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ABSTRACT: Venous thromboembolism (VTE) is a major problem for hospitalized patients. Nevertheless, adherence to VTE prophylaxis guidelines is suboptimal, partly because of physicians' neglect due to excessive workload. Simplified risk assessment methods (RAMs) facilitate timely risk stratification and thromboprophylaxis. However, the accuracy of such RAMs has not been extensively studied. Using the prospectively collected data from hospitalized patients of Masih-Daneshvari Hospital, we tested the accuracy of the Goldhaber RAM and the Harinath and St. John RAM for VTE prophylaxis, compared with the eighth edition of the American College of Chest Physicians (ACCP) recommendations. We evaluated 1091 patients. With reference to the ACCP recommendations, both RAMs had high specificities for detection of patients at risk of VTE (97.33 and 99.11%, respectively); however, we found significant interdepartment differences. The Goldhaber RAM had superior accuracy in medical oncology patients (P = 0.03), whereas the Harinath and St. John method was superior among surgical patients (P < 0.001). Overall accuracies of Goldhaber RAM for appropriate VTE risk assessment and for proper detection of at-risk patients were close to 60%. Corresponding figures were close to 70% for the Harinath and St. John method. Simplified VTE prophylaxis RAMs are valuable, especially for transmitting electronic alerts and for timely risk assessment and thromboprophylaxis. Both of the studied RAMs had high specificities and positive-predictive values, minimizing the risk of overprophylaxis. Improving the sensitivity of such RAMs can help for timely risk assessment for a greater array of real-world patients.
Blood coagulation & fibrinolysis: an international journal in haemostasis and thrombosis 01/2013; · 1.25 Impact Factor
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ABSTRACT: Pulmonary embolism is major cause of hospital death. Clinical prediction rules such as Wells' prediction rules can help in selection of at-risk patients who need further testing for pulmonary embolism. We evaluated the usefulness of such criteria for detection of patients with diagnosed pulmonary embolism. Patients enrolled in National Research Institute of Tuberculosis and Lung Disease (NRITLD) deep venous thrombosis (DVT) registry were evaluated and those with objective data about presence or absence of pulmonary embolism were selected for this study. Diagnosis of pulmonary embolism was based on computed tomography pulmonary angiography (CTPA). We calculated the embolic burden in those with CTPA-confirmed pulmonary embolism. Eighty-six patients entered the study (58 males, 28 females, mean age = 54.39 ± 1.74 years). Fifty-four cases had coexisting pulmonary embolism (embolic burden score: 10.77 ± 1.181). Embolic burden score was correlated to presence of massive pulmonary embolism (Pearson rho: 0.43, P = 0.002). There was no association between Wells' pulmonary embolism score and the occurrence of pulmonary embolism (Spearman's rho: 0.085, P = 0.51). Dividing the patients into two, or three, risk groups according to Wells' model did not reveal an association with occurrence of pulmonary embolism either (P = 0.99 and P = 0.261, respectively). Tachycardia and hemoptysis were the only parameters from the Wells' pulmonary embolism score correlated to presence of pulmonary embolism (Spearman's rho: 0.373, P < 0.000 and Spearman's rho: 0.297, P = 0.005, correspondingly). Wells' pulmonary embolism score could not predict the occurrence of pulmonary embolism in DVT patients suspected of having coexisting pulmonary embolism. Until further studies shed light on this patient subset, overreliance on Wells' prediction rules as the solo decision making tool should be cautioned.
Blood coagulation & fibrinolysis: an international journal in haemostasis and thrombosis 08/2012; 23(7):614-618. · 1.25 Impact Factor
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Babak Sharif-Kashani,
Payman Shahabi,
Sasan Raeissi, Neda Behzadnia,
Alireza Shoaraka,
Mahan Shahrivari,
Leila Saliminejad,
Saviz Pozhhan,
Mohammad-Reza Hashemian,
Mohammad-Reza Masjedi,
Behnood Bikdeli
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ABSTRACT: Background: Venous thromboembolism (VTE) accounts for several cases of in-hospital mortality (over 100 000 deaths annually in the West). Despite the existence of effective prophylaxis guidelines for at-risk patients, the guidelines adherence is missing. Methods: We evaluated the thromboprophylaxis reception and appropriateness based on the eighth edition of the American College of Chest Physicians (ACCP) guidelines on VTE prophylaxis, among hospitalized patients of a World Health Organization (WHO)-collaborating teaching hospital in a 3-month period. Results: From the 904 evaluated cases, 481 entered the study. Appropriate decision on whether to prophylaxe or not, was made in 305 (63.40%), however, complete appropriateness (considering correct regimen type, dosing, and duration) was seen only in 229 patients (47.60%). The ACCP risk for VTE was the strongest predictor of thromboprophylaxis prescription (odds ratio [OR]: 2.62, 95% confidence interval [CI]: 1.35-5.05). Conclusions: Our thromboprophylaxis results were comparable to that of Western countries. Improved thromboprophylaxis appropriateness, which requires improving the physicians' thromboprophylaxis awareness and knowledge, could reduce the rate of in-hospital VTE and translate into better patient care.
Clinical and Applied Thrombosis/Hemostasis 03/2012; 18(5):462-8. · 1.33 Impact Factor
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ABSTRACT: Venous thromboembolism (VTE) is a major cause of in-hospital mortality. Several international guidelines provide thromboprophylaxis recommendations; however, guidelines adherence is missing worldwide. We evaluated the chest physicians' knowledge regarding VTE prophylaxis, using a systematically developed questionnaire. The Prophylaxis-foR-venOus-throMbOembolism-assessmenT-questionnairE (PROMOTE) questionnaire was developed using an algorithm encompassing the most important VTE prophylaxis topics and included 13 clinical scenarios. Responses were evaluated with reference to the eighth edition of American College of Chest Physicians guidelines for VTE prevention to assess thromboprophylaxis appropriateness. The questionnaires were distributed during the fourth International Congress on Pulmonary Disease, Intensive Care and Tuberculosis. From the 88 received questionnaires (response rate: 39.8%), 82 were acceptable (62 men, 20 women). The most commonly cited VTE risk factors were immobility (79.2%), surgery (68.2%), and cancer (60.9%). The mean correct response ratio to the questions was 67% [95% confidence interval (CI) 64-70%] with highest appropriateness ratios amongst cardiologists (77.1 ± 5.8%) and lowest ratios among thoracic surgeons (59.2 ± 5%). Physicians' specialty had a significant effect on the overall appropriateness (P = 0.04) and most of appropriateness subcategories. Thoracic surgeons had the lowest rate of over-prophylaxis (P = 0.02). Years passed from graduation were inversely associated with overall appropriateness (P = 0.006). Physicians with academic engagements had a higher overall appropriateness (P = 0.04). We found a wide gap between the guideline recommendations and the responses. PROMOTE is the first systematically developed questionnaire that addresses chest physicians' thromboprophylaxis knowledge and could be useful to strategies to improve VTE prophylaxis. Because of the dissimilar prophylaxis pitfalls of different specialists, distinct educational programs seem necessary to improve their knowledge of proper VTE prophylaxis.
Blood coagulation & fibrinolysis: an international journal in haemostasis and thrombosis 12/2011; 22(8):667-72. · 1.25 Impact Factor
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ABSTRACT: Warfarin is widely used anticoagulant drug for the prophylaxis and treatment of venous and arterial thromboembolic disorders and exerts its anticoagulant effect by inhibiting the vitamin K epoxide reductase. To determine the impact of genetic variants of the vitamin K epoxide reductase complex subunit 1 gene (VKORC1) on the anticoagulant response to warfarin, polymorphisms in exon 1, exon 3, and 3'-untranslated region (3' UTR) were assessed. Results: Sixty patients (34 males and 26 females) with stable INR (2-3) were selected from cardiology and anticoagulant clinic. Three VKORC1 frameshift mutations were detected. The first frameshift mutation was nucleotide deletion (91delCC) in exon 3 (1 patient). The second variation was nucleotide addition (51addCT) in exon 3 (2 patients). All the 3 patients reported bleeding during warfarin use, while no other bleeding was reported during the study period. Warfarin maintenance dose was significantly different between 3 patients with mutations and patients without mutations. The use of a fixed-dose warfarin for all patients and in range INR may not be sufficient for warfarin monitoring. Many factors including unknown ones may also play an important role in highly variable response among patients. Our data for the first time, suggested a new possible call for screening to reduce the risk of bleeding and guide for dosing.
Cardiovascular Therapeutics 08/2011; 29(4):e1-5. · 2.35 Impact Factor
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ABSTRACT: Deep vein thrombosis (DVT) is a major health problem. Despite the wealth of studies on its epidemiology, few have described the thrombus sidedness and particularly the association of thrombus sidedness with clinical presentation and subsequent complications. This article reviews current knowledge regarding this topic and in light of recent data from a large prospective study. This is the first report from the prospective National Research Institute of Tuberculosis and Lung Disease DVT registry. Patients with ultrasound-confirmed symptomatic DVT were enrolled, and thrombus sidedness was investigated in each case. Computed tomography pulmonary angiography was used to diagnose coexisting pulmonary embolism (PE) in DVT patients with suggestive symptoms. Embolic burden score was calculated for those with PE. From the total of 100 patients, 45 had left-sided DVT, 41 had right-sided DVT, and 14 had bilateral DVT. Presenting symptoms and comorbidities were comparable, except for cancer, which was more common in those with right-sided involvement (either right-sided or bilateral DVT; P = 0.004). Compared with those with left-sided DVT, PE happened more frequently in right-sided DVT patients. Right-sided DVT patients also had a higher rate of massive PE ( P = 0.03) and a greater mean embolic burden (13.32 ± 1.63 versus 6.05 ± 1.06; P = 0.001). These findings support raised awareness for global reconsideration of the assumption of complete identicalness of right-sided and left-sided DVT. Although future studies are needed to better elucidate epidemiological and prognostic differences based on the thrombus sidedness, our preliminary findings suggest that the two are not completely identical and right-sided DVT might be more ominous.
Seminars in Thrombosis and Hemostasis 04/2011; 37(3):298-304. · 4.52 Impact Factor
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Babak Sharif-Kashani,
Sasan Raeissi,
Behnood Bikdeli,
Payman Shahabi, Neda Behzadnia,
Leila Saliminejad,
Mojgan Samiei-Nejad,
Fatemeh Nasiri,
Maryam Khayyami,
Batool Forootan,
Saviz Pozhan,
Mohammad-Reza Masjedi
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ABSTRACT: Venous thromboembolism (VTE) is a major health problem. Even though effective thromboprophylaxis measures exist to prevent VTE, close adherence to guidelines is missing. We assessed the effects of pasting VTE prophylaxis sticker reminders, on the appropriateness of thromboprophylaxis and prophylaxis underutilization.
Thromboprophylaxis reception was sought prospectively in two time points before and two time points after pasting sticker reminders in hospitalized patients of Masih Daneshvari Medical Center, Tehran, Iran. Thromboprophylaxis reception appropriateness was evaluated by the eighth American College of Chest Physicians (ACCP) guidelines on antithrombotic and thrombolytic therapy. Co-morbidities and conditions considered to affect the risk of venous thromboembolism were also recorded.
Prophylaxis reception and appropriateness were studied in 298 patients before and 306 patients after the intervention. Based on the ACCP guidelines, overall thromboprophylaxis appropriateness was improved after the intervention (70.4% before, and 78.1% after the intervention, P=0.03). Prophylaxis underutilization, and prophylaxis initiation delay in those who needed thromboprophylaxis, were also reduced (P=0.03, and P=0.011 respectively). The intervention did not result in an increased rate of overprophylaxis (P=0.45).
Sticker reminders could be safely and effectively incorporated into strategies to improve VTE prophylaxis and prophylaxis appropriateness, particularly in healthcare settings where electronic alert systems are not available.
Thrombosis Research 09/2010; 126(3):211-6. · 2.44 Impact Factor
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ABSTRACT: We aimed to assess the acute cardiopulmonary effects of a 100-mg oral single dose of sildenafil in patients with idiopathic pulmonary hypertension (IPAH) using a well-validated but less-used noninvasive echocardiographic method for the measurement of both systolic and diastolic pulmonary artery pressure (PAP), by tricuspid regurgitation (TR) velocity curve analysis. We studied 12 consecutive patients with IPAH (10 patients with New York Heart Association functional class III, and 2 patients with functional class II). A 100-mg oral single dose of sildenafil was added to previous medications of all patients and its immediate effects were evaluated 1, 5, and 12 h after treatment. Using paired analysis, administration of a 100-mg oral single dose of sildenafil led to a significant reduction in mean PAP and a remarkable increase in pulmonary acceleration time (PAT) 1 h after treatment (P = 0.000; 95% confidence interval [CI] 18.99-26.00 and P = 0.005; 95% CI -12.89 to -2.95, respectively). In addition, although the right heart dimensions (right atrium and right ventricle) showed a trend toward improvement, the differences were not statistically significant (P = 0.13 and P = 0.08, respectively). Our results demonstrated that Doppler examination of TR alone can be easily used for the estimate of systolic and diastolic PAP in patients with IPAH. This study also shows that sildenafil is the only drug given orally that can evaluate the vasodilatory capacity of the pulmonary vascular bed in patients with IPAH, with promising effects on mPAP and PAT in these patients.
Heart and Vessels 07/2010; 25(4):313-8. · 2.05 Impact Factor
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ABSTRACT: Since the introduction of the Inoue technique for percutaneous balloon mitral valvuloplasty (PBMV), various criteria have been proposed for ideal balloon sizing. In routine practice, balloon size is chosen based on the patient's height according to a simple formula. We tried to define a simple and practical echocardiographic measure for adjusting balloon catheter size to achieve better success rates and fewer complications.
Patients with moderate to severe mitral stenosis who were candidates for PBMV were selected. Maximal mitral commissural diameter at a fully opened state during diastole was measured by transthoracic echocardiography and compared with the values from the height-based formula. Data were compared by paired sample t-test.
Eighty-three patients (mean age 45±13.2 years; 77 female) participated. The median balloon size was 28 mm (standard deviation [SD] 1.2) according to the height-based formula and 26 mm (SD 1.6) according to echocardiography (p<0.001). Using a Bland-Altman plot, an excellent agreement was observed between the two methods. Regression models were fitted to estimate the balloon size using the patients' height, commissural diameter, and mitral valve score.
Selection of balloon size according to echocardiographic commissural diameter is a good alternative method. Assuming the possible discrepancy between height-based and commissural-based estimated balloon sizes in some cases, adjustment of balloon sizes according to the maximal commissural diameter may result in acceptable results and fewer complications.
The American Heart Hospital Journal 01/2010; 8(1):29-32.
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ABSTRACT: To determine the role of digital photoplethysmography in screening asymptomatic patients who are susceptible for developing deep vein thrombosis.
Three hundred and thirty-seven limbs in 169 patients who were high risk for development of deep vein thrombosis were assessed by ultrasonography digital photoplethysmography and the results were compared.
Thirteen limbs were found to have deep vein thrombosis as demonstrated by ultrasonography. All limbs with a venous refilling time greater than 12 seconds had a normal ultrasonography. Compared with ultrasonography and using refilling time less than 12 seconds as the cutoff point, digital photoplethysmography achieved a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 73.8%, 13.3%, and 100% respectively, for detecting deep vein thrombosis in asymptomatic high-risk patients.
Digital photoplethysmography is a simple, noninvasive, and highly sensitive test for screening of deep vein thrombosis.
Angiology 11/2008; 60(3):301-7. · 1.51 Impact Factor
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Archives of Iranian medicine 05/2007; 10(2):268, 270-1. · 0.97 Impact Factor
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ABSTRACT: Traumatic myocardial injury occurs in up to 55% of patients sustaining blunt chest trauma. We report two cases of myocardial infarction following blunt chest trauma in two young men due to a car accident. They were both suffering multiple trauma and were hospitalized in ICU. Diagnostic and therapeutic procedures performed for these patients are presented in this article.
Tanaffos 01/2007;
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ABSTRACT: The latest American Heart Association (AHA) statement for preventing infectious endocarditis, has not recommended prophylactic antibiotic therapy prior to fiberoptic bronchoscopy (FB) except for patients with preexisting predisposing cardiac conditions. Our aim was to determine the incidence of bacteriemia and fever following FB in our experience and compare with those which have been mentioned in AHA guideline as well as other studies. Venous blood of 85 consecutive patients was evaluated for both aerobic and anaerobic cultures before (for detecting possible previous bacteriemia) and after FB. None of the patients were treated with antibiotics prior to the procedure. All the patients were examined during the first 24 hours after FB for detecting fever defined as temperature more than 38 °C. Positive hemocultures were noted in 7 (8.2 %) patients after FB examination. Coagulase negative Staphylococcus, coagulase positive Staphylococcus, beta haemolytic Streptococcus, Citrobacter freundii and Streptococcus viridans were found in 4, 1, 1 and 1 cultures of patients, respectively. By excluding 6 contaminated samples, the rate of bacteriemia reduced to 1 (1.1%) patient in whom the identical pathogen (Streptococcus viridans) was found both in bronchial lavage and venous blood culture. We also found fever in 9 (10.5 %) cases in the first 24 hours following the bronchoscopy. Our results were in consistent with AHA recommendations regarding prevention of infectious endocarditis as a practical gridline in patients who schedule for FB. Besides, transient fever following bronchoscopy is a common self-limited event which does not need medical intervention.
Acta medica Iranica 48(6):385-8.
