Comparative efficacy and safety of pharmacological prophylaxis and intermittent pneumatic compression for prevention of venous thromboembolism in adult undergoing neurosurgery: a systematic review and network meta-analysis.

Whether intermittent pneumatic compression (IPC) is a more effective form of thromboprophylaxis than anticoagulants in individuals undergoing neurosurgery remains controversial. Relevant studies are sparse and inconsistent. Therefore, direct comparisons are difficult to perform and impractical. Hence, we summarized and compared the efficacy and safety of IPC and anticoagulants for the prevention of venous thromboembolism (VTE) in adults undergoing cranial or spinal procedures. Several electronic databases were searched for randomized controlled trials on the use of IPC and anticoagulants for thromboembolism prevention in neurosurgical patients, from inception to August 6, 2019. Studies reporting the selected endpoints were included in direct and Bayesian network meta-analyses to estimate the relative effects of the interventions. Overall, our analysis included 18 trials comprising 2474 patients. Both IPC (RR, 0.41; 95% CrI, 0.26-0.60) and chemical prophylaxis (RR, 0.48; 95% CrI, 0.28-0.68) were found to be more efficacious than the placebo in reducing the risk of deep vein thrombosis (DVT). In addition, our analysis also demonstrated that both IPC (RR, 0.10; 95% CrI, 0.01-0.60) and chemical prophylaxis (RR, 0.31; 95% CrI, 0.05-1.00) reduced the risk of pulmonary embolism (PE) significantly more than the placebo. Based on the available evidence of moderate-to-good quality, IPC is equivalent to anticoagulants for thromboprophylaxis in terms of efficacy. Evidence to support or negate the use of pharmacological prophylaxis in terms of safety is lacking. The results of ongoing and future large randomized clinical trials are needed.

Correlation of disease comorbidity with prescribed treatment among insured U.S. lymphedema patients.

OBJECTIVE: The objective of this study was to define the current forms of treatment in a contemporary population of lymphedema (LED) patients for LED related to breast cancer, the most prevalently diagnosed LED comorbidity in Western countries, and phlebolymphedema with venous leg ulcer (PLEDU), a sequela of chronic venous disease. The goals of LED therapy are to reduce edema, thereby improving function and related symptoms, and to improve skin integrity to prevent development of infection. Treatment is generally nonsurgical: conservative care, including complex physical therapy, manual lymphatic drainage, and compression bandaging; or pneumatic compression device (PCD) therapy by a simple nonprogrammable device or an advanced programmable device. METHODS: To determine the frequency of individual types of treatment for LED and their relationship to breast cancer-related lymphedema (BCRL) and PLEDU, we queried claims from a deidentified Health Insurance Portability and Accountability Act-compliant commercial administrative insurance database with >165 million members. A total of 26,902 patients identified with LED who had been enrolled with continuous medical benefits for 12 months before and after the index date for the complete years 2012 through 2016 were separated into four treatment categories: no treatment, conservative care, simple PCD (SPCD), and advanced PCD. LED treatment was related to the BCRL and PLEDU comorbidities. RESULTS: BCRL patients, who represented 32.1% of all study patients, made up 41% of all patients receiving conservative care and 24% of patients receiving PCD therapy. By contrast, PLEDU patients (9.6% of study patients) were proportionally under-represented in the conservative care group (7.8%) but composed a disproportionately high share of the PCD therapy group (17.7%). PLEDU patients represented 23.5% of all LED patients prescribed SPCD therapy, whereas BCRL patients composed 10.3% of total LED patient SPCD prescriptions (P < .001). CONCLUSIONS: Our analysis of a large health care administrative database showed clear differences between the way BCRL and PLEDU patients are treated. Compared with BCRL patients, PLEDU patients were less likely to receive conservative care and more likely to be prescribed SPCDs for pneumatic compression therapy. These differences suggest that lymphatic therapy may be undervalued for treatment of chronic venous swelling and prevention and treatment of PLEDU.

Effectiveness of Sequential Compression Devices in Prevention of Venous Thromboembolism in Medically Ill Hospitalized Patients: A Retrospective Cohort Study

Objective: To evaluate the effectiveness of sequential compression devices (SCDs) for venous thromboembolism (VTE) prevention in medically ill hospitalized patients. Materials and Methods: Adult patients admitted to a teaching hospital from April 2015 to March 2016 were included. Patients on anticoagulants with or without SCDs were excluded. We analyzed VTE risk, length of hospital stay, and other comorbidities among propensity score-matched patients on SCDs and those without thromboprophylaxis (NONE). Results: Among 30,824 patients, 67 patients (0.22%) developed VTE during their hospital stays, with deep vein thrombosis (DVT) in 55 cases and pulmonary embolism (PE) in 12. VTE was seen in 47 out of 20,018 patients on SCDs (41 DVT, 6 PE) and 20 out of 10,819 patients without SCDs (14 DVT, 6 PE). Risk-adjusted analysis showed no significant difference in VTE incidence in the SCD group compared to NONE (odds ratio 0.99, 95% confidence interval 0.57-1.73, p=0.74). Conclusion: Compared to the NONE group, SCDs are not associated with decreased VTE incidence during hospital stay.

Current Trends in Breast Augmentation: Analysis of 2011-2015 Maintenance of Certification (MOC) Tracer Data.

BACKGROUND: Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. OBJECTIVES: The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. METHODS: A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. RESULTS: There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were "not applicable" or "other" in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. CONCLUSIONS: Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015.

Effect of intermittent pneumatic compression on disability, living circumstances, quality of life, and hospital costs after stroke: secondary analyses from CLOTS 3, a randomised trial.

BACKGROUND: The results of the CLOTS 3 trial showed that intermittent pneumatic compression (IPC) reduced the risk of deep vein thrombosis and improved survival in immobile patients with stroke. IPC is now being widely used in stroke units. Here we describe the disability, living circumstances, quality of life, and hospital costs of patients in CLOTS 3. METHODS: In CLOTS 3, a parallel group trial in 94 UK hospitals, immobile patients with stroke from days 0 to 3 of admission were assigned with a computer-generated allocation sequence in a 1:1 ratio to IPC or no IPC through a central randomisation system. We followed up patients at about 6 months with postal or telephone questionnaire to assess the secondary endpoints: disability (Oxford Handicap Scale [OHS]), living circumstances, health-related quality of life (EQ5D-3L), and hospital costs (based on use of IPC and length of hospital stay). Patients and carers who completed the postal questionnaires were not masked to treatment allocation, but telephone follow-up in non-responders was masked. All analyses were by intention to treat. This trial is registered, number ISRCTN93529999. FINDINGS: Between Dec 8, 2008, and Sept 6, 2012, we enrolled 2876 patients, with 1438 in each group. Despite the previously reported reduction in the risk of proximal deep vein thrombosis at 30 days (primary endpoint), there were no significant differences in disability (OHS 0-2 vs 3-6, adjusted odds ratio [OR] 0·98, 95% CI 0·80 to 1·19, p=0·83; adjusted ordinal analysis common OR 0·97, 95% CI 0·86 to 1·11), living circumstances (institutional care vs not; adjusted OR 1·11, 95% CI 0·89 to 1·37; p=0·358), or health-related quality of life (median utility value 0·26, IQR -0·07 to 0·66 with IPC, and 0·27, -0·06 to 0·64, with no IPC; p=0·952). The estimated cost of IPC was £64·10 per patient (SD 28·3). The direct costs of preventing a deep vein thrombosis and death were £1282 (95% CI 785 to 3077) and £2756 (1346 to not estimable), respectively, with IPC. Hospital costs increased by £451 with IPC compared with no IPC because of a longer stay in hospital (mean 44·5 days [SD 37·6] vs 42·8 days [37·2]; mean difference 1·8 days, 95% CI -1·0 to 4·5). By 6 months, despite an increase in survival (IPC 152·5 days [SD 60·6] vs no IPC 148·1 days [64·3]; mean difference 4·5 days, 95% CI -0·2 to 9·1), there was a non-significant increase in quality-adjusted survival associated with IPC (IPC 27·6 days [SD 40·6] vs no IPC 26·7 days [39·6]; mean difference 0·9 days, 95% CI -2·1 to 3·9). INTERPRETATION: IPC is inexpensive, prevents deep vein thrombosis, improves survival but not functional outcomes, and does not lead to a significant gain in quality-adjusted survival. When deciding whether to treat patients with IPC, clinicians need to take into account all these potential effects. FUNDING: National Institute of Health Research Health Technology Assessment Programme, Chief Scientist Office of Scottish Government, and Covidien.

[New aspects of stroke medicine]. / Neues aus der Schlaganfallmedizin.

Systemic thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) remains the only effective and approved medical treatment of acute ischemic stroke. Several studies have demonstrated the importance of rapid recanalization. The efficacy of thrombectomy has so far not been sufficiently shown in randomized clinical trials; therefore, inclusion of suitable patients in one of the currently ongoing randomized trials is of great importance. The early treatment with magnesium after acute ischemic stroke during the pre-hospital phase did not prove to be neuroprotective. Intermittent pneumatic compression of the lower extremities in immobilized stroke patients effectively prevents deep venous thrombosis and pulmonary embolism. In patients with lacunar stroke the combination of aspirin and clopidogrel is not superior to aspirin alone and causes more bleeding complications. The novel oral anticoagulants are superior to warfarin in secondary prevention and carry a lower risk of intracranial and systemic bleeding complications. New studies will investigate whether dabigatran or rivaroxaban are superior to aspirin in secondary prevention after cryptogenic stroke.

[Cardiosynchronized sequential antegrade pneumocompression in treatment of patients with multifocal atherosclerosis].

The work was aimed at assessing efficacy and safety of indications for and contraindications to a promising method of treatment for multifocal atherosclerosis - enforced external counterpulsation, suggesting a new noninvasive method of treatment of chronic obliterating diseases of lower-limb arteries - cardiosynchronized sequential antegrade pneumocompression.

New advances in compression therapy for venous leg ulcers.

Leg ulceration, often caused by venous stasis, arterial insufficiency, or both, is a common chronic health condition often associated with a prolonged healing trajectory and frequent recurrence. It is estimated that approximately 1.5 to 3.0 per 1,000 adults have active leg ulcers, and the prevalence continues to increase due to an aging population. Management of chronic edema using compression is crucial to promote healing of venous leg ulcers. The principle of compression therapy is simple, involving the use of external pressure in the forms of bandages or wraps to move the fluid from the interstitial space back into the intravascular compartment and prevent reflux. This article synthesizes and appraises the evidence for various types of compression therapies. It also addresses best practice recommendations for the management of leg ulcers when arterial circulation is considered suboptimal.

[Treatment for chronic obliterating diseases of lower limb arteries].

The work is dedicated to a new method of treatment for chronic obliterating diseases of lower limb arteries - cardiosynchronized sequential antegrade pneumocompression. The author describes the basic principles of the method, its physiological effects, and the results of treatment on volunteers.

Fundas de compresión neumática intermitente / Intermitent pneumatic compression hosiery

La utilización de sistemas de compresión gradual, como terapéutica asociada para el control de las patologías tromboembólicas, está comúnmente extendida (medias compresivas graduales, vendaje con vendas de crêpe…), aunque incrementa las cargas de trabajo para el profesional de enfermería, y su indicación son limitadas en pacientes de alto riesgo. Se ha generalizado la necesidad de utilizar dispositivos mecánicos, ampliamente reconocida por un nivel de evidencia razonable, para el control de la enfermedad tromboembólica venosa en aquellos enfermos con alto riesgo de sangrado en los que no es posible, o bien cuando está limitado el uso de fármacos para controlar dicha complicación en el paciente encamado. La compresión neumática intermitente (CNI) está integrada en buena parte de recomendaciones y guías de práctica clínica de asociaciones científicas y entidades especializadas como la American College of Chest Physicians (ACCP), y National Institute for Health and Clinical Excellence (NICE), entre otras. Por ello, queremos mostrar la sencillez de manejo de un dispositivo altamente eficaz en la prevención enfermedad tromboembólica venosa (ETEV), y cómo puede reducir las cargas de trabajo del personal de enfermería, a la vez que nos garantiza cuidados de alta calidad(AU)

The use of gradual compression systems (gradual compression hosiery, bandages composed of crepe strips,…) as therapeutic measures associated with the control of thromboembolic pathologies is a rather extensive common practice although their use increases the work load generated for nursing professionals; while at the same time, they have some indications to bear in mind and limited efficiency for use on high risk patients. The need to utilize mechanical devices has become a generally accepted practice, widely recognized as having a reasonable effectiveness level, to control thromboembolic vascular diseases on those bedridden patients who have a high risk of bleeding on whom the use of drugs to control this complication is not possible, or is limited. Intermitent pneumatic compression is integrated in the majority of recommendations and clinical practice guides published by scientific associations and specialized agencies such as the American College of Chest Physicians (ACCP), National Institute for Health and Clinical Excellence (NICE), among others. Therefore, the authors want to demonstrate the easy handling of a highly effective device to help prevent venous thromboembolic disease, and how it is possible to reduce the workload for nursing personnel while at the same time guarantee high quality care(AU)

Intermittent pneumatic compression - systems and applications.

PRIMARY OBJECTIVE: The purpose of this review is to survey the types of intermittent pneumatic compression systems that are currently used, and their medical applications. MAIN OUTCOMES AND RESULTS: Intermittent compression devices have taken many forms since their initial development, but medical justifications for particular properties of cuff design, compression timing and pressure are often weak. Intermittent compression is well established, and effective in the prevention of deep vein thrombosis (DVT) and reduction of lymphoedema. Other therapeutic applications, such as in chronic arterial and venous disease, are not yet as well accepted, but may become more popular as published evidence increases. CONCLUSIONS: The full potential of intermittent pneumatic compression has probably not yet been realized, and requires better quality research. System design must follow physiological evidence, and while complexity in that design may allow greater therapeutic flexibility, it may incur greater financial cost, difficulty in use, and in the prevention of DVT in particular may be unnecessary.

Drenagem linfática manual e compressão pneumática em linfedemas de membro superior / Manual lymphatic drainage and pneumatic compression in upper limb lymphedema

O objetivo do artigo foi analisar a resposta linfática após acompanhamento terapêutico de linfedemas de membro superior utilizando-se as técnicas de drenagem linfática manual seguidas da compressão pneumática seqüencial em pacientes submetidas a cirurgia por câncer de mama. A amostra foi dividida aleatoriamente em dois grupos: grupo 1, pacientes submetidas a drenagem linfática manual (n = 6), e grupo 2, pacientes submetidas a drenagem linfática manual seguida de compressão pneumática (n = 10). Todas as voluntárias realizaram avaliação perimétrica inicial e, ao término das dez intervenções, uma avaliação final. Após a realização das intervenções fisioterapêuticas, as médias das medidas perimétricas finais do grupo 1 foram menores em todos os pontos avaliados (18,08±0,970; 14,96±0,516; 19,17±1,751; 23,18±2,482; 27,83±2,442; 29,58±2,268; 38,50±1,897, P < 0,05). Da mesma forma, as médias das medidas perimétricas finais do grupo 2 também foram menores em todos os mesmos sete pontos avaliados (18,10±1,206; 16,24±1,200; 21,72±2,587; 26,22±2,754; 30,61±4,071; 32,38±4,860; 40,30±4,043, P<0,05). A relação das medidas perimétricas dos membros superiores tratados dos dois grupos mostra que as médias dessas medidas nas pacientes do grupo 1 foram menores em relação às do grupo 2, apresentando valores com diferença significativa nas variáveis 2, 3 e 4. A relação das medidas perimétricas dos membros superiores tratados dos dois grupos mostra que as médias dessas medidas nas pacientes do grupo 1 foram menores em relação aos membros superiores tratados do grupo 2.

The aim of the study was to analyse the lymphatic response after treatment of upper limb lymphedema using by techniques of manual lymphatic drainage alone or followed of the sequential pneumatic compression in patients submitted to the breast cancer Surgery. The sample was at random divided in two groups: group 1 - submitted to the manual lymphatic drainage (n = 6) and group 2 - submitted to the manual lymphatic drainage followed of pneumatic compression (n = 10). All the volunteers had carried through a perimetrical initial evaluation and at the end of the 10 interventions, a final evaluation. After the accomplishment of the physical therapy interventions, the averages of the final perimetrical measures of group 1, had been lesser in all points evaluated (18,08±0,970; 14,96±0,516; 19,17±1,751; 23,18±2,482; 27,83±2,442; 29,58±2,268; 38,50±1,897, P< 0,05). In the same way, the averages of the final perimetrical measures of group 2, had also been lesser in all same seven evaluated points (18,10±1,206; 16,24±1,200; 21,72±2,587; 26,22±2,754; 30,61±4,071; 32,38±4,860; 40,30±4,043, P<0,05). The perimetrical analyses of treated upper limbs in two groups showed that the average in group 1 were lower when compared to the group 2 with significant difference in the 2, 3 and 4 dates. The relation of the perimetrical measures of the upper limb treated in both groups showed that the averages of these measures in the patients of group 1 had been lesser in relation to the upper limb treated to group 2.