Hospitalization For Acute Medical Illness Research Articles

The possible role of gut microbiota dysbiosis in the pathophysiology of delirium in older persons.

Delirium is a clinical syndrome characterized by an acute change in attention, awareness and cognition with fluctuating course, frequently observed in older patients during hospitalization for acute medical illness or after surgery. Its pathogenesis is multifactorial and still not completely understood, but there is general consensus on the fact that it results from the interaction between an underlying predisposition, such as neurodegenerative diseases, and an acute stressor acting as a trigger, such as infection or anesthesia. Alterations in brain insulin sensitivity and metabolic function, increased blood-brain barrier permeability, neurotransmitter imbalances, abnormal microglial activation and neuroinflammation have all been involved in the pathophysiology of delirium. Interestingly, all these mechanisms can be regulated by the gut microbiota, as demonstrated in experimental studies investigating the microbiota-gut-brain axis in dementia. Aging is also associated with profound changes in gut microbiota composition and functions, which can influence several aspects of disease pathophysiology in the host. This review provides an overview of the emerging evidence linking age-related gut microbiota dysbiosis with delirium, opening new perspectives for the microbiota as a possible target of interventions aimed at delirium prevention and treatment.

A Retrospective Analysis of Thromboprophylaxis in Hospitalized Patients with Cancer

Venous thromboembolism (VTE) is a known complication of hospitalization for acute medical illness; hospitalized patients with cancer represent a particularly high thrombotic risk population. However, there is significant underuse of thromboprophylaxis in medical inpatients with cancer. The objective of this study is to characterize the use of thromboprophylaxis in hospitalized patients with cancer at Windsor Regional Hospital (WRH), a large, community-based hospital in Ontario, Canada. Specifically, we investigated use of both pharmacologic and mechanical thromboprophylaxis, along with clinical determinants underlying lack of VTE prophylaxis to better understand our local practice patterns. This study is a retrospective, single center cohort study of 120 adult patients admitted to WRH with a primary solid tumor diagnosis (n=57) and hematologic cancer diagnosis (n=63) over a 3-month period. Chart review was performed for the first ten days of admission or until discharge. Multi-variate analyses were employed to determine clinical predictors of thromboprophylaxis use. Sixty-one (51%) medical inpatients with cancer received pharmacologic thromboprophylaxis during their hospitalization. The majority of patients (n=39; 68.4%) with a solid tumor malignancy received prophylaxis, while only twenty-two (34.9%) patients with a hematologic malignancy were provided pharmacologic VTE prophylaxis. In the subgroup of patients without contraindications to pharmacologic prophylaxis, 60% of patients with a primary hematologic diagnosis and 75% of patients with a primary solid tumor diagnosis received pharmacologic prophylaxis (Figure 1). 4 of 58 patients who did not receive pharmacologic prophylaxis received mechanical prophylaxis during admission (6.9%). Risk of VTE stratified by Khorana score >2 or ≤2 was not associated with use of pharmacologic prophylaxis (p=0.255). Platelet nadir <25x109/L (OR=0.12, 95% CI 0.0256-0.4087), active hormonal therapy (OR=0.11, 95% CI 0.0055-0.6707) and pulmonary disease at baseline (OR=4, 95% CI 1.0031-22.9064) were the only patient variables significantly related to the odds of pharmacologic prophylaxis. Given the limited number of patients in the study with pulmonary disease and maintained on hormonal therapy at baseline, the statistical significance may not correlate to clinical significance. In conclusion, thromboprophylaxis is an integral adjunct to the management of medical inpatients with active cancer yet is often neglected in clinical practice. In our population, nearly half of patients were not provided VTE prophylaxis. Severe thrombocytopenia and active hormonal therapy were negative predictors of pharmacologic thromboprophylaxis use while the presence of pulmonary disease favored prescription of prophylaxis on admission. Further studies are needed to better understand the rationale underlying omission of VTE prophylaxis in medical inpatients with cancer, and raise awareness of measures to prevent VTE in this patient population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Inpatient primary prophylaxis of cancer-associated thromboembolism (CAT)

Cancer-associated thrombosis (CAT) increases morbidity and mortality in oncology patients. The risk of CAT is increased with hospitalization for acute medical illness. The goal of this review will be to examine the available evidence for (1) risk assessment and (2) primary thromboprophylaxis, (3) international published guideline recommendations, and (4) future directions to manage oncology patients admitted for an acute medical illness. A review was performed for each subject to gather information on the available evidence and recommendations available for oncology patients hospitalized for an acute medical illness. Risk assessments for thrombosis are primarily developed and validated in the general population. There is not a risk assessment that has specifically been developed and validated in oncology patients hospitalized for an acute medical illness. Most evidence for thromboprophylaxis of oncology patients is from sub-group analysis of larger randomized-controlled trials in the general population. Evidence is conflicting and suggests an individualized approach evaluating the risk-benefit of thromboprophylaxis. The strength of recommendations of international guidelines is limited because of the available evidence. Guidelines usually recommend utilizing and/or offering thromboprophylaxis to oncology patients hospitalized for an acute medical illness barring contraindications. Future evidence needs to improve risk assessments and knowledge of the appropriate agent, dose, and duration of thromboprophylaxis if indicated. Evidence for risk assessments and primary prophylaxis for oncology patients hospitalized for acute medical illness appears limited, with many research opportunities available to improve understanding on management of this patient population.

Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study.

To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization. Prospective cohort study. New Haven, Connecticut. A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge. Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month. Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization. Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020.

Risk of Thrombosis in Cancer: Clinical Factors and Role of Primary Prophylaxis.

Cancer and its treatments are commonly complicated by venous thromboembolism (VTE), but there is a substantial variation in risk between individual cancer patients. The risk of VTE in cancer patients is influenced by multiple risk factors including primary site of cancer, stage, comorbidities, use of specific antineoplastic agents. Several biomarkers have been associated with subsequent VTE including D-dimer and tissue factor, although no single risk factor or biomarker accurately is predictive of VTE on its own. The risk of VTE is best predicted by a validated risk assessment score. Cancer patients at risk of VTE benefit from thromboprophylaxis, supported by evidence in the setting of hospitalization for acute medical illness and surgery, and emerging data from two large randomized trials in the outpatient setting. This chapter focuses on approaches to identifying risk of VTE and approaches to reducing this risk with appropriate thromboprophylaxis.

Association between hospitalization for acute medical illness and VTE risk: A lower efficacy of thromboprophylaxis in elderly patients? Results from the EDITH case-control study

IntroductionWhether the association between hospitalization and venous thromboembolism (VTE) is modified by the use of thromboprophylaxis in older patients remains insufficiently evaluated. Our objective was to estimate VTE risk associated with hospitalization for acute medical illness depending on prescription of pharmacological thromboprophylaxis, in two different age categories using a 75years cutoff. MethodsUsing a case-control design, we estimated the risk for symptomatic VTE associated with hospitalization for acute medical illness depending on prescription of pharmacological thromboprophylaxis in two different age categories using a 75 years cut-off. Results750 symptomatic VTE cases and their 750 age and sex-matched controls were analyzed. A total of 145 cases (19.3%) and 91 controls (12.1%) were hospitalized for acute medical illness in the preceding 3months prior to inclusion in the study (p<0.001). Hospitalization for acute medical illness was associated with a 75% increase in VTE risk: OR 1.75 (95% CI: 1.32–2.33). In patients <75years, there was a 2-fold increase in VTE risk associated with hospitalization when thromboprophylaxis was not prescribed: OR 2.01 (95% CI: 1.11–3.62), whereas no association was found when thromboprophylaxis was prescribed: OR 0.93 (95% CI: 0.44–1.95). In patients ≥75years, VTE risk associated with hospitalization remained significant whether or not thromboprophylaxis was prescribed: OR 2.69 (95% CI 1.28–5.66) and OR 2.02 (95% CI: 1.01–4.03) respectively. ConclusionOur results suggest that VTE prevention in acutely ill medical patients may be less effective in patients ≥75years. This finding needs to be addressed in further studies.

A Predictive Score for Thrombosis Associated with Breast, Colorectal, Lung, or Ovarian Cancer: The Prospective COMPASS-Cancer-Associated Thrombosis Study.

The stratification of outpatients on chemotherapy for breast, colorectal, lung, and ovarian cancers at risk of venous thromboembolism (VTE) remains an unmet clinical need. The derivation of a risk assessment model (RAM) for VTE in these patients was the aim of the study "Prospective Comparison of Methods for thromboembolic risk assessment with clinical Perceptions and AwareneSS in real life patients-Cancer Associated Thrombosis" (COMPASS-CAT). The derivation cohort consisted of 1,023 outpatients. Patients on low molecular weight heparin (LMWH) thromboprophylaxis were excluded. Documented symptomatic VTE was the endpoint of the study. Patients had breast (61%), colorectal (17%), lung (13%), or ovarian cancer (8.6%) at localized (30%) or advanced stage (70%). In 64% of patients, cancer was diagnosed within the last 6 months prior to inclusion. Most of them were on chemotherapy when assessed. Symptomatic VTE occurred in 8.5% of patients. The COMPASS-CAT RAM includes the following variables: (a) anthracycline or anti-hormonal therapy, (b) time since cancer diagnosis, (c) central venous catheter, (d) stage of cancer, (e) presence of cardiovascular risk factors, (f) recent hospitalization for acute medical illness, (g) personal history of VTE, and (h) platelet count. At 6 months, patients stratified at low/intermediate and high-risk groups had VTE rates of 1.7% and 13.3%, respectively. The area under the curve of receiver operating characteristics analysis was 0.85. The sensitivity and specificity of the RAM were 88% and 52%, respectively. The negative and positive predictive values of the RAM were 98% and 13%, respectively. The COMPASS-CAT RAM includes reliable and easily collected VTE risk predictors and, in contrast to the Khorana score, it is applicable after the initiation of anticancer treatment in patients with common solid tumors. Its robustness for stratification of patients at high and low/intermediate VTE risk needs to be externally validated. The Prospective Comparison of Methods for thromboembolic risk assessment with clinical Perceptions and AwareneSS in real life patients-Cancer Associated Thrombosis (COMPASS-CAT) study provides a new risk assessment model (RAM) for venous thromboembolism (VTE) applicable in outpatients with breast, colorectal, lung or ovarian cancer. The COMPASS-CAT RAM is robust, applicable during chemotherapy and determines the need for VTE prévention by including reliable and easily collected VTE predictors associated with cancer status, its treatment as well as with patients' characteristics and comorbidities. An independent external validation of the RAM is indicated before its use in clinical practice.

Prophylaxis of venous thromboembolism in cancer patients

ABSTRACTVenous thromboembolism (VTE) is an independent prognostic factor and the second leading cause of death in cancer patients. VTE is however a largely preventable disease when thromboprophylaxis is appropriately used. As recommended worldwide by international Clinical Practice Guidelines, cancer patients undergoing surgery or hospitalization for acute medical illness or with reduced mobility should benefit from thromboprophylaxis, in the absence of bleeding or other contraindications to anticoagulants. Thromboprophylaxis in cancer outpatients receiving systemic therapies is still under debate, except for pancreatic ambulatory cancer patients where prophylaxis confers a sustained reduction in VTE. Numerous strategies are currently developed to improve VTE prophylaxis practices in cancer patients, and to elucidate the best appropriate anticoagulant regimen for each individual cancer patient.

Factors associated with the recovery of activities of daily living after hospitalization for acute medical illness: a prospective cohort study.

[Purpose] This study investigated the factors associated with the recovery rate of activities of daily living of elderly patients hospitalized for acute medical illness. [Subjects and Methods] A total of 238 elderly patients were enrolled in this study. The main outcome measure was the functional independence measure score which was used as an assessment of activities of daily living. The participants were divided into 2 groups based on their activities of daily living before onset: the independent group and the partially dependent group. The participants of each group were further divided into 2 subgroups based on recovery rates of activities of daily living: the high-recovery group (80%) and the low-recovery group (<80%). The factors associated with the recovery rate were examined using multivariate logistic regression analysis. [Results] The factors associated with the recovery rate were: days of inactivity and cognitive status at the start of rehabilitation for the independent group, and days of inactivity and nutritional status at the start of rehabilitation for the partially dependent group. [Conclusion] The results of this study suggest that the important factors for return to normal activities of daily living are: days of inactivity and cognitive status for the independent group; and days of inactivity and management of nutrition for the partially dependent group.

Association Between Hospitalization for Acute Medical Illness and VTE Risk: A Lower Efficacy of Thromboprophylaxis in Elderly Patients? Results from the Edith Case-Control Study

Background: Randomized controlled trials demonstrated that low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux, are efficient for venous thromboembolism (VTE) prevention in acutely ill medical patients. However, asymptomatic VTE, whose clinical relevance is unknown, represented the vast majority of outcome events of these trials.Objectives: Using a case-control design, we aimed to estimate the association between admission to hospital for acute medical illness, prescription of pharmacological thromboprophylaxis during admission and symptomatic VTE.Methods: 750 symptomatic non-surgical, non-cancer, and non-pregnancy-related VTE cases and their 750 age and sex-matched controls were analyzed. Patients hospitalized for an acute medical illness within three months prior to inclusion in the study were identified, and their hospital charts were reviewed. We considered that patients receiving pharmacological thromboprophylaxis were those prescribed either 1) LMWH at an approved preventive dose; 2) low dose UFH (5000 units bid or tid); or 3) fondaparinux 2.5mg once daily, for at least 6 days.Results: Patients' mean age was 67.2 ± 17.1 years, and 664 (44.3%) were men. A total of 145 cases (19.3%) and 91 controls (12.1%) were hospitalized for acute medical illness at least once in the preceding 3 months prior to inclusion in the study (p<0.001). Hospitalization for acute medical illness in the preceding three months was associated with a 75% increase in VTE risk: OR 1.75 (95% CI: 1.32-2.33). Pharmacological thromboprophylaxis was prescribed in 46.2% of the hospitalized cases (n=67) and in 51.6% of the controls (n=47) (p=0.49). As compared with patients who were not hospitalized, there was a significant 2-fold increased risk of VTE when thromboprophylaxis was not prescribed during hospitalization: OR 2.01 (95% CI: 1.22-3.29), and a non-significant 61% increased risk when thromboprophylaxis was prescribed during hospitalization: OR 1.61 (95% CI: 0.55-1.69). Proportions of admitted patients and prescription of pharmacological thromboprophylaxis are shown in table. Table 1Age<75Age≥75CasesControlsOR (95% CI)CasesControlsOR (95% CI)No hospitalization365 (83.5%)380 (87.5%)Ref.240 (76.7%)279 (88.3%)Ref.Hospitalization for acute medical illness72 (16.5%)54 (12.5%)1.42 (0.96-2.08)73 (23.3%)37 (11.7%)2.25 (1.46-3.47)- No prescription of pharmacological thromboprophylaxis51 (70.8%)28 (51.9%)2.01 (1.11-3.62)27 (37.0%)16 (43.2%)2.02 (1.01-4.03)- Prescription of pharmacological thromboprophylaxis21 (29.2%)26 (48.1%)0.93 (0.44-1.95)46 (63.0%)21 (56.8%)2.69 (1.28-5.66)In patients <75 years, VTE risk associated with hospitalization for acute medical illness was low and not significant (OR 1.42 (95% CI: 0.96-2.08) as compared with no hospitalization. When pharmacological thromboprophylaxis was not prescribed during admission, there was a significant 2-fold increase in VTE risk associated with hospitalization: OR 2.01 (95% CI: 1.11-3.62), whereas no association was found when thromboprophylaxis was prescribed: OR 0.93 (95% CI: 0.44-1.95). In patients ≥75 years, we observed an overall 2.25-fold increase in VTE risk associated with hospitalization for acute medical illness as compared with no hospitalization: OR 2.25 (95% CI: 1.46-3.47). VTE risk associated with hospitalization remained significant whether or not pharmacological thromboprophylaxis was prescribed during hospitalization: OR 2.69 (95% CI 1.28-5.66) and OR 2.02 (95% CI: 1.01-4.03) respectively. Adjustment for a priori VTE risk stratification of medical hospitalized patients did not modify estimates.Conclusion: Our case-control study suggests that VTE prevention in acutely ill medical patients may be less effective in patients ≥75 years as compared with younger patients. This finding will be addressed in a randomized double blind controlled trial comparing enoxaparin 40mg once daily to placebo for the prevention of symptomatic VTE and fatal PE in patients ≥75 years admitted to hospital for an acute medical illness (NCT02379806). DisclosuresNo relevant conflicts of interest to declare.

The prediction of death up to 100 days after admission to hospital for acute medical illness – the comparison of two ECG interpretation methods with ECG-dispersion mapping

Background: the prognostic performances of different ECG interpretation methods have not been compared. Methods: the 100 day mortality of 513 patients predicted by Marquette proprietary ECG software, Tan et al’s scoring system and the myocardial micro-alternation index (MMI) were compared. Results: 33 patients (6.4%) died within 100 days of hospital admission. The c statistics for Mar Abstract quette and Tan ECG interpretation and MMI were not statistically different (i.e. 0.64, 0.68 and 0.73, respectively). Only MMI was independent from age as a predictor of mortality. The c statistic for MMI plus age of 0.81 was significantly higher than that of Marquette ECG interpretation (p 0.015). Conclusion: predictions of 100 day mortality by of all three ECG interpretation methods are equivalent.

Abstract 303: Risk Factors for Venous Thromboembolism (VTE) among Patients with Neurologic Disease and Leg Paresis: A Population-based Case-control Study.

Background: Whether VTE risk can be further stratified among patients with neurologic disease and leg paresis is unknown. Objective: To identify independent risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) among patients with neurologic disease and leg paresis. Methods: Using the population-based resources of the Rochester Epidemiology Project, we identified all Olmsted County, MN residents with incident DVT or PE over the 45-year period, 1966 to 2010. We performed a case-control study nested within the Olmsted County population with incident VTE associated with neurologic disease and leg paresis over the 18-year period, 1988-2010 (n=192). For each VTE case, we identified 1 Olmsted County resident with neurologic disease, leg paresis and no VTE (control) matched to each case on sex, date of birth (+/- 5 years), calendar year (+/- 1 year) and duration of medical records. Using conditional logistic regression, we tested duration of paresis (index-3 months, 3-12 months, and &gt; 12 months), paresis etiology, and degree of immobility as potential risk factors for VTE after adjusting for other known VTE risk factors, including hospitalization for major surgery or acute medical illness, trauma/fracture, and active cancer. Results: In univariate analyses of the 192 pairs, trauma/fracture, hospitalization for major surgery or for acute medical illness, active cancer, duration of paresis, and degree of immobility were associated with VTE. In the multivariable analysis, hospitalization for acute medical illness, active cancer, degree of immobility (ambulatory without/with assistance, function from a wheelchair base, bed bound; OR: 2.60; 95%Cl: 1.65-4.11); p=&lt;0.0001) were independent predictors of VTE. Conclusion: Among patients with neurologic disease and leg paresis, VTE risk can be further stratified by hospitalization for acute medical illness, active cancer and degree of immobility; these patients should be considered for VTE prophylaxis.

A survey of thrombosis experts evaluating practices and opinions regarding venous thromboprophylaxis in patients with active cancer hospitalized with an acute medical illness.

BackgroundCurrent clinical practice guidelines recommend the use of prophylactic doses of low molecular weight heparins for cancer patients requiring hospitalization for acute medical illness. However, a recently published meta-analysis suggested that the risk-benefit ratio of current thromboprophylaxis regimens administered to all cancer patients admitted for medical illness is unclear. We sought to assess the clinical equipoise in using thromboprophylaxis for hospitalized medically ill cancer patients.MethodsAn electronic survey was conducted. The target sample included Thrombosis experts and members of Thrombosis Canada or the VECTOR research group.ResultsThe survey was distributed 54 participants. The final response rate was 67% (36/54). The majority (75%; 95% CI: 60.3 to 85%) of responders indicated that the benefits of pharmacological parenteral thromboprophylaxis outweigh the risks. However, 63.9% (95% CI: 50.6 to 77.3%) believe that there is still clinical equipoise around the use of thromboprophylaxis in this patient population, and 88.9% (95% CI: 77.3 to 95.8%) would consider participating in a randomized trial—30.6% and 58.3% in a placebo-controlled or comparison of different agents/dosing-controlled randomized trial, respectively. For participants who would consider a randomized-controlled trial comparing different doses of thromboprophylaxis agents, the MCID was 2% between the two arms. The most common drug to be compared was enoxaparin (26%), and the two suggested doses were 30 mg and 40 mg SC twice daily.ConclusionsOur clinical survey of thrombosis experts confirms that there is equipoise regarding the use of current regimens of parenteral pharmacological thromboprophylaxis in medically ill cancer patients. A majority of physicians would participate in a randomized-controlled trial comparing different dose of LMWH. The MCID in the risk of VTE identified was 2%.

Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study.

Dementia is common in older people admitted to acute hospitals. There are concerns about the quality of care they receive. Behavioural and psychiatric symptoms of dementia (BPSD) seem to be particularly challenging for hospital staff. AIMS To define the prevalence of BPSD and explore their clinical associations. Longitudinal cohort study of 230 people with dementia, aged over 70, admitted to hospital for acute medical illness, and assessed for BPSD at admission and every 4 (± 1) days until discharge. Other measures included length of stay, care quality indicators, adverse events and mortality. Participants were very impaired; 46% at Functional Assessment Staging Scale (FAST) stage 6d or above (doubly incontinent), 75% had BPSD, and 43% had some BPSD that were moderately/severely troubling to staff. Most common were aggression (57%), activity disturbance (44%), sleep disturbance (42%) and anxiety (35%). We found that BPSD are very common in older people admitted to an acute hospital. Patients and staff would benefit from more specialist psychiatric support.

Interim Exposures As Predictors Of Venous Thromboembolism (VTE) Recurrence: A Population-Based, Case-Cohort Study

BackgroundRecurrent VTE is frequent and may be fatal; the 2-week case fatality rate after recurrent pulmonary embolism is 11%. However, predictors of VTE recurrence remain uncertain. ObjectiveTo identify independent predictors of VTE recurrence, including interim exposures, adjusted for baseline characteristics and treatments. MethodsUsing the resources of the Rochester Epidemiology Project, we identified all Olmsted County, MN residents with objectively-diagnosed incident VTE over the 13-year period, 1988-2000. All patients surviving ≥1 day were followed forward in time for first objectively-diagnosed VTE recurrence, death or other loss to follow-up, or 12/31/2005, whichever came first. VTE recurrence was defined as new thrombosis of a previously uninvolved venous territory or re-thrombosis of a previously involved venous territory after interim clearing of the incident thrombosis. We estimated the cumulative incidence of VTE recurrence using the Kaplan Meier product limit method, both overall and by incident cancer-associated, idiopathic and non-cancer secondary VTE. For all patients with VTE recurrence, and a random sample of all patients with incident VTE, we reviewed the complete medical records in the community and collected demographic and baseline characteristics, treatments (heparin and warfarin [including proportion of time in therapeutic range], IVC filter, aspirin, statins) and interim VTE risk factor exposures. Using a case-cohort study design with Barlow's weighting scheme, we tested these demographic, baseline and interim characteristics as potential predictors of VTE recurrence using time-dependent Cox proportional hazards modeling. ResultsAmong 1261 incident VTE patients who survived ≥1 day, 306 developed recurrent VTE over 6,485 person-years of follow-up. The cumulative incidence of VTE recurrence at 30 and 180 days, and 1 and 5 years, were 4.5%, 8.2%, 10.5% and 20.3%, respectively. The five-year cumulative recurrence rates among patients with incident cancer-associated, idiopathic and non-cancer secondary VTE were 42.6%, 26.8% and 18.5%, respectively. Among the random cohort of 415 incident VTE cases, 381 (92%) and 359 (87%) received heparin and warfarin therapy for a median (IQR) 5 (4 - 7) and 119 (63 - 194) days, respectively. From multivariable analysis, interim exposure to trauma, major surgery (general, cardiac or gynecologic), infection, hospitalization for acute medical illness or active cancer after the incident VTE were each associated with an increased hazard of VTE recurrence, while use of warfarin and achievement of a therapeutic APTT within the first day of starting heparin were associated with reduced hazards. Although measures of time in therapeutic range while on heparin or warfarin were associated with a reduced risk of recurrence from univariate analyses, these results were not significant when adjusting for other risk factors. ConclusionsAmong patients with incident VTE, new exposure to trauma, major surgery, infection, hospitalization for acute medical illness or active cancer are independent predictors of VTE recurrence; patients with such exposures should be considered for VTE prophylaxis. Disclosures:No relevant conflicts of interest to declare.

Performance measures for improving the prevention of venous thromboembolism: achievement in clinical practice

Venous thromboembolism (VTE) is a common complication during and after hospitalization for acute medical illness or surgery. Despite the existence of evidence-based guidelines for VTE prevention, real-world prescribing practices are frequently suboptimal. Specific performance measures relating to VTE prevention and treatment have been developed by US health care organizations to increase adherence with best-practice recommendations and ultimately reduce the number of preventable VTE events. Two measures developed by the Surgical Care Improvement Project have been endorsed by the National Quality Forum (NQF) and focus on VTE prevention. In addition, six measures have been developed recently by The Joint Commission in collaboration with the NQF; three measures relate to VTE prevention and three focus on treatment. To attain widespread achievement of these performance goals, it is essential to raise awareness of their existence and specifications. It is also imperative that hospitals develop and implement effective VTE protocols. The use of multiple, active strategies, such as computer decision support systems with regular audit and feedback, may be particularly valuable approaches to improve current practices within an integrated quality improvement program. During practical implementation of VTE protocols at Norton Healthcare (Kentucky's largest healthcare system), strong leadership, physician engagement, and caregiver accountability were identified as key factors influencing the process. As such, more hospitals may be able to increase adherence with guidelines, improve achievement of quality goals, and help to reduce the substantial burden associated with avoidable VTE.

The Association of Active Cancer With Venous Thromboembolism Location: A Population-Based Study

To test active cancer for an association with venous thromboembolism (VTE) location. Using the resources of the Rochester Epidemiology Project, we identified all Olmsted County, MN, residents with incident VTE during the 35-year period 1966-2000 (N = 3385). We restricted analyses to residents with objectively diagnosed VTE during the 17-year period from January 1, 1984, to December 31, 2000 (N = 1599). For each patient, we reviewed the complete medical records in the community for patient age, gender, and most recent body mass index at VTE onset; VTE event type and location; and previously identified independent VTE risk factors (ie, surgery, hospitalization for acute medical illness, active cancer, leg paresis, superficial venous thrombosis, and varicose veins). Using logistic regression we tested active cancer for an association with each of 4 symptomatic VTE locations (arm or intra-abdominal deep venous thrombosis [DVT], intra-abdominal DVT, pulmonary embolism, and bilateral leg DVT), adjusted for age, gender, body mass index, and other VTE risk factors. In multivariate analyses, active cancer was independently associated with arm or intra-abdominal DVT (odds ratio [OR], 1.76; P = .01), intra-abdominal DVT (OR, 2.22; P = .004), and bilateral leg DVT (OR, 2.09; P = .02), but not pulmonary embolism (OR, 0.93). Active cancer is associated with VTE location. Location of VTE may be useful in decision making regarding cancer screening.

Risk Factors for Venous Thromboembolism (VTE) Among Nursing Home Residents: A Population-Based Case Control Study

AbstractAbstract 476 Background:The burden of VTE among nursing home (NH) residents is known to be high. Yet very little data exist to help determine which NH residents to target for VTE prophylaxis. The need to characterize VTE risk in this population is especially great because the advanced age and high comorbidity that typify NH residents contribute to increased likelihood of adverse consequences from VTE prophylaxis. To compound the problem, results of our prior univariate analyses of certain factors known to contribute substantially to VTE risk in the general population (e.g., major surgery, medical hospitalization, trauma) suggest that impact of these factors on VTE may be less substantial among NH residents. Objective:To use the longitudinal population-based resources of the Rochester Epidemiology Project (REP) to investigate the contribution of multiple clinical characteristics to risk of VTE among NH residents. Methods:We took advantage of the previous identification of all Olmsted County, MN residents who met research criteria for incident VTE 1988 through 2005 (N=2,332). We then determined which individuals were resident of a local NH at time of VTE symptom onset, regardless of location of symptom onset (i.e., individuals whose VTE occurred in-hospital having been admitted from a NH were considered NH residents). For each such NH VTE case (N=269), we identified 2 same sex Olmsted County residents of similar age and duration of medical history who were also resident of a local NH at the time of the case's VTE event (i.e., index date) (N=538). We reviewed the detailed provider-linked medical records of NH VTE cases and NH non-VTE controls for 3 months before index for information on multiple characteristics identified or hypothesized as contributing to VTE risk in studies of the general population and other at-risk subgroups by our group and others (e.g., patient demographics, body mass index, major surgery, hospitalization for acute medical illness, outpatient surgical procedures, trauma/fracture, leg paresis, active cancer, superficial vein thrombosis, varicose veins, infections, diabetes mellitus, coronary artery disease, congestive heart failure, and multiple medications, including anticoagulants, statins, beta-blockers, ACE inhibitors and angiotensin II receptor antagonists). We tested and estimated the odds ratio associated with each factor using step-wise conditional logistic regression. Variables for which <10 cases or <10 controls exhibited the characteristic were excluded from analysis. Results:The first five variables to enter the model were urinary tract infection, active cancer, superficial vein thrombosis, pneumonia, and leg paresis. The respective odds ratios (95% confidence intervals) with all five in the model were 1.7 (1.2, 2.4); 2.1 (1.3, 3.5); 2.1 (1.3, 3.4); 1.9 (1.3, 2.8); 2.3 (1.3, 4.2); each p value was <0.01. Variables associated with high VTE risk in the general population (i.e., surgery, hospitalization for medical illness, trauma/fracture) were not included in the top five risk factors for NH residents. Conclusions:Infection is a potent VTE risk factor among NH residents. Our study results will help inform development of practice guidelines in the NH and stimulate future research on putative VTE mechanisms. REP data afford limited information on cognitive and physical disability, immobility, and need for NH care. Additional investigations are needed that combine information from clinical and NH assessments. Disclosures:No relevant conflicts of interest to declare.

Lack of prophylaxis before the onset of acute venous thromboembolism among hospitalized cancer patients: the SWIss Venous ThromboEmbolism Registry (SWIVTER)

Background: Venous thromboembolism (VTE) prophylaxis remains underutilized, particularly in cancer patients. We explored clinical predictors of prophylaxis in hospitalized cancer patients before the onset of acute VTE.Methods: In the SWiss Venous ThromboEmbolism Registry, 257 cancer patients (61 ± 15 years) with acute VTE and prior hospitalization for acute medical illness or surgery within 30 days (91% were at high risk with Geneva VTE risk score ≥3) were enrolled.Results: Overall, 153 (60%) patients received prophylaxis (49% pharmacological and 21% mechanical) before the onset of acute VTE. Outpatient status at the time of VTE diagnosis [odds ratio (OR) 0.31, 95% confidence interval (CI) 0.18–0.53], ongoing chemotherapy (OR 0.51, 95% CI 0.31–0.85), and recent chemotherapy (OR 0.53, 95% CI 0.32–0.88) were univariately associated with the absence of VTE prophylaxis. In multivariate analysis, intensive care unit admission within 30 days (OR 7.02, 95% CI 2.38–20.64), prior deep vein thrombosis (OR 3.48, 95% CI 2.14–5.64), surgery within 30 days (OR 2.43, 95% CI 1.19–4.99), bed rest >3 days (OR 2.02, 95% CI 1.08–3.78), and outpatient status (OR 0.38, 95% CI 0.19–0.76) remained the only independent predictors of thromboprophylaxis.Conclusions: Although most hospitalized cancer patients were at high risk, 40% did not receive any prophylaxis before the onset of acute VTE. There is a need to improve thromboprophylaxis in cancer patients, particularly in the presence of recent or ongoing chemotherapy.

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. Observational. Tertiary care hospital, community teaching hospital. Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998). Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.