Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
Our Experience with Pre-Operative Haemostatic Assessment of Paediatric Patien...Dr Gav Terna
: In 2-4% of all patients requiring adenoidectomy, tonsillectomy or adenotonsillectomy, preoperative screening tests for coagulation disorders are indicated to detect surgical bleeding complications. But because of cost effect on the patients, the usefulness of these tests is being challenged. We therefore highlight our experience in Paediatric patients undergoing adenoidectomy, tonsillectomy or both in our Centre
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
BLOOD TRANSFUSIONS ARE ASSOCIATED WITH MORTALITY IN PEDIATRIC PATIENTS WITH S...Texas Children's Hospital
Restrictive thresholds for red blood cell (RBC) transfusion have not been shown to be inferior to liberal transfusion thresholds after cardiac surgery in pediatric or adult patients.1,2
RBC transfusions are associated with readmission due to heart failure (HF) in adults after aortic valve replacements, and with increased risk of right ventricle-pulmonary artery conduit failure in pediatric patients.3,4
Data are limited about RBC transfusions in pediatric patients with HF.
Our Experience with Pre-Operative Haemostatic Assessment of Paediatric Patien...Dr Gav Terna
: In 2-4% of all patients requiring adenoidectomy, tonsillectomy or adenotonsillectomy, preoperative screening tests for coagulation disorders are indicated to detect surgical bleeding complications. But because of cost effect on the patients, the usefulness of these tests is being challenged. We therefore highlight our experience in Paediatric patients undergoing adenoidectomy, tonsillectomy or both in our Centre
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
A primary Percutaneous Coronary Intervention (PCI) Primary PCI continues to be the optimal reperfusion therapy in
patients with ST elevation myocardial infarction however, in areas where PCI centers are not readily available, a pharmaco-invasive strategy has been proposed. This study investigated the safety, efficacy and cost effective analysis of a pharmaco-invasive strategy compared with primary (PCI) strategy for ST-Segment Elevation Myocardial Infarction (STEMI) in Gaza.
Methods: We ran domized 145 patients presenting within 2 hours of symptom onset of acute ST elevation myocardial infarction to primary PCI or for pharmaco-invasive PCI 2-24 hours after streptokinase, except in the event of failed reperfusion, in which case, emergency angiography was recommended. The primary endpoint a composite of death, shock and congestive heart failure at 30 days. Secondary end points: total bleeding and failed streptokinase required emergent PCI. Tertiary end points: cost effective analysis.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
A primary Percutaneous Coronary Intervention (PCI) Primary PCI continues to be the optimal reperfusion therapy in
patients with ST elevation myocardial infarction however, in areas where PCI centers are not readily available, a pharmaco-invasive strategy has been proposed. This study investigated the safety, efficacy and cost effective analysis of a pharmaco-invasive strategy compared with primary (PCI) strategy for ST-Segment Elevation Myocardial Infarction (STEMI) in Gaza.
Methods: We ran domized 145 patients presenting within 2 hours of symptom onset of acute ST elevation myocardial infarction to primary PCI or for pharmaco-invasive PCI 2-24 hours after streptokinase, except in the event of failed reperfusion, in which case, emergency angiography was recommended. The primary endpoint a composite of death, shock and congestive heart failure at 30 days. Secondary end points: total bleeding and failed streptokinase required emergent PCI. Tertiary end points: cost effective analysis.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
Deep Venous Thrombosis and Pulmonary Embolism : Diagnostic Approach and Curre...Bassel Ericsoussi, MD
Acute pulmonary embolism: Overview, Diagnosis, Treatment
DVT/PE in pregnancy
Prevalence of PE in COPD exacerbations
Diagnostic vascular ultrasonography
Risk factors of chronic liver disease amongst patients receiving care in a Ga...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Is routine thromboprophylaxis warranted in all patients of tibial fracture ma...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Malignant Mixed Mullerian Tumor – Case Reports and Review ArticleApollo Hospitals
Malignant mixed mullerian tumors are very rare genital tumors. They are biphasic neoplasms composed of an admixture of malignant epithelial and mesenchymal elements. In descending order of frequency they originate in the uterus, ovaries, fallopian tubes, cervix and vagina. Also they arise denovo from peritoneum. They are highly aggressive and tend to occur in postmenopausal low parity women. Because of rarity, there is as such no treatment guidelines available. Multimodality treatment in the form of radical surgery followed by adjuvant chemotherapy or radiotherapy or combined chemoradiation gives a better prognosis & outcome. Two case reports of such tumors, one from ovary and other from penitoneum are presented along with the review of literature.
Intra-Fetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Success...Apollo Hospitals
To interrupt blood supply to the acardiac twin in a case of TRAP sequence of monochorionic diamniotic multiple pregnancy to allow for continuation of the normal twin.
Breast Cancer in Young Women and its Impact on Reproductive FunctionApollo Hospitals
Breast cancer is the most common cancer in women in developed countries. Chemotherapy for breast cancer is likely to negatively impact on reproductive function. We review current treatment; effects on reproductive function; breastfeeding and management of menopausal symptoms following breast cancer.
Turner syndrome (gonadal dysgenesis) is one of the most common chromosomal abnormalities occuring 1 in 2500 to 1 in 3000 live-born girls. It is an important cause of short stature in girls and primary amenorrhea in young women that is usually caused by loss of part or all of an X chromosome. This review briefly summarises the current knowledge about the syndrome and the management strategies.
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Growth Hormone Deficiency (GHD) can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. Growth harmone (GH) therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.
Advances in the management of thalassemia have led to marked improvements in the life span and quality of life of children and young adults. This poses new challenges for the treating physicians. There is now increasing recognition that thalassemics have impaired bone health which is multifactorial in etiology. This paper aims to highlight the factors that predispose these patients to osteoporosis and suggests measures to minimise the impact on bone health.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Occupational Blood Borne Infections: Prevention is Better than CureApollo Hospitals
Viral infections like HIV, hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the attending health care workers. Blood, semen, vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination, laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface, mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis, side effects and risk of carrying the infection to his familial contacts and its prevention.
Evaluation of Red Cell Hemolysis in Packed Red Cells During Processing and St...Apollo Hospitals
Storage of red cells causes a progressive increase in hemolysis. Inspite of the use of additive solutions for storage and filters for leucoreduction some amount of hemolysis is still inevitable. The extent of hemolysis however should not exceed the permissible threshold for hemolysis even on the 42nd day of storage.
Efficacy and safety of dexamethasone cyclophosphamide pulse therapy in the tr...Apollo Hospitals
Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
Severe skin adverse drug reactions can result in death. Toxic epidermal necrolysis (TEN) has the highest mortality (30–35%); Stevens-Johnson syndrome and transitional forms correspond to the same syndrome, but with less extensive skin detachment and a lower mortality (5–15%). Hypersensitivity syndrome, sometimes called Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), has a mortality rate evaluated at about 10%. It is characterised by fever, rash and internal organ involvement. Prompt diagnosis is vital, along with identification and early withdrawal of suspect medicines and avoidance of re-exposure to the responsible agent is essential. Cross-reactivity to structurally-related syndrome caused by Carbamazepine medicines is common, thus first-degree relatives may be predisposed to developing this syndrome. We report a case of DRESS secondary to use of Carbamazepine.
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
The spread of dengue and dengue haemorrhagic fever is increasing, atypical manifestations are also on the rise, although they may be under reported because of lack of awareness. We report two such cases of dengue hemorrhagic fever with hepatitis, intraocular hemorrhage, ARDS and myocarditis.
A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.
Pediatric Liver Transplant (LT) is now an established procedure for End Stage Liver Disease (ESLD) with biliary atresia being the commonest indication. Intensive pre-transplant evaluation, nutritional buildup and immunization are the fundamental pre-requisites of a successful LT. With improvement in surgical micro-anastomotic techniques and superior immunosuppressive regimens the success rate of pediatric LT is in excess of 90%. Most of the transplants in our country however are Living related, due to which a fairly large number of children expire awaiting a donor liver. There should be a concerted effort to evolve the cadaveric donation program, so that majority of the children are benefitted.
Ultrasound Elastography is a new imaging technique that allows a noninvasive estimation and imaging of tissue elasticity distribution within biological tissues using conventional, Real Time Ultrasound equipment with modified software. It can be viewed as an electronic palpation of tissues. Introduced by Ophir et al in 1991, it subsequently evolved into a Real Time Imaging tool.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Deep vein thrombosis prophylaxis in a tertiary care center: An observational study
1. Deep vein thrombosis prophylaxis in a tertiary care center:
An observational study
2. Original Article
Deep vein thrombosis prophylaxis in a tertiary care
center: An observational study
Aparna Yerramilli a,
*, Shilpa Katta b
, Supriya Kidambi b
,
Naveen Kumar Kotari b
, Santosh Devulapally b
, Sanjeev Sharma c
a
Associate Professor, Pharm. D Head of the Department, Sri Venkateshwara College of Pharmacy, Affiliated to
Osmania University, Hyderabad 500081, Telangana, India
b
Pharm. D Interns, Sri Venkateshwara College of Pharmacy, Madhapur, Hyderabad, India
c
Clinical Pharmacologist, Apollo Hospitals, Jubilee Hills, Hyderabad, India
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 15 February 2015
Accepted 24 August 2015
Available online xxx
Keywords:
Deep vein thrombosis
Venous thromboembolism
DVT prophylaxis
Risk stratification
Enoxaparin
a b s t r a c t
Background: Deep vein thrombosis (DVT) is a major health problem with substantial mor-
tality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification
and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is
the most rational means of reducing morbidity and mortality.
Objective: To study the management strategies for DVT prophylaxis in a tertiary care center
and evaluate the prophylactic dosing patterns for DVT prevention.
Methods: A prospective, observational study was performed in the intensive care units and
medical wards of a tertiary care center. A structured proforma was designed for risk
assessment and stratification of DVT in critically ill patients with recommended thrombo-
prophylaxis. The dosing patterns of all medications given for DVT prophylaxis were ana-
lyzed for their appropriateness according to 8th ACCP guidelines.
Results: A total of 480 patient charts were reviewed. It was observed that 358 patients (74.6%)
were on mixed prophylaxis, 38 patients (18.5%) were on pharmacological prophylaxis, and 33
patients (6.9%) were on mechanical prophylaxis only. Enoxaparin and graduated compres-
sion stockings were the most commonly used pharmacological and mechanical prophylax-
es, respectively. The prophylaxis guidelines were followed in 77% of the study population.
The reasons for inappropriate dosing patterns were found to be subtherapeutic dosing and
overdosing.
Conclusions: Our study revealed that a higher proportion of the patients who are at high risk
are currently given thromboprophylaxis as per the standard prophylactic recommenda-
tions. There is still considerable scope for improvement in the management of DVT in all
units of the institution.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author at: Sri Venkateshwara College of Pharmacy, 86, Hitech City Road, Madhapur, Hyderabad 500081, Andhra Pradesh,
India. Tel.: +91 9704231971.
E-mail address: svcppharmd.hod@gmail.com (A. Yerramilli).
APME-317; No. of Pages 5
Please cite this article in press as: Yerramilli A, et al. Deep vein thrombosis prophylaxis in a tertiary care center: An observational study,
Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.08.002
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.08.002
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.
3. 1. Introduction
Venous thromboembolism (VTE), which includes deep venous
thrombosis (DVT) and pulmonary embolism (PE), is a common
and potentially life-threatening condition in critically ill
patients. Anticoagulant drug therapy is aimed at preventing
pathological clot formation in patients at risk and preventing
clot extension and/or embolization in patients who have
developed thrombosis.1,2
Majority of the studies have been conducted and published
in western countries where DVT is more common, whereas,
there is paucity of data from Indian subcontinent regarding the
incidence of VTE. Some of the recent studies published from
Asian countries have shown that DVT is not a rarity in Asian
patients as was thought earlier.3
The prevailing belief that VTE
in the ASIAN population is less than in the western population
has been disproved by recent studies and there appears no
reason to believe that it is any different in India.5
The incidence of DVT in India as reported is 1% of the adult
population after the age of forty and 15–20% in hospitalized
patients. The risk of DVT is 50% in patients undergoing
orthopedic surgery, particularly involving the hip and knee,
and it is 40% in patients undergoing abdominal or thoracic
surgery. About 1 in 100 who developed DVT can develop PE,
which can be fatal. As per India-specific ENDORSE study data
presented at Geneva, 50% of hospitalized patients in India are
at high risk of developing VTE at any point in time and the
proportion of Indian patients considered at risk for VTE (53.6%)
was similar to that of the global patients at risk for VTE
(51.8%).3,4,6
In developing countries, such as India, a significant
prevalence of etiological risk factors for DVT and prothrom-
botic factors has been shown amongst hospitalized
patients.7
Studies have shown a need of DVT prophylaxis
in 95% of intensive care unit (ICU) patients in India with
significant underuse of prophylaxis in only 55% of the high-
risk patients.8
Another study in the Indian population has
shown an overall incidence of confirmed DVTs to be 17.46
per one lakh patients with 64% being nonsurgical non-
trauma patients.9
Critically ill patients are at increased risk of VTE due to
predisposing comorbid conditions, occurrence of sepsis,
trauma, and postadmission events.10
Individual identification
of suspected DVT cases could be a difficult task and many
cases could be missed. However, blanket prophylaxis of all
admitted patients may not be cost-effective, especially in a
developing country, such as India.11
Thus primary prevention
of VTE with risk assessment and stratification for DVT and
subsequent antithrombotic prophylaxis in moderate- to
severe-risk category patients is the most rational means of
reducing mortality and morbidity.
The need for DVT prophylaxis is usually underestimated.
Only 10% of individuals who require DVT prophylaxis actually
get it; the remaining 90% of individuals are deprived of DVT
prophylaxis because of lack of awareness or skill.12
The 8th conference of American College of Chest Physicians
(ACCP) developed guidelines for the use of low-molecular
weight heparins (LMWHs) and unfractionated heparins (UFH)
in the prevention of VTE in patients with acute illnesses.12
DVT can be prevented by regular physical activity,
especially if an individual is immobilized for longer time.
Mechanical DVT prophylaxis may be considered in all
immobile patients and should be used for those who cannot
receive anticoagulants, such as intermittent pneumatic
compression (IPC) devices, graded compression stockings
(GCS), and venous foot pumps. Pharmacological prophylaxis
includes low-dose unfractionated heparin (LDUH), LMWH,
vitamin K antagonists (most often warfarin), and fondapar-
inux. The guideline recommendations for thromboprophy-
laxis in patients at risk of VTE are given in Appendix.14
However, the use of DVT prophylaxis in hospitalized
medical patients still remains suboptimal, around 15–16%.13
Hence, we sought to study the patient profiles for risk
factors and evaluate the drug dosing patterns for DVT
prophylaxis among medically ill and surgical patients treated
at our institution. This study aims to evaluate the usage of
prophylaxis in our institution.
2. Methods
A single-center, prospective, and observational study was
carried out for six months at Apollo Hospitals, Jubilee Hills,
Hyderabad, which is a 630 bedded tertiary care hospital with 50
superspecialty services in India. Ethical clearance was
obtained from the Institutional Ethics Committee (IEC)
(Protocol No. SVCP/04/2013) before initiating the study.
A structured proforma was designed for risk stratification
of DVT in critically ill patients adapted from Caprini's risk
stratification scorecard. The risk factors for DVT used in this
protocol to stratify patients are similar to that published by
ACCP and the International Union of Angiology (IUAS)
consensus statement and have been used previously for
DVT risk assessment alongside ACCP and IUAS risk score
models in other studies done in developing countries. The risk
assessment and stratification scorecard and data collection
form used are given in Appendix.
All the patient charts were reviewed in the medical and
surgical units and the data of 480 patients who were on DVT
prophylaxis were collected. Individual Risk factor screening
was done to calculate risk factor score, thus categorizing
patients into low, moderate, and high risk.
Demographic data, including patient's age, sex, and body
weight, were collected. Other baseline information like
diagnosis, comorbidities, past medication history, past surgi-
cal history, family history, social history, allergies, any
invasive instrumentation, such as ventilators, venous cathe-
ters, baseline laboratory data (hematological data, coagulation
profile and renal parameters), etc. were also noted down. Renal
data plays a crucial role because as per enoxaparin package
insert dose adjustment is recommended in patients with
severe renal impairment (creatinine clearance <30 mL/min).
Patients were stratified to low-, moderate-, and high-risk
categories. Any prophylaxis given and relevant investigations
for DVT (D-dimer, Doppler ultrasound, high-resolution chest
computed tomography, pulmonary angiography) that was
done was also noted. Assessment of risk of bleeding and
contraindications to thromboprophylaxis was performed. The
current prescribed prophylaxis (mechanical and chemical)
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
APME-317; No. of Pages 5
Please cite this article in press as: Yerramilli A, et al. Deep vein thrombosis prophylaxis in a tertiary care center: An observational study,
Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.08.002
4. with dose, frequency, route of administration, date of drug
initiation and stop date, and monitoring parameters were
collected.
Data were analyzed for the risk factor categorization and
appropriateness of thromboprophylaxis compared to the 8th
ACCP guidelines and reported. Descriptive statistical analysis
was performed in calculation of categorical variables.
3. Results
A total of 480 patient charts were reviewed and analyzed. It
was observed that male patients were relatively higher than
female patients. Of the total 480 patients, 58% were medical
patients and 42% were surgical patients. Majority of the study
population receiving thromboprophylaxis were in the age
group of 61–80 years (40.1%) and least in the age group of 81–
100 years (4.6%), with a mean age of 56.7 years and mean BMI
25.3 kg/m2
. The demographic characteristics are shown in
Table 1. An average risk factor range of 3–4 per patient was
observed with top three multiple risk factors being age (82.5%),
obesity (48.1%), and surgery (42%) (Fig. 1). Orthopedic surgery
(45%) was the most common type of surgery among the
surgical patients.
Risk factor screening was done and the patients were
categorized into low (3%), moderate (24%), and high risk (73%)
based on the risk factor scoring (Table 1). It was observed that
93.3% were on pharmacological prophylaxis and 6.7% were on
only mechanical prophylaxis, of which 74.6% were on mixed
prophylaxis, 18.5% were on only pharmacological prophylaxis,
and 6.9% were on only mechanical prophylaxis.
In our study, LMWH (92.7%), with enoxaparin 40 mg, was
the preferred choice of anticoagulant in surgical as well as
medical ward patients, followed by fondaparinux (1%). Among
mechanical prophylaxis available, graduated compression
stockings (68%) were commonly used followed by sequential
compression devices (SCD) (13.3%) (Fig. 2). The most common
contraindications to pharmacological prophylaxis were active
bleeding (4.17%), clinically relevant renal impairment (1.04%),
hepatic impairment (0.63%), and low platelets count (0.63%).
ACCP recommended prophylaxis guidelines were followed
in 77% of the study population, which was significantly higher
compared to global ENDORSE data.
The most common reasons attributed to the inappropriate
thromboprophylaxis were subtherapeutic dosing (15.6%),
overdosing (1.5%), and renal impairment (6%) (Table 2).
4. Discussion
This study explores the use of DVT prophylaxis in a tertiary
care center. Out of 480 patient charts reviewed, majority of our
study population were males, overweight, and above 50 years.
Nearly two-thirds of the study population was in medical
wards and the remaining in surgical units requiring acute care.
Fig. 1 – Patient risk factors for DVT. THR, total hip
replacement; TKR, total knee replacement; COPD, chronic
obstructive pulmonary disease; DVT, deep vein
thrombosis; PE, pulmonary embolism.
Fig. 2 – Management strategies for DVT prophylaxis. GCS,
graded compression stocking; SCD, sequential
compression devices.
Table 1 – Demographic characteristics of the study
population.
Variables Total no of patients, n = 480 (%)
Gender
Males 257 (54%)
Females 223 (46%)
Other characteristics
Mean age (years) 56.7 Æ 15.27
Mean BMI (kg/m2
) 25.3 Æ 4.81
Medical department
Wards 315 (66%)
ICU 165 (34%)
Unit
Medicine 279 (58%)
Surgery 201 (42%)
Comorbidities
Cardiovascular 243 (51%)
Respiratory 35 (7%)
Others 112 (23%)
No comorbidities 90 (19%)
Level of risk
Low (0–1) 14 (3%)
Moderate (2–4) 117 (24%)
High (≥5) 349 (73%)
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
APME-317; No. of Pages 5
Please cite this article in press as: Yerramilli A, et al. Deep vein thrombosis prophylaxis in a tertiary care center: An observational study,
Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.08.002
5. About half of the study population showed cardiovascular
comorbidities followed by other comorbidities. Multiple
system involvement was seen in many patients. Whereas in
a study conducted by Pandey et al., at AIIMS, India, it was
shown that respiratory system involvement was seen in 41.8%
of the patients while cardiovascular system involvement was
seen in only 17.1% of the patients.15
Nearly half of the study population was postsurgical, of
which 75% are at highest risk for DVT. Orthopedic surgery runs
a higher risk for DVT (45%). In addition to surgery, age, obesity,
and immobility were among the most frequently documented
risk factors. Patients at high risk (73% vs. 48.4%) were higher in
our study when compared to TUNE-IN study conducted by
Wessels and Riback.16
Overall prophylaxis in at-risk VTE patients was high (77%)
in our study and as per ACCP recommendations, enoxaparin
40 mg once daily (54.3%) was the most common agent used.
Whereas the Indian data from ENDORSE study revealed that
despite a similar proportion of patients at risk in India and
other participating countries, there was major underutiliza-
tion of prophylaxis (17.4%) in India as compared to higher
usage of prophylaxis globally (50.2%).4,17
Pharmacological prophylaxis in medical and surgical
patients was evaluated for appropriateness. Pharmacological
prophylaxis was commonly used type of prophylaxis (93.1%).
Inappropriate thromboprophylaxis was observed in 111
patients (23%). The most common reasons attributed to the
inappropriate thromboprophylaxis were overdosing due to
overweight or obesity, renal impairment, and subtherapeutic
dosing.
The combination of enoxaparin 20 mg and mechanical
prophylaxis is not appropriate according to the ACCP guide-
lines, hence considered as subtherapeutic dosing. This might
be due to the misconception of some clinicians that the
combination of enoxaparin 20 mg with mechanical prophy-
laxis would be sufficient to reduce the DVT incidence. The
standard dose recommended is enoxaparin 40 mg OD and/or
mechanical prophylaxis in moderate- to high-risk patients.
Studies have not shown significant benefit of mechanical
prophylaxis relative to anticoagulant therapy; however, accord-
ing to CHEST guidelines, mechanical prophylaxis is an accept-
able option in certain patient groups or in combination with
anticoagulant therapy to improve efficacy.11,18
Documented
contraindications (active bleeding, renal impairment, hepatic
impairment, and low platelet counts) were noted in few
patients, who were on only mechanical prophylaxis. Among
mechanical prophylaxis available, graduated compression
stockings were commonly used followed by SCD.
A Point Prevalence study of DVT prophylaxis in the
institution was conducted. Out of 226 patient charts reviewed,
more than half of the study population (120 patients) had a
very high risk for DVT. It was found that 25.6% were on DVT
prophylaxis, which was greater compared to that of Indian
data from ENDORSE study (17.4%).
The study showed that a significant percentage of admis-
sions in medical wards and ICU were subject to very high risk
of DVT. Early recognition of these risk factors and prompt
prophylaxis in high-risk cases can be really effective in
preventing these life-threatening complications. Though,
ACCP has laid down clear guidelines on DVT prophylaxis in
medically ill patients, several studies done in the Western
countries have also shown the underuse of DVT prophylaxis in
hospitalized medical patients.19,20
Overdosing may be due to lack of proper risk factor
screening techniques, practical feasibility, lack of experience
and awareness in healthcare personnel, and poor implemen-
tation of recommended guidelines.
Reasons for underutilization or subtherapeutic dosing of
prophylactic agents include:
Concerns about an increased risk of bleeding from antic-
oagulants.
Lack of clear indications and contraindications for antico-
agulant prophylaxis.
Lack of time to consider DVT prophylaxis in every patient.
Physicians' belief that mixed prophylaxis would be sufficient
to reduce DVT incidence.
Lack of awareness and concerns for cost of DVT prophylaxis
in all critically ill patients could also be an important factor,
particularly in developing countries, such as India.
5. Limitations
All the patients who are at risk of DVT were not considered.
Only those patients on any thromboprophylaxis were studied.
This was a single-center study and the results cannot be
generalized to other medical centers. There was no follow-up
to evaluate the duration of prophylaxis. Another limitation of
the study was that pediatric patients, who were excluded, also
might have been at risk for VTE.
6. Conclusion
The findings of our study showed that a relatively larger
proportion of the patients were currently on prophylaxis as per
standard prophylactic recommendations. The overall rate of
inappropriate thromboprophylaxis was 23%, the most com-
mon reasons being: overdosing and subtherapeutic dosing. A
high rate of appropriateness and increased use of LMWH was
seen in our study population due to frequent awareness
campaigns in hospital. Risk assessment forms are being used
Table 2 – Reasons for inappropriate DVT prophylaxis.
Reasons for inappropriate dosing Medical patients (n = 58) Surgical patients (n = 53) Total patients n = 480 (%)
Overdosing Renal impairment 20 9 29 (6%)
Obesity 6 1 7 (1.5%)
Subtherapeutic dosing 32 43 75 (15.6%)
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4
APME-317; No. of Pages 5
Please cite this article in press as: Yerramilli A, et al. Deep vein thrombosis prophylaxis in a tertiary care center: An observational study,
Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.08.002
6. in some units but need to be followed in more units and
patients.
This study data may be useful to implement DVT risk
stratification strategy in hospitalized patients and improve the
prescribing patterns of prophylaxis where indicated. Success-
ful programs like incorporation of risk assessment and
stratification tools in routine patient work-up and interven-
tions to increase awareness of DVT prophylaxis in health care
professionals need to be implemented in our heath care
system to improve VTE prophylaxis and decrease rates of VTE
and its complications.
Conflicts of interest
The authors have none to declare.
Acknowledgements
We are immensely thankful to Dr Rajib Paul, Internal Medicine
for his guidance and support during the Point Prevalence
study; Apollo Hospitals, Osmania University, Principal Prof.
Prathima Srinivas; and Management of Sri Venkateshwara
College of Pharmacy, for the encouragement and support
provided.
Appendix. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.apme.2015.08.002.
r e f e r e n c e s
1. Koda Kimble MA, Young LY, Alldredge BK, et al. Applied
therapeutics: the clinical use of drugs. 9th ed. United States of
America: Lippincott Williams Wilkins; 2009.
2. Sukhendu SB, Swapan B, Mohit K, Tapan KC, Subhangkar N.
Utilization of DVT prophylaxis in non ICU hospitalized
patients. Asian Pac J Trop Dis. 2012;2:S707–S711.
3. Angral R, Islam MS, Kundan S. Incidence of deep vein
thrombosis and justification of chemoprophylaxis in Indian
patients: a prospective study. Bangladesh Med Res Counc Bull.
2012;38(2):67–71.
4. Ramakrishna P. Venous thromboembolism risk
prophylaxis in the acute hospital care setting (ENDORSE), a
multinational cross-sectional study: results from the Indian
subset data. Indian J Med Res. 2012;136:60–67.
5. Gandharba R, Manoranjan B. Venous thromboembolism –
Indian perspective. Med Update. 2010;20:329–334.
6. Kanaan AO, Silva MA, Donovan JL, Roy T, Al-homsi AS. Meta
analysis of venous thromboembolism prophylaxis in
medically ill patients. Clin Ther. 2007;29(11):2395–2405.
7. Garewal G, Das R, Ahluwalia S, Mittal N, Varma S. Prevalence
of risk factors for VTE: a study from north India. J Thromb
Haemost. 2005;3(1):1270.
8. Ansari K, Dalal K, Patel M. Risk stratification and utilisation of
thrombo-embolism prophylaxis in a medical – surgical ICU: a
hospital based study. J Indian Med Assoc. 2007;105:536–540.
9. Lee AD, Stephen E, Agarwal S, Premkumar P. Venous
thromboembolism in India. Eur J Vasc Endovasc Surg. 2009;37
(4):482–485.
10. Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts W.
Prophylaxis of venous thromboembolism in the critically ill.
Arch Intern Med. 2001;161:1268–1279.
11. Nuijten MJ, Berto P, Kosa J. Cost-effectiveness of enoxaparin
as thromboprophylaxis in acutely ill medical patients from
the Italian NHS perspective. Recenti Prog Med. 2002;93:80–91.
12. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
thromboembolism: the seventh ACCP conference on
antithrombotic and thrombolytic therapy. Chest. 2004;126
(3):338S–400S.
13. Kahn SR, Panju A, Geerts W, et al. Multicenter evaluation of
the use of venous thromboembolism prophylaxis in acutely
ill medical patients in Canada. Thromb Res. 2007;119:145–155.
14. Caprini JA. Thrombosis risk assessment as a guide to quality
patient care. Dis Mon. 2005;7:3–74.
15. Ambarish P, Nivedita P, Mansher S, Randeep G. Assessment
of risk and prophylaxis for deep vein thrombosis and
pulmonary embolism in medically ill patients during their
early days of hospital stay at a tertiary care center in a
developing country. Vasc Health Risk Manag. 2009;5:643–648.
16. Wessels P, Riback WJ. DVT prophylaxis in relation to patient
risk profiling – the tune-in study. S Afr Med J. 2012;102(2):85–89.
17. Cohen AT, Tapson VF, Bergmann JF, et al. Venous
thromboembolism risk and prophylaxis in the acute
hospital care setting (ENDORSE study): a multinational
cross-sectional study. Lancet. 2008;371:387–394.
18. Kalodki EP, Hoppensteadt DA, Nicolaides AN. Deep venous
thrombosis prophylaxis with low molecular weight heparin
and elastic compression in patients having total hip
replacement. A randomised controlled trial. Int Angiol.
1996;15:162–168.
19. Geerts W, Selby R. Prevention of venous thromboembolism
in the ICU. Chest. 2003;124(6S):357S–363S.
20. Kakkar AK, Davidson BL, Haas SK. Compliance with
recommended prophylaxis for venous thromboembolism:
improving the use and rate of uptake of clinical practice
guidelines. J Thromb Haemost. 2004;2:221–227.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5
APME-317; No. of Pages 5
Please cite this article in press as: Yerramilli A, et al. Deep vein thrombosis prophylaxis in a tertiary care center: An observational study,
Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.08.002