Risk Assessment Models for Venous Thromboembolism in Medical Inpatients.

Importance: 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. Objectives: To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. Design, Setting, and Participants: 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. Exposures: 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. Main Outcomes and Measures: Symptomatic VTE within 90 days. Results: 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. Conclusions and Relevance: 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.

Adherence to 2020 ESC recommendations on physical activity in a population with different cardiovascular risk levels: A prospective population-based study from the CoLaus/PsyCoLaus study.

Introduction: In 2020, the European Society of Cardiology (ESC) recommends 150 min of moderate or 75 min of vigorous-intensity PA per week. While general population PA adherence is suboptimal, its status among those with previous ASCVD or high ASCVD risk remains unknown. We aimed to assess objective adherence to ESC PA recommendations using accelerometer-based measurement among these populations. Methodology: We used data from the Swiss CoLaus|PsyCoLaus cohort study (2014-2016). PA was measured using a 14-day wrist accelerometer. Adherence was defined as > 80 % of recommended PA achievement. Adherence was investigated separately among participants with previous ASCVD and among cardiovascular risk groups (based on the Systematic Coronary Risk Evaluation SCORE-1 and more recent SCORE2) with simple and multivariable logistic regressions. Participants' characteristics were also evaluated as independent factors after adjustment. Results: We studied 1867 participants (median age: 61.2 years, 51.3 % female). ESC PA Adherence reached 55.5 % overall, and 37 % in those with previous ASCVD. Multivariable analysis showed no significant association between previous ASCVD or high cardiovascular risk and PA adherence (Odds ratio adjusted [ORa] 0.9, 95 % Confidence Interval [CI] 0.6-1.4 and ORa 0.7, 95 % CI 0.4-1.2, respectively). Age (≥60 years old), obesity, smoking, chronic renal disease, hypertension, diabetes and benzodiazepine use were significantly associated with lower likelihood of PA adherence in multivariable logistic regression. Conclusion: Adherence to ESC PA guidelines, particularly in participants with higher cardiovascular risk, was poor. Since PA adherence was associated with modifiable risk factors (e.g., obesity, smoking, and benzodiazepine use), maintained efforts to implement the ESC recommendations are advised.

Core stories of physicians on a Swiss internal medicine ward during the first COVID-19 wave: a qualitative exploration.

INTRODUCTION: The first COVID-19 wave (2020), W1, will remain extraordinary due to its novelty and the uncertainty on how to handle the pandemic. To understand what physicians went through, we collected narratives of frontline physicians working in a Swiss university hospital during W1. METHODS: Physicians in the Division of Internal Medicine of Lausanne University Hospital (CHUV) were invited to send anonymous narratives to an online platform, between 28 April and 30 June 2020. The analysed material consisted of 13 written texts and one audio record. They were examined by means of a narrative analysis based on a holistic content approach, attempting to identify narrative highlights, referred to as foci, in the texts. RESULTS: Five main foci were identified: danger and threats, acquisition of knowledge and practices, adaptation to a changing context, commitment to the profession, and sense of belonging to the medical staff. In physicians' narratives, danger designated a variety of rather negative feelings and emotions, whereas threats were experienced as being dangerous for others, but also for oneself. The acquisition of knowledge and practices focus referred to the different types of acquisition that took place during W1. The narratives that focused on adaptation reflected how physicians coped with W1 and private or professional upheavals. COVID-19 W1 contributed to revealing a natural commitment (or not) of physicians towards the profession and patients, accompanied by the concern of offering the best possible care to all. Lastly, sense of belonging referred to the team and its reconfiguration during W1. CONCLUSIONS: Our study deepens the understanding of how physicians experienced the pandemic both in their professional and personal settings. It offers insights into how they prepared and reacted to a pandemic. The foci reflect topics that are inherent to a physician's profession, whatever the context. During a pandemic, these foundational elements are particularly challenged. Strikingly, these topics are not studied in medical school, thus raising the general question of how students are prepared for the medical profession.

Association of pharmacologic thromboprophylaxis with clinically relevant bleeding and hospital-acquired anemia in medical inpatients: the risk stratification for hospital-acquired venous thromboembolism in medical patients study.

BACKGROUND: Pharmacologic thromboprophylaxis (pTPX) might exacerbate the risk of clinically relevant bleeding (CRB) and hospital-acquired anemia (HAA) in older multimorbid inpatients. OBJECTIVES: We aimed to evaluate the association of pTPX use with CRB and HAA. METHODS: We used data from a prospective cohort study conducted in 3 Swiss university hospitals. Adult patients admitted to internal medicine wards with no therapeutic anticoagulation were included. pTPX use was ascertained during hospitalization. Outcomes were in-hospital CRB and HAA. We calculated incidence rates by status of pTPX. We assessed the association of pTPX with CRB using survival analysis and with HAA using logistic regression, adjusted for infection, length of stay, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score. RESULTS: Among 1305 patients (mean age, 63.7 years; 44% women, 90% at low risk of bleeding), 809 (62%) received pTPX. The incidence of CRB was 2.4 per 1000 patient-days and was not significantly higher in patients with pTPX than in those without. We found no significant association between pTPX and CRB. HAA was frequent (20.2%) and higher in patients with pTPX than in those without (23.2% vs 15.3%). The incidence of HAA was 21.2 per 1000 patient-days and did not significantly differ between patients with pTPX and those without. We found an association between pTPX and HAA (adjusted odds ratio, 1.4; 95% CI, 1.0-2.1). CONCLUSION: Our study confirmed the safety of pTPX in medical inpatients at low risk of bleeding but identified an association between pTPX and HAA. Adherence to guidelines that recommend administering pTPX to medical inpatients at increased venous thromboembolism risk and low bleeding risk is necessary.

European Society of Cardiology guidelines and 1 year outcomes of acute heart failure treatment in Central Asia and Europe.

AIMS: Outcomes reported for patients with hospitalization for acute heart failure (AHF) treatment vary worldwide. Ethnicity-associated characteristics may explain this observation. This observational study compares characteristics and 1-year outcomes of Kyrgyz and Swiss AHF patients against the background of European Society of Cardiology guidelines-based cardiovascular care established in both countries. METHODS AND RESULTS: The primary endpoint was 1 year all-cause mortality (ACM); the secondary endpoint was 1 year ACM or HF-related rehospitalization. A total of 538 Kyrgyz and 537 Swiss AHF patients were included. Kyrgyz patients were younger (64.0 vs. 83.0 years, P < 0.001); ischaemic or rheumatic heart disease and chronic obstructive pulmonary disease were more prevalent (always P < 0.001). In Swiss patients, smoking, dyslipidaemia, hypertension, and atrial flutter/fibrillation were more frequent (always P ≤ 0.035); moreover, left ventricular ejection fraction (LVEF) was higher (47% vs. 36%; P < 0.001), and >mild aortic stenosis was more prevalent (P < 0.001). Other valvular pathologies were more prevalent in Kyrgyz patients (P < 0.001). At discharge, more Swiss patients were on vasodilatory treatment (P < 0.006), while mineralocorticoid receptor antagonists (P = 0.001), beta-blockers (P = 0.001), or loop diuretics (P < 0.001) were less often prescribed. In Kyrgyz patients, unadjusted odds for the primary and secondary endpoints were lower [odds ratio (OR) 0.68, 95% confidence interval (CI): 0.51-0.90, P = 0.008; OR 0.72, 95% CI: 0.56-0.91, P = 0.006, respectively]. After adjustment for age and LVEF, no difference remained (primary endpoint: OR 1.03, 95% CI: 0.71-1.49, P = 0.894; secondary endpoint: OR 0.82, 95% CI: 0.60-1.12, P = 0.206). CONCLUSIONS: On the background of identical guidelines, age- and LVEF-adjusted outcomes were not different between Central Asian and Western European AHF patients despite of large ethnical disparity.

[An unusual asthma attack]. / 5 minutes pour apprendre. Une crise d'asthme pas banale.

A pregnant woman presented with an asthma attack with a poor clinical evolution, requiring intubation. Medications traditionally used for the treatment of asthma in non-pregnant patients (short-acting beta-2 agonists, short-acting muscarinic antagonists, systemic corticosteroids) are considered safe during pregnancy, except for epinephrine. A systematic obstetrical evaluation is a key component in the evaluation and management of an asthmatic crisis during pregnancy. The use of peak-flow spirometers and arterial blood gas can help to recognize the degree of severity of an acute asthma attack.

Impact of an INtervention to increase MOBility in older hospitalized medical patients (INTOMOB): Study protocol for a cluster randomized controlled trial.

BACKGROUND: Low mobility during an acute hospitalization is frequent and associated with adverse effects, including persistent functional decline, institutionalization and death. However, we lack effective interventions to improve mobility that are scalable in everyday practice. The INTOMOB trial - INtervention to increase MOBility in older hospitalized medical patients - will test the effect of a multilevel intervention to improve mobility of older hospitalized patients on functional mobility. METHODS: The INTOMOB multicenter superiority parallel cluster randomized controlled trial will enroll in total 274 patients in Swiss hospitals. Community-dwelling adults aged ≥ 60 years, admitted to a general internal medicine ward with an anticipated length of hospital stay of ≥ 3 days, will be eligible for participation. Unit of randomization will be the wards. A multilevel mobility intervention will be compared to standard of care and target the patients (information and exercise booklets, mobility diary, iPad with exercise videos), healthcare professionals (e-learning, oral presentation, mobility checklist), and environment (posters and pictures on the wards). The primary outcome will be life-space level, measured by the University of Alabama at Birmingham Study of Aging Life-Space Assessment (LSA), at 30 days after enrollment. The LSA is a measure of functional mobility, i.e., how far participants move from bedroom to outside town. Secondary outcomes include, among others, LSA at 180 days, mobility and falls during hospitalization, muscle strength at discharge, and falls, emergency room visits, readmissions, and death within 180 days. DISCUSSION: This study has the potential to improve outcomes of older hospitalized patients through an intervention that should be scalable in clinical practice because it fosters patient empowerment and does not require additional resources. The tools provided to the patients can help them implement better mobility practices after discharge, which can contribute to better functional outcomes. The choice of a functional patient-reported outcome measure as primary outcome (rather than a "simple" objective mobility measure) reinforces the patient-centeredness of the study. TRIAL REGISTRATION: clinicaltrials.gov (NCT05639231, released on December 19 2022); Swiss National Clinical Trial Portal (SNCTP000005259, released on November 28 2022).

[Do we all suffer from imposter syndrome?] / Souffrons-nous toutes et tous d'un syndrome d'imposture?

Imposture syndrome is widespread among physicians and medical students. It is defined as a psychological experience in which people doubt their own skills and achievements despite proven successes and thus have an unfounded fear of being found out. This can have serious consequences, such as anxiety and/or depressive disorders, and can lead to burn-out. The Clance scale is a self-assessment tool used to measure the level of imposture experienced and, when appropriate, to assess the suffering caused. The aim of this article is to help recognise this syndrome, which is one way of preventing it.

Le syndrome d'imposture est largement répandu chez les médecins et les étudiant-e-s en médecine. Il est défini comme une expérience psychologique où l'individu, malgré des succès démontrés, doute de ses compétences et réussites et, ainsi, éprouve une crainte infondée d'être démasqué. D'importantes conséquences comme des troubles anxieux et/ou dépressifs associés à un burnout peuvent en découler. L'échelle de Clance est un outil d'autoévaluation permettant de mesurer le niveau d'imposture ressenti et, le cas échéant, d'en évaluer la souffrance engendrée. Le but de cet article est d'aider à reconnaître ce syndrome, ce qui constitue l'un des axes de sa prévention.

[A map for the improvement of healthcare: Swiss Health Care Atlas]. / Cartographie pour l'amélioration des soins : Atlas suisse des services de santé.

The Swiss Health Care Atlas (ASSS) is a free platform accessible to healthcare professionals and the general public. It provides a detailed overview of healthcare practices and the use of pharmaceutical and technological resources in both acute and outpatient care settings throughout Switzerland. It serves as an interactive tool for visualizing medical services and practices in Switzerland, along with regional variations. The ASSS allows the identification of potential under and overutilization of healthcare services, making it a valuable planning and management tool for healthcare and political authorities. This article reviews healthcare practices related to general internal medicine and guides the reader in interpreting a selection of ASSS indicators.

L'Atlas suisse des services de santé (ASSS) est une plateforme gratuite accessible aux professionnels de santé, mais aussi au grand public. Il permet un aperçu détaillé des pratiques de soins et de l'utilisation des ressources pharmacologiques et technologiques, en milieux hospitalier et/ou ambulatoire, sur le territoire helvétique. Il s'agit d'un moyen interactif permettant de visualiser certaines prestations médicales, ainsi que leur variation régionale. L'ASSS permet d'identifier une potentielle sous/surutilisation des services de soins et constitue ainsi un outil de planification et de pilotage pour les autorités sanitaires et politiques. Cet article passe en revue les pratiques de soins liées à la médecine interne générale et guide le lecteur dans l'interprétation d'une sélection d'indicateurs de l'ASSS.

Feasibility and Acceptability of an INtervention TO Increase MOBility in Older Hospitalized Medical Patients (INTOMOB): A Mixed-Methods Pilot Study.

Background: To reduce adverse outcomes of low hospital mobility, we need interventions that are scalable in everyday practice. This study assessed the feasibility and acceptability of the INTOMOB multilevel intervention addressing barriers to hospital mobility without requiring unavailable resources. Methods: The INTOMOB intervention, targeting older patients, healthcare professionals (HCPs) and the hospital environment, was implemented on acute general internal medicine wards of three hospitals (12/2022-03/2023). Feasibility and acceptability of the intervention were assessed and two types of accelerometers compared in a mixed methods study (patient and HCP surveys and interviews). Quantitative data were analyzed descriptively and qualitative data using a deductive approach. Results were integrated through meta-inferences. Results: Of 20 patients (mean age 74.1 years), 90% found the intervention helpful and 82% said the environment intervention (posters) stimulated mobility. The majority of 44 HCPs described the intervention as clear and helpful. There was no major implementation or technical issue. About 60% of patients and HCPs preferred a wrist-worn over an ankle-worn accelerometer. Conclusions: The INTOMOB intervention is feasible and well accepted. Patients' and HCPs' feedback allowed to further improve the intervention that will be tested in a cluster randomized trial and provides useful information for future mobility-fostering interventions.

Overuse and underuse of thromboprophylaxis in medical inpatients.

Background: Thromboprophylaxis (TPX) prescription is recommended in medical inpatients categorized as high risk of venous thromboembolism (VTE) by validated risk assessment models (RAMs), but how various RAMs differ in categorizing patients in risk groups, and whether the choice of RAM influences estimates of appropriate TPX use is unknown. Objectives: To determine the proportion of medical inpatients categorized as high or low risk according to validated RAMs, and to investigate the appropriateness of TPX prescription. Methods: This is a prospective cohort study of acutely ill medical inpatients from 3 Swiss university hospitals. Participants were categorized as high or low risk of VTE by validated RAMs (ie, the Padua, the International Medical Prevention Registry on Venous Thromboembolism, simplified, and original Geneva scores). We assessed prescription of any TPX at baseline. We considered TPX prescription in high-risk and no TPX prescription in low-risk patients as appropriate. Results: Among 1352 medical inpatients, the proportion categorized as high risk ranged from 29.8% with the International Medical Prevention Registry on Venous Thromboembolism score to 66.1% with the original Geneva score. Overall, 24.6% were consistently categorized as high risk, and 26.3% as low risk by all 4 RAMs. Depending on the RAM used, TPX prescription was appropriate in 58.7% to 63.3% of high-risk (ie, 36.7%-41.3% underuse) and 52.4% to 62.8% of low-risk patients (ie, 37.2%-47.6% overuse). Conclusion: The proportion of medical inpatients considered as high or low VTE risk varied widely according to different RAMs. Only half of patients were consistently categorized in the same risk group by all RAMs. While TPX remains underused in high-risk patients, overuse in low-risk patients is even more pronounced.

Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study.

It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists.

INTRODUCTION: Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear. MATERIALS AND METHODS: We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models. RESULTS: Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07-0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction. CONCLUSIONS: Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.

[In-hospital withdrawal of benzodiazepines in long term users : a bad idea with good intentions]. / 5 minutes pour apprendre. Less is more: sevrage d'un traitement chronique de benzodiazépine à l'hôpital ­ Mauvaise bonne idée.

Benzodiazepines are among the most frequently prescribed medications in Switzerland, particularly in the elderly. Due to their unfavourable side effect profile, especially in the elderly population, this class of medication should not be prescribed for the treatment of insomnia or non-refractory anxiety disorders. A gradual withdrawal procedure, which is safe and effective according to the literature, should be offered to the patient taking such medication, with adequate monitoring of withdrawal symptoms. This procedure should, in principle, be performed in an outpatient setting but may be initiated in the hospital after discussion with the patient and the primary care physician.

Temporal changes in fecal microbiota of patients infected with COVID-19: a longitudinal cohort.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a multifaceted disease potentially responsible for various clinical manifestations including gastro-intestinal symptoms. Several evidences suggest that the intestine is a critical site of immune cell development, gut microbiota could therefore play a key role in lung immune response. We designed a monocentric longitudinal observational study to describe the gut microbiota profile in COVID-19 patients and compare it to a pre-existing cohort of ventilated non-COVID-19 patients. METHODS: From March to December 2020, we included patients admitted for COVID-19 in medicine (43 not ventilated) or intensive care unit (ICU) (14 ventilated) with a positive SARS-CoV-2 RT-PCR assay in a respiratory tract sample. 16S metagenomics was performed on rectal swabs from these 57 COVID-19 patients, 35 with one and 22 with multiple stool collections. Nineteen non-COVID-19 ICU controls were also enrolled, among which 14 developed ventilator-associated pneumonia (pneumonia group) and five remained without infection (control group). SARS-CoV-2 viral loads in fecal samples were measured by qPCR. RESULTS: Although similar at inclusion, Shannon alpha diversity appeared significantly lower in COVID-19 and pneumonia groups than in the control group at day 7. Furthermore, the microbiota composition became distinct between COVID-19 and non-COVID-19 groups. The fecal microbiota of COVID-19 patients was characterized by increased Bacteroides and the pneumonia group by Prevotella. In a distance-based redundancy analysis, only COVID-19 presented significant effects on the microbiota composition. Moreover, patients in ICU harbored increased Campylobacter and decreased butyrate-producing bacteria, such as Lachnospiraceae, Roseburia and Faecalibacterium as compared to patients in medicine. Both the stay in ICU and patient were significant factors affecting the microbiota composition. SARS-CoV-2 viral loads were higher in ICU than in non-ICU patients. CONCLUSIONS: Overall, we identified distinct characteristics of the gut microbiota in COVID-19 patients compared to control groups. COVID-19 patients were primarily characterized by increased Bacteroides and decreased Prevotella. Moreover, disease severity showed a negative correlation with butyrate-producing bacteria. These features could offer valuable insights into potential targets for modulating the host response through the microbiota and contribute to a better understanding of the disease's pathophysiology. TRIAL REGISTRATION: CER-VD 2020-00755 (05.05.2020) & 2017-01820 (08.06.2018).

Quality of life in elderly patients with venous thromboembolism assessed using patient-reported outcome measures.

BACKGROUND: We aimed to evaluate the quality of life (QoL), using patient-reported outcome measures (PROMs), in elderly patients with venous thromboembolism (VTE) and to explore whether VTE complications (recurrence, bleeding, or postthrombotic syndrome) had an impact on later QoL. METHODS: We used data from the SWIss venous Thromboembolism COhort of older patients(SWITCO65+), a prospective multicenter cohort of patients aged ≥65 years with acute, symptomatic VTE. Primary outcome was changes in QoL up to 24 months, assessed using generic (36-Item Short-Form Health Survey), with physical (PCS) and mental component score (MCS), and disease-specific (Venous Insufficiency Epidemiological and Economic Study [VEINES]-QoL, [VEINES-Sym], and Pulmonary Embolism QoL) PROMs. PROM scores ranged from 0 to 100 points, higher scores indicating a better QoL. Longitudinal latent class analysis was used to group patients with similar PCS trajectories. Repeated-measures linear regression analyses were used to assess effects of VTE complications on changes in QoL scores. RESULTS: In 923 patients (median age, 75; male, 54%), 140 (15%) patients died, 97 (11%) experienced recurrent VTE, and 106 (12%) major bleeding during follow-up. Compared with patients with higher PCS trajectories, patients with lower PCS trajectories were more likely to be older, female, sicker, and less physically active. On average, generic and disease-specific QoL scores improved over time (+11% in PCS, +3% in MCS, +6% in VEINES QoL, and +16% in Pulmonary Embolism QoL at 3 months). VTE complications were always associated with significantly lower QoL scores (for VTE recurrence: PCS adjusted difference -2.57, 95% CI, -4.47 to -0.67). CONCLUSION: Although QoL following VTE tended to improve over time, patients with VTE-related complications had lower QoL than patients without complications.

Prediction of in-hospital bleeding in acutely ill medical patients: External validation of the IMPROVE bleeding risk score.

INTRODUCTION: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

Prediction of very early major bleeding risk in acute pulmonary embolism: an independent external validation of the Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score.

BACKGROUND: The Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score was derived to predict very early major bleeding (MB) in patients with acute pulmonary embolism (PE). Before adoption into practice, the score requires external validation in different populations. OBJECTIVES: We independently validated the PE-SARD score in a prospective multicenter Swiss cohort of 687 patients aged ≥65 years with acute PE. METHODS: The PE-SARD score uses 3 variables (syncope, anemia, and renal dysfunction) to classify patients into 3 categories of increasing bleeding risk. The outcomes were very early MB at 7 days (primary) and MB at later time points (secondary). We calculated the PE-SARD score for each patient and classified the proportion of patients as being at low, intermediate, and high risk. To assess discrimination and calibration, we calculated the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: The prevalence of MB was 2.0% (14/687) at 7 days and 14.0% (96/687) after a median follow-up of 30 months. The PE-SARD score classified 40.2%, 42.2%, and 17.6% of patients as low, intermediate, and high risk for MB, respectively. The frequency of observed very early MB at 7 days was 1.8% in low-, 2.1% in intermediate-, and 2.5% in high-risk patients. The area under the receiver operating characteristic curve was 0.52 (95% CI, 0.48-0.56) at 7 days and increased to 0.60 (95% CI, 0.56-0.64) at the end of follow-up. Score calibration was adequate (p > .05) over the entire follow-up. CONCLUSION: In our independent validation, the PE-SARD score did not accurately predict very early MB and may not be transportable to older patients with PE.

Effects of a Multimodal Transitional Care Intervention in Patients at High Risk of Readmission: The TARGET-READ Randomized Clinical Trial.

Importance: Hospital readmissions are frequent, costly, and sometimes preventable. Although these issues have been well publicized and incentives to reduce them introduced, the best interventions for reducing readmissions remain unclear. Objectives: To evaluate the effects of a multimodal transitional care intervention targeting patients at high risk of hospital readmission on the composite outcome of 30-day unplanned readmission or death. Design, Setting, and Participants: A single-blinded, multicenter randomized clinical trial was conducted from April 2018 to January 2020, with a 30-day follow-up in 4 medium-to-large-sized teaching hospitals in Switzerland. Participants were consecutive patients discharged from general internal medicine wards and at higher risk of unplanned readmission based on their simplified HOSPITAL score (≥4 points). Data were analyzed between April and September 2022. Interventions: The intervention group underwent systematic medication reconciliation, a 15-minute patient education session with teach-back, a planned first follow-up visit with their primary care physician, and postdischarge follow-up telephone calls from the study team at 3 and 14 days. The control group received usual care from their hospitalist, plus a 1-page standard study information sheet. Main Outcomes and Measures: Thirty-day postdischarge unplanned readmission or death. Results: A total of 1386 patients were included with a mean (SD) age of 72 (14) years; 712 (51%) were male. The composite outcome of 30-day unplanned readmission or death was 21% (95% CI, 18% to 24%) in the intervention group and 19% (95% CI, 17% to 22%) in the control group. The intention-to-treat analysis risk difference was 1.7% (95% CI, -2.5% to 5.9%; P = .44). There was no evidence of any intervention effects on time to unplanned readmission or death, postdischarge health care use, patient satisfaction with the quality of their care transition, or readmission costs. Conclusions and Relevance: In this randomized clinical trial, use of a standardized multimodal care transition intervention targeting higher-risk patients did not significantly decrease the risks of 30-day postdischarge unplanned readmission or death; it demonstrated the difficulties in preventing hospital readmissions, even when multimodal interventions specifically target higher-risk patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03496896.

Thrombophilia and outcomes of venous thromboembolism in older patients.

Background: Limited data exist on thrombophilic risk factors and clinical outcomes in the elderly with venous thromboembolism (VTE). Objectives: To describe the prevalence of laboratory thrombophilic risk factors and their association with VTE recurrence or death in a cohort of elderly people with VTE. Methods: In 240 patients aged ≥65 years with acute VTE without active cancer or an indication for extended anticoagulation, we performed laboratory thrombophilia testing 1 year after the index VTE. Recurrence or death was assessed during the 2-year follow-up. Results: A total of 78% of patients had ≥1 laboratory thrombophilic risk factor(s). Elevated levels of von Willebrand factor, homocysteine, coagulant activity of factor VIII (FVIII:C), fibrinogen, FIX:C, and low antithrombin activity were the most prevalent risk factors (43%, 30%, 15%, 14%, 13%, and 11%, respectively). Additionally, 16.2% of patients experienced VTE recurrence and 5.8% of patients died. Patients with a von Willebrand factor of >182%, FVIII:C level >200%, homocysteine level >15µmol/L, or lupus anticoagulant had a significantly higher rate of recurrence than those without these risk factors (15.0 vs. 6.1 [P = .006], 23.5 vs. 8.2 [P = .01], 17.0 vs. 6.8 [P = .006], and 89.5 vs. 9.2 [P = .02] events per 100 patient-years, respectively). Furthermore, patients with a high fibrinogen level or hyperhomocysteinemia with a homocysteine level ≥30 µmol/L had significantly higher mortality than patients with normal levels (18.5 vs. 2.8 [P = .049] and 13.6 vs. 2 [P = .002] deaths per 100 patient-years, respectively). After adjustments for relevant confounders, these associations remained unchanged. Conclusion: Laboratory thrombophilic risk factors are common in elderly people with VTE and allow for the identification of a population at the risk of worse clinical outcomes.