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showed that of the 762 surgical patients assessed in Portugal&#44; 69&#37; were at risk&#46; Despite the importance of awareness of outcome indicators&#44; there have been few epidemiological studies on postoperative VTE in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">The primary objective of the postoperative venous thromboembolism &#40;TREVO&#41; study was to estimate the incidence of symptomatic postoperative VTE&#44; overall and by surgical specialty&#44; at a tertiary hospital&#46; The secondary objective was to analyze severity of and mortality from thromboembolic events&#44; including the characteristics of the patients involved and their treatment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">TREVO is a retrospective epidemiological study of an adult population of surgical patients at Centro Hospitalar de S&#227;o Jo&#227;o&#44; a tertiary university hospital&#46; The study was approved by the institution&#39;s ethics committee&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">All hospitalizations recorded in the hospital&#39;s database of patients aged 18 or over admitted for at least one elective or urgent surgical procedure between January 1&#44; 2008 and December 31&#44; 2012 were analyzed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cases of VTE as a secondary diagnosis during the first 120 days of hospital stay were identified based on the codes of the International Classification of Diseases&#44; Ninth Revision&#44; Clinical Modification &#40;ICD-9&#41;&#46; The criteria used were those of the Joint Commission International<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Medical records&#44; both electronic and paper versions&#44; of the cases identified were reviewed&#46; The relevant data were entered on a specially designed form&#44; and included demographic characteristics and associated diseases&#44; admission and discharge diagnoses&#44; treatment details&#44; including type of anesthesia&#44; type of surgery&#44; central venous catheterization&#44; postoperative immobility for more than two days and prescription of postoperative thromboprophylactic drugs&#44; and vital status at discharge&#46; The severity of postoperative VTE was classified into four groups&#58; fatal PE&#44; non-fatal PE&#44; DVT and other VTE&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgical patients who were admitted but not operated&#44; those with incomplete records and those in whom a secondary diagnosis of VTE was not confirmed were excluded&#44; as were those in whom VTE occurred before surgery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The selection of cases was based on a recorded diagnosis of VTE&#44; supported by a report of imaging findings&#46; PE was confirmed by spiral computed tomography&#44; digital subtraction angiography or high-probability ventilation-perfusion scan&#59; DVT by ultrasound or venography&#59; and other VTE by ultrasound&#44; venography or magnetic resonance angiography&#46; The images were not reviewed by the investigators&#44; who nevertheless checked the information recorded against the ICD-9 code&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The episodes initially identified were subsequently reviewed by a different investigator in order to confirm the data collected&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The outcome analyzed was symptomatic VTE&#44; since the hospital&#39;s policy is to refer patients for imaging studies based on clinical assessment rather than to screen for VTE&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In cases in which there was more than one VTE event&#44; only the most severe was considered in the statistical analysis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Descriptive statistics were used to analyze the data&#44; expressed as medians and interquartile range &#40;P25-P75&#41; for quantitative variables and percentages for qualitative variables&#46; Estimates are presented with 95&#37; confidence intervals &#40;CI&#41;&#46; The incidence of VTE and PE among the subgroups was compared by the chi-square test&#46; Tests for linear tendency were used to assess changes over time in the risk for a VTE event&#46; The data were analyzed using Stata for Windows&#44; version 11&#46;1 &#40;StataCorp LP&#44; College Station&#44; TX&#41; and Microsoft Excel 2010 &#40;Microsoft Corp&#46;&#44; Redmond&#44; WA&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Case selection</span><p id="par0080" class="elsevierStylePara elsevierViewall">The study sample consisted of 67<span class="elsevierStyleHsp" style=""></span>635 admissions of adult patients for cardiothoracic&#44; general&#44; plastic&#44; vascular&#44; neurological&#44; orthopedic&#44; otorhinolaryngological or urological surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Of the 178 cases initially identified with VTE according to the ICD-9 diagnostic codes&#44; 35 patients were excluded as they were not operated&#44; 16 due to incomplete data&#44; nine due to diagnostic codes inconsistent with the clinical information&#44; and 28 because the VTE event occurred before surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Demographic characteristics</span><p id="par0090" class="elsevierStylePara elsevierViewall">The overall incidence of VTE was similar in men and women &#40;1&#46;35 vs&#46; 1&#46;31&#47;1000 admissions&#44; respectively&#44; p&#61;0&#46;96&#41;&#44; but 63&#46;6&#37; of those with fatal PE were female&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The median age of those with VTE was 59 years &#40;P25-P75&#58; 46-70&#41;&#46; There was no significant difference in mean age between cases of VTE and the overall study population &#40;p&#61;0&#46;191&#41;&#46; Fatal PE occurred at a mean age of 63&#46;3&#177;10&#46;6 years&#46; Patients with VTE tended to be younger &#40;mean 54&#177;16&#46;3 years&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Risk by surgical specialty</span><p id="par0100" class="elsevierStylePara elsevierViewall">The 90 confirmed cases of symptomatic postoperative VTE correspond to an incidence of 1&#46;33&#47;1000 admissions &#40;95&#37; CI&#58; 1&#46;1-1&#46;6&#47;1000&#41;&#46; Regarding estimated risk by surgical specialty&#44; neurosurgery had the highest risk &#40;4&#46;07&#47;1000&#41;&#44; followed by urological surgery &#40;1&#46;55&#47;1000&#41; and general surgery &#40;1&#46;42&#47;1000&#41; &#40;p&#60;0&#46;001&#41;&#46; Plastic surgery had the lowest risk &#40;0&#46;47&#47;1000&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Among the neurosurgical cases&#44; PE was observed in five procedures to remove neoplastic lesions &#40;two acoustic neuromas&#44; one astrocytoma&#44; one hypophyseal adenoma and one meningioma&#41; and in another five procedures &#40;two to drain brain abscess&#44; one brain biopsy&#44; one to drain cerebral hemorrhage&#44; and one to implant an intracranial pressure monitor&#41;&#46; There were three cases of DVT in procedures to drain subdural hematomas and one in a procedure to drain an intracerebral hemorrhage&#46; One patient with Parkinson&#39;s disease undergoing implantation of a deep brain stimulator had another type of VTE&#46; None of the patients with neoplastic lesions had fatal PE&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the 14 urological patients&#44; four underwent kidney transplantation and PE occurred in three of these and another type of VTE in one&#46; One of the transplant patients presented PE&#44; DVT and another type of VTE&#46; This patient and another transplant recipient&#44; both male&#44; died&#46; PE was also a complication in a transurethral resection of the prostate&#44; a ureteroscopy with biopsy and a nephroureterectomy&#46; All other episodes in urological patients were DVT&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Of the 90 cases of TVE&#44; 11 &#40;12&#46;2&#37;&#41; occurred under neuraxial anesthesia&#44; which in three cases was combined with general anesthesia and in two was combined subarachnoid and epidural block&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The distribution of TVE cases according to the American Society of Anesthesiology &#40;ASA&#41; classification of physical status was as follows&#58; ASA III &#40;55&#46;1&#37;&#41;&#44; ASA II &#40;21&#46;4&#37;&#41; and ASA IV &#40;13&#46;5&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The overall incidence of TVE fell over the study period&#44; from 1&#46;95&#47;1000 in 2008 to 1&#46;01&#47;1000 in 2012 &#40;p&#61;0&#46;036 for linear tendency&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Severity of events</span><p id="par0130" class="elsevierStylePara elsevierViewall">Of the total&#44; 50 cases of PE were identified&#44; corresponding to an incidence of 0&#46;75&#47;1000 episodes &#40;95&#37; CI&#58; 0&#46;56-0&#46;99&#47;1000&#41;&#44; highest in neurosurgery &#40;2&#46;39&#47;1000&#41;&#44; followed by orthopedic &#40;0&#46;91&#47;1000&#41; and urological procedures &#40;0&#46;89&#47;1000&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">There were 11 fatal PE &#40;22&#46;0&#37; mortality&#41;&#44; most frequently associated with neoplastic disease or renal failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Over half of these patients had undergone central venous catheterization of the right subclavian vein&#44; and 72&#46;7&#37; had a central catheter if those with catheterization of the internal jugular are included &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Immobility for more than two days was associated with a greater number of severe events &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">At least 37&#46;7&#37; of patients with events received a prophylactic dose of injectable anticoagulant postoperatively &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nineteen patients with VTE died&#46; Possible causes are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Overall mortality due to VTE events was 21&#46;1&#37; &#40;95&#37; CI&#58; 13&#46;6-30&#46;4&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">The TREVO study included elective and urgent surgical patients from eight specialties&#46; The incidence of VTE &#40;as indicated by in-hospital outcome&#41; was estimated at 1&#46;33&#47;1000 admissions&#46; This figure is extremely low compared to the risk attributed to the Portuguese surgical population in the ENDORSE study &#40;69&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;10</span></a> However&#44; the latter assessed risk factors rather than outcome and only in acute patients undergoing general surgery or urogynecological or ortho trauma surgery&#44; which carry a higher risk of VTE&#46; Bilimoria et al&#46; reported a risk of 5&#46;35&#47;1000 in a multicenter study in the US assessing outcomes in patients undergoing orthopedic&#44; neurological&#44; cardiothoracic&#44; urological and general surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> The authors highlight the fact that surveillance bias is a major factor influencing results&#44; especially when local protocols are more interventionist in requesting imaging exams&#46; Some events may have only mild symptoms that are disregarded in centers where standard diagnostic imaging is guided by symptoms&#44; while in others&#44; such as trauma centers&#44; imaging studies are performed as routine&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The incidence of VTE in this study reflects our institutional protocol for thromboprophylaxis&#44; which decreases the incidence of VTE by 50-75&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> In addition&#44; symptomatic VTE&#44; the outcome considered&#44; accounts for only around 50&#37; of all VTE events&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> Even so&#44; the TREVO study shows lower rates than reported in the literature&#44; which may be related to exclusion of cases for inconsistencies in medical records or less precise diagnosis and&#47;or recording&#46; The latter would explain the high mortality&#44; since recording of fatal events is necessarily stricter&#59; the literature shows a lower incidence of PE than of other VTE&#44; unlike in our study&#44; which raises the possibility that VTE other than PE was underdiagnosed&#46; On the other hand&#44; the lower incidence may reflect more effective thromboprophylaxis&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the TREVO study&#44; the specialty with the highest risk of VTE was neurosurgery&#44; while in the literature<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;10&#8211;13</span></a> it is orthopedic surgery&#46; In a retrospective study of 94 cases of in-hospital VTE&#44; Wang et al&#46; identified cranial surgery as an independent predictor of VTE&#44; with a particularly high odds ratio of 16&#46;1&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> In an earlier study&#44; Hamilton et al&#46; observed that half of neurosurgical patients presented detectable VTE on screening&#44; while only 5&#37; developed symptomatic VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> A known risk factor for VTE that may account for this finding is the fact that cranial surgery entails central venous catheterization in a high proportion of cases&#44; and a retrospective study found that central venous catheterization doubled the risk of in-hospital VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; many of these patients are hospitalized in intensive care units and have longer operating times and hospital stays&#44; which are additional risk factors for VTE&#46; Limitations on the use of pharmacological thrombophylaxis in neurosurgery&#44; irrespective of patient characteristics&#44; may also help explain the increased risk observed&#46; This further highlights the need&#44; already stated in some guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;5</span></a> for mechanical thromboprophylaxis beginning in the preoperative period in neurosurgical patients as well as pharmacological thromboprophylaxis in those at increased risk of VTE&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The aim of the TREVO study was to estimate the risk of in-hospital VTE&#46; While the high risk of VTE in major orthopedic surgery is well known&#44; symptomatic postoperative event rates up to discharge do not reflect overall risk&#44; since mean time to symptomatic events is 17 days in the case of hip arthroplasty and seven days in the case of knee arthroplasty&#44; the high-risk period extending to 12 weeks for the former and six weeks for the latter&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;13</span></a> With enhanced recovery programs becoming increasingly common&#44; such patients are now discharged long before the periods referred to above&#44; which introduces even more bias into recorded in-hospital events as a measure of risk and may explain why orthopedic surgery occupied fifth place &#40;1&#46;09&#47;1000 episodes&#41; in the TREVO study&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The risk associated with urological procedures &#40;1&#46;55&#47;1000&#41; was the second highest in our study&#46; Although risk in this patient group has been less studied&#44; a recent cohort study reported moderate to high VTE event rates for total &#40;3&#46;96&#37;&#41; and partial cystectomy &#40;2&#46;35&#37;&#41;&#44; followed by radical open nephrectomy &#40;1&#46;67&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> Other studies have reported a high risk of VTE in renal transplant recipients &#40;7&#46;9-9&#46;1&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#44;18</span></a> The TREVO study population included patients in a renal transplantation unit&#44; which would have contributed to the high values observed&#46; Beyer et al&#46; reported a high incidence of PE &#40;5&#46;8&#37;&#41; in prostatectomy&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> another common procedure in the population studied&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The year-on-year trend for declining overall VTE rates between 2008 and 2012 supports the hypothesis of progressively more effective thromboprophylaxis&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Overall mortality due to VTE events &#40;21&#46;1&#37;&#41; was higher than reported in the literature and close to mortality due to PE &#40;22&#46;0&#37;&#41;&#44; which was also high&#46; Reis reports early VTE mortality of 12&#46;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Data from the Nationwide Inpatient Sample in the US indicate in-hospital mortality from PE of 12&#46;3&#37; to 8&#46;2&#37;&#44; with a falling trend over the years&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> A Norwegian study reported 30-day mortality of 9&#46;7&#37; from PE and 4&#46;6&#37; from DVT&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> Comparison of the mortality observed in the TREVO study with the above findings supports the idea that non-fatal events are underdiagnosed&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Neuraxial anesthesia was used in 12&#46;2&#37; of procedures in this study&#46; In a meta-analysis&#44; Rodgers et al&#46; showed that epidural anesthesia dramatically reduces risk for VTE&#44; by 44&#37; for DVT and by 55&#37; for PE&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> Another meta-analysis confirmed the benefit of continuous lumbar epidural anesthesia in the postoperative period to reduce the risk of VTE following lower-limb surgery or prostatectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> This may help explain the lower risk found in orthopedic procedures&#44; since neuraxial anesthesia is the most commonly used technique in major lower-limb surgery&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">With regard to ASA physical status&#44; most of the study population &#40;55&#46;1&#37;&#41; was classified as ASA III&#46; The literature reports a worsening of VTE risk in hip arthroplasty with progressively higher ASA classification&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The study has certain limitations&#46; Firstly&#44; it was retrospective and therefore observational and dependent on the information available in medical records&#46; Secondly&#44; cases were excluded for inconsistencies in medical records&#46; Thirdly&#44; there may also have been surveillance bias between departments&#44; which&#44; together with the second limitation&#44; may have contributed to underdiagnosis&#46; Fourthly&#44; it analyzed in-hospital events only&#44; disregarding those that occurred after discharge&#46; Lastly&#44; data on thromboembolic prophylaxis was not available in all cases&#44; particularly preoperative assessment of VTE risk &#40;and indication for prophylaxis in light of the latest evidence&#41; in order to more accurately assess the impact of thromboprophylaxis&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">On the positive side&#44; the TREVO study is&#44; as far as we know&#44; the only study on postoperative venous thromboembolism in Portugal apart from the ENDORSE study&#44; which had a much smaller sample&#59; TREVO included 67<span class="elsevierStyleHsp" style=""></span>635 patients&#44; with 90 documented cases of VTE&#44; which is comparable to other international studies&#46; The study was based on outcomes rather than assessment of risk&#44; and care was taken to avoid selection bias&#44; through use of ICD codes and the VTE criteria defined by the Joint Commission International&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0215" class="elsevierStylePara elsevierViewall">In this study&#44; the incidence of symptomatic postoperative VTE was 1&#46;33&#47;1000 admissions&#46; Neurosurgery showed the greatest risk for VTE and PE&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Mortality was 21&#46;1&#37;&#46; Underdiagnosis cannot be excluded&#44; nor can failure to record non-fatal events&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical disclosures</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Risk"
            2 => "Surgical specialties"
            3 => "Incidence"
            4 => "Complication"
            5 => "Patient safety"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec884866"
          "palabras" => array:6 [
            0 => "Tromboembolismo venoso"
            1 => "Risco"
            2 => "Especialidades cir&#250;rgicas"
            3 => "Incid&#234;ncia"
            4 => "Complica&#231;&#227;o"
            5 => "Seguran&#231;a do doente"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Venous thromboembolism&#44; risk of which is increased in surgical patients&#44; is a preventable cause of morbidity and death&#46; The primary objective of this study was to estimate the incidence of symptomatic postoperative venous thromboembolism in adults at a tertiary university hospital&#44; overall and by surgical specialty&#46; The secondary objective was to analyze severity of and mortality from thromboembolic events&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study to identify cases of in-hospital postoperative venous thromboembolism&#44; encoded by the International Classification of Diseases&#44; Ninth Revision&#44; according to the Joint Commission International criteria&#46; Adult patients admitted for surgery in 2008-2012 were included&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Among 67<span class="elsevierStyleHsp" style=""></span>635 hospitalizations&#44; 90 cases of postoperative symptomatic venous thromboembolism were identified &#40;median age 59 years&#41;&#44; corresponding to an incidence of 1&#46;33&#47;1000 admissions &#40;95&#37; confidence interval &#91;CI&#93; 1&#46;1-1&#46;6&#47;1000&#41;&#46; Neurosurgery had the highest risk &#40;4&#46;07&#47;1000&#41;&#44; followed by urological surgery and general surgery &#40;p&#60;0&#46;001&#41;&#46; There were 50 cases of pulmonary embolism&#44; 11 of which were fatal&#46; Of the 90 cases&#44; 12&#46;2&#37; occurred under neuraxial anesthesia and 55&#46;1&#37; in patients with American Society of Anesthesiology III physical status&#46; At least 37&#46;7&#37; of patients with events received a prophylactic dose of injectable anticoagulant postoperatively&#46; The overall risk decreased from 2008 to 2012&#46; Venous thromboembolism-associated mortality during hospitalization was 21&#46;1&#37; &#40;95&#37; CI 13&#46;6-30&#46;4&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The incidence of postoperative symptomatic venous thromboembolism was 1&#46;33&#47;1000&#46; Neurosurgery showed the greatest risk&#46; Mortality was 21&#46;1&#37;&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O tromboembolismo venoso&#44; cujo risco est&#225; aumentado no doente cir&#250;rgico&#44; &#233; uma causa evit&#225;vel de morbimortalidade&#46; O objetivo prim&#225;rio deste estudo foi estimar o risco de tromboembolismo venoso sintom&#225;tico p&#243;s-operat&#243;rio global e por especialidade cir&#250;rgica&#44; num hospital terci&#225;rio&#46; Secundariamente&#44; foram analisadas a gravidade e mortalidade dos eventos tromboemb&#243;licos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo retrospetivo para a identifica&#231;&#227;o de casos de tromboembolismo venoso p&#243;s-operat&#243;rio intra-hospitalar&#44; codificados pela Classifica&#231;&#227;o Internacional de Doen&#231;as &#8211; 9&#46;&#170; revis&#227;o&#44; pelos crit&#233;rios da <span class="elsevierStyleItalic">Joint Commission International</span>&#46; Foram inclu&#237;dos epis&#243;dios de internamento de doentes adultos&#44; operados&#44; no per&#237;odo 2008-2012&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Em 67<span class="elsevierStyleHsp" style=""></span>635 epis&#243;dios de internamento com cirurgia identificaram-se 90 casos de tromboembolismo venoso p&#243;s-operat&#243;rio &#40;mediana de idades&#58; 59 anos&#41;&#44; correspondendo a um risco de 1&#44;33&#47;1000 epis&#243;dios &#40;intervalo de confian&#231;a a 95&#37; &#91;IC95&#37;&#93;&#44; 1&#44;1-1&#44;6&#47;1000&#41;&#46; A neurocirurgia apresentou maior risco &#40;4&#44;07&#47;1000&#41;&#44; seguida pela urologia e pela cirurgia geral p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#46; Houve 50 epis&#243;dios de embolia pulmonar&#44; dos quais 11 foram fatais&#46; Dos 90 casos&#44; 12&#44;2&#37; decorreram sob anestesia do neuro-eixo e 55&#44;1&#37; em doentes com estado f&#237;sico ASA <span class="elsevierStyleSmallCaps">III</span>&#46; Foi administrada dose profil&#225;tica de anticoagulante injet&#225;vel no p&#243;s-operat&#243;rio a&#44; pelo menos&#44; 37&#44;7&#37; dos doentes&#46; O risco decresceu de 2008 at&#233; 2012&#46; A mortalidade associada aos eventos de tromboembolismo venoso durante o internamento foi 21&#44;1&#37; &#40;IC95&#37;&#44; 13&#44;6-30&#44;4&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O risco de tromboembolismo venoso sintom&#225;tico p&#243;s-operat&#243;rio foi de 1&#44;33&#47;1000&#46; A neurocirurgia apresentou maior risco&#46; A mortalidade foi de 21&#44;1&#37;&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Amaral C&#44; Guimar&#227;es Pereira L&#44; Moreto A&#44; S&#225; AC&#44; Azevedo A&#46; Estudo TRomboEmbolismo Venoso p&#243;s-Operat&#243;rio &#40;TREVO&#41; &#8211; risco e mortalidade por especialidade cir&#250;rgica&#46; Rev Port Cardiol&#46; 2017&#59;36&#58;609&#8211;616&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Identification of cases of venous thromboembolism in the study population&#46; ICD-9&#58; International Classification of Diseases&#44; Ninth Revision&#59; VTE&#58; venous thromboembolism&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Risk of venous thromboembolism&#44; with or without pulmonary embolism&#44; by surgical specialty&#46; CT&#58; cardiothoracic&#59; DVT&#58; deep vein thrombosis&#59; Neuro&#58; neurological&#59; ORL&#58; otorhinolaryngological&#59; PE&#58; pulmonary embolism&#59; Plastic&#58; reconstructive and maxillofacial&#59; VTE&#58; venous thromboembolism&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Annual changes in overall risk of venous thromboembolism&#44; 2008-2012&#46; VTE&#58; venous thromboembolism&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ICD-9&#58; International Classification of Diseases&#44; Ninth Revision&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICD-9 code&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">415&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Iatrogenic pulmonary embolism and infarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">415&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other pulmonary embolism and infarction &#40;excludes septic embolism and that complicating pregnancy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phlebitis and thrombophlebitis of femoral vein &#40;deep&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phlebitis and thrombophlebitis of other deep veins of lower extremities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phlebitis and thrombophlebitis of lower extremities&#44; unspecified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phlebitis and thrombophlebitis of iliac vein&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">451&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phlebitis and thrombophlebitis of unspecified site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venous embolism and thrombosis of unspecified deep vessels of distal lower extremity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Venous embolism and thrombosis of deep vessels of proximal lower extremity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acute venous embolism and thrombosis of other thoracic veins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acute venous embolism and thrombosis of other specified veins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">453&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Other venous embolism and thrombosis of unspecified site&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Joint Commission International criteria for a diagnosis of venous thromboembolism&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">COPD&#58; chronic obstructive pulmonary disease&#59; DVT&#58; deep vein thrombosis&#59; n&#58; number of cases by characteristic&#59; N&#58; total number of events&#59; ND&#58; no data&#59; NYHA&#58; New York Heart Association&#59; PE&#58; pulmonary embolism&#59; SD&#58; standard deviation&#59; VTE&#58; venous thromboembolism&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Fatal PE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male&#47;female&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; mean &#177; SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;3&#177;10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#46;8&#177;17&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&#46;3&#177;16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;1&#177;15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Body mass index &#62;30 kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;ND 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;ND 8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#47;33 &#40;ND 5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Associated acute disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heart failure NYHA III&#47;IV&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;39 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory failure &#40;COPD or pneumonia&#41;&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;7 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acute&#44; chronic or terminal renal failure&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;11 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;39 &#40;17&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;7 &#40;71&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Associated neoplastic disease&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;11 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;39 &#40;17&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;33 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sepsis&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;39 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;33 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;7 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">DVT&#58; deep vein thrombosis&#59; n&#58; number of cases by characteristic&#59; N&#58; total number of events&#59; PE&#58; pulmonary embolism&#59; VTE&#58; venous thromboembolism&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Fatal PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Non-fatal PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">DVT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Other VTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#40;N&#61;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Type of anesthesia</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>General&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#47;11 &#40;90&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#47;39 &#40;84&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#47;33 &#40;81&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;7 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neuraxial&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;11 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;39 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;33 &#40;6&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>General &#43; neuraxial&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;39 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;33 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Central venous catheter</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Internal jugular&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;11 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;39 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;33 &#40;15&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;7 &#40;42&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subclavian&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;11 &#40;54&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;39 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;33 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postoperative immobility &#62;2 days&#44; n&#47;N &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;11 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;39 &#40;23&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#47;33 &#40;45&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;7 &#40;42&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Postoperative thromboprophylaxis</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enoxaparin dose&#58; prophylactic or more&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;11 &#40;36&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#47;39 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#47;33 &#40;42&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#47;7 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enoxaparin dose&#58; less than prophylactic&#44; n&#47;N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;39 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unfractionated heparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;39 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cases with no information available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiogenic shock&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Septic shock&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis &#43; multiorgan failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DVT &#43; IVCS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Causes associated with mortality in patients with venous thromboembolism&#46;</p>"
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