American College Of Chest Physicians Research Articles

PULMONARY REHABILITATION IN ROMANIA: FROM THE BEGINNINGS TO THE PRESENT

Pulmonary rehabilitation is the standard of care for patients with chronic lung disease. Material and method: Starting from the systematic review of specialized literature and practical expertise obtained both internationally and nationally, the exposition emphasizes the aspects related to pulmonary rehabilitation in patients with chronic lung diseases. Results: The cornerstone of pulmonary rehabilitation is the American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation published in 2006 and developed based on the documents of the American College of Chest Physicians (ACCP) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) published in 1997 and 2004. The document was subsequently updated in 2007, 2013, 2015, 2021 and 2023, with the concept of pulmonary rehabilitation constantly evolving over the years. In Romania, pulmonary rehabilitation is carried out according to these guidelines and international standards, Iasi being a reference center in this field. Conclusions: Pulmonary rehabilitation is one of the most powerful evidence-based therapies for patients with chronic lung disease. Keywords: COPD, exercise capacity, training, quality of life.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update.

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Noteworthy in Cardiothoracic Surgery 2023.

Noteworthy in Cardiothoracic Surgery 2023 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery and transplantation this past year. Transplantation using organs procured from donation after circulatory death (DCD) continues to increase, and the American Society of Transplant Surgeons released recommendations on best practices in 2023. We review a summary of data on the impact of DCD on heart and lung transplantation. There has been increased interest in extracorporeal life support (ECLS), particularly after the COVID-19 pandemic, and we review the results of the highly discussed ECLS-SHOCK trial, which randomized patients in cardiogenic shock with planned revascularization to ECLS vs usual care. With improving survival outcomes in complex aortic surgery, there is a need for higher-quality evidence to guide which cooling and cerebral perfusion strategies may optimize cognitive outcomes in these patients. We review the short-term outcomes of the GOT ICE trial (Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest), a multicenter, randomized controlled trial of three different nadir temperatures, evaluating outcomes in cognition and associated changes in functional magnetic resonance imaging. Finally, both the Society of Thoracic Surgeons (STS) and the American College of Cardiology, American Heart Association, American College of Chest Physicians and Heart Rhythm Society (ACC/AHA/ACCP/HRS) updated atrial fibrillation guidelines in 2023, and we review surgically relevant updates to the guidelines and the evidence behind them.

Evaluation of Initial Enoxaparin Dosing and Antifactor Xa Levels in Infants Admitted to the Neonatal Intensive Care Unit.

Infants are at risk for thrombotic conditions due to multiple risk factors such as congenital heart defects and sepsis. According to the American College of Chest Physicians (ACCP) 2012 guidelines, enoxaparin may be given for thrombotic conditions at a dose of 1.5 mg/kg/dose every 12 h for patients less than 2 months of age and 1 mg/kg/dose every 12 h for those older than 2 months. Several studies have reported that infants typically require a higher initial dose of enoxaparin to reach therapeutic antifactor Xa levels than what is currently recommended. This is a single-center retrospective case-control study of hospitalized infants less than 12 months of age who received treatment with enoxaparin while admitted to the neonatal intensive care unit (NICU) at a freestanding children's hospital. The primary objective was the difference between the initial enoxaparin dose (mg/kg) compared to the enoxaparin dose in which the patient first achieved a therapeutic antifactor Xa level of 0.5-1.0 units/mL. A total of 56 infants were included in this study. The median enoxaparin dose at initiation was 1.5 mg/kg/dose, and the median enoxaparin dose at the first therapeutic antifactor Xa level was 1.9 mg/kg/dose (z = -12.7, p < 0.0001). There was no correlation between gestational age and weight with the enoxaparin dose required to reach a therapeutic antifactor Xa level. Infants admitted to the NICU, specifically those less than 4 months of age, require higher initial enoxaparin dosing to reach therapeutic antifactor Xa levels than what is currently recommended.

Chronic cough in children: an evidence-based clinical practice guideline adapted for the use in Egypt using ‘Adapted ADAPTE’

BackgroundWe recently adopted a guideline for chronic cough in children in the Egyptian health system. Adapting clinical practice guidelines (CPGs) to the local healthcare setting is a valid alternative to de-novo development that can improve their uptake and implementation without demanding a substantial drain on resources. The objective of this study was to adapt evidence-based recommendations from global high-quality CPGs for children with a chronic cough to suit the Egyptian healthcare context.MethodsWe followed the Adapted ADAPTE methodological framework for guideline adaptation. This process includes three phases: set-up, adaptation, and finalization. A guideline adaptation group (GAG) and an external review group including clinical content experts and methodologists conducted the process.ResultsThe GAG adapted 10 sections of recommendations from three original CPG(s) including (i) the American College of Chest Physicians (ACCP) 2006–2020, (ii) the European Respiratory Society (ERS) 2019, (iii) the Korean Academy of Asthma, Allergy and Clinical Immunology (KAAACI) 2018. A set of CPG implementation tools was added to enhance implementability including an algorithm, a slide presentation for clinical diagnosis, investigations and treatment of chronic cough, patient education, and online resources.ConclusionThe adapted CPG provides pediatricians and related healthcare workers with applicable evidence-based recommendations for chronic cough in children in Egypt. The project also highlighted the utility of Adapted ADAPTE and the invaluable collaboration between the clinical and methodological experts for the adaptation of pediatric national guidelines.

Management of lower-extremity venous thromboembolism: An updated review.

According to the 2021 updated guidelines of the American College of Chest Physicians, the location of venous thromboembolism, the severity of symptoms, the risk of thrombus extension vs that of bleeding, and comorbidities all affect the decision to treat, the choice of anti-thrombotic agent, and the duration of therapy. In patients with isolated distal deep vein thrombosis without high-risk features, monitoring progression is recommended over initiating anticoagulation. However, treatment of proximal deep vein thrombosis with anticoagulation is strongly recommended by the guidelines. More evidence now supports the treatment of superficial vein thrombosis with anticoagulation in high-risk patients.

The efficacy of aspirin as a prophylactic agent for patients recovering from total knee arthroplasties

Guidelines regarding deep vein thrombosis (DVT) prophylaxis following total knee arthroplasties (TKAs) have had conflicting information regarding the use of aspirin as a prophylactic agent in recent years. The National Institute for Clinical Excellence refrains from listing the drug in its guidelines, while the American College of Chest Physicians advocates for the drug. Despite the conflicting guidelines, physicians have favored the drug in recent years, with more than 80% utilizing it as a prophylactic agent in TKAs. Although a consensus may have been reached by physicians regarding the use of the drug, a consensus has not been reached regarding the preferred dosage. With this in mind, a search of the PubMed database was conducted, which yielded six studies that discussed the efficacy of various dose ranges of aspirin. All studies corroborated that not only was aspirin an effective prophylactic agent but also that there was no significant difference between dosages regarding efficacies. Due to factors such as aspirin resistance and the potential of aspirin to cause gastrointestinal injuries, this literature review concludes that the dosage of aspirin given for the prophylaxis of DVT in TKAs should be considered on a patient-to-patient basis.

Management of isolated distal deep vein thrombosis.

Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound series and is a frequent medical condition, which management is not well established. Data arising from registries and non-randomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. This data had some impact on international recommendations like the American College of Chest Physicians (ACCP), whose last version stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only seven randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. When considering randomized placebo-controlled trials, one included low-risk patients and was hampered by a limited statistical power (CACTUS study). Nevertheless, data from this trial tend to confirm that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a higher risk of bleeding. A second randomized placebo-controlled trial did not assess the necessity of anticoagulant treatment but rather the long-term risk of recurrence and compared 6 weeks versus 12 weeks of treatment with rivaroxaban (RIDTS study). Finally, the last available randomized trial compared a 3-month versus a 12-month edoxaban treatment in patients with cancer and mainly asymptomatic distal DVT, detected by systematic compression ultrasonography. Overall, available data suggest that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE. High risk patients (previous VTE, active cancer, inpatients) might benefit from a course of anticoagulant treatment. However, the optimal anticoagulant intensity and duration are uncertain and further studies are needed.

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement.

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update.

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians.

Assessment of Advanced Diagnostic Bronchoscopy Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American College of Chest Physicians Research Statement.

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

The effects of the menstrual cycle on the physiological responses to exercise in eumenorrheic women at high-altitude

Introduction&#x0D; The acute mountain sickness (AMS) prevalence increases with altitude; i.e.,10-25% at 2,500 m and 50-85% at ~5,000 m (Bärtsch &amp; Swenson, 2013). Women are more likely affected by AMS than men (Richalet et al., 2012). AMS can affect exercise performance. However, the effects of the menstrual cycle (MC) on physiological responses to exercise and on tolerance to high-altitude (HA) remain underexplored. It has been reported that ovarian hormones stimulate ventilation in normoxic conditions (Saaresranta &amp; Polo, 2002). Early findings suggest that running economy is lower in the mid-luteal (ML) compared to the early-follicular (EF) phase in normoxia (Goldsmith &amp; Glaister, 2020). However, cycling efficiency at HA has not been explored yet. Thus, we investigated the effects of acute HA exposure on ventilatory responses at rest and during exercise in healthy females during two different phases of their MC.&#x0D; Methods&#x0D; Sixteen eumenorrheic women (age: 33 ± 7 yr; MC length: 27 ± 2 days; not taking any hormonal contraceptive) took part in this study. First, over a 6-month period, the participants’ MC were monitored using a calendar method. Then, they reached the Torino Hut (3,375 m) by cable car and spent one night at HA on two different MC phases; i.e., during the early-follicular (EF; MC day 4 ± 1) and the mid-luteal (ML; day 20 ± 2) phases. Each time, they underwent a submaximal (1.2 W/kg) test on a cycle ergometer ~17 h after arrival at HA. In addition to this, participants filled in two questionnaires, the Lake Louise AMS Score and the Groningen Sleep Quality Scale, ~16 h after arrival at HA.&#x0D; Results&#x0D; Resting ventilation was significantly higher during EF compared to ML (15.2 ± 1.9 vs. 13.2 ± 2.5 L/min, p = 0.039), while no differences were found for ventilation during exercise (53.9 ± 13.2 vs. 53.5 ± 13.4 L/min, p = 0.695), cycling efficiency (21.7 ± 0.0% vs. 19.8 ± 0.0%, p = 0.244), saturation at rest (92.4 ± 1.3 vs. 91.3 ± 3.2%, p = 0.142) and during exercise (87.2 ± 5.7 vs. 89.0 ± 4.0%, p = 0.528). Moreover, no differences in the Lake Louise AMS (2.2 ± 1.5 vs. 1.7 ± 1.5, p = 0.266) or Groningen (8.0 ± 3.3 vs. 7.5 ± 3.4, p = 0.668) scores were noted between the two MC phases.&#x0D; Discussion/Conclusion&#x0D; Despite a slightly higher resting ventilation during EF, when both oestrogens and progesterone are at their lowest levels, there were no differences in ventilatory responses to exercise and in AMS between the different phases of the MC. Consequently, there is currently very little evidence to aptly recommend a specific MC phase for mountaineering or any other HA activities (Burtscher et al., 2023). Further investigations are requested to assess whether other physiological responses to HA may be influenced by hormonal variations.&#x0D; References&#x0D; Bärtsch, P., &amp; Swenson, E. R. (2013). Acute high-altitude illnesses. New England Journal of Medicine, 368, 2294–2302. https://doi.org/10.1056/NEJMcp1214870&#x0D; Burtscher, J., Raberin, A., Brocherie, F., Malatesta, D., Manferdelli, G., Citherlet, T., Krumm, B., Bourdillon, N., Antero, J., Rasica, L., Burtscher, M. &amp; Millet, G. P. (2023). Recommendations for women in mountain sports and hypoxia training/conditioning. Sports Medicine. Advance online publication. https://doi.org/10.1007/s40279-023-01970-6&#x0D; Goldsmith, E., &amp; Glaister, M. (2020). The effect of the menstrual cycle on running economy. The Journal of Sports Medicine and Physical Fitness, 60(4), 610–617. https://doi.org/10.23736/s0022-4707.20.10229-9&#x0D; Richalet, J.-P., Larmignat, P., Poitrine, E., Letournel, M., &amp; Canouï-Poitrine, F. (2012). Physiological risk factors for severe high-altitude illness: A prospective cohort study. American Journal of Respiratory and Critical Care Medecine, 185(2), 192–198. https://doi.org/10.1164/rccm.201108-1396OC&#x0D; Saaresranta, T., &amp; Polo, O. (2002). Hormones and breathing. American College of Chest Physicians, 122(6), 2165–2182. https://doi.org/10.1378/chest.122.6.2165

Addendum: Treatment of atrial fibrillation.

The Interruption of Anticoagulation section of our article on Treatment of Atrial Fibrillation cited the recommendations of the American College of Chest Physicians on perioperative management of antithrombotic therapy (JD Douketis et al. Chest 2022; 162:e207). A reader suggested that our general statement on when to discontinue an oral anticoagulant would have benefited from inclusion of the recommendations of the American College of Cardiology/American Heart Association (JA Joglar et al. Circulation 2024; 149:e1).

Prevention of venous thromboembolism in surgical patients: A proposal for a protocol based on the reality of a university hospital

Introduction: Venous thromboembolism (VTE) results from the formation of thrombi in the endothelial space, following factors related to endothelial injury, venous stasis and coagulation disorders. This scenario can result in deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE), which is the third leading cause of cardiovascular death worldwide. Given the possibility of preventing VTE in the majority of in-hospital cases, it is recommended that every hospital has a formal strategy for VTE prevention, including in patients undergoing elective surgery. To this end, it is possible to use risk stratification scales, both for the development of VTE and the baseline risk of bleeding in post-operative patients. Objective: To provide an institutional protocol that is systematized and updated according to the main national and international literature on the prevention of venous thromboembolism in elective surgeries at the Júlio Muller University Hospital (HUJM/ UFMT). Materials and Methods: A protocol was drawn up based on a systematic analysis of up-to-date scientific evidence on thromboprophylaxis in elective surgeries, adapted to the routine of the Júlio Muller University Hospital (HUJM/UFMT), using the UpToDate, Pubmed and Cochrane Library platforms, as well as the Guidelines of the Brazilian Society of Angiology and Vascular Surgery (SBACV) and the American College of Chest Physicians (ACCP). Conclusion: The patient's risk of developing VTE is largely due to avoidable or predictable risk factors, depending on the type of surgery, mobilization time and risk of bleeding. The use of a protocol for the prevention of venous thromboembolism through risk stratification will allow greater individualization of the patient in relation to established prophylaxis, based on scientific evidence. Further studies on the subject are still needed, especially in the setting of elective surgery.

Anticoagulation Stewardship to Bridge the Implementation Gap in Perioperative Anticoagulation Management.

Lack of alignment of care protocols among providers in health care is a driver of increased costs and suboptimal patient outcomes. Perioperative anticoagulation management is a good example of a complex area where protocol creation is a clinical challenge that demands input from multiple experts. Questions regarding the need for anticoagulation interruptions are frequent. Yet, due to layers of complexity involving analysis of anticoagulation indication, surgical risk, and anesthesia-associated bleeding risk as well as institutional practices, there is heterogeneity in how these interruptions are approached. The recent perioperative anticoagulation guidelines from the American College of Chest Physicians summarize extensive evidence for the management of anticoagulant and antiplatelet medications in patients who undergo elective interventions. However, implementation of these guidelines by individual clinicians is highly varied and often does not follow the best available clinical evidence. Against this background, anticoagulation stewardship units, which exist to improve safety and quality monitoring for the anticoagulated patient, are of growing interest. These units provide a bridge for the implementation of value-based, high-quality guidelines for patients who need perioperative anticoagulation interruption. We use a case to pragmatically illustrate the problem and tactics for change management and implementation science that may facilitate the adoption of perioperative anticoagulation guidelines.

Wilderness Medical Society Clinical Practice Guidelines on Water Treatment for Wilderness, International Travel, and Austere Situations: 2024 Update.

To provide guidance to medical providers, wilderness users, and travelers, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for treating water in situations where the potability of available water is not assured, including wilderness and international travel, areas impacted by disaster, and other areas without adequate sanitation. The guidelines present the available methods for reducing or eliminating microbiological contamination of water for individuals, groups, or households; evaluation of their effectiveness; and practical considerations. The evidence base includes both laboratory and clinical publications. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians.

An Evaluation of the Appropriateness of Initial Enoxaparin Dosing Among Pediatric Patients.

Background Enoxaparin is a low molecular weight heparin that irreversibly inactivates factor Xa leading to the inhibition of clot formation. Despite the non-FDA approval in pediatrics, enoxaparin is recommended with an initial dose of 1.5mg/kg/q12hrs for patients aged ≤ 2 months and 1mg/kg/q12hrs for patients > 2 months, targeting therapeutic anti-Xa with a range of 0.5 to 1 units/mL. Due to more rapid clearance in pediatrics, our study aims to assess the need for initial higher doses than recommended by the guideline to reach the target anti-Xa level. Methods A retrospective chart review of all pediatric patients under all specialties who were treated with enoxaparin either in inpatient or outpatient settings between February 2021 and June 2022 at children's specialized hospital and meet the inclusion criteria, including age ≤ 15 years old and treated with enoxaparin with initial dose according to the American College of Chest Physicians (CHEST) guideline, while patients who received prophylaxis dosesdid not have anti-Xa levels or creatinine clearance < 30 mL/min/1.73m2 were excluded. Demographic data, laboratory data, and enoxaparin dosing were all collected to assess whether the initial enoxaparin dose will result in a therapeutic level as a primary endpoint and secondary endpoints including the average enoxaparin dose required to achieve the therapeutic level and to report any side effects. All data were entered and analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25, Armonk, NY), and all categorical variables were reported as frequency and percentage while continuous variables expressed as mean ± SD and the study was approved by our research center institutional review board (IRB). Results Thirty patients were included in the study (17 males), 10 patients were aged ≤ 2 months, four were between 3 and 12 months and 16 were > 12 months, most of the patients received enoxaparin for deep vein thrombosis. In the majority of patients (76.7%), the initial dose failed to achieve the target anti-Xa while a mean dose of 2 mg/kg/q12hrs in patients ≤ 2 months, 1.7mg/kg/q12hrs in patients 3-12 months and 1.3 mg/kg/q12hrs in patients > 12 months was sufficient to reach the target level. After achieving a therapeutic anti-Xa level, only one patient experienced major bleeding while four patients experienced minor bleeding, no edema or thrombocytopenia were reported. Conclusion In conclusion, initiating enoxaparin according to the recommended dose by the guideline failed to achieve target anti-Xa in the majority of patients which necessitates starting enoxaparin with initial higher doses according to the patient's age to provide more prompt achievement of target anti-Xa.

Venous thromboembolism in orthopedic surgery: Global guidelines.

Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM. Level of Evidence: Level V, Expert opinion.

Guideline Compliance and Indications for Inferior Vena Cava Filter Placement at a Quaternary Care Medical Center.

This study investigated physician compliance with indications for inferior vena cava (IVC) filter placement according to the 2012 American College of Chest Physicians (ACCP) and the 2011 Society of Interventional Radiology (SIR) guidelines. A retrospective medical record review of 231 retrievable IVC filters placed between August 15, 2016, and December 28, 2017, at a large urban academic medical center. Guideline compliance to the 2012 ACCP and the 2011 SIR guidelines, and indications for IVC filter placements were assessed through an adjudication protocol. Filter retrieval and complication rates were also examined. Compliance to guidelines was low (60.2% for ACCP; 74.0% for SIR), especially for non-intensive care unit (ICU) patients (ICU 74.6% vs non-ICU 54.8%, p=0.007 for ACCP; ICU 82.5% vs non-ICU 70.8%, p=0.092 for SIR). After adjudication, 8.2% (19/231) of filters were considered non-indicated but reasonable, 17.7% (41/231) non-indicated and unreasonable, and 13.9% (32/231) SIR-indicated but not ACCP-indicated. The most common indication was venous thromboembolism with contraindication to anticoagulation. The most common reasons for non-compliance were distal deep venous thrombosis with contraindication to anticoagulation (19/60, 31.6%) and clot burden (19/60, 31.6%). One-year filter retrieval and 90-day complication rates were 32.0% (74/231) and 6.1% (14/231), respectively. Compliance to established guidelines was low. Reasons for non-compliance included limitations or discrepancies in guidelines, as well as non-evidence-based filter placements. Despite increasing utilization of inferior vena cava (IVC) filters, guideline compliance for IVC filter placement among providers is unclear. The results of this study indicate that physician compliance to established guidelines is poor, especially in non-intensive-care-unit patients. Noncompliance stems from non-evidence-based filter placement as well as differences and limitations in guidelines. Avoiding non-indicated IVC filter placement and consolidation of guidelines may significantly improve guideline compliance. The critical insights gained from this study can help promote judicious use of IVC filters and highlight the role of venous thromboembolism experts in navigating complex cases and nuances of guidelines.

Racial and ethnic disparities in eligibility for postpartum venous thromboembolism prophylaxis in the United States

BackgroundPostpartum venous thromboembolism (VTE) incidence differs by race and ethnicity in the United States. However, it is unclear whether the eligibility criteria for postpartum VTE prophylaxis mirror this disparity. ObjectiveTo characterize the prevalence of risk factors and eligibility for postpartum VTE prophylaxis, among US Birthing people, stratified by race and ethnicity. MethodsWe analyzed the National Inpatient Sample from October 2015 to December 2019, using diagnosis and procedure codes to identify postpartum individuals and their VTE risk factors. We compared proportion of delivery hospitalizations meeting eligibility for thromboprophylaxis stratified by race or ethnicity, according to American College of Gynecology and Obstetrics, American College of Chest Physicians, Royal College of Obstetricians and Gynecologists (RCOG), and American Society for Hematology guidelines. ResultsAmong a national estimate of 14 967 861 delivery hospitalizations in the United States, the proportion of individuals eligible for thromboprophylaxis using the RCOG, American College of Chest Physicians, American College of Gynecology and Obstetrics, and American Society for Hematology guidelines were 32.9%, 8.0%, 0.2%, and 0.2%, respectively. Using the RCOG criteria, non-Hispanic Black individuals had the highest proportion of thromboprophylaxis eligibility (39.7%), whereas it was lowest among Hispanic individuals (30.8%). Racial disparities in thromboprophylaxis eligibility were driven by differences in clinical risk factors (38.8% non-Hispanic Black population vs 30.5% Hispanic population) and cesarean section rates (35.9% vs 32.2%), rather than history of VTE (0.3% vs 0.1%), inherited thrombophilia (0.2% vs 0.2%), or sickle cell disease (0.4% vs <0.1%). ConclusionNon-Hispanic Black individuals were most likely to qualify for postpartum thromboprophylaxis, attributable to clinical risk factors rather than inherited risk factors. An urgent need exists to better understand ethno-racial disparities in thromboprophylaxis use and to equitably address modifiable risk factors for postpartum VTE.