American College Of Chest Physicians Research Articles

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.

Empowering lung cancer survivors and family members to “breathe easier”: Adaptation and evaluation of a m-health intervention.

e23046 Background: Survivors of lung cancer often experience a myriad of symptoms that have devastating effects on their physical and psychological functioning such as dyspnea, fatigue, and stress. To combat these symptoms, the American College of Chest Physicians has recommended the use of complementary therapies. Mindfulness-based Cancer Recovery (MBCR) can empower survivors, and caregivers who often cope with their own health problems and the stress related to caring for a survivor. Our goal is to deliver a tailored, culturally sensitive, MBCR intervention to survivors and family members via a mHealth app. Methods: This research was comprised of four phases. Phase I was the development and testing of an 8-week in-person intervention called Breathe Easier with survivors and family members (dyads). Phase II adapted Breathe Easier into a mHealth app prototype utilizing user-centered design. Phase III was a focus-group evaluation of the usability and acceptance of the mHealth app prototype by survivors and family members. Phase IV was comprised of additional interviews with an African-American subset of survivors and family members to assess the cultural sensitivity of the mHealth app. Results: Findings from the in-person intervention (n = 62) showed that all agreed the intervention materials were acceptable, different levels of yoga, breathing exercises, and meditations helped them, and involving a family member was important. Preliminary analyses showed survivors had less dyspnea and perceived stress over time (T1 vs T2). Both groups had improved fatigue and sleep scores. Findings from the mHealth app design and acceptance evaluation were organized into two primary categories: usefulness and ease of use. User-friendly design recommendations included aesthetic appeal, navigation layout, and display of content. Furthermore, potential health outcomes, privacy concerns, and comparison to in-person interventions also influenced app usefulness and acceptance. Lastly, findings from our cultural sensitivity assessment demonstrated that the mHealth app was culturally sensitive for African-Americans, but some changes were recommended. Conclusions: MBCR interventions hold great promise for improving the lives of racially diverse survivors of lung cancer and family members. An mHealth app will increase accessibility. However, special consideration of app design is needed to ensure future acceptance and longer-term usage.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients.

BackgroundA recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings.ObjectivesTo examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals.MethodsThe primary source for this retrospective observational study was the MarketScan® 2013–2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated.ResultsOf the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year.ConclusionsThe majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

No Apparent Workup for most new Indeterminate Pulmonary Nodules in US Commercially-Insured Patients

Background: A recent study estimated that more than 1.5 million Americans have an indeterminate pulmonary nodule (IPN) identified on a chest computed tomography (CT) scan each year outside of lung cancer screening programs. However, the cost and pattern of subsequent IPN workup have not been described for real-world settings. Objectives: To examine the pattern and cost of IPN workup in real-world practice using insurer administrative claims data for commercially-insured individuals. Methods: The primary source for this retrospective observational study was the MarketScan® 2013-2016 databases, which include information on 28 to 47 million insured lives. The newly diagnosed IPN study population consisted of members with an IPN diagnosis code on a claim in 2014 who did not have prior diagnosis of an IPN or lung cancer in 2013 and who had coverage from 2014 to 2016. Subsequent claims were examined for workups included in the American College of Chest Physicians (ACCP) guideline recommendations and the costs of workup were tabulated. Results: Of the 15 064 patients in the study population, only 5471 (36%) received any subsequent workup. The average and median costs of workup for these patients were $3270 and $2068, respectively. Spread across the commercially-insured population, the workup is estimated to cost between $1 and $2 per member per year. Conclusions: The majority of commercially-insured members with newly identified IPNs do not appear to have any guideline-recommended workup, despite a low incremental cost of such workup services on a population basis.

Risk factors and outcomes of urosepsis in patients with calculous pyonephrosis receiving surgical intervention: a single-center retrospective study

BackgroundUrosepsis is a catastrophic complication, which can easily develop into septic shock and lead to death if not diagnosed early and effectively treated in time. However, there is a lack of evidence on the risk factors and outcomes in calculous pyonephrosis patients. Therefore, this study was conducted to identify risk factors and outcomes of intra- and postoperative urosepsis in this particular population.MethodsClinical data of 287 patients with calculous pyonephrosis were collected. In the univariate and multivariate analysis, all patients were divided into urosepsis group and non-urosepsis group. The diagnosis of urosepsis was mainly on the basis of the criteria of American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM). Patient characteristics and outcomes data were analyzed, and risk factors were assessed by binary logistic regression analysis.ResultsOf 287 patients, 41 (14.3%) acquired urosepsis. Univariate analysis showed that white blood cell (WBC > 10*10^9/L) before surgery (P = 0.027), surgery types (P = 0.009), hypotension during surgery (P < 0.001) and urgent surgery (P < 0.001) were associated with intra- and postoperative urosepsis for calculous pyonephrosis patients. In multivariate analysis, hypotension during surgery and urgent surgery were closely related to intra- and postoperative urosepsis. Outcome analysis suggested that patients developing urosepsis had a longer intensive care unit (ICU) stay and postoperative hospital stay and higher mortality.ConclusionsHypotension during surgery and urgent surgery were risk factors of intra- and postoperative urosepsis for calculous pyonephrosis patients, which may lead to a prolonged ICU stay, postoperative hospital stay and higher mortality.

Occupational and Environmental Exposures and Their Role in Chronic Cough

To review the mechanisms by which occupational and environmental factors can contribute to chronic cough and to discuss the approach to diagnosis and management of these patients with review of recent publications in this area. An Expert Panel Report from the American College of Chest Physicians in 2016 addressed this topic. Recent publications improve understanding of mechanisms of effects. Inhaled dust, fumes, gases, and vapor can cause an irritant or inflammatory response in upper and lower airways leading to cough. Physico-chemical properties, exposure conditions, and host factors can influence effects. Particles ≤ 5 μm mass mean aerodynamic diameter are more likely to reach and affect the terminal lung units and the sinuses. Type I, type III, and type IV hypersensitivity responses contribute to diseases causing chronic cough. Improved diagnostic and immunologic tests are needed for many causative exposures such as home or work fungal exposures.

La recherche systématique de la thrombocytopénie induite par héparinothérapie après arthroplastie du membre inférieur est-elle justifiée ? Étude prospective dans un hôpital général de district en Grande-Bretagne

IntroductionHeparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition associated with heparin administration. Many orthopaedic units routinely prescribe low-molecular weight heparins as thromboprophylaxis after hip and knee arthroplasty. HypothesisWe postulated that routine platelet monitoring following heparin administration is of no clinical benefit. We therefore asked: firstly, what was the rate of thrombocytopenia in a large population of patients undergoing lower limb arthroplasty? Secondly, did this rate justify routine platelet monitoring? Materials and methodsUnless contraindicated, all patients (n=1999, 53.05% female, mean age 69.23 years) at a UK district general hospital undergoing hip and knee arthroplasty were given daily prophylactic enoxaparin. Platelet counts were obtained between the 8th and 10th postoperative days and compared to pre-operative baselines. A>50% fall in platelet count was classified as “possible HIT”. The minimal acceptable risk of thrombocytopenia was defined using The American College of Chest Physicians (ACCP) 2012 guidelines, which recommend monitoring platelet counts in patients receiving heparin where the expected risk of HIT is>1% and by descriptive cost-benefit analysis based on the cost of routine platelet monitoring in the clinical setting. ResultsComplete results were available for 1361 (68.1%) patients, comprising: 653 primary hips, 22 revision hips, 1 hip resurfacing, 665 primary knees, 19 revision knees and 1 unicompartmental knee replacement. Mean platelet level was 281.9×109/L pre-operatively and 527.83×109/L postoperatively. Forty-four patients (3.2%) experienced a postoperative fall in platelet levels. However, no patient experienced a drop in platelets to less than 50% of the pre-operative value. DiscussionThe incidence of HIT in the elective arthroplasty population is low. Therefore, routine postoperative monitoring of platelets is not necessary in this population of patients. Level of EvidenceII, Prospective study.

On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years

On Being the Editor in Chief of the Journal CHEST: 14 Memorable Years

Abstract 216: Evolution of Medicare Formulary Coverage Changes for Antithrombotic Therapies after Guideline Revisions

Introduction: The 2014 ACC/AHA/HRS atrial fibrillation (AF) guideline recommends either warfarin or direct oral anticoagulants (DOACs) as first-line antithrombotic therapies for patients with non-valvular AF. In 2016, the American College of Chest Physicians (CHEST) venous thromboembolism (VTE) guideline recommended DOACs over warfarin in non-cancer patients. Formulary coverage and utilization management can be used to promote guideline recommended medications, but the impact of these guidelines is unknown. Methods: We used Medicare Prescription Drug Plan Formulary Files, which include data on all Medicare Advantage and Part D plans, to compare coverage in the second quarters of 2013 (pre-guidelines), 2015 (post-ACC/AHA/HRS AF guideline), and 2017 (post-CHEST VTE guideline) for warfarin and each of the following DOACs: apixaban, dabigatran, edoxaban, and rivaroxaban. We determined formulary coverage and, among formularies that provided coverage, formulary restrictiveness based on use of utilization management strategies (i.e., cost-sharing tier level 3 or higher, prior authorization requirement, or step therapy requirement). Formularies were categorized as unrestrictive if no strategies were used, restrictive if any strategy was used, and no coverage. Results: In 2013, 2015, and 2017, there were 314, 389, and 378 Medicare formularies, respectively. All but one plan provided unrestrictive coverage of warfarin in all 3 time periods (Figure). Among DOACs, in 2013, 12% and 38% of formularies provided unrestrictive and restrictive coverage of apixaban, 20% and 78% of dabigatran, and 25% and 62% of rivaroxaban, whereas by 2017, 24% and 70% provided unrestrictive and restricted coverage of apixaban, 24% and 73% of dabigatran, and 30% and 69% of rivaroxaban ( p &lt; .001). From 2013 to 2017, formularies providing restrictive or unrestrictive coverage for at least one DOAC increased from 84% to 100% ( p &lt; .001). Most plans restricted DOAC coverage by increased tier-level cost-sharing, which increased over time, while prior authorization requirements decreased. Conclusions: After guidelines recommended DOACs as first-line or preferred therapy for AF and VTE, unrestrictive coverage increased, but the vast majority of plans restrict coverage by requiring high patient cost-sharing through tier placement.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned to a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Matteo BassettiMatteo BassettiMatteo Bassetti is Head of the Infectious Diseases Division of the Santa Maria Misericordia University Hospital in Udine and Associate Professor of Infectious Diseases at the University of Udine, Italy. Dr Bassetti studied at the University of Genoa School of Medicine, Italy and continued his medical education at the Yale University School of Medicine, New Haven, USA with an Infectious Diseases fellowship. Dr Bassetti is chair of the Critically Ill Study Group of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the secretary of the Infectious Diseases Group of the European Organisation for Research and Treatment of Cancer (EORTC). Dr Bassetti is also co-chair of the Intra-abdominal Infections Study Group and secretary of the Bone, Skin and Soft Tissue Infections of the International Society of Chemotherapy (ISC). He is the vice-president of Italian Society of Anti-infective Therapy (SITA). He is member-elected (2018–2022) of International Council of the Immunocompromised Host Society (ICHS). He serves on the editorial board of several journals including Intensive Care Medicine (Associate-Section Editor), Nature Scientific Reports, Italian Journal of Medicine (Section Editor), Drugs in Context (Associate editor), Journal of Infection and Public Health, Journal of Global Antimicrobial Resistance, Reviews in Medical Microbiology, GMS Infectious Diseases, Journal of Chemotherapy, Infectious Disease, Clinical Microbiology and Antimicrobial Chemotherapy and is a reviewer for several international journals. Author or co-author of more than 350 papers (H index 51; 10500 citations) published in international peer-review journals on antibiotic therapy, fungal infections, antimicrobial resistances, infections in immunocompromised patients and critically ill patients. Michael S. NiedermanMichael S. NiedermanProfessor Michael S. Niederman is Clinical Director and Associate Chief in the division of Pulmonary and Critical Care Medicine at Weill Cornell Medical Center, New York, and Professor of Clinical Medicine at Weill Cornell Medical College, New York. Prior to this, he was Professor in the Department of Medicine at State University of New York at Stony Brook, and Chairman of the Department of Medicine at Winthrop University Hospital in Mineola, New York for sixteen years. He obtained his medical degree from the Boston University School of Medicine, Massachusetts, and then completed his training in internal medicine at the Northwestern University School of Medicine, Illinois, before undertaking a Pulmonary and Critical Care fellowship at Yale University School of Medicine, Connecticut. His interests lie in respiratory tract infections, and include mechanisms of airway colonization, the management of community - and hospital-acquired pneumonia, the role of guidelines for pneumonia, and the impact of antibiotic resistance on the management and outcomes of respiratory tract infections. He has published over 400 peer-reviewed or review articles, and has lectured widely both nationally and internationally. Prof. Niederman served as co-chairman of the committees that created the American Thoracic Society 1993 and 2001 guidelines for the treatment of community-acquired pneumonia, as well as the 1996 and 2005 committees that wrote guidelines for the treatment of nosocomial pneumonia. In addition, he was a member of the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) committee that published guidelines for community-acquired pneumonia in 2007 and co-lead author of the 2017 European Respiratory Society/European Society of Intensive Care Medicine (ERS/ESICM) guidelines for nosocomial pneumonia. He served for 6 years as a member of the Board of Regents of the American College of Chest Physicians and in 2013 was elected as a Master of the American College of Physicians. He is also Editor-in-Chief of Clinical Pulmonary Medicine, and serves on the editorial boards of Critical Care Medicine, Intensive Care Medicine, Critical Care, and Chest. He has previously served on the editorial board of The American Journal of Respiratory and Critical Care Medicine.

Preconditioning of the lungs and circulation before visceral and thoracic surgical interventions

Estimation of the perioperative risk plays adecisive role in the surgical indications, particularly in view of the demographic change. For this reason, prehabilitation concepts for reducing perioperative risk nowadays play an increasingly important role. Presentation of the current recommendations for preoperative diagnostics in thoracic surgical interventions as well as existing prehabilitation concepts and their practical applicability. Aselective review of the literature was carried out by searching the electronic databases PubMed, Cochrane Library and ISRCTN, including the guidelines of the American College of Chest Physicians (ACCP) and the European Society of Thoracic Surgery (ESTS). Preconditioning includes the conservative treatment of underlying diseases, smoking cessation and prehabilitation. Prehabilitation is an increasingly pressing concept in routine clinical practice, even though the evidence is limited due to the very heterogeneous study situation. Overall, however, there is atendency for positive effects on the quality of life and postoperative complications as well as convalescence. In addition to preoperative diagnostics to assess the perioperative risk, effective preconditioning of patients is also necessary. For this an interdisciplinary approach including anesthesia, pneumology, psychotherapy and physiotherapy is necessary. In addition to the conservative medicinal optimization, prehabilitation concepts are gaining in importance and will certainly become established in routine clinical practice. From the surgical perspective, minimally invasive approaches and parenchyma-sparing resections also serve to reduce risks.

Routine monitoring for heparin-induced thrombocytopenia following lower limb arthroplasty: Is it necessary? A prospective study in a UK district general hospital

IntroductionHeparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition associated with heparin administration. Many orthopaedic units routinely prescribe low-molecular-weight heparins as thromboprophylaxis after hip and knee arthroplasty. HypothesisWe postulated that routine platelet monitoring following heparin administration is of no clinical benefit. We therefore asked: firstly, what was the rate of thrombocytopenia in a large population of patients undergoing lower limb arthroplasty? Secondly, did this rate justify routine platelet monitoring? Materials and methodsUnless contraindicated, all patients (n=1999, 53.05% female, mean age 69.23 years) at a UK district general hospital undergoing hip and knee arthroplasty were given daily prophylactic enoxaparin. Platelet counts were obtained between the 8th and 10th postoperative days and compared to preoperative baseline. A > 50% fall in platelet count was classified as “possible HIT”. The minimal acceptable risk of thrombocytopenia was defined using The American College of Chest Physicians (ACCP) 2012 guidelines, which recommend monitoring platelet counts in patients receiving heparin where the expected risk of HIT is>1% and by descriptive cost-benefit analysis based on the cost of routine platelet monitoring in the clinical setting. ResultsComplete results were available for 1361 (68.1%) patients, comprising: 653 primary hips, 22 revision hips, 1 hip resurfacing, 665 primary knees, 19 revision knees and 1 unicompartmental knee replacement. Mean platelet level was 281.9×109/L preoperatively and 527.83×109/L postoperatively. Forty-four patients (3.2%) experienced a postoperative fall in platelet levels. However, no patient experienced a drop in platelets to less than 50% of the preoperative value. DiscussionThe incidence of HIT in the elective arthroplasty population is low. Therefore, routine postoperative monitoring of platelets is not necessary in this population of patients. Level of evidenceII, prospective study.

Postoperative Venous Thromboembolism after Extracranial Otologic Surgery.

To determine the incidence of postoperative venous thromboembolism (VTE) in adults undergoing otologic surgery. Cross-sectional retrospective study. Single tertiary academic center. Adults undergoing nononcologic, extracranial otologic surgery from August 2009 to December 2016. Patients with postoperative diagnosis VTE codes were identified. Imaging and clinical documents were searched for VTE evidence within the first 30 postoperative days. Methods of thromboprophylaxis were documented, and Caprini risk scores were calculated. In total, 1213 otologic surgeries were evaluated. No postoperative VTE events were identified (0/1268). Mean age was 51.0 ± 17.3 years (range, 18.1-93.4 years). Average length of surgery was 136.0 ± 79.0 minutes (range, 5-768 minutes). The average Caprini score in all patients was 4.0 ± 1.7 (range, 1-15). Eighty-five percent of patients had a Caprini score ≥3, the threshold at which chemoprophylaxis has been recommended in general surgery patients by the American College of Chest Physicians 2012 guidelines. Six patients had documented preoperative chemoprophylaxis and a Caprini score of 4.8 ± 1.7. This was not significantly different from that of patients who did not receive preoperative chemoprophylaxis (t test, P = .3). The literature would estimate a rate of 3.7% VTE in adults with similar Caprini scores undergoing general surgery procedures with no VTE prophylaxis. The Caprini risk assessment model may overestimate VTE risk in patients undergoing extracranial otologic surgery. Postoperative VTE following otologic surgery is rare, even in patients traditionally considered moderate or high risk. Chemoprophylaxis guidelines in this group should be balanced against the potential risk of increased intraoperative bleeding and its associated effects on surgical visualization and morbidity.

US pediatric pulmonology workforce

Children with respiratory conditions benefit from care provided by pediatric pulmonologists. As these physicians are a small portion of the overall pediatric workforce, it is necessary to understand the practices and career plans of these specialists. An internet survey was developed by the American Academy of Pediatrics Division of Workforce and Medical Education Policy and sent to members of the American Academy of Pediatrics and American College of Chest Physicians who identified as pediatric pulmonary physicians. Responses were received from 485 physicians and were compared to the results of a similar survey done in 1997. Of those completing the survey, 63% were male and 37% female, with increased number of females since the earlier poll. The average calculated age was 56 years. They worked 54 h per week, down from 59 h in the prior survey. Pediatric pulmonologists are overwhelmingly clinicians (92%) with major responsibilities for administration (79%), teaching (78%), and research. Basic science research was rarely reported (7%). Pediatric pulmonologists felt that referrals had become more complicated in the recent past. Nearly all planned to maintain Pediatric Pulmonology Sub-board certification, though one third planned to cut back on clinical workload in the next decade. Many were concerned that the number needed in the profession in a decade would be inadequate with significant concerns about funding for those positions. Overall, these results reflect the current state of the workforce and the need to monitor the supply of practitioners in the future.

YouTube as a source of patient education in idiopathic pulmonary fibrosis: a media content analysis

ABSTRACTPurpose: Idiopathic pulmonary fibrosis (IPF) is a common cause of pulmonary fibrosis, with millions of individuals affected in the world. Patients may use multiple resources to educate themselves regarding their illness, including popular social media video hosting site YouTube. We set out to determine the quality of patient education material discussing IPF available on YouTube.Methods: 100 consecutive videos were surveyed for review, of which 59 were included in the final analysis. Three independent blinded reviewers were assigned to score each video on a scoring system designed along patient education material available publicly at the American Thoracic Society and the American College of Chest Physicians. Scores by each reviewer were compared to others using means, standard deviation, Cohen’s Kappa, and intra-class reliability.Results: Video content had a mean score of 5.9, SD 3.96 out of a maximum of 20 points. Cohen’s Kappa between the three raters was calculated to a value of 0.92 and Interclass reliability was 0.79 (0.70–0.86, 95% CI) indicating appropriateness of comparison between the three raters.Conclusion: Patient education material regarding IPF on YouTube was found deficient in quantity and quality. Providers should be aware of the best information resources available and utilize these to educate their patients.

Venous Thromboembolism: Role of the Clinical Laboratory in Diagnosis and Management.

Venous thromboembolism (VTE) is the third most common cause of cardiovascular illness and is projected to double in incidence by 2050. It is a spectrum of disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE). In February 2016, the American College of Chest Physicians provided updated management guidelines for DVT and PE to address some of the unresolved questions from the previous version and to provide recommendations related to newer anticoagulants. Here we review current concepts for screening, diagnosis, thromboprophylaxis, and management of DVT and PE. We also describe the management of VTE in acute, long-term, and extended phases of treatment. Thrombophilia testing is rarely necessary and should be used judiciously; the laboratory can serve an important role in preventing unnecessary testing. The direct oral anticoagulants are as effective as conventional treatment and are preferred agents except in the case of cancer. The initial management of PE should be based on risk stratification including the use of D-dimer testing. Thrombolysis is used in cases of hemodynamically unstable PE and not for low-risk patients who can be treated on an outpatient basis. This review is intended to provide readers with updated guidelines for screening, testing, prophylaxis, and management from various organizations.

A Critical Evaluation of Enoxaparin Dose Adjustment Guidelines in Children.

The purposes of this study are to perform a large-scale evaluation of the standardized dosage adjustment nomogram recommended by the American College of Chest Physicians (CHEST) for the management of enoxaparin in hospitalized pediatric patients and to determine the necessity of routine and repeated anti-factor Xa (anti-Xa) levels. A retrospective cohort study was designed, and charts were reviewed in a single tertiary care institution for all patients who received enoxaparin between October 1, 2010, through September 30, 2016. Patients were included if they were receiving treatment doses of enoxaparin according to the pediatric CHEST guidelines, had a subtherapeutic or supratherapeutic anti-Xa level drawn at 3.5 to 6 hours after a dose, had a dose changed in an attempt to attain a therapeutic anti-Xa level, and had a second anti-Xa level drawn 3.5 to 6 hours after the dose change. Descriptive statistical methods were used to characterize the ability of dose adjustment via a nomogram to attain an anti-Xa of 0.5 to 1 unit/mL. A total of 467 patients were identified who received the appropriate initial dose and dosage adjustment and whose levels were drawn according to the CHEST guidelines. In patients who had an initial anti-Xa level of <0.35 units/mL and received the nomogram recommended dose increase of 25% ± 5%, 28 out of 96 patients (29.2%) reached therapeutic levels. Of 197 patients who had an initial anti-Xa level between 0.35 and 0.49 units/mL and who received the nomogram recommended dose increase of 10% ± 5%, 116 (58.9%) reached therapeutic levels. Of 50 patients with an initial anti-Xa level between 1.1 and 1.5 units/mL and who received the nomogram dose decrease of 20% ± 5%, 31 (62%) reached therapeutic levels. The current dosage adjustment nomogram recommended by the CHEST guidelines does not reliably lead to therapeutic anti-Xa levels when used to adjust enoxaparin doses in pediatric patients.

Editorial introductions

Editorial introductions

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.

The Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients Undergoing Arthroscopic Rotator Cuff Repair.

Venous thromboembolic disease (VTED) is a rare complication following arthroscopic rotator cuff repair (RCR). The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have no prophylaxis guidelines specific to shoulder arthroscopy, yet many surgeons prescribe aspirin following RCR. The purpose of this study was to evaluate the effectiveness of aspirin and mechanical prophylaxis compared with mechanical prophylaxis alone in preventing VTED following RCR. A total of 914 patients underwent RCR between January 2010 and January 2015. A retrospective case-control study was performed. The control group (n=484) consisted of patients treated with compression boots and early mobilization. The study group (n=430) used compression boots, early mobilization, and 81 mg/d of aspirin. The primary outcome was symptomatic VTED, including deep venous thrombosis (DVT) and pulmonary embolism (PE). A total of 7 VTED events occurred during the study period: 6 DVTs and 1 PE; 1 patient experienced both DVT and PE. The percentage of patients with VTED, DVT, and PE was 0.66%, 0.66%, and 0.11%, respectively. There was no significant difference for DVT or PE between the 2 groups. The incidence of DVT and PE was 0.62% and 0.00%, respectively, for the control group (no aspirin) and 0.70% and 0.23%, respectively, for the study group (aspirin). Aspirin does not lead to a clinically significant reduction in either DVT or PE rate in patients undergoing RCR. The authors conclude that the use of mechanical prophylaxis and early mobilization is a sufficient method of VTED prophylaxis in this low-risk population. [Orthopedics. 2019; 42(2):e187-e192.].