[Optimizing the prophylaxis of hospital-acquired deep vein thrombosis and pulmonary thromboembolism]. / Optimizatsiya profilaktiki vnutrigospital'nykh trombozov glubokikh ven i tromboembolii legochnoi arterii.

AIM: To reduce the number of preventable hospital-acquired venous thromboembolic events (HA-VTE) and to improve the quality of VTE prophylaxis at multiprofile hospital. MATERIAL AND METHODS: A comprehensive approach to preventing HA-VTE was developed, which involved the global trigger tool method to assess adverse events, as well as the computerized clinical decision support system (CDSS) to prevent HA-VTE on the basis of relevant clinical practice guidelines, and HA-VTE registry. RESULTS: A total of 50 patients (15 men, 35 women; their median age was 70.5 years) with HA-VTE were included in the HA-VTE registry in January 2014 to June 2015. Assessment of a trend in the prevalence of HA-VTE when introducing CDSS to prevent VTE showed its statistically significant decline in the total number of HA-VTE cases (χ2=7.325, df=1; p=0.0068) and in that of HA-VTE in surgical patients (χ2=7.266, df=1; p=0.0070). The statistical significance of χ2 for linear trend was not achieved for medical patients, which is probably due to the small sample size (χ2=2.764, df=1; p=0.0964). While introducing CDSS, there was a statistically significant reduction in the incidence of postoperative VTE from 8.76 to 4.17 cases per 1000 interventions (χ2=5.347, df=1; p=0.0208; the absolute values of HA-VTE and surgical interventions were used for the calculation). CONCLUSION: The proposed comprehensive approach can substantially increase the detection rate of HA-VTE and decrease its incidence rates. This requires a personified assessment of the risk of VTE and hemorrhage in all hospitalized patients on day 1 of their admission, timely initiation of recommended VTE prophylaxis, and dynamic assessment of the risk of VTE and hemorrhage for timely correction of the prophylaxis.

Decision support systems in clinical practice: The case of venous thromboembolism prevention.

BACKGROUND: Today medicine is facing a "knowledge crisis" in that explosively expanding medical knowledge encounters limited abilities to disseminate new practices [1]. Clinical practice guidelines (CPGs) are intended to promote high standards of care in specific areas of medicine by summarizing best clinical practice based on careful reviews of current research. However, doctors are often short of time to study these documents and check their updates, have little motivation for strict adherence to them. A systematic review of 11 studies reporting on 29 recommendations has found that median adherence to all recommendations was 34%, suggesting that potential benefits for patients from health research may be lost [2].Clinical decision support systems (CDSS) can serve as a knowledge translation tool, mediator between clinical guidelines and physicians by providing the right information to the right person at the right time. OBJECTIVE: To evaluate the effectiveness of implementation of international and national CPGs for venous thromboembolism (VTE) prevention with the help of CDSS in a general hospital. METHODS: A multifunctional CDSS based on national and international guidelines on the VTE prevention was developed and implemented in the Medical Center of the Bank of Russia (MC). The system has the following functionalities: 1) it supports the decision on the VTE prevention based on individual risk assessment of thrombosis (scales of Caprini, Rogers and Khorana, Padua Prediction Score, additional risk factors) and bleeding (IMPROVE scale for non-surgical patients, major bleeding scale for surgical patients and major orthopedic surgeries, hemorrhagic complications risk in cancer patients); 2) generates the summary containing the grade of recommendations and the level of evidence, personalized recommendations on regimen and duration of preventive antithrombotic therapy, dose correction according to creatinine clearance; 3) provides an audit form for and statistical analysis of VTE cases; 3) automatically generates a quality register for VTE prevention.CDSS was implemented in June 2014. We analyzed VTE cases identified by triggers (deep vein thrombosis diagnosed by Doppler ultrasound and pulmonary embolism at the chest CT) that occurred in 2014 before and after CDSS implementation, as well as in the first half of 2015. Patients with VTE diagnosed during the first 48 hours of hospitalization or receiving anticoagulants in therapeutic doses were excluded from the analysis. Chi-square test for linear trend and non-parametric methods of descriptive statistics were used for data analysis. RESULTS: CDSS utilization was regulated by a special hospital-wide policy; lectures were organized to educate doctors how to use the system. Although international recommendations require VTE risk assessment for all hospitalized patients (except those receiving anticoagulant in therapeutic doses), the doctors filled forms for only 306 patients during the first 6 months of CDSS functioning (14.1% of discharges with length of stay >48 hours during this period). In the first half of 2015 the coverage of VTE risk assessment with CDSS was 19% (n = 506). Correctness of filling out the forms was 78.4%, in the rest of cases doctors made mistakes in choosing patient's profile or when filling in risk scales.Doctors adhere to given recommendations in 85.4% of cases. Most often (47.5%) pharmacotherapy with low molecular weight heparin (LMWH), preventive doses, was recommended by the system, and in this category the adherence to recommended practice was the lowest (74.6%). Among patients who underwent pharmacoprophylaxis, in 21.1% cases the use of anticoagulants was inconsistent with clinical guidelines or drug package insert (typically inappropriate choice of LMWH prophylactic doses, delaying or reducing the duration of prophylaxis).The rate of hospital-acquired VTE significantly decreased after CDSS implementation and was 11.71, 8.28 and 4.84 per 1,000 hospitalizations in the first and second half of 2014 and in the first half of 2015, respectively (χ2 = 7.325, df = 1, p = 0.0068). The rate of postoperative VTE for the same period amounted to 8.76, 3.39 and 4.17 per 1,000 operations, respectively (χ2 = 7.266, df = 1, p = 0.007), reaching a level of the correspondent AHRQ safety indicator (4.99 per 1,000 operations) [3]. Deviations from clinical guidelines or anticoagulant package inserts were revealed in 74% of VTE cases; and more than 1/3 of deviations affected treatment outcomes. CONCLUSIONS: Coverage of hospitalized patients with documented VTE risk assessment gradually increased after the CDSS implementation, but remained at a low level (19% of eligible patients). Partly it may be attributed to the lack of CDSS integration in electronic health record or computerized physician order entry systems that would facilitate routine documentation of VTE and bleeding risks. However, the introduction of CDSS has allowed reducing significantly the rate of hospital-acquired VTE. This can be explained by drawing doctor's attention to the VTE problem and by training effect of CDSS. After receiving appropriate recommendations doctors adhere to them, on average, in 85.4% of cases, although for LMWH pharmacoprophylaxis this level was lower (74.6%). Development of hospital-acquired VTE in most cases (74%) was accompanied by non-compliance with CPGs recommendations, emphasizing the importance of additional measures for better adherence to evidence-based clinical practices.

[Effectiveness of one-stage microdiscectomy and radiofrequency denervation of intervertebral joints compared to microdiscectomy in patients with spinal disc herniation].

The article analyzes of the early and long-term outcomes in 113 patients who underwent surgical treatment for lumbosacral disc herniations. The first group of patients (n=32) underwent microdiscectomy in a combination with radiofrequency destruction (RFD) of the facet nerves. The control group patients (n=81) underwent microdiscectomy. This study demonstrates the advantage of combining RFD with open surgery. In this case, regression of both nerve root and back pain is achieved, which greatly accelerates rehabilitation of patients, restoration of their work ability, and therefore their return to normal life.

[Necessity of development of Russian vertebrologic registry].

Development of national and international registers for the most socially significant diseases is an important problem of contemporary medicine. Importance and priority of vertebrological register is explained by relatively young age of spinal neurosurgery as specialty, in which many questions concerning indications and optimal methods of treatment remain unsolved, and accumulated experience is quite limited. Nevertheless, vertebrology is on the way from opinions of certain experts to evidence-based scientific proofs. This transition needs generally accepted and convenient instruments for assessment of outcomes of treatment and procedures which should be presented by national vertebrological register. Aims of its development include accumulation of clinically valuable resources and knowledge in vertebrology by means of organization of society of interested professionals and patients. The paper discusses architecture, contents and importance of development of Russian vertebrological register targeted on neurosurgeons, orthopaedic surgeons, vertebrologists and other specialists dealing with this problem. Foreign vertebrological registers are analyzed, their advantages and disadvantages are summarized, requirements for inclusion of criteria in the register are investigated.

[Novel method of analysis of risk of development of ischemic heart disease with the use of genomic and computer technologies].

AIM: to assess effectiveness of the use of modern methods of prognostication for assessment of risk of development of ischemic heart disease (IHD). MATERIAL AND METHODS: We examined 131 patients with diagnosis of IHD verified by coronary angiography and 159 subjects of control group. Initial information on each patient included the following parameters: traditional risk factors, laboratory parameters, results of instrumental examination, genetic markers. We studied 29 polymorphisms in 27 genes which according to international databases were associated with IHD. Genotype was assessed as 2 models: dominant and recessive. For each patient we calculated individual genetic index as sum of present polymorphic markers with addition of data of familial anamnesis. The data obtained were analyzed with the "RECOGNITION" system which used for solution of prognostication problems main approaches and algorithms of the theory of recognition by precedents. RESULTS: Accuracy of recognition varied from 70 to 75% with small number of traits and up to 90% on informative trait subsystems. The method "linear machine" showed the highest accuracy. The voting algorithm showed maximal accuracy of prognosis relative to some algorithms. In IHD prognostication most information systems comprised genetic markers, most significant of which was the genetic index representing sum of available polymorphic markers with addition of data of familial anamnesis. CONCLUSION: Analysis with the use of methods of recognition by precedents is a perspective technique for stratification of IHD risk and support of optimal decision making on prevention. The use of collectives of different methods of prognostication allows to increase accuracy of prognosis.

[Prediction of outcomes of surgical treatment of degenerative lumbar disk disease].

The paper focuses on algorithms of outcomes assessment of surgical treatment of the patients with degenerative lumbar disk disease. From 1997 to 2006 389 patients with discogenic lumbar pain were operated in the Medical Center of Central Bank of Russia. 185 patients underwent radiofrequency destruction of facet nerves, laser percutaneous lumbar discectomy was performed in 39 patients, microdiscectomy -- in 131, and decompression combined with lumbar spine stabilization -- in 31 cases. Clinical and radiological data of each patient were recorded in the database using 3-point scale according to intensity of the feature. Assessment of patients' condition was performed pre- and postoperatively (after discharge and after 6, 12 and 24 months interval). Postoperative outcome was recorded for the current period in compliance with modified criteria of Kawabata et al. Obtained data were mathematically and statistically processed. Developed algorithms allowed assessment of postoperative outcome in the patients with degenerative lumbar disk disease. Outcome data can be used for evaluation of feasibility of surgical treatment as well as for selection of surgical technique.

[The role of genetic predisposition in the development of cardiovascular diseases (myocardial infarction, ischemic stroke, unstable stenocardia) and its interaction with conventional risk factors].

To assess the risk of cardiovascular events, the diagnostic effectiveness of molecular-genetic markers (polymorphisms in APOE, ACE (I/D) and MTHFR (C677T) genes) in combination with conventional risk factors has been studied. The prognostic effectiveness of common algorithms (the Framingham scale) is not sufficient for evaluation of risk factors for cardiovascular diseases. The combination of results of molecular-genetic testing with conventional risk factors allows to increase the predictability of cardiovascular risks.

[D-dimer in diagnosis of acute thromboses of lower-limb deep veins].

Analysed herein is a potential role the D-dimer plays in diagnosis of acute venous thromboses of the lower limbs. The D-dimer blood plasma levels were determined in a total of 195 patients with either suspected or known acute thrombosis of the lower-limb deep veins. The D-dimer concentration was measured by the immunoturbidimetric method. Acute venous thrombosis (AVT) was either confirmed or negated by means of ultrasonographic scanning. Of the 195 patients examined, thrombosis in the system of the inferior vena cava was detected in 161 subjects, whereas in the remaining 34 cases the tentative diagnosis was not confirmed. Amongst the patients with established AVT, the D-dimer level was elevated in 156 (96.9%). Of the 34 patients with unconfirmed AVT, the test for the presence of D-dimer was negative in 20 (58.8%) patients and positive in 14 (41.2%) subjects. Hence, the sensitivity of the test understudy amounted to 96.9%, while its specificity did not exceed 58.8%. A direct correlation between the incidence of AVT and the D-dimer level was revealed. Given high sensitivity of the D-dimer in AVT, this test should be used in a suspicion for or a high risk of phiebothrombosis in order to reliably exclude the diagnosis if the result proves negative.

[Transillumination-assisted phlebectomy with the help of the TriVex system in comprehensive management of varicose disease of lower-limb veins].

The present work was undertaken to evaluate a new minimally invasive method of surgical management of varicose disease by means of the TriVex unit. The method is based on transillumination of saphenous veins in an aqueous medium, which makes it possible to perform radical removal thereof form separate punctures under visual control with the help of a specially designed vein stripper. Transillumination-assisted phlebectomy (TIP) was compared with microphlebectomy (MPE) according to the Varady's technique. We operated on a total of one hundred and eight patients suffering from varicose disease of the lower extremities. All of them underwent duplex scanning of the veins. Group One (study group) was composed of fifty-six patients subjected to TIP within the scope of a comprehensive treatment for varicose disease. Group Two consisted of fifty-two patients who were subjected to removal of varicosely altered affluents on the crus by means of microphlebectomy. The results of surgical management for varicose disease were analysed according to the following parameters, the duration of a surgical intervention, intensity of the pain syndrome in the postoperative extremity, a cosmetic outcome by visual analogue scales, and the incidence rate of complications. The obtained findings demonstratively showed that the duration of the operation in the study group was substantially shorter, averagely amounting to 35.5+/-6.2 minutes, as compared with as long as 65.0+/-6.2 minutes (P<0.0001) in the control group. The number of incisions in the study group turned out to be also significantly less than that in the control group, amounting to 4.0+/-1.3 vs. 12.0+/-2.5 (p<0.0001), which largely contributed to both a decrease in the level of the pain syndrome and obtaining aesthetically pleasing cosmetic outcomes. Hence, TIP being a minimally invasive procedure in surgical management of varicose disease, by its clinical efficiency appeared to be not inferior and at least equivalent to microphlebectomy, displaying at the same time certain advantages over the latter, consisting in the very positive cosmetic outcome obtained, a lesser operative injury inflicted, and shorter terms of rehabilitation of the patients involved.

[Analysis of efficacy of extensive systematic transperineal TRUS-guided cor biopsy of the prostate].

The paper presents the technique of extensive systemic transperineal TRUS-guided cor biopsy of the prostate. Some aspects of the patients' safety and quality of biopsy cores are considered. The analysis of TNM stages of the detected cancers (55 cases out of 142 patients who have undergone systemic biopsy) showed 65.4% of local cancer (T1-2). The quality of cores was adequate for histological examination in 92.8% cases. None serious complications was reported. Only in two of ten patients subjected to radical prostatectomy stage T2 was changed to stage T3 in the absence of metastases to regional lymph nodes and distant metastases.

[Prognosis of the severity of acute pancreatitis by the neural network method].

For prognozing the character of the development of acute pancreatitis a neural network of the direct spread of the signal was developed with 15 inlets, 5 neurons of the latent layer and two outlets. The network was trained with the help of an algorithm of an inverse spread of the error. The sensitivity of the produced prognostic model was 100%, specificity at admission--70%, on the first day--80%, on the second and third day--90%. Before the moment of hospitalization 57 patients were observed during 72 hours. The diagnosis was confirmed in all cases by the methods of computed tomography with contrast amplification.

[How to manage patients with atrial fibrillation in a general hospital]. / Problemy organizatsii vedeniia bol'nykh s fibriliatsiei predserdii v usloviiakh mnogoprofil'nogo statsionara.

AIM: To evaluate efficacy of use of technological charts (TC) in upgrading management and treatment safety in patients with atrial fibrillation (AF). MATERIAL AND METHODS: Two groups of AF patients were compared: 196 patients treated before introduction of TC (group 1) and 431 patients managed according to TC technology (group 2). RESULTS: In group 2 treatment duration reduced from 26.1 to 18.5 days, rehospitalizations occurred by 6% less frequently, number of unexpected side effects fell 2.5-fold, the rate of varfarin prescription for prevention of thromboembolic complications rose from 18 to 64%, the patients were satisfied with the treatment in 97% vs past 79%. CONCLUSION: TC was a tool of treatment improvement and introduction of the latest clinical recommendations into clinical practice with reference to facilities and staff qualification of an individual hospital without additional financial input.

[Significance of parameters of automated reticulocyte analysis in diagnosis and evaluation of treatment outcome in B12-deficient anemia]. / Znachenie pokazatelei avtomatizirovannogo analiza retikulotsitov dlia diagnostiki i otsenki éffektivnosti lecheniia B12-defitsitnoi anemii.

The results of examinations of reticulocytes in blood samples of 12 patients with the confirmed diagnosis of B12-deficit anemia and of 20 virtually healthy subjects (control group) by means of the GEN-S hematological analyzer (Beckman-Coulter) are described in the paper. Typical changes of the reticulocyte parameters are defined and their dynamics (with treatment by Vitamin B12) is studied. It was established that the additional parameters of the reticulocyte analysis, characterizing the quantity of immature reticulocytes and the fraction of immature reticulocytes, increase by 3 days before the total quantity of erythrocytes increases, which means that the above parameters can be used earlier as criteria in evaluating the treatment efficiency.

[Current technologies for enhancing efficiency of laboratory techniques]. / Sovremennye tekhnologii povysheniia éffektivnosti ispol'zovaniia vozmozhnostei laboratorii.

The current approaches to promoting the efficiency of applying the laboratory tools were comprehensively analyzed. It was for the first time that the above issue was considered from the standpoint of a scientifically substantiated management scheme applicable to the laboratory examination volume and within the framework of the modern conclusive medicine. The problem can be solved through starting, in each clinic, an independent research project and through patient management (critical course--technological card) with respect to available technological and personnel resources. Finally, the basic principles are outlined that are needed for designing the technological cards; the related role of experts in clinical laboratory diagnostics is demonstrated.