Journal scan: A review of ten recent papers of immediate clinical significance, harvested from major international journals
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From the desk of the Editor-in-Chief
1. Physical rehabilitation for older patients hospitalized for heart failure, N Engl J Med. 2021
Background
Older patients who are hospitalized for acute decompensated heart failure have high rates of physical frailty, poor quality of life, delayed recovery, and frequent re-hospitalizations. Interventions to address physical frailty in this population are not well established.
Methods
We conducted a multicenter, randomized, controlled trial to evaluate a transitional, tailored, progressive rehabilitation intervention that included four physical function domains (strength, balance, mobility, and endurance).
The intervention was initiated during, or early after, hospitalization for heart failure and was continued after discharge for 36 outpatient sessions. The primary outcome was the score on the Short Physical Performance Battery (total scores range from 0 to 12, with lower scores indicating more severe physical dysfunction) at 3 months. The secondary outcome was the 6-month rate of re-hospitalization for any cause.
Results
A total of 349 patients underwent randomization; 175 were assigned to the rehabilitation intervention and 174 to usual care (control). At baseline, patients in each group had markedly impaired physical function, and 97% were frail or prefrail; the mean number of coexisting conditions was five in each group. Patient retention in the intervention group was 82%, and adherence to the intervention sessions was 67%. After adjustment for baseline Short Physical Performance Battery score and other baseline characteristics, the least-squares mean (± SE) score on the Short Physical Performance Battery at three months was 8.3 ± 0.2 in the intervention group and 6.9 ± 0.2 in the control group (mean between-group difference, 1.5; 95% confidence interval [CI], 0.9 to 2.0; p < 0.001). At six months, the rates of re-hospitalization for any cause were 1.18 in the intervention group and 1.28 in the control group (rate ratio, 0.93; 95% CI, 0.66 to 1.19).
There were 21 deaths (15 from cardiovascular causes) in the intervention group and 16 deaths (eight from cardiovascular causes) in the control group. The rates of death from any cause were 0.13 and 0.10, respectively (rate ratio, 1.17; 95% CI, 0.61 to 2.27).
Conclusions
In a diverse population of older patients who were hospitalized for acute decompensated heart failure, an early, transitional, tailored, progressive rehabilitation intervention that included multiple physical-function domains resulted in greater improvement in physical function than usual care.
2. Algae proteins partially restore man’s sight, https://www.bbc.co.uk/news/health-57226572
The vision of a completely blind man has been partially restored using light-sensing proteins first found in algae. He was treated with optogenetics, which used the proteins to control cells in the retina. Nature Medicine reports.
The man was diagnosed with retinitis pigmentosa – which leads to the death of light-sensing cells on the surface of the retina – 40 years ago. It affects more than two million people worldwide, and although complete blindness is rare, the man has had no vision for the past two decades.
Optogenetics is a field new to medicine, but one that has long been a staple of fundamental neuroscience.
It uses light to control precisely the activity of brain cells and was used by the scientists to restore the ability of one of his eyes to detect light.
The technique is based on proteins, produced in algae, called channel rhodopsins, which change their behaviour in response to light. The microbes use them to move towards the light.
The first step in the treatment was gene therapy. The genetic instructions for making the rhodopsins were taken from algae and given to cells in the deep surviving layers of the retina. Now when they were hit with light they would send an electrical signal to the brain.
However, they would respond only to amber light, so the patient wore a pair of goggles with a video camera on the front and a projector on the back, to capture what was happening in the real world and project a version in the right wavelength onto the retina.
It took months for high enough levels of the rhodopsins to build up in the eye and for the brain essentially to learn a new language to be able to see again.
The first sign it was working was when the patient was out on a walk and suddenly, the stripes of a pedestrian crossing appeared.
This patient initially was a bit frustrated because it took a long time between the injection and the time he started to see something. The man does not have perfect sight, but the difference between no vision and even limited vision can be life-changing.
The findings provide proof-of-concept that using optogenetic therapy to partially restore vision is possible.
There are several other approaches being used to try to restore sight. One includes repairing the genetic defects that cause disease, but retinitis pigmentosa can be down to mutations in more than 71 different genes, making that more of a challenge. Another involves connecting a camera to electrodes implanted in the back of the eye.
Optogenetics itself is also being researched in conditions such as Parkinson’s disease, and to see whether it can enhance recovery from a stroke.
This exciting new technology might help people whose eyesight is very severely impaired.
3. Rituximab versus Mycophenolate Mofetil in Patients with Pemphigus Vulgaris, N Engl J Med. 2021
Background
Rituximab and mycophenolate mofetil are used to treat pemphigus vulgaris, but they have not been adequately compared in clinical trials.
Methods
In a randomized, controlled trial, we assigned patients with moderate-to-severe pemphigus vulgaris in a 1:1 ratio to receive intravenous rituximab (1000 mg on days 1, 15, 168, and 182) or oral mycophenolate mofetil (2 g per day), in addition to an oral glucocorticoid administered on the same tapering schedule in the two groups. The primary end point was sustained complete remission at week 52, defined as the healing of lesions with no new active lesions, as reflected by a Pemphigus Disease Area Index (PDAI) activity score of 0 (on a scale of 0 to 250, with higher scores indicating greater disease severity), for at least 16 weeks without the use of glucocorticoids. Secondary end points were the cumulative dose of glucocorticoids, the number of disease flares, and the change from baseline in the score on the Dermatology Life Quality Index (DLQI; scores range from 0 to 30, with higher scores indicating greater impairment).
Results
Of the 135 patients who underwent randomization, 67 were assigned to receive rituximab and 68 to receive mycophenolate mofetil. The primary outcome was assessed in the modified intention-to-treat population: 62 patients in the rituximab group and 63 in the mycophenolate mofetil group. The median PDAI activity scores at baseline were 22.7 in the rituximab group and 18.3 in the mycophenolate mofetil group. At week 52, sustained complete remission was observed in 25 patients (40%) in the rituximab group and in 6 (10%) in the mycophenolate mofetil group (difference, 31 percentage points; 95% confidence interval [CI], 15 to 45; p < 0.001). The mean cumulative glucocorticoid dose during the 52-week treatment period was 3545 mg in the rituximab group and 5140 mg in the mycophenolate mofetil group (difference, −1595 mg; 95% CI, −2838 to −353; p < 0.001). There were 6 disease flares in the rituximab group and 44 in the mycophenolate mofetil group (adjusted rate ratio, 0.12; 95% CI, 0.05 to 0.29; p < 0.001). The mean change in DLQI score was −8.87 points and −6.00 points, respectively (difference, −2.87 points; 95% CI, −4.58 to −1.17; p = 0.001). Serious adverse events occurred in 15 of 67 patients (22%) in the rituximab group and in 10 of 68 (15%) in the mycophenolate mofetil group.
Conclusions
Rituximab was superior to mycophenolate mofetil in producing sustained complete remission at 52 weeks in patients with pemphigus vulgaris. Rituximab resulted in a greater reduction in glucocorticoid use than mycophenolate mofetil, but more patients in the rituximab group had serious adverse events. Further trials are needed to determine the comparative efficacy and safety of rituximab and mycophenolate mofetil beyond 52 weeks of treatment.
4. Factors associated with access to and receipt of liver transplantation in veterans with end-stage liver disease, JAMA Intern Med. 2021
Question
Organ scarcity means few individuals with advanced liver disease receive a liver allograft; are there other common failures in the transplantation process that further impede access to liver transplantation?
Findings
In a national-level cohort study of 34,494 patients with cirrhosis, few were referred for, placed on a waiting list for, or received a liver allograft within three years of meeting clinical criteria for transplantation, and most of the deficits occurred at the earlier referral step. Age, comorbidity, and social determinants were associated with low referral, wait-listing, and transplant rates; when documented, medical and psychosocial barriers explained most of the gaps in referral.
Meaning
This study’s findings suggest that separate benchmarks for referral and wait-listing and interventions that target potentially modifiable barriers may have an association with improved access to organ transplants.
Importance
Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy.
Objective
To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts.
Design, setting, and participants
This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021.
Exposures
Sociodemographic (e.g., age, insurance, income), clinical (e.g., liver disease etiology, severity, comorbidity), and health care facility (e.g., complexity, rural or urban, presence of a liver transplant program) factors were evaluated.
Main outcomes and measures
Referral, wait-listing, and liver transplantation.
Results
Of the 34,494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral.
Conclusions and Relevance
In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.
5. Effectiveness of Tocilizumab in Patients Hospitalized with COVID-19, A Follow-up of the CORIMUNO-TOCI-1 Randomized Clinical Trial. JAMA Intern Med. 2021.
Background
Eight randomized clinical trials of tocilizumab for treating patients with COVID-19 have reported heterogeneous results. Although 4 of them achieved their primary end point, improved 28-day survival was demonstrated only in the 2 largest studies and those with the highest mortality, RECOVERY and REMAP-CAP. Moreover, only RECOVERY enrolled only patients with elevated C-reactive protein (CRP) levels. The RECOVERY and REMAP-CAP trials involved a high rate of patients using dexamethasone (>80% of the patients in both treatment arms). Differences in trial outcomes may be associated with differences in power, populations, design, management, or length of follow-up.
We previously published a trial of tocilizumab in hospitalized patients who were receiving oxygen (rate, ≥3 L/min) but did not require high-flow or mechanical ventilation. The study met its primary composite end point, which was the proportion of patients who required noninvasive ventilation or intubation or who died at day 14, but found no survival difference at day 28. In this follow-up article, we extended follow-up to 90 days and examined whether survival varied with baseline CRP levels.
Methods
The details of the trial have been previously reported. In this follow-up article, we compared survival at 3 months using random-effects Cox models that were adjusted for age at randomization and center. We performed a post-hoc analysis that was stratified by CRP. Statistical analyses were conducted using R, version 3.6.4 (R Foundation).
Results
By day 90, death had occurred in 7 of 63 (11%) and 11 of 67 patients (18%) in the tocilizumab and usual care arms, respectively (adjusted hazard ratio [HR], 0.64; 95% CI, 0.25-1.65). When outcomes were analyzed according to CRP levels, we found a statistical interaction between CRP levels and the primary composite end point at day 14 and survival at day 90, with a benefit of tocilizumab in patients if their CRP levels were greater than 15.0 mg/dL (to convert to mg/L, multiply by 10), but not if CRP levels were 15.0 mg/dL or less. In patients with CRP levels greater than 15.0 mg/dL, the chance of achieving the primary end point (the percentage of patients who received noninvasive or invasive ventilation or those who died) was 18% and 57% in the tocilizumab and usual care groups, respectively (HR, 0.18; 95% CI, 0.06-0.59) (Table). Likewise, day-90 mortality was 9% and 35% in the tocilizumab and usual care groups, respectively (HR, 0.18; 95% CI, 0.04-0.89) (Table). Usual care could differ among centers and over time, and few patients were taking steroids at randomization (16% and 18% in the tocilizumab and usual care arms, respectively). The sample size was small and credibility intervals were wide. Lastly, in this trial, we targeted a narrow segment of the COVID-19 patient population (patients with a World Health Organization Cognitive Performance Scale score of 5 exactly and requiring at least 3 L/min of oxygen), and our results are not generalizable to other populations.
Discussion
This follow-up analysis suggests that tocilizumab may be considered for treating patients with moderate-to-severe COVID-19–associated pneumonia and high CRP levels. Further studies will help determine which patients with COVID-19–associated pneumonia would benefit the most from a combination of tocilizumab and dexamethasone.
6. Prevalence of Asymptomatic SARS-CoV-2 Infection, a narrative review. Annals of Int Med. 2021
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly throughout the world since the first cases of coronavirus disease 2019 (COVID-19) were observed in December 2019 in Wuhan, China. It has been suspected that infected persons who remain asymptomatic play a significant role in the ongoing pandemic, but their relative number and effect have been uncertain. The authors sought to review and synthesize the available evidence on asymptomatic SARS-CoV-2 infection.
Asymptomatic persons seem to account for approximately 40% to 45% of SARS-CoV-2 infections, and they can transmit the virus to others for an extended period, perhaps longer than 14 days.
Asymptomatic infection may be associated with subclinical lung abnormalities, as detected by computed tomography. Because of the high risk for silent spread by asymptomatic persons, it is imperative that testing programs include those without symptoms.
To supplement conventional diagnostic testing, which is constrained by capacity, cost, and its one-off nature, innovative tactics for public health surveillance, such as crowdsourcing digital wearable data and monitoring sewage sludge, might be helpful.
Key Summary Points
The likelihood that approximately 40% to 45% of those infected with SARS-CoV-2 will remain asymptomatic suggests that the virus might have greater potential than previously estimated to spread silently and deeply through human populations.
Asymptomatic persons can transmit SARS-CoV-2 to others for an extended period, perhaps longer than 14 days.
The absence of COVID-19 symptoms in persons infected with SARS-CoV-2 might not necessarily imply an absence of harm. More research is needed to determine the significance of subclinical lung changes visible on computed tomography scans.
The focus of testing programs for SARS-CoV-2 should be substantially broadened to include persons who do not have symptoms of COVID-19.
In the early months of the coronavirus disease 2019 (COVID-19) pandemic, an iconic image has been the “proned” patient in intensive care, gasping for breath, in imminent need of artificial ventilation. This is the deadly face of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which as of 26 May 2020 had claimed more than 348 000 lives worldwide). But it is not the only face, because SARS-CoV-2 now seems to have a dual nature: tragically lethal in some persons and surprisingly benign in others.
Since February 2020, there have been reports of persons who were infected with SARS-CoV-2 but did not develop symptoms of COVID-19. In some cases, the viral load of such asymptomatic persons has been equal to that of symptomatic persons, suggesting similar potential for viral transmission. The prevalence of asymptomatic SARS-CoV-2 infection, however, has remained uncertain. We sought to review and synthesize the available evidence on testing for SARS-CoV-2 infection, carried out by real-time reverse transcriptase polymerase chain reaction using nasopharyngeal swabs in all studies that specified the method of testing.
Most data from the 16 cohorts in this narrative review are not the output of large, carefully designed studies with randomly selected, representative samples. They do not generally purport to depict anything more than certain circumscribed cohorts at specific moments in time. We have not attempted to pool them for the purposes of statistical analysis. When viewed as a collection, though—as a kind of mosaic or patchwork—these data may offer potentially valuable insights into SARS-CoV-2 incidence and the highly variable effect of infection.
The difficulty of distinguishing asymptomatic persons from those who are merely presymptomatic is a stumbling block. To be clear, the asymptomatic individual is infected with SARS-CoV-2 but will never develop symptoms of COVID-19. In contrast, the presymptomatic individual is similarly infected but eventually will develop symptoms. The simple solution to this conundrum is longitudinal testing—that is, repeated observations of the individual over time. Unfortunately, only 5 of our cohorts include longitudinal data. We must therefore acknowledge the possibility that some of the proportions of asymptomatic persons are lower than reported.
7. Safety and Immunogenicity of Anti–SARS-CoV-2 Messenger RNA Vaccines in Recipients of Solid Organ Transplants. Annals of Int Med. 2021
Background
Recipients of solid organ transplant (SOT) are a high-risk group for severe SARS-CoV-2 infection. The mortality rate of patients with SOT during the COVID-19 pandemic has been reported to be approximately 20%. The anti–SARS-CoV-2 vaccines represent a hope to protect this population against this life-threatening infection.
Objective
To assess the humoral response to messenger RNA (mRNA)–based vaccination in recipients of SOT.
Methods
All patients with heart, kidney, liver, or pancreas transplants from the Midi-Pyrénées region (southwest France) are followed in our department. When the vaccination campaign started (7 January 2021), these patients were invited via text message, e-mail, or transplant patients’ associations to be vaccinated. Patients were asked to register via a dedicated telephone number or website. They were vaccinated consecutively according to their registration date. According to the recommendations of the Francophone Society of Transplantation, anti–SARS-CoV-2 spike protein antibodies were monitored before and after vaccination. We used the SARS-CoV-2 total antibodies enzyme-linked immunosorbent assay test (Beijing Wantai Biological Pharmacy Enterprise) (80% of patients) or another validated anti–SARS-CoV-2 spike protein assay.
Findings
By 16 April 2021, 950 patients of the 2666 from our cohort had received at least 1 dose of an mRNA vaccine (BNT162b2 vaccine [Pfizer-BioNTech], n = 942; mRNA-1273 vaccine [Moderna], n = 8) and had anti–SARS-CoV-2 antibodies monitored. Fifty patients had vaccination without monitoring of antibodies, 80 patients are planned to be vaccinated within the next month, and 257 patients declined the vaccine. We had no feedback from the remaining 1329 patients.
A total of 895 of the 950 patients had an available serologic screening just before the first injection. The prevalence of anti–SARS-CoV-2 antibodies was 2.1% (95% CI, 1.3% to 3.3%; n = 19 of 895). Only 5 of the 19 patients who were seropositive previously had symptomatic COVID-19. A total of 576 patients benefited from a second injection at day 28. The prevalence of anti–SARS-CoV-2 antibodies before the second injection was 6.4% (CI, 4.6% to 8.8%; n = 37 of 576).
In 367 patients who had a 4-week follow-up after the second dose, the prevalence of anti–SARS-CoV-2 antibodies increased from 1.4% (CI, 0.4% to 3.2%; n = 5 of 367) at baseline to 6.3% (CI, 4.0% to 9.3%; n = 23 of 367) at day 28 and 33.8% (CI, 29.0% to 38.9%; n = 124 of 367) 1 month after the second dose (Figure). Characteristics of patients who were vaccinated with and without a 4-week follow-up after the second dose are presented in the Table.
The tolerance of mRNA vaccines was excellent, with no serious adverse events reported, except in 1 patient with a liver transplant who developed paresthesia of the lower limb. Kidney function and liver enzymes remained stable in recipients of kidney and liver transplants before and 28 days after the first dose.. One recipient of a kidney transplant presented 3 weeks after the first injection with a 50% increase in serum creatinine level related to drug-induced dehydration. The patient recovered after rehydration and reduction of diuretics. Only 1 patient, who had vaccination without the requested biological monitoring and who is not included in this report, had an acute cellular rejection.
Discussion
In immunocompetent patients, mRNA vaccines have shown strong antibody response, even after a single dose. In immunocompromised patients, such as recipients of SOT, a weak humoral response to mRNA vaccines was reported. Boyarsky and colleagues reported the appearance of specific antibodies in 17% of transplant recipients 3 weeks after a single dose of an mRNA vaccine. Recently, in a small series of patients with SOT, including mainly those who had a kidney transplant, anti–SARS-CoV-2 antibodies were detected in 37.5% to 58.8% of patients at 4 weeks after the second dose. Our study, which included many patients with SOT, confirms a weak immunogenicity of mRNA vaccines in those who had a transplant. Recipients of liver transplant showed a better humoral response than recipients of other organs. Considering the good tolerance of mRNA vaccines, an increased antigen dose or a third vaccine dose can be proposed to improve the vaccination response in this specific population. In France, the French National Authority for Health has recently recommended offering a third dose to immunosuppressed patients.
Further studies are required to assess both cellular and humoral responses to vaccines and to determine their long-term protective capacity. Meanwhile, enhanced barrier measures should be maintained, and vaccination of household members and close contacts is recommended.
8. SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans. Nature 2021.
Abstract
Long-lived bone marrow plasma cells (BMPCs) are a persistent and essential source of protective antibodies. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) convalescent individuals have a significantly lower risk of reinfection. Nonetheless, it has been reported that anti-SARS-CoV-2 serum antibodies experience rapid decay in the first few months after infection, raising concerns that long-lived BMPCs may not be generated and humoral immunity against this virus may be short-lived. Here we demonstrate that in patients who experienced mild infections (n=77), serum anti-SARS-CoV-2 spike (S) antibodies decline rapidly in the first 4 months after infection and then more gradually over the following 7 months, remaining detectable at least 11 months after infection. Anti-S antibody titers correlated with the frequency of S-specific BMPCs obtained from bone marrow aspirates of 18 SARS-CoV-2 convalescent patients 7 to 8 months after infection. S-specific BMPCs were not detected in aspirates from 11 healthy subjects with no history of SARS-CoV-2 infection. We demonstrate that S-binding BMPCs are quiescent, indicating that they are part of a long-lived compartment. Consistently, circulating resting memory B cells directed against the S protein were detected in the convalescent individuals. Overall, we show that SARS-CoV-2 infection induces a robust antigen-specific, long-lived humoral immune response in humans.
9. Atrial fibrillation: diagnosis and management—summary of NICE guidance. BMJ 2021.
This article summarizes the updated National Institute for Health and Care Excellence (NICE) guideline, Atrial fibrillation: diagnosis and management, focusing on three areas where new evidence has led to a change in recommendations: bleeding risk prediction, anticoagulation, and ablation.
What you need to know
Bleeding risk assessment should be used to derive accurate absolute risk scores that can support discussion between clinician and patient about risk modification and appropriate vigilance during anticoagulation. It should not be used to set a threshold for who should be offered anticoagulation.
The ORBIT bleeding prediction tool currently provides the most accurate level of absolute bleeding risk.
Direct-acting oral anticoagulants (DOACs) should be used in preference to warfarin for most patients; the choice of DOAC depends on patient choice and clinical indication.
Radiofrequency point-by-point ablation is the most cost-effective treatment for people who have not responded to antiarrhythmic drugs, although laser and cryoballoon ablation may be appropriate in some patients.
Continue anticoagulation after ablation according to risk tools.
10. Which is the best model to assess risk for venous thromboembolism in hospitalised patients? BMJ 2021
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major global health burden. North American data report a 30-day case fatality rate of 10.6% following VTE. Between 30% and 50% of survivors go on to have long term complications. About half of VTE episodes occur during hospitalisation for surgery or acute medical illness, or within 90 days from discharge. These events are classified as hospital acquired thrombosis (HAT).
HAT events are potentially preventable through patient education and pharmacological thromboprophylaxis.
A meta-analysis (seven trials, 15 095 hospitalised patients) showed greater than 50% risk reduction for VTE with heparins compared with control. In many elective surgical settings, thromboprophylaxis has become established practice.
However, pharmacological thromboprophylaxis is not suitable for all patients admitted to hospital in an emergency. It can increase the baseline risk of major bleeding by approximately 0.4%. When given inappropriately, the consequences can be potentially harmful, notably for patients with occult bleeding on admission or those undergoing emergency procedures.
VTE risk assessment models (RAMs) aim to minimise unnecessary pharmacological thromboprophylaxis and reduce the associated harm and costs. They can also potentially provide individualised and reproducible evaluation of VTE risk, independent of seniority, expertise or bias of the assessing clinician.
What you need to know
Venous thromboembolism in hospitalised patients can be potentially prevented through patient education and pharmacological thromboprophylaxis.
Risk assessment models (RAMs) help clinicians decide who should be offered pharmacological thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high and low risk.
Uncertainty exists over which RAM is optimal for hospitalised patients and whether any complex RAM outperforms simple criteria or subjective clinical opinion.