Deep Vein Thrombosis and Pulmonary Embolism in Cirrhosis Patients

Background and Aims It is a commonly held notion that patients with cirrhosis do not suffer from deep vein thrombosis (DVT) or pulmonary embolism (PE) because they are naturally anticoagulated. However, to date, no studies have been carried out that objectively address this issue. We conducted a study to examine the relationship between cirrhosis and DVT/PE events. Methods A case–control study of patients seen at a tertiary care hospital was performed. Cases were hospitalized patients with biopsy and/or imaging plus clinical evidence of cirrhosis. Well-matched patients with no known evidence of cirrhosis served as controls. The DVT/PE events were identified by the international classification of disease-9 (ICD-9) codes and confirmed with radiographic/nuclear imaging. The Charlson Index was calculated to determine the comorbidity. The incidence of DVT/PE in cirrhotic patients was also compared to patients with chronic kidney disease (CKD), congestive heart failure (CHF), and solid organ cancers. Results This study consisted of 963 cirrhotics and 12,405 controls. Both the incidence of DVT/PE (1.8 vs. 0.9%, P = 0.007) and Charlson Index scores (3.2 ± 1.8 vs. 0.9 ± 1.5, P < 0.001) were higher in cirrhotics than in the controls. However, in the multivariate analysis, the presence of cirrhosis was not associated with DVT/PE [odds ratio (OR) 0.87, P = 0.06]. Partial thromboplastin time (PTT; OR 0.88, P = 0.04) and serum albumin (OR 0.47, P = 0.03) were the independent predictors of DVT/PE. The incidence of DVT/PE in cirrhotics (1.8%) was lower than that in patients with other medical illnesses: 7.1% in CKD, 7.8% in CHF, and 6.1% in cancers. Conclusion Patients with cirrhosis do not have a lower risk of DVT/PE than non-cirrhotic controls without other significant co-morbidities, such as CHF, CKD, and solid organ cancers. Partial thromboplastin time and serum albumin were found to be independently predictive of DVT/PE in cirrhotic patients.     

风险护理在糖尿病患者下肢深静脉血栓形成中的应用价值分析

目的研究风险护理在糖尿患者下肢深静脉血栓形成中的应用价值。方法根据随机数表法将2018年6月—2019年6月期间该院接收的糖尿病患者110例分为两组,对照组55例实施常规干预,观察组55例予以风险护理。将两组的血糖水平、血液流变学指标、血流速度、下肢深静脉血栓发生率进行比对。结果观察组患者干预后的空腹血糖水平、餐后2 h血糖水平显著低于对照组,干预后的血液流变学指标均优于对照组,股静脉血流速度及血流峰值速度快于对照组,下肢深静脉血栓发生率低于对照组,差异有统计学意义(P<0.05)。结论对糖尿病患者实施风险护理可提高血糖控制效果,改善血流速度,可有效预防下肢深静脉血栓形成,临床应用价值高。     

Genetic Risk Factors for Deep Vein Thrombosis among Japanese: Importance of Protein S K196E Mutation

There is mounting evidence that mutations associated with a given disease arise with different frequencies among ethnic groups, thus ethnicity-specific studies are needed to identify causative mutations and properly assess risk. In particular, ethnic differences in the genetic background of thrombophilia have been reported. We recently conducted a large-scale analysis of the plasma activities of proteins C, S, antithrombin, and plasminogen within the Japanese general population. We found age- and sex-related differences and estimated the prevalence of deficiencies of protein C (0.13%), antithrombin (0.15%), protein S (1.12%), and plasminogen (4.29%). We also evaluated the genetic contribution to deep vein thrombosis and found that protein S mutation K196E is a genetic risk factor in the Japanese population. We estimated allele frequency to be 0.009, suggesting that 1 of 12,000 Japanese may be homozygous for the E allele, thus possibly as many as 10,000 individuals. Accordingly, a substantial proportion of the Japanese population carries the protein S E allele and is at risk of developing deep vein thrombosis. Given the frequency of this mutation and its strong correlation with deep vein thrombosis, it may be valuable to conduct a large-scale screening for this allele and advise concerned persons to avoid environmental risk factors known to be associated with deep vein thrombosis.     

下肢深静脉血栓形成的临床诊断价值及危险因素

在连续２８２例临床拟诊为下肢急性深静脉血栓形成（ＤＶＴ）的有症状患者中，经超声静脉检查证实为ＤＶＴ者仅９７例（３４．４％）．表明临床表现只能提示、而不能可靠诊断ＤＶＴ。年龄（≥５５岁）、恶性肿瘤和近期（３个月内）手术史是ＤＶＴ的危险因素。与对照组相比，有上述各项危险因素的患者，ＤＶＴ检出率均显著增高（Ｐ＜０．０５）。     

A Prospective Study of Adequacy of Anticoagulation with Fixed Dose Weight Adjusted Unfractionated Heparin in Patients with Deep Vein Thrombosis

Weight adjusted fixed dose subcutaneous unfractionated heparin (UFH) is one of the options for the treatment of deep vein thrombosis (DVT), but the degree of its anticoagulant effect has not been tested in India. This was a prospective observational study, conducted at a tertiary care hospital in South India between September 2012 and March 2014. DVT was diagnosed using compression ultrasonography. UFH was given as an initial loading dose of 333 U/kg followed by a maintenance dose of 250 U/kg twice daily subcutaneously. aPTT was done on day 2 and day 4 after 6 h of the morning dose of heparin. Patients were categorized based on aPTT ratios. Fifty five patients treated for proximal lower limb DVT had received UFH. Their median age was 41 years. DVT was secondary to malignancy, immobilisation or pro-coagulant state. No obvious etiology was found in 47 % of the patients. The mean aPTT on day 2 was 41.8 s and 51.7 s on day 4. The aPTT ratio was subtherapeutic in 63.6 % and therapeutic in 32.7 % of the patients on day 2. Five patients had adverse events in the hospital. Three patients died and two other patients had confirmed pulmonary embolism. Death was due to pulmonary embolism in one patient and metastatic malignancies in the other two. No bleeding manifestation had occurred. Caution is required in implementing this UFH regimen as this preliminary investigation has found predominantly subtherapeutic aPTT ratios during the initial phase of anticoagulation.     

Extrahepatic Portal Vein Obstruction and Portal Vein Thrombosis in Special Situations: Need for a New Classification

Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized.     

Per-Capita Medicare Expenditures,Primary Care Access,Mortality Rates,and the Least Healthy Cities in America

Purpose

To determine whether several measures of health care expenditures, access, and outcomes for the 25 recently identified “least healthy cities in America” differed from those in the rest of America.

Trends and Outcomes in the Hospitalization of Older Americans for Cardiac Conduction Disorders or Arrhythmias, 1991–1998

OBJECTIVE: To identify epidemiological trends and measure outcomes in elderly patients hospitalized for cardiac conduction disorders or arrhythmias. DESIGN: Review of the standard 5% samples of the Medicare Provider Analysis and Review Files to characterize 144,512 discharges from 1991 through 1998 in which the principal diagnosis was a conduction disorder or arrhythmia, using the corresponding Enrollment Databases for denominator data. SETTING: Short-stay hospitals in the United States. PARTICIPANTS: Medicare beneficiaries age 65 and older in the standard 5% sample. MEASUREMENTS: Diagnosis-specific trends and rates; discharges by year; cumulative age-, race-, and sex-specific discharge rates; mean length of stay in hospital and in intensive care; mean Medicare reimbursement to the hospital; case-fatality rate in hospital; discharge destinations of patients discharged alive. RESULTS: Annual hospitalizations for sinoatrial node dysfunction, atrial flutter, atrial fibrillation, or ventricular fibrillation increased more rapidly than did the elderly Medicare beneficiary population. Hospitalizations with a principal diagnosis of ventricular extrasystoles or asystole showed steep secular declines. Discharge rates for sinoatrial node dysfunction, a group of rhythms with a nonsinus pacemaker, atrial fibrillation, Mobitz I, or complete atrioventricular block all increased steeply and continuously with patient age. In contrast, discharge rates for atrial flutter or ventricular tachycardia or fibrillation peaked among 75- to 84-year-old patients. White men were at uniquely high risk of hospitalization for atrial flutter or ventricular tachycardia or fibrillation, and, among the white majority, men had higher discharge rates than women for nine of the 11 commonest rubrics. Whites, particularly white women, had the highest discharge rates for atrial fibrillation. Blacks, especially black women, were at disproportionate risk for hospitalization for the group of nonsinus pacemaker rhythms. Diagnosis-specific mean resource costs were strongly correlated with each other and with mean Medicare reimbursement but not with case-fatality rate. CONCLUSION: Medicare claims data demonstrated striking differences among and within diagnoses of heart blocks or arrhythmias in terms of the populations at greatest risk for hospitalization. This variation should be explored further to generate and test hypotheses about differential causation or delivery of care.     

Deep vein thrombosis prophylaxis in hospitalized medical patients: current recommendations, general rates of implementation, and initiatives for improvement

Venous thromboembolism (VTE), which encompasses deep vein thrombosis and pulmonary embolism, is a leading cause of preventable morbidity and mortality following hospitalization. In the last decade, investigators have used randomized controlled trials to assess the efficacy and safety of various methods of VTE prevention for more than 20,000 medical patients. Identifying medical patients at risk for VTE and providing effective prophylaxis is now an important health care priority to reduce the burden of this morbid and sometimes fatal disease. Pharmacologic prophylaxis is the mainstay of VTE prevention. It is effective, safe, and cost effective. Multiple scientific guidelines support VTE prophylaxis in medical patients. Regulatory and accreditation agencies have mandated that hospitals use formalized systems to assess VTE risk and provide clinically appropriate prophylaxis measures to patients at risk.     

Trends in 30-Day Readmission Rates for Medicare and Non-Medicare Patients in the Era of the Affordable Care Act

Background

Temporal changes in the readmission rates for patient groups and conditions that were not directly under the purview of the Hospital Readmissions Reduction Program (HRRP) can help assess whether efforts to lower readmissions extended beyond targeted patients and conditions.

Medicare utilization,screening, and costs among participants in the Southeastern Diabetes Initiative: A population-based evaluation

Aims

Type 2 diabetes mellitus imposes significant burdens on patients and health care systems. Population-level interventions are being implemented to reach large numbers of patients at risk of or diagnosed with diabetes. We describe a population-based evaluation of the Southeastern Diabetes Initiative (SEDI) from the perspective of a payer, the Centers for Medicare & Medicaid Services (CMS). The purpose of this paper is to describe the population-based evaluation approach of the SEDI intervention from a Medicare utilization and cost perspective.