Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients.

Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.

Characterisation of baroreflex sensitivity of recreational ultra-endurance athletes.

Altered autonomic function has been identified following ultra-endurance event participation among elite world-class athletes. Despite dramatic increases in recreational athlete participation in these ultra-endurance events, the physiological effects on these athletes are less known. This investigation sought to characterise changes in surrogate measures of autonomic function: heart rate variability (HRV), blood pressure variability (BPV) and baroreceptor sensitivity (BRS) following ultra-endurance race participation. Further, we sought to compare baseline measures among ultra-endurance athletes and recreationally active controls not participating in the ultra-endurance race. Recreational ultra-endurance athletes (n = 25, 44.6 ± 8.2 years, 8 females) and recreationally active age, sex and body mass index matched controls (n = 25) were evaluated. Measurements of HRV, BPV and BRS were collected pre- and post-race for recreational ultra-endurance athletes and at baseline, for recreationally active controls. Post-race, ultra-endurance athletes demonstrated significantly greater sympathetic modulation [low frequency (LF) power HRV: 50.3 ± 21.6 normalised units (n.u.) to 65.9 ± 20.4 n.u., p = 0.01] and significantly lower parasympathetic modulation [high frequency (HF) power HRV: 45.0 ± 22.4 n.u. to 23.9 ± 13.1 n.u., p < 0.001] and BRS. Baseline measurements BRS (spectral: 13.96 ± 10.82 ms·mmHg(-1) vs. 11.39 ± 5.33 ms·mmHg(-1)) were similar among recreational ultra-endurance athletes and recreationally active controls, though recreational ultra-endurance athletes demonstrated greater parasympathetic modulation of some HRV and BPV measures. Recreational ultra-endurance athletes experienced increased sympathetic tone and declines in BRS post-race, similar to previously reported elite world-class ultra-endurance athletes, though still within normal population ranges.