The use of thrombolysis for the treatment of pulmonary embolism David A Fitzmaurice pp 1-3 Pulmonary embolism (PE) is one
manifestation of venous thromboembolism
(VTE), and can vary in its clinical presentation
from sudden death to acute shortness of
breath. At its most severe, PE is associated
with significant mortality and morbidity,
including pulmonary hypertension.
The mainstay of treatment for PE has
been initial treatment with heparin
followed by an extended period of
treatment with oral anticoagulation
(principally warfarin),
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Comment: Chronic obstructive pulmonary disease Peter Rose pp 2-2 In this edition of Thrombus, practical advice is given for the
implementation of hospital inpatient thromboprophylaxis. The
recent production of a template for thromboprophylaxis is to be
considered a substantial step forward; however, from local experience,
production of a form for thromboprophylaxis assessment, and its
distribution to all wards, does not equate with assessments actually
undertaken or thromboprophylaxis actually prescribed.
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Using the international normalised ratio in patients with liver disease Anne M Sermon and Steve Kitchen pp 4-6 The international normalised ratio (INR)
and the international sensitivity index
(ISI) systems were developed as ways to
standardise the prothrombin time (PT)
during the monitoring of patients
undergoing oral anticoagulant therapy
with vitamin K antagonists (VKAs) such
as warfarin. The wide acceptance of the
INR has led to its use in other clinical
scenarios, including as one of three
parameters in the Model for End-Stage
Liver Disease (MELD) scoring system (to
aid the prioritisation of patients for liver
transplant). Recently published literature
has highlighted the potential inadequacy
of the INR system in this context.
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The 8th ACCP guidelines on thrombosis prevention – core reading for everyone John Pasi pp 7-7 Venous thromboembolism (VTE) is a
major public health issue. Each year,
more than 25,000 people in the UK die
as a result of VTE that occurs in hospital.
This is more than the combined total of
deaths from breast cancer, AIDS and
traffic accidents, and five times the
number who die from methicillinresistant
Staphylococcus aureus (MRSA).
Not only is the human cost of this huge,
so is the financial cost to the nation: it is
estimated the total cost of VTE morbidity
to the UK is over £600 million per
annum. Despite shorter hospital stays,
with an increase in the number of
surgical operations, cancer treatments
and cases of obesity within the general
population, it is probable that the cost of
VTE will rise if appropriate preventive
strategies are not used.
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American College of Chest Physicians guidelines on thromboprophylaxis Catherine Bagot pp 8-12 In June 2008, a new edition of the
American College of Chest Physicians
(ACCP) guidelines, Antithrombotic and
Thrombolytic Therapy: American College
of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition),
was published. This article reviews the
chapter Prevention of Venous
Thromboembolism.
The guidelines given in Prevention of
Venous Thromboembolism refer almost
exclusively to the management of
hospitalised patients. This article seeks to
highlight the major changes that have
been made to this chapter since the
previous edition in 2004, examine the
evidence base for these changes, and
discuss the limitations of the guidance
given. In particular, it concentrates on
new sections that have been introduced
for specific patient groups.
Providing a system
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Intravenous drug use, deep vein thrombosis and anticoagulation Caroline Baglin pp 14-15 Deep vein thrombosis (DVT) and
pulmonary embolism (PE) can be
triggered by a variety of risk factors.
Using the iliofemoral vein by intravenous
drug users is considered to be a
significant cause. However, many
anticoagulant service staff say
intravenous drug users do not present
with venous thromboembolism (VTE)
to their service. It is thought the reason
for this is that these patients do not
continue with treatment and do not
attend anticoagulant clinics. It is difficult
for anticoagulant staff to share their
experience of caring for these patients
due to the small number attending
each service. Also, there have not been
any randomised, controlled trials of this
group of patients and no grade A
recommendations are available.
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