Effect of a Physiotherapist-Guided Home-Based Exercise Intervention on Physical Capacity and Patient-Reported Outcomes Among Patients With Acute Pulmonary Embolism: A Randomized Clinical Trial.

Importance: Survivors of acute pulmonary embolism (PE) experience long-term negative physical and mental consequences, but the effects of rehabilitation on outcomes among these patients have not been investigated. Objective: To investigate the effect of a rehabilitation intervention, comprising an 8-week home-based exercise program and nurse consultations, on physical capacity and patient-reported outcomes among patients with acute PE. Design, Setting, and Participants: This multicenter randomized clinical superiority trial was conducted at 4 regional hospitals and 1 university hospital in Denmark. The 140 consecutively included participants had been diagnosed with an acute PE between April 2016 and February 2018 and had 6 months of follow-up. An intention-to-treat analysis was conducted. Intervention: Patients in the control group received a brief nurse consultation, while patients in the exercise group participated in an 8-week home-based exercise program in addition to receiving nurse consultations. Main Outcomes and Measures: The primary outcome was the Incremental Shuttle Walk Test, and secondary outcomes were the Pulmonary Embolism Quality of Life and the EuroQol-5 Dimensions-3 Levels questionnaires, self-reported number of sick-leave days, and self-reported use of psychotropic drugs. Results: A total of 140 patients (90 [64.3%] men) were included, with a mean (SD) age of 61 (11) years. Of 70 participants (50.0%) randomized to each group, 69 participants (49.3%) received the intervention and 68 (48.6%) received the control intervention. Both groups achieved improvements in all outcomes (eg, mean [SD] improvement on Incremental Shuttle Walk Test: control group, 78 (127) m; intervention group, 104 [106] m; median [interquartile range] improvement on Pulmonary Embolism Quality of Life: control group, -17 [-22 to -11] points; intervention group, -20 [-24 to -15] points). Between-group differences were nonsignificant. The mean differences between the intervention group and the control group were 25 m (95% CI, -20 to 70 m; P = .27) on the Incremental Shuttle Walk Test, 3.0 points (95% CI, -3.7 to 9.9 points; P = .39) on the Pulmonary Embolism Quality of Life questionnaire, and 0.017 point (95% CI, -0.032 to 0.065 point; P = .50) on the EuroQol-5 Dimensions-3 Levels questionnaire. Of the 27 patients in the intervention group on sick leave at baseline, 24 (88.9%) reported fit-for-duty at the 6-month follow-up, and of 18 patients in the control group on sick leave, 17 (94.4%) reported fit-for-duty at the 6-month follow up. The between-group risk difference was not significant (5.5 points; P = .49). Conclusions and Relevance: An 8-week rehabilitation intervention with exercise added to nurse consultations did not show significantly better outcomes than nurse consultations alone. However, because of a ceiling effect on the primary outcome of physical capacity and an inclusion of patients with a low comorbidity burden and low PE disease severity, definitive conclusions could not be drawn. Initiating an exercise intervention shortly after pulmonary embolism was safe and without adverse events. Trial Registration: ClinicalTrials.gov Identifier: NCT02684721.

Instrument for Assessing Knowledge of Oral Anticoagulant Therapy: Construction and Validation.

BACKGROUND AND PURPOSE: A valid and reliable assessment tool is fundamental for evaluating the knowledge of individuals about using oral anticoagulant therapy (OAT). The purpose of this study was to develop a tool to assess knowledge about OAT and provide evidence to support its use in people living in developing countries. METHODS: Construction and validation: development of items; assessment of face and content validity; pilot study; application of the instrument to a sample of 500 users of OAT to analyze dimensionality, convergent validation, and reliability. RESULTS: Analysis of dimensionality suggested a unidimensional instrument. Direct correlation between knowledge of OAT and educational level was confirmed (r = .61, p < .001) (validity of construct). Reliability measured by KR-20 was 0.86. CONCLUSIONS: The new instrument was shown to be valid and reliable for assessing knowledge of OAT in the population studied.

Cuidados de Enfermería en el tromboembolismo pulmonar en urgencias extrahospitalarias / Nursing care of pulmonary embolism in out-of-hospital emergencies

El tromboembolismo pulmonar es una de las enfermedades tromboembólicas venosas más graves, tanto por su mortalidad como por el elevado número de complicaciones que lleva asociadas y por su repercusión en la calidad de vida. Las primeras horas son clave y su correcto manejo durante este periodo puede determinar las futuras secuelas. Por ello, en el ámbito extrahospitalario, la enfermera ha de tener los conocimientos y herramientas adecuadas para actuar de manera rápida y eficiente. En este trabajo presentamos el caso clínico de un varón de 77 años que en su domicilio particular, tras haber sido dado de alta de una intervención de prótesis de rótula, comienza con un cuadro compatible con tromboembolismo pulmonar. Se realiza un proceso de atención de Enfermería según los patrones funcionales de Margory Gordon y se elabora un plan de cuidados en base a la taxonomía NNN (NANDA, NOC, NIC). Como diagnóstico enfermero principal se selecciona «patrón respiratorio ineficaz» y como posible complicación potencial del tromboembolismo pulmonar se elige el «infarto pulmonar». Los resultados obtenidos tras llevar a cabo el plan de cuidados son satisfactorios, con una mejora de los signos y síntomas que presentaba el paciente, razón por la cual creemos que puede ser de utilidad para las enfermeras a la hora de enfrentarse a situaciones clínicas de características similares

Pulmonary embolism is one of the most severe venous thromboembolic diseases, both in mortality and the high number of associated complications and their impact on quality of life. The early hours are critical and proper management during this period can determine future sequels. Therefore, in the outpatient setting, nurses must have adequate knowledge and tools to act quickly and efficiently. In this paper, we present a case of a 77 year-old male in his home that after being discharged from a knee replacement surgery starts with symptoms compatible with pulmonary thromboembolism. A Nursing Care Process is performed, according to the functional patterns of Margory Gordon and a care plan is developed based on NNN taxonomy (NANDA, NOC, NIC). As main nursing diagnosis ‘ineffective breathing pattern’ is selected and as possible potential complication of the pulmonary embolism the ‘pulmonary infarction’ is chosen. The results obtained after conducting the care plan are satisfactory, improving the signs and symptoms presented by the patient, hence why we believe it is useful for nurses when facing similar clinical situations

[Nursing care of pulmonary embolism in out-of-hospital emergencies]. / Cuidados de Enfermería en el tromboembolismo pulmonar en urgencias extrahospitalarias.

Pulmonary embolism is one of the most severe venous thromboembolic diseases, both in mortality and the high number of associated complications and their impact on quality of life. The early hours are critical and proper management during this period can determine future sequels. Therefore, in the outpatient setting, nurses must have adequate knowledge and tools to act quickly and efficiently. In this paper, we present a case of a 77 year-old male in his home that after being discharged from a knee replacement surgery starts with symptoms compatible with pulmonary thromboembolism. A Nursing Care Process is performed, according to the functional patterns of Margory Gordon and a care plan is developed based on NNN taxonomy (NANDA, NOC, NIC). As main nursing diagnosis 'ineffective breathing pattern' is selected and as possible potential complication of the pulmonary embolism the 'pulmonary infarction' is chosen. The results obtained after conducting the care plan are satisfactory, improving the signs and symptoms presented by the patient, hence why we believe it is useful for nurses when facing similar clinical situations.

Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Derrame pleural por síndrome de Dressler / No disponible

El síndrome de Dressler (SD) se caracteriza por fiebre, dolor torácico de tipo pleurítico y derrame pericárdico después de 2-3 semanas de un infarto agudo del miocardio o lesión pericárdica; suele mejorar con AAS u otro AINE; los glucocorticoides se reservan para pacientes con dolor intenso y refractario. Se presenta el caso de un varón con derrame pleural (DP) secundario a SD en paciente con antecedente de cirugía cardiaca reciente recidivante y con mala evolución, en probable relación a tratamiento con dosis bajas de antiinflamatorios y rápido descenso de los mismos de forma inicial, presentando mejoría al reintroducir tratamiento a dosis altas y de forma prolongada

Dressler’s syndrome (DS) is characterized by fever, chest pleuritic pain and pericardial effusion that may appear 2-3 weeks after an acute myocardial infarction or pericardial injury and usually improves with aspirin or other NSAIDs; glucocorticoids reserved for patients with severe and refractory pain. The case of a man with pleural effusion (PE) secondary to DS with history of recent heart surgery, which was recurrent and poor outcome, probably related to treatment with low doses of anti-inflammatory and rapid decline of the same initial presenting improvement to reintroduce treatment with high doses and for long periods

Proactivity in VTE prevention: a concept analysis.

Venous thromboembolism (VTE) prevention is an international patient safety issue. The author has observed gaps in prescription and provision of VTE prophylaxis, and that the attitude to VTE is often reactive rather than proactive. This concept analysis aims to explore proactivity and apply it to VTE prevention to address this. Ten databases were searched (1992-2012) using the keywords proactive, proactivity, nurse, nursing, VTE/venous thromboembolism, prevent/prevention/preventing, behaviour, DVT/PE (deep vein thrombosis, pulmonary embolism). The Walker and Avant (2010) method of concept analysis identified the defining attributes as personal initiative, taking charge and feedback-seeking behaviour. Antecedents and consequences have been identified, and empirical referents are demonstrated. Defining proactivity in VTE prevention has the potential to increase prescription and, crucially, provision of prophylaxis, thereby improving patient care, reducing avoidable harm and improving the patient experience.

Care of the patient with an acute pulmonary embolism.

There are evidence-based prevention strategies known to reduce the risk of pulmonary embolism formation. However, pulmonary emboli remain a leading cause of death in critically ill patients with a 3-month mortality of 10% to 15%. This article addresses patients' risk factors, pulmonary embolism prevention strategies, clinical manifestations, and treatment modalities the interdisciplinary team should understand.

[A tool for the management of patients with pulmonary embolism]. / Un outil pour la prise en charge d'un patient atteint d'une embolie pulmonaire.

In order to develop materials for the validation of skills in the pulmonology intensive care unit, a steering committee on 'Learning situations' was created in the University Hospitals Paris-West (Hupo-AP-HP). A tool was developed based on knowledge and skills to be validated by students in the event of pulmonary embolism.

Improving rates of intermittent pneumatic compression therapy utilization.

BACKGROUND: The most preventable causes of death in the hospitalized patient are deep vein thrombosis (DVT) and pulmonary embolism. Despite the long-term (> 15 years) availability of evidence-based consensus guidelines for prevention of venous thromboembolism, thromboprophylaxis remains underused. Improving staff and patient utilization of prophylactic treatment for postoperative patients reduces hospital-acquired venous thromboembolism and improves patient outcomes. Anecdotal evidence and observations of intermittent pneumatic compression (IPC) therapy utilization at the authors' institution suggested that ordered IPC therapy was not consistently in use with postsurgical patients. OBJECTIVES: We sought to increase the use of IPC devices by all staff on our hospital pilot units and to promote sustained use of IPC devices. METHODS: Multiple methodologies were employed to address this issue, including point prevalence audits, root-cause analyses, a nursing survey, and a pilot project on selected surgical units. RESULTS: Statistically significant improvements on the pilot units were achieved by implementing a 3-tier interventional plan. CONCLUSION: Our pilot project demonstrated that nurse education, patient education, and nurse attention to solving systems issues can significantly improve IPC use in surgical patients.

Alteplase treatment of acute pulmonary embolism in the intensive care unit.

Acute pulmonary embolism accounts for 50 000 to 100 000 deaths each year in the United States. Because of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli, stratifying and treating patients according to their signs and symptoms is important when an acute embolism is suspected. Patients' clinical findings can range from no signs or symptoms to unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60% in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli, explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care unit also are discussed.

Pacientes con tratamiento anticoagulante oral. ¿qué saben sobre su tratamiento? / Profile of women with breast disease wich does self-exploration. Which are the factors associated with this practice?

Introducción. Los pacientes anticoagulados con tratamiento oral (ACO) deben tener unos conocimientos de los riesgos que dicho tratamiento conlleva. Para ello el personal sanitario debe formar tanto al paciente como a su familia. Objetivos. Determinar el nivel de adhesión terapéutica que tienen los pacientes tratados con ACO en una consulta de atención primaria (AP) y en un área de salud urbana, como Plasencia. Material y método. Se realizó un estudio observacional descriptivo retrospectivo con 34 pacientes con tratamiento ACO. Se recogen datos de patologías, parámetros biométricos de las historias clínicas y entrevistas a los sujetos que acuden a la consulta de enfermería. Resultados. Una vez analizados los datos, el número de pacientes –según el sexo– estaba igualado; no sucedía lo mismo por edades donde la población entre 80-90 años constituía el 26,5 % del total; dentro de las patologías de las que se deriva el tratamiento, la fibrilación auricular (FA) es la más frecuente, con un 50%, siguiéndole el tromboembolismo pulmonar, con un 23%. El control de los resultados se distribuía de la siguiente manera: los más jóvenes se controlaban en atención especializada (AE), en su hospital de referencia; los de mayor edad en AP. En relación con la adhesión al tratamiento y la patología principal, quienes padecían FA y portaban una prótesis valvular cumplían el tratamiento en mayor número. Discusión. Para el profesional sanitario es necesario conocer el perfil del paciente con ACO, y si este sabe los riesgos que conlleva el tratamiento. Los enfermos jóvenes con patología cardiovasculares son controlados en el hospital por sus mayores oscilaciones en los resultados; la población mayor es vigilada en la consulta de atención primaria (AP), y los residentes en zonas rurales cuentan con una mayor adherencia y un mejor control. Con una completa información el personal sanitario puede efectuar intervenciones que ayuden a la adhesión, seguimiento del control y tratamiento, así como a la colaboración de familiares(AU)

Background/Aims: In recent decades the fight against breast cancer has focused primarily on the treatment and secondary prevention (early detection mainly). In the case of breast self-examination, althought it has not been prove to reduce mortality, it is important in cases detected by women themselves (it is estimated 90% of total), mainly in the interval cancers. Objectives: To identify within women with breast cancer, how many do self-examination and identify associated factors. Describe the clinical and pathological features of cancers in women who do perform self-examination. Methodology: In women diagnosed with breast cancer during 2007 in a hospital in the province of Cadiz, Spain, is reconstructed in retrospect the story related the cancer process: symptoms, psychosocial factors that determine the contact with the health system, preventive practices (self-examination, mammography screening). A description of the pathological tumor: presenting symptom, tumor size, node negative, grade of differentiation… Results: We studied 149 women with breast cancer, from whom 52% did self-exploration. Women who performed self-examination were younger (54.78 years) against the women who did not (65.63 years), married (66.2%), active workers and have a higher educational level. The assessment of the first symptoms in these women as «important» is positively correlated with those women who practice self-examination. For other preventive practices, women who does self-examination are also the most actives in early detection programs (74.4% against 29.5% which didn’t do self-examination). For the pathologic characteristics of tumor in women who did self-examination: the tumor size was 2.5 cm, 50.7 / are well differentiated, and 59.1% of cases the nodes are negative. Conclusions: Women who does self-examination are younger, have higher educational level, are married, are active workers and are often involved in other preventive practices. On them, the tumors diagnosed have a smaller size, are diagnosed at earlier stages and usually present better degree of differentiation (AU)

Prevention of venous thromboembolism in hospitalized patients: analysis of reduced cost and improved clinical outcomes.

The impact of implementing a guideline on venous thromboembolism (VTE) prophylaxis was evaluated in a metropolitan private hospital with a before- and after-intervention study. This subsequent study aimed to identify if improved prophylaxis rates translated into cost savings and improved clinical outcomes. A conceptual decision-tree analytical model incorporating local treatment algorithms and clinical trial data was used to compare prophylaxis costs and clinical outcomes before and after the guideline implementation. The study analyzed data from 21,942 medical and surgical patients admitted to a 250-bed acute-care private hospital in Sydney, Australia. The modeled simulation estimated the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as adverse events such as heparin-induced thrombocytopenia (HIT), post-thrombotic syndrome (PTS), major bleeding, and mortality. The costs of prophylaxis therapy and treating adverse events were also calculated. The improvement in prophylaxis rates following the implementation of the guideline was estimated to result in 13 fewer deaths, 84 fewer symptomatic DVTs, 19 fewer symptomatic PEs, and 512 fewer hospital-bed days. Improved adherence to evidence-based prophylaxis regimens was associated with overall cost savings of $245,439 over 12 months. We conclude that improved adherence to evidence-based guidelines for VTE prophylaxis is achievable and is likely to result in fewer deaths, fewer VTE events, and a significant overall cost saving.

Awareness of patients who undergo cesarean section about venous thromboembolism prophylaxis.

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially life-threatening condition and the most well-known cause of postpartum maternal death, especially in patients undergoing cesarean section (CS). The aim of this study was to evaluate the level of awareness of VTE among patients who undergo CS. This study was cross-sectional, involving 230 patients who underwent CS at a major university hospital. A validated standardized questionnaire was used to determine the awareness of VTE among CS patients. Approximately 46% of the patients were aware of DVT, and 18.7% were aware of PE. Most patients recognized obesity or immobility as risk factors of DVT, and 22.6% of them recognized CS as a risk factor for DVT. Only 25.4% recognized pregnancy as a risk factor for DVT. The level of patient knowledge about both DVT and PE were not affected by parity. The study showed that most patients who underwent CS were not aware of VTE as a complication of CS and the factors that may increase its risk, which could reflect inadequate patient counseling/education on the part of healthcare professionals.

Prevención del tromboembolismo en cirugía bariátrica / Prevention of thromboembolism in bariatric surgery

La enfermedad tromboembólica (ETEV) es una de las complicaciones más importantes que pueden aparecer tras cualquier cirugía, y constituye la primera causa de muerte en el postoperatorio de cirugía bariátrica. Entre otros factores, se debe tener en cuenta que estos pacientes presentan un riesgo adicional de ETEV debido a la propia obesidad (IMC>30). Tras la cirugía bariátrica el riesgo de padecer eventos tromboembólicos varía según las series consultadas. En líneas generales, se estima que el peligro de EP (embolia pulmonar) es del 0,8% y el de TVP (trombosis venosa profunda) de 1,7%. La mortalidad global por ETEV se estima del 0,1 al 2%(AU)

Disease thromboembolic (ETEV) is one of the major complications that can occur after surgery, and is the leading cause of death in the postoperative period of Bariatric Surgery. Among other factors, should be aware that these patients are at additional risk of ETEV due to own obesity (IMC>30). After Bariatric Surgery the risk of thromboembolic events varies according to the surveyed series. In general, it is estimated that danger EP (pulmonary embolism) is 0.8% and DVT (deep vein thrombosis) of 1.7%. ETEV global mortality estimates of 0.1 to 2%(AU)

Acute pulmonary embolism.

Over the next 5 days, Mr. R continues to respond well to treatment. He'll continue on the prescribed warfarin regimen, with scheduled follow-up to evaluate his condition and adjust the dosage if necessary. He's instructed to continue wearing his GCS as an outpatient. Mr. R and his wife are given individualized instructions to prepare Mr. R for discharge. Mr. and Mrs. R participate in a thorough review of safe anticoagulation management, including the importance of taking warfarin exactly as prescribed. They're taught strategies to avoid missing a dose, and Mr. R is instructed not to take more than the prescribed dose. They're taught to recognize signs and symptoms of lower extremity DVT such as pain, redness, swelling, and warmth. Signs and symptoms of PE are also reviewed, including sudden onset of difficulty breathing, rapid respiratory rate, and pleuritic chest pain. If any of these symptoms occur, Mr. and Mrs. R are instructed to call emergency medical services immediately. The importance of postdischarge follow-up appointments with Mr. R's PCP is emphasized. Mr. R is advised to avoid eating foods or using supplements high in vitamin K. Mr. R is also encouraged to stay active, but to use caution to prevent injuries and avoid falls by engaging in activities such as walking and, when approved, swimming.