Indications For Thromboprophylaxis Research Articles

Venous Thromboembolism Risk and Adherence to Pharmacological Thromboprophylaxis in Hospitalized Patients in Uruguay: First Nationwide Study.

Venous thromboembolism (VTE) is a serious, frequent, and preventable medical complication in hospitalized patients. Although the efficacy of prophylaxis (pharmacological and/or mechanical) has been demonstrated, compliance with prophylaxis is poor at international and national levels. To determine the indication and use of pharmacological thromboprophylaxis in hospitalized patients in Uruguay. An observational, descriptive, cross-sectional, multicentre study involving 31 nationwide healthcare facilities was conducted. Baseline characteristics associated with hospital admission, the percentage of the population with an indication for thromboprophylaxis, and the percentage of patients receiving pharmacological thromboprophylaxis were assessed. The VTE risk was determined using the Padua score for medical patients; the Caprini score for surgical patients; the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for pregnant-postpartum patients. 1925 patients were included, representing 26% of hospitalized patients in Uruguay. 71.9% of all patients were at risk of VTE. Of all patients at risk of VTE, 58.6% received pharmacological thromboprophylaxis. The reasons for not receiving thromboprophylaxis were prescribing omissions in 16.1% of cases, contraindication in 15.9% and 9.4% of patients were already anticoagulated for other reasons. Overall, just 68% of patients were "protected" against VTE. Recommendations of major thromboprophylaxis guidelines were followed in 70.1% of patients at risk. Despite the progress made in adherence to thromboprophylaxis indications, nonadherence remains a problem, affecting one in six patients at risk of VTE in Uruguay.

Enoxaparin for VTE thromboprophylaxis during inpatient rehabilitation care: assessment of the standard fixed dosing regimen

BackgroundWe aimed to examine the efficiency of fixed daily dose enoxaparin (40 mg) thromboprophylaxis strategy for patients undergoing inpatient rehabilitation.MethodsThis was an observational, prospective, cohort study that included 63 hospitalized patients undergoing rehabilitative treatment following sub-acute ischemic stroke (SAIS) or spinal cord injury (SCI), with an indication for thromboprophylaxis. Anti-Xa level measured three hours post-drug administration (following three consecutive days of enoxaparin treatment or more) was utilised to assess in vivo enoxaparin activity. An anti-Xa level between 0.2-0.5 U/ml was considered evidence of effective antithrombotic activity.ResultsWe found sub-prophylactic levels of anti-Xa (<0.2 U/ml) in 19% (12/63). Results were within the recommended prophylactic range (0.2-0.5 U/ml) in 73% (46/63) and were supra-prophylactic (>0.5 U/ml) in 7.9% (5/63) of patients. Anti-Xa levels were found to inversely correlate with patients’ weight and renal function as defined by creatinine clearance (CrCl) (p<0.05).ConclusionsOur study confirmed that a one-size-fits-all approach for venous thromboembolism (VTE) prophylaxis may be inadequate for rehabilitation patient populations. The efficacy of fixed-dose enoxaparin prophylaxis is limited and may be influenced by renal function and weight. This study suggests that anti-Xa studies and prophylactic enoxaparin dose adjustments should be considered in certain patients, such as those who are underweight, overweight and or have suboptimal renal function.Trial registrationNo. NCT103593291, registered August 2018.

Venous thromboembolism: risk factors and prophylaxis

Venous thromboembolism is an important complication in tumour patients as it occurs frequently in these patients and causes relevant morbidity. The risk of thromboembolic complications in tumour patients is 3-9 times higher than in non-tumour patients and is the second most common cause of death in tumour patients. The risk of thrombosis depends on tumour-induced coagulopathy and on individual factors, type and stage of cancer, time since cancer diagnosis as well as type of systemic cancer therapy. Thromboprophylaxis in tumour patients is effective but can be associated with increased bleeding. Even though there are currently no dedicated recommendations for individual tumour entities, international guidelines recommend prophylactic measures in high-risk patients. A thrombosis risk of >8-10% can be considered an indication for thromboprophylaxis, which is indicated by a Khorana score ≥2, and should be calculated individually using nomograms. In particular, patients with a low risk of bleeding should receive thromboprophylaxis. Risk factors and symptoms of a thromboembolic event should also be intensively discussed with the patient and materials for patient information should be handed out.

P–706 Impaired fibrinolysis during estrogen substitution in relation to frozen-thawed embryo transfer

Abstract Study question Is the clot lysis time prolonged in women undergoing estrogen substitution in artificial cycle during frozen-thawed embryo transfer (AC-FET)? Summary answer Women receiving AC-FET have a prolonged clot lysis time that could result in increased venous thromboembolic risk during estrogen substitution. What is known already High doses of estrogen are used for women treated with AC-FET; this in contrast to women treated with natural cycle frozen-thawed embryo transfer (NC-FET). Based on previous research on hormone replacement therapy in other settings, estrogen substitution is probably associated with an increased risk of thromboembolism. Moreover, it has formerly been shown that pregnant women followed assisted reproductive technology (ART) treatment as compared to natural fertilization, has an increased risk of thrombosis. However, changes in fibrinolysis has never been examined in women undergoing estrogen substitution during treatment with AC-FET. Study design, size, duration Prospective cohort study of women receiving AC-FET with oestrogen/progesterone substitution or NC-FET. Blood samples were obtained four times: 1) prior to hormone substitution (baseline), 2) confirmation of biochemical pregnancy, 3) gestational week 8 and 4) gestational week 13 (5 weeks after cessation of hormone substitution). Inclusion criteria: women aged &amp;gt; 18 years assigned for FET. Exclusion criteria: egg donor recipients, known bleeding disorders, indication for thromboprophylaxis and treatment with anti-platelet medication or non-steroid-anti-inflammatory drugs. Participants/materials, setting, methods We included women at the Department of Obstetrics and Gynaecology, Horsens Fertility Clinic, Denmark, from August 2019 – November 2020. In total, 34 participants were included: 19 women treated with AC-FET and 15 women receiving NC-FET. We examined fibrinolysis measured by a dynamic fibrin clot lysis assay that can assess the capacity for fibrin formation and fibrinolysis. This detailed information of the fibrinolytic activity are used as a surrogat marker of thromboembolic risk. Main results and the role of chance Our results showed a significantly longer lysis time (908 ± 234 vs 1157 ± 218) (p &amp;lt; 0.001) within the AC-FET group after hormone substitution compared to baseline. Moreover, we found a higher area under the curve (AUC) (919 ± 305 vs 1167 ± 391) (p = 0.006) within the AC-FET group. However, we observed no changes in mean lag phase or maximum absorbency after estrogen substitution within the AC-FET group. Since we observed a significantly higher AUC within the AC-FET group after estrogen substitution, this is probably due to the prolonged lysis time, indicating hypofibrinolysis. No significant changes was found comparing the NC-FET group with the AC-FET group. Limitations, reasons for caution Our data are based on a small study population. Additionally, we cannot exclude that the coagulation parameters could be affected by estrogen prior to study enrollment as we had no wash out period. Wider implications of the findings: Our findings indicate prothrombotic changes in the AC-FET group. It is relevant to individually consider the indication for AC-FET and restrict the use of unnecessary hormone exposure. These data should be followed by a populations-based study to clarify how this potentially increased venous thromboembolic risk will manifest itself clinically. Trial registration number NCT04359576

Thromboprophylaxie pharmacologique chez les patients hospitalisés pour une affection médicale aiguë

Venous thromboembolic events (VTE) occur in approximately 50% of cases during or following hospitalization; VTE are a major cause of morbidity and mortality. Thromboprophylaxis for 6 to 14 days with heparins or fondaparinux has been demonstrated to be effective in VTE prevention in patients hospitalized for acute medical illnesses and reduced mobility. Nevertheless, the level of recommendation has been gradually downgraded as the benefit has been mainly demonstrated on the basis of systematic imaging diagnosed events. Direct oral anticoagulants have been assessed only as an extended prophylaxis, and are currently not recommended in medical thromboprophylaxis. Assessing the risk of VTE and bleeding in medical patients is complex. VTE and bleeding risk assessment scores were constructed but have not been validated. In order to improve the adequacy of prescriptions for thromboprophylaxis, the impact of different interventions has been the subject of several studies but these yielded varying results. The aim of this review is to analyze the indications for thromboprophylaxis in a medical setting with the latest available data.

National consensus on the cardiological treatment and follow-up of Kawasaki disease

Abstract Kawasaki disease is a self-limiting acute vasculitis that affects small and medium-sized vessels, and is the most common cause of acquired heart disease in children in our environment. Up to 25% of untreated patients develop coronary aneurysms. It is suspected that an infectious agent may be the trigger of the disease, but the causative agent is still unknown. Based on the previous evidence, recommendations are proposed for the diagnosis, treatment of acute disease, and the long-term management of these patients, in order to unify criteria. The diagnosis must be quick, based on easy-to-use algorithms and with the support of complementary tests. This document includes the indication of available imaging techniques, as well as the planning of cardiological examinations based on the initial involvement. Intravenous immunoglobulin is the basis of the initial treatment. The role of corticosteroids is still controversial, but there are studies that support its use as adjuvant treatment. A multidisciplinary working group has developed a scheme with different treatment guidelines depending on the risk factors at diagnosis, the patient's clinical situation, and response to previous treatment, including indications for thromboprophylaxis in patients with coronary involvement. The stratification of risk for long-term treatment is essential, as well as the recommendations on the procedures based on the initial cardiological involvement and its progression. Patients with coronary aneurysms require continuous and uninterrupted cardiological monitoring for life.

Profilaxis tromboembólica en pacientes posparto. Estudio de corte transversal en tres instituciones en Colombia

&lt;p&gt;&lt;strong&gt;Objetivo:&lt;/strong&gt; describir el nivel de riesgo de enfermedad tromboembólica en pacientes posparto y hacer una aproximación al uso actual de la tromboprofilaxis.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales y métodos:&lt;/strong&gt; estudio descriptivo de corte transversal. Se incluyeron pacientes que fueron hospitalizadas para atención de parto entre agosto de 2012 y abril de 2013 en tres instituciones generales de alta complejidad en Bogotá y Medellín. Se aplicó la Guía de manejo del Royal College Obstetrics &amp;amp; Gynecology (RCOG) para establecer el riesgo de enfermedad tromboembólica. Las pacientes fueron evaluadas en el posparto y clasificadas en alto, intermedio y bajo riesgo. Se midió la frecuencia real de aplicación de tromboproilaxis. Los resultados se presentan como proporciones.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Resultados:&lt;/strong&gt; se evaluaron un total de 3516 pacientes, el 1,9 % de las pacientes fueron clasificadas como de alto riesgo, 42 % de riesgo medio y 56,1 % de riesgo bajo. La tromboprofilaxis solo se aplicó a un 7,4 % de las pacientes con alto riesgo y riesgo intermedio.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusión:&lt;/strong&gt; según los criterios de la Guía del RCOG, un 43,9 % de las pacientes tendrían indicación de tromboprofilaxis; sin embargo, solo un 7,4 % de ellas la recibió. Se requieren estudios complementarios para evaluar los riesgos y beneficios del uso de la tromboprofilaxis según la guía del Reino Unido.&lt;/p&gt;

Quantification of the External Validity of Randomized Controlled Trials Supporting Clinical Care Guidelines: The Case of Thromboprophylaxis

BackgroundClinical guidelines are based on the results of several randomized controlled trials. However, due to the stringent exclusion criteria of these trials, their external validity may be low. We aimed to evaluate the external validity of the randomized controlled trials cited in the American College of Chest Physicians guidelines for the use of pharmacological thromboprophylaxis in hospitalized medical patients. MethodsWe conducted a cross-sectional, chart-review study of a random sample of patients admitted between July 1, 2013 and June 30, 2014 to the Internal Medicine ward of a large Canadian teaching university hospital. We identified the proportion of our population presenting exclusion criteria used in the randomized controlled trials cited in support of clinical care guidelines on thromboprophylaxis in the medical setting. ResultsNine trials were identified for a total of 28,793 included patients following 23 distinct exclusion criteria. We included 429 patients. Median age was 65 years (interquartile ratio 51-77 years), and 236 (55%) were males. Of those not already anticoagulated at admission (n = 351), between 26% and 67% (weighted average, 51%) of our population presented at least one exclusion criterion, making them ineligible to be enrolled in randomized controlled trials. When restricting our population to patients with an indication for thromboprophylaxis based on a Padua risk score at admission ≥4, 21% to 76% (weighted average 55%) were ineligible to be enrolled in individual trials. ConclusionsOur cross-sectional study illustrates that the external validity of randomized controlled trials cited in the guidelines was low in our population, and lower when applying the risk-stratification tool recommended by guidelines. This can bias the clinicians toward treating patients that were not represented in the supporting evidence.

Prévention des évènements thromboemboliques veineux par fondaparinux 2,5 mg chez des patients hospitalisés pour une affection médicale aiguë. Étude ArchiMed. ArchiMed hôpital – étude observationnelle d’usage du fondaparinux 2,5 mg en vie réelle ; 718 patients inclus par 107 pharmaciens hospitaliers

To evaluate the average duration of in-hospital treatment with fondaparinux 2.5mg prescribed for venous thromboprophylaxis in acutely ill medical patients and to describe the treatment population. Prospective, observational, national, multicentre, epidemiological study, performed in France at the request of the Transparency Commission of the French National Health Authority (Haute Autorité de Santé). This is part of a larger study program that also included a study with similar design in the general practice setting. The hospital practice part of the study was conducted by hospital pharmacists who were asked to include the first 15 adult subjects hospitalized in a non-surgical ward for whom fondaparinux 2.5mg was initiated for prophylaxis. Fifty-three pharmacists (49.5%) included a total of 718 patients. The average age was 71 ±16 years (47%<75 years old); 54% were women. For 41% of patients, duration of fondaparinux 2.5mg administration ranged from 6 to 14 days. Eighty-five percent of patients had at least one acute illness related to the prescription of fondaparinux 2.5mg for thromboprophylaxis. Ten percent of the population had at least one risk factor listed on the Case Report Form. Characteristics of patients from the hospital practice study differ from those included in the general practice part of the ArchiMed Study program. The hospital practice part of the ArchiMed Study, which is similar to "audits of practices", shows that the real-life conditions of prescription of fondaparinux 2.5mg in patients hospitalized are generally in line with guidelines with respect to indication for thromboprophylaxis in acute medical illness.

Knowledge, attitudes and practices related to venous thromboembolism prophylaxis in hospitalists in Lome (Togo)

The purpose of this study was to assess the knowledge and practices related to the prevention of venous thromboembolism (VTE) in medical settings in Lome (Togo). Hospitalists in Lome are relatively well aware of the risk of VTE in patients. They report risk factors for VTE as the primary indications for thromboprophylaxis. Few physicians cited acute medical conditions among these indications.

Shifting Paradigm In Physician Practice Patterns In The Application Of Thromboprophylaxis Guidelines: An Updated Analysis Of Venous Thromboembolism Prevention At a University-Affiliated Tertiary Care Center

BackgroundVenous thromboembolism (VTE) is an important cause of morbidity and mortality in hospitalized patients. Prophylactic antithrombotic therapy has been shown to be the most effective method to reduce the health and economic burden of an often silent disease. The American College of Chest Physicians (ACCP) has been instrumental in developing guidelines for the use of prophylactic antithrombotic therapy. However, several studies have consistently demonstrated underuse of these guidelines. One such study, conducted in 2001 at our university- affiliated hospital (Jewish General Hospital, Montreal, Canada), showed that 17.4% of all VTE cases in hospitalized patients were potentially avoidable (Arnold DM, Kahn SR, et al. Chest2001) and that this represented 2/3 of all VTE cases for which thromboprophylaxis had been indicated. Consequently, in 2005, we implemented an institution-wide thromboprophylaxis policy with the aim of improving VTE prevention. Five years after this change, we reassessed physician practice patterns at our institution with regards to application of thromboprophylaxis guidelines, and determined the avoidability of each case of VTE. ObjectiveTo identify and characterize cases of potentially avoidable VTE: cases for which thromboprophylaxis was indicated according to ACCP consensus guidelines for VTE prevention, yet was administered inadequately. MethodsWe conducted a retrospective cohort study, which included all patients with objectively diagnosed VTE who were admitted in 2010 to the Jewish General Hospital, a university-affiliated tertiary care institution. A standardized case-report form was used to obtain data from patient charts on patient characteristics, risk factors for VTE, risk factors for bleeding, presence of indications for thromboprophylaxis as per ACCP guidelines (e.g. surgery in last 3 months, hospitalization for pneumonia), and thromboprophylaxis regimen received. Each case was classified as avoidable (a case in which thromboprophylaxis was indicated but inadequately administered), non-avoidable (a case in which thromboprophylaxis was indicated and was correctly administered), spontaneous (a case in which a VTE occurred with no evident indications for thromboprophylaxis), and ineligible (a case in which there was either contraindication to thromboprophylaxis, or which occurred at another institution). The proportions with avoidable, non-avoidable and spontaneous VTE were compared to the results we obtained in our 2001 study. ResultsOf the 230 cases of VTE diagnosed in 219 patients, 55 cases were classified as avoidable (23.9%), 87 were non-avoidable (37.8%), and 74 were spontaneous (32.2%). Therefore, of the 142 (i.e. 55+87) cases for which thromboprophylaxis was indicated, 38.7% were potentially avoidable. Of the avoidable VTE cases, the majority (51.0%) were due to omission of thromboprophylaxis, with another 40.0% due to delay in initiation of thromboprophylaxis. The majority (75%) of avoidable cases occurred during general medical admissions, with a minority occurring in the context of orthopedic surgery. Common additional VTE risk factors in avoidable cases were cancer, obesity and prolonged immobility. Conclusions1 in 4 cases of all VTE, and 1 in 2.5 cases of VTE for which thromboprophylaxis was indicated could potentially have been avoided had thromboprophylaxis been administered according to ACCP guidelines. The ratio of avoidable to non-avoidable cases (38.7%; 1 in 2.5) has significantly improved since 2001(67.7%; 2 in 3). Physician education and the adoption of an institution-wide protocolized approach to thromboprophylaxis may be largely responsible for this favorable shift. However, there has also been a significant decrease in the number of VTE cases deemed “spontaneous” from 2001 to 2010 (70.8% to 32.2%). During this time period, there were no major guideline changes in indications for VTE prophylaxis that might have led to fewer VTE being labeled spontaneous and more VTE being labeled provoked. The decrease in spontaneous cases of VTE might be ascribable to a change in patient population (e.g. increased numbers of hospitalizations for malignancy-related complications), as well as a shift towards having a lower threshold to identify patients as having risk factors for VTE (e.g. patients with pneumonia, non-fracture injuries). Disclosures:No relevant conflicts of interest to declare.

Postoperative Deep Vein Thrombosis (DVT) In Patients With Hemophilia Undergoing Major Orthopedic Surgery

BackgroundPatients undergoing major orthopedic surgery such as hip and knee arthroplasty are at particularly high risk for venous thromboembolism (VTE) due to the nature of the surgery and postoperative immobilization, and thus routine thromboprophylaxis has been the standard of care for more than 15 years. Peri-operative clotting factor concentrate replacement is administered to reverse the inherent hemostatic defect in persons with hemophilia (PWH), potentially rendering these patients at risk for developing deep vein thrombosis (DVT) postoperatively. Currently, no published guidelines address the risk of DVT or the indications for thromboprophylaxis in PWH undergoing hip or knee arthroplasty. Consequently, given their underlying bleeding risk, thromboprophylaxis practice in individuals with hemophilia undergoing orthopedic procedures varies considerably among Hemophilia Treatment Centers (HTCs). ObjectiveTo determine the rate of ultrasound-detectable lower extremity DVT (asymptomatic or symptomatic) or clinically apparent pulmonary embolism (PE) in PWH undergoing total hip or knee arthroplasty. MethodsThis was a prospective, multicenter observational study. All patients with hemophilia A or B scheduled for knee or hip replacement at participating centers were eligible to participate. Patients with a prior history of VTE or those receiving anticoagulation prior to surgery were excluded. Baseline venous duplex ultrasounds of the lower extremities (proximal and distal) were obtained within 7 days prior to surgery, and follow-up ultrasounds were performed 4-6 weeks after surgery. Patients were otherwise evaluated and treated per the local institutional standard of care. Coagulation factor dosing and plasma factor activity levels were recorded, as was use of mechanical (intermittent pneumatic compression) or pharmacologic thromboprophylaxis. Major bleeding was defined as bleeding that resulted in a decrease of hemoglobin of 2 g/dL or more over a 24 hour period, bleeding that led to transfusion of 2 or more units of packed red blood cells, bleeding into a critical site, or bleeding that led to death. Minor bleeding was defined as clinically overt bleeding that did not satisfy any of the major bleeding criteria. Results11 HTCs enrolled a total of 46 patients between February 2010 and June 2013. 44 patients completed the study (2 withdrew due to surgery cancellation); 13 had hip replacement (median age 50.9 years) and 31 had knee replacement (median age 49.1 years). 15 patients (34.1%) had a history of inhibitor prior to surgery. 6 patients (13.6%) were treated with bypassing agents perioperatively; 3 of these patients had active inhibitors present at the time of surgery. The remaining 38 patients received factor VIII or IX replacement. 22 patients (50%) received some form of mechanical prophylaxis during hospitalization, and 3 patients (6.8%) also received low molecular weight heparin (LMWH) prophylaxis. 22 patients (50%) did not receive any form of prophylaxis. 1 patient (2.3%, 95% CI 0-12%) with moderate hemophilia A and no history of inhibitor who received mechanical prophylaxis was diagnosed with symptomatic distal DVT on postoperative day 6 (confirmed by ultrasound). No patients (0%, 95% CI 0-8.0%) had asymptomatic DVT or clinically apparent PE. 16 patients (36.4%) had major bleeding during hospitalization. 4 of the 6 patients treated with a bypassing agent had major bleeding, and 1 of these patients required a re-operation due to bleeding in the replaced joint. 2 of the 3 patients who received LMWH prophylaxis had major bleeding events. 4 patients (9.1%) experienced minor bleeding. ConclusionsIn this prospective study, the observed prevalence of ultrasound detectable DVT in PWH following total knee or hip arthroplasty was very low. In the general population, when thromboprophylaxis is not administered, DVT prevalence (measured by venography) after knee and hip replacement is 40-84% and 40-57%, respectively. With mechanical prophylaxis, these rates decrease to 20.3% for hip replacement and 28.3% for knee replacement. Although these prevalence rates are expected to be somewhat lower when ultrasound is used for diagnosis, the low prevalence of DVT (2.3%) and the high rate of bleeding complications (36.4% major; 9.1% minor) in this study suggest that pharmacologic prophylaxis should not be used following knee or hip replacement in PWH with no prior history of VTE. Disclosures:Kempton:Baxter Healthcare: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Research Funding.

The Use of a Scoring System to Guide Thromboprophylaxis in a High-Risk Pregnant Population

Guidelines for thromboprophylaxis in pregnancy are usually based upon clinical observations and expert opinion. For optimal impact, their use must be attended by consistency in the advice given to women. In this observational study, we evaluated the performance of a scoring system, used as a guide for clinicians administering dalteparin to pregnant women at increased risk of venous thromboembolism. The work included 47 women treated with dalteparin prior to adoption of the scoring system and 58 women treated with dalteparin after its adoption. The indication for thromboprophylaxis was recorded in each case together with details of the regimen employed, obstetric, and haematological outcomes. The main outcome measure was to determine whether consistency improved after adoption of the scoring system. We also recorded the occurrence of any new venous thromboembolism, haemorrhage, the use of regional anaesthesia during labour, evidence of allergy, and thrombocytopenia. We found that use of the scoring system improved the consistency of advice and increased the mean duration of thromboprophylaxis. None of the subjects suffered venous thromboembolism after assessment using the scoring system. There was no increase in obstetric or anaesthetic morbidity when dalteparin was given antenatally period and no evidence of heparin-induced thrombocytopenia.

Évaluation de la thromboprophylaxie dans un service de médecine interne

There is a lack for French official guidelines for prophylaxis of venous thromboembolism. Therefore an internal referential based on MEDENOX study inclusion criteria was proposed in our internal medicine department. The main goal of this study was to assess the appropriateness of thromboprophylaxis prescriptions regarding the internal referential. A retrospective and observational study included all the patients older than 18 years hospitalized in February and July 2007 in our internal medicine department for at least 48 hours and receiving no anticoagulant treatment. For each patient the following criteria were recorded: admission diagnosis, past medical history, current treatment, creatinine clearance, duration of hospitalisation, thromboprophylactic treatment and course during hospital stay. Eighty-nine patients were included. Forty-two (47.2%) patients had a thromboprophylaxis indication. Among them 40 (95.2%) actually received a thromboprophylaxis. Ten of the 47 patients (21.2%) without thromboprophylaxis indication also received a thromboprophylaxis. The most frequent indications for thromboprophylaxis were an infectious disease with an age greater than 75 years old and a cardiac failure stage III or IV of the NYHA. Most of the studies concerning medical thromboprophylaxis highlight its underutilization in the absence of a referential. In our study the referential use increased the percentage of patients with appropriate thromboprophylaxis but was associated with over-prescriptions in 21.2% of the cases. The use of electronic alerts may increase the number of patients receiving the appropriate treatment.

Evaluation of the frequency of venous thromboembolism prophylaxis in a selected population of patients hospitalized in nonsurgical wards. Results of the all‑Poland EPID Registry

The results of the Prophylaxis in Medical Patients with Enoxoparin (MEDENOX) trial demonstrated the benefit of thromboprophylaxis in patients hospitalized because of acute heart failure, respiratory failure and rheumatic disease. Analysis of clinical practice shows that thromboprophylaxis is rarely used in these patients. To assess thromboprophylaxis use in a selected population of patients hospitalized in internal departments in Poland. Between the years 2002 and 2006, 14,707 hospitalized patients were included into the EPID Registry. The study population, selected for the purpose of this analysis, involved 5246 patients (mean age 71, 95% CI: 70.6 -71.4 years), reported by 60 internal wards, who met the entry criteria of the MEDENOX study. Patients receiving long-term antithrombotic treatment and patients with indications for initiating antithrombotic treatment were not enrolled. Thromboprophylaxis was administered in 63% of patients. The average duration of thromboprophylaxis was 8.1 days (95% CI: 7.8-8.4). In the group of patients admitted to the intensive care unit thromoprophylaxis was administered in 81% of cases compared with 58% in nonsurgical departments (p < 0.0001). Low-molecular-weight heparins were used in 93% of patients receiving prophylaxis. The risk of hemorrhage (9.5%) and lack of indications for thromboprophylaxis (27%) according to the physicians were the main reasons for not using prophylaxis. The frequency of thromboprophylaxis use varied from 35% to 89% between different regions of Poland. Hemorrhagic complications were reported in 0.8% of patients receiving prophylaxis. Administration of thromboprophylaxis in the MEDENOX-like population is of great importance from an epidemiological point of view because this patient group accounts for 31% of in-patients. Thromboprophylaxis is underused with large differences between regions, which should be improved by an adequate educational program for physicians from internal wards.

Day surgery and thromboembolic complications: time for structured assessment and prophylaxis

This article provides an overview of studies on thromboembolic complications and thromboprophylaxis in outpatients. The aim is to evaluate the indications and practice of thromboprophylaxis in day surgery. Retrospective studies reported a low incidence of venous thromboembolism after day surgery, although some prospective studies that included systematic screening for deep vein thrombosis reported a high incidence of this entity among outpatients. There are few randomized controlled trial data to inform indications for thromboprophylaxis in day surgery, however. After the decision to start treatment has been made, the optimal time for the first dose is 6 h postoperatively. There is no evidence favouring 1-2 days of prophylaxis, and the duration should be 7-10 days. Increasing numbers of elderly patients with comorbidity and younger patients with risk factors for venous thromboembolism are undergoing surgery, and procedures of increased complexity are performed in the day-care setting. There is a lack of data on indications for thromboprophylaxis, however, and the practice is thus opinion based. Screening for risk factors for venous thromboembolism should become routine, and randomized controlled trials are needed to provide data to inform institutional guidelines.

The under use of thromboprophylaxis in older medical in-patients: a regional audit

The risk of venous thromboembolism (VTE) among medical in-patients increases with age. Thromboprophylaxis using low-molecular-weight heparin can reduce the incidence by 50%, but anecdotally is under-used in medical patients, particularly the elderly. To examine prescribing practice for thromboprophylaxis in elderly in-patients in the Yorkshire region. Regional audit of medical records and drug charts. A simultaneous audit was done of all medical in-patients >75 years on 30 wards in 10 hospitals. Guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) on the use of thromboprophylaxis were used as the standard. Data were collected on contraindications and/or indications for thromboprophylaxis and the type of prophylaxis used. Of 601 patients studied (mean age 84.6 years), 117 (19.5%) had indications for thromboprophylaxis with no contraindications. Of these 117, 34 (29%) were receiving prophylaxis as per guidelines. There was more than one indication for thromboprophylaxis in 17% of those left untreated. The mean age of those receiving therapy was similar to those not receiving it (84.0 vs. 84.5 years, p = 0.66, t-test). Elderly in-patients on medical wards were more likely to receive appropriate treatment than those on geriatric wards (43% vs. 23%, p = 0.03, chi(2) test). Thromboprophylaxis is under-used in older medical in-patients, despite their increased risk of VTE, particularly on geriatric wards. Greater consideration by doctors attending to older medical patients is needed if VTE is to be prevented.

Deep Vein Thrombosis in Myeloma: Estimate of Prevelance and Recommendations for Therapy Based upon a Survey of Members of the International Myeloma Working Group (IMWG).

Purpose: Deep vein thrombosis (DVT) is increasingly recognized as a major complication of thalidomide (T; Thal) and lenalidomide (R; Rev) based therapy for multiple myeloma. Estimated incidence varies widely in the literature. There is no consensus on specific risk factors, indications for thromboprophylaxis or the agent of choice for DVT prophylaxis. The purpose of this study was to develop a consensus among members of the IMWG.Patients and Methods: A survey was electronically mailed to 67 IMWG members on July 21, 2006 and consisted of 24 multiple-choice questions.Results: Twenty-three IMWG members (34%) sent in their responses by the cut-off date. All (100%) felt that DVT was an important question, but most (95%) did not avoid Thal/Rev based therapy because of the DVT risk. Overall results are summarized in the Table below. A majority of physicians felt that concomitant therapy with high dose dexamethasone (90% of physicians), alkylators (55%), doxorubicin/liposomal doxorubicin (90%), and erythropoietin (75%) increase the risk of DVT associated with Thal or Rev based therapy. Aspirin (81 mg or 325 mg per day) was the preferred choice of prophylaxis when necessary. However, 65% of respondents preferred warfarin to a therapeutic INR or LMW heparin if either doxorubicin or liposomal doxorubicin was added to the regimens. Most (95–100%) felt that DVT prophylaxis was not indicated for: VAD, MP, bortezomib +/− dexamethasone regimens. Seventy-five percent felt it to be safe to resume therapy with Thal/Rev after therapeutic anticoagulation. Most (95%) believed randomized trials were needed.Conclusion: DVT is recognized as a major clinical problem associated with Thal/Rev containing regimens. Most respondents felt that the DVT risk did not warrant any prophylaxis when either Thal or Rev were used as single agents. Aspirin was the preferred form of DVT prophylaxis for most Thal/Rev containing regimens, except when doxorubicin/liposomal doxorubicin or melphalan were added. Additional responses will be analyzed both electronically and by conference call prior to the meeting.TherapyEstimated incidence of DVT (% respondents)Choice of thromboprophylaxis (% respondents)Single agent thal<5% (61%)None (65%)Single agent Rev<5% (80%)None (65%)Thal-Dex10–20% (52%)Aspirin (60%)Rev-Dex10–20% (48%)Aspirin (60%)MPT10–20% (65%)Aspirin (40%)R-MP5–10% (57%)Aspirin (70%)

Thromboprophylaxis in medically ill patients at risk for venous thromboembolism

According to guidelines from the American College of Chest Physicians, low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) should be prescribed to medical (nonsurgical) patients at high risk of venous thromboembolism. Thromboprophylaxis and mortality rates were determined in medical inpatients with indications for thromboprophylaxis. Cost differences between patient groups were investigated and are discussed. Using Solucient's ACTracker Inpatient Database, medical discharges between January 2001 and December 2004 were extracted and patients who had indications for thromboprophylaxis (acute myocardial infarction, ischemic stroke, cancer, heart failure, or severe lung disease) were identified. Patients < 40 years or with deep-vein thrombosis or pulmonary embolism, active peptic ulcer, malignant hypertension, blood disease, HIV infection, or intubation of gastrointestinal or respiratory tract were excluded. Rates of thromboprophylaxis and mortality were compared between groups. Mean total drug costs and hospital costs per patient discharge were compared between patient groups. Of 12,887,080 medical discharges extracted from 330 hospitals, there were 2,367,362 patients with indications for thromboprophylaxis. Patients were subdivided on the basis of whether they received thromboprophylaxis (n = 717,850) or not (n = 1,649,512). The thromboprophylaxis rate was low, despite increasing from 26% to 33% over the study period. Patients receiving thromboprophylaxis had significantly lower risk-adjusted mortality rates than those who did not (p < 0.001), except those with ischemic stroke. The mean total drug cost per patient receiving LMWH and UFH ($791 and $569, respectively) was higher than for patients not receiving thromboprophylaxis ($372) (p < 0.001). The mean total hospital cost per patient receiving UFH ($7615) was higher than for LMWH ($6866, p < 0.001). The thromboprophylaxis rate among medical patients was low, with no significant improvement between 2001 and 2004. Thromboprophylaxis can impact patient mortality rates. Economic evaluation revealed that the use of LMWH for thromboprophylaxis in at-risk medical patients was associated with higher total drug costs but lower total hospital costs than UFH. Efforts should be made to increase clinicians' awareness of clinical guidelines.

Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada

Background Venous thromboembolism (VTE) prophylaxis in acutely ill medical patients has been shown to be safe and effective. Underutilization of this patient safety practice may result in avoidable mortality and morbidity. Objectives We aimed to determine the proportion of hospitalized, acutely ill medical patients across Canada who were eligible to receive thromboprophylaxis and to evaluate the frequency, determinants and appropriateness of its use. Patients/Methods CURVE is a national, multicenter chart audit of 29 Canadian hospitals. Data were collected on consecutive patients admitted to hospital for an acute medical illness during a defined 3-week study period. Information on demographic and clinical characteristics, risk factors for VTE and bleeding and use of VTE prophylaxis were recorded. The indications for and appropriateness of VTE prophylaxis were assessed using pre-specified criteria based on international consensus guidelines. Multivariable analyses were performed to identify determinants of prophylaxis use. Results Of the 4124 medical admissions screened over the study period, 1894 patients (46%) were eligible for study inclusion. The most common specified admitting diagnoses were severe infection (28%), COPD exacerbation or respiratory failure (12%), malignancy (9%) and congestive heart failure (8%). Thromboprophylaxis was indicated in 1702 (90%) study patients. Overall, some form of prophylaxis was administered to 23% of all patients. However, only 16% received appropriate thromboprophylaxis. Factors independently associated with greater use of prophylaxis included internist (vs. other specialty) as attending physician (OR 1.33, 95% confidence interval (CI) [1.03, 1.71]), university-associated (vs. community) hospital (OR 1.46, 95% CI [1.03, 2.07]), immobilization (per day) (OR 1.60, 95% CI [1.45, 1.77]), presence of ≥ 1 VTE risk factors (OR = 1.78, 95% CI [1.35, 2.34]) and duration of hospitalization (per day of stay) (OR 1.05, 95% CI [1.03, 1.07]), however, use of prophylaxis was unacceptably low in all groups. Patients with cancer had a significantly reduced likelihood of receiving prophylaxis (OR = 0.40, 95% CI [0.24, 0.68]). Presence of risk factors for bleeding did not influence the use or choice of prophylaxis. Conclusion Most patients hospitalized for medical illness had indications for thromboprophylaxis, yet only 16% received appropriate prophylaxis. Efforts should be made to elucidate the reasons that underlie the very low rate of thromboprophylaxis in medical patients and to develop and test strategies to improve implementation of this patient safety practice.