Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients.

BACKGROUND: The American College of Chest Physicians addressed the dilemma of identifying optimal therapy for venous thromboembolism (VTE) prophylaxis and published their Fourth Consensus Conference on Antithrombotic Therapy in 1995, with recommendations for prophylactic therapy. Despite these recommendations, appropriate VTE prophylactic therapy is underused. OBJECTIVES: To examine routine practices in the prevention of VTE in high-risk surgical patients and to determine the extent of adoption of grade A prophylactic therapies as recommended by the American College of Chest Physicians. METHODS: Retrospective medical record review in 10 teaching or community-based hospitals located in the United States. Medical charts of 1907 patients were randomly selected for review from the population of patients who underwent high-risk major abdominal surgery, total hip replacement, hip fracture repair, or total knee replacement between January 1, 1996, and February 28, 1997. RESULTS: Of 1907 patients, VTE prophylaxis was used in 89.3%; use was 93.7% in each of the 3 orthopedic surgery groups and 75.2% in the high-risk major abdominal surgery group. The percentage of patients receiving grade A therapy was highest in the hip replacement group (84.3%) vs. the other groups (knee replacement, 75.9%; hip fracture repair, 45.2%; abdominal surgery, 50.3%). CONCLUSIONS: The use of grade A prophylaxis was related to the type of surgery, with the highest use seen in total hip replacement and the lowest in hip fracture repair. One in 4 patients who underwent high-risk major abdominal surgeries failed to receive any form of VTE prophylaxis. Publication of consensus statements alone may be insufficient to ensure the incorporation of important new clinical information into routine practice.

Patient education: a tool in the outpatient management of deep vein thrombosis.

A key to effective outpatient management of thromboembolic disease is patient education. Although highly effective for the treatment of deep vein thrombosis (DVT), antithrombotic treatment may fail as a result of inadequate patient education. The risk of hemorrhage from antithrombotic drugs is related to a number of factors including intensity of anticoagulation achieved, comorbid illness, concurrent drug therapy, and lifestyle. When patients receive inadequate antithrombotic treatment, the risk of recurrent thromboembolic events and long-term complications are substantially increased. A well-organized, structured education program enables patients to learn the necessary skills that permit complex and valuable therapies to be managed on an outpatient basis. Health care professionals who are part of an outpatient DVT treatment program should possess working knowledge of adult learning theory and instructional design. To be effective, education programs should be systematically planned, have an educationally sound structure, and attempt to meet specific objectives. In addition, they should build on patients' existing knowledge, skills, and attitudes. Periodic evaluation of the education program is important to ensure that overall goals are being adequately met and to identify areas of weakness.

Diagnosis of deep vein thrombosis.

The diagnosis of deep vein thrombosis (DVT) is discussed. Accurately diagnosing DVT is critical to making appropriate treatment decisions. Careful patient assessment, combined with objective testing, improves the accuracy of the diagnosis and reduces the likelihood of inappropriate treatment. Venography remains the reference standard for the diagnosis of DVT but is expensive, invasive, and prone to inducing complications. Ultrasonography has become the most frequently used noninvasive test for symptomatic DVT because it is highly sensitive and specific in the hands of an experienced examiner. Impedance plethysmography also has been widely used, but recent studies suggest that it is less sensitive than once believed. The radiolabeled 125I-fibrinogen uptake test is no longer available because of concerns about the transmission of blood-borne pathogens. Current thermographic techniques have relatively high sensitivity but poor specificity for DVT. Magnetic resonance imaging and computed tomography are useful adjunctive tests, but their use is limited by cost and availability. D-dimer whole-blood testing may prove to be a rapid and convenient means of ruling out the diagnosis of DVT at the bedside, but further study is needed. When used alone, none of the noninvasive methods is sufficiently sensitive for the evaluation of asymptomatic patients. The diagnostic strategy used should be based on whether the patient is symptomatic or asymptomatic, whether the event is a first one or is recurrent, and a careful clinical assessment. Accurate diagnosis of deep vein thrombosis relies on both testing and patients assessment.

Alternatives to estrogen replacement therapy for preventing osteoporosis.

Osteoporosis is a leading cause of disability and death in older Americans; women are at higher risk than men. Bone is a living tissue that undergoes continuous remodeling throughout life. Several drugs-including sex hormones, bisphosphonates, calcitonin, and sodium fluoride-can arrest the progression of osteoporosis and prevent fractures. Calcium and vitamin D supplementation may prevent the development of osteoporosis in high-risk individuals and are useful adjuncts when used with other treatments.

Thrombosis and the pharmacology of antithrombotic agents.

OBJECTIVE: To provide an overview of the current state of knowledge regarding the physiology of hemostasis, the pathophysiology of thrombosis, and the pharmacology of antithrombotic agents. DATA SOURCES: A MEDLINE search was conducted to identify pertinent literature published since 1984. Recently published textbooks devoted to the subjects of hematology, hemostasis, and thrombosis also were reviewed, particularly their bibliographies. The bibliographies of selected review articles also were reviewed. STUDY SELECTION: As the amount of literature was vast, only the most significant and noteworthy published studies were reviewed. Review articles and book chapters authored by researchers of international reputation also were reviewed. DATA EXTRACTION: Identified studies from the primary literature and selected reviews were analyzed carefully. Information regarding hemostasis, thrombosis, and antithrombotic drugs was extracted. Particular attention was given to data regarding drugs currently available or soon to be available on the US market. DATA SYNTHESIS: Knowledge regarding the regulation of blood coagulation has expanded substantially in recent years. Hemostasis involves the dynamic interplay of numerous intravascular constituents, including the vessel wall, circulating procoagulants and anticoagulants, platelets, and fibrinolytic proteins. Thrombosis is the abnormal formation of a clot within the vascular system. When sufficiently large, thrombi can prevent the flow of blood and nutrients to vital tissues. Thrombosis is associated with many common diseases and is among the leading causes of death in developed countries. Many drugs are now available to prevent the formation and propagation of thrombi. These agents work by different pharmacologic mechanisms and are useful in different clinical situations. CONCLUSIONS: Thrombosis research has increased our understanding of the pharmacology of antithrombotic drugs and promoted the discovery of new agents targeted more specifically toward the critical steps in pathologic clot formation. New agents have the potential for greater efficacy and fewer adverse effects. An increased understanding of hemostasis, thrombosis, and the pharmacology of antithrombotic drugs should enable the clinician to use these agents appropriately.

Treating constipation in the patient with diabetes.

Patients with diabetes have a significant risk of developing severe constipation often due to dysfunction of the autonomic nervous system. Constipation is a symptom, rather than a disease, and is characterized by decreased defecation frequency, increased stool hardness, and/or difficulty passing fecal matter. Self-treatment of constipation with over-the-counter laxative products, home remedies, and foodstuffs is commonplace. Patients frequently call upon health professionals for advice regarding constipation. The diabetes educator should be familiar with the causes and rational treatment of this disorder in the person with diabetes.

Treatment of infantile spasms.

OBJECTIVE: To summarize and evaluate the literature regarding the clinical features, epidemiology, etiology, pathophysiology, and treatment of infantile spasms. DATA SOURCES: A literature search of articles from January 1966 to July 1993 using MEDLINE, EM-Base, and Current Concepts/Life Sciences, as well as bibliographies of relevant articles. STUDY SELECTION: All identified original and review publications regarding the clinical features, epidemiology, etiology, pathophysiology, and treatment of infantile spasms were reviewed. Emphasis was placed on original studies published since 1975. DATA EXTRACTION: Data from published research were extracted and evaluated according to study design, sample size, dosing regimen, outcome measures, and treatment efficacy and safety. DATA SYNTHESIS: Infantile spasms constitute a rare epileptic syndrome with a poor long-term prognosis for normal intellectual development. The spasms are characterized by a brief symmetric contraction of the muscles of the neck, trunk, and/or extremities, often occurring in a series of 2 to more than 100 spasms during a single episode. The disorder is age-specific, with the peak onset of symptoms occurring between 2 and 8 months of age. Spasms of no identifiable cause in infants with normal development prior to the onset of infantile spasms are classified as cryptogenic or idiopathic, whereas those with an identifiable cause are classified as symptomatic. Long-term prognosis is best in cryptogenic cases, with 30-70 percent attaining normal intellect compared with 5-19 percent in symptomatic cases. The etiology and pathophysiology are not well understood. Recent theory postulates that infantile spasms may be caused by an excess of corticotropin-releasing hormone activity during infancy. The suspected association between the whole-cell pertussis vaccine and infantile spasms is coincidental. Few well-designed, prospective, controlled clinical trials for the treatment of infantile spasms have been conducted. CONCLUSIONS: Standard anticonvulsants such as phenytoin, the barbiturates, carbamazepine, and the succinimides have been ineffective. Of the anticonvulsants, only the benzodiazepines, valproic acid, and vigabatrin have shown efficacy in reducing spasm frequency and severity. Hormonal therapy with adrenocorticotropic hormone (ACTH) and/or prednisone has been the most frequently studied treatment modality and appears to be the most effective. Hormonal therapy achieves complete spasm control in 50-75 percent of infants within four weeks of initiation. Opinions differ regarding the relative efficacy between ACTH and prednisone, the need for early initiation of hormonal treatment, and the benefits of high dosages of ACTH (> 40 units/d). No treatment has been shown conclusively to improve the long-term intellectual development of these infants. Neurosurgery may be the treatment of choice in select cases when a localized central nervous system abnormality can be demonstrated. Well-designed, blind, prospective clinical trials are needed to answer definitively many lingering questions regarding the treatment of infantile spasms.