BACKGROUND:We evaluated venous thromboembolism (VTE) prophylaxis rates in hospitalized medical patients in a teaching hospital, the State University of New York-Downstate Medical Center-University Hospital of Brooklyn, before and after implementation of a multifaceted VTE prophylaxis quality improvement intervention that combined regular education, dissemination of a decision support tool, and regular audit-and-feedback to resident physicians. METHODS:The charts of 312 hospitalized medical patients were retrospectively reviewed to assess baseline rates of appropriate VTE prophylaxis. Rates of appropriate VTE prophylaxis were then determined 12 and 18 months after implementation of the quality improvement intervention. Data collected included risk factors for VTE, contraindications to anticoagulant prophylaxis, type of VTE prophylaxis prescribed, and whether the prophylaxis was appropriate. RESULTS:Most of the hospitalized medically ill patients had 3 or more risk factors for VTE. At baseline, the proportion of patients receiving any form of VTE prophylaxis, primarily unfractionated heparin, was 47%. The proportion of patients for whom a physician provided appropriate prophylaxis was 43%. After the intervention, the proportion of patients receiving prophylaxis significantly increased, to 86% at 12 months, and this level was maintained at 18 months. The rate of appropriate prophylaxis increased to 68% and 85% after 12 and 18 months, respectively. V enous thromboembolism (VTE), which encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of the morbidity and mortality of hospitalized medical patients. CONCLUSIONS:1 Hospitalization for an acute medical illness has been associated with an 8-fold increase in the relative risk of VTE and is responsible for approximately a quarter of all VTE cases in the general population. 2,3Current evidence-based guidelines, including those from the American College of Chest Physicians (ACCP), recommend prophylaxis with low-dose unfractionated heparin (UFH) or lowmolecular-weight heparin (LMWH) for medical patients with risk factors for VTE. 4,5 Mechanical prophylaxis methods including graduated compression stockings and intermittent pneumatic compression are recommended for those patients for whom an- O R I G I N A L R E S E A R C H 331ticoagulant therapy is contraindicated because of a high risk of bleeding. 4,5 However, several studies have shown that adherence to these guidelines is suboptimal, with many at-risk patients receiving inadequate prophylaxis (range 32%-87%). 6 -10 Physician-related factors identified as potential barriers to guideline adherence include not being aware or familiar with the guidelines, not agreeing with the guidelines, or believing the guideline recommendations to be ineffective. 11 More specific studies have shown that some physicians may lack basic knowledge regarding the current treatment standards for VTE and may underestimate the significance of VTE.12-13 As distinct strategies, education aimed at disseminatin...

Chylothorax and chylopericardium refer to the presence of milky, triglyceride-rich chylous fluid in the thoracic and pericardial spaces, respectively. Both conditions are extremely uncommon in end-stage renal disease patients on dialysis. We report the first known case of combined chylothorax and chylous pericardial tamponade in a dialysis patient associated with catheter-induced superior vena cava (SVC) stenosis. A successful outcome was achieved with drainage of both chylous effusions in combination with angioplasty of the SVC stenosis.

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Five doses of rATG versus 3 doses did not provide any additional benefit in preventing BPAR.