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SummaryThe EXCLAIM study enrolled hospitalised acutely ill medical patients with age >40 years and recently-reduced mobility into a trial of extended-duration anticoagulant thromboprophylaxis. This post-hoc analysis evaluated the impact of age on patient outcomes. After completion of open-label therapy with enoxaparin 40 mg once-daily (10 ± 4 days), eligible patients underwent randomisation to receive double-blind therapy of enoxaparin (n=2,975) or placebo (n=2,988) for 28 ± 4 days. During follow-up, the venous thromboembolism (VTE) risk increased with age in both treatment groups. In patients with age >75 years, those who received extended-duration enoxaparin had lower incidence of VTE (2.5% vs 6.7%; absolute difference [AD] [95% confidence interval]: −4.2% [−6.5, −2.0]), proximal deep-vein thrombosis (2.5% vs 6.6%; AD −4.1 % [−6.2, −2.0]), and symptomatic VTE (0.3% vs 1.5%; AD −1.2% [−2.2, −0.3]), in comparison to those who received placebo. In patients with age ≤75 years, those who received enoxaparin had reduced VTE (2.4% vs 2.8%; AD −0.4% [−1.5, 0.7]) and symptomatic VTE (0.2% vs 0.7%; AD −0.6% [−1.0, −0.1]) in comparison to those who received placebo. In both age subgroups, patients who received enoxaparin had increased rates of major bleeding versus those who received placebo: age >75 years (0.6% vs 0.2%; AD +0.3% [−0.2, 0.9], respectively); age ≤75 years (0.7% vs 0.2%; AD +0.5% [0.1, 0.9]). Patients in both age subgroups that received enoxaparin had similar low bleeding rates (0.6% and 0.7%, respectively). VTE risk increased with age, though the bleeding risk did not. Patients with age >75 years had a more favourable benefit-to-harm profile than younger patients.

OBJECTIVE: To evaluate venous thromboembolism (VTE) risk in patients who underwent a major operation, including the use of, and factors influencing, American College of Chest Physicians-recommended types of VTE prophylaxis. SUMMARY BACKGROUND DATA: The Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) survey, conducted in 358 hospitals in 32 countries, reported that globally, more than 40% of at-risk patients do not receive VTE prophylaxis. Limited data are available regarding VTE prophylaxis practices according to surgery type and patient characteristics. METHODS: Patients aged >or=18 years undergoing major surgery were included in this prespecified subanalysis. VTE risk and use of prophylaxis were determined from hospital medical records according to the 2004 American College of Chest Physicians guidelines. Multivariable analyses were performed to identify factors associated with VTE prophylaxis use. RESULTS: Of the 18,461 patients in ENDORSE who had undergone major surgery, 17,084 (92.5%) were at-risk for VTE and 10,638 (62.3%) received prophylaxis. Use of prophylaxis varied according to major surgery type from 86.0% for orthopedic surgery to 53.8% in urologic/gynecologic and 53.6% in other procedures. Major orthopedic surgery was most strongly associated with prophylaxis use (hip replacement: odds ratio 6.2, 95% confidence interval [CI] 5.0-7.6; knee replacement: odds ratio 5.9, 95% CI 4.6-7.8). CONCLUSIONS: The majority of surgical patients are at high-risk for VTE. Despite long-standing recognition of the high-risk for VTE in surgical patients, thromboprophylaxis remains underutilized.

Resume Objectif Decrire le profil des patients consultant pour une rhinite allergique saisonniere (Ras) printaniere en medecine generale et en allergologie de ville. Methodes Trois mille trois cent quarante-huit medecins (3284 generalistes et 64 allergologues) ont recense en 4 vagues mensuelles de recrutement de mars a juin 1998, 34851 patients consultant pour une Ras. A l’aide d’un questionnaire, les donnees demographiques concernant les medecins consultes et tous les patients ont ete collectees. Pour 12420 patients, la symptomatologie, les antecedents d’asthme, le traitement en cours pour la Ras ont ete analyses en comparant la population consultant un generaliste (A) et celle consultant un allergologue (B). Resultats La moyenne d’âge de tous les patients suspects de Ras etait de 37,1 ± 15,7 ans avec un nombre plus important de femmes (54,9 %). Pour 1441 patients, il s’agissait de la premiere consultation pour ce motif en particulier chez le generaliste (11,1 % vs 2,4 %). La rhinorrhee aqueuse, les eternuements et l’obstruction nasale etaient les plaintes les plus citees sans difference significative selon le type de medecins consulte. Cinq mille sept cent onze patients avaient eu de tests allergiques dont un plus grand nombre de tests cutanes pour les patients consultant un allergologue (78 % vs 44,9 %). L’association d’antecedent d’asthme etait frequente dans les 2 groupes (30 %). Le retentissement de la Ras sur la vie quotidienne etait presque identique, qu’elle soit isolee ou associee a des antecedents d’asthme (56 % vs 51,6 %) mais different pour le sommeil (56,7 % vs 21,1 %). Lors de la consultation, 5 889 patients etaient deja traites par des anti-H1 (83,2 %) quel que soit le medecin consulte. Conclusion La rhinite allergique saisonniere printaniere est une pathologie frequente qui altere significativement la qualite de vie. Il semble que le profil des patients differe peu qu’ils consultent un medecin generaliste ou un allergologue.

Background Histamine-induced wheal-and-flare studies are useful, objective tests for determining differences in the peripheral H 1 -receptor blockade activities of antihistamines. Objective To evaluate the time of occurrence of 95% inhibition of histamine-induced wheal and flare after administration of fexofenadine hydrochloride, 180 mg, or cetirizine, 10 mg. Methods Forty-two volunteers (aged 18–60 years) were included in a randomized, double-blind, crossover study. Skin prick tests were undertaken using histamine (100 mg/mL) before treatment and 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, and 4.0 hours after treatment. Wheal and flare areas were evaluated, and the time to occurrence of 95% inhibition and the frequency of subjects exhibiting 95% inhibition before median time to 95% inhibition were calculated. Results Mean ± SD time to 95% wheal inhibition was 2.46 ± 0.71 hours with fexofenadine and 2.55 ± 0.57 hours with cetirizine. The estimated mean difference between fexofenadine and cetirizine (−7 minutes in favor of fexofenadine; 2-sided 95% confidence interval, −21 to +7 minutes) was not statistically significant ( P = .34). For wheal, 29% of subjects receiving fexofenadine and 24% receiving cetirizine achieved 95% inhibition before the median time of inhibition (2.5 hours). An exact permutation test yielded a P = .37. For flare, 26% of subjects receiving fexofenadine and 10% receiving cetirizine achieved 95% inhibition before the median time of inhibition (3 hours; P = .12 by exact permutation test). Conclusions Fexofenadine and cetirizine have comparable onset of action times and similar frequencies of inhibition, as evaluated by the occurrence of 95% inhibition of histamine-induced wheal and flare.

Background Venous thromboembolism prophylaxis is suboptimal in the US despite long-standing evidence-based recommendations. The aim of this subset analysis of the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) study was to identify characteristics of hospitals with high guideline-recommended prophylaxis use. Methods Between September and November 2006, charts from eligible patients aged ≥40 years with an acute medical illness or age ≥18 years and undergoing a surgical procedure were reviewed from randomly selected US acute-care hospitals. Hospitals were ranked based on the proportion of at-risk patients who received American College of Chest Physicians–recommended types of prophylaxis. Hospital characteristics were compared to determine factors related to more frequent prophylaxis use. Hospitals were followed up 1 year after the chart audit. Results Overall, 9257 patients were evaluated from 81 hospitals. Appropriate types of prophylaxis were prescribed to more at-risk patients in hospitals in the highest quartile compared with the lowest quartile of prophylaxis use (74% vs 36%). All quartiles had a similar percentage of at-risk patients (61%-65%). Significantly more hospitals in the highest quartile had residency training programs (43% vs 5%), a larger median number of beds (277 vs 140), and had adopted hospital-wide prophylaxis protocols (76% vs 40%). In the follow-up survey, more hospitals overall had adopted hospital-wide written guidelines for venous thromboembolism prevention. Conclusions These findings support the value of hospital-wide protocols and local audits for VTE prevention, as recommended by several national quality-of-care groups.

Introduction: Findings from the recent EXCLAIM study demonstrate that selected acutely ill medical patients with reduced mobility benefit from extended-duration enoxaparin venous thromboembolism (VTE) prophylaxis (Blood2007;110:1862). However, it is unknown whether the EXCLAIM population is representative of acutely ill medical patients admitted to hospitals worldwide. In this subanalysis, we assessed whether the EXCLAIM population was representative of the medical patients enrolled in the multinational IMPROVE (Chest2007;132:936–45) and ENDORSE (Lancet2008;371:387–94) registries known to be at risk for VTE. Methods: Using patient data from IMPROVE and ENDORSE, we applied the EXCLAIM eligibility criteria to a representative, multinational population of acutely ill medical patients at risk for VTE. The IMPROVE and ENDORSE studies assessed VTE-risk and prophylaxis use of enrolled patients according to the 2004 American College of Chest Physicians (ACCP) guidelines (Chest2004;126:338S–400S). ACCP criteria for VTE risk were met in 46% (6,907/15,156) of IMPROVE and 43% (15,487/36,351) of ENDORSE study patients (Chest2007;132:936–45; Lancet2008;371:387–94). The EXCLAIM eligibility criteria required patients to be confined to total bed rest (level 1 immobility), or bed rest with bathroom privileges (level 2 immobility) and have at least 1 of 3 predefined risk factors for VTE (i.e., age > 75 years; history of VTE; active or prior cancer). Results: EXCLAIM eligibility criteria were met in 30% (2,072/6,907) IMPROVE and 36% (5,535/15,487) ENDORSE medical patients considered at risk for VTE by ACCP. During hospitalization, ACCP-recommended prophylaxis was provided to 69% (1,426/2,072) and 46% (2,548/5,535) of EXCLAIM-eligible patients enrolled in IMPROVE and ENDORSE, respectively. Following discharge from hospital (median length of stay 5 days for US, 8 days for non-US), only 9% (153/1,719) of EXCLAIM-eligible patients in the IMPROVE study received any type of ACCP-recommended VTE prophylaxis. Conclusions: Evidence from the EXCLAIM study demonstrated that the benefit-to-risk ratio in selected hospitalized medical patients favors the use of prolonged VTE prophylaxis. This population corresponds to one in three of the representative hospitalized patients with acute medical illness enrolled in IMPROVE and ENDORSE. Data on prophylaxis use from the IMPROVE registry suggest that only 9% of such patients are currently receiving optimal VTE prophylaxis following hospital discharge.