resources need to be in place to deliver and evaluate care recommended in the SBLCB.

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