American College Of Chest Physicians Guidelines Research Articles

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

Incidence and Risk Factors for Venous Thromboembolism Following 2462 Major Abdomino-Pelvic Surgeries in Tertiary Hospital.

PurposeTo determine the incidence and risk factor of postoperative venous thromboembolism (VTE) in Thai populations and to evaluate morbidity, mortality, bleeding complications and the benefit of thromboprophylaxis in real-world practice.Patients and MethodsWe performed a retrospective, single-center, cohort study of patients from all age groups who underwent elective open or laparoscopic major abdomino-pelvic surgery between January 2008 and December 2018 at Chulabhorn Hospital, Bangkok, Thailand. We collected general medical information and specific data based on items from the Caprini risk scoring system.ResultsA total of 2462 major abdomino-pelvic surgeries were included. The study population consisted of 742 males (30.1%) and 1720 females (69.9%) aged 54.59 ± 13.27 years. The incidence of VTE in Thai patients that underwent major abdominal surgery was 0.48%. The most frequent influencing factor for VTE was a history of pulmonary embolism, which increased the risk of VTE 98.28-fold, whereas a history of deep vein thrombosis increased the risk of VTE by 12.34-fold. Other factors influencing VTE development were obesity, anticoagulant use, postoperative chemotherapy, preoperative chemotherapy, endometrium cancer, tumor-node-metastasis (TNM) stage 4 and American College of Chest Physicians (ACCP) class 4. Protective factors included no history of VTE, laparoscopic surgery, TNM stage 0 and benign disease and BMI<30. VTE significantly increased mortality whereas following ACCP guideline reduced mortality.ConclusionPost-operative VTE incidence in Thai patients undergoing major abdomino-pelvic surgery was lower compared with Western patients. Factors influencing for VTE were history of VTE, anticoagulant use, postoperative chemotherapy, preoperative chemotherapy, endometrium cancer, TNM stage 4 and ACCP class 4. Following ACCP guideline reduced the incidence of mortality.

Estimating the risk thresholds used by guidelines to recommend postpartum thromboprophylaxis

BackgroundGuidelines for postpartum thromboprophylaxis are mostly expert based. Acceptable postpartum venous thromboembolism (VTE) risk thresholds to justify the use of thromboprophylaxis are ill defined. ObjectiveTo compare the proportion of postpartum women with recommended thromboprophylaxis according to the Royal College of Obstetricians and Gynecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and American College of Chest Physicians (ACCP) guidelines, and to estimate their threshold of risk of VTE. MethodsWe collected maternal, obstetrical, and fetal characteristics among all women who delivered at the Geneva University Hospitals in January 2019 through medical chart review. We determined for each woman the recommended strategy of thromboprophylaxis according to each guideline. We indirectly estimated individual absolute VTE risks using a validated risk prediction model (Sultan). ResultsAmong 344 women (mean age 32.2 years), with 23.3% of cesarean deliveries (CD), the RCOG guideline categorized 40.1% of all deliveries, 25.4% of vaginal deliveries (VD), and 88.8% of CD as requiring thromboprophylaxis. The ACOG and ACCP guidelines, which focus on CD, categorized fewer women as high risk (35.0% and 40.0% of CD, respectively). The mean estimated risk of VTE was 0.07% in all participants, 0.12% in those with recommended thromboprophylaxis according to the RCOG, and 0.20% among women after CD with recommended thromboprophylaxis by the ACOG and ACCP guidelines. ConclusionsOur data highlight important variations in the proportion of thromboprophylaxis recommendation between guidelines. Risk thresholds to recommend the use of heparin appear very low, and may correlate with a high, and perhaps undesirable, number needed to treat to prevent VTE events.

Editorial introductions

Editorial introductions

Performance of Lung Nodule Management Algorithms for Lung-RADS Category 4 Lesions

To test the performance of the American College of Chest Physicians (ACCP) and British Thoracic Society (BTS) algorithms to stratify high-risk nodules identified at lung cancer screening. Patients with Lung-RADS category 4 nodules identified on lung cancer screening computed tomography (CT) between March 2014 and August 2018 were identified, and a subset of 150 were randomly selected. Nodule characteristics and, if available, fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET)-CT scan were recorded. Radiologists blinded to final diagnosis and downstream testing performed five-point visual assessment score for probability of nodule malignancy; their accuracies are averaged below. Probabilities of malignancy according to Brock and Herder models were calculated. ACCP and BTS algorithms were applied to the nodules. Final diagnosis of malignancy was made in 65/150 (43%) of patients. The sensitivity, specificity and accuracy for nodule malignancy were: radiologist visual score (92%, 85%, 88%); BTS (76%, 91%, 85%); ACCP (63%, 89%, 78%); and Brock calculator (77%, 71%, 73%). The sensitivity, specificity, and accuracy for nodule malignancy in patients with FDG PET-CT scan (n = 78) were: FDG uptake (91%, 64%, 83%); Herder probability (91%, 68%, 83%); radiologist visual score (93%, 69%, 86%); BTS (84%, 64%, 78%); Brock probability (82%, 50%, 72%); and ACCP (68%, 59%, 65%). Thoracic radiologist visual analysis yielded the greatest accuracy for nodule triage in the entire cohort. BTS performed better than ACCP guidelines and both performed better than the Brock model alone.

What's new in endobronchial ultrasound for mediastinal staging?

The essential role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in lung cancer diagnosis and staging is now well established. With a growing body of evidence seen over the last decade, the objective of this article was to review the newest findings, provide evidence-based guidance to clinicians and identify areas for future research related to EBUS-TBNA and staging in lung cancer. Recent literature regarding EBUS-TBNA for lung cancer staging was reviewed, with a focus on evidence published subsequent to the 2016 guideline on technical aspects of EBUS-TBNA by the American College of Chest Physicians (ACCP). New findings were reported for the following: role of rapid on-site cytological evaluation (ROSE), needle size, lymph node ultrasound characteristics, molecular testing, as well as practice patterns and gaps in quality of care. Significant advances in EBUS-TBNA have been realized since the publication of the 2016 ACCP guideline. Future areas of investigation have been identified and will require collaboration between centers of expertise. Additional work will be required to translate these technological advances into improved value-based care in the lung cancer population.

Adherencia a las guías internacionales de tromboprofilaxis en pacientes sometidos a cirugía ortopédica mayor en Colombia: Resultados del Registro DEIMOS

BackgroundPatients who undergo major orthopaedic surgery have an elevated risk of venous thromboembolism (VTE). International guidelines recommendations for VTE prevention have shown to be effective in reducing the frequency of thromboembolic events, but compliance to these recommendations is still low. The purpose of the present study is to report the adherence to the American College of Chest Physicians (ACCP) guidelines 2008 in Colombia. Material and methodsA report is presented on the Colombian results for the DEIMOS registry. This is a multinational, multicentre, observational, longitudinal study. Twenty orthopaedic wards were asked to include consecutive patients who were admitted for major orthopaedic surgery.Patient demographics, surgical information, type of anaesthesia and VTE prophylaxis were prospectively recorded, and the use of VTE prevention methods was assessed during the following visits. Adherence to the 2008 ACCP guidelines was then determined. ResultsA total of 244 patients were included in Colombia, and 240 of them had a complete follow-up. The analysis included 108 total knee arthroplasties, 77 hip replacements and 59 hip fracture surgeries. Adherence to 2008 ACCP guidelines for in-hospital prophylaxis was 80.5% (95% CI; 71.7-89.4) for hip arthroplasty, 82.4% (95% CI; 75.2-89.6) for knee arthroplasty, and 94.9% CI; 89.3-100.0) for hip fracture surgeries.Adherence for extended prophylaxis was 75.3% (95% CI; 65.7-85.0) for hip arthroplasties, 73.1% (95% CI; 64.8-81.5) for knee arthroplasties, and 93.2% (95% CI; 86.8-99.6) for hip fracture surgery. DiscussionThe DEIMOS registry reports good compliance to VTE prophylaxis guidelines after hip fracture surgery in Colombia. However, adherence to extended prophylaxis guidelines is still low after total hip and knee arthroplasties. Efforts should be made to improve the protection of these patients after hospital discharge.

Cardiopulmonary Testing Before Lung Resection: What Are Thoracic Surgeons Doing?

Cardiopulmonary assessment for lung resection is important for risk stratification, and the American College of Chest Physicians (ACCP) guidelines provide decision support. We ascertained the cardiopulmonary assessment practices of thoracic surgeons and determined whether they are guideline concordant. An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database. We analyzed survey responses by practice type (general thoracic [GT] versus cardiothoracic [CT]) and years in practice (0-9, 10-19, and ≥20) with the use of contingency tables. We compared adherence of survey responses with the guidelines. The response rate was 24.0% (n= 203). Most surgeons (n= 121, 59.6%) cited a predicted postoperative forced expiratory volume in 1 second or diffusing capacity of lung for carbon monoxide threshold of 40% for further evaluation. Experienced surgeons (≥20 years) were more likely to have a threshold that varies by surgical approach (31.3% versus 23.5% with 10-19 years of experience and 15.9% for 0-9 years of experience, P= .007). Overall, 52.2% refer patients with cardiovascular risk factors to cardiology and 42.9% refer patients with abnormal stress testing. CT surgeons were more likely to refer all patients to cardiology than GT surgeons (17.6% versus 2.4%, P < .001). Only one respondent (0.5%) was 100% adherent to the ACCP guidelines, and 4.4% and 45.8% were 75% and 50% adherent, respectively. Among thoracic surgeons, there is variation in preoperative cardiopulmonary assessment practices, with differences by practice type and years in practice, and marked discordance with the ACCP guidelines. Further study of guideline adherence linked to postoperative morbidity and mortality is warranted to determine whether adherence affects outcomes.

Magnitude of Venous Thromboembolism Risk in US Hospitals: Impact of Evolving National Guidelines for Prevention of Venous Thromboembolism

BackgroundThe annual number of US hospital discharges at risk for venous thromboembolism and the impact of evolving American College of Chest Physicians (ACCP) consensus guidelines for prevention of venous thromboembolism are unknown. MethodsThree risk-assessment algorithms based on 2004, 2008, and 2012 ACCP guidelines for prevention of venous thromboembolism were applied to the 2014 US National Inpatient Sample to derive estimates of the annual number of US inpatients at risk for venous thromboembolism. ResultsOf 35.4 million discharges from US acute-care hospitals in 2014, 25.3 million (71%) met study inclusion criteria of age ≥18 years and length of stay (LOS) ≥2 days. Among 7.5 million patients who underwent a procedure in an operating room, more than 4.4 million (59%) were at ACCP-defined risk for venous thromboembolism, irrespective of which version of the ACCP guidelines applied. With an additional 8.4/8.5/7.3 million eligible discharges meeting criteria for venous thromboembolism prophylaxis due to medical risk factors, the total annual numbers of inpatients at risk for venous thromboembolism were 12.8/12.9/11.7 million according to 2004/2008/2012 ACCP guidelines, respectively. ConclusionsOver half of adult patients who had an LOS ≥2 days in US acute-care hospitals met ACCP criteria for consideration of venous thromboembolism prophylaxis based on risk factors associated with surgery or acute medical illness. These data provide an objective basis for estimating the potential impact of venous thromboembolism prevention on patient care, together with associated costs, risks, and benefits.

Updates on Prophylaxis for Deep Venous Thrombosis and Venous Thromboembolism

Purpose To concisely present recommendations and guidelines for venous thromboembolism (VTE) treatment and prevention for common subgroups of surgical patients as a comprehensive reference for clinical surgical practice.Methods Thorough literature review, including the consensus guidelines and recommendations of various professional surgical societies, was evaluated and conglomerated to provide a comprehensive reference for practicing surgeons. Common surgical patient subgroups were investigated for differing recommendations. Recommendations, guidelines, and resources were tabulated into user-friendly formats for easy reference purposes.Results Substantial updates have been made to the recommendations for VTE prevention and treatment. The American College of Chest Physicians (ACCP) have updated their VTE recommendations. The Eastern Association for the Surgery of Trauma has also released updated recommendations regarding VTE management. The Society of American Gastrointestinal and Endoscopic Surgeons has recalled their own specific recommendations for VTE treatment and prophylaxis in support of tenth edition of the ACCP guidelines on the subject.Conclusions VTE affects up to 25% of hospitalized patients, with up to 30% of those experiencing complications. Risk stratification is important in choosing therapy for prevention and management of VTE. Management of VTE depends on precipitating factors and future risk of VTE progression versus bleeding. Low-molecular-weight heparin is the preferred anticoagulant for initial treatment of VTE. The tenth edition of ACCP VTE guidelines provides comprehensive management recommendations.

Estimation of Acutely Ill Medical Patients at Venous Thromboembolism Risk Eligible for Extended Thromboprophylaxis Using APEX Criteria in US Hospitals.

Major medical illnesses place patients at risk of venous thromboembolism (VTE). Some risk factors including age ≥75 years or history of cancer place them at increased risk of VTE that extends for at least 5 to 6 weeks following hospital admission. Betrixaban thromboprophylaxis is now approved in the United States for this indication. We estimated the annual number of acutely ill medical patients at extended risk of VTE discharged from US hospital. Major medical illnesses (stroke, respiratory failure/chronic obstructive pulmonary disease, heart failure, pneumonia, other infections, and rheumatologic disorders) and 2 common risk factors for extended VTE risk, namely, age ≥75 years and history of cancer (active or past) were examined in 2014 US hospital discharges using the first 3 discharge diagnosis codes in the National Inpatient Sample (database of acute-care hospital discharges from the US Agency for Health Care Quality and Research). In 2014, there were 20.8 million discharges with potentially at risk of nonsurgical-related VTE. Overall, 7.2 million (35%) discharges corresponded to major medical illness that warranted thromboprophylaxis according to 2012 American College of Chest Physicians (ACCP) guideline. Among them, 2.79 million were aged ≥75 years and 1.36 million had a history of cancer (aged 40-74 years). Overall, 3.48 million discharges were at extended risk of VTE. Many medical inpatients at risk of VTE according to 2012 ACCP guideline might benefit from the awareness of continuing risk and some of these patients might benefit from extended thromboprophylaxis, depending on the risk of bleeding and comorbidities.

MS18.04 Retreatment with Platinum and Etoposide and Treatment Beyond Second Line

Extensive stage small cell lung cancer (SCLC) is characterized by an initial response to chemotherapy followed by progression usually within 6 months. The clinical approach to second line therapy and beyond depends on patient wishes, performance status (PS), and duration of response to initial therapy or progression free interval (PFI). While some have challenged the importance of PFI in selection of subsequent therapy (1), guidelines by the European Society of Medical Oncologists (ESMO) (2) and the American College of Chest Physicians (ACCP)(3), recommend treatment options based on PFI. This presentation will focus on retreatment with platinum-based chemotherapy and treatment beyond second line. The ACCP guidelines, which have been endorsed by the American Society of Medical Oncology (ASCO) recommend re-challenge with the first line regimen in patients with a PFI of at least 6 months. The ESMO guidelines define sensitive relapse as a PFI of more than 3 months and suggest these patients may derive benefit from re-challenge with the original, usually platinum based, regimen. Genestreti (4) evaluated the benefit of re-challenge with platinum-etoposide in a retrospective, multi-institutional review. In 112 patients who progressed more than 90 days after initial chemotherapy, re-challenge with platinum-etoposide resulted in a response rate (RR) of 45% and a median overall survival (mOS) from re-challenge of 7.9 months. There was no difference in survival using PFI of 90, 120, or 150 days. A second European multicenter study (5) reported outcomes of 161 patients receiving second line therapy. Platinum sensitive patients (PFI 3 months) who were re-challenged had a higher RR and longer mOS. Response to first line therapy and PS were independent predictors of survival. Single institutional series have also supported the importance of sensitivity to first line therapy in determining second line treatment. Nagy-Mignotte (6) defined sensitive disease as PFI of at least 3 months. Of the 300 patients who received first line platinum-etoposide therapy, 48% had sensitive disease and the majority of these (72%) were re-challenged. The RR to re-challenge was 65% (21% complete response) and mOS from second line was 9.3 months. Patients with resistant or refractory disease were primarily treated with taxanes or topotecan. The RR in these patients was 21% with mOS of 5.2 months and 3.8 months. Kim et al (7) found response to initial therapy and PS to be significantly associated with survival after second line therapy in 232 patients from a single institution in Japan. Treatment Beyond Second Line There are currently no approved third line therapies for SCLC and the evidence for benefit from any therapy consists of retrospective reports and phase II trials. In the largest series reported from Japan (8) only 30% of SCLC patients receiving first line therapy went on to receive third line treatment. The majority of patients received single agent therapy in third line with amrubicin being most common (47%). Independent prognostic factors were time to treatment failure of at least 5 months and PS at time of third line therapy. A Dutch study found only 18% of their SCLC patients received at least 3 lines of therapy. The RR to third line was 25% with mOS of 5 months (9). An international multi-center retrospective analysis (10) found that the majority of patients were re-challenged with a regimen previously received in first or second line, with 6% of patients receiving platinum-based chemotherapy in all 3 lines. The RR was modest at 18% with mOS from third line of 4.7 months. Response to second line therapy was predictive of response to third line but only baseline LDH was prognostic for survival. It is clear that few patients with SCLC go on to receive treatment beyond second line. However, carefully selected patients with good PS may derive benefit. There is a need for new, active therapies. The most promising new options for treatment beyond second line include targeted therapy to DLL3 (rovalpituzumab-T) and immunotherapy. Updated results with these agents will be discussed. Lara P et al Journal of Thoracic Oncology 2015; 10(1):110-115 Fruh M et al Annals of Oncology 2013; 24 (Suppl 6): vi99-vi 105 Jett J et al Chest 2013; 143 (5) (Supp): e4005-e4019 Genestreti G et al Clinical Lung Cancer 2015; 6: 223-8) Garassino MC et al Lung Cancer 2011; 72: 378-83 Nagy-Mignotte H Clinical Lung Cancer 2012; 78: 112-120 Kim YH et al Cancer 2008; 113: 2518-23 Saruwatari K et al Clinical Lung Cancer 2016; 17:581-87 DeJong WK et al, Lung Cancer 2006; 52: 339-42 Simos D et al Clinical Lung Cancer 2014; 15: 110-118 retreatment small cell

Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study.

Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.

Wishing It True Doesn't Make It So: Commentary on an article by Gregory M. Mendez, MD, et al.: "Aspirin for Prophylaxis Against Venous Thromboembolism After Orthopaedic Oncologic Surgery".

Commentary In this article, Mendez et al. offer their experience with use of aspirin for venous thromboembolism (VTE) prophylaxis specifically in orthopaedic oncology patients. They conclude that aspirin is a “suitable” chemoprophylactic agent. I wish this were so because aspirin is such a simple agent to prescribe and use. However, few topics in orthopaedics are as controversial as the selection of appropriate prophylaxis postoperatively. Prophylaxis for VTE in general has been the focus of numerous randomized prospective clinical trials with Level-I evidence, but even those have not always agreed. Hence, study panels of the American College of Chest Physicians (ACCP), American Academy of Orthopaedic Surgeons (AAOS), and American Society of Clinical Oncology (ASCO) continue to publish guidelines based on their interpretation of the latest literature. Despite these guidelines, there is considerable flexibility in a physician’s or surgeon’s choices for VTE prophylaxis. The controversy about VTE prophylaxis has been particularly contentious with respect to aspirin. As noted by Mendez et al., the ACCP guidelines recommended against its use in 2008 but then added aspirin as an acceptable agent in 2012. ASCO guidelines recommend against aspirin use and suggest only unfractionated heparin or low-molecular-weight heparin (LMWH) be used for patients with cancer who are undergoing major surgery. However, they do allow for aspirin use in patients on chemotherapy for myeloma. Citing ambiguity in the evidence, the AAOS guidelines allow use of aspirin as well as a pneumatic compressive device or any other chemotherapeutic agent for postoperative VTE prophylaxis following hip and knee arthroplasty. Mendez et al. are correct in asserting that universal surgical guidelines do little to direct the orthopaedic oncologist in the selection of VTE prophylaxis. However, does their article provide us the missing but desired direction? I believe that it is difficult to know how to use their findings. First, the number of patients in their study was relatively small (130 patients with a total of 142 procedures). In a recent systematic review and meta-analysis of computerized clinical decision support systems for VTE prophylaxis, 11 publications (including 9 prospective cohort trials) involving 156,366 subjects (an average 14,408 subjects per trial) were reviewed1. Even among 7 prior studies of VTE in orthopaedic oncology, the average number of patients was 348 (range, 94 to 986). Moreover, 5 of those studies were focused on incidence and risk factors for VTE. The only 2 treatment studies in orthopaedic oncology involved 348 subjects (treated with aspirin and a pneumatic compression device or with LMWH and a pneumatic compression device) and 986 subjects (treated with LMWH)2,3. Second, although this was a retrospective study, and hence intention-to-treat (ITT) analysis was not applicable, the authors clearly intended for all of their patients to receive aspirin; however, only 73% did so. Reasons for protocol deviation included an outpatient operative procedure not requiring chemoprophylaxis, patient refusal, aspirin allergy, VTE history, and a desire for a readily reversible option in case an early return to the operating room was necessary. Third, the orthopaedic oncology patient population studied by Mendez et al. was broad in its scope of inclusion criteria, which included metastatic carcinoma, myeloma, lymphoma, and sarcoma, further diluting the numbers for subgroup analysis. It also differs somewhat from prior reports in that more than one-half of the patients had metastatic carcinoma whereas some larger studies in orthopaedic oncology included predominantly or exclusively patients with sarcoma4,5. Thus, we must greatly temper our enthusiasm for the conclusion that aspirin is a suitable agent with the realization that the data are based on a small number of patients relative to the large body of literature on this topic. Also, the study was not a pure evaluation of patients treated only with aspirin, but rather a real-practice evaluation in which there were protocol deviations for various reasons; hence, its conclusions should not be extended to patients who had outpatient surgical procedures or a VTE history, for instance. Finally, although a broad range of orthopaedic oncology diagnoses were included, this actually makes it difficult to know how readily the results could be applied to patients with any one of those diagnoses. In conclusion, as much as I want aspirin to be a safe and efficacious VTE chemoprophylactic agent for all of my orthopaedic oncology patients, these results should not be interpreted as definitive support until additional studies are done.

MTE 27.02 Pulmonary Nodule Guidelines: How Do We Decide Between the IELCAP, ACCP, NCCN, Fleischner Society, BTS, and Lung-RADS?

In the era of multidetector CT and lung cancer screening with low-dose CT, there are increasing number of incidentally or screen detected pulmonary nodules. Because a pulmonary nodule is an important finding of lung cancer, how to manage these nodules has become an essential issue in dealing with lung cancer, which explains why many guidelines on this topic are available. In this talk, overview of several well-established guidelines or protocols of International Early Lung Cancer Action Program (IELCAP), the American College of Chest Physicians (ACCP), National Comprehensive Cancer Network (NCCN), Fleischner Society, British Thoracic Society (BTS), and Lung CT screening Reporting and Data System (Lung-RADS) will be introduced. Nodule management protocols are different whether nodules are detected at screening programs or incidentally. Screening programs target high-risk subjects who need consistent monitoring, whereas incidentally detected lung nodules represent a different population that needs a varied clinical management. ACCP, BTS, and Fleischner Society guidelines deal with incidental nodules, while IELCAP and Lung-RADS are protocols for screening programs. NCCN guidelines state both issues with separate algorithms. Most pulmonary nodule guidelines have common components: risk factor assessment, nodule size, and nodule consistency. Baseline and annual repeat protocols are different at screening programs. Risk factors include age, smoking history, family history, previous cancer history, occupation exposure, etc. Nodules smaller than certain thresholds (NCCN, < 4 mm; ACCP and BTS, < 5 mm; Fleischner, IELCAP, and Lung-RADS, < 6 mm) do not require routine follow-up. The management for larger nodules varies with guidelines, but 8 mm and/or 15 mm are frequently recommended thresholds for more workups. Nodules can be classified into solid, part-solid, and pure ground-glass nodule according to their consistency. Because the likelihood of malignancy and growth rates are quite different depending on the nodule consistency, this classification is important in nodule management. Nodule volumetry and risk-prediction models such as the Brock University tool, currently employed in BTS guidelines, may be used more frequently in future guidelines. While the Fleischner Society, IELCAP, and Lung-RADS guidelines are relatively straightforward focused on the initial workup, ACCP, NCCN, and BTS guidelines also deal with the further workup and treatment. Some studies have shown that there is high awareness and adoption of these guidelines, but there are varying degrees of conformance with these recommendations. With the accumulation of large data, these guidelines will be more meticulous and evidence-based. Computerized tools that can assess both clinical and radiologic information will facilitate handling the issue of nodule management. 1. I-ELCAP protocol documents at http://www.ielcap.org/protocols Gould MK, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e93S-e120S. 2. NCCN guidelines at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp. 3. Callister ME, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-ii54. 4. MacMahon H, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. Lung-RADS at https://www.acr.org/Quality-Safety/Resources/LungRADS. guidelines, lung cancer, lung nodule management

ES 02.02 The Fleischner Guideline / Lung-RADs

ES 02.02 The Fleischner Guideline / Lung-RADs

Epidemiology, Risk Factors and Risk Stratification of Venous Thromboembolism in Pregnancy and the Puerperium

Venous thromboembolism (VTE) remains a leading cause of direct maternal deaths in the developed countries. The incidence of VTE has increased significantly during the past two decades. The absolute risk of VTE is estimated 0.6-2.2 per 1000 deliveries. Compared with age-matched non-pregnant women, the daily risk of VTE is increased 7- to 10-fold for antepartum VTE, but it is 15- to 35-fold for postpartum VTE. The incidence of pulmonary embolism (PE) during the first 6 weeks postpartum is nearly 15-fold higher compared to the incidence in pregnancy, and remains significantly increased up to 12 weeks postpartum. The case fatality rate of PE ranges from 2.2 to 6.6%.The basis of VTE prevention is careful assessment of individual risk factors of VTE and proper risk stratification.It is necessary to differentiate preexisting maternal from transient pregnancy-specific risk factors. Women with previous VTE or hereditary high-risk thrombophilias or with the antiphospholipid syndrome have the highest risk for VTE in pregnancy and the puerperium.Other most important pregnancy-specific risk factors in the antenatal period are severe ovarian hyperstimulation syndrome, hyperemesis, major surgery, severe comorbidities (e.g., systemic lupus erythematodes), hospitalization in women with a body mass index > 25 kg/m2, and inflammatory bowel diseases.Heart diseases, stillbirth, systemic infections, severe postpartum hemorrhage in combination with blood product replacement and/or surgery and emergency caesarean section are predominant risk factors in the postpartum period.Recommendations for risk stratification vary among current international guidelines. According to the SOGC (Society of Obstetricians and Gynaecologists of Canada) 2014, pharmacologic VTE prophylaxis is recommended if the estimated absolute risk of one or multiple risk factors is greater than 1%.The ACCP (American College of Chest Physicians) Guideline 2012 presents specific recommendations only for post-caesarean risk-factor-based prophylaxis.The recent RCOG (Royal College of Obstetricians and Gynaecologists) Guideline No. 37a 2015 recommends risk stratification for VTE prophylaxis on the basis of a special risk scoring system weighting individual risk factors between one point (low risk) to a maximum of 4 points (very high risk).A check list of important risk factors and a management plan for thromboprophylaxis based on current guidelines should be readily available in each obstetric unit.

44: DETERMINATION OF FREQUENCY PERCENTAGE OF PROPHYLAXIS UTILIZATION AGAINST DEEP VEIN THROMBOSIS AMONG PATIENTS HOSPITALIZED IN DIFFERENT WARDS OF IMAM KHOMEINI TEACHING HOSPITAL

Background and aims:The current survey aims at determining the frequency percentage of Prophylaxis usage against deep vein thrombosis (DVT) according to ACCP instruction among the patients hospitalized in Imam Khomeini...

Role of the clinical pharmacist in improving the appropriateness of venous thromboembolism prophylaxis in hospitalised patients in Jordan

AbstractBackgroundVenous thromboembolism (VTE) is one of the most important preventable causes of death in hospitalised patients. The role of the clinical pharmacist in Jordan is still at its beginnings in this field; this study explored the contribution of the clinical pharmacist to improving the frequency of appropriate VTE prophylaxis.AimTo evaluate the role of the clinical pharmacist in improving appropriate VTE prophylaxis in a tertiary hospital.MethodsThis study with a single‐group pretest‐post test design. Recommendations of the clinical pharmacist concerning VTE prophylaxis for a group of hospitalised patients with odd ID numbers were provided to physicians. The main outcome measure was the appropriateness of VTE prophylaxis; therapy was defined as appropriate when it was fully concordant with the American College of Chest Physicians (ACCP) guidelines. Appropriateness of VTE prophylaxis was measured before and after the provision of recommendations.ResultsThe extent of concordance with the ACCP guidelines increased from 78.9% to 87.8%, with a statistically significant increase of 8.9% (p &lt; 0.001).ConclusionEmployment of a clinical pharmacist coincided with an improvement in the rate of appropriate VTE prophylaxis.