***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: The rate of bleeding complications after major orthopedic surgery approximates 2 % . It is unclear whether a systematic switch of routine thromboprophylaxis has an impact on the rate of postoperative bleeding complications . We analyzed prospect ively recorded postoperative bleeding complications and symptomatic venous thromboembolic events  in 8,176 consecutive orthopedic patients at the Schulthess Clinic Zurich during a systematic switch of thromboprophylaxis from nadroparin to enoxaparin in the year 2004 . Overall , 3,893 patients received nadroparin in the first nine-month observation period before the switch and 4,283 patients received enoxaparin in the second nine-month observation period after the switch . Overall , 96 ( 2.5 % ) patients in the first period and 70 ( 1.6 % ) patients in the second period suffered a postoperative bleeding complication requiring surgical revision , puncture , or transfusion ( p < 0.01 ) . Five objective ly confirmed symptomatic venous thromboembolic events during hospitalization in the first period and three events in the second period were recorded . In conclusion , the switch of thromboprophylaxis in a large orthopedic clinic did not cause an increase of postoperative bleeding complications and therefore was accompanied by high patient safety The peri- and postsurgical thromboembolic prophylaxis with low molecular weight heparins is a well established therapy regimen , but the optimum duration of prophylaxis after surgery still remains uncertain . A few studies have pointed to the fact that the thromboembolic risk of high-risk patients persists longer than the in-hospital period correlating with respective hypercoagulatory conditions . The aim of the present study was to test if a prolongation of thromboprophylaxis with the low molecular weight heparin Certoparin further reduces the rate of thromboembolism in high-risk patients after orthopedic surgery . The " Long-term Thromboprophylaxis"- Study was a multicenter , r and omized , double-blind , placebo-controlled trial . 360 patients who underwent endoprothetic joint replacement or osteo synthesis of the lower limb were initially enrolled , all of them received prophylactically 3000 U anti-Xa of Certoparin once daily for 14 days followed by r and omization to prolonged Certoparin application or to placebo up to day 42 . Patients were screened for deep vein thrombosis by sonography every week . Coagulation markers ( fibrin monomers and D-dimers ) were determined during the course of the study . Venous thromboembolism during the prolongation period was observed in 18 patients receiving placebo versus 8 patients of the prolonged Certoparin group ( 12.1 % versus 5.0 % , intention-to-treat sample ) . The analysis revealed a statistically significant difference in favor of Certoparin ( p=0.020 ) , which was confirmed by per- protocol analysis ( 14.2 % versus 5.5 % , p=0.012 ) . The differences remained significant , if analyses considered only clinical ly symptomatic thromboembolic events ( p=0.040 ) . Patients who developed a thrombosis showed a strong increase of coagulation markers as compared to patients without subsequent thrombosis . The respective differentiation started around 18 days before diagnosis of thrombosis . Only one minor bleeding complication was observed during prolonged Certoparin prophylaxis . The present study shows that patients after joint replacement or osteo synthesis of the lower extremities have a persisting risk to develop thromboembolic complications beyond the routine duration of thromboprophylaxis . Extended prophylaxis with Certoparin result ed in a significantly lower rate of thromboembolism and should be strongly recommended Among out patients with schizophrenia , antipsychotic non-adherence is common , grossly under-detected by patients and their prescribers , and is associated with poor clinical outcomes . Using electronic monitoring ( EM ) as the reference st and ard we evaluated the reliability and validity as well as the sensitivity and specificity of a recently developed , brief , pencil-paper , clinician-administered adherence instrument [ the Brief Adherence Rating Scale ( BARS ) ] to assess the oral antipsychotic medication adherence of out patients with schizophrenia and schizoaffective disorder .  EM and BARS adherence and symptom severity ratings were gathered at baseline and prospect ively at 6 monthly visits in 61 participants ( n=35 with schizophrenia ; n=26 with schizoaffective disorder ) . A significant positive relationship was found between mean BARS and EM adherence ( beta=0.98 ; rs=0.59 , p<0.0001 ) . Cronbach 's coefficient alpha revealed very high internal reliability for the BARS ( alpha=0.92 ) . A moderate-to-strong degree of test-retest reliability was also found for the BARS ( beta ranged from 0.53 to 0.92 and rs ranged from 0.46 to 0.86 ) . Regarding concurrent validity of the BARS , greater mean  BARS adherence was significantly related to lower mean PANSS total scores ( beta=-0.40 ; rs=-0.39 , p=0.002 ) and to lower mean Positive symptom sub-scale scores ( beta=-0.08 , p=.007 ; rs=-0.28 , p=.02 ) . An initial 3-month monitoring period with the BARS also demonstrated good sensitivity ( 73 % ) and specificity ( 74 % ) in identifying non-adherent out patients ( defined as < 70 % mean EM adherence ) . Relative to EM , the BARS appears to provide valid , reliable , sensitive , and specific estimates of antipsychotic medication adherence of out patients with schizophrenia and schizoaffective disorder . The BARS appears to be a promising c and i date as a brief adherence assessment instrument for feasible use in community-based setting In the Penthifra Plus trial , extended prophylaxis with the synthetic pentasaccharide fondaparinux for 1 month versus 1 week in hip fracture surgery has been shown to reduce the risk of venous thromboembolic events by 96 % . The cost – effectiveness of extended prophylaxis with fondaparinux still remains to be determined . The authors developed a decision analytic cost – effectiveness model comparing the use of fondaparinux for 4 weeks with 1 week from a healthcare perspective . The analyses were performed for patients undergoing hip fracture surgery and total hip replacement ( THR ) .  Efficacy data were extracted from published r and omized controlled trials and natural history data after venous thromboembolic events from observational studies . Cost data were derived from the literature and other published sources . Costs were expressed in 2004 Swiss Francs ( CHF ) and effects as life-years gained ( LYG ) . In patients undergoing hip fracture surgery , the incremental cost – effectiveness ratio of extended 4-week fondaparinux prophylaxis versus a 1-week regimen was CHF 2801/LYG after 30 days , with cost-savings after 5 years . In patients undergoing THR , the respective incremental cost – effectiveness ratio of extended fondaparninux prophylaxis was CHF 20,294/LYG after 30 days , with cost-savings after 5 years . In the authors ’ model , the substantial clinical benefit of extended thromboembolism prophylaxis with fondaparinux in major orthopedic surgery translates into favorable cost – effectiveness figures in the short term and cost savings when a 5-year time horizon is used BACKGROUND Oral anticoagulants , such as dabigatran etexilate , an oral , direct thrombin inhibitor , that do not require monitoring or dose adjustment offer potential for prophylaxis against venous thromboembolism ( VTE ) after total knee replacement surgery . METHODS In this r and omized , double-blind study , 2076 patients undergoing total knee replacement received dabigatran etexilate , 150 mg or 220 mg once-daily , starting with a half-dose 1 - 4 hours after surgery , or subcutaneous enoxaparin 40 mg once-daily , starting the evening before surgery , for 6 - 10 days . Patients were followed-up for 3 months . The primary efficacy outcome was a composite of total VTE ( venographic or symptomatic ) and mortality during treatment , and the primary safety outcome was the incidence of bleeding events . RESULTS The primary efficacy outcome occurred in 37.7 % ( 193 of 512 ) of the enoxaparin group versus 36.4 % ( 183 of 503 ) of the dabigatran etexilate 220 mg group ( absolute difference , -1.3 % ; 95 % CI , -7.3 to 4.6 ) and 40.5 % ( 213 of 526 ) of the 150 mg group ( 2.8 % ; 95 % CI , -3.1 to 8.7 ) . Both doses were noninferior to enoxaparin based on the pre-specified noninferiority criterion . The incidence of major bleeding did not differ significantly between the three groups ( 1.3 % versus 1.5 % and 1.3 % respectively ) . No significant differences in the incidences of liver enzyme elevation and acute coronary events were observed during treatment or follow-up . CONCLUSIONS Dabigatran etexilate ( 220 mg or 150 mg ) was at least as effective and with a similar safety profile as enoxaparin for prevention of VTE after total knee-replacement surgery The need for prophylaxis against venous thromboembolic disease following lower-extremity joint replacement is well documented and accepted . Although low molecular weight heparin is approved for inpatient and extended prophylaxis beyond the hospital environment , orthopedic surgeons must determine the duration of injectable low molecular weight heparin based on the period of venous thromboembolic disease risk and on patient compliance with self-administration of medication at home . Lack of confidence in patients ' ability to self-administer injections may contribute to hesitancy in prescribing injectable prophylaxis . This observational study evaluated the effectiveness of a self-injection education program .  Findings demonstrate that when properly instructed , patients safely and efficaciously self-administer low molecular weight heparin at home . With shorter hospital stays , self-administration of low molecular weight heparin may optimize the clinical outcomes of orthopedic patients The Hill-Bone Compliance to High Blood Pressure Therapy Scale assesses patient behaviors for three important behavioral domains of high blood pressure treatment : 1 ) reduced sodium intake ; 2 ) appointment keeping ; and 3 ) medication taking . This scale is comprised of 14 items in three subscales . Each item is a four point Likert type scale . The content validity of the scale was assessed by a relevant literature review and an expert panel , which focused on cultural sensitivity and appropriateness of the instrument for low literacy . Internal consistency reliability and predictive validity of the scale were evaluated using two community based sample s of hypertensive adults enrolled in clinical trials of high blood pressure care and control . The st and ardized alpha for the total scale were 0.74 and 0.84 , and the average interitem correlations of the 14 items were 0.18 and 0.28 , respectively . The construct and predictive validity of the scale was assessed by factor analysis and by testing of theoretically derived hypotheses regarding whether the scale demonstrated consistent and expected relationships with related variables . In this study , high compliance scale scores predicted significantly lower levels of blood pressure and blood pressure control . Moreover , high compliance scale scores at the baseline were significantly associated with blood pressure control at both baseline and at follow up in the two independent sample s. This brief instrument provides a simple method for clinicians in various setting s to use to assess patients ' self reported compliance levels and to plan appropriate interventions BACKGROUND : The factors influencing medication adherence have not been fully eluci date d. Inadequate health literacy skills may impair comprehension of medical care instructions , and thereby reduce medication adherence . OBJECTIVES : To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions . RESEARCH DESIGN : Prospect i ve cohort study .SUBJECTS : New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease , hypertension , diabetes mellitus , and /or hyperlipidemia ( n=1,549 ) . MEASURES : Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults ( S-TOFHLA ) . Prospect i ve administrative data were used to calculate the cumulative medication gap ( CMG ) , a valid measure of medication refill adherence , over a 1-year period . Low adherence was defined as CMG ≥ 20 % . RESULTS : Overall , 40 % of the enrollees had low refill adherence . Bivariate analyses indicated that health literacy , race/ethnicity , education , and regimen complexity were each related to medication refill adherence ( P<.05 ) . In unadjusted analysis , those with inadequate health literacy skills had increased odds ( odds ratio [OR]=1.37 , 95 % confidence interval [ CI ] : 1.08 to 1.74 ) of low refill adherence compared with those with adequate health literacy skills . However , the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses ( OR=1.23 , 95 % CI : 0.92 to 1.64 ) . CONCLUSIONS : The present study suggests , but did not conclusively demonstrate , that low health 
    Output:
    
Subjective factors can play a role in increasing NA ; such factors include a lack of knowledge of or having no fear concerning thrombosis in general and a lack of specific knowledge regarding measures to prevent it , as well as a negative evaluation of injections as the form of therapy application .
Current trends in patient care ( e.g. , shorter hospital stays and lengthened ambulant care ) are likely to increase both the number of nonadherent patients and the extent of NA , if the current state of knowledge proves an accurate predictor of the future .