Jordanna Hostler

Validation of the International Medical Prevention Registry on Venous Thromboembolism Bleeding Risk Score

Objectives Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for venous thromboembolism (VTE). The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well defined population of medical inpatients but it has not been externally validated. We sought to externally validate the IMPROVE BRS. Methods We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day on all patients admitted for a medical illness to the Walter Reed Army Medical Center (WRAMC) over an 18 month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. Results From September 2009 through March 2011 there were 1668 inpatients who met the IMPROVE inclusion criteria. Bleeding events occurred during 45 (2.7%) separate admissions; 31 (1.9%) events were major and 14 (0.8%) were non-major but clinically relevant. 256 (20.7%) patients had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major (p=0.02) and clinically important (major plus clinically relevant non-major) (p=0.06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR 2.6, 95% CI: 1.1-5.9; p=0.03); there was a trend toward significant association with clinically important bleeding (OR 1.9, 95% CI: 0.9-3.7; p=0.07). Conclusions The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess relative risks of bleeding and VTE before chemoprophylaxis is administered.BACKGROUND Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS. METHODS We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. RESULTS From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major (P = .02) and clinically important (major plus clinically relevant nonmajor) (P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07). CONCLUSIONS The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.

Asbestos–Related Pleuropulmonary Diseases: Benign and Malignant

Abstract Asbestos is known for its desirable properties of thermal and heat resistance along with excellent strength and durability. It was widely used in many industries since the late 19th century, until its adverse effects on health were recognized. The occurrence of pleuropulmonary changes from exposure to asbestos often has a latency period of 20 to 30 years. The use of asbestos has been banned, regulated, and minimized in many countries, but in several developing countries, the use of asbestos in industries is still a common practice. In this article, the benign and malignant clinical manifestations of asbestos exposure are discussed.

Venous thromboembolism prophylaxis for patients receiving regional anesthesia following injury in Iraq and Afghanistan.

BACKGROUND Soldiers with combat-related traumatic injury are at high risk for venous thromboembolism (VTE) and often require regional anesthesia (RA) for pain control. We evaluated whether the recommended reduction in chemoprophylaxis in the presence of RA increases VTE rates. METHODS We collected data each hospital day for all soldiers admitted to the Walter Reed Army Medical Center following injury in Iraq or Afghanistan. We analyzed thromboprophylaxis and RA rates and assessed risk factors for VTE. We separated outcomes by whether RA was central neuraxial (cNAB) or peripheral blockade. RESULTS Among 1,259 patients, 323 received RA for a median of 12 days (5–27 days). Those with RA were younger and more likely to have been injured in combat or by an improvised explosive device. They also received more packed red blood cell transfusions and had longer admissions. Patients with RA spent a greater percentage of days on enoxaparin 40 mg daily compared with those without RA (34.4% vs. 22.0%, p < 0.001) and more hospital days without any chemoprophylaxis (2.0 [1.0–6.0] vs. 1.0 [0.0–3.0], p < 0.001). Patients with cNAB were less likely to be placed on enoxaparin 30 mg twice daily. Patients with RA in place had mechanical prophylaxis ordered at the same rate as those without RA. Neither the presence of any RA nor cNAB specifically was associated with an increased risk for VTE. No bleeding or neurologic complications occurred in those receiving RA. CONCLUSION Despite changes to chemoprophylaxis, soldiers wounded in combat who receive RA are not at increased risk for VTE. LEVEL OF EVIDENCE Therapeutic study, level III.

A mobile, web-based system can improve positive airway pressure adherence

SleepMapper is a mobile, web‐based system that allows patients to self‐monitor their positive airway pressure therapy, and provides feedback and education in real time. In addition to the usual, comprehensive support provided at our clinic, we gave the SleepMapper to 30 patients initiating positive airway pressure. They were compared with patients initiating positive airway pressure at our clinic without SleepMapper (controls) to determine whether SleepMapper affected adherence. A total of 61 patients had polysomnographic and adherence data analysed, 30 were given SleepMapper and 31 received our standard of care. The two groups were well matched at baseline to include no significant differences in age, apnea–hypopnea index, percentage receiving split‐night polysomnographs and starting pressures. Patients in the control group received significantly more non‐benzodiazepine sedative hypnotics the night of their polysomnography and during positive airway pressure initiation. At 11 weeks, patients in the SleepMapper group had a greater percentage of nights with any use (78.0 ± 22.0 versus 55.5 ± 24.0%; P < 0.001) and >4 h positive airway pressure use (78.0 ± 22.0 versus 55.5 ± 24.0%; P = 0.02). There was a trend toward more patients in the SleepMapper group achieving >4 h of use for at least 70% of nights [9/30 (30%) versus 3/31 (9.7%); P = 0.06]. In multivariate linear regression, the SleepMapper remained significantly associated with percentage of nights >4 h positive airway pressure use (β coefficient = 0.18; P = 0.02). Added to our usual, comprehensive programme to maximize positive airway pressure adherence in new users, the SleepMapper was independently associated with an 18% increase in nights >4 h of use.

Diagnosis of Obstructive Sleep Apnea in Adults

My candle burns at both ends; It will not last the night; But ah, my foes, and oh, my friends It gives a lovely light. Edna St. Vincent Millay TO THE EDITOR: We read with concern the ACP clinical guideline about the diagnosis of OSA (1). This guideline offers PSG as a solitary tool for sleep-related symptoms; the guidelines broad application could result in unnecessary testing and treatment. Polysomnography performed with current technologies and scored using the criteria recommended by the AASM in 2012 will yield an average apneahypopnea index that is 3-fold higher than that obtained with the equipment and scoring criteria available at the time of most of the studies cited to support this guideline. Flow changes are currently graded using a pressure-transduced air flow monitorwhich is far more sensitive than the thermistor used in prior studiesand the new AASM guideline does not require oxygen desaturation to be present for a breathing event to be scored (2). In fact, a recent trial showed that the prevalence of an apneahypopnea index of 5 or more events per hour using the current criteria was 94.6% in a population with a mild-moderate pretest probability of OSA (3). This condition exists on a spectrum, and apneahypopnea index cutoffs are largely arbitrary. Given the changes in diagnosis, are we measuring clinically meaningful disease? What are the costs of overdiagnosis? Furthermore, the term unexplained sleepiness (which is pivotal in the guidelines first recommendation) is meaningful only when clinicians thoroughly understand the causes of sleepiness. The average physician receives approximately 2 hours of formal medical education on the evaluation of sleep disorders (4). This guideline fails to acknowledge that behaviorally induced insufficient sleep, insomnia, mood disorders, the restless legs syndrome, and many other problems cannot be measured by PSG or treated with continuous positive airway pressure. We know from survey data that the average person in the United States effectively burns the candle at both ends, obtaining 6 hours and 40 minutes of sleep on the average workday (5). Recommending PSG for every patient whose sleepiness is unexplainedwithout also recommending qualitative and quantitative assessment of sleep durationis ill-advised. We suggest that the ACP develop a comprehensive sleepsymptom guideline that encourages a more holistic evaluation of the patient who presents with sleepiness and focuses more attention on the limitations of PSG.