Mandatory Risk Assessment Reduces Venous Thromboembolism in Bariatric Surgery Patients.

INTRODUCTION: Bariatric surgery patients are at high risk for venous thromboembolism (VTE), and chemoprophylaxis is recommended. METHODS: Sheikh Khalifa Medical City (SKMC) is an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) member since 2009. We report the rates of VTE in bariatric surgery patients from 2010 to 2016 compared to ACS NSQIP bariatric surgery programs before and after switching from heparin to low molecular weight heparin (LMWH), initiating mandatory risk assessment using Caprini scoring for VTE and adopting an aggressive strategy for high-risk patients regarding dosage of LMWH and chemoprophylaxis after discharge. RESULTS: During the study period, there were 1152 cases (laparoscopic Roux-en-Y gastric bypass (LRYGB) 625 and laparoscopic sleeve gastrectomy (LSG) 527) at Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to 65,693 cases (LRYGB 32,130 and LSG 33,563) at ACS NSQIP bariatric surgery programs. VTE rates remained stable at ACS NSQIP bariatric surgery programs from 2010 to 2016 (0.45, 0.45, 0.45, 0.25, 0.35, 0.3, and 0.3%). In contrast, VTE rates at BMI Abu Dhabi decreased from 2.2% in 2011 to 0.35% after we adopted an aggressive strategy to VTE without an increase in bleeding complications. LRYGB patients with VTE had higher OR time, leak, collection, and mortality at ACS NSQIP hospitals compared to those at BMI Abu Dhabi. In contrast, rates were similar in LSG patients with VTE. CONCLUSION: Changing our approach to VTE management led our VTE rates to decrease and become like those of ACS NSQIP bariatric surgery patients in LSG and LRYGB.

Legal aspects of cancer deseases prophylactics: patients rights context.

OBJECTIVE: Introduction: In accordance with Resolution on Cancer Control WHA58.22 Cancer prevention and control The Fifty-eighth World Health Assembly it is obvious technology for diagnosis and treatment of cancer is mature, and that many cases of cancer may be cured, especially if detected earlier Some key points on concept of legal regulation of abovementioned sphere is a base of this study. However, the problems of using an effective mechanism for protecting the rights of patients in certain types of disease, in particular cancer patients, by providing early diagnosis, are not fully developed by medical law specialists. The aim of the article is to determine the means of ensuring the right to health and life of cancer patients in particular through early diagnosis. PATIENTS AND METHODS: Material and Methods: This study is based on regulation acts, World health report (2013), The Fifty-eighth World Health Assembly, WHA58.22 Cancer prevention and control, Universal Declaration of Human Rights, International Covenant on Civil and Political Rights, International Covenant on Economic, Social and Cultural Rights, European Convention for the Protection of Human Rights and Fundamental Freedoms, Charter of Fundamental Rights of the European Union, research papers and views of progressive-minded people in this sphere. Article is grounded on dialectical, comparative, analytic, synthetic and comprehensive research methods. RESULTS: Review: Most countries have declared a compliance of their national legislation with international standards regarding the right to life and health. The analysis of the abovementioned international acts in context of protection of the rights of patients with cancer leads to the conclusion that countries that have undertaken international legal obligations to protect the right to life are required to take the necessary measures to ensure the effective treatment of cancer patients. Taking into account that the lack of such treatment due to the specificity of the disease entails the death of the patient, the state inaction in this area should be regarded as a violation of a human right for life. Absence of state's policy in terms of early detection of cancer brings a huge problem of human rights violation and providing the standards of fundamentally different approach of the European Union countries could become a great solution. CONCLUSION: Conclusions: Individual states do not pay sufficient attention to the need of effective public health policy. In today's world, there are objective prerequisites for changing the system of protection of patients' rights and, consequently, for changing views on health protection in general, especially in the part of functioning of diagnostic procedures system. Formation of a state policy on ensuring the rights of citizens to health and life, taking into account the various consequences of such a policy, cannot be narrowed down only to the proclamation of such rights, but also requires planning and development of relevant state programs. Failure by the state to provide the proper organization of health care through the establishment of early diagnosis for cancer patients, considering wide incidence and mortal danger of cancer in case of late diagnosis, should be considered as a violation of human rights. It also does not conform to ECHR practice in terms of provisions of Articles 2, 3 and 8 of European Convention.

Preexposure Prophylaxis (PrEP) for HIV Prevention: The Primary Care Perspective.

Until recently there have been few primary care office-based strategies to reduce the transmission of HIV. In May 2014 the Centers for Disease Control and Prevention published updated practice guidelines recommending the use of preexposure prophylaxis (PrEP) with daily oral dosing of tenofovir/emtricitabine to help prevent HIV infection in high-risk individuals (strength of recommendation, A). Knowledge of PrEP among primary care providers is low, however, and this intervention is likely reaching only a small fraction of eligible patients. PrEP is recommended for certain injection drug users, nonmonogamous men who have sex with men, heterosexual women who have sex with men who have sex with men or injection drug users, and those in HIV serodiscordant relationships. Providers should obtain baseline laboratory values and provide initial counseling before prescribing PrEP. Regular office visits are necessary to ensure adherence, provide ongoing counseling, and monitor for side effects, including nausea, abdominal pain, headache, and, less commonly, increased creatinine. Guidelines and toolkits have been developed to assist in incorporating PrEP into primary care practice. PrEP is gaining widespread acceptance and has become a crucial tool in the fight to stop the spread of HIV.

Venous thromboembolism in hospitalized adolescents: an approach to risk assessment and prophylaxis.

BACKGROUND: Pediatric hospital-acquired venous thromboembolism (VTE) is an increasingly prevalent and morbid disease. A multidisciplinary team at a tertiary children's hospital sought to answer the following clinical question: "Among hospitalized adolescents, does risk assessment and stratified VTE prophylaxis compared with no prophylaxis reduce VTE occurrence without an increase in significant adverse effects?" METHODS: Serial literature searches using key terms were performed in the following databases: Medline, Cochrane Database, CINAHL (Cumulative Index to Nursing and Allied Health), Scopus, EBMR (Evidence Based Medicine Reviews). Pediatric studies were sought preferentially; when pediatric evidence was sparse, adult studies were included. Abstracts and titles were screened, and relevant full articles were reviewed. Studies were rated for quality using a standard rating system. RESULTS: Moderate evidence exists to support VTE risk assessment in adolescents. This evidence comes from pediatric studies that are primarily retrospective in design. The results of the studies are consistent and cite prominent factors such as immobilization and central venous access. There is insufficient evidence to support specific prophylactic strategies in pediatric patients because available pediatric evidence for thromboprophylaxis efficacy and safety is minimal. There is, however, high-quality, consistent evidence demonstrating efficacy and safety of thromboprophylaxis in adults. CONCLUSIONS: On the basis of the best available evidence, we propose a strategy for risk assessment and stratified VTE prophylaxis for hospitalized adolescents. This strategy involves assessing risk factors and considering prophylactic measures based on level of risk. We believe this strategy may reduce risk of VTE and appropriately balances the adverse effect profile of mechanical and pharmacologic prophylactic methods.

Adherence with postdischarge venous thromboembolism chemoprophylaxis recommendations after colorectal cancer surgery among elderly Medicare beneficiaries.

OBJECTIVES: To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery. BACKGROUND: Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis. METHODS: Medicare beneficiaries undergoing open colorectal cancer resections in 2008-2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weight-heparin and other anticoagulants was assessed. RESULTS: A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weight-heparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07-3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23-3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01-1.25; vs lower index). CONCLUSIONS: Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients.

Severe meningococcal infection: a review of epidemiology, diagnosis, and management.

Neisseria meningitidis, also known as meningococcus, is a relatively uncommon cause of invasive infection, but when it occurs it is frequently severe and potentially life threatening. Meningococcus should be considered and investigated promptly as a potentially etiologic pathogen in any patient with meningitis, or sepsis accompanied by a petechial rash. Suspected patients should receive early appropriate antimicrobial therapy concomitantly with confirmatory invasive diagnostic tests. Vaccines have reduced the incidence of infection with certain non-B meningococcal serogroups, and new serotype B vaccines are on the horizon. This article reviews the epidemiology, diagnosis, and management of severe meningococcal infections.

Implementing NICE guidelines on risk assessment for venous thromboembolism: failure, success and controversy.

PURPOSE: Venous thromboembolism (VTE) prophylaxis guidelines were originally published by the National Institute of Clinical Excellence (NICE) in April 2007. Controversy eclipsed their release. Consequently, the VTE prophylaxis publication was reviewed and republished in January 2010. The NICE guidelines recommend that all patients are assessed for risk before pharmacological prophylaxis is offered and reassessed at 24 hours to check adverse reactions; and that prophylaxis is appropriate. This paper aims to look at their implementation. DESIGN/METHODOLOGY/APPROACH: A prospective audit and re-audit in one orthopaedic department was completed to see how well the new guidelines were adhered to, find out first-hand what problems there were, and how they might be remedied. FINDINGS: Audit and re-audit highlighted that attaching an assessment tool to drug charts is plausible. RESEARCH LIMITATIONS/IMPLICATIONS: The study was limited to one centre and used a relatively weak research design. PRACTICAL IMPLICATIONS: As a process, the clinical impact of risk assessment for VTE is questionable as many patients will be high risk. Removing reassessment at 24 hours from the NICE guidance is recommended. ORIGINALITY/VALUE: The authors put the NICE guideline into clinical practice, demonstrating how effectively it can work with their method, but also highlighting its flaws.

Determining utility values related to malaria and malaria chemoprophylaxis.

BACKGROUND: Chemoprophylaxis for travellers' malaria is problematic. Decision modeling may help determine optimal prevention strategies for travellers' malaria. Such models can fully assess effect of drug use and disease on quality of life, and help travellers make informed values based decisions. Such models require utility values reflecting societal preferences over different health states of relevance. To date, there are no published utility values relating to clinical malaria or chemoprophylaxis adverse events. METHODS: Utility estimates for health states related to falciparum malaria, sequelae and drug-related adverse events were obtained using a self-administered visual analogue scale in 20 individuals. Utility values for health states related to clinical malaria were obtained from a survey of 11 malaria experts questioned about length of hospital stay or equivalent disability with simple and severe travellers' malaria. RESULTS: The general public (potential travellers), were more tolerant of taking prophylaxis if associated with no or mild AEs and least tolerant of mild sequelae from malaria and severe drug related events. The rating value reported for taking no prophylaxis was quite variable. Tropical medicine specialists estimated a mean hospital stay 3.23 days (range 0.5-4.5 days) for simple and 6.36 days (range 4.5-7 days) for severe malaria. CONCLUSIONS: This study provides a benchmark for important utility value estimates for modeling malaria and drug-related outcomes in non-immune travellers.

Health plan pharmacy director: considerations for treatment and management of RSV disease.

RSV immunoprophylaxis presents a challenge for MCOs. Despite its demonstrated ability to protect high-risk infants against serious RSV infection and to reduce morbidity, immunoprophylaxis with palivizumab incurs high costs that MCOs must grapple with every year. If MCOs, physicians, and professional organizations can agree on common guidelines for RSV management, then MCOs will be able to provide affordable treatment for those children at high risk.

Innovative approaches to increase deep vein thrombosis prophylaxis rate resulting in a decrease in hospital-acquired deep vein thrombosis at a tertiary-care teaching hospital.

BACKGROUND AND OBJECTIVE: Hospital-acquired venous thromboembolic events (VTEs) in medically ill patients account for a significant percentage of in-hospital mortality. Unfractionated heparin and low-molecular-weight heparin have been shown to be effective in the prevention of VTEs. However, use of these medications for thromboprophylaxis remains suboptimal. The objective of this article is to report the impact of a continuous quality improvement project on adherence with DVT prophylaxis guidelines and on the subsequent incidence of hospital-acquired DVT in medical patients at a teaching hospital between 2002 and 2005. METHODS: In November 2002, Kings County Hospital Center Department of Medicine embarked on a project to increase the rate of thromboprophylaxis use. Quality improvement strategies included an active, multifaceted, layered combination of provider education, provider reminders with decision support, and audit with feedback. RESULTS: The DVT prophylaxis rate on the general medicine house-staff service increased from a baseline of 63% in 2002 to 96% in 2005. The number of hospital-acquired DVTs decreased from a baseline of 14 in 2002 to 1 in 2005. The hospital-acquired DVT rate fell significantly, from 2.6 per 1000 discharges in 2002 (95% CI 1.5-4.4) to 0.2 per 1000 discharges in 2005 (95% CI 0.0-1.1), P = .007. CONCLUSIONS: A layered combination of provider education, provider reminders with decision support, and audit with feedback increased the DVT prophylaxis rate and decreased the rate of hospital-acquired DVTs in the medicine department at a tertiary-care hospital center.

[Cancer prevention].

The 12 th Oncology Forum discussed the progress and future strategy of cancer prevention in Japan. The National Cancer Center has established a research center for screening focusing on the most common six cancer, stomach, lung, liver, colon, breast and uterus cancer. The program so far had a cumulative detection rate of 3.3%, which is high,and may reflect the selection of subjects. Screening and chemoprevention is also being investigated in prostate cancer, but the issues centre on how to make this widely available. High risk subjects can also be identified for breast cancer. Obesity and family history are especially important. In colorectal cancer studies are evaluating different diets, but general application is not yet possible and the infrastructure to implement any general screening and prevention does not exist. Development of pharmaceutical treatments for prevention is difficult because of the need for very safe treatments, and also because of the length of time needed to carry out studies. Overall, cancer prevention is still in evolution. New approaches are needed, and new infrastructure will be needed at a government level to implement this.

Prevention of human immunodeficiency virus-related opportunistic infections in France: a cost-effectiveness analysis.

A simulation model of human immunodeficiency virus (HIV) disease, which incorporated French data on the progression of HIV disease in the absence of antiretroviral therapy and on cost, was used to determine the clinical impact and cost-effectiveness of different strategies for the prevention of opportunistic infections in French patients who receive highly active antiretroviral therapy (HAART). Compared with use of no prophylaxis, use of trimethoprim-sulfamethoxazole (TMP-SMZ) increased per-person lifetime costs from euro 185,600 to euro 187,900 and quality-adjusted life expectancy from 112.2 to 113.7 months, for an incremental cost-effectiveness ratio of euro 18,700 per quality-adjusted life-year (euro/QALY) gained. Compared with use of TMP-SMZ alone, use of TMP-SMZ plus azithromycin cost euro 23,900/QALY gained; adding fluconazole cost an additional euro 54,500/QALY gained. All strategies that included oral ganciclovir had cost-effectiveness ratios that exceeded euro 100,000/QALY gained. In the era of HAART, on the basis of French data, prophylaxis against Pneumocystis carinii pneumonia, toxoplasmic encephalitis, and Mycobacterium avium complex bacteremia is cost-effective. Prophylaxis against fungal and cytomegalovirus infections is less cost-effective than are other therapeutic options for HIV disease and should remain of lower priority.