Venous Thromboembolism Risk Assessment Research Articles

Socioeconomic status and risk of incident venous thromboembolism

BackgroundAlthough venous thromboembolism (VTE) is a leading cause of morbidity and mortality, and socioeconomic status (SES) affects human health and health behavior, few studies have examined the association between SES and VTE. ObjectivesWe aimed to investigate the association between SES, assessed individually and in a composite score by levels of education, income, and employment status, and incident VTE. MethodsWe used Danish national registries to identify 51 350 persons aged 25–65 years with incident VTE during 1995–2016. For each case, we used incidence density sampling to select five age‐, sex‐, and index‐year‐matched controls from the general Danish population (n = 256 750). SES indicators, including education, income, and employment status, were assessed 1 and 5 years before the VTE. We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to individual SES indicators and a composite SES score in analyses adjusted for age, sex, and comorbidities. ResultsCompared with low levels, high educational level (OR 0.74; 95% CI 0.71–0.77), high income (OR 0.70; 95% CI 0.68–0.72), and high employment status (OR 0.66; 95% CI 0.64–0.68) were associated with decreased risk of VTE, even after adjusting for comorbidities. A composite SES score was superior to the individual indicators in assessing VTE risk (OR for high vs. low score: 0.61; 95% CI 0.59–0.63). In sensitivity analysis with SES indicators measured 5 years before the VTE, the risk estimates remained essentially the same. ConclusionHigh levels of both individual SES indicators and a composite SES score were associated with decreased VTE risk.

A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery.

Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient. This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage. Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens. Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.

An abbreviated Caprini model for VTE risk assessment in trauma.

The Caprini risk assessment model (RAM) is widely used to assess risk of venous thromboembolism (VTE). However, it is cumbersome with 31 variables and poses challenges with inter-rater reliability. This study aimed to determine if an abbreviated model could perform similarly in VTE risk assessment. We performed a retrospective review of trauma patients ≥ 18years old and admitted for over 24h at a Level I trauma center from January 1, 2018, to December 31, 2018. Demographic and clinical data were analyzed to generate Caprini scores. Using a p-value cutoff of < 0.05, the individual components of the original Caprini RAM most highly associated with VTE were identified and used to calculate an abbreviated Caprini score. Logistic regression assessed odds of inpatient VTE with the original or abbreviated Caprini RAMs. Receiver operating characteristic curves and c-statistics were generated to assess discriminatory ability. The study sample included 1279 patients. Ten risk factors were included in the abbreviated model (recent major surgery, length of surgery > 2h, transfusion, restricted mobility > 72h, central venous catheter, current major surgery, age, history of VTE, hip or leg fracture, and serious trauma). Compared to the original, the abbreviated model had a similar odds ratio (1.17 vs 1.07, both p-values < 0.001), c-statistic (0.747 vs 0.753), sensitivity (0.73 vs 0.76) and specificity (0.62 vs 0.61). An abbreviated Caprini RAM performs similarly to the original, may streamline workflow and allow for automation in electronic health records, potentially enhancing its use in resource limited settings.

A Snapshot of Venous Thromboembolism (VTE): Retrospective Audit of Events at a Metropolitan Tertiary Referral Hospital

BackgroundFacility-level review of hospital-acquired venous thromboembolism (HA-VTE) cases, including pulmonary embolism (PE) and deep vein thrombosis (DVT), can provide insight into the local drivers of this preventable complication.AimTo determine the nature of HA-VTE, patient characteristics, VTE risk assessment completion and appropriateness of prescribed VTE prophylaxis at a metropolitan tertiary referral hospital and to compare the number of HA-VTE detected by audit of imaging scans with those reported by clinical coding.MethodsWe conducted a retrospective electronic medical record audit encompassing all patients diagnosed with HA-VTE via ventilation-perfusion scan, computed tomographic pulmonary angiography and/or doppler ultrasound using a demographic and VTE risk assessment audit tool during selected months of 2017-2019. We compared the number of manually audited cases with the number of performance unit-coded cases for the same months.ResultsThe months of May 2017, October 2017, April to July 2018 and April to July 2019 were included. There was a significant difference between HA-VTE detected via manual audit (147 events) and hospital coding (18 events), p=0.002. Manual audit patients were majority non-surgical (65%), female (58%), over 60 years (80%), at moderate VTE risk (71%) with reduced mobility (52%). There were 108 DVT-only (73%), 23 PE-only (16%) and 16 DVT plus PE events (11%). Notable risk factors were moderate to major surgery (30%), active malignancy or cancer treatment (24%) and active infection (27%). Most patients were prescribed appropriate VTE prophylaxis (74%) and had documented VTE risk assessment (68%). Appropriate VTE prophylaxis was significantly associated with using an electronic clinical decision support tool during VTE risk assessment (p=0.024).ConclusionFacility-driven HA-VTE audits provide opportunity to developed targeted initiatives for at-risk patients at a local level. Greater numbers of HA-VTE identified via manual audit suggest the need for future real-time documentation of HA-VTE to assist with efficient case review. DisclosuresNo relevant conflicts of interest to declare.

Assessment of Venous Thromboembolism Risk Based on the Khorana Predictive Model and Compliance with Prophylactic Anticoagulation at a Regional Cancer Center- a Quality Improvement Study

Background:Malignancy is an independent risk factor for venous thromboembolism. Factors like site of the primary cancer, associated comorbidities, obesity, and baseline cytopenias play an important role in predicting the risk in cancer patients. Several risk assessments models have been proposed in the literature, however, the Khorana risk predictive model is the most favored tool used in the literature. Patient characteristics like site of primary, baseline hemoglobin/platelets/WBC and BMI are the main components of this scoring system. Patients are classified into low (0), intermediate (1-2) and high (> 3) risk groups. Low dose prophylactic anticoagulation (Apixaban 2.5 mg BID or Rivaroxaban 10 mg daily) for up to 6 months is indicated in patients with score 2 or higher.Methods:83 patients with a new cancer diagnosis in the years 2018 and 2019 who received chemotherapy and developed a venous thromboembolism (VTE) after the cancer diagnosis were identified from the cancer registry at Edwards Comprehensive Cancer Center. All the components of Khorana score including patient's baseline body mass index (BMI), white blood cell count (WBC), hemoglobin, platelet count and site of the primary were collected. Compliance with prophylactic anticoagulation (Khorana score =/>2) was evaluated.Results:Among 83 patients identified, 61 % and 39 % were female and males, respectively with a mean age of 59 years. The mean duration of onset of VTE was 18 months from the time of cancer diagnosis. The mean Khorana score was 1.1. 34 % of patients(n=28) were found to have a Khorana score of =/> 2 and prophylactic anticoagulation was indicated. Only 7 % of patients (n=2) received prophylactic anticoagulation. The reason for no prophylactic anticoagulation was not documented in all the cases.Conclusion:In patients with a higher risk of VTE, a very low compliance rates for prophylactic anticoagulation were found at our cancer center. Poor documentation and failure to address the risk of VTE are possible reasons for the low compliance rates. Necessary steps needed to improve the compliance rates are warranted including education of the healthcare providers about current available guidelines to decrease risk of VTE in cancer patients. Dedicated lectures and sessions will be organized and educational materials highlighting the importance of VTE risks and prophylactic anticoagulation will be provided to the healthcare providers at the cancer center. DisclosuresNo relevant conflicts of interest to declare.

Thrombin Generation As a Predictive Biomarker for Venous Thromboembolism in Patients with Pancreatic and Lung Cancer Undergoing Systemic Therapy

Introduction:Venous thromboembolism (VTE) is common in patients with active malignancy. Whilethromboprophylaxis can mitigate this risk, current guidelines do not support routine use as the benefit ismodest and maybe negated by an increase in bleeding complications. However, there is significantvariation in VTE risk within the cancer population, thus prophylaxis can be considered in high-riskpatients. The Khorana score (KS) is validated to predict chemotherapy-associated VTE; however, it hasseveral limitations including variable performance based on tumor type as well as a static riskcategorization, based on pre-chemotherapy laboratory data, rather than a continuous assessment.Thrombin generation (TG) is an emerging biomarker that assesses global coagulation activation andpredicted increased VTE risk in cancer patients in the Vienna Cancer and Thrombosis Study (PMID:21464402). This study enrolled a heterogeneous cancer population, however, peak TG was not reportedby tumor type nor were the TG levels monitored over time in response to systemic therapy. The primaryaim of this study was to assess the relationship between TG (both peak TG and endogenous thrombinpotential, ETP) and KS. Secondary outcomes were to evaluate the impact of systemic therapy on peakTG and ETP levels over time and to assess the relationship between TG and clinical outcomes.Methods:This was a prospective study that enrolled adults with newly diagnosed, locally advanced or metastaticadenocarcinoma of the lung or pancreas. All patients received their care at Dartmouth HitchcockMedical Center. Those with a history of active VTE or use of full dose anticoagulant within 30 days priorto enrollment were excluded. After informed consent, KS was calculated and blood was collected insodium citrate tubes at 3 different time points (at initiation of therapy, and at the beginning of the 2 ndand 3 rd cycles of systemic therapy). Platelet-poor plasma was prepared by centrifugation and stored at -80°C until analysis by calibrated automated thrombogram (CAT; Thrombinoscope BV, Maastricht,Netherlands) using 1 pM tissue factor and 4 uM phospholipids to trigger coagulation reactions.Measurements were performed in triplicate for each specimen, and raw data were converted to peakTG and ETP. Information about VTE events, response to treatment and survival was obtained by chartreview. Mean and standard deviation were calculated for continuous variables and unpaired T test wasused for statistical analysis.Results:We report the results from 32 participants (17 lung, 15 pancreas). The majority of patients hadmetastatic disease (94%) and all received systemic therapy. The median age was 67 and 56% ofparticipants were male. The KS breakdown for the cohort was: KS1, 25%; KS2, 53%; KS3, 19%; KS4, 3%.Mean peak TG was 279, 352, 487 and 325 nmole and mean ETP was 1320, 1653, 2252, 1726 nmole/minfor KS 1, 2, 3 and 4, respectively. Initial peak TG and ETP levels were significantly higher in the KS ≥2group compared to those with KS=1 (peak TG: 384 ±135 vs 279 ±82, p 0.047; Initial ETP: 1806 ±632 vs1320 ±286, p 0.045). There were 8 VTE events (25%) with all but one occurring in the pancreatic cancercohort; all events occurred in KS 2 and 3 groups (75% and 25% respectively). No statistically significant difference was observed for initial peak TG or ETP in those with VTE vs those without (Peak TG: 342±171 vs 363 ±119, p 0.701; ETP: 1736 ±720 vs 1667 ±571, p 0.783). Both peak TG and ETP decreased inresponse to systemic therapy (initial peak TG vs final: 376 ±115 vs 225 ±125, p 0.0001; initial ETP vs final:1799 ±498 vs 1254 ±423, p 0.0003). No significant difference in survival was noted based on initial ETPlevel of <1500 nmole/min vs ≥1500 nmole/min (574 ±620 vs 287 ±227, p 0.069).Conclusions:There appears to be an association between KS and peak TG and ETP. In addition, both peak TG and ETPdeclined in response to systemic therapy, suggesting that the degree of coagulation activation is relatedto tumor burden. Our findings in this small study support further investigation of TG for VTE riskassessment in cancer patients. Future strategies incorporating TG into risk stratification models mayallow oncologists to better identify the population that may benefit most from pharmacologicthromboprophylaxis.Funding: Northern New England Clinical Oncology DisclosuresNo relevant conflicts of interest to declare.

Advances in the Prediction and Risk Assessment of Lung Cancer-Associated Venous Thromboembolism.

According to the most recent data from the National Cancer Center, venous thromboembolism (VTE) has unsurprisingly become one of the most common complications in lung cancer. VTE not only interferes with the equilibrium of the clotting system but it also affects tumor progression and prognosis. For the identification of high-risk patients, many clinical risk assessment models have been developed and validated based on the risk factors found in previous studies. In this review, we will summarize advances in prediction and risk assessment of VTE, with a focus on early diagnosis and therapy, reduction of mortality, and the burden of medical costs in lung cancer patients.

EP.FRI.771 National audit on VTE prophylaxis for lower limb injuries treated in a plaster cast

Abstract Aims Audit to assess Orthopaedic departments’ compliance with NICE guidelines on Venous thromboembolism (VTE) prophylaxis published in 2010, specifically looking at VTE practices for patients with lower limb injuries treated in a plaster cast. Methods A telephonic survey was carried out on junior doctors within orthopaedic departments of 66 hospitals across all regions of England. A questionnaire was completed regarding VTE risk assessment, prophylaxis and hospital guidelines etc. Data collected from August 2016 till February 2017. Results 83% (n = 55) of trusts routinely give VTE prophylaxis to these patients. 96% (n = 64) give Chemoprophylaxis of some sort. Formal VTE assessments are performed in 81% (n = 54) and 77% (n = 51) have a local VTE prophylaxis policy. Conclusions We conclude that Orthopaedic departments across England have increased compliance with NICE guidelines for VTE prophylaxis. However there is considerable variation in practice, especially in duration and chemoprophylaxis agent. We attribute this to the lack of specific NICE guidelines for this cohort of patients. We aim that this study can influence NICE to introduce added guidance that will standardise practice.

EP.FRI.495 A retrospective audit of electronic venous thromboembolism risk assessment compliance across three surgical wards in a district general hospital

Abstract Aims Venous thromboembolism (VTE) is the leading cause of preventable hospital deaths; with hospital-acquired VTEs accounting for 50% to 60% of all VTEs seen. This project aims to review and improve the number of VTE risk assessments completed for surgical in-patients. Methods This retrospective, cross-sectional study involved data collection from surgical in-patients (n = 648) over three consecutive months, using an electronic VTE risk assessment tool. Data was categorised into ‘First VTE prophylaxis risk assessment completed within 24 hours of admission’ and ‘Second VTE prophylaxis risk assessment completed within 48 hours of admission’. This was further sub-categorised into surgical specialties. Results were presented in departmental meetings and educational posters were displayed. The study was re-audited using the same method over one month (n = 216). Results Results demonstrated improvement from the initial audit cycle, particularly in relation to the mean number of VTE risk assessments completed for patients undergoing breast surgery (100% from 95.3%), colorectal surgery (93.3% from 90%) and general surgery (88.0% from 86.6%). The mean number of first VTE risk assessments completed in 24 hours across all surgical wards remained above 65%, whilst the mean number of second VTE risk assessments completed in 48 hours improved from 36.1% to 47.6%. Conclusions Variation in compliance is still evident across the surgical in-patient wards. Going forward, responsibility to complete outstanding VTE risk assessments will be handed to the FY1 on the late shift. Following this intervention, a further audit cycle will be performed, with the aim of 100% compliance in VTE risk assessment completion.

EP.TU.601Improving extended venous thromboembolism prophylaxis prescription compliance at discharge for colorectal cancer resection patients

Abstract Aims Extended venous thromboembolism prophylaxis (exVTEp) is used to reduce venous thromboembolism (VTE) incidence following colorectal cancer (CRC) resection. Within our tertiary care centre patients undergoing CRC resection should receive an electronic VTE risk assessment (eVTE) within 24 hours and exVTEp at discharge, compliance targets set at 95%. Our aim was to improve absolute compliance rates of exVTEp prescription at discharge following CRC surgery. Methods Data were collected prospectively on CRC resection patients pre and post an educational intervention for doctors during surgical induction, with posters placed in key areas highlighting discharge exVTEp importance. Patients discharged between August-December 2019 served as pre-intervention and those between December 2019-March 2020 as post-intervention cohorts. Time periods reflected junior doctor rotating periods within the country’s healthcare system thus providing more comparable data sets. The service evaluation was registered within the Trust (19-562Q) Results Of 80 pre-intervention and 40 post-intervention eligible patients: 81.25% vs. 92.68% received exVTEp at discharge, 70.19% vs. 72.34% had a valid eVTE and 32.50% vs. 36.59% had exVTEp recorded in the post-operative note. Those missing exVTEp documentation in the post-operative plan were significantly less likely to receive exVTEp at discharge with an 80% decrease in exVTEp prescription compared to patients with exVTEp documented within the post-operative note (unadjusted-OR 0.2051, 95%CI 0.0431-0.9773; p = 0.0276). Conclusions Educational and visual interventions have shown improvement in exVTEp prescription at discharge. Despite suboptimal eVTE scores true service quality in delivering exVTEp is high. The relationship between exVTEp post-operative instruction and exVTEp prescription needs further investigation.

TP9.2.11Venous Thromboembolism Assessment and Thromboprophylaxis in Pregnant Women admitted to Hospital under Non-Obstetric Specialties

Abstract Aims During a non-obstetric admission, there is minimal awareness amongst other specialties regarding the need to reassess venous thromboembolism (VTE) prophylaxis requirements. The primary aim of this study was to review whether perinatal patients are accurately assessed for VTE risk factors during non-obstetric admissions and being prescribed appropriate thromboprophylaxis upon discharge. Methods Data collection was carried out by retrospectively identifying all admissions of pregnant women in hospital under a non-obstetric team over a period of six months. Patients were scored according to their individual risk factors related to pregnancy and the admission. Comparison was made between the recommended and actual prophylaxis given. Results 152 patients were included in the study. Only 13 women received appropriate VTE management whilst 35 patients were deemed high-risk and did not receive prophylaxis. VTE assessment was not documented in nearly 60% of patients. 68% of patients were found to be at intermediate risk. Conclusion Reassessment for risk of VTE in antenatal and postnatal patients is poorly documented when managed by non-obstetric led teams. Women with both established and transient risk factors for VTE are not receiving appropriate thromboprophylaxis. Raised awareness of this specific problem is required amongst non-obstetric teams. Key Statement Appropriate thromboprophylaxis is vital at the point of admission of a pregnant patient to hospital as this is associated with an 18-fold increased risk of VTE. Further improvements need to be made in order to educate non-obstetric teams caring for obstetric patients regarding the importance of VTE risk assessment.

531 An Admission Proforma to Improve Clerking Documentation in the ENT Department During the Covid-19 Pandemic: A Full Cycle Audit

Abstract Aim Good Surgical Practice states that surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained for all their interactions with patients. It is therefore critical that the clerking document, as the initial record of an admission, meets this standard. During the Covid-19 pandemic, an emergency rota meant that cross-covering of ENT at junior level was increasingly required in our hospital. Understandably, these trainees were less familiar with admitting ENT patients and of departmental standards. Our aim was to evaluate the quality of clerking documentation in our department during this period and investigate whether a standardised admission proforma could improve this. Method Clerking documents for all patients admitted in April 2020 were checked for completion of venous thromboembolism (VTE) risk assessment and inclusion of ten key pieces of information as outlined by the Surgical Tool for Auditing Records score. As was standard at this time, all clerking documentation had been completed on blank hospital continuation paper. A departmental admission proforma was introduced before admissions in June 2020 were then assessed identically. Results Improvement was noted in all measured parameters with no adverse effects. There was particular improvement in documentation of referral source (28% to 97%), consultant in charge (35% to 90%), name/grade/bleep (25% to 94%) and VTE risk assessment (14% to 78%). Trainee response was positive. Conclusions A simple admission proforma can markedly improve the standard of clerking documentation and therefore increase patient safety during a turbulent time. We would encourage other departments to consider developing their own.

37 Accuracy of Venous Thromboembolism Risk Assessments in The Trauma and Orthopaedics Wards of The Gloucestershire Royal Hospital

Abstract Introduction Venous thromboembolism (VTE) risk assessment is crucial for patients undergoing orthopaedic surgery. An accurate risk assessment leads to patient stratification into risk groups for appropriate VTE prophylaxis. Aim To evaluate the accuracy of VTE risk assessment in the orthopaedic wards of the Gloucestershire Royal Hospital (GRH). Method We used the drug charts available on the wards of GRH which follow the NICE Clinical guideline [CG92]. We identified four variables out of the 19 questions that assess thrombosis risk: age, BMI, presence of infection/inflammatory conditions and surgery to the lower limb. Drug charts from the 10th of November to the 15th of November 2020 were assessed for completeness and accuracy. The number and accuracy of drug charts with VTE risk assessments on admission and 24 hours after admission were assessed. Results Fifty-seven drug charts with VTE risk assessments were identified over this period. Only 66.7% of VTE risk assessments were complete on admission and 21.1% were complete 24 hours after admission. Accuracy of assessment on admission was 92.1%, 86.1%, 81.6% and 79.0% for age, BMI, categories of surgery to the lower limbs and presence of inflammation, respectively. Accuracy of assessment at 24 hours was 91.7%, 83.3%, 50.0% and 91.7% for age, BMI, surgery to the lower limbs and presence of infection/inflammation, respectively. Conclusions VTE risk assessment upon admission and at 24 hours is relatively low and needs improvement. A further enquiry is necessary to evaluate the reasons for defective VTE assessment.

Age, personal and family history are independently associated with venous thromboembolism following acute Achilles tendon rupture

PurposeThe primary aim was to determine independent patient, injury and management-related factors associated with symptomatic venous thromboembolism (VTE) following acute Achilles tendon rupture (ATR). The secondary aim was to suggest a clinical VTE risk assessment tool for patients with acute ATR. MethodsFrom 2010–2018, 984 consecutive adults (median age 47yrs, 73% [n = 714/984] male) sustaining an acute ATR were retrospectively identified. Ninety-five percent (n = 939/984) were managed non-operatively in a below-knee cast (52%, n = 507/984) or walking boot (44%, n = 432/984), with 5% (n = 45/984) undergoing primary operative repair (<6wks post-injury). VTE was diagnosed using local medical records and national imaging archives, reviewed at a mean 5yrs (range 1–10) post-injury. Multivariate logistic regression was performed to determine independent factors associated with VTE. ResultsThe incidence of VTE within 90 days of ATR was 3.6% (n = 35/984; deep vein thrombosis 2.1% [n = 21/984], pulmonary embolism 1.9% [n = 19/984]), and the median time to VTE was 24 days (interquartile range 15–44). Age ≥50yrs (adjusted OR [aOR] 2.3, p = 0.027), personal history of VTE/thrombophilia (aOR 6.1, p = 0.009) and family history of VTE (aOR 20.9, p<0.001) were independently associated with VTE following ATR. These non-modifiable risk factors were incorporated into a VTE risk assessment tool. Only 23% of patients developing VTE (n = 8/35) had a relevant personal or family history, but incorporating age ≥50yrs into the VTE risk assessment tool (alongside personal and family history) identified 69% of patients with VTE (n = 24/35). Non weight-bearing for ≥2wks after ATR was also independently associated with VTE (aOR 3.2, p = 0.026). ConclusionsAge ≥50 years, personal history of VTE/thrombophilia and a positive family history were independently associated with VTE following ATR. Incorporating age into our suggested VTE risk assessment tool enhanced its sensitivity in identifying at-risk patients. Early weight-bearing in an appropriate orthosis may be beneficial to all patients in VTE risk reduction.

Venous thromboembolism prophylaxis after ambulatory arthroscopic knee surgery: a systematic review and meta-analysis of incidence and risk factors (109)

Objectives:Over 100,000 anterior cruciate ligament (ACL) reconstructions are performed in the United States annually, yet the reported incidence of venous thromboembolism (VTE) and the use of VTE thromboprophylaxis after ACL reconstruction and other arthroscopic knee surgeries still varies widely. Current VTE risk assessment scores, for example the Caprini score, incorporate arthroscopic surgery as a known risk factor but were not developed for stratification of an outpatient ambulatory surgical patient population. There is no current consensus to guide the orthopedic surgeon in prescribing chemoprophylactic agents after arthroscopic knee surgery. The objectives of this study were to determine the incidence, efficacy, and risk factors for VTE specifically following knee arthroscopic procedures. The null hypotheses of this study was that previously defined risk factors for VTE after ambulatory knee arthroscopy (age over 60 years, BMI greater than 30 kg/m2, tobacco use, prior VTE, malignancy, coagulopathy, oral contraceptive use, family history of coagulopathy, and prolonged tourniquet time greater than 90 minutes) would not reach statistical significance when compared across multiple cohorts. Our hypothesis is that a systematic review and meta-analysis of these variables will reject the null hypotheses with a significance of level of p < .05.Methods:A systematic review and meta-analysis was performed using data collected from 30 cohort and therapeutic trials (721,005 patients) published between January 2000 and April 2020 to compare both the incidence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) and associated risk factors after knee arthroscopy with or without thromboprophylaxis in adults. Ultrasound, venography, and International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes were deemed acceptable detection methods for VTE. We also performed a meta-analysis of published patient characteristics and risk factors in developing VTE after arthroscopic knee procedures. Individual studies were not evaluated for symptomatic versus asymptomatic VTE detection criteria or methods.Results:Of 331 eligible articles, 6 therapeutic RCTs and 24 cohort studies met the inclusion criteria. Overall incidence of DVT and PE was found to be 0.97% and 0.03% respectively. Analysis of the RCTs was found to support the use of prophylactic anticoagulation in preventing DVTs (relative risk: 0.24, 95% confidence interval [CI]: 0.13-0.44). After analysis of the cohort studies, age greater than 60 years was found to be a statistically significant risk factor for VTE (OR: 1.84, 95% CI: 1.03 – 3.29; p=.04) while a history of malignancy (OR: 2.61, 95% CI: 0.97 – 7.00; p=.06), and history of previous VTE (OR: 4.14, 95% CI: 0.90 – 19.14, p=.07) trended toward significance. Other factors such as BMI greater than 30 kg/m2, tobacco use, tourniquet time, personal or family history of coagulopathy, and oral contraceptive use were not found to be statistically significant risk factors for VTE after knee arthroscopy, however there were limited studies (one to three studies per risk factor) available to distinguish of a majority of these variables.Conclusions:Our results show that the overall incidence of DVT in adults after arthroscopic knee surgery is approaching 1% and that of PE is exceedingly rare, however this may be underestimated if asymptomatic VTE is not identified. Despite a low incidence of VTE after knee arthroscopy, thromboprophylaxis is effective in preventing VTE and trends in risk factors exist in ambulatory sports medicine patients diagnosed with VTE post-operatively. The risk for adverse bleeding events while taking chemoprophylaxis and requires further research. Only rejection of the null hypothesis on age over 60 years was statistically significant, however other defined risk factors may be clinically significant. With these results, we conclude that a preoperative assessment may be warranted in identifying at-risk, high risk, or multi-risk patients for which prophylactic anticoagulation postoperatively after knee arthroscopic procedures may be beneficial. A modified version of the Caprini score specifically stratifying these risk factors in an ambulatory sports medicine population may be valuable to the practicing orthopedic arthroscopic surgeon. More research is warranted for identifying risk factors to better stratify this unique patient population.

Incidence of symptomatic image-confirmed venous thromboembolism in outpatients managed in a hospital-led COVID-19 virtual ward.

Incidence of symptomatic image-confirmed venous thromboembolism in outpatients managed in a hospital-led COVID-19 virtual ward.

Evaluation of In-Hospital Venous Thromboembolism Prevention and Management System Using Hospital-Level Metrics: A Nationwide Cross-Sectional Survey in China.

Countries in the world have taken actions to prevent venous thromboembolism (VTE) in hospitals. We have conducted a study in China to assess the establishment of hospital-based systems for VTE prevention and management. A nationwide hospital survey was conducted in China to collect hospital-level metrics on their system for VTE prevention between 2019 and 2020. We analyzed hospital-level metrics potentially influencing the implementation of thromboprophylaxis using a multivariable regression model. Characteristics of the hospital, organizational structure, quality control, and staff training were analyzed. Among 435 hospitals responding to the survey, 328 (75.4%) were able to implement thromboprophylaxis. They performed VTE and bleeding risk assessments and had prophylactic interventions. Institutional VTE steering committee and unit-based working group were set up in 317 (72.9%) and 339 (77.9%) hospitals, respectively. More than 80% of the hospitals performed quality control and staff training. In contrast, digitalization of risk assessment was only accomplished in 196 (45.1%) hospitals. Proportions of the aforementioned metrics were consistently higher in tertiary hospitals than secondary hospitals (P < 0.01) except for quality control. There were geographical disparities in the establishment of VTE steering committees (P = 0.0004). In multivariable analysis, VTE steering committee was an independent factor for the implementation of thromboprophylaxis (odds ratio, 2.22, 95% confidence interval, 1.17-4.23). Working group, quality control, and training on VTE were also positively associated with the implementation of thromboprophylaxis. In-hospital VTE prevention has been undertaken in China, but system establishment remains suboptimal. Implementation of VTE prevention programs was associated with a decrease in thrombolytic events. Hospitals with VTE steering committees performed better on implementing preventive strategies. Suboptimal adoption of information digitization was identified, and the implementation of computer supporting techniques would be expected to improve the implementation of thromoboprophylaxis.

Risk Asessment and Thromboprophylaxis for Venous Thromboembolism (VTE) in the Antenatal Population in a Tertiary Health Facility in Nigeria

Aim: To review the venous thromboembolism (VTE) risk assessment and thromboprophylaxis in the antenatal population in a tertiary health facility in Nigeria and to perform a retrospective VTE risk assessment of the patients with a view of determining those patients that would have needed VTE prophylaxis.&#x0D; Design: It was a retrospective cross-sectional study.&#x0D; Place and Duration of Study: The study was carried out at the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria from the 1st of February to the 30th of April, 2020.&#x0D; Materials and Methods: The following data were extracted from the hospital notes of 347 consecutive antenatal patients: history/demographic characteristics, risk factors for VTE, thromboprophylaxis, diagnosis and treatment of VTE, using the RCOG guideline 37a of 2015 as a benchmark for comparison. Data was analysed with the aid of a Statistical Package for Social Science (SPSS) software, version 18.&#x0D; Results: VTE risk assessment and thromboprophylaxis was not a routine practice at the UPTH. Apart from antenatal admission, the most frequent VTE risk factors in pregnancy were BMI ≥30, Parity ≥ 3, Age &gt; 5 years and current pre-eclampsia at 48.48%, 41.04%, 36.04% and 15.56% of the study population respectively. 131 (37.75%) of the 347 antenatal population fulfilled the criteria for venous thromboprophylaxis with low molecular weight heparin (LMWH) but they were not assessed and the drug was not given. 63 (18.16%) of the study population was to receive LMWH from 28 weeks of pregnancy while 68 (19.60%) of them were to be given from the first trimester. The prevalence of VTE was however very low at 0.02% (1 patient out of the 347 maternities), irrespective of the fact that 41 (11.82%) of the patients had symptoms and signs of VTE.&#x0D; Conclusion: 131 (37.75%) out of the total 347 antenatal patients fulfilled the criteria to be given thromboprophylaxis but the prevalence of VTE was low at 0.02%. It was therefore recommended that a unified Nigerian national guideline should be written.

Rotational thromboelastometry in patients with acute respiratory distress syndrome owing to coronavirus disease 2019: Is there a viscoelastic fingerprint and a role for predicting thrombosis?

ObjectivesWe evaluated rotational thromboelastometry tracings in 44 critically ill coronavirus disease 2019 patients, to determine whether there is a viscoelastic fingerprint and to test the hypothesis that the diagnosis and prediction of venous thromboembolism would be enhanced by the addition of rotational thromboelastometry testing. ResultsRotational thromboelastometry values reflected an increase in clot strength for the EXTEM, INTEM, and FIBTEM assays beyond the reference range. No hyperfibrinolysis was noted. Fibrinolysis shutdown was present but did not correlate with thrombosis; 32% (14/44) of patients experienced a thrombotic episode. For every 1 mm increase of FIBTEM maximum clot formation, the odds of developing thrombosis increased 20% (95% confidence interval, 0–40%, P = .043), whereas for every 1,000 ng/mL increase in D-dimer, the odds of thrombosis increased by 70% (95% confidence interval, 20%–150%, P = .004), after adjustment for age and sex (AUC 0.96, 95% confidence interval, 0.90–1.00). There was a slight but significant improvement in model performance after adding FIBTEM maximum clot formation and EXTEM clot formation time to D-dimer in a multivariable model (P = .04). ConclusionsD-dimer concentrations were more predictive of thrombosis in our patient population than any other parameter. Rotational thromboelastometry confirmed the hypercoagulable state of coronavirus disease 2019 intensive care unit patients. FIBTEM maximum clot formation and EXTEM clot formation time increased the predictability for thrombosis compared with only using D-dimer. Rotational thromboelastometry analysis is most useful in augmenting the information provided by the D-dimer concentration for venous thromboembolism risk assessment when the D-dimer concentration is between 1,625 and 6,900 ng/dL, but the enhancement is modest. Fibrinolysis shutdown did not correlate with thrombosis.

1670MO Validation of a new risk-assessment model for prediction of venous thromboembolism in cancer outpatients: The ONKOTEV score

The assessment of Venous Thromboembolism (VTE) risk in cancer outpatients still represents an evolving topic. Current international guidelines recommend an intermediate to high-risk group as identified by a Khorana score (KS) ≥ 2 as the cut-off for considering primary prophylaxis. In the previously reported prospective ONKOTEV study, we developed a 4 variables risk-assessment-model (RAM): KS > 2, metastatic disease, vascular/lymphatic compression and previous VTE. The goal of the current study is to validate the ONKOTEV score as a novel RAM in an independent cohort.