Explicit versus implicit risk assessment for the indication of antithrombotic prophylaxis in acutely ill medical in-patients.

QUESTIONS UNDER STUDY: The indication of venous thromboembolism (VTE) prophylaxis in acutely ill patients admitted to medical departments is not well-defined. Consensus groups have published recommendations and guidelines, addressing this issue. We investigated whether a guideline (explicit risk assessment) would improve the formerly used implicit risk assessment. METHODS: We compared two groups of patients consecutively admitted to our department during a 4-months period each. Group 1 was assessed prospectively and treated according to a guideline (explicit assessment). Group 2 consisted of the patients hospitalised in the four months prior to the introduction of the guideline (implicit assessment). Their data were abstracted retrospectively from the medical charts. Main outcome measures were symptomatic VTE and major bleedings, and the consumption of unfractionated (UFH) and fractionated (LMWH) heparins. Follow-up lasted until 90 days after hospital discharge. RESULTS: Symptomatic VTE occurred in 5/686 (0.7%) patients of group 1 vs 9/622 (1.4%) patients of group 2 during the hospital phase (p>0.05), and in 9/646 (1.4%) vs 10/572 (1.7%) during the whole study period (p>0.05). In group 1, 350 (51%) patients did not qualify for thromboprophylaxis according to the guideline, and none of them experienced any symptomatic VTE event. Three patients (0.5%) in group 1 and 4 patients (0.6%) in group 2 experienced a major bleeding event (p>0.05). Average consumption of UFH and LMWH did not differ between the groups. CONCLUSIONS: The introduction of a guideline for explicit assessment of thromboembolic risk was not significantly superior to the formerly used implicit assessment. However, based on the small number of events observed in this study, a minor advantage cannot be ruled out. Targeted indication for thromboprophylaxis, whether explicit or implicit, avoided application of UFH or LMWH in half of the patients in our setting.

Long-term antibiotic cost savings from a comprehensive intervention program in a medical department of a university-affiliated teaching hospital.

We tested a low-cost, multifaceted intervention program comprising formulary restriction measures, continued comprehensive education, and guidelines to improve in-hospital use of antibiotics and related costs. In a short-term analysis, total antibiotic consumption per patient admitted, which was expressed as defined daily doses (DDD), decreased by 36% (P < .001), and intravenous DDDs decreased by 46% (P < .01). Overall expenditures for antibiotic treatment decreased by 53% (100 US dollars per patient admitted). The 2 main cost-lowering factors were a reduction in prescription of antibiotics (35% fewer treatments; P < .0001) and more diligent use of 5 broad-spectrum antibiotics (23% vs. 10% of treatments; P = .001). Quality of care was not compromised. A pharmacy-based, prospective, long-term surveillance of DDDs and costs over 4 years showed an ongoing effect. This comprehensive intervention program, which aimed to reduce antibiotic consumption and costs, was highly successful and had long-lasting effects.

Dynamics of cytochrome P4502E1 activity in man: induction by ethanol and disappearance during withdrawal phase.

BACKGROUND/AIMS: Chronic ethanol consumption results in the induction of hepatic cytochrome P4502E1 (CYP2E1) in man, which is believed to play an important role in the pathogenesis of alcoholic liver disease. However, the amount and duration of alcohol intake associated with CYP2E1 induction is not known but limited information is available on the disappearance of CYP2E1 following alcohol withdrawal. METHODS: To study these questions, five healthy male volunteers received ethanol daily (40 g/day) over 4 weeks. CYP2E1 induction was monitored by using the chlorzoxazone test before and every week following the start of alcohol ingestion. In addition, CYP2E1 was also determined in five alcoholics 1, 3, 8 and 15 days following ethanol withdrawal and in five patients with non-alcoholic liver disease. RESULTS: A significant CYP2E1 induction occurred 1 week following the ingestion of 40 g ethanol per day and increased further after 4 weeks. The disappearance of CYP2E1 was found to be significant 3 days following ethanol withdrawal and further decreased up to day 8. Thereafter, no significant change occurred and CYP2E1 activities were comparable with those in patients with non-alcoholic liver disease. CONCLUSIONS: These data show a significant and quick induction of CYP2E1 activity, already at moderate alcohol consumption, which may be of importance in the pathogenesis of alcoholic liver disease, of ethanol, drug and vitamin A interactions and in alcohol associated carcinogenesis.