Chronic obstructive pulmonary disease (COPD) is a major contributor to global morbidity and mortality, particularly during acute exacerbations that frequently require intensive care unit (ICU) admissions. Considering the hypercoagulability associated with COPD, which intensifies during acute episodes, prophylactic anticoagulation therapy may help reduce ICU mortality. However, this potential has not been explored specifically in this population of patients.

We conducted a retrospective cohort study using data from the Medical Information Mart for Intensive Care IV, spanning patient records from 2008 to 2019 at the Beth Israel Deaconess Medical Center in Boston. This study focused on critically ill patients with COPD, employing feature selection methods, to identify key variables influencing clinical outcomes. The impact of prophylactic enoxaparin on prognosis was assessed using logistic regression models and Kaplan-Meier survival analysis.

Our analysis included 4,433 critically ill patients with COPD, of whom 446 received enoxaparin within the first 72 h of ICU admission. The primary analysis showed that patients treated with enoxaparin experienced a 48% lower ICU mortality (odds ratio 0.52 [95% confidence interval 0.31-0.86]) than that of those not treated with enoxaparin, with an E-value of 3.26. This association between enoxaparin use and lower ICU mortality persisted across all subgroups examined. Additionally, a visual analysis of patients with varying Oxford acute severity of illness score (OASIS) indicated that early enoxaparin use was linked to an improved prognosis in critically ill patients with COPD who had higher OASIS than in those without.

Early initiation of prophylactic enoxaparin therapy was significantly associated with low ICU mortality in critically ill patients with COPD, especially in high-risk subgroups. These findings support the need for randomized controlled trials to confirm the effectiveness of thromboprophylaxis in this specific patient population and to evaluate the potential bleeding risks.

ObjectivesTo investigate the prevalence, clinical characteristics and risk factors of hospital acquired venous thromboembolism (HA-VTE) in a Chinese Hospital.MethodsRetrospective analysis of patients diagnosed as HA-VTE in a single institution from January 2016 to December 2022 was performed. Patients with VTE prior to admission or within 48 h after admission were excluded. Demographic data of patients was retrieved from the electronic medical database, and parameters affecting the occurrence of HA-VTE were analyzed.Results4,022 patients from 321,997 episodes of medical admissions were diagnosed as VTE. Among these, 952 (23.7%) fulfilled the criteria of HA-VTE, corresponding to an incidence of 0.296%. 76% of patients presented with HA-deep vein thrombosis (DVT) alone, 13% presented with isolated HA-pulmonary embolism (PE), and 11% presented with concomitant HA- DVT and PE. Risk factor analyses showed statistically higher incidence in patients with elder age (67.5 ± 15.5 vs 48.3 ± 17.2 years, p < .001), male gender (0.346% vs 0.262%, p < .001), malignancy (0.513% vs 0.252%, p < .001), trauma (0.659% vs 0.28%, p < .001), emergency admission (0.664% vs 0.186%, p < .001), ICU stay (2.981% vs 0.226%, p < .001), and patients undergoing major surgery (0.702% vs 0.176%, p < .001). Patients with HA-VTE had longer hospital stay (22.5 ± 26.6 vs 7.21 ± 9.23 days, p < .001) and higher mortality rate (8.51% vs 1.01%, p < .001). The crude incidence rate of HA-VTE increased annually from 0.75 per 1,000 patients in 2016 to 5.89 per 1,000 patients in 2022. The subspecialties with the highest incidence rate of HA-VTE were cardiovascular surgery (1.40%), neurosurgery (1.10%), and respiratory medicine (0.72%).ConclusionThis is one of the few large scale studies to show that HA-VTE, accounting for nearly one quarter of all VTE events, occurs in 0.296% of adult hospitalizations. Patients with elder age, malignancy, ICU stay, and undergoing major surgery require more intensive HA-VTE surveillance and prevention.

The optimal risk assessment model (RAM) for venous thromboembolism in hospitalized medical patients remains controversial. This study aimed to assess the prognostic performance of Padua, International Medical Prevention Registry on Venous Thromboembolism (IMPROVE), and National Institute for Health and Care Excellence (NICE) guidelines' RAMs.

A multicenter prospective observational study was conducted in 15 Spanish hospitals, monitoring consecutive medical inpatients for symptomatic venous thromboembolism over a 90-day follow-up period. The discriminative performance was evaluated using time-to-event analyses and competing risk models accounting for nonvenous thromboembolism-related mortality. Sensitivity, specificity, and area under the receiver operating characteristic curve were calculated to assess predictive accuracy.

Among 1273 patients, the 90-day cumulative venous thromboembolism incidence was 1.0%. After adjusting for pharmacological thromboprophylaxis, high-risk patients did not exhibit a significantly increased venous thromboembolism risk compared to low-risk patients according to Padua (aSHR 5.71; 95% confidence intervals [CI] 0.70-46.86), IMPROVE (aSHR 3.72; 95% CI 1.00-13.87), and NICE RAM (aSHR 0.97; 95% CI 0.30-3.18). Padua had the highest sensitivity (92.3% [95% CI, 62.1%-99.6%]) but lowest specificity (32.3% [95% CI, 29.7%-35.0%]), whereas IMPROVE exhibited the highest specificity (52.9% [95% CI, 50.1%-55.7%]) with moderate sensitivity (76.9% [95% CI, 46.0%-93.8%]). Discriminative performance was suboptimal for all RAMs (area under the curve: Padua 62.3%, IMPROVE 64.9%, NICE 50.1%).

Padua, IMPROVE, and NICE RAMs demonstrated poor predictive accuracy in stratifying venous thromboembolism risk among hospitalized medical patients. These findings underscore the need for more precise, dynamic RAMs tailored to real-world clinical settings to enhance thromboprophylaxis and patient outcomes.

During hospitalization, a significant number of patients at risk of thromboembolism do not receive prophylaxis, despite established standards and viable procedures for preventing deep vein thrombosis (DVT). This study aimed to assess the appropriateness of vein thrombosis prophylaxis use among patients admitted to the medical ward of Debre Tabor Comprehensive Specialized Hospital (DTCSH) in Northwest Ethiopia.

An observational follow-up study was conducted in the medical wards of Debre Tabor Comprehensive Specialized Hospital in Northwest Ethiopia to determine whether thromboprophylaxis was appropriately used, based on the Padua risk assessment tool. To identify factors associated with the occurrence of inappropriate thromboprophylaxis use, a binary logistic regression model was used. Statistical significance was considered when the p-value was <0.05, with a 95% confidence interval.

Among the 365 patients in the study, 21.37% received inappropriate thromboprophylaxis, while 78.63% received it correctly. Patients admitted to the ICU [AOR = 4.276, 95% CI: 1.878-16.134; p = 0.000], those who stayed for more than 6 days [AOR =6.192, 95% CI: 2.085-14.391; p = 0.000], and general practitioners [AOR = 1.816, 95% CI: 1.007-3.207; p = 0.048] were more likely to receive inappropriate thrombophylaxis.

The appropriateness of DVT prophylaxis use was suboptimal, especially among the patients treated by general practitioners, those hospitalized in the intensive care unit, and those who stayed for more than a few days in the ward. Using an integrated risk stratification checklist is an effective way to promote the more rational use of DVT prophylaxis.

Recognition of the importance of effective pulmonary embolism treatment and prophylaxis has improved inpatient care in many settings. Recommended drug treatment and prophylaxis of acute pulmonary embolism have changed little over the past 10 years. However, new information has emerged, which when combined with early pharmacology studies of unfractionated heparin and low molecular weight heparin, clearly shows important deficits in current practice that, if remedied, could reduce risk and likely save lives. These involve ensuring improved bioavailability of low molecular weight heparin prophylaxis dosing by abandoning once-daily dosing, adopting weight- or weight-category based dosing, and dosing twice daily or by continuous infusion in critically ill patients. For pulmonary embolism treatment, failure to recognize that presenting patients often have subnormal perfusion resulting in unpredictable bioavailability of subcutaneous anticoagulant has meant undertreatment, and delay in reaching a therapeutic anticoagulant level, assuredly resulting in failure of timely improvement as well as recurrent thromboembolism. Intravenous anticoagulant should be rapidly adopted as first treatment for acute pulmonary embolism until normal hemodynamic values are restored and cutaneous perfusion returns. Treatments under development include clinical investigation of intensive care unit (ICU) patients receiving intravenous low molecular weight heparin prophylaxis, weight-based, targeting an anticoagulant level in anti-Xa units that is both effective and safe. The same would be useful for pulmonary embolism treatment, although return to initial anticoagulation with unfractionated heparin is more easily monitored by activated partial thromboplastin time (aPTT) and is an easy standard of care to adopt. Pulmonary embolism clot removal is being accomplished by suction thrombectomy and catheter-directed lysis, each with its own different procedural characteristics. Whether either confers benefit compared to conscientiously administered intravenous anticoagulation cannot be shown in ongoing studies using subcutaneous treatment in control patients with subnormal perfusion. Factor XI/XIa inhibition is another treatment approach being studied. Another approach to lytic therapy under study, administering an inhibitor of alpha-2-antiplasmin, may cause less bleeding than tissue plasminogen activators.

Venous thromboembolism (VTE) is a recognized complication of acutely ill patients, but its incidence and risk factors in those with cirrhosis are uncertain.

We retrospectively studied a consecutive cohort of cirrhosis patients non-electively admitted to our medical unit to determine the rates of symptomatic VTE during hospitalization. Firstly, we explored associations with baseline, clinical and laboratory characteristics using logistic regression. Secondly, we developed a clinical prediction model that could predict the risk of in-hospital VTE.

We included 687 patients (median age 61 years old; 68% male; Child-Pugh A/B/C, 13%/40%/47%). During hospitalization, 34 patients (4.9%) experienced VTE. Multivariate analysis showed that male sex (OR: 2.56, p = 0.05), AKI (OR: 3.1, p = 0.001), bacterial infections (OR: 2.6, p = 0.008), Pugh score (OR: 1.6. p < 0.001), family history of thrombosis (OR: 3.1, p = 0.04), reduced mobility (OR: 4.6, p < 0.001), and C-reactive protein (OR: 1.1, p = 0.005) were independent predictors of VTE. We combined these variables in a prediction model (CirrhosisThrombosisModel) that accurately discriminated between high- and low-risk patients. The AUROC of CiThroModel was significantly higher than that of Padua prediction score (0.882 vs. 0.742). After validating the CiThroModel using bootstrapping, the adjusted model maintained optimal discrimination ability (0.862) and calibration. The adjusted formula to calculate the in-hospital risk of VTE was -9.00 + 0.82 [Male sex] + 1.14 [AKI] + 0.98 [Infection] + 0.48 * Child Pugh score + 1.14 [VTE family history] + 1.54 [Reduced mobility] + 0.15 * PCR/10.

The CiThroModel seems a valuable tool for identifying hospitalized patients with cirrhosis at risk of VTE (https://majinzin.shinyapps.io/vterisk/).

Same-day emergency care (SDEC) is an expanding area of hospital acute medical care. It aims to minimize delays and manage medical emergency patients within the same day, enabling hospitalization to be avoided; the expectation is that the patients would have required inpatient hospitalization in the absence of the SDEC service. Venous thromboembolism (VTE) prevention is a key medical inpatient safety measure. Whether VTE prevention should be considered for SDEC patients is unknown.

To examine the incidence and predictors of VTE diagnosed within 90 days of SDEC assessment.

Data were obtained from electronic health records of people who received SDEC at our hospital during a 5-year period (April 2016 to March 2021).

There were 40 045 attendance episodes by 33 715 individuals. Median age was 60 years (IQR, 41.0-76.0 years), and 55.2% were women. Three hundred forty-nine patients (0.9%) developed a VTE within 90 days of SDEC. Increased risk of VTE was associated with age more than 60 years, prior malignancy (adjusted odds ratio [OR], 4.12; 95% CI, 3.19-5.32; P < .0001), history of diseases of the circulatory system (adjusted OR, 2.92; 95% CI, 2.27-3.76; P < .0001), and having 1 or more additional SDEC attendances within 30 days (adjusted OR, 4.61; 95% CI, 3.65-5.82; P < .0001). In the 90 days prior to VTE diagnosis, 36.6% of patients had a separate inpatient admission in addition to SDEC. There was no association with completion of an electronic VTE risk assessment (adjusted OR, 0.96; 95% CI, 0.76-1.20).

The incidence of VTE following SDEC is similar to that reported for symptomatic VTE in traditional medical inpatients without thromboprophylaxis.

Patients hospitalized in Internal Medicine Units (IMUs) may frequently experience both an increased risk for thrombosis and bleeding. The use of risk assessment models (RAMs) could aid their management. We present a post-hoc analysis of the FADOI-NoTEVole study, an observational, retrospective, multi-center study conducted in 38 Italian IMUs. The primary aim of the study was to evaluate the predictors associated with the prescription of thromboprophylaxis during hospitalization. The secondary objective was to evaluate RAMs adherence. Univariate analyses were conducted as preliminary evaluations of the variables associated with prescribing pharmacological thromboprophylaxis during hospital stay. The final multivariable logistic model was obtained by a stepwise selection method, using 0.05 as the significance level for entering an effect into the model. Thromboprophylaxis was then correlated with the RAMs and the number of predictors found in the multivariate analysis. Thromboprophylaxis was prescribed to 927 out of 1387 (66.8%) patients with a Padua Prediction score (PPS) ≥ 4. Remarkably, 397 in 1230 (32.3%) patients with both PPS ≥ 4 and an IMPROVE bleeding risk score (IBS) < 7 did not receive it. The prescription of thromboprophylaxis mostly correlated with reduced mobility (OR 2.31; 95% CI 1.90-2.81), ischemic stroke (OR 2.38; 95% CI 1.34-2.91), history of previous thrombosis (OR 2.46; 95% CI 1.49-4.07), and the presence of a central venous catheter (OR 3.00; 95% CI 1.99-4.54). The bleeding risk assessment using the IBS did not appear to impact physicians' decisions. Our analysis provides insight into how indications for thromboprophylaxis were determined, highlighting the difficulties faced by physicians with patients admitted to IMUs.

The study's main aim was to determine the prevalence of elevated D-dimer levels in adult patients hospitalized for acute medical illnesses not suspected to have venous thromboembolism (VTE). The secondary aims were to determine VTE prophylaxis rates and VTE events.

This multicenter, prospective, observational study included patients who were admitted across nine US hospitals. Patients who were ≥60 years of age, admitted for an acute medical illness (nonsurgical/nontraumatic), and not suspected to have VTE (deep vein thrombosis [DVT]/pulmonary embolism [PE]) were enrolled. Current use of anticoagulation and recent major surgery were exclusion criteria. D-dimers were measured at hospital admission, and the analysis was performed at a central laboratory using the STA-Liatest D-Di test kit (Diagnostica Stago, Asnières sur Seine, France). The upper limit of normal (ULN) for D-dimer was defined as ≥500 ng/mL. Age-adjusted thresholds were calculated as age × 10 ng/mL. VTE events included symptomatic DVT (distal or proximal) or PE occurring during admission.

Among 995 patients (50.7% female; mean age, 70 ± 8 years), 74.4% (n = 740) had a D-dimer ≥ ULN, 62.2% (n = 619) had elevated age-adjusted levels, and 48.8% (n = 486) had D-dimers at least two times the ULN. The rate of VTE prophylaxis was 66.5% (n = 662); in this cohort, 1.8% (n = 18) developed a VTE.

Most hospitalized acute medically ill patients ≥60 years of age had elevated D-dimer levels on admission. Although an elevated D-dimer may be associated with VTE risk, its poor specificity indicates that it should not guide prophylaxis management without a multifactor risk assessment.

Inpatients with high risk of venous thromboembolism (VTE) usually face serious threats to their health and economic conditions. Many studies using machine learning (ML) models to predict VTE risk overlook the impact of class-imbalance problem due to the low incidence rate of VTE, resulting in inferior and unstable model performance, which hinders their ability to replace the Padua model, a widely used linear weighted model in clinic. Our study aims to develop a new VTE risk assessment model suitable for Chinese medical inpatients.

3284 inpatients in the medical department of Peking Union Medical College Hospital (PUMCH) from January 2014 to June 2016 were collected. The training and test set were divided based on the admission time and inpatients from May 2016 to June 2016 were included as the test dataset. We explained the class imbalance problem from a clinical perspective and defined a new term, "fuzzy population", to elaborate and model this phenomenon. By considering the "fuzzy population", a new ML VTE risk assessment model was built through population splitting. Sensitivity and specificity of our method was compared with five ML models (support vector machine (SVM), random forest (RF), gradient boosting decision tree (GBDT), logistic regression (LR), and XGBoost) and the Padua model.

The 'fuzzy population' phenomenon was explained and verified on the VTE dataset. The proposed model achieved higher specificity (64.94% vs. 63.30%) and the same sensitivity (90.24% vs. 90.24%) on test data than the Padua model. Other five ML models couldn't simultaneously surpass the Padua's sensitivity and specificity. Besides, our model was more robust than five ML models and its standard deviations of sensitivities and specificities were smaller. Adjusting the distribution of negative samples in the training set based on the 'fuzzy population' would exacerbate the instability of performance of five ML models, which limited the application of ML methods in clinic.

The proposed model achieved higher sensitivity and specificity than the Padua model, and better robustness than traditional ML models. This study built a population-split-based ML model of VTE by modeling the class-imbalance problem and it can be applied more broadly in risk assessment of other diseases.

The Spanish Society of Medical Oncology (SEOM) last published clinical guidelines on venous thromboembolism (VTE) and cancer in 2019, with a partial update in 2020. In this new update to the guidelines, SEOM seeks to incorporate recent evidence, based on a critical review of the literature, to provide practical current recommendations for the prophylactic and therapeutic management of VTE in patients with cancer. Special clinical situations whose management and/or choice of currently recommended therapeutic options (low-molecular-weight heparins [LMWHs] or direct-acting oral anticoagulants [DOACs]) is controversial are included.

Randomized controlled trials suggest that prophylactic doses of anticoagulants effectively prevent venous thromboembolism (VTE) in hospitalized medical patients with high thromboembolic risk. However, no prospective studies exist regarding the real-world prevalence of prophylactic anticoagulant use. This prospective study aimed to determine the rate and predictors of thromboprophylaxis in an unselected population of patients hospitalized in medical departments.

We conducted a multicenter prospective observational study (AURELIO - rAte of venous thrombosis in acutely iLl patIents hOspitalized) to assess the rate of deep vein thrombosis (DVT) in unselected acutely ill patients hospitalized in medical wards using compression ultrasound (CUS) at admission and discharge. Additionally, we evaluated the rate of pharmacological thromboprophylaxis administration in this population and analyzed the thrombotic risk by assessing RAMs (Risk Assessment Models) such as the IMPROVE-VTE and PADUA scores following the clinician's decision to administer thromboprophylaxis. Patients with IMPROVE-VTE scores ≥3 and/or PADUA scores ≥4 were classified as high thrombotic risk; those with IMPROVE-VTE scores <3 and/or PADUA scores <4 were classified as low risk.

We recruited 2371 patients (1233 males [52 %] and 1138 females [48 %]; mean age 72 ± 16 years). The median length of hospitalization was 13 ± 12 days. Overall, 442/2371 (18.6 %) patients received prophylactic parenteral anticoagulants (subcutaneous low weight molecular heparin or fondaparinux once daily) at admission. Assessing the thrombotic risk of the population recruited 1016 (42.9 %) patients were classified as high risk and 1354 (57.1 %) were low risk. Among high-risk patients, 339/1016 (33.4 %) received anticoagulant prophylaxis compared to 103/1354 (7.6 %) low-risk patients. During hospitalization, 9 patients developed DVT, comprising 7 asymptomatic and 2 symptomatic cases of proximal DVT. Of these, 3 patients were on anticoagulant prophylaxis, while 6 were not. Among the high-risk population, 7 out of 1016 patients (0.7 %) experienced proximal DVT during hospitalization, with 2 out of these 7 (28 %) receiving anticoagulant thromboprophylaxis. In the low-risk population, 2 out of 1354 patients (0.2 %) developed DVT, with 1 out of these 2 (50 %) receiving anticoagulant thromboprophylaxis. Age, heart or respiratory failure, pneumonia, active neoplasia, previous VTE, reduced mobility, and absence of kidney failure were more frequent in patients receiving prophylaxis. Multivariable logistic regression identified age (RR 1.010; CI 95 % 1002-1019; p = 0.015), heart/respiratory failure (RR 1.609; CI 95 % 1248-2075; p < 0.0001), active neoplasia (RR 2.041; CI 95 % 1222-2141; p < 0.0001), pneumonia (RR 1.618; CI 95 % 1557-2676; p < 0.0001), previous VTE (RR 1.954; CI 95 % 1222-3125; p < 0.0001), and reduced mobility (RR 4.674; CI 95 % 3700-5905; p < 0.0001) as independent predictors of thromboprophylaxis.

This study, conducted without pre-established thromboembolic risk scores, offers a comprehensive view of venous thromboembolism prophylaxis in medical patients with acute conditions hospitalized in internal medicine departments. It reveals that advanced age, heart or respiratory failure, active cancer, pneumonia, previous VTE, and reduced mobility are predictors that may influence the decision to administer thromboprophylaxis in these patients.

Clinical guidelines for postpartum thromboprophylaxis differ due to its uncertain effect and varying preferences of experts. Women's preferences for postpartum thromboprophylaxis are unknown, although they may inform practices and future research.

Our aim was to elicit the pregnant women's preferences for postpartum thromboprophylaxis according to different risks of venous thromboembolism (VTE) and bleeding.

In 2 Swiss and French maternity hospitals, we conducted structured interviews of pregnant or postpartum women. Participants were instructed on pulmonary embolism, deep vein thrombosis, postpartum hemorrhage, and subcutaneous injections of low-molecular-weight heparin (LMWH). First, we randomized women to either standard gamble or time trade-off (2 different validated methods) to estimate the utilities (quality of life, from 0 to 1) of these health states. Second, we elicited the preference for the use of short-term postpartum thromboprophylaxis with LMWH vs none across different risks of postpartum VTE and bleeding through direct-choice exercises.

Among 122 participants, median (IQR) health state utilities were 0.725 (0.30-0.925) for pulmonary embolism, 0.75 (0.40-0.97) for postpartum hemorrhage, 0.85 (0.60-0.97) for deep vein thrombosis, and 0.96 (0.96-0.999) for LMWH injections. The median risk of postpartum VTE for preference of the use of postpartum thromboprophylaxis over no treatment was 0.1% (IQR, 0.01%-0.50%) without LMWH-associated bleeding risk and 0.2% (IQR, 0.1%-5%) with a 1% bleeding risk.

European pregnant women appear to have a high willingness for 10-day postpartum thromboprophylaxis, preferred over no treatment even for low risks of postpartum VTE. This perspective from patients supports the urgent need for a randomized trial evaluating the efficacy and safety of postpartum thromboprophylaxis.

Guidelines recommend pharmacological venous thromboembolism (VTE) prophylaxis only for high-risk patients, but the probability of VTE considered "high-risk" is not specified. Our objective was to define an appropriate probability threshold (or range) for VTE risk stratification and corresponding prophylaxis in medical inpatients.

Patients were adults admitted to any of 10 Cleveland Clinic Health System hospitals between December 2020 and August 2021 (N = 41,036). Hospital medicine physicians and internal medicine residents from included hospitals were surveyed between June and November 2023 (N = 214). We compared five approaches to determining a threshold: decision analysis, maximizing the sensitivity and specificity of a logistic regression model, deriving a probability from a point-based model, surveying physicians' understanding of VTE risk, and deriving a probability from physician behavior. For each approach, we determined the probability threshold above which a patient would be considered high-risk for VTE. We applied each threshold to the Cleveland Clinic VTE risk assessment model (CCM) and calculated the percentage of the 41,036 patients in our cohort who would be considered eligible for prophylaxis due to their high-risk status. We compared these hypothetical prophylaxis rates with physicians' observed prophylaxis rates.

The different approaches yielded thresholds ranging from 0.3% to 5.4%, corresponding inversely with hypothetical prophylaxis rates of 0.2% to 75%. Multiple thresholds clustered between 0.52% to 0.55%, suggesting an average hypothetical prophylaxis rate of approximately 30%, whereas physicians' observed prophylaxis rates ranged from 48% to 76%.

Multiple approaches to determining a probability threshold for VTE prophylaxis converged to suggest an optimal threshold of approximately 0.5%. Other approaches yielded extreme thresholds that are unrealistic for clinical practice. Physicians prescribed prophylaxis much more frequently than the suggested rate of 30%, indicating opportunity to reduce unnecessary prophylaxis. To aid in these efforts, guidelines should explicitly quantify high-risk.

Upper extremity deep vein thrombosis (UEDVT) is associated with pulmonary embolism and other complications, but there are no recommendations for UEDVT prophylaxis. The purpose of this study was to establish incidence and risk factors for UEDVT and to determine efficacy of pharmacologic prophylaxis for UEDVT prevention.

For this retrospective cohort study, we identified medical patients aged 18 years and older admitted to 13 Cleveland Clinic hospitals from January 2011 to December 2019. Patients with venous thromboembolism (VTE) on admission, length of stay <1 day, and who received therapeutic anticoagulation were excluded. The potential risk factors included demographics, comorbidities, and medical procedures. Comorbidities were identified via International Classification of Diseases codes, (ICD9 and ICD10), procedures from flowsheets, and prophylaxis from medications administered in the electronic medical record. DVT events were identified by a combination of International Classification of Diseases codes and confirmed by chart review. We performed multivariable logistic regression to identify independent risk factors and the association between VTE prophylaxis and UEDVT. The model's C statistic was obtained using 1000 bootstrap runs.

Of 194,809 patients, 496 (0.25% of cohort, 36.8% of all VTE) developed UEDVT by 14 days. In the logistic regression model (bias-corrected C statistic 0.87), 11 risk factors predicted UEDVT, the strongest being peripherally inserted central catheter (odds ratio [OR] 4.62, 95% confidence interval [CI] 3.81-5.60) and central venous catheter (OR 3.57, 95% CI 2.91-4.37). The predicted risk among individuals ranged from 0.02% to 23.4%. Prophylaxis was negatively associated with the development of UEDVT (OR 0.72, 95% CI 0.60-0.87).

UEDVT is rare but some patients are high risk. Therefore, UEDVT risk factors should be added to VTE risk assessment models, and patients at high risk for UEDVT should receive chemoprophylaxis.

Dysregulated hemostasis in cancer patients is associated with various clinical conditions, from thromboembolic complications to disseminated intravascular coagulation. Despite the well-established association between cancer and thromboembolic complications, the mechanisms involved are not completely elucidated. There are several predisposing factors in cancer for increased thrombus generation, such as immobilization and chemotherapy. The term cancer-associated thrombosis (CAT) has been introduced to describe the close bidirectional relationship between cancer and thromboembolic events. Conventional coagulation tests (PT/aPTT) are more accurate in detecting a hypocoagulable rather than a hypercoagulable state; thus, their contribution to CAT management is limited. Traditionally, D-dimer levels have been the most common laboratory study for the evaluation of thrombotic risk. However, D-dimer levels only display a snapshot of the coagulation cascade, and they cannot provide a dynamic evaluation of evolving clot formation. Non-conventional assays, such as viscoelastic methods and microparticle formation are promising tools for the identification of patients at risk for developing CAT. Recent guidelines from the American Society of Clinical Oncology counsel against the estimation of thrombotic risk through a single test and recommend the use of scoring systems that take into account several risk factors. The present review outlines the current insights into the pathophysiological mechanisms of CAT and provides a comprehensive review of the latest advances in the laboratory assessment of CAT and the recent guidelines for the management of patients at risk for developing thromboembolic complications.

Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking.

To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs.

This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included.

At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM.

Symptomatic VTE within 90 days.

Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score.

This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Low molecular weight heparin has proven to be safe and effective but is not without potential risks such as spontaneous bleeding in the abdominal cavity. There is limited evidence evaluating the true incidence of this potential risk and the available literature is primarily via case reports.

The purpose of this study was to identify the incidence and risk factors associated with enoxaparin use (prophylaxis or treatment) abdominal hematomas in a 350-bed community hospital during an 8-month time period. A total of 44 patients were identified as clinically significant bleeds receiving enoxaparin treatment or prophylactic therapy. Ultimately, 25 patients were excluded from the analysis due to an external cause of the abdominal hematoma or a temporal mismatch in enoxaparin administration and hematoma formation. After exclusion, there were a total of 19 patients that were assessed for the risk factors such as age, gender, renal function, and weight. After evaluation of risks, over half of the patients developing a clinically significant bleed were considered elderly (>65 years of age) and impaired renal function with a creatinine clearance of 60ml/min or less.

Patients at risk for an enoxaparin associated hematoma include female patients with a CrCl <60ml/min and/or BMI >30 kg/m2 receiving enoxaparin treatment dosing.

Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs.

We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research.

We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.

NHS hospitals, with primary data collection at four sites.

Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions.

Prophylaxis for all patients, none and according to selected risk assessment models.

Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models.

We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%.

Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias.

Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research.

Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation.

This study is registered as PROSPERO CRD42020165778 and Researchregistry5216.

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.

Recently, it has been reported that there is a great diversity in strategies used for thromboprophylaxis in patients with Cushing's syndrome (CS). An aim of this review was to discuss these practices in light of the existing data on the thrombotic risk in patients with CS and guidelines for medically ill patients.

The four relevant topics and questions on thrombotic risk in CS were identified. The current guidelines on prevention and diagnosis of venous thromboembolism (VTE) were reviewed for the answers. An algorithm to consider in the assessment of the thrombotic risk in patients with CS was proposed.

To address both generic and CS-specific risk factors for VTE, the algorithm includes the stepwise approach consisting of Padua Score, urine free cortisol, and CS-VTE score, with no indication for routine thrombophilia testing in the prediction of an index VTE episode. Having confirmed VTE, selected patients require thrombophilia testing to aid the duration of anticoagulant treatment. The separate part of the algorithm is devoted to patients with ectopic adrenocorticotropic hormone syndrome in whom exclusion of VTE precedes introducing routine thromboprophylaxis to prevent VTE. The cancer-related VTE also prompts thromboprophylaxis, with the possible vessel invasion. The algorithm presents a unifactorial and multifactorial approach to exclude high-bleeding risks and safely introduce thromboprophylaxis with low-molecular-weight heparin.

Our article is the first to present an algorithm to consider in the thrombotic risk assessment among patients with Cushing's syndrome as a starting point for a broader discussion in the environment. A plethora of factors affect the VTE risk in patients with CS, but no studies have conclusively evaluated the best thromboprophylaxis strategy so far. Future studies are needed to set standards of care.

Inflammatory bowel disease (IBD) patients are three times more likely to develop venous thromboembolism (VTE), and guidelines recommend prophylaxis during all hospitalizations. In this systematic review, we sought to assess for the benefits and risks of VTE prophylaxis in hospitalized IBD patients.

We performed a systematic review and meta-analysis. We searched MEDLINE and others up to 2/2022, for studies on IBD inpatients treated with prophylactic anticoagulation during hospitalization, compared to no prophylaxis. Primary efficacy and safety outcomes were any VTE and major bleeding, respectively. Results were pooled using random-effects models, calculating odds ratios (OR), and 95% confidence intervals (CI). The ROBINS-I tool was used to assess bias.

We extracted data from 18 observational studies and 2 randomized-trial subgroups. The studies were highly variable regarding the included populations, interventions, and outcome definitions. Meta-analysis of all studies showed a nonsignificant effect of prophylaxis on VTEs (OR: 0.97 [95% CI: 0.49-1.95]). An analysis of eight lower-risk-of-bias studies showed a significant reduction in VTEs (OR: 0.27 [95% CI: 0.13-0.55], number needed to treat (NNT) 34.8 [95% CI: 26.8-49.8]). A significant protective effect persisted in several subgroups. Major bleeding was reported in three studies and showed a significant increase with prophylaxis (OR: 2.02 [95% CI: 1.11-3.67], number needed to harm (NNH) 113.6 [95% CI: 40.7-very-large-number]).

In studies with lower-risk-of-bias, a significant reduction in VTEs was shown in patients treated with VTE prophylaxis (NNT = 35), which should be carefully considered against an increased major-bleeding risk (NNH = 114). However, current data are limited and randomized trials dedicated to IBD inpatients would aid in understating whether universal prophylaxis should be recommended.

We aimed to describe the event rates and risk-factors for symptomatic venous thromboembolism (VTE) and major bleeding in a population of hospitalized acutely ill medical patients.

Patients ≥40 years old and hospitalized for acute medical illness who initiated enoxaparin prophylaxis were selected from the US Optum research database. Rates of symptomatic VTE and major bleeding at 90-days were estimated via the Kaplan-Meier (KM) method. Risk factors were identified via the Cox proportional hazards model.

A total of 123,022 patients met the selection criteria. The KM rates of VTE and major bleeding at 90-days were 3.5 % and 2.2 %, respectively. Among subgroups, the risk of VTE varied from 3.0 % in patients with ischemic stroke to 6.9 % in patients with a cancer-related hospitalization, and the risk of major bleeding varied from 1.9 % in patients with inflammatory conditions to 3.6 % in patients with ischemic stroke. Key risk factors for VTE were prior VTE (HR=4.15, 95 % confidence interval [CI] 3.80-4.53), cancer-related hospitalization (HR=2.35, 95 % CI 2.10-2.64), and thrombophilia (HR=1.64, 95 % CI 1.29-2.08). Key risk factors for major bleeding were history of major bleeding (HR=2.17, 95 % CI 1.72-2.74), history of non-major bleeding (HR=2.46, 95 % CI 2.24-2.70), and hospitalization for ischemic stroke (2.42, 95 % CI 2.11-2.78).

There is substantial heterogeneity in the event rates for VTE and major bleeding in acute medically ill patients. History of VTE and cancer related hospitalization represent profiles with a high risk of VTE, where continued VTE prophylaxis may be warranted.

To investigate pulmonary thromboembolism (PE) in acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) patients in plateau regions, we performed a prospective cohort study to evaluate the prevalence, risk factors and clinical characteristics of PE in the cohort of hospitalized patients at high altitude.

We did a prospective study with a total of 636 AE-COPD patients in plateau regions. Demographic and clinical data, laboratory data, including ultrasound scans of the lower extremities and cardiac ultrasound, and computed tomographic pulmonary angiography (CTPA) variables were obtained, and comparisons were made between groups with and without PE. We also conducted logistic regression to explore the risk factors of PE.

Of the 636 patients hospitalized with AE-COPD (age 67.0 ± 10.7 years, 445[70.0%] male), 188 patients developed PE (29.6% [95% CI: 26.0%, 33.1%]). Multivariable logistic regression showed that ethnic minorities, D-dimer > 1 mg/L, AST > 40 U/L, chest pain, cardiac insufficiency or respiratory failure, Padua score > 3, and DVT were associated with a higher probability of PE.

The prevalence of PE is high and those with a higher Padua score, the occurrence of deep venous thrombosis, higher neutrophil count, chest pain, cardiac insufficiency or respiratory failure, higher levels of AST, and a higher level of D-dimer had a higher risk of PE. The analysis of AE-COPD may help to provide more accurate screening for PE and improve clinical outcomes of patients with AE-COPD in plateau regions.

To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission.

Decision analysis modelling study.

NHS hospitals in England.

Eligible adult medical inpatients, excluding patients in critical care and pregnant women.

Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts.

Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival.

Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% v base case sensitivity 49.3% and specificity 73.0%).

Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.

Venous thromboembolism (VTE) is considered a preventable cause of mortality. The evidence for the benefit of VTE prophylaxis in acute medical patients is non-conclusive. Meta-analysis of RCTs failed to demonstrate reduction of all-cause mortality, while showing higher risk of bleeding. The Israeli Ministry of Health has instructed to assess all acute medical patients for the risk for VTE using the Padua Prediction Score, without mandating prophylaxis.

To evaluate the effect of filling the Padua score on clinical outcomes and VTE prophylaxis rates.

Retrospective Study was performed in Israel during the years 2014-2017. The participants were divided to Padua compliance vs non-compliance group. Primary outcome: 30-day mortality. Secondary outcomes: 90-day incidence of VTE and suspected major bleeding. A propensity-weighted logistic multiple regression was performed.

18,890 patients were included in the study. The fulfillment of the Padua score was associated with an increased use of VTE prophylaxis, OR 1.66 (95% CI 1.49-1.84). However, there was no reduction of mortality or VTE events, OR 1.13 (95% CI 0.97-1.31) and OR 1.22 (95% CI 0.79-1.8) respectively. Hospitalizations related to hemoglobin decrease were not statistically different between the two groups.

Padua score for the assessment of VTE risk in medical wards was associated with higher administration of pharmacological prophylaxis without reduction in VTE or mortality rate. Its usage should be reassessed as a performance measure.

Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.

COVID-19 is associated with an increased risk for thrombotic complications. The trials investigating the optimal thromboprophylactic dose are performed in challenging times and seemingly produce conflicting evidence. The burdensome circumstances, divergent endpoints, and different analytical approaches hamper comparison and extrapolation of available evidence. Most importantly, clinicians should provide thromboprophylaxis in hospitalized COVID-19 patients while (re)assessing bleeding and thrombotic risk frequently. The COVID-19 Thromboprophylaxis Working Group of the BSTH updated its guidance document. It aims to summarize the available evidence critically and to guide clinicians in providing the best possible thromboprophylaxis.

Chronic obstructive pulmonary disease (COPD) is a frequent and devastating chronic respiratory disease. COPD is ranked among the top five causes of death worldwide. Patients with COPD suffer from persistent dyspnea, with periods of acute worsening, called exacerbations. Such exacerbations may be severe. In fact, one-third of COPD patients will be hospitalized because of an exacerbation. Hospitalization due to respiratory failure has been identified as a powerful predisposing risk factor for venous thromboembolism (VTE) for many years. Therefore, COPD is recognized as a moderate risk factor for VTE, with an odds ratio between 2 and 9, similar to other risk factors such as estrogen-containing contraceptives or (any) cancer. However, unlike other risk factors such as contraception, the presence of COPD can modify the initial presentation of VTE and worsen the short-term prognosis of patients who have acute pulmonary embolism (PE), particularly during a COPD exacerbation. It is not only that both stable COPD and acute exacerbations of COPD might increase the risk of VTE, but PE itself may mimic the symptoms of a COPD exacerbation. Hence, some authors have evaluated the prevalence of PE among COPD patients with acute worsening. This clinical review (1) gives an update on epidemiological data, clinical presentation, and prognosis of PE associated with COPD; (2) presents the results of the Prevalence de l'Embolie Pulmonaire chez les patients admis pour exacerbation de BPCO study, which aimed at determining the frequency of PE in COPD patients hospitalized for an acute exacerbation; (3) discusses the results of the Significance of Pulmonary Embolism in COPD Exacerbations study, the first randomized trial having compared the efficacy of a systematic search for PE versus routine care on admission for a COPD exacerbation; and (4) provides a selection of remaining unmet needs on the association between COPD and PE.

Early enoxaparin 30 mg BID administration at 24 h post-injury has been demonstrated in patients with traumatic brain injury (TBI). However this dose can also yield subtherapeutic anti-Xa levels in 30-50% of trauma patients, suggesting that larger doses may be required for adequate prophylaxis against venous thromboembolism (VTE). The safety of enoxaparin 40 mg BID in trauma patients has previously been shown - however, these studies have largely excluded TBI patients. Therefore, we sought to demonstrate the safety of early enoxaparin 40 mg BID in a low-risk group of TBI patients.

A retrospective review of TBI patients at a Level 1 trauma center was performed. Patients with stable computed tomography (CT) of the head at 6 to 24 h post-injury who received enoxaparin 40 mg BID were included and serial GCS evaluations to identify possible clinical complications. To evaluate the safety of this dosing regimen, data was then compared to patients from our institution with similar TBI profiles who had received 5,000 units (U) of subcutaneous heparin (SQH) prophylaxis.

199 TBI patients were identified over a nine month period, 40/199 (19.7%) received DVT prophylaxis after traumatic injury. Of these 40, 19 (47.5%) received enoxaparin 40 mg BID and 21 (52.5%) received 5,000U of SQH. Low risk TBI patients who were either given enoxaparin (n = 7) or SQH (n = 4), demonstrated no clinical decline in mental status during their inpatient stay.

Prior studies have demonstrated that enoxaparin 40 mg BID dosing is superior to traditional VTE prophylaxis in trauma patients. However, TBI patients are often excluded from this dosing due to concern for progression. Our study showed no clinical decline in mental status in a small cohort of low-risk TBI patients who received enoxaparin 40 mg BID.

Underweight patients may be at an increased risk of bleeding while receiving venous thromboembolism (VTE) prophylaxis. Additional evidence is needed to identify patient-specific factors associated with bleeding. The objective of the study was to describe the incidence and identify risk factors associated with bleeding in low-weight (⩽ 60 kg) adult patients receiving subcutaneous unfractionated heparin (SQH) for VTE prophylaxis.

This was a single-center, retrospective, nested case-control study of low-weight patients receiving SQH for VTE prophylaxis for ⩾ 48 hours. Cases, patients with clinically relevant bleeding while receiving SQH, and controls, patients without a bleeding event, were matched in a 1:3 ratio for age, sex, primary service (surgical or medical), and time at risk of bleeding on SQH to determine factors associated with bleeding.

A total of 3761 patients met the inclusion criteria, of which 38 cases of clinically relevant bleeding were identified. The bleeding incidence was 1% at hospital day 6 and 2.8% at hospital day 14. Most patients in this study (69%) received SQH 5000 units three times daily. ICU admission at SQH start was associated with bleeding, OR 2.97 (95% CI 1.21-7.29).

Bleeding in low-weight patients on prophylactic SQH was uncommon. Patients admitted to the ICU at time of SQH start may be at a higher risk of bleeding. Further studies are needed to detect additional risk factors associated with bleeding and investigate the effects of reduced dosing in this population.

Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data.

We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC).

Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB.

The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted.

Medical patients, admitted acutely to hospital, are at risk of venous thromboembolism (VTE). Clinical guidelines advise thromboprophylaxis prophylaxis for those at high risk of VTE. VTE is a common sequela of cancer, but guidelines take little consideration of cancer as an independent risk factor and their utility in palliative care patients is unclear. The hospice inpatient deep vein thrombosis (DVT) detection study (HIDDen) reported a 28% prevalence of asymptomatic iliofemoral DVT in hospice patients of poor performance status (PS) and prognosis, calling into question the utility of thromboprophylaxis in the palliative care setting. However, the majority of cancer inpatients receiving palliative care are admitted to hospital through the acute medical setting, yet their risk factors for VTE may differ from those admitted to hospices.

To better understand the prevalence and behaviours of VTE in patients with cancer receiving palliative care who are admitted as an acute medical emergency.

Multicentre, observational cohort study.

Secondary care acute hospitals in South Wales, UK.

We plan to recruit 232 patients≥18 years old with a diagnosis of incurable cancer, and/or receiving palliative or best supportive care who are admitted acutely to hospital. Patients will be followed up for a maximum of 6 months following registration.

Presence of lower extremity DVT.

Symptom burden attributed to DVT or pulmonary embolism, patient PS, patient demographics and development of new VTE within 90 days of registration.

The study statistical analysis plan will document analysis, methodology and procedures.

Ethical approval was obtained from the Wales Research Ethics Committee, reference 22/WA/0037 (IRAS 306352)-the main trial results will be analysed as soon as practically possible and the publication shared with investigators and on sponsor website; applications to access trial data will be subject to sponsor review process.

Challenges and Lessons from Our VTE Prophylaxis TrialIn this Clinical Trials Case Study, the authors describe the challenges faced and lessons learned conducting a trial of venous thromboembolism prophylaxis among hospitalized older adults.

To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations.

The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing.

All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events.

A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality.

pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.

The association between cancer and venous thromboembolism (VTE) is well-established with cancer patients accounting for approximately 20% of all VTE incidents. In this paper, we have performed a comparison of machine learning (ML) methods to traditional clinical scoring models for predicting the occurrence of VTE in a cancer patient population, identified important features (clinical biomarkers) for ML model predictions, and examined how different approaches to reducing the number of features used in the model impact model performance.

We have developed an ML pipeline including three separate feature selection processes and applied it to routine patient care data from the electronic health records of 1910 cancer patients at the University of California Davis Medical Center.

Our ML-based prediction model achieved an area under the receiver operating characteristic curve of 0.778 ± 0.006 (mean ± SD) when trained on a set of 15 features. This result is comparable with the model performance when trained on all features in our feature pool [0.779 ± 0.006 (mean ± SD) with 29 features]. Our result surpasses the most validated clinical scoring system for VTE risk assessment in cancer patients by 16.1%. We additionally found cancer stage information to be a useful predictor after all performed feature selection processes despite not being used in existing score-based approaches.

From these findings, we observe that ML can offer new insights and a significant improvement over the most validated clinical VTE risk scoring systems in cancer patients. The results of this study also allowed us to draw insight into our feature pool and identify the features that could have the most utility in the context of developing an efficient ML classifier. While a model trained on our entire feature pool of 29 features significantly outperformed the traditionally used clinical scoring system, we were able to achieve an equivalent performance using a subset of only 15 features through strategic feature selection methods. These results are encouraging for potential applications of ML to predicting cancer-associated VTE in clinical settings such as in bedside decision support systems where feature availability may be limited.