Venous thromboembolism (VTE) remains highly prevalent in medically ill patients, and often leads to increased mortality and cost burden during hospitalization and post-discharge. Nearly half of all VTEs occur during or after hospitalization, with pulmonary embolism accounting for 10% of inpatient mortality. Appropriate prophylaxis in high-risk medically ill patients has been shown to reduce risk of VTE and related mortality. Despite current evidence-based guidelines, VTE prophylaxis has been under-used. This owes greatly to ambiguity and concerns related to appropriate patient and prophylactic agent selection, and duration of prophylaxis. Because many acutely ill medical patients have multiple comorbidities, the risk of major bleeding must be considered when choosing to implement pharmacological VTE prophylaxis. Multiple risk assessment models have been developed and validated to help estimate VTE and bleeding risks in this population. While studies have shown that the risk for VTE often extends far beyond hospital discharge, there is no evidence to support extending prophylaxis after hospital discharge. The appropriate selection of VTE prophylaxis requires consideration for cost, availability, patient preference, compliance, and underlying comorbidities. Our paper reviews the current evidence and reasoning for appropriate selection of VTE prophylaxis in acutely medical ill patients, and highlights our own approach and recommendations.
As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.
e18500 Background: A recent review of the medical literature of rural health cancer care delivery has not been published. We conducted a preliminary review of the last twenty years of rural health cancer care delivery literature utilizing medical subject headings (MeSH) within the PubMed NCBI) database. Methods: Using PubMed MeSH Major Topic terms “rural population” and “cancer” we identified publications published from 2000 to 2020. We searched PubMed for publications that included the major topic MeSH terms “rural population” and “cancer”. We individually reviewed articles, confirmed the focus of the article, and subcategorized the articles. Results: We identified 580 publications which met the search criteria, the majority were focused on the United States (266), followed by China (56), Australia (54), and India (27). Among the publications focusing on the United States, 76 involved Appalachian States. Kentucky (18) and Georgia (10) were the states most frequently represented. Malignancies most commonly represented were: breast cancer (148), uterine/cervical (84), and colorectal cancers (68). The journals which published the most rural health cancer care delivery were The Journal of Rural Health (42), Asian Pacific Journal of Cancer Prevention (20), Cancer (14), Rural and Remote Health (13), Journal of Cancer Education (13), Australian Journal of Rural Health (12). Conclusions: The rural health cancer care literature in the last two decades focuses primarily on the United States, China, Australia, and India. Within the United States, the research focus is Appalachia. The majority of articles focus on breast cancer, uterine/cervical, and colorectal cancers. The journal which published the majority of rural health cancer care articles was the Journal of Rural Health.
e18503 Background: This study examines the geographic distribution of clinical trials for common types of metastatic cancer in the United States and the accessibility of these trials to the general population. Methods: We accessed the ClinicalTrials.gov website and conducted a search for interventional clinical trials that were actively recruiting patients for diagnoses of metastatic lung, colon, pancreas, breast, and prostate cancers on November 25, 2022. We identified unique zip codes for all the clinical trials offered and calculated the U.S. population living within 50 miles of a clinical trial site using geographic information system software based on 2020 census data. We created maps for each cancer type, demonstrating the geographic distribution of clinical trial access in the United States. Results: We found a significant number of clinical trials providing access for most Americans diagnosed with the most common types of metastatic cancer. The majority of the United States population lives within 50 miles of a clinical trial. The access varied by cancer type studied, from 75.0% of the United States population for metastatic colon cancer to 90.2% for metastatic lung and breast cancers. See table for details. Conclusions: When considering the accessibility of these trials, we found that a large proportion of the United States population lived within 50 miles of a clinical trial site. This suggests that while many clinical trials are available, they may not be evenly distributed across the country and may not be accessible to all individuals. [Table: see text]
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