ƵƚŚŽƌ ĐŽŶƚƌŝďƵƟŽŶƐ͗ All the authors met ICMJE authorship criteria. SP, SW, PD, SS conceived and designed the research plan. SP, SW, PD, ^^ ĐŽůůĞĐƚĞĚ ĂŶĚ ĐŽŶĚƵĐƚĞĚ ƚŚĞ ĚĂƚĂ ĂŶĂůLJƐŝƐ ĂŶĚ ŝŶƚĞƌƉƌĞƚĂƟŽŶ͘ ^W ǁƌŽƚĞ ƚŚĞ ĮƌƐƚ ĚƌĂŌ ŽĨ ƚŚĞ ŵĂŶƵƐĐƌŝƉƚ͘ ^t͕ W͕ ^^ ĐƌŝƟĐĂůůLJ ƌĞ|ŝĞǁĞĚ ƚŚĞ ŵĂŶƵƐĐƌŝƉƚ ĨŽƌ ŝŵƉŽƌƚĂŶƚ ŝŶƚĞůůĞĐƚƵĂů ĐŽŶƚĞŶƚ͘ ůů ĂƵƚŚŽƌƐ ĂŐƌĞĞ ǁŝƚŚ ƚŚĞ ƌĞƐƵůƚƐ ĂŶĚ ĐŽŶĐůƵƐŝŽŶƐ͘ ůů ĂƵƚŚŽƌƐ ĂƉƉƌŽ|ĞĚ ƚŚĞ ĮŶĂů |ĞƌƐŝŽŶ ŽĨ ƚŚĞ manuscript.
a desirable benefit-to-risk ratio. 1,2 In the UK, fixed doses of low molecular weight heparin (LMWH) are used for VTE prophylaxis regardless of patient weight. 3 While the effects of LMWHs are not usually routinely monitored, levels of anti-Xa have been used to determine if standard prophylactic doses of LMWH provide adequate prophylactic cover to obese patients. An inverse correlation between anti-Xa levels in the first 10 hours and body weight with fixed prophylactic doses of 40 mg enoxaparin has been demonstrated, which suggests that current fixed-dose thromboprophylaxis is likely inadequate in heavier patients. 3,4 A review of observational studies suggests that with fixed dose thromboprophylaxis, VTE rates in the obese are twice that of the non-obese, with a subgroup analysis of the PREVENT trial demonstrating no benefit of standard-dose dalteparin over placebo in the morbidly obese population. 3 Randomised control trials involving bariatric surgery groups have demonstrated lower rates of VTE with higher doses of LMWH, with no associated increase in bleeding events. Severely and morbidly obese patients have been consistently under-represented in larger studies of thromboprophylaxis thus far, making it challenging to apply fixed-dose thromboprophylaxis to this growing segment of the population with any confidence. 3,5 Furthermore, studies have shown that obese patients have increased renal clearance compared to the non-obese, and LMWHs are renally excreted. 3,4 Royal Bournemouth Hospital and Poole Hospital had two serious untoward incidents in which patients died due to pulmonary emboli. The patients had both been on standard VTE prophylaxis as per the trust guidelines. This led to a review of practice, which produced a revised weight-based prophylactic dosing regimen (Table 1).The new guidelines were introduced early in 2015. We audited all new medical admissions over a 48-hour period in February 2015, supplemented by a questionnaire sent to all junior doctors regarding their knowledge of the changes. Out of 74 patients, 64 had completed VTE assessments (86.5%). Out of 59 patients assessed as requiring VTE prophylaxis, 49 were prescribed either mechanical prophylaxis, LMWH, unfractionated heparin or oral anticoagulants (83.05%). Of the 33 patients prescribed dalteparin, the LMWH used in the trust, only 24 were dosed appropriately for their weight as per the revised hospital guidelines (72.72%).The survey was sent to 60 junior doctors, 17 responded to the survey. Only 65% of these were aware that there had been a change in guidelines, with only 29% of these aware of the correct dosing for 100-150 kg and only 18% aware of the correct dosing for >150 kg.These data show that thorough and wide-reaching education is needed when essential guidelines are changed. Weight-based thromboprophylaxis should be considered by all trusts in view of the current evidence, and further work should be undertaken if more robust evidence is needed for this to be nationally recognised. ■
We report the case of an elderly Asian man where a medical error and diagnostic delays obscured the diagnosis of pleural tuberculosis (TB). The patient was hospitalized for evaluation of a unilateral pleural effusion. Initially, the patient was subjected to a pleural aspiration on the wrong side due to a lack of bedside ultrasound guidance. Subsequently, the patient underwent several investigations but not a blind closed pleural biopsy (BCPB) due to a lack of equipment. Furthermore, the patient was deemed to be too sick to undergo a thoracoscopic pleural procedure. Eventually, a bronchoscopy was performed, and washings from the right upper lobe were cultured, which established the diagnosis of TB. This case highlights the need to use bedside ultrasound in the investigation of pleural effusions, the role of BCPB especially in frail patients and finally the utility of bronchoscopy in establishing a diagnosis of pleural TB.
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