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Hoque L, Dewolf R, Meyers D, White DK, Mazor KM, Stefan M, Crawford S, Alavi K, Yates J, Maxfield M, Lou F, Uy K, Walz M, Kapoor A. Improving stamina and mobility with preop walking in surgical patients with frailty traits -OASIS IV: randomized clinical trial study protocol. BMC Geriatr 2020; 20:394. [PMID: 33028223 PMCID: PMC7542706 DOI: 10.1186/s12877-020-01799-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022] Open
Abstract
Background Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits. Methods We will be conducting a randomized clinical trial with a total of 120 patients permitting up to a 33% rate of attrition, to reach a final sample size of 80 (with 40 patients for each study arm). We will include patients who are age 60 or higher, score 4 or greater on the Edmonton Frailty Scale assessment, and will be undergoing a surgical operation that requires a 2 or more night hospital stay to be eligible for our trial. Using block randomization stratified on baseline 6MWD, we will assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) will provide a daily step count goal reflecting a 10–20% increase from baseline. Subsequently, the AT will call weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls will receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We will also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps. Conclusion If changes in a 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints. Trial registration The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019.
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Affiliation(s)
- Laboni Hoque
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - Ryan Dewolf
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - David Meyers
- University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | | | - Kathleen M Mazor
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA
| | - Mihaela Stefan
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,Baystate Medical Center, Springfield, MA, USA
| | - Sybil Crawford
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA
| | - Karim Alavi
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Jennifer Yates
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Mark Maxfield
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Feiran Lou
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Karl Uy
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Matthias Walz
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA.,University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Alok Kapoor
- University of Massachusetts Medical School, 365 Plantation St, Worcester, MA, 01605, USA. .,University of Massachusetts Memorial Health Care, Worcester, MA, USA. .,Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, MA, USA.
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2
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Ko D, Kapoor A, Rose AJ, Hanchate AD, Miller D, Winter MR, Palmisano JN, Henault LE, Fredman L, Walkey AJ, Tripodis Y, Karcz A, Hylek EM. Temporal trends in pharmacologic prophylaxis for venous thromboembolism after hip and knee replacement in older adults. Vasc Med 2020; 25:450-459. [PMID: 32516054 DOI: 10.1177/1358863x20927096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trends in prescription for venous thromboembolism (VTE) prophylaxis following total hip (THR) and knee replacement (TKR) since the approval of direct oral anticoagulants (DOACs) and the 2012 guideline endorsement of aspirin are unknown, as are the risks of adverse events. We examined practice patterns in the prescription of prophylaxis agents and the risk of adverse events during the in-hospital period (the 'in-hospital sample') and 90 days following discharge (the 'discharge sample') among adults aged ⩾ 65 undergoing THR and TKR in community hospitals in the Institute for Health Metrics database over a 30-month period during 2011 to 2013. Eligible medications included fondaparinux, DOACs, low molecular weight heparin (LMWH), other heparin products, warfarin, and aspirin. Outcomes were validated by physician review of source documents: VTE, major hemorrhage, cardiovascular events, and death. The in-hospital and the discharge samples included 10,503 and 5722 adults from 65 hospitals nationwide, respectively (mean age 73, 74 years; 61%, 63% women). Pharmacologic prophylaxis was near universal during the in-hospital period (93%) and at discharge (99%). DOAC use increased substantially and was the prophylaxis of choice for nearly a quarter (in-hospital) and a third (discharge) of the patients. Aspirin was the sole discharge prophylactic agent for 17% and 19% of patients undergoing THR and TKR, respectively. Warfarin remained the prophylaxis agent of choice for patients aged 80 years and older. The overall risk of adverse events was low, at less than 1% for both the in-hospital and discharge outcomes. The low number of adverse events precluded statistical comparison of prophylaxis regimens.
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Affiliation(s)
- Darae Ko
- Section of Cardiovascular Medicine, Boston University Medical Center, Boston, MA, USA
| | - Alok Kapoor
- Division of Hospital Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Amresh D Hanchate
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Donald Miller
- Center for Healthcare Organization and Implementation Research, Bedford VA, MA, USA
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N Palmisano
- Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Lori E Henault
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Lisa Fredman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Allan J Walkey
- Section of Pulmonary, Allergy, Sleep, and Critical Care, Boston University Medical Center, Boston, MA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Anita Karcz
- Institute for Health Metrics, Cambridge, MA, USA
| | - Elaine M Hylek
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
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3
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Podmore B, Hutchings A, van der Meulen J, Aggarwal A, Konan S. Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis. BMJ Open 2018; 8:e021784. [PMID: 29997141 PMCID: PMC6082478 DOI: 10.1136/bmjopen-2018-021784] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To systematically perform a meta-analysis of the association between different comorbid conditions on safety (short-term outcomes) and effectiveness (long-term outcomes) in patients undergoing hip and knee replacement surgery. DESIGN Systematic review and meta-analysis. METHODS Medline, Embase and CINAHL Plus were searched up to May 2017. We included all studies that reported data to allow the calculation of a pooled OR for the impact of 11 comorbid conditions on 10 outcomes (including surgical complications, readmissions, mortality, function, health-related quality of life, pain and revision surgery). The quality of included studies was assessed using a modified Newcastle-Ottawa Scale. Continuous outcomes were converted to ORs using the Hasselblad and Hedges approach. Results were combined using a random-effects meta-analysis. OUTCOMES The primary outcome was the adjusted OR for the impact of each 11 comorbid condition on each of the 10 outcomes compared with patients without the comorbid condition. Where the adjusted OR was not available the secondary outcome was the crude OR. RESULTS 70 studies were included with 16 (23%) reporting on at least 100 000 patients and 9 (13%) were of high quality. We found that comorbidities increased the short-term risk of hospital readmissions (8 of 11 conditions) and mortality (8 of 11 conditions). The impact on surgical complications was inconsistent across comorbid conditions. In the long term, comorbid conditions increased the risk of revision surgery (6 of 11 conditions) and long-term mortality (7 of 11 conditions). The long-term impact on function, quality of life and pain varied across comorbid conditions. CONCLUSIONS This systematic review shows that comorbidities predominantly have an impact on the safety of hip and knee replacement surgery but little impact on its effectiveness. There is a need for high-quality studies also considering the severity of comorbid conditions.
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MESH Headings
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Hip/psychology
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/mortality
- Arthroplasty, Replacement, Knee/psychology
- Comorbidity
- Humans
- Patient Readmission/statistics & numerical data
- Postoperative Complications/epidemiology
- Quality of Life
- Recovery of Function
- Reoperation/statistics & numerical data
- Risk Factors
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Affiliation(s)
- Bélène Podmore
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Andrew Hutchings
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sujith Konan
- Orthopaedics and Trauma, University College London Hospitals NHS Foundation Trust, London, UK
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4
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Hurria A, High KP, Mody L, McFarland Horne F, Escobedo M, Halter J, Hazzard W, Schmader K, Klepin H, Lee S, Makris UE, Rich MW, Rogers S, Wiggins J, Watman R, Choi J, Lundebjerg N, Zieman S. Aging, the Medical Subspecialties, and Career Development: Where We Were, Where We Are Going. J Am Geriatr Soc 2017; 65:680-687. [PMID: 28092400 DOI: 10.1111/jgs.14708] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Historically, the medical subspecialties have not focused on the needs of older adults. This has changed with the implementation of initiatives to integrate geriatrics and aging research into the medical and surgical subspecialties and with the establishment of a home for internal medicine specialists within the annual American Geriatrics Society (AGS) meeting. With the support of AGS, other professional societies, philanthropies, and federal agencies, efforts to integrate geriatrics into the medical and surgical subspecialties have focused largely on training the next generation of physicians and researchers. They have engaged several subspecialties, which have followed parallel paths in integrating geriatrics and aging research. As a result of these combined efforts, there has been enormous progress in the integration of geriatrics and aging research into the medical and surgical subspecialties, and topics once considered to be geriatric concerns are becoming mainstream in medicine, but this integration remains a work in progress and will need to adapt to changes associated with healthcare reform.
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Affiliation(s)
- Arti Hurria
- Cancer and Aging Research Program, City of Hope National Medical Center, Duarte, California
| | - Kevin P High
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Lona Mody
- University of Michigan, Ann Arbor, Michigan
| | | | | | - Jeffrey Halter
- University of Michigan Health System, Ann Arbor, Michigan
| | - William Hazzard
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Kenneth Schmader
- Duke University, Durham, North Carolina.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs, Durham, North Carolina
| | - Heidi Klepin
- Wake Forest University, Winston-Salem, North Carolina
| | - Sei Lee
- University of California, San Francisco, San Francisco, California
| | - Una E Makris
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - Jennifer Choi
- Cancer and Aging Research Program, City of Hope National Medical Center, Duarte, California
| | | | - Susan Zieman
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland
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5
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Kapoor A, Chew PW, Reisman JI, Berlowitz DR. Low Self-Reported Function Predicts Adverse Postoperative Course in Veterans Affairs Beneficiaries Undergoing Total Hip and Total Knee Replacement. J Am Geriatr Soc 2016; 64:862-9. [PMID: 27100581 DOI: 10.1111/jgs.14020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To measure association between self-reported function and an adverse postoperative course and improvement in performance on the American College of Surgeons Universal Risk Calculator (ACS calculator) with inclusion of self-reported function available through the Veteran Rand-12 based Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. DESIGN Cohort analysis. SETTING Veteran Affairs health system. PARTICIPANTS Surgeries (n = 3,503) for older male veterans undergoing hip and knee replacement from 2002 to 2009. MEASUREMENTS Serious complication (per ACS definition), discharge to facility, readmission, and death within 30 days after surgery as a function of PCS and MCS; comparison of prediction of net reclassification index (NRI) for serious complication using a modified version of the ACS calculator with prediction using the ACS calculator with MCS and PCS added. RESULTS Being in the lowest PCS quartile (vs highest quartile) predicted more than twice the risk of a serious complication (odds ratio (OR) = 2.27, 95% confidence interval (CI) = 1.44-3.58), twice the risk of discharge to facility (OR = 1.97, 95% CI = 1.39-2.79), and almost twice the risk of readmission (OR = 1.80, 95% CI = 1.37-2.36). The lowest quartile of MCS predicted each outcome, although to a lesser extent than PCS. The enhanced model had a NRI of 29.4% (95% CI = 15.4-43.3%), reflecting that 20.8% of events were appropriately upgraded and 8.6% of nonevents appropriately downgraded. CONCLUSION Low PCS and MCS predicted an adverse postoperative course and enhanced the ACS calculator. Clinicians evaluating older adults undergoing orthopedic surgery could enhance the accuracy of their assessments by including self-reported functional status.
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Affiliation(s)
- Alok Kapoor
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Priscilla W Chew
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Joel I Reisman
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
| | - Dan R Berlowitz
- Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts
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6
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Comparing co-morbidities in total joint arthroplasty patients using the RxRisk-V, Elixhauser, and Charlson Measures: a cross-sectional evaluation. BMC Musculoskelet Disord 2015; 16:385. [PMID: 26652166 PMCID: PMC4676184 DOI: 10.1186/s12891-015-0835-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 11/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Joint arthroplasty patients have a high prevalence of co-morbidities and this impacts their surgical outcomes. There are different ways to ascertain co-morbidities and appropriate measurement is necessary. The purpose of this study was to: (1) describe the prevalence of co-morbidities in a cohort of total hip arthroplasty (THA) and knee arthroplasty (TKA) patients using two diagnoses-based measures (Charlson and Elixhauser) and one prescription-based measure (RxRisk-V); (2) compare the agreement of co-morbidities amongst the measures. METHODS A cross-sectional study of Australian veterans undergoing THAs (n = 11,848) and TKAs (n = 18,972) between 2001 and 2012 was conducted. Seventeen co-morbidities were identified using the Charlson, 30 using the Elixhauser, and 42 using the RxRisk-V measure. Agreement between co-morbidities was calculated using Kappa (κ) statistics. RESULTS Combining measures, 64 conditions were identified, of these 28 were only identified using the RxRisk-V, 11 using the Elixhauser, and 2 using the Charlson. The most prevalent conditions was pain treated with anti-inflammatories (58.7% THAs, 55.9% TKAs), pain treated with narcotics (55.0% THAs, 50.9% TKAs), hypertension (56.0% THAs and TKAs), and anticoagulation disorders (53.0% THAs, 48.6% TKAs). Diabetes was the only condition with substantial agreement (all κ > 0.6) amongst all measures. When comparing the diagnoses based algorithms, agreement was high for overlapping conditions (all κ > 0.71). CONCLUSIONS Different measures identified different co-morbidities, provided different estimates for the same co-morbidity, and had different levels of agreement for common co-morbidities. This highlights the importance of understanding co-morbidity measures and using them appropriately in studies and case-mix adjustments analyses.
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7
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Tang L, Wu YY, Lip GYH, Yin P, Hu Y. Heart failure and risk of venous thromboembolism: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2015; 3:e30-44. [PMID: 26765646 DOI: 10.1016/s2352-3026(15)00228-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Venous thromboembolism is a major global health problem that is often secondary to other clinical situations. Many studies have investigated the association between venous thromboembolism and heart failure, but have yielded inconsistent findings. We aimed to quantify the absolute and relative risks (RR) for venous thromboembolism in patients with heart failure after hospital admission. We also assessed rates of venous thromboembolism in patients in different settings. METHODS In this systematic review and meta-analysis, we searched for studies investigating the risk of venous thromboembolism in patients in hospital with heart failure. We searched for studies published between Jan 1, 1955, and March 31, 2015, in PubMed, Embase, Evidence-Based Medicine Reviews, Allied and Complementary Medicine Database, Ovid HealthSTAR, Global Health, Ovid Nursing Database, Web of Science, CINAHL Plus, ProQuest Central, Conference Papers Index, BIOSIS Previews, and ClinicalTrials.gov. All cohort studies and subgroup analyses of randomised controlled trials (RCTs) were eligible for inclusion if they reported venous thromboembolism rates (number of events per follow-up period) or RR estimates. We extracted data from published reports and contacted the corresponding authors of records with insufficient quantitative data. RRs and 95% CIs were pooled using a random-effects model. This study is registered with PROSPERO, number CRD42014015504. FINDINGS Of 8673 records identified, we included 71 studies with data from 88 cohorts in our analysis, with 59 cohorts included in the assessment of venous thromboembolism rates and 46 cohorts included in the meta-analysis of heart failure and risk of venous thromboembolism. Venous thromboembolism rates varied widely in patients in hospital with heart failure from different settings. The overall median symptomatic venous thromboembolism rate was 2·48% (IQR 0·84-5·61); rates was were 3·73% (1·05-7·31) for patients who did not receive thromboprophylaxis and 1·47% (0·64-3·54) for those who did. Overall, patients with heart failure in hospital had an RR of 1·51 (1·36-1·68) for venous thromboembolism. The overall I(2) statistic was 96·1% and there was no evidence of publication bias (Egger's test, p=0·46). INTERPRETATION Heart failure is a common independent risk factor for venous thromboembolism. Thromoboprophylaxis should be considered in clinical practice for high-risk patients. FUNDING National Natural Science Foundation.
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Affiliation(s)
- Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Ying Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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8
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Low-molecular-weight heparin and intermittent pneumatic compression for thromboprophylaxis in critical patients. Exp Ther Med 2015; 10:2331-2336. [PMID: 26668637 DOI: 10.3892/etm.2015.2795] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 09/24/2015] [Indexed: 11/05/2022] Open
Abstract
The efficacy and safety of physiotherapeutic prophylaxis for venous thromboembolism in critically ill patients with heparin contraindication remains unclear. In the present study it was hypothesized that physiotherapy prophylaxis with intermittent pneumatic compression (IPC) would be safe and effective for patients unable to receive low-molecular-weight heparin (LMWH). In addition, this study investigated whether a combined therapy of IPC with LMWH would be more effective for the prophylaxis of deep vein thrombosis (DVT) in critical patients. A total of 500 patients were divided into four groups according to the prophylaxis of DVT. The IPC group consisted of 95 patients with heparin contraindication that received IPC treatment; the LMWH group consisted of 185 patients that received an LMWH injection; the LMWH + IPC group consisted of 75 patients that received IPC treatment and LMWH injection; and the control group consisted of 145 patients that received no IPC treatment or injection of LMWH. Each patient was evaluated clinically for development of DVT and the diagnosis was confirmed by Doppler study. Venous thromboembolism was a common complication among the trauma patients with severe injuries. Patients responded positively to the treatment used in the intervention groups. Patients exhibited an improved response to LMWH + ICP compared with IPC or LMWH alone, while no significant difference was detected between the IPC and LMWH groups. These results were applicable to patients that had a Wells score of ≥3; however, no significant differences in DVT incidence were observed among the patients who had a Wells score of <3. In this observational study, LMWH + ICP appeared to be more effective than either treatment alone in treating critically ill trauma patients with severe injuries that are at high risk for VTE and bleeding simultaneously.
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9
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Günther KP, Haase E, Lange T, Kopkow C, Schmitt J, Jeszenszky C, Balck F, Lützner J, Hartmann A, Lippmann M. [Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]. DER ORTHOPADE 2015; 44:555-65. [PMID: 25925089 DOI: 10.1007/s00132-015-3097-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty. OBJECTIVES To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction. MATERIALS AND METHODS Review of relevant clinical studies, meta-analyses, and presentation of our own results. RESULTS Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction. CONCLUSIONS It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.
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Affiliation(s)
- K-P Günther
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
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10
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Low frequency of symptomatic venous thromboembolism after multiligamentous knee reconstruction with thromboprophylaxis. Clin Orthop Relat Res 2014; 472:2705-11. [PMID: 24696048 PMCID: PMC4117890 DOI: 10.1007/s11999-014-3576-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Reconstruction of the multiligament-injured knee often involves extended surgical and tourniquet use times and often is performed in patients who have sustained concomitant fractures as well as vascular injuries, all of which would appear to predispose the patient to the potentially serious complications of deep vein thrombosis and perhaps pulmonary embolism, yet little is known about the frequency of venous thromboembolic (VTE) events after multiligamentous knee reconstruction. QUESTIONS/PURPOSES The purposes of this study were to (1) determine the frequency of symptomatic VTE after multiligamentous knee reconstruction at a single institution; and (2) to determine associated risk factors for VTE in these patients. METHODS The records of 134 (63% of the 213 consented individuals in our longitudinal database) patients who underwent primary (129 [96%]) or revision (five [4%]) multiligamentous knee reconstruction at a single institution between 1992 and 2013 were retrospectively reviewed. With two patients undergoing procedures bilaterally, this resulted in a total of 136 multiligamentous knee reconstructions. VTE for which clinical symptoms were evident and confirmed by imaging within 3 months after the reconstructive procedure was noted. Pre- and perioperative data were collected with respect to demographics, associated injuries, medical history, smoking status, and surgical data. Standard rehabilitation and thromboprophylaxis protocols were used in all patients. RESULTS Three cases of symptomatic VTE (three deep vein thromboses) occurred after the 136 reconstructions (2%; 95% confidence interval, 0.53%-7.3%). Two of the three patients were obese and the remaining patient smoked and abused alcohol. However, as a result of a low frequency of VTE, no risk factors could be identified in this series. CONCLUSIONS Symptomatic VTE occurred in 2% of multiligamentous knee reconstructions at our institution while receiving thromboprophylaxis. This is similar to rates documented after anterior cruciate ligament reconstruction without thromboprophylaxis. Further multicenter research is required to identify the true frequency of and risk factors for developing VTE in patients undergoing multiligamentous knee reconstruction after knee dislocation. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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