Practical Recommendations for Optimal Thromboprophylaxis in Patients with COVID-19: A Consensus Statement Based on Available Clinical Trials.

Coronavirus disease 2019 (COVID-19) has been shown to be strongly associated with increased risk for venous thromboembolism events (VTE) mainly in the inpatient but also in the outpatient setting. Pharmacologic thromboprophylaxis has been shown to offer significant benefits in terms of reducing not only VTE events but also mortality, especially in acutely ill patients with COVID-19. Although the main source of evidence is derived from observational studies with several limitations, thromboprophylaxis is currently recommended for all hospitalized patients with acceptable bleeding risk by all national and international guidelines. Recently, high quality data from randomized controlled trials (RCTs) further support the role of thromboprophylaxis and provide insights into the optimal thromboprophylaxis strategy. The aim of this statement is to systematically review all the available evidence derived from RCTs regarding thromboprophylaxis strategies in patients with COVID-19 in different settings (either inpatient or outpatient) and provide evidence-based guidance to practical questions in everyday clinical practice. Clinical questions accompanied by practical recommendations are provided based on data derived from 20 RCTs that were identified and included in the present study. Overall, the main conclusions are: (i) thromboprophylaxis should be administered in all hospitalized patients with COVID-19, (ii) an optimal dose of inpatient thromboprophylaxis is dependent upon the severity of COVID-19, (iii) thromboprophylaxis should be administered on an individualized basis in post-discharge patients with COVID-19 with high thrombotic risk, and (iv) thromboprophylaxis should not be routinely administered in outpatients. Changes regarding the dominant SARS-CoV-2 variants, the wide immunization status (increasing rates of vaccination and reinfections), and the availability of antiviral therapies and monoclonal antibodies might affect the characteristics of patients with COVID-19; thus, future studies will inform us about the thrombotic risk and the optimal therapeutic strategies for these patients

Approaches to teach evidence-based practice among health professionals: an overview of the existing evidence

Athina E Patelarou,1,* Konstantinos G Kyriakoulis,2,3,* Aliki A Stamou,2,3 Aggelos Laliotis,4 Dimitra Sifaki-Pistolla,5 Michail Matalliotakis,6 Emmanuel Prokopakis,7 Evridiki Patelarou8 1Department of Anesthesiology, University Hospital of Heraklion, Crete, 2Society of Junior Doctors, 3Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece; 4Department of Oesophago-Gastric Surgery, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK; 5Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, 6Department of Obstetrics and Gynaecology, Venizeleio General Hospital, Heraklion, 7Department of Otorhinolaryngology, School of Medicine, University of Crete, Crete, Greece; 8Department of Family and Child Health, Florence Nightingale Faculty of Nursing and Midwifery, London, UK *These authors contributed equally to this work Abstract: Health care professionals’ adoption of evidence-based practice (EBP) remains limited, although most health care professionals are familiar with EBP and believe in its value. This systematic review aimed to bring together the best methods used to teach EBP to health professionals. The authors conducted a systematic search for the period 2005–2015 (an update of the search took place in October 2016) using PubMed interface (Medline). MeSH terms as well as free-text keywords were used. Studies were analyzed and evaluated by title and abstract. Those studies which fulfilled the inclusion criteria were assessed by full text. References of articles were also taken into consideration for identifying relevant studies not found through algorithm search. Twenty articles were found to be relevant. The majority of the studies were conducted among nurses (n=7) and physicians (n=6), and only a few among professionals from mixed disciplines (n=5). Two studies were conducted among chiropractors (n=1) and faculty members from a naturopathic and classical Chinese medicine institution (n=1). Researchers used a variety of different approaches, which varied with respect to duration and organization. We divided interventions into two categories. Single interventions included either a workshop, or a journal club, or a conference, or a lecture, or online learning tools, whereas multiple interventions included a combination of these approaches. An increase in EBP competencies and attitudes was reported in nine studies. Teaching methods for optimizing EBP among health professionals could become a robust standardized procedure of the medical educational curricula and lifelong learning of health care professionals. Keywords: advanced clinical practice, health personnel, teaching strategies, nurses, physicians, lifelong educatio

Home blood pressure monitoring schedule: optimal and minimum based on 2122 individual participants' data

Objectives: Home blood pressure (HBP) monitoring has become a primary method for hypertension diagnosis and management. This analysis aimed to investigate the optimal and minimum schedule for HBP monitoring. Methods: A retrospective analysis of cross-sectional data was performed, which involved HBP and 24-h ambulatory blood pressure (ABP) monitoring in adults performed within the context of clinical studies in Finland, Greece and UK. Participants with six to seven HBP monitoring days and at least 12 HBP readings were included. The stability of HBP was assessed by evaluating the average value of an increasing number of readings and its variability (SD). Its association with awake ABP was also assessed. Results: Data from 2122 participants were analysed (mean age 53.9 ± 11.3 years, males 53%, treated 34%). A progressive HBP decline was observed in succeeding days, reaching a plateau after day 3. Day 1 HBP was higher than in the next days by about 2.8/1.4 mmHg (systolic/diastolic, P Conclusion: These data support the recommendation for 7 days of HBP monitoring with a minimum of 3 days. Readings of the first day should be discarded, particularly when the minimum 3-day monitoring schedule is obtained (average readings of second and third day).</p

Phenotypes of masked hypertension: isolated ambulatory, isolated home and dual masked hypertension

Objectives: Masked hypertension (MH) is defined as normal office blood pressure (OBP) and elevated ambulatory (ABP) or home blood pressure (HBP). This study assessed MH identified by each of these two methods. Methods: A retrospective analysis of cross-sectional data in treated and untreated adults from Greece, Finland and UK who had OBP, HBP and 24-h ABP measurements was performed. Dual MH was defined as normal OBP and elevated HBP and ABP, isolated ambulatory MH as normal OBP and HBP and elevated ABP and isolated home MH as normal OBP and ABP and elevated HBP. Results: Of 1971 participants analyzed, 445 (23%) had MH on ABP and/or HBP (age 57.1 ± 10.8 years, men 55%, treated 49%). Among participants with any MH, 215 had dual MH (48%), 132 isolated ambulatory MH (30%) and 98 isolated home MH (22%). Moreover, 55% had high-normal, 35% normal and 10% optimal OBP. In logistic regression analysis isolated ambulatory MH was predicted by younger age (OR 0.35, P &lt; 0.01 per 10 years increase), whereas isolated home MH was predicted by older age (OR 2.05, P &lt; 0.01 per 10 years increase). Conclusion: Masked hypertension diagnosed by ABP and not HBP monitoring or the reverse is not uncommon. Age appears to be the most important determinant of isolated ambulatory or home MH, with the former being more common in younger participants and the latter in older ones. Only half of participants with MH have high-normal OBP, whereas the rest have lower levels

Phenotypes of masked hypertension: isolated ambulatory, isolated home and dual masked hypertension

Objectives: Masked hypertension (MH) is defined as normal office blood pressure (OBP) and elevated ambulatory (ABP) or home blood pressure (HBP). This study assessed MH identified by each of these two methods. Methods: A retrospective analysis of cross-sectional data in treated and untreated adults from Greece, Finland and UK who had OBP, HBP and 24-h ABP measurements was performed. Dual MH was defined as normal OBP and elevated HBP and ABP, isolated ambulatory MH as normal OBP and HBP and elevated ABP and isolated home MH as normal OBP and ABP and elevated HBP. Results: Of 1971 participants analyzed, 445 (23%) had MH on ABP and/or HBP (age 57.1 ± 10.8 years, men 55%, treated 49%). Among participants with any MH, 215 had dual MH (48%), 132 isolated ambulatory MH (30%) and 98 isolated home MH (22%). Moreover, 55% had high-normal, 35% normal and 10% optimal OBP. In logistic regression analysis isolated ambulatory MH was predicted by younger age (OR 0.35, P < 0.01 per 10 years increase), whereas isolated home MH was predicted by older age (OR 2.05, P < 0.01 per 10 years increase). Conclusion: Masked hypertension diagnosed by ABP and not HBP monitoring or the reverse is not uncommon. Age appears to be the most important determinant of isolated ambulatory or home MH, with the former being more common in younger participants and the latter in older ones. Only half of participants with MH have high-normal OBP, whereas the rest have lower levels

Cuffless blood pressure measuring devices: review and statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability

Background: Many cuffless blood pressure (BP) measuring devices are currently on the market claiming that they provide accurate BP measurements. These technologies have considerable potential to improve the awareness, treatment, and management of hypertension. However, recent guidelines by the European Society of Hypertension do not recommend cuffless devices for the diagnosis and management of hypertension. Objective: This statement by the European Society of Hypertension Working Group on BP Monitoring and Cardiovascular Variability presents the types of cuffless BP technologies, issues in their validation, and recommendations for clinical practice. Statements: Cuffless BP monitors constitute a wide and heterogeneous group of novel technologies and devices with different intended uses. Cuffless BP devices have specific accuracy issues, which render the established validation protocols for cuff BP devices inadequate for their validation. In 2014, the Institute of Electrical and Electronics Engineers published a standard for the validation of cuffless BP devices, and the International Organization for Standardization is currently developing another standard. The validation of cuffless devices should address issues related to the need of individual cuff calibration, the stability of measurements post calibration, the ability to track BP changes, and the implementation of machine learning technology. Clinical field investigations may also be considered and issues regarding the clinical implementation of cuffless BP readings should be investigated. Conclusion: Cuffless BP devices have considerable potential for changing the diagnosis and management of hypertension. However, fundamental questions regarding their accuracy, performance, and implementation need to be carefully addressed before they can be recommended for clinical use.</p