Intervention targeted at nurses to improve venous thromboprophylaxis.

International audienceOBJECTIVE: To assess the effectiveness of an intervention targeting both physicians and nurses vs. physicians only in improving venous thromboprophylaxis for older patients. DESIGN: Cluster randomized trial. SETTING: Fifty hospital-based post-acute care departments in France. PARTICIPANTS: Patients aged 65 years or older. INTERVENTION: A multifaceted intervention to implement a clinical practice guideline addressing venous thromboprophylaxis. MAIN OUTCOME MEASURES: The effectiveness outcomes were elastic stocking use, ambulation or mobilization under the supervision of a physical therapist and anticoagulant-based prophylaxis. Patient outcomes included deep vein thrombosis and anticoagulant-related adverse events. RESULTS: One department allocated to the intervention targeted at physicians only and seven departments allocated to the intervention targeted at both physicians and nurses dropped out of the study. Compared with the intervention targeted at physicians only (n = 497 patients), the intervention targeted at both physicians and nurses (n = 315 patients) was associated with a higher rate of mobilization (62 vs. 37%, P < 0.001) and comparable levels of elastic stocking (32 vs. 39%, P = 0.74) and anticoagulant (55 vs. 48%, P = 0.36) use. The rates of deep vein thrombosis (15 vs. 13%, P = 0.50), bleeding (1 vs. 1%, P = 0.99) and thrombocytopaenia (0 vs. 0.2%, P = 0.99) did not differ between the two groups. CONCLUSIONS: A multifaceted intervention targeting nurses in addition to physicians can increase the frequency of mobilization of older patients to prevent venous thromboembolism but does not alter the use of elastic stockings and anticoagulant. A differential drop-out of departments might have contributed to creating imbalances in baseline characteristics and outcomes in this study

Critical limb ischemia: thrombogenic evaluation of two autologous cell therapy products and biologic profile in treated patients

International audienceBackground: Cell therapy has been proposed as a salvage limb procedure in critical limb ischemia (CLI). Autologous cell therapy products (CTP) are obtained from patients with advanced peripheral arterial disease to be injected at the site of ischemia. Thrombogenicity of CTPs has not yet been assessed. The objectives were: 1) to assess thrombotic risk in candidates for cell therapy, 2) to evaluate two different CTPs in terms of thrombogenic potential, and 3) to evaluate clinical thrombotic events.Study design and methods: In this ancillary study of a Phase I and II clinical trial, bone marrow (BM)-CTPs (n = 20) and CTPs obtained by cytapheresis (peripheral blood [PB]-CTPs; n = 20) were compared. Inflammatory and coagulation markers were measured at baseline and 24 hours after CTP implantation. CTP cell content and tissue factor (TF) expression (mRNA and protein) were analyzed. Thrombin generation assessed CTP-related thrombogenicity.Results: All patients presented cardiovascular risk factors. At baseline, the patients' biologic profile was characterized by high levels of fibrinogen, C-reactive protein (CRP), D-dimer, interleukin (IL)-6, and plasmatic TF, whereas IL-10 was low. Although different in terms of cell composition, both BM- and PB-CTPs support low thrombin generation. Twenty-four hours after implantation, biologic markers remained stable in the PB-CTP group, except for IL-6. In the BM-CTP group, a significant increase of IL-6 but also of CRP and D-dimer was observed. Clinically, one single patient developed deep vein thrombosis 24 hours after the implantation of autologous PB-CTP.Conclusion: CTPs supported low thrombin generation and were well tolerated after calf implantation

Risk factors for deep vein thrombosis in older patients: a multicenter study with systematic compression ultrasonography in postacute care facilities in France.

OBJECTIVES: To identify risk factors for deep vein thrombosis (DVT) in older patients with restricted mobility or functional disability. DESIGN: Cross-sectional. SETTING: Forty-two postacute care departments in France. PARTICIPANTS: Eight hundred twelve patients aged 65 and older. MEASUREMENTS: Twenty-two predefined characteristics were investigated, including medical and surgical risk factors, dependence in six basic activities of daily living (ADLs) rated using the Katz index, mobility, the reported value of the Timed Up and Go Test, and pressure ulcers. All patients underwent lower limb ultrasonography on the day of the cross-sectional study. RESULTS: DVT was found in 113 patients (14%, 33 proximal DVTs (4%) and 80 isolated distal DVTs (10%)). A positive trend was found in the odds of DVT for higher values on the Timed Up and Go Test for patients who were not bedridden or confined to a chair (P=.007). In two-level multivariable analysis adjusting for prophylaxis against venous thromboembolism, independent risk factors for DVT were aged 80 and older (adjusted odds ratio (aOR)=1.71, 95% confidence interval (CI)=1.05-2.79), previous history of venous thromboembolism (aOR=2.03, 95% CI=1.06-3.87), regional or metastatic-stage cancer (aOR=2.71, 95% CI=1.27-5.78), dependence in more than three ADLs (aOR=2.18, 95% CI=1.38-3.45), and pressure ulcers (aOR=1.85, 95% CI=1.05-3.24). CONCLUSION: Severe dependence in basic ADLs and higher Timed Up and Go Test score are associated with greater odds of DVT in older patients in postacute care facilities in France

[Venous thromboembolism in the elderly: Results of a program to improve prevention]

International audienceINTRODUCTION: Venous thromboembolism is highly prevalent in the elderly population. However, this age group often receives inadequate thromboprophylaxis because of concerns about bleeding risk, denying patients the benefit of proven antithrombotic regimens. Besides, there is a lack of data in non-surgical patients in postacute care facilities. METHODS: A multifaceted intervention program addressing venous thromboembolism prophylaxis has been conducted and evaluated in 50 postacute care facilities. Data were collected in two cross-sectional, epidemiologic studies of 1664 patients aged 65 years or older, including a systematic venous complete compression ultrasound. RESULTS: Despite the fact that 56% of patients received pharmacologic prophylaxis, the prevalence of asymptomatic deep venous thromboses (DVT) was 15%. Specific risk factors in this population have been identified: dependence in basic activities of daily living (ADLs), a higher timed Up and Go test score and the presence of pressure ulcers. Implantation of a multifaceted program was followed by a reduction in DVT prevalence (OR=0.58, CI95%, 0.40-0.83). Implication of nurses and physical therapists was associated with an increase in patient's mobilization (62% versus 37%, p<0.01). Nevertheless, we were unable to find any efficacy of medical compression in venous thomboembolism prevention for medical patients. CONCLUSION: This project shows the high prevalence of venous thromboembolism in postacute care facilities and enhances the need for a multidisciplinary approach to this disease

Outcomes for inpatients with normal findings on whole-leg ultrasonography: a prospective study.

International audienceBACKGROUND: Ultrasonography is used routinely for ruling out suspected deep vein thrombosis in hospitalized patients, although most evidence supporting this strategy is derived from the outpatient setting. This study aimed to estimate the rate of venous thromboembolism when anticoagulant therapy was withheld from inpatients with normal findings on whole-leg ultrasonography. METHODS: As part of a prospective multicenter cohort study, 1926 medical and surgical inpatients with clinically suspected deep vein thrombosis during their stay were enrolled. Ultrasonography of all lower extremities was performed by board-certified vascular medicine physicians using a standardized examination protocol. Deep vein thrombosis was detected in 395 patients (20%). Anticoagulant therapy was withheld from patients with normal findings, and 523 of them were randomly selected for follow-up. The main outcome measure was 3-month incidence of symptomatic venous thromboembolism. RESULTS: A total of 513 patients with normal findings on ultrasonography successfully completed 3 months of follow-up, 9 patients were lost to follow-up, and 1 patient received anticoagulant therapy during follow-up. Three patients (0.6%) experienced nonfatal symptomatic venous thromboembolic events confirmed by objective testing. The cause of death was judged to be possibly related to pulmonary embolism for 7 other patients (1.3%). Overall, the 3-month rate of venous thromboembolism was 1.9% (10/513; 95% confidence interval, 0.9-3.5). CONCLUSION: Although withholding anticoagulant therapy after a single negative whole-leg ultrasonography seems to be safe, up to 3.5% of inpatients may nevertheless develop venous thromboembolism in the next 3 months. Further study is warranted to determine whether this strategy is equivalent to serial compression ultrasonography limited to proximal veins