Thromboprophylaxis in non-surgical patients: who, when and how?

Because of the serious lack of useable, relevant information, most recommendations for prevention of thrombosis in non-surgical patients are extrapolations from much larger clinical trials experienced in surgery. Directly relevant evidence comes predominantly from very small randomized trials, many of them open label and carried out more than 20 years before the introduction of more recent and important changes in clinical care that may have substantially reduced the baseline thrombosis risk. In these early studies, low-dose heparin and low-molecular-weight heparins prevented subclinical deep vein thrombosis in ischaemic stroke, myocardial infarction and among elderly medical inpatients. Although it is likely that these drugs also prevent subclinical deep vein thrombosis after spinal cord injury or other major trauma, and when patients require intensive medical care, the supporting evidence in these circumstances comes mainly from cohort studies and poorly controlled comparisons. In contrast, the heparins have not reduced mortality or demonstrably prevented pulmonary embolism after ischaemic stroke or among elderly medical inpatients in large and well-conducted clinical endpoint trials, from which no clinically important benefit could be demonstrated. From analyses it is suggested that such benefit is probably more difficult to demonstrate for medical than for surgical patients. In the absence of sufficient information that is specific to medical patients, various forms of prophylaxis known to be effective in surgery will continue to be applied in high-risk individuals. After venous thromboembolism, it now appears that the best duration of oral anticoagulant therapy to prevent a recurrence is determined to a greater extent by whether the thrombotic episode was idiopathic or triggered by a clinically recognizable cause, whether it was transient or continuing, and whether the deep vein thrombosis was extensive, limited to the calf veins or was a first or recurrent event.     

Hospital experience and mortality in patients with systemic lupus erythematosus: which patients benefit most from treatment at highly experienced hospitals?

OBJECTIVE: To determine if hospitalization at a hospital experienced in the treatment of systemic lupus erythematosus (SLE), compared to hospitalization at a less experienced hospital, is associated with decreased in-hospital mortality in all subsets of patients with SLE, or if the decrease in mortality is greater for patients with particular demographic characteristics, manifestations of SLE, or reasons for hospitalization. METHODS: Data on in-hospital mortality were available for 9989 patients with SLE hospitalized in acute care hospitals in California from 1991 to 1994. Differences in in-hospital mortality between patients hospitalized at highly experienced hospitals (those hospitals with more than 50 urgent or emergent hospitalizations of patients with SLE per year) and those hospitalized at less experienced hospitals were compared in patient subgroups defined by age, sex, ethnicity, type of medical insurance, the presence of common SLE manifestations, and each of the 10 most common principal reasons for hospitalization. RESULTS: In univariate analyses, in-hospital mortality was lower among those hospitalized at a highly experienced hospital for women, blacks, and Hispanics, and those with public medical insurance or no insurance. The risk of in-hospital mortality was similar between highly experienced and less experienced hospitals for men, whites, and those with private insurance. Patients with nephritis also had lower risks of in-hospital mortality if they were hospitalized at highly experienced hospitals, but this risk did not differ in subgroups with other SLE manifestations or subgroups with different principal reasons for hospitalization. In multivariate analyses, only the interaction between medical insurance and hospitalization at a highly experienced hospital was significant. Results were similar in the subgroup of patients with an emergency hospitalization (n = 2,372), but more consistent benefits of hospitalization at a highly experienced hospital were found across subgroups of patients with an emergency hospitalization due to SLE (n = 405). CONCLUSION: Risks of in-hospital mortality for patients with SLE were similar between highly experienced hospitals and less experienced hospitals for patients with private medical insurance, but patients without private insurance had much lower risks of mortality if hospitalized at highly experienced hospitals. The benefit of hospitalization at highly experienced hospitals was more consistent across subgroups of patients with a hospitalization due to SLE, suggesting that differences specifically in the treatment of SLE, rather than differences in the general quality of medical care, account for the lower mortality among patients with SLE hospitalized at highly experienced hospitals.     

Intravenous immunoglobulin application following immunoadsorption: benefit or risk in patients with autoimmune diseases?

OBJECTIVE: To evaluate infection rates, side-effects and autoantibody resynthesis after immunoadsorption with and without intravenous immunoglobulin substitution. METHODS: Thirty-five patients with autoimmune diseases who were on long-term immunoadsorption therapy participated in a prospective, randomized study. Results and conclusions. Infections were rare but similar in frequency in patients receiving combined immunoadsorption and intravenous immunoglobulins (intervention group, n=17, 1.3 infections per patient-year) and in a control group (n=18, 0.9 infections per patient-year) treated by immunoadsorption alone. The reduction in IgG achieved with two immunoadsorptions within 3 days was 95.0+/-2.5%. The extent of removal of pathogenic autoantibodies was similar to the removal of IGG: Substitution of immunoglobulins was not associated with an increased circulating IgG level before the following immunoadsorption. Infusion of immunoglobulins at a dose of 0.14 g/kg (interquartile range 0.12-0.16) body weight in patients in whom circulating immunoglobulins had been depleted was associated with a high incidence of serious side-effects; these necessitated the termination of treatment in 24% of the patients. No evidence was found that immunoglobulin administration had any beneficial effect with respect to autoantibody resynthesis after immunoadsorption.     

Thrombosis prophylaxis in hospitalised medical patients: does prophylaxis in all patients make sense?

BACKGROUND: Most studies on thrombosis prophylaxis focus on postoperative venous thrombosis. In medical wards thrombosis prophylaxis is generally restricted to patients who are immobilised. Our primary aim was to investigate the incidence of venous thrombosis in a general internal ward, to assess whether more rigorous prophylaxis would be feasible. METHODS: We investigated the incidence of venous thrombosis in patients hospitalised from 1992 to 1996 and related our findings to literature reports. RESULTS: The incidence of symptomatic venous thrombosis in internal patients during hospitalisation was 39/6332 (0.6%). Among these 39 patients, 24 had a malignancy, whereas 876 out of all 6332 patients had a known malignancy. So, the incidence in this group with cancer was 2.7% compared with 0.3% (15/5456) in the non-cancer group (relative risk for venous thrombosis due to malignancy was 10.0 (95%C.I. 5.3-18.9). CONCLUSION: The incidence of venous thrombosis during hospitalisation in a department of general internal medicine is low and does not justify prophylaxis in all internal patients. Cancer is a strong risk factor for hospital-acquired thrombosis in the medical ward. Further studies may answer the question as to whether thrombosis prophylaxis in this subgroup is feasible.     

Is there benefit in referring patients with fibromyalgia to a specialist clinic?

OBJECTIVE: To examine the benefit of specialist rheumatology consultation and followup for the first 238 patients referred to a tertiary care fibromyalgia (FM) clinic with emphasis on final diagnosis and outcome. METHODS: A retrospective chart review was performed for the first 238 patients attending a rheumatology subspecialty FM clinic. The main variables of interest were management received at the clinic, final diagnosis, and outcome. RESULTS: The final diagnosis was FM in 68%, and some other condition in the remaining 32%. Specialist contact was identified as useful in 73% of the total patient group, 96 with FM and 74 with non-FM. In the patients with FM who received followup in the clinic, outcome was judged favorable in 54%, whereas 46% showed no change or decline in health status. CONCLUSION: An important value of specialist rheumatology contact for patients with a symptom suggestive of diffuse musculoskeletal pain is to ensure that some other potentially treatable condition is not overlooked, rather than the provision of ongoing care for those with FM. Continued followup in a specialist clinic for patients with a primary diagnosis of FM is of questionable benefit.