A multifaceted clinical decision support intervention to improve adherence to thromboprophylaxis guidelines

Background Venous thromboembolism is a potentially fatal complication of hospitalisation, affecting approximately 3% of non-surgical patients. Administration of low molecular weight heparins to the appropriate patients adequately decreases venous thromboembolism incidence, but guideline adherence is notoriously low. Objective To determine the effect of a multifaceted intervention on thromboprophylaxis guideline adherence. The secondary objective was to study the effect on guideline adherence specifically in patients with a high venous thromboembolism risk. As an exploratory objective, we determined how many venous thromboembolisms may be prevented. Setting A Dutch general teaching hospital. Method A prospective study with a pre- and post-intervention measurement was conducted. A multifaceted intervention, consisting of Clinical Decision Support software, a mobile phone application, monitoring of duplicate anticoagulants and training, was implemented. Guideline adherence was assessed by calculating the Padua prediction and Improve bleeding score for each patient. The number of preventable venous thromboembolisms was calculated using the incidences of venous thromboembolism in patients with and without adequate thromboprophylaxis and extrapolated to the annual number of admitted patients. Main outcome measure Adherence to thromboprophylaxis guidelines in pre- and post-intervention measurements. Results 170 patients were included: 85 in both control and intervention group. The intervention significantly increased guideline adherence from 49.4 to 82.4% (OR 4.78; 95%CI 2.37-9.63). Guideline adherence in the patient group with a high venous thromboembolism risk also increased significantly from 54.5 to 84.3% (OR 2.46; 95%CI 1.31-4.62), resulting in the potential prevention of +/- 261 venous thromboembolisms per year. Conclusions Our multifaceted intervention significantly increased thromboprophylaxis guideline adherence

Health-related quality of life in transplant ineligible newly diagnosed multiple myeloma patients treated with either thalidomide or lenalidomide-based regimen until progression: a prospective, open-label, multicenter, randomized, phase 3 study

Data on the impact of long term treatment with immunomodulatory drugs (IMiD) on health-related quality of life (HRQoL) is limited. The HOVON-87/NMSG18 study was a randomized, phase 3 study in newly diagnosed transplant ineligible patients with multiple myeloma, comparing melphalan-prednisolone in combination with thalidomide or lenalidomide, followed by maintenance therapy until progression (MPT-T or MPR-R). The EORTC QLQ-C30 and MY20 questionnaires were completed at baseline, after three and nine induction cycles and six and 12 months of maintenance therapy. Linear mixed models and minimal important differences were used for evaluation. 596 patients participated in HRQoL reporting. Patients reported clinically relevant improvement in global quality of life (QoL), future perspective and role and emotional functioning, and less fatigue and pain in both arms. The latter being of large effect size

Physical learning beyond the quasistatic limit

Physical networks, such as biological neural networks, can learn desired functions without a central processor, using local learning rules in space and time to learn in a fully distributed manner. Learning approaches such as equilibrium propagation, directed aging, and coupled learning similarly exploit local rules to accomplish learning in physical networks such as mechanical, flow, or electrical networks. In contrast to certain natural neural networks, however, such approaches have so far been restricted to the quasistatic limit, where they learn on time scales slow compared to their physical relaxation. This quasistatic constraint slows down learning, limiting the use of these methods as machine learning algorithms, and potentially restricting physical networks that could be used as learning platforms. Here we explore learning in an electrical resistor network that implements coupled learning, both in the lab and on the computer, at rates that range from slow to far above the quasistatic limit. We find that up to a critical threshold in the ratio of the learning rate to the physical rate of relaxation, learning speeds up without much change of behavior or error. Beyond the critical threshold, the error exhibits oscillatory dynamics but the networks still learn successfully.Comment: 26 pages, 5 figure

Rituximab in patients with primary CNS lymphoma (HOVON 105/ALLG NHL 24): a randomised, open-label, phase 3 intergroup study

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Accuracy of X-ray with perfusion scan in young patients with suspected pulmonary embolism.

BACKGROUND: Computed tomography pulmonary angiogram (CTPA) has become the standard test in the diagnostic workup of patients with suspected pulmonary embolism (PE). However, young patients may have an increased risk of cancer with CTPA. Perfusion scanning combined with chest X-ray (X/Q) may offer an adequate alternative, but has never been prospectively validated. We directly compared this strategy with CTPA in patients aged ≤50years with suspected PE. METHODS: Consecutive patients with a likely clinical probability or an abnormal D-dimer level underwent both CTPA and X/Q. Two trained and experienced nuclear physicians independently analyzed the X/Q-scans. The accuracy of X/Q according to the PISAPED criteria was calculated in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Seventy-six patients were included, with a PE rate of 33%. The inter-observer agreement for X/Q-scan reading was high (κ=0.89). After consensus reading, 21 patients (28%) were categorized as 'PE present', 53 (70%) as 'PE absent', and two (2.6%) as 'non-diagnostic'. In 22%, there was a discrepancy between the X/Q-scan and CPTA for the diagnosis or exclusion of PE. The PPV and NPV were 71% and 83%, respectively. CONCLUSION: In patients with a high risk of PE, a diagnostic strategy of chest X-ray and perfusion scanning using the PISAPED criteria seems less safe than CTPA. Additional studies should further investigate this diagnostic algorithm

The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded

textabstractFour clinical decision rules (CDRs) (Wells score, Revised Geneva Score(RGS), simplified Wells score and simplified RGS) safely exclude pulmonaryembolism (PE), when combined with a normal D-dimer test. Recently,an age-adjusted cut-off of the D-dimer (patient's age x 10 μg/l)safely increased the number of patients above 50 years in whom PEcould safely be excluded. We validated the age-adjusted D-dimer testand assessed its performance in combination with the four CDRs in patientswith suspected PE. A total of 414 consecutive patients with suspectedPE who were older than 50 years were included. The proportionof patients in whom PE could be excluded with an 'unlikely' clinicalprobability combined with a normal age-adjusted D-dimer test was calculatedand compared with the proportion using the conventionalD-dimer cut-off. We assessed venous thromboembolism (VTE) failurerates during three months follow-up. In patients above 50 years, a normalage-adjusted D-dimer level in combination with an 'unlikely' CDRsubstantially increased the number of patients in whom PE could besafely excluded: from 13-14% to 19-22% in all CDRs similarly. In patientsover 70 years, the number of exclusions was nearly four-foldhigher, and the original Wells score excluded most patients, with an increasefrom 6% to 21% combined with the conventional and age-adjustedD-dimer cut-off, respectively. The number of VTE failures was alsocomparable in all CDRs. In conclusion, irrespective of which CDR isused, the age-adjusted D-dimer substantially increases the number of patients above 50 years in whom PE can be safely excluded