OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized cancer patients. The Khorana and Padua risk scores are widely used tools for predicting VTE, but their comparative performance in hospitalized cancer patients has not been fully assessed. This study aims to evaluate the predictive performance of these two risk assessment models in predicting VTE in hospitalized patients with malignancy.

METHODS

This cross-sectional study was conducted at a tertiary hospital between January 2022 and December 2023. A total of 200 hospitalized patients with malignancy were enrolled. Their baseline demographics, medical history and diagnostic data were collected. Patients were stratified into risk categories using the Khorana and Padua models, and their predictive abilities were assessed through sensitivity, specificity and area under the curve (AUC) analyses. The diagnosis of deep vein thrombosis (DVT) was confirmed with evidence of an intraluminal deep venous filling defect on CT or catheter venography, or a deep vein thrombus identified by color Doppler. Pulmonary embolism (PE) was diagnosed by pulmonary angiography showing an intraluminal filling defect of the pulmonary artery visualized through computed tomography pulmonary angiography or magnetic resonance imaging.

RESULTS

The Khorana score demonstrated a sensitivity of 83.3%, specificity of 77.5% and an AUC of 0.81. The Padua score showed a sensitivity of 76.7%, specificity of 85.5% and an AUC of 0.79. Both models showed good predictive accuracy. However, the Khorana score having a high sensitivity makes it suitable for identifying high-risk patients, while the Padua score having a high specificity makes it better at ruling out low-risk patients.

CONCLUSION

Both the Khorana and Padua scores are valuable tools for predicting VTE in hospitalized cancer patients, but the Khorana score may be more effective for cancer-specific risk stratification. Further prospective studies are needed to confirm these findings.

Human ; Male ; Female ; Morbidity ; Neoplasms ; Thromboembolism ; Venous Thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized cancer patients. The Khorana and Padua risk scores are widely used tools for predicting VTE, but their comparative performance in hospitalized cancer patients has not been fully assessed. This study aims to evaluate the predictive performance of these two risk assessment models in predicting VTE in hospitalized patients with malignancy.

METHODS

This cross-sectional study was conducted at a tertiary hospital between January 2022 and December 2023. A total of 200 hospitalized patients with malignancy were enrolled. Their baseline demographics, medical history and diagnostic data were collected. Patients were stratified into risk categories using the Khorana and Padua models, and their predictive abilities were assessed through sensitivity, specificity and area under the curve (AUC) analyses. The diagnosis of deep vein thrombosis (DVT) was confirmed with evidence of an intraluminal deep venous filling defect on CT or catheter venography, or a deep vein thrombus identified by color Doppler. Pulmonary embolism (PE) was diagnosed by pulmonary angiography showing an intraluminal filling defect of the pulmonary artery visualized through computed tomography pulmonary angiography or magnetic resonance imaging.

RESULTS

The Khorana score demonstrated a sensitivity of 83.3%, specificity of 77.5% and an AUC of 0.81. The Padua score showed a sensitivity of 76.7%, specificity of 85.5% and an AUC of 0.79. Both models showed good predictive accuracy. However, the Khorana score having a high sensitivity makes it suitable for identifying high-risk patients, while the Padua score having a high specificity makes it better at ruling out low-risk patients.

CONCLUSION

Both the Khorana and Padua scores are valuable tools for predicting VTE in hospitalized cancer patients, but the Khorana score may be more effective for cancer-specific risk stratification. Further prospective studies are needed to confirm these findings.

Human ; Male ; Female ; Morbidity ; Neoplasms ; Thromboembolism ; Venous Thromboembolism

Objective To investigate the common molecular features of immunothrombosis, thus enhancing the comprehension of thrombosis triggered by immune and inflammatory responses and offering crucial insights for identifying potential diagnostic and therapeutic targets. Methods Differential gene expression analysis and functional enrichment analysis were conducted on datasets of systemic lupus erythematosus (SLE) and venous thromboembolism (VTE). The intersection of differentially expressed genes in SLE and VTE with those of neutrophil extracellular traps (NET) yielded cross-talk genes (CG) for SLE-NET and VTE-NET interaction. Further analysis included functional enrichment and protein-protein interaction (PPI) network assessments of these CG to identify hub genes. Venn diagrams and receiver operating characteristic (ROC) curve analysis were employed to pinpoint the most effective shared diagnostic CG, which were validated using a graft-versus-host disease (GVHD) dataset. Results Differential expression genes in SLE and VTE were associated with distinct biological processes, whereas SLE-NET-CG and VTE-NET-CG were implicated in pathways related to leukocyte migration, inflammatory response, and immune response. Through PPI network analysis, several hub genes were identified, with matrix metalloproteinase 9 (MMP9) and S100 calcium-binding protein A12 (S100A12) emerging as the best shared diagnostic CG for SLE (AUC: 0.936 and 0.832) and VTE (AUC: 0.719 and 0.759). Notably, MMP9 exhibited good diagnostic performance in the GVHD dataset (AUC: 0.696). Conclusion This study unveils the common molecular features of SLE, VTE, and NET, emphasizing MMP9 and S100A12 as the optimal shared diagnostic CG, thus providing valuable evidence for the diagnosis and therapeutic strategies related to immunothrombosis. Additionally, the expression of MMP9 in GVHD highlights its critical role in the risk of VTE associated with immune system disorders.
Humans ; Computational Biology/methods* ; Lupus Erythematosus, Systemic/immunology* ; Protein Interaction Maps/genetics* ; Venous Thromboembolism/therapy* ; Matrix Metalloproteinase 9/genetics* ; Extracellular Traps/metabolism* ; Gene Regulatory Networks ; Thrombosis/immunology* ; Graft vs Host Disease/genetics* ; Gene Expression Profiling

BACKGROUND

Balancing the benefits of preventing venous thromboembolism (VTE) against the risks of bleeding is important for patients who need prophylactic anticoagulants. This study compared which of the bleeding scores (IMPROVE and HAS-BLED BRS scores) is better at predicting anticoagulant-related bleeding events in critically ill and non-critically ill patients at a tertiary hospital who received prophylactic enoxaparin.

METHODOLOGY

Sixty-nine (69) patients in the ICU and ward who received prophylactic enoxaparin were included in the study and followed until discharge. Demographic data, comorbidities and IMPROVE and HAS-BLED BRS scores were recorded, and bleeding events monitored.

RESULTS

During the study, 16% (11/69) of the study population experienced bleeding events, both major and minor. Patients with IMPROVE BRS ≥ 7 (high risk) were more likely to bleed than those with scores of < 7 (low risk) (p < 0.001). The average HAS-BLED BRS was 2.20 (±1.09). Patients with higher HASBLED BRS scores had a slightly higher rate of bleeding (bleeding event, 2.73 [±1.19] versus no bleeding event, 2.09 [±1.04]), but this difference was not statistically significant (p = 0.079). The IMPROVE BRS had a higher area under the curve (AUC) (0.96) than the HAS-BLED BRS (0.67) in predicting anticoagulant-related bleeding events.

CONCLUSION

In patients receiving prophylactic anticoagulants for VTE, the IMPROVE BRS was better at predicting major anticoagulant-related bleeding events than the HAS-BLED BRS, with higher sensitivity, specificity and accuracy. Both risk scoring systems are useful for assessing bleeding risk before starting pharmacologic VTE prophylaxis, but the IMPROVE BRS is more accurate.

Human ; Venous Thromboembolism

Humans ; Venous Thromboembolism/drug therapy* ; Anticoagulants/administration & dosage* ; Child ; Consensus ; China ; Practice Guidelines as Topic

OBJECTIVE: To analyze the clinical characteristics of venous thromboembolism (VTE) in patients with multiple myeloma (MM) and to identify the risk factors of VTE in MM patients. METHODS: 179 newly diagnosed MM (NDMM) patients admitted to The Second Hospital of Shanxi Medical University from January 2014 to December 2020 who were followed up for more than 6 months were collected, and they were divided into VTE group and control group according to whether combined with VTE. The clinical and laboratory data were compared between the two groups. Mann-whitney U test was used for inter-group comparison of measurement data, Chi-square test or Fisher's exact test was used for inter-group comparison of count data, and multivariate logistic regression analysis was performed to explore the risk factors of VTE in MM patients. RESULTS: Compared with control group, the serum albumin (ALB) level in VTE group was significantly lower (P =0.033), the fibrinogen (FIB) level was significantly higher (P =0.016), and the proportion of patients with D-dimer≥2 000 ng/ml was significantly higher than that in the control group (26.3% vs 4.4%, P =0.002). There was a significant difference in M-component type between the two groups (P =0.028), and the proportion of IgG type in VTE group was higher. There were no statistically significant differences between two groups in age, sex, body mass index (BMI), the proportions of patients with hypertension, diabetes, coronary heart disease and cerebral infarction, white blood cell (WBC) count, platelet (PLT) count, liver and kidney function, plasma cells ratio in bone marrow, serum globulin (GLO), lactate dehydrogenase (LDH), β₂-microglobulin (β₂-MG) level, C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), prothrombin time (PT), activated partial thromboplastin time (APTT), disease stage, thrombosis prevention and the use of immunomodulators (P >0.05). Multivariate logistic regression analysis showed that FIB level (OR=1.578, 95%CI:1.035-2.407, P =0.034), D-dimer≥2 000 ng/ml (OR=5.467, 95%CI:1.265-23.621, P =0.023) and IgG type (OR=4.780, 95%CI: 1.221-18.712, P =0.025) were independent risk factors for VTE in MM patients. CONCLUSION MM patients are prone to VTE, and FIB level, D-dimer≥2 000 ng/ ml and IgG type are independent risk factors for VTE in MM patients.
Humans ; Venous Thromboembolism ; Multiple Myeloma/complications* ; Risk Factors ; Anticoagulants ; Immunoglobulin G ; Retrospective Studies

Humans ; Venous Thromboembolism/prevention & control* ; Anticoagulants/therapeutic use* ; Pulmonary Embolism ; Patients ; Hospitalization ; Risk Factors

PURPOSE: Static progressive stretch (SPS) can be applied to treat chronic joint stiffness. However, the impacts of subacute application of SPS to the distal lower limbs, where deep vein thrombosis (DVT) is common, on venous thromboembolism remain unclear. This study aims to explore the risk of venous thromboembolism events following subacute application of SPS. METHODS: A retrospective cohort study was conducted on patients diagnosed with DVT following a lower extremity orthopedic surgery before being transferred to the rehabilitation ward from May 2017 to May 2022. Patients with unilateral lower limb comminuted para-articular fractures, transferred to rehabilitation ward for further treatment within 3 weeks after operation, followed up more than 12 weeks since initial manual physiotherapy, and diagnosed DVT by ultrasound before rehabilitation course were included in the study. Patients with polytrauma, without evidence of previous peripheral vascular disease or incompetence, had medication for thrombosis treatment or prophylaxis before the operation, detected with paralysis due to nervous system impairment, infected after operation during the regime, or with acute progression of DVT were excluded. The included patients were randomized to the standard physiotherapy and the SPS integrated groups for observation. Associated DVT and pulmonary embolism data were collected during the physiotherapy course to compare the groups. SSPS 28.0 and GraphPad Prism 9 were used for data processing. A p < 0.05 was set significant difference. RESULTS: In total of 154 patients with DVT participating in this study, 75 of them were treated with additional SPS for postoperative rehabilitation. The participants in the SPS group showed improved range of motion (12.3° ± 6.7°). However, in the SPS group, there was no difference in thrombosis volume between the start and termination (p = 0.106, p = 0.787, respectively), although difference was seen intra-therapy (p < 0.001). Contingency analysis revealed the pulmonary embolism incidence (OR = 0.703) in the SPS group compared to the mean physiotherapy. CONCLUSION The SPS technique is a safe and reliable option to prevent potential joint stiffness without aggravating the risk of distal DVT for postoperative patients suffering from relevant trauma.
Humans ; Venous Thromboembolism/prevention & control* ; Venous Thrombosis/etiology* ; Retrospective Studies ; Pulmonary Embolism/complications* ; Lower Extremity ; Risk Factors

BACKGROUND: Lung cancer is the first leading cause of morbidity and mortality among the malignant tumors, which has become a hot issue in current research. Clinically, lung cancer is divided into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) according to the pathological types. NSCLC includes adenocarcinoma, squamous cell carcinoma and other types of lung cancer, accounting for about 80% of all lung cancer. Venous thromboembolism (VTE) includes deep venous thrombosis (DVT) and pulmonary embolism (PE), which is a recognized complication in lung cancer patients with higher morbidity and mortality. The aim of this study is to determine the incidence of DVT and reveal the risk factors for DVT in the postoperative patients with lung cancer. METHODS: We collected 83 postoperative patients with lung cancer admitted to the Department of Lung Cancer Surgery, Tianjin Medical University General Hospital from December 2021 to December 2022. All these patients were examined by color Doppler ultrasound of lower extremity vein upon admission and after operation to analyze the incidence of DVT. In order to explore the possible risk factors for DVT in these patients, we further analyzed the correlations between DVT and their clinical features. At the same time, the changes of coagulation function and platelet were monitored to investigate the value of blood coagulation in the patients with DVT. RESULTS: DVT occurred in 25 patients after lung cancer operation, and the incidence rate of DVT was 30.1%. Further analysis found that the incidences of postoperative lower limb DVT were higher in lung cancer patients of stage III+IV or over 60 years of age (P=0.031, P=0.028). D-Dimer level in patients with thrombosis was significantly higher than that in non-thrombus patients on the 1st, the 3rd, and the 5th day after operation (P<0.05), and there was no significant difference in platelets and fibrinogen (FIB) (P>0.05). CONCLUSIONS The overall incidence of DVT in our center after lung cancer patients operation was 30.1%. Late-stage and older postpatients were more likely to develop DVT, and these patients with higher D-Dimer values should be considered the possibility of VTE events.
Humans ; Middle Aged ; Aged ; Lung Neoplasms/surgery* ; Incidence ; Carcinoma, Non-Small-Cell Lung ; Venous Thromboembolism ; Venous Thrombosis/etiology*