Use Of Pharmacologic Prophylaxis Research Articles

Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California.

Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.

Long-term management and treatment of acute intermittent porphyria with recurring attacks using pharmacological prophylaxis.

There is no definitive guidance on whether patients with acute intermittent porphyria (AIP) with recurrent attacks need pharmacological prophylactic treatment. The management strategies for patients with frequent (defined as ≥4 annualized attack rate (AAR) and less frequent attacks (<4 AAR), including treatment for acute attacks and duration of prophylaxis (weekly heme arginate 3mg/kg body weight and/or investigational drug, givosiran), were summarized. The AAR for the following periods were presented: the first 2 years after diagnosis, before/after prophylaxis, and the most recent 2 years. A total of 29 patients with AIP were included, 19 (34.5%) had <4 AAR and 10 (65.6%) had ≥4 AAR in the first 2 years after diagnosis. All patients experienced reduced attacks during the treatment course, 23 (79.3%) were attack-free during the most recent 2 years. Among the 9 patients who received prophylaxis (7 heme arginate; 1 givosiran, 1 heme arginate followed by givosiran), 5 (55.6%) were attack-free in the most recent 2-year period and prophylaxis was discontinued because there had been no attacks for >1 year. For patients without prophylaxis (n = 20), 18 (90.0%) were attack-free in the most recent 2-year period and 15 (75.0%) experienced attacks only in the first 2 years after diagnosis. Prophylaxis could be considered for patients with AIP with ≥4 biochemically confirmed attacks/year after routine treatment of 1-2 years, during which the severity and frequency of attacks should be closely monitored to determine the necessity of pharmacologic prophylaxis. More studies are needed to reach a consensus on the use of pharmacological prophylaxis and treatment of AIP.

Comprehensive dental care in pediatric patients with hematological diseases

Introduction: hematological disorders constitute one of the most interesting problems to be considered by the stomatologist in his daily practice. Objective: to characterize the comprehensive stomatological care in patients with hematological diseases at the Provincial Pediatric Teaching Hospital "Pepe Portilla" in the period from September 2020 to September 2021. Methods: An observational, descriptive, cross-sectional study was developed with the purpose of characterizing the comprehensive stomatological care in patients with hematological diseases at the "Pepe Portilla" Pediatric Provincial Teaching Hospital, from September 2020 to September 2021. The universe and the sample consisted of 21 patients, the sample was selected intentionally, according to the inclusion and exclusion criteria. The data were obtained from the clinical history of the patients. Descriptive and inferential statistical methods were used to describe the variables. Results: patients aged between 7 and 12 years had a greater presence with 52,38 %. There was a greater presence of white patients with 42,86 %, with a greater predominance of the female sex. Conservative treatment was the most needed in 52,34 % of these patients. The use of pharmacological prophylaxis in 47,62 % of the cases, of which 28,57 % were destined to surgical type treatment. Conclusions: Most of the patients examined presented poor oral hygiene. Pharmacological prophylaxis was the most used method prior to stomatological treatment. Supportive physiotherapy, analgesia and antimicrobial therapy were part of the treatment for all postsurgical complications.

Safety and efficacy of venous thromboembolism prophylaxis in patients with cirrhosis: A systematic review and meta-analysis.

Patients with cirrhosis are considered in a haemostatic balance, though weaker than in normal subjects. In these patients, however, the use of pharmacological prophylaxis for venous thromboembolism (VTE) remains controversial. Therefore, in this study, we aimed to assess the safety and efficacy of VTE prophylaxis in patients with cirrhosis. We conducted a systematic review of studies reporting the occurrence of bleeding and VTE events in patients with cirrhosis, and controls, undergoing VTE prophylaxis. Meta-regression analysis was conducted to further explore the determinants of heterogeneity in the study of the occurrence of either bleeding or VTE events. In a total of 10 studies, including 5712 patients, of which 2330 undergoing VTE prophylaxis, bleeding (n = 5513) and VTE events occurred in 8.2% and 2.8% patients respectively. A total of 2963 and 3162 patients were included from low-risk of bias studies in bleeding and VTE analysis respectively: while administration of VTE prophylaxis did not seem to reduce VTE (OR = 1.07, CI 0.39-2.96, p = .89), importantly prophylaxis was not associated with increased bleeding risk (OR = 0.56, CI 0.20-1.59, p = .27). Meta-regression analysis showed that no parameter significantly influenced the heterogeneity of data regarding bleeding or VTE events. In patients with cirrhosis, current evidence is insufficient to advise for or against the use of VTE prophylaxis, mainly due to lack of quality and homogeneity of available data. However, its use does not appear to be associated with a significant bleeding risk. Adequately designed studies are required to provide a measure of its overall utility.

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

Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring.

Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries. To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery. We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor. A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis. Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.

Outcomes after implementation of prophylactic protocol for venous thromboembolism in surgical patients: A retrospective cohort study

IntroductionVenous thromboembolism (VTE) in surgical patients is a preventable cause of hospital death. In previous studies, the prevalence of VTE decreased after implementing a prophylactic protocol. Because of the low rate of VTE prophylaxis in Thailand, we studied the outcomes after the implementation of a VTE prophylactic protocol in our hospital. MethodsA retrospective cohort single-center study was conducted from November 2019 to November 2020 in the Department of Surgery. We established the VTE prophylactic protocol using a multidisciplinary team approach and the Caprini score risk assessment model. The outcomes were the incidence of symptomatic VTE, VTE-related death, risk factors, and safety. ResultsIn total, 6983 patients were admitted to the surgical department during the study period. After excluding patients with current VTE and missing data, 4579 patients were enrolled in this study, and 1579 (34.5%) patients at high risk for VTE were identified. The use of pharmacological prophylaxis, mechanical prophylaxis, and early ambulation in the entire cohort was lower than that in high-risk patients (7.99%, 19.81%, and 21.56% vs. 15.77%, 31.10%, and 46.55%, respectively). In the comparison of before and after implementation, the prevalence of symptomatic VTE and 30-day mortality of VTE decreased from 1.20% to 0.37% and from 0.11% to 0.02%, respectively. No major bleeding occurred. ConclusionsAfter protocol implementation, the prevalence of symptomatic VTE and VTE-related death decreased. The VTE prophylaxis was safe. We highly recommended using a multidisciplinary team approach VTE prophylaxis in high-risk surgical patients.

IJU this Issue

This issue of International Journal of Urology contains one Review Article, 10 Original Articles, and eight editorial comments. Yuan et al. (Jiangsu, China) updated a meta-analysis for the diagnostic performance of the Vesical Imaging–Reporting And Data System (VI-RADS) for predicting muscle-invasive bladder cancer (MIBC) with 20 studies published between September 2018 and July 2021. VI-RADS was introduced in 2018 to define a standardized approach to imaging and reporting multiparametric magnetic resonance imaging for patients with bladder cancer. The diagnostic performance of the VI-RADS for predicting MIBC was excellent in both cutoff points of the VI-RADS 3 and 4. Multiple image acquisition planes of diffusion-weighted imaging should be given more attention in the VI-RADS. We hope that VI-RADS will become more mature and prevalent, which should lead to better management of bladder cancer via further studies. In the original articles, Nishimura et al. (Nara, Japan) evaluated the clinical outcomes and prognostic factors in Japanese patients with bacillus Calmette-Guerin (BCG)-unresponsive nonmuscle-invasive bladder cancer (NMIBC) who underwent early radical cystectomy (RC) using a large-scale multicenter retrospective study and concluded the highest-risk status among the pre-BCG factors was associated with upstaging to extravesical tumors and poor prognosis, despite early RC procedures. The Japanese Urological Association Clinical Practice Guidelines for Bladder Cancer 2019 recommended that patients with BCG-unresponsive disease are considered unlikely to benefit from further BCG therapy and early RC. This study seems to be one of those with the evidence based on a pathological evaluation. Although some new strategies such as intravesical nadofargene firadenovec gene therapy (Lancet Oncol. 2021; 22: 107–17), pembrolizumab monotherapy (Lancet Oncol. 2021; 22: 919–30) have been reported, there is no doubt that BCG-unresponsive disease is a risk factor and RC will continue to be required in a certain proportion of patients with BCG-unresponsive NMIBC. Kato et al. (Osaka, Japan) evaluated the long-term incidence and clinical features of post-transplant lymphoproliferative disorders (PTLD) in kidney transplant recipients from two major transplantation centers in Japan. Graft survival has improved due to a reduction in the acute rejection rate by advances in immunosuppressive agents; however long-term survival after kidney transplantation remains unchanged. Therefore, it is extremely important to focus on malignancy, especially PTLD after kidney transplantation. They emphasized the strategies to identify PTLD and suggested the benefits of positron emission tomography-computed tomography for ascertaining PTLD. They also revealed that mycophenolate mofetil contributed the onset of PTLD, and rituximab was not significantly associated with the incidence of PTLD. We have to be careful for each immunosuppressive agent. Yamashita et al. (Shizuoka, Japan) examined the incidence and location of lower extremity deep vein thrombosis (DVT) in patients undergoing RC. Venous thromboembolism (VTE) including DVT and pulmonary embolism is a serious perioperative complication in urological surgery. RC, whether open or robot-assisted surgery, is the procedure with the highest risk of perioperative VTE in urological surgery according to the European Association of Urology (EAU) guidelines on thromboprophylaxis in urological surgery. They also identified that preoperative D-dimer level was a significant risk factor for preoperative DVT, and preoperative D-dimer level, type of urinary diversion (ileal neobladder), and preoperative DVT were significant risk factors for postoperative DVT. EAU guidelines strongly recommended the use of pharmacological prophylaxis in all patients undergoing open and robot-assisted RC. These results might suggest appropriate patients for pharmacological prophylaxis in RC. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of the International Journal of Urology. None declared.

Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy

To evaluate whether the addition of pharmacologic prophylaxis to mechanical prophylaxis for venous thromboembolism (VTE) is associated with changes in perioperative outcomes in hysterectomy for benign indications. Retrospective cohort study. Michigan Surgical Quality Collaborative database. Patients who underwent hysterectomy between July 2012 and June 2015 when VTE prophylaxis data were collected. Patients who received mechanical prophylaxis alone were compared with those receiving dual prophylaxis (mechanical and pharmacologic). Minimally invasive surgeries (MIS) included laparoscopic, vaginal, robotic-assisted, and laparoscopic-assisted vaginal hysterectomies and were analyzed separately from abdominal (ABD) hysterectomy. Propensity score matching was used to minimize confounding because of the differences in demographic and perioperative characteristics. The primary outcome was estimated blood loss (EBL). The secondary outcomes were operative time, postoperative blood transfusion, VTE, surgical site infection, reoperation, readmission, and death. There were 1803 matched pairs in the MIS analysis. In the ABD hysterectomy analysis, 2:1 matching was used with a total of 1168 patients receiving mechanical prophylaxis alone matched to 616 patients receiving dual prophylaxis. EBL was higher by 54.5 mL (95% confidence interval [CI], 16.9-92.1) in those receiving dual prophylaxis in the ABD hysterectomy analysis but did not differ between groups in the MIS analysis. Operative time was significantly longer with dual prophylaxis in both MIS (18.3 minutes; 95% CI, 13.8-22.8) and ABD (15.3 minutes; 95% CI, 9.0-21.6) surgical approaches. There was no difference in other secondary outcomes. The addition of pharmacologic prophylaxis to mechanical prophylaxis in benign hysterectomy was associated with longer operative time, regardless of surgical approach and increased EBL in ABD hysterectomy. Given very low rates of VTE, no difference in other perioperative outcomes, and possible harm, it seems reasonable to encourage individualized rather than routine use of pharmacologic prophylaxis in patients undergoing benign hysterectomy receiving mechanical prophylaxis.

Specifičnosti tromboprofilakse kod starijih pacijenata u ortopedskoj hirurgiji kuka i kolena

Elderly patients with a hip fracture are at significantly higher risk for developing venous thromboembolism (VTE). The incidence of fatal pulmonary embolism (PE) occurs in 2-3% of patients after elective hip and knee surgery and about 6-7% after hip fracture surgery, with a higher risk in men (10,2%) than in women (4,7%). The use of pharmacological prophylaxis significantly reduces the incidence of symptomatic VTE. Pharmacological prophylaxis includes the use of antiplatelet drugs (aspirin), unfractionated heparin (UFH), low molecular weight heparins (LMWH), vitamin K antagonists (VKA), Fondaparinux and direct oral anticoagulants (DOAC). The use of low molecular weight heparins (LMWH) - enoxaparin, represents the gold standard of thromboprophylaxis in orthopedic surgery, and for now, they are the only drugs that are recommended for thromboprophylaxis in hip fracture surgery. Rivaroxaban is used in the prophylaxis of VTE in elective hip and knee surgeries at a fixed dose of 10 mg once daily, and apixaban at a dose of 2,5 mg twice daily in knee arthroplasty for at least 14 days, and after hip arthroplasty for at least 35 days. Early hip fracture surgery as soon as possible, preferably within 24 hours, and no later than 48 hours after admission to the hospital, significantly reduces the morbidity and mortality of elderly patients.

No difference in the incidence or location of deep venous thrombosis according to use of pharmacological prophylaxis following total knee arthroplasty

BackgroundThe incidence and characteristics of deep vein thrombosis (DVT) following total knee arthroplasty (TKA) without pharmacologic prophylaxis have not been fully investigated. This study aimed to determine whether there are any differences in the incidence, location, and characteristics of DVT following TKA with pharmacologic prophylaxis and without pharmacologic prophylaxis.MethodsA total of 156 knees were retrospectively evaluated for DVT following TKA by duplex ultrasound on postoperative day 7, after excluding 60 knees from 216 consecutive knees because of antiplatelet or anticoagulant use before surgery, history of venous thromboembolism, or bleeding risk. The 156 knees included in the analysis were divided into two groups: with pharmacologic prophylaxis (n = 79) and without pharmacologic prophylaxis (n = 77).ResultsThe overall incidence of DVT was 34% (54/156 knees). DVT was detected in 31.6% of knees with pharmacologic prophylaxis and in 37.6% of knees without pharmacologic prophylaxis; the difference was not statistically significant. Soleal vein thrombus was observed in 74.6% of the knees with DVT and non-floating thrombus was observed in 98.7%. There were no obvious between-group differences in thrombus characteristics such as compressibility, echogenicity, mean vein diameter, and whether the thrombus was attached to the vein wall or free-floating.ConclusionsNo differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis.

Use of Pharmacologic Prophylaxis Against Venous Thromboembolism in Hospitalized Injured Children.

Despite a practice management guideline and risk prediction model for venous thromboembolism (VTE), pediatric-specific evidence on pharmacologic prophylaxis is lacking. In a retrospective study, we characterized receipt of prophylaxis and explored its effectiveness in hospitalized injured patients below 18 years old using data from the Trauma Quality Improvement Program. Concordance of receipt of prophylaxis with guideline and predicted risk of VTE was estimated using κ statistic. Effectiveness was explored using cohorts matched based on the risk prediction model. A total of 11,165 (6.2%) of 180,932 patients received prophylaxis. Those who received prophylaxis were more commonly post-pubertal and more severely injured. Receipt of prophylaxis was fairly concordant with the guideline (κ=0.32) and predicted risk of VTE (κ=0.29). Receipt of prophylaxis was associated with higher rates of VTE likely due to confounding by indication. Low molecular weight heparin seemed more effective against VTE than unfractionated heparin (incidence rate ratio: 0.52; 95% confidence interval: 0.36, 0.75), but less effective when received ≥72 hours after admission to the hospital. We showed that hospitalized injured children did not commonly receive prophylaxis. We also showed that prophylaxis may be effective in hospitalized injured children, but it needs to be proven definitively in a randomized clinical trial.

Prevalence of Preoperative Lower Extremity Deep Vein Thrombosis in Bilateral Calcaneal Fractures

There are no studies on epidemiologic characteristics of deep vein thrombosis (DVT), when specified at in patients with bilateral calcaneal fractures. This study aimed to address the preoperative DVT in bilateral calcaneal fractures. Between October 2014 and December 2018, adult patients presenting with bilateral calcaneal fractures and having preoperative Duplex ultrasound (DUS) of bilateral lower extremities for detection of DVT were included. Their medical data were collected, with regards to demographics, comorbidities, injury-related data and biomarkers. Baseline characteristics between patients with and without DVT were compared using bivariate tests. The further multivariate logistics regression analysis was conducted to identify independent factors associated with DVT. In total, 258 patients with bilateral calcaneal fractures were included, with 21 (8.1%) having preoperative DVT, diagnosed at 7.7 ± 4.2 days after injury. The prevalence rate of proximal DVT was 1.9% and of distal DVT was 6.2%. Thirty five thrombi were found, with 6 (17.1%) in proximal veins and 29 (82.9%) in distal veins. Nine patients had DVTs in multiple veins, and 2 patients had bilateral DVTs. The multivariate analyses showed history of allergy (odds ratio [OR] = 2.17), concurrent other fractures (OR = 4.53), prolonged time since injury (for each day, OR = 1.16), elevated plasma D-dimer level (≥1.73 vs <1.73 mg/L, OR = 3.74) and reduced albumin level (<34.2 g/L vs ≥34.2 g/L, OR = 2.92) were independent factors associated with DVT. Multiple factors were identified to be associated with DVT and greater consideration should be given to the use of pharmacologic prophylaxis in patients involving these factors, to reduce DVT occurrence.

Compliance with American College of Chest Physicians (ACCP) recommendations for thromboembolic prophylaxis in the intensive care unit: a level I trauma center experience

BackgroundRecommendations are for nearly universal venous thromboembolism (VTE) prophylaxis in critically ill hospitalized patients because of their well-recognized risks. In those intensive care units (ICUs) where patient care is more uniformly directed, it may be expected that VTE prophylaxis would more closely follow this standard over units that are less uniform, such as open-model ICUs.MethodsThis was a retrospective cohort study on all patients aged 18+ admitted to an open ICU between 6/1/2017 and 5/31/2018. Patients were excluded if they had instructions to receive comfort measures only or required therapeutic anticoagulant administration. Prophylaxis administration practices, including administration of mechanical and/or pharmacologic prophylaxis and delayed (≥48 h post-ICU admission) initiation of pharmacologic prophylaxis, were compared between patients admitted to the ICU by the trauma service versus other departments. Root causes for opting out of pharmacological prophylaxis were documented and compared between the two study groups.ResultsOne-hundred two study participants were admitted by the trauma service, and 98 were from a non-trauma service. Mechanical (98% trauma vs. 99% non-trauma, P = 0.99) and pharmacologic (54% vs. 44%, P = 0.16) prophylaxis rates were similar between the two admission groups. The median time from ICU admission to pharmacologic prophylaxis initiation was 53 h for the trauma service and 10 h for the non–trauma services (P ≤ 0.01). In regression analyses, trauma-service admission (odds ratio (OR) = 2.88, 95% confidence interval (CI) 1.21–6.83) and increasing ICU length of stay (OR = 1.13, 95% CI 1.05–1.21) were independently associated with pharmacologic prophylaxis use. Trauma-service admission (OR = 8.30, 95% CI 2.18–31.56) and increasing hospital length of stay (OR = 1.15, 95% CI 1.03–1.28) were independently associated with delayed prophylaxis initiation.ConclusionsOverall, the receipt of VTE prophylaxis of any type was close to 100%, due to the nearly universal use of mechanical compression devices among ICU patients in this study. However, when examining pharmacologic prophylaxis specifically, the rate was considerably lower than is currently recommended: 54% among the trauma services and 44% among non-trauma services.

Pharmacological Prophylaxis and Personal Protective Equipment (PPE) Practices in Gynecological Cancer Surgery During COVID-19 Pandemic.

PurposeIn the absence of vaccine, proper use of personal protective equipment (PPE) is the most important strategy to protect healthcare workers against COVID-19 infection. The recommendations on pharmacological prophylaxis against COVID-19 infection are controversial. The aim of current study was to assess PPE practices during surgery on COVID-19 negative gynecological cancer patients and use of pharmacologic prophylaxis by clinicians practicing gynecologic oncology.MethodsWe disbursed a survey questionnaire through various social media platforms among clinicians practicing gynecologic oncology. The survey consisted of 37 questions divided into five subgroups evaluating demographic details, use of pharmacological prophylaxis against COVID-19, preoperative COVID-19 screening protocol, details on PPE usage and associated discomfort, if any.ResultsTwo hundred twenty oncologists from 13 countries responded to the survey. Pharmacological prophylaxis was being used by 85 (38.6%) respondents; most common agent was hydroxychloroquin (HCQ) by 24.5% respondents. Routine preoperative screening for COVID-19 was performed by 214 (97.3%) respondents. Some degree of discomfort during surgery due to PPE use was reported by 170 (77.3%) respondents, which was moderate to severe in 73 (33.2%) respondents. Most common difficulties associated with face mask/shield were problems in communication (69.5%) and breathing (58.1%). Eye protection was associated with poor visibility, fogging and headache. Unusual fatigue attributed to PPE use was experienced by 143(65%) respondents.ConclusionUse of pharmacological prophylaxis against COVID-19 is controversial and the same is reflected in our survey. Most respondents adhered to PPE use despite experiencing some physical discomfort.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40944-021-00500-4.

Timing and characteristics of venous thromboembolism after noncancer surgery

BackgroundVenous thromboembolism (VTE) is a major cause of morbidity and mortality postoperatively. The use of pharmacologic prophylaxis is effective in reducing the incidence of VTE. However, the prophylaxis is often discontinued at hospital discharge, especially for those with benign disease. The implications of this practice are not known. We assessed the data from a large, ongoing registry regarding the time course of VTE and outcomes after noncancer surgery. MethodsWe analyzed the RIETE (Computerized Registry on Venous Thromboembolism) registry, which includes data from consecutive patients with symptomatic confirmed VTE. In the present study, we focused on general surgical patients who had developed symptomatic postoperative VTE in the first 8 weeks after noncancer surgery. The main objective was to assess the interval between surgery and the occurrence of VTE. Additional variables included the clinical presentation associated with the event, the use of thrombosis prophylaxis, and unfavorable outcomes. ResultsThe data from 3296 patients were analyzed. The median time from surgery to the detection of VTE was 16 days (interquartile range, 8-30 days). Of the VTE events, 77% were detected after the first postoperative week and 27% after 4 weeks. Overall, 43.9% of the patients with VTE had received pharmacologic prophylaxis after surgery for a median of 8 days (interquartile range, 5-14 days), and three quarters of the VTE events were detected after pharmacologic prophylaxis had been discontinued. Overall, 54% of the patients with VTE had presented with pulmonary embolism. For 15% of the patients, the clinical outcome was unfavorable, including 4% who had died within 90 days. ConclusionsThe risk of VTE after noncancer general surgery remains high for ≤2 months. More than one half of the patients had presented with symptomatic PE as the VTE event, and 15% had had unfavorable outcomes. Only 44% of these patients had received pharmacologic prophylaxis for around 1 week.

Prescribing patterns and outcomes of venous thromboembolism prophylaxis in hospitalized medical and cancer patients: Observations from the Ottawa Hospital

Guidelines suggest broad use of pharmacologic prophylaxis to prevent venous thromboembolism (VTE) in hospitalized medical patients, however little ‘real-world’ data exists to support this. Our goal was to describe the use of thromboprophylaxis among general medical and cancer patients admitted to hospital, compare VTE and bleeding outcomes according to use of thromboprophylaxis, and to determine what variables influence prescribing patterns and outcomes. Patients admitted to the general medical and oncology services at The Ottawa Hospital between 2010 and 2015 were retrospectively reviewed and classified according to whether they received initial, delayed, or no pharmacologic thromboprophylaxis during their first hospitalization. Patients with an alternate indication for anticoagulation or those admitted with a bleeding event were excluded from analysis. The primary efficacy outcome was any symptomatic VTE during index hospitalization or within 90 days of discharge, and the primary safety outcome was clinically relevant bleeding during the index hospitalization. 17,262 patients were included in our final analysis. General medical patients selected to receive no, initial, or delayed thromboprophylaxis had 0.4%, 0.7%, and 2.4% rates of VTE; and 0.2%, 0.7%, and 1.5% rates of clinically relevant bleeding complications, respectively. Cancer patients had significantly higher rates of VTE: 3.3%, 3.9%, and 5.0%; and 0.9%, 0.7%, and 3.0% rates of clinically relevant bleeding among those selected to receive no, initial, or delayed thromboprophylaxis, respectively. Overall, our study suggests that broad use of pharmacologic thromboprophylaxis may be unnecessary in select low-risk general medical patients and may be less effective in cancer patients in whom new studies are indicated.

Effects of Pharmacologic Venous Thromboembolism (VTE) Prophylaxis in Benign Minimally Invasive Hysterectomy

Study Objective To evaluate if the addition of pharmacologic prophylaxis (heparin, low molecular weight heparin) for VTE is associated with adverse perioperative outcomes in minimally invasive surgery (MIS) hysterectomy for benign indications compared to mechanical prophylaxis alone. Design Retrospective cohort study. Setting Michigan Surgical Quality Collaborative (MSQC). Patients or Participants Patients who underwent a benign MIS hysterectomy (i.e. laparoscopic, vaginal, laparoscopic-assisted vaginal, or robotic-assisted laparoscopy) performed between July 2012 and June 2015 and received mechanical prophylaxis for thromboembolism. Interventions Patients were divided into cohorts who received mechanical prophylaxis alone (MPpx) or mechanical + pharmacologic prophylaxis (M+Pppx). Propensity score matching was used to minimize confounding due to differences in age, race, body mass index>40, hypertension, congestive heart failure, smoking, functional status, preoperative transfusion, preoperative anemia or thrombocytopenia, length of stay, and hospital teaching status. Outcomes evaluated in the propensity-matched cohorts were estimated blood loss, intraoperative time, postoperative blood transfusion, postoperative VTE, surgical site infection, reoperation, and readmission. Measurements and Main Results There were 1944 matched pairs of patients in the Mppx and M+Pppx cohorts. Intraoperative time was 21 minutes longer (168 minutes ± 63 min vs 189 ± 75 mins, p Conclusion Further research is needed into the addition of pharmacologicprophylaxis to mechanical prophylaxis and its association with longer operative time for benign minimally invasive hysterectomy. Given extremely low rates of VTE in both groups and no difference detected in other significant peri-operative outcomes using a large database, it seems reasonable to question routine use of pharmacologic prophylaxis in these patients.

Venous Thromboembolism Prophylaxis in Elective Spine Surgery.

Study Design:Review.Objective:Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients.Methods:A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery.Results:VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners.Conclusion:The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Sequential Compression Device Adherence is Low in Hospitalized Antepartum Patients.

This study was aimed to describe sequential compression device (SCD) adherence and its associations with SCD education in hospitalized antepartum women. This study included antepartum, nonlaboring women admitted from 2016 to 2018, 1 year before and after an SCD education intervention. SCD use was assessed through the Kendall SCD 700 series compliance meter, which tracks the time the SCD machine takes within the monitoring interval. Recruitment occurred after 60 to 80 hours of monitoring, at which time a patient survey was completed. SCD use was the percentage of time the machine was on during monitoring. Mann-Whitney U and Chi-square tests were used to compare associations between SCD use, education, and pharmacologic prophylaxis. Among 125 recruited women, 123 provided adherence data, 69 before and 54 after the education. Median SCD use was 17.3% before and 20.7% after (p = 0.71). Pharmacologic prophylaxis use was similar between the two periods and was not associated with SCD use. Among 121 surveys, the most common reason as to why SCDs were not worn was prevention of walking (52/121 [43.0%]). Using a novel monitoring technique, we found low-SCD use among antepartum inpatients, which was neither affected by education nor concurrent pharmacologic prophylaxis. Improving mobility with SCDs may improve use in this population. · SCD use was low in this cohort of hospitalized antepartum patients.. · A patient/nursing education intervention was not associated with SCD adherence.. · Concurrent pharmacologic VTE prophylaxis was not associated with SCD adherence..