Factors Modulating The Risk Of Development Of Venous Thromboembolism

Methodology

DVT is a physiological manifestation of venous thromboembolism (VTE) and can be defined as blood clot that forms inside the veins, which are present in the interior portion of the muscles (Becattini et al., 2012; Schulman et al., 2013). Since the blood clot occurs in the vein, DVT is also popularly known as venous thrombosis (Patel, Chunand & Brenner, 2014). The occurrence of DVT is mainly common in large veins that run deep inside the leg through the calf muscles of the thighs. This review of literature aims to establish factors modulating the risks of development of venous thromboembolism (VT) among the adults. This topic was selected because VT is the third most common form of cardiovascular disorder with an incidence rate of one or two per 1000 people and this risk increases with age (Goldhaber, 2012). According to National Health Service (NHS) UK, every 1 out of 1000 person gets affected with DVT. People who are above 40 years of age are at an increased risk of developing DVT (National Health Service, 2017). Different disease conditions that increases the risk of developing DVT include blood vessel damage, pregnancy, heart and lung disease, Other significant reasons behind the development of DVT include surgery or serious injury that might have damaged the blood vessels. Examples of such chronic surgeries include knee replacement and surgeries carried out during the cancer treatment. (Lee et al., 2013). Some people suffer from a genetic problem of blood clotting and thus has genetic predisposition of developing DVT for example Von Willebrand disease (vWD) (Sanders et al., 2013). Therefore the objective is to analyse the main risk factors that increases the susceptibility of developing VT among the adults patients and analyse of the factors that leads to the decrease the chronicity of the disease.

This review of literature will initiate with an introduction stating the topic selected and the associated background information that are currently existing about VT. The introduction will be follow by a detailed clarification of the methodology undertaken, via stating the main key words used for the literature search, along with an explanation of the different research methods employed and selection the relevant research papers employing the critique appraisal skills programme (CASP) tool. The second chapter will analyse two themes that will be generate via analysis of the literary articles. The analysis of the literature review will draw a final conclusion in chapter three along with the limitations of the literature review, implications and recommendations for further professional practice.

Health-related conditions increasing the risk of VTE in adults

DVT is a common disease among the adult population.  DVT mostly notify its presence in the form of pain and the physical manifestation comes in the form of swelling. At times the pain may worsen, as the patient attempts to bend the foot upward towards the direction of the knees (Patel, Chunand & Brenner, 2014). Other symptoms of DVT include redness of skin and generation of local heat at the infected area.

The main complication arising out of DVT is pulmonary embolism (PE) (Chatterjee et al., 2014). It is one of the most serious complication of DVT and one out of 10 people who are suffering from DVT and are left untreated suffers from this disease (National Health Service, 2017).  PE is a serious condition where a piece of blood breaks off from the running blood stream and blocks the passage of the blood, mainly that is flowing away or towards the lungs. The condition DVT and PE is together termed as venous thromboembolism (VTE) (National Health Science UK, 2017). Both DVT and PE require serious medical attention on an immediate basis (Goldhaber & Bounameaux, 2012). Post-thrombotic syndrome is another complication arising out of DVT. It mainly affects 20 to 40% of people who are patients of DVT (National Health Service, 2017). Post-thrombotic syndrome gives rise to calf pain, swelling and in severe cases, ulcers on the calf (Galanaud & Kahn, 2014).

Apart from the age factor, other reasons that are susceptible in endangering people with DVT includes previous family history for the development of DVT or pulmonary embolism and family history of developing blood clots (National Health Science, 2017). People who remain physically inactive for a long span of time are also at an increased risk of developing DVT. For example, people who have experience spinal cord injuryhave a risk of developing DVT along with pulmonary embolism (Chung et al., 2014).

So the importance of this review of literature is, it aims at elucidating the reasons that are responsible for the development of the DVT especially among the elderly people along with proper direction towards the nursing care plan that must be undertaken in order to fight against the disease in an effective manner. This subject is of particular interest among the adult nursing as elderly people are the major victims of the DVT and they lose their locomotary ability under the attack of DVT (Do, Kim & Sung, 2013). Moreover, if DVT left untreated, it can lead to serious complications like sudden breathlessness and unbearable chest pain (Patel, Chun & Brenner, 2014). All these may lead to sudden collapse, resulting in death. Thus both DVT and pulmonary embolism demands instant investigation along with proper treatment.

Factors decreasing VTE in adults

Methodology

The methodology employed to erect the framework this review of literature is a comprehensive approach of literature review approach. According to Sui and Comerasamy (2013), there are two types of methodology that falls under the category of systematic review. First one is quantitative research and another one is comprehensive review that utilizes a mix of both quantitative and qualitative research. This enables an array of literary articles to be used that will add to the richness of the research. According to by Petticrew and Roberts (2006), qualitative research alone would not suffice the requirement of reliability as qualitative research lacks clear frameworks in their research design. However, Higgins and Green (2011) stated that quantitative framework of research is extremely rigorous. Nevertheless, at present there is growing prevalence behind the use of mixed methodologies because of its associated strengths and neither qualitative nor quantitative approach is better in comprehensive manner. Plano Clarke and Cresswell (2008) has opined that the approach must dependent on the situation which in turn depends on the research question. In order to follow an organised and defined process of development of the literature review, the review of literature will focus Machi and McEvoy’s (2012) six-step literature review model.

Numerous searches were undertaken in order to acquire the appropriate research papers for review of literature. Guidance provided by Aveyard’s (2014) in the domain of inclusion and exclusion criteria was cited to keep the track of the accurate conditions required for the research (Appendix Two). Electronic search of the research articles were preferred for the searching academic articles and for this electronic databases like MEDLINE, CINAHL Plus with Full text, InfoTrac Health Reference Center Academic, PubMed, ScienceDirect, EbscoHost were used. The online databases and research journals are accessed through the gateway of University of Greenwich online. Google Scholar was used further to broaden the window of the search and this allowed a comprehensive coverage further. The search was initially filtered from the tenure of 2000 to 2017 with no stringent restriction on geographical location and this helped to understand the entire span of available research. The search provided a significant amount of overseas journal articles which failed in the parameter of relevancy as the UK healthcare systems ha certain unique framework in comparison to most of the worldwide healthcare systems (Gregory, 2016). Filtering options were enabled to only select UK based research papers which were between 2007 to 2017 so that the data extracted for the research is contemporary. Few of the papers were discarded as there were no full-text access and demanded purchasing. However, the majority of the research papers were accessed for free viewed via logging in through university ID.

Key words for literature search
Increase	Primary Care	Deep?Vein Thrombosis
Pulmonary Embolism	Risks	Increase
Adults	Reduce	United Kingdom
Population-based	Prevent	Nursing care
Recurrent Venous Thromboembolism	Unprovoked Deep Vein Thrombosis	Upper Extremity Deep Vein Thrombosis
Diagnosis	Treatment	elderly care
High Risk Patients	Nursing Care

Conclusion

Alternative endings (truncation) were employed to refine the search further as per the findings of Aveyard (2014) and Whittaker (2011). For example, via using the CINAHL database, using asterisk at the end of each word generated numerous related terms. The table of illustration is given below:

Original search words	Alternative endings
Increas*	Increasing, Increases, Increased
Decreas*	Decreasing, Decreases, Decreased
Reduc*	Reducing, Reducers, Reduces, Reduction
Suitab*	Suitability, Suitably
Efficien*	Efficiency, Efficiently

Boolean search options are employed with the majority of the databases. According to Ridley (2012), the re-search method of adding words ‘OR’, ‘AND’ and ‘NOT’ helps to get multiple searches when two very similar words are used and this in turn reduces the time searching separately. For example, research papers in the UK are referred to as either the ‘Vein Thrombosis’ or the ‘Deep Vein Thrombosis’ so it was important to include these alternatives.

This chapter covers the two themes that have been identified after reviewing the research studies. The first theme is related to the health related conditions that increased the risk of VTE in adults and the second theme discusses about those factors that decreases VTE in adults. The paper discussing about the first theme has been marked with plus (+) sign and those discussing about the second theme has been marked with asterisk sign (*).

Though earlier it was recognized that VTE was a form of complication seen in hospital after major surgery, however the review of recent evidences have proved that venous thromboembolism increases in medical patients compared to those after surgery (Martinelli, De Stefano & Mannucci 2014). Although surgery is a common risk factor for VTE, however the risk of VTE also increases because of the presence of many health conditions. By means of a population wise cohort study, Chung et al., (2014) proved that asthma increases pulmonary thromboembolism risk. The research utilized patient data related to newly diagnosed asthma patient and those without asthma from Longitudnal Health Insurance Database (LHID). The main outcome measure for the study included incidence of pulmonary embolism and history or surgery or medications. Analysis of outcome measure of immobilization and medication is an effective step as this condition also leads to the development of embolism (Parker, Coupland & Hippisley-Cox, 2010)). The results of the study proved that rate of pulmonary embolism increases three fold in asthma patient compared to non-asthmatic cohort. This finding is consistent with other research work as also stated that asthma increases risk of VTE (Børvik et al., 2015). However, the only limitation of this study is that the databases and hospital record could not give insight about the lifestyle factors of patient such as smoking and level of physical activity. Another limitation is that it could not explain the mechanism by which asthma increases the risk of VTE in asthma patient.

Limitations, Implications, and Recommendations for Further Professional Practice

In contrast to Chung et al. (2014), Majoor et al. (2013) used survey method to investigate about the role of severe asthma on increasing the risk of thromboembolic complications. Patient with mild-moderate and severe asthma were taken as sample population and survey questionnaires to assess the prevalence of VTE were distributed during their follow-up to the outpatient clinic. The survey questionnaires were about history of VTE, risk factors for VTE as well as asthma and anticoagulant therapy. The research rigor is understood by the researcher’s consideration to make the research feasible for the subjects and ensuring that survey question has all elements to confirm that asthma increases the risk of VTE. The strategy to interview patient about risk factor of both VTE as well as asthma is commendable as in COPD patient, risk of VTE increases due to presence of other risk factors such as immobilization, right ventricular failure and venous statis (Børvik et al., 2015). The survey also incorporated specific questions on inhaled or oral corticosteroid treatment at the time of VTE event. Quantitative method was analyzed to assess primary and secondary outcome measure of first episode of VTE and other covariables. The credibility of the study is enhanced by large sample size and considering about overestimation factors.

By the use of quantitative survey method, Majoor et al. (2013) gave statistically significant data related to increase in VTE in patients with asthma. This is understood from the research outcome that incidence of VTE in severe asthma patient was high compared to those with mild-moderate asthma. By comparison of the research outcome with general population, the result indicated nine-fold increase in risk of VTE in patients with severe asthma. This was also greatly linked to the use of oral corticosteroids by patient. This is a reliable result as Waljee et al. (2017) argued that long term use of corticosteroid result in risk of acute complications like infection and VTE in patient. For this reason, corticosteroid is one the most common reason for drug related adverse event and hospitalization. Hence, this study has many clinical implications as by establishing link between use of corticosteroid in asthma patient and VTE risk, it gave the indication that attentions needs to given regarding routine use of these drugs to prevent adverse events in hospitals and promote safety of patient. By the result outcome given by Majoor et al. (2013), it also pointed out to mechanism by which corticosteroid induced hypercoagulability increases risk for patient. Hence, the study is reliable and transferable to other setting. This research evidence can also be utilized to increase awareness of clinicians related to risk associated with corticosteroid drug during evaluation of patients with severe asthma.

Chung et al. (2014) discussed about another health condition that increases the risk of deep vein thrombosis and pulmonary thromboembolism in patient by investigating about the association between rheumatoid arthritis and VTE. The effect of RA on risk of VTE was evaluated by means of a nationwide prospective cohort study. Prospective cohort study is done when the aim is to determine how specific factors have an impact on certain outcome (Bryman 2017). Based on review of study objective, this method is found to be suitable for getting answer to the research question. The study was done with Taiwan population and patients with rheumatoid arthritis were identified by checking the registry of the Taiwan National Health Insurance Research Database (NHIRD). In patients following up in 2010, the incidence ratio of deep vein thrombosis and pulmonary thromboembolism was calculated. The research showed age associated difference in risk of VTE, as rheumatoid arthritis has high impact of developing VTE in young adults compared to older adults. By comparison with general population too, it was found that rheumatoid arthritis increases risk of VTE in patient. This research is consistent with the research done by Kim et al., (2013), however it was done by retrospective cohort study.

The strength of the study by Chung et al. (2014) is that it gave statistically significant result regarding the risk of VTE in rheumatoid arthritis patient. However, the limitation of the study is it research design as by the use National registry, it could not identify other factors that might increase the risk of VTE in patient. There was also lack of discussion regarding the pathological links between research outcomes and risk of VTE in rheumatoid arthritis patient. Ungprasert et al. (2014) states that VTE risk increase when there is an alteration in blood flow, changes in blood status and vascular endothelial injury. In case of patients with rheumatoid arthritis, chronic inflammation increases due to the increase in level of C-reactive protein. This study has many important clinical implications. By the awareness of factors related to risk of VTE in rheumatoid arthritis patient, adverse patient event can be minimized in hospital setting by taking integrated approach to care. The multidisciplinary team needs to routine assess rheumatoid arthritis patient for any possibility of VTE risk and provide appropriate intervention accordingly.

Surgery is found to be one common factor that increases risk of VTE and evidence also shows that large number of rheumatoid arthritis patient requires major orthopedic surgery. Hence, as surgery further increases the likelihood of VTE in patient, it is necessary that multiprofessional health care team consider about appropriate prophylaxis in patients going for knee replacement surgery. The care process for patient needs to be individualized so that favorable patient outcome can be obtained and all factors that put patient at risk of thrombotic event is eliminated (Mameli & Marongiu, 2014).

Rheumatoid arthritis is a chronic inflammatory autoimmune disease, which puts the life at risk of patients with the condition. It is generally observed that the patients with such conditions have shorter life expectancies due to increased rate of cardiovascular failure. The primary cause of this morbidity is due to increased rate of pulmonary embolism (PE) and deep vein thrombosis (DVT) in legs and around organs. The research conducted by Choi et al. in 2012, wanted to understand the incidence of PE and DVT after initial diagnosis with RA. They scientists conducted a cohort study conducted a cohort study by assessing the medical history of patients of the populations in UK from the time-period 1986-2010. The susceptibility of the said conditions was compared with the patients without RA, keeping in mind the age, sex, smoking habits et cetra.  The results revealed that 82 out 1000 people with RA showed increased risk of PE ad DVT than the people without RA, which were 35 out of 1000. These results were analyzed considering the health habits, age and gender. The paper although approaches the study in a epidemiological scale but could support their hypothesis with laboratory data which would state as to why and exactly how the PE and DVT is influenced by RA condition biologically. Chung et al. conducted a similar nationwide cohort study in 2014 in Taiwan, keeping in mind the Taiwanese population under the National Health Insurance Research Database gathered between 1998 and 2008 with a follow up on 2010. The sample size of this research was more extensive with approximately less than 24 million people along with women and men of a specific age group and similar comparison was made and found out that the risk of PE and DVT is definitively higher in patients with RA than the general population (Chung et al., 2014). Overall, the paper is highly generalized in terms of its study approach, which provides better understanding of the situation and the study was holistic. The limitation of the study was that the study was based on medical history from various healthcare facilities which has the possibility of clinical errors with regards to the information. The findings of the paper provide peers to develop research area for understanding the importance of DVT and PE clinical manifestation in the arthritic patients. Biologists can develop clinical symptoms, which would help early detection methods for DVT, and PE and RA patients and prophylaxis can be commenced to minimize the risk of morbidity.

The association of cancer and venous thrombo-embolism was first discovered in the nineteenth century and has been recognized ever since as a reason for morbidity in cancer patients (Lyman Bohlke & Falanga, 2015). The malignant condition induces many cytokines and growth factors which alternate the blood coagulator factors inducing clotting in arbitrary location of the blood vessel. This can result in pain, respiratory or cardiac out defect. Studies have shown that the risk of VTE is higher in case of the cancer patient is four times that that of a normal individual (Merkow et al., 2011). Severe cases have been shown to causes morbidity in complicated stages of cancer patients (Horsted et al., 2012). Such cases where the impact of VTE causing death in cancer patients is as high as six times.  The importance of the prophylaxis regarding VTE in cancer patients is quite underrated which is also responsible for the death of such patients. A group of scientist conducted a qualitative research of analyzing meta-analysis, systematic reviews, and international articles related to VTE risks prophylaxis, and its management in cancer patients from medical databases. The scientists searched databases like Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and ISI Web of Science by searching keywords specific o the issue.  They also studied conference presentation of American Society of Clinical Oncology and American Society of Hematology and researched current material to understand the approach of modern healthcare providers about the effect of VTE and cancer. The scientist looked for the reasons for the development of cancer and the VTE condition. This could help find the specific markers or regulators, which could be potential target for cancer therapy.  The important components were found to be tissues factors, inflammatory cytokines and platelets, which participated in the coagulation pathway. The incidence of tissue factors were 60% higher in cancer patients 27% in patients without cancer. The comparative study helped understanding the severity of morbidity to which the patients were exposed. They research study developed risk factors associated with the symptoms of cancer with respect to the target tissue. The research paper helps understanding how important the thromboembogenic factors can be for treating cancer patients and provides recommendations for oncologists to treat such cases and prevent morbidity. Patient education is also an important factor that has been discussed in this paper as the link between VTE and cancer is not known popularly.  The paper addresses the issue very efficiently but fails to provide primary laboratory data, which would have further supported their hypothesis. This is the major flaw in the paper along with the fact there are no proposed limitations, which would allow peers to perform further research.

Previously it was a perceived notion that in Asian population, the incidence of DVT is uncommon for which in many surgical procedures did not include routine thrombo-embolic prophylactic measures. This was in comparison to the Caucasian population who have an incidence of DVT was between 65-152 out of 100,000 people and the incidence of PE was between 49-189 per 100,000 population (Law, Chan & Cheng, 2018). The r4esearch team formulated their hypothesis from the published epidemiological data regarding the morbidity cases analysis which was related to DVT and PE following the census reports of 2011. The research paper aims to study the population based in china, to review the epidemiological effects of DVT and help healthcare providers and patients understand the importance for better patient outcome and reduced surgical risk. The research group studied healthcare databases from the year 2010 to 2011, which are stored in computers. The target demographic was the Han Chinese population who constitute to about 7.1 million. The incidence, demographics, and hospital mortality rates of DVT and pulmonary embolism (PE) was studied and analyzed for different surgical categories. The annual incidence of the DVT and PE conditions were found to be in 30 out of 100,000 people and 8.7 out of 100,000 respectively.  The ratio of female and male in the population was 1:1.24. The paper showed that the incidence of VT is more prevalent with older age group and is dependant with respect to the gender. The research group performed contemporary literature review of journal articles from medical databases from PubMed, OVID MEDLINE, and EMBASE which comprised of population based studies of DVT and PE cases keeping the focus on Chinese population. Their search results supported the proposed hypothesis that in comparison to Caucasian population, the Chinese population has lower rates of DVT and PE incidence. The results showed that in comparison to the previous census report the incidence of DVT and PE have been doubled from 17.1 to 30 out of 100,000 people. The suspected causation could be due to adoption of a western country based diet which altered their genetic composition and physiological composition of the body. Analyzing the surgical cases of morbidity, it was found that Neurosurgical patients had the highest incidence of postoperative DVT and PE, 0.64% and 0.61% respectively. The research paper can be a good benchmark for the health practitioners to learn about the outcomes related to post operative risk of DVT and PE in Asian populations.

Reflecting on the health related conditions that can increase the risk of the VTE in patients, the author Attia et al., (2015) have proposed that thromboprophylaxis does not mitigate the risks of venous thromboembolism after  a major surgery. According to Attia et al., (2015) P.E is a life threatening condition that can be nightmares to most of the surgeons after the surgery. The study suggests that patients who have had major orthopedic surgery or abdominal surgery and have received VTE prophylaxis have shown cases of venous thromboembolism. The study involved a survey where the patients who had undergone a major abdominal surgery and major orthopedic surgery and they were evaluated for the incidence of DVT within 30 post operative days. All the patients were provided compression stockings and prophylaxis. The incidence of DVT and PE present in the in the patients in the study was found to be 2.23% and 2.03%. All the patients were diagnosed with DVT. It has been found that most of the patient has developed DVT within the first five post operative days. As per the results the incidence of PE among the patients with femoral fractures was high, even after the provision of thromboprophylaxis. This can be justified by the fact that most of the patients having femoral fractures are elderly and bone fractures increases tye risk of VTE due to factor like immobilization and higher endothelial injury. VTE occurs within the first 5 postoperative days because the early effect of the endothelial surgery. According to the author, with the vascular endothelial damage and venous stasis, hypoxia can occur that can increase the activation of the coagulation cascade. The fibrinolytic activity of the body prevents the formation of the thrombosis. One of the studies has shown that increased prophylaxis decreased the incidence of VTE to some extent but could not solve the problem. The study has also shown that the incidence of DVT and PE in patients who have undergone abdominal surgery is also high. This can be explained by the aspects like complications related to post-operative infections, prolonged surgery and pelvic dissection.

Hence it can be found that in spite of the thrombo-prophylaxis, PE and DVT is common after major abdominal surgeries. Attia et al., (2015) have reported that the incidence of VTE in the patients with colorectal surgery who have received prophylaxis have shown less chances of VTE occurrences than the ones who have not received. The occurrence of VTE in patients, mostly the elderly patients is linked with decreased mobility and other underlying illnesses.

 Bouras et al., (2015) on the other hand have stated that the chance of the post-operative VTE after the discharge increases. The paper studied about the risks of mortality in the patients due to VTE after general surgery. The main aim of the paper was to improve the understanding of the type of harm related to VTE that can occur after the discharge. The evaluation was done by the collection of the data from the national Cancer Information network database. Previous studies have stated that the risk of VTE remains 90 days after the commencement of the surgery. Subjected to one of the general surgical procedures have been taken as the study population. VTE rates were calculated for 30, 60 and 90 days after the surgery. Multiple regression analysis was done for the post-operative VTE (Bouras et al., 2015).  One of the principle finding of the study is that about 40 % of the mortality cases were found to be linked with VTE. VTE was observed at higher rate among the in-patients but was also found after the hospital discharge. Predictor associated with VTE was age, history of VTE, BMI, stage of the diseases such as cancer as well as the duration of the surgical procedures such as prolonged stay and emergency surgery. The strength of the data was that it was successful in founding the harm in the patient. The incidence of the VTE was found to be lower in patients who are regular with the clinical follow u right after the discharge. Combination of the routined database was successful in finding out the population level outcomes. A limitation of the study is the lack of information regarding the thromboprophyaxis applied in the patients. One of the implications for this study is that the complications related to VTE can be decreased using thrombo-prophylaxis, which refutes the information discussed in the previous paper that thrombo-prophylaxis is not suitable in managing VTE in the post-operative periods. NICE have recommended the use of thrombo-prophylaxis up to 28 days after the surgery in patients with major cancer.

Jones et al., (2017), on the other hand have shown the Adherence to prophylaxis in the post-operative period helps in preventing VTE in patients. In order to validate this, a case control study was done using 2011- 2015 ACS-NSQIP database. Patients who have received post-operative prophylaxis within 30 days of the surgery were selected. Majority of the patient’s received Enoxaparin as the chemical prophylaxis for preventing VTE. The doses ranged between 30 mg to 40 mg. The significant findings from the paper were that nearly half of VTE caused in patients who have received chemical prophylaxis after he surgery (Jones et al., 2017). The author has justified the interpretations by the surgical procedures, bleeding and underlying health care reasons. Some of the cases were related to central venous line which cannot be even prevented by chemical prophylaxis.  The study also provides information that VTE prophylaxis cannot be used in case of the critically ill patients. This study supports the fact, that although prophylaxis can identify the patients who are at high risk of DVT, but it cannot possibly prevent DVT. The main implication of this study is that new methods of prophylaxis are required to improve the safety in the post-operative period during the hospital stage and even after the discharge. Hence it can be said that in spite of the application of appropriate prophylaxis, the prevention of the VTE is still questionable (Jones et al., 2017).

Most of the papers have indicated towards the prevalence of DVT in patients after the surgical procedures. Results have found that patients who have had major orthopedic surgery or abdominal surgery are at a greater risk of developing VTE and PE. The development of VTE in patients with orthopedic surgery can be related to old age, surgical complications and other factors. As per the papers some of the evidences shows that thromboprophylaxis has been helpful in preventing DVT in patients during the post-surgical period. But majority of the paper could not provide evidence for the usefulness of the prophylaxis after a major surgery. VTE is considered as the never event and is one of the most costly morbidities following the surgery. Unless more progress is made in the field of thrombo-prophylaxis, VTE should be considered as a measure of the quality of care provided in a hospital setting.

Several studies have been conducted to understand the techniques using which the risk related to Deep Vein Thrombosis or DVT can be decreased. In a research conducted by Ageno et al., (2016), the researcher were determined to find out the effectiveness of oral Rivaroxaban and compared that with the standard anticoagulation and used these to treat patients of symptomatic deep vein thrombosis. This study had greater implication as it was conducted internationally and total 21 country’s hospitals and community care centers were involved in this research (Ageno et al., 2016). The treatment lasted for three months and in the two yearlong research, more than 5000 patients were treated. The results observed from the research observed major bleeding in both the group, which was found in Rivaroxaban group as 0.8% and in standard anticoagulation group 2.1%. Further, the recurrence of venous Thromboembolism was found as 1.4% in Rivaroxaban group and 2.3% in standard anticoagulation group. Whereas, the rate of treatment emergent adverse effect was found similar in both the groups (Ageno et al., 2016). While critically discussing the article it should be mentioned that as per Harper & Cole (2012), as the study included a comparative group in the research process, practice patterns within each clinical facilities were established using contemporary environment. However, as this was an international research process, all the centers where this process was conducted, providing training regarding the usage of Rivaroxaban was not provided, that limited the effectiveness of the research. Further, discussed in the research by Prinset al., (2014), usage of rivaroxaban in combination with vitamin K and enoxaparin did not provided extraordinary results compared to intervention applied by normal healthcare facilities to prevent bleeding. However, the broad aspect of this study, its clinical reach and variance and level of application increased the efficacy of the research result.

In an another research conducted by Nelson et al., (2015), the researchers aimed to calculate the number of post-operative venous thromboembolism and for that purpose they searched HER and 111 veteran affairs system and in the process they observed all the operations occurring within those 111 VA system which was around 3,493,378. This study was conducted for 30 days and within that period 49.4% possible VTEs and 47% of probable cases of VTEs were observed. Whereas, in another set of experiment, having frame of 90 days, 86% were developed VTE in post-operative system, within which only 3.3% had the probable risk of VTE after 30 days frame. However, while discussing the reason of increased number of patient developing VTE, the article explained the lack of patient safety measures within the healthcare facility (Nelson et al., 2015). Further, usage of three aspects to determine the occurrence of VTE in patient such as 12 months prior to operation, 3 months later the operation and 9 months later the operation provided the researchers with opportunity to avoid the false positives and obtain authentic results. Therefore the obtained result of 1.4% surgical admissions, more than 60% of post-operative VTE and 14% within which VTE occurred after discharge provided clear and concise interpretation (Nelson et al., 2015). However, according to van Staaet al., (2012), as the data was collected from EHRs and VA systems, there is a possibility of technical error as all these data related to VTE was developed by surgeons that conducted the operation within the system, therefore chances of manual error are still there. Further as the data was collected from the databases with the consent of the healthcare facilities and patients, there is a possibility that maximum of the data cannot be accessed due to the consent issue from the healthcare facility or the patient. However, as the data collected were authentic, the reliability of the research increases and it was able to find out the rate at which occurrence of VTE hampers the health in post-operative state (Nelson et al., 2015).

Another research article should be mentioned in this context as the research was conducted by Cassidy, Rosenkranz and McAneny (2014), and the aim of the research process was to determine the effectiveness of the standardized protocol to treat post-operative VTE in patients with mobilization program. The researchers used the Caprini grading system to specifically observe the post-operative VTE in patients and effect of early post-operative mobilization on the development of VTE. The score obtained from the grading was used to generate VTE prophylaxis before, after and after the discharge of the patient. With that the pharmacological prophylaxis was used by the researchers to understand the effectiveness of the effect of standardized protocol in a combination with the postoperative mobilization program (Cassidy, Rosenkranz & McAneny, 2014). The researchers used a recommended prophylaxis regiments to determine the lower risk of VTE and score more than 9 determines highest risk of VTE. Therefore, the result obtained from the research determined that prior to implementation of risk-stratified prophylaxis the rate of VTE in post-operative setting and mobilization period was found to be 1.9%, and after the usage of these measures in current healthcare setting the risk of VTE decreased by 84% and now it is 0.3% within 1323 patients. However, the authors were unable to explain the reason behind the similar result that was observed in case of Incidences of DVT in post-operative system, which was steady at 0.8% even after the usage of the abovementioned means (Cassidy, Rosenkranz & McAneny, 2014). Further, implementation of mobilization was found to be effective as according to Kahn et al., (2012), the immobilized patients have higher risk of VTE compared to those who are been mobilized to some other place. Therefore being several methodological limitations, the study was able to determine the effectiveness of strategic implementation of intervention and usage of mobilization technique to prevent the outrage of VTE in post-operative patients.

The research papers selected showed quantitative collection methods over qualitative methods in the majority of the cases. However, according to, Shneerson and Gale (2015), the authenticity of the quantitative data is considered more valuable. Shneerson and Gale (2015) further stated that within health research, qualitative analysis could answer clinical questions in order to calculate results. Furthermore, Punch (2013) have opined that qualitative methods are useful when employed along with quantitative methods and thus generating a mixed method theory. This has presently increased the development to narrating effective results along with evidence (Punch, 2013). Therefore, it is possible if HES was used along with GPPS this might allow for reliable yet relevant mixed method approach from patient perspective.

Conclusion

Thus from the discussion as presented in theme 1 of the literature review, it can be concluded that although surgery is a common risk factor for the development of DVT, several other health conditions also increases the risk of developing DVT. Among the risk factors, the main health conditions which are associated with the development of DVT are asthma. Asthma also increases the threat of developing pulmonary embolism. However, proper application of corticosteroids reduces the severity of the disease. It can also be said that venous thrombosis associated with cancer is common conditions, however, the reported cases vary largely with the studies depending among the population of the patients, duration of the disease, method used to treat cancer and the disease follow-up. Moreover, cancer is a heterogeneous and the risk of developing venous thrombosis depends on stages and types of cancer. In general it can be said that cancer patient with DVT have an increased rate of mortality in comparison with cancer patients without DVT. This can be further explained by more aggressive type of malignancies which are associated with this condition. From the papers reviewed in relation to cancer and DVT showed that approximately same rate of occurrence of DVT among the cancer patient both in UK and worldwide. One of the primary types of cancer detected with increase rate of incidence of DVT is abdominal cancer and pancreatic cancer and lower rate of incidence is detected among the patients with breast cancer and prosthetic cancer. Another high risk group of DVT are the patients suffering from rheumatoid arthritis. The risk ration is fairly consistent among the population group of UK and worldwide. The occurrence of DVT is verified on the basis of three determinative factors known as Virchow triad. Under virchow triad there lies hypercoagulability, venous statis and endothelial dysfunction. RA appears to interfere with all the three factors and thereby causing impairmentin anticoagulation pathways and inhibition in the fibrinolytic process. However, the risk of RA increases with the lack of physical activity and this further increases the chance of developing DVT.

Finally the second theme of the literature review highlights the importance of the use of oral medication in the treatment of DVT among the high risk patients along with the use of anti-coagulant therapy. The review also brings about a comparison of the new oral anticoagulants such as rivaroxaban with the standard anticoagulation therapy. A prospective study shows that Rivaroxaban is more efficient than the conventional old anticoagulants. The new oral anticoagulants not only differ from conventional Warfarin in their mechanism of action but pose some disadvantages of increased bleeding. The report emphasizes upon the importance of maintaining the duration of the anticoagulant therapy. The anticoagulation therapy occurs for three months and can also be continued in case of patients with low risk of bleeding. The decision to stop anticoagulation therapy before three months can give rise to recurrence of DVT. The research process to determine the effectiveness of the standardized protocol to treat post-operative VTE in patients with mobilization program recommended prophylaxis regiments to determine the lower risk of DVT.

Due to time constrain, the review of the literature fails to analyse enough journals via. Limited access and review of the journals may lead to the generation of biased response in theme. Moreover, the literature review consisted journals of randomised control trials, meta-analysis and cohort studies and these may again the cause of biasness in the response. Moreover, the review only highlighted the occurrence of DVT among rheumatoid arthritis, asthma and cancer and due to the constrain of the word count, the review fail to analyse the risk of developing DVT among the pregnant women and the group of population suffering from cardiac problems.

Anticoagulant treatment for the prevention of venous thrombotic events in cancer helps in the improvement of the disease prognosis and quality of life. However, such treatment has certain disadvantages like increased rate of bleeding and thus resulting in huge blood loss. Hence it is recommended that patients showcasing symptoms of DVT and who have generated positive non-invasive test results should be treated for DVT while other patients with negative test results must repeat the non-invasive test 2 times in-order to detect the extending calf-vein thrombosis. This approach is most appropriate for the patients who are at a high-risk of developing DVT (Mclintock et al. 2012).According to National Institute for Health and Care Excellence (NICE), there must be a definite diagnosis plan for detecting venous thromboembolism or DVT under primary, secondary and tertiary care. This diagnosis pattern of the DVT starts with the screening with the adults who are expressing signs and symptoms of DVT or pulmonary embolism. The screening is followed by the initial diagnostic investigations. After initial diagnostic investigation the clinical probability of the deep vein thrombosis is estimated via the application of the two-level Wells score. This two-levels Wells score will reveal the variations is certain conditions like DVT-likely, DVT unlikely, pulmonary embolism likely and pulmonary embolism unlikely. Upon the classification or gradation of the disease, the disease treatment is being propagated (National Institute for Health and Care Excellence 2017).

While admitted in hospital there a number of things that a nurse or other health care professionals need to abide by in order prevent the patients from the ill-effects of DVT. The nurses are require to make sure than the patients always remain hydrated while they are in a long sedentary mode before and after the surgery like leg or abdominal surgery. Adequate intake of water helps to prevent DVT or reduces the severity of the DVT (National Health Service UK 2017). Experienced yet registered nurse must employ proper mechanical methods like compression stockings in order to prevent venous stasis. Other medical therapies that are employed for the prevention of DVT include anti-platelets therapy, external administration of heparins and heparinioids (Field and Hill 2012).  Low molecular weight heparin is used for the treatment of the DVT and is mostly employed after the pregnancy. Unfractioned heparin used to treat DVT in the people who are suffering acute kidney failure (National Health Service 2017).

References

Ageno, W., Mantovani, L. G., Haas, S., Kreutz, R., Monje, D., Schneider, J., …&Turpie, A. G. (2016). Safety and effectiveness of oral rivaroxaban versus standard anticoagulation for the treatment of symptomatic deep-vein thrombosis (XALIA): an international, prospective, non-interventional study. The Lancet Haematology, 3(1), e12-e21.

Attia, A., Ali, H., Al Amory, M., & Othman, H. (2015). Thromboprophylaxis does not prevent venous thromboembolism after major surgery. Egyptian Journal of Chest Diseases and Tuberculosis, 64(1), 249-254.

Aveyard, H. (2014) Doing a literature review in health and social care: a practical guide. Berkshire: Open University Press

Becattini, C., Agnelli, G., Schenone, A., Eichinger, S., Bucherini, E., Silingardi, M., Bianchi, M., Moia, M., Ageno, W., V&elli, M.R. & Gr&one, E., (2012).Aspirin for preventing the recurrence of venous thromboembolism.New Engl& Journal of Medicine, 366(21), pp.1959-1967.

Børvik, T., Brækkan, S. K., Enga, K., Schirmer, H., Brodin, E. E., Melbye, H., & Hansen, J. B. (2015). COPD and risk of venous thromboembolism and mortality in a general population. European Respiratory Journal, ERJ-00402.

Bouras, G., Burns, E. M., Howell, A. M., Bottle, A., Athanasiou, T., & Darzi, A. (2015). Risk of post-discharge venous thromboembolism and associated mortality in general surgery: a population-based cohort study using linked hospital and primary care data in England. PLoS One, 10(12), e0145759.

Bryman, A. (2017). Quantitative and qualitative research: further reflections on their integration. In Mixing methods: Qualitative and quantitative research (pp. 57-78). Routledge.

Cassidy, M. R., Rosenkranz, P., &McAneny, D. (2014). Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. Journal of the American College of Surgeons, 218(6), 1095-1104.

Choi, H. K., Rho, Y. H., Zhu, Y., Cea-Soriano, L., Aviña-Zubieta, J. A., & Zhang, Y. (2012). The risk of pulmonary embolism and deep vein thrombosis in rheumatoid arthritis: a UK population-based outpatient cohort study. Annals of the rheumatic diseases, annrheumdis-2012.

Chung, W. S., Lin, C. L., Ho, F. M., Li, R. Y., Sung, F. C., Kao, C. H., & Yeh, J. J. (2014). Asthma increases pulmonary thromboembolism risk: a nationwide population cohort study. European Respiratory Journal, 43(3), 801-807.

Chung, W. S., Peng, C. L., Lin, C. L., Chang, Y. J., Chen, Y. F., Chiang, J. Y., … & Kao, C. H. (2014). Rheumatoid arthritis increases the risk of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study. Annals of the rheumatic diseases, 73(10), 1774-1780.

Chung, W.S., Peng, C.L., Lin, C.L., Chang, Y.J., Chen, Y.F., Chiang, J.Y., Sung, F.C. and Kao, C.H., 2014. Rheumatoid arthritis increases the risk of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study. Annals of the rheumatic diseases, 73(10), pp.1774-1780

Chung, W.S., Peng, C.L., Lin, C.L., Chang, Y.J., Chen, Y.F., Chiang, J.Y., Sung, F.C. & Kao, C.H., (2014). Rheumatoid arthritis increases the risk of deep vein thrombosis & pulmonary thromboembolism: a nationwide cohort study. Annals of the rheumatic diseases, 73(10), pp.1774-1780.

Do, J.G., Kim, D.H. & Sung, D.H., (2013). Incidence of deep vein thrombosis after spinal cord injury in Korean patients at acute rehabilitation unit. Journal of Korean medical science, 28(9), pp.1382-1387.

Field, T.S. & Hill, M.D. (2012). Prevention of deep vein thrombosis and pulmonary embolism in patients with stroke. Clinical and Applied Thrombosis/Hemostasis, 18(1), pp.5-19.

Galanaud, J.P. & Kahn, S.R., (2014). Post?thrombotic Syndrome. Hemostasis & Thrombosis, pp.186-196.

Goldhaber, S.Z. & Bounameaux, H., (2012). Pulmonary embolism & deep vein thrombosis.The Lancet, 379(9828), pp.1835-1846.

Gregory, S (2016) ‘How do the healthcare systems in the UK compare with others internationally?’, The BMJ, Available at: https://blogs.bmj.com/bmj/2016/05/03/how-do-the-healthcare-systems-in-the-uk-compare-with-others-internationally/ (Accessed: 04/04/18)

Harper, M., & Cole, P. (2012). Member checking: can benefits be gained similar to group therapy?. The Qualitative Report, 17(2), 510-517.

Higgins, J.P.T. & Green, S. (eds) (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [Updated March 2011]. The Cochrane collaboration. Available at: www.cochrane-handbook.org (Accessed: 02/10/17)

Horsted, F., West, J., & Grainge, M. J. (2012). Risk of venous thromboembolism in patients with cancer: a systematic review and meta-analysis. PLoS medicine, 9(7), e1001275.

Jones, C. E., Hollis, R. H., Gullick, A. A., Wahl, T., Richman, J. S., Graham, L. A., … & Morris, M. S. (2017). Venous thromboembolic events: How low can you go?. The American Journal of Surgery, 213(4), 706-710.

Kahn, S. R., Lim, W., Dunn, A. S., Cushman, M., Dentali, F., Akl, E. A., …& Schulman, S. (2012). Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2), e195S-e226S.

Kim, S. C., Schneeweiss, S., Liu, J., & Solomon, D. H. (2013). Risk of venous thromboembolism in patients with rheumatoid arthritis. Arthritis care & research, 65(10), 1600-1607.

Law, Y., Chan, Y. C., & Cheng, S. W. (2018). Epidemiological updates of venous thromboembolism in a Chinese population. Asian journal of surgery, 41(2), 176-182.

Lyman, G. H., Bohlke, K., & Falanga, A. (2015). Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. Journal of oncology practice, 11(3), e442-e444.

Machi, L.A. & McEvoy, B.T. (2012) The literature review: six steps to success. London: Sage publications

Majoor, C.J., Kamphuisen, P.W., Zwinderman, A.H., ten Brinke, A., Amelink, M., Rijssenbeek-Nouwens, L., Sterk, P.J., Büller, H.R. and Bel, E.H., 2013. Risk of deep vein thrombosis and pulmonary embolism in asthma. European Respiratory Journal, 42(3), pp.655-661.

Mameli, A., & Marongiu, F. (2014). Thromboembolic disease in patients with rheumatoid arthritis undergoing joint arthroplasty: Update on prophylaxes. World journal of orthopedics, 5(5), 645.

Martinelli, I., De Stefano, V. & Mannucci, P.M., 2014. Inherited risk factors for venous thromboembolism. Nature Reviews Cardiology, 11(3), p.140.

Mclintock, C., Brighton, T., Chunilal, S., Dekker, G., Mcdonnell, N., Mcrae, S., Muller, P., Tran, H., Walters, B.N. &Young, L., (2012).Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Australian and New Zealand Journal of Obstetrics and Gynaecology, 52(1), pp.14-22.

Merkow, R. P., Bilimoria, K. Y., McCarter, M. D., Cohen, M. E., Barnett, C. C., Raval, M. V., … & Bentrem, D. J. (2011). Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Annals of surgery, 254(1), 131-137.

Nelson, R. E., Grosse, S. D., Waitzman, N. J., Lin, J., DuVall, S. L., Patterson, O., … & Reyes, N. (2015). Using multiple sources of data for surveillance of postoperative venous thromboembolism among surgical patients treated in Department of Veterans Affairs hospitals, 2005–2010. Thrombosis research, 135(4), 636-642.

nhs.uk. ((2017)). Deep vein thrombosis. [online] Available at: https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/ [Accessed 16 Dec. (2017)].

Parker, C., Coupland, C., & Hippisley-Cox, J. (2010). Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. Bmj, 341, c4245.

Petticrew, M. & Roberts, H. (2006) Systematic reviewing of literature in the social sciences: A practical guide. Oxford: Blackwell

Plano Clarke, V.L. &Cresswell, J.W. (2008) The mixed methods reader. London: Sage Publications Ltd.

Prins, M. H., Lensing, A. W., Brighton, T. A., Lyons, R. M., Rehm, J., Trajanovic, M., …& Cohen, A. T. (2014). Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN-DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials. The Lancet Haematology, 1(1), e37-e46.

Punch, K.F. (2013) Introduction to social research: Qualitative and quantitative approaches. 3^rd Edition. London: SAGE Publications, Inc

S&ers, Y.V., Eikenboom, J., Wee, E.M., Bom, J.G., Cnossen, M.H., Degenaar?Dujardin, M.E., Fijnv&raat, K., Kamphuisen, P.W., Laros?van Gorkom, B.A., Meijer, K. & Mauser?Bunschoten, E.P., (2013). Reduced prevalence of arterial thrombosis in von Willebr& disease.Journal of Thrombosis & Haemostasis, 11(5), pp.845-854.

Schulman, S., Kakkar, A.K., Goldhaber, S.Z., Schellong, S., Eriksson, H., Mismetti, P., Christiansen, A.V., Friedman, J., Le Maulf, F., Peter, N. & Kearon, C., (2013). Treatment of acute venous thromboembolism with dabigatran or warfarin & pooled analysis.Circulation, pp.CIRCULATIONAHA-113.

Shneerson, C.L. & Gale, N.K. (2015) Using mixed methods to identify and answer clinically relevant research questions, Qualitative health record, 25(6), pp. 845-856

Sui, C. &Comerasamy, H. (2013) Doing a research project in Nursing & Midwifery: a basic guide to research using the literature review methodology. London, UK: Sage Publications Ltd.

Ungprasert, P., Srivali, N., Spanuchart, I., Thongprayoon, C., & Knight, E. L. (2014). Risk of venous thromboembolism in patients with rheumatoid arthritis: a systematic review and meta-analysis. Clinical rheumatology, 33(3), 297-304.

vanStaa, T. P., Goldacre, B., Gulliford, M., Cassell, J., Pirmohamed, M., Taweel, A., … &Smeeth, L. (2012). Pragmatic randomised trials using routine electronic health records: putting them to the test. Bmj, 344, e55.

Waljee, A.K., Rogers, M.A., Lin, P., Singal, A.G., Stein, J.D., Marks, R.M., Ayanian, J.Z. and Nallamothu, B.K., 2017. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. bmj, 357, p.j1415.

Walker, A. J., Card, T. R., West, J., Crooks, C., & Grainge, M. J. (2013). Incidence of venous thromboembolism in patients with cancer–a cohort study using linked United Kingdom databases. European journal of cancer, 49(6), 1404-1413.

Whittaker, A. (2011) Succeeding in research project plans and literature reviews for nursing students. Exeter: Learning Matter