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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism &#40;VTE&#41; in nonsurgical patients represents 75&#37; of all cases of VTE in hospitalized patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;2</span></a> Despite the effectiveness of thromboprophylaxis&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> recent international<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> and national<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> studies have shown that the procedure is often omitted&#44; reaching only 25&#8211;36&#37; of medical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the magnitude of the problem and to determine the adequacy of thromboprophylaxis in hospitalized medical patients in our setting and the potential areas for improvement&#44; we conducted an observational descriptive study using the 2012 recommendations of the American College of Chest Physicians &#40;ACCP&#41; as the gold standard&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We included all patients hospitalized in the Department of Internal Medicine of University Clinic Hospital of Valladolid over 2 weeks&#44; excluding those who were treated with long-term anticoagulation and those hospitalized for acute VTE&#46; We collected demographic variables&#44; the reason for hospitalization&#44; contraindications for anticoagulation&#44; risk factors for VTE and hemorrhage and the type of thromboprophylaxis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 191 hospitalized patients&#44; 112 met the inclusion criteria and constituted the study population&#46; The patients&#8217; mean age was 75&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;5 years&#44; 61 &#40;46&#37;&#41; were women&#44; and 48 &#40;43&#37;&#41; had a glomerular filtration rate &#60;60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; The most common reason for hospitalization was infectious diseases &#40;44 patients&#44; 39&#46;2&#37;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Twenty-six patients &#40;23&#37;&#41; presented some contraindication for anticoagulation &#40;in 94&#37; of the cases&#44; they were relative&#41;&#46; One hundred patients &#40;89&#37;&#41; had VTE risk factors&#44; the most common of which were severe acute infection &#40;43 cases&#44; 42&#37;&#41;&#44; prolonged immobility &#40;40 cases&#44; 35&#37;&#41;&#44; diabetes mellitus &#40;32 cases&#44; 28&#37;&#41;&#44; bedridden for more than 4 days &#40;26 cases&#44; 23&#37;&#41;&#44; obesity &#40;19 cases&#44; 17&#37;&#41; and heart failure &#40;16 cases&#44; 14&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sixty-nine patients &#40;62&#37;&#41; had a high VTE risk &#40;according to the Padua Prediction Score<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> &#91;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#93;&#41;&#44; and 16 &#40;14&#37;&#41; patients had a high hemorrhagic risk &#40;score &#62;7 on the hemorrhagic risk scale developed from the IMPROVE registry<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> &#91;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#93;&#41;&#46; Prophylactic treatment was started with low-molecular-weight heparin &#40;LMWH&#41; in 77 patients &#40;69&#37;&#41;&#59; physical measures were not used in any case&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In accordance with the 2012 ACCP recommendations&#44; 62 patients &#40;55&#37;&#41; received appropriate thromboprophylaxis&#44; while 32 &#40;29&#37;&#41; were overtreated and 18 &#40;16&#37;&#41; were undertreated&#46; Of the overtreated patients&#44; 22 &#40;69&#37;&#41; were patients with low-risk VTE treated with LMWHs&#44; 7 &#40;22&#37;&#41; were patients with high-risk VTE with LMWH doses greater than indicated&#44; and 3 &#40;9&#41; were patients with high-risk VTE with high hemorrhagic risk or contraindication for pharmaceutical prophylaxis who were treated with LMWHs&#46; As for the undertreated patients&#44; 10 &#40;55&#37;&#41; had high-risk VTE with no contraindication for prophylaxis and were not treated with LMWHs&#59; 8 &#40;44&#37;&#41; were patients with high-risk VTE with a high hemorrhagic risk or contraindication for pharmaceutical prophylaxis&#44; who were not administered physical measures&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">This study revealed areas of improvement in the thromboprophylaxis practiced in our setting&#44; given that its adequacy &#40;55&#37;&#41; was lower than that of other national<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5&#44;9</span></a> and international studies&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> This is partly explained by the broad definition of overtreatment used in the study&#44; which represented the leading cause of inadequacy &#40;29&#37; of all patients included in the study&#41;&#46; Although most of the hospitalized patients had a high risk of VTE &#40;62&#37;&#41; and therefore an indication for thromboprophylaxis&#44; the rest of the patients did not require it&#46; The use of objective VTE and hemorrhagic risk assessment scales would help improve the adequacy of thromboprophylaxis&#44; thereby avoiding the almost systematic prescription of LMWHs during patient admission&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As with other series&#44; it is worth noting the scarce use of physical measures of thromboprophylaxis&#46; Although there is no solid evidence of their use in medical patients&#44; these physical measures are a good alternative for those with a high VTE risk and contraindication for LMWHs<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> &#40;9&#46;8&#37; of the patients in our series&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our center has therefore implemented improvement activities&#44; such as updating the thromboprophylaxis protocol&#44; the use of VTE and hemorrhage risk scales for adjusting the thromboprophylaxis to the patient&#39;s risk&#44; the dissemination of these scales during training sessions with all department practitioners and through pocket guides &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; However&#44; these passive methods are not sufficiently effective&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> We will therefore continue getting feedback from practitioners&#44; analyzing activity registries and following the protocol &#40;individual&#47;group benchmarking&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; the adequacy of thromboprophylaxis in hospitalized medical patients is low in our setting&#46; 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Journal Information
Vol. 218. Issue 2.
Pages 112-114 (March 2018)
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Vol. 218. Issue 2.
Pages 112-114 (March 2018)
Correspondence
Areas of improvement in thromboprophylaxis of hospitalized medical patients
Áreas de mejora en la tromboprofilaxis de pacientes médicos hospitalizados
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M. Martín Asenjo
Corresponding author
miguel.martin.asenjo@gmail.com

Corresponding author.
, J.M. Martín Guerra, I. Usategui Martín, L.A. Sánchez Muñoz
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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