Infections and inflammatory diseases as risk factors for venous thrombosis. A systematic review

Pylephlebitis: A Case of Inferior Mesenteric Vein Thrombophlebitis in a Patient with Acute Sigmoid Diverticulitis—A Case Report and Clinical Management Review

Pylephlebitis is a rare complication of intra-abdominal infections and describes thrombosis and infection as two different pathophysiological phenomena in the cause of this disease. The nonspecific presentation of disease makes its diagnosis difficult and thus leads to high mortality. The treatment comprises antibiotics and also includes controversial use of anticoagulation in these patients. Here, we present a patient with past medical history of human immunodeficiency virus and past diverticulitis who presented with fever, chills, diarrhea, neck pain, and photophobia. He was diagnosed with acute sigmoid diverticulitis with associated inferior mesenteric vein thrombophlebitis. He improved after intravenous antibiotics and anticoagulation and was discharged. He underwent sigmoid colectomy 3 months after his initial presentation and was advised to take anticoagulation for a total of 6 months.

Expression variations and clinical significance of MMP-1, MMP-2 and inflammatory factors in serum of patients with deep venous thrombosis of lower extremity

Expression levels and clinical significance of matrix metalloproteinase-1 (MMP1), MMP-2 and inflammatory factors in the serum of patients with deep venous thrombosis (DVT) of lower extremity were investigated. Fifty untreated DVT patients were selected as the DVT group, and 50 patients undergoing health examination were enrolled as the normal control group. Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of MMP-1, MMP-2, interleukin-6 (IL-6), IL-8 and tumor necrosis factor-α (TNF-α) in the serum. Western blotting was adopted to detect the expression levels of MMP-1 and MMP-2 proteins. Fluorescent reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was applied to examine the messenger ribonucleic acid (mRNA) expression levels. Moreover, the circumferences of the patients were measured. The difference between the circumference of affected extremity and unaffected extremity was calculated. Correlation analysis was conducted separately for the levels of serum MMP-1, MMP-2, IL-6, IL-8 and TNF-α of patients in the DVT group. In the DVT group, the levels of MMP-1, MMP-2, IL-6, IL-8, and TNF-α at 7 days after treatment were significantly lower than those before treatment (P<0.01). Compared with that before treatment, the circumference difference of the affected and unaffected extremities of the patients was reduced at 7 days after treatment (P<0.01). The levels of IL-6, IL-8 and TNF-α were positively correlated with the levels of MMP-1 and MMP-2, respectively in the DVT group (P<0.05 or P<0.01). MMP-1, MMP-2 and inflammatory factors play an important role in the occurrence and development of DVT, of which the levels of IL-6, IL-8 and TNF-α are positively correlated with the levels of MMP-1 and MMP-2, respectively. Therefore, monitoring the concentration of MMP-1, MMP-2 and inflammatory factors is of significant value for the diagnosis, progression and judgement of treatment effect of DVT in clinical practice.

Predictive value of lymphocyte to monocyte ratio and monocyte to high-density lipoprotein ratio for acute deep vein thrombosis after total joint arthroplasty: a retrospective study

Background

Deep vein thrombosis (DVT) is one of the most dangerous complications of total joint arthroplasty (TJA). Systemic inflammation has proved to have a great contribution to thrombosis and has been considered as a risk factor for DVT recently. The lymphocyte to monocyte ratio (LMR) and monocyte to high-density lipoprotein (HDL) ratio (MHR) are two biomarkers used widely for systemic inflammation. This study aims to find out the potential predictive value of LMR and MHR for DVT after TJA.

Methods

A total of 853 patients who underwent primary TJA were finally included in this retrospective study. Acute DVT after TJA was evaluated by venography. Preoperative and postoperative LMR and MHR were calculated according to the blood routine test and blood biochemistry test. The association between LMR or MHR and DVT and their predictive value were evaluated by multiple logistic regression analysis and ROC curve respectively.

Results

Totally, 126 patients (14.8%) were diagnosed with DVT by venography. Patients with DVT had a significantly higher level of preoperative MHR (P < 0.001) and postoperative MHR (P < 0.001), along with a significantly lower level of preoperative LMR (P < 0.001) and postoperative LMR (P < 0.001). Multiple logistic regression indicated that BMI (OR = 1.10, P = 0.001), preoperative LMR (OR = 0.72, P<0.001), and postoperative LMR (OR = 0.32, P < 0.001) were independent risk factors for DVT. Besides, BMI (OR = 1.17, P = 0.001), female (OR = 4.6, P = 0.004), preoperative MHR (OR = 10.43, P = 0.008), postoperative Hb (OR = 0.96, P = 0.002), and postoperative LMR were independently associated with symptomatic DVT. The ROC curve suggested that the postoperative LMR had a potential to predict DVT after TJA.

Conclusion

In summary, the present study found out a significant association of perioperative LMR or MHR with DVT after TJA. Moreover, the postoperative LMR had a potential to predict DVT accurately.

Antiplatelets and profibrinolytic activity of Citrullus colocynthis in control and high-fat diet-induced obese rats: mechanisms of action

The current study aimed to investigate the effect of Citrullus colocynthis (C. colocynthis) hydro-alcoholic extract on blood haemostasis in control and high-fat diet (HFD) induced obese rats. In control rats, the extract significantly enhanced bleeding time and plasma levels of tPA and significantly decreased plasma levels PAI-1 and serum levels of thromboxane B2 leading to inhibition of platelets aggregation. In HFD induced obese rats, similar effects were seen and the extract was also able to reverse HFD induced increases in fibrinogen and VWF. Searching for the mechanism, C. colocynthis acts by (1) inhibiting of food intake, (2) inhibiting the activity of pancreatic lipase, (3) decreasing levels of TNF-α and IL-6 and (4) decreasing circulatory levels of the prothrombotic adipokine, leptin and enhanced circulatory levels of the antithrombic adipokines and adiopnectin. In conclusion, C. colocynthis has antiplatelets and profibrinolytic activity in both control and HFD induced obese rats.

C-reactive protein and risk of venous thromboembolism: results from a population-based case-crossover study

Long-term, low-grade inflammation does not seem to be a risk factor for venous thromboembolism. The impact of acute inflammation, regardless of cause, on risk of venous thromboembolism is scarcely studied. We aimed to investigate the impact of acute inflammation, assessed by C-reactive protein, on short-term risk of venous thromboembolism. We conducted a case-crossover study of patients with venous thromboembolism (n=707) recruited from a general population. Information on triggers and C-reactive protein levels were retrieved from hospital records during the 90 days before the event (hazard period) and in four preceding 90-day control periods. Conditional logistic regression was used to obtain β coefficients for change in natural log (ln) transformed C-reactive protein from control to hazard periods and to determine corresponding odds ratios for venous thromboembolism. Median C-reactive protein was 107 mg/L in the hazard period, and ranged from 7 mg/L to 16 mg/L in the control periods. The level of C-reactive protein was 58% (95% CI 39-77%) higher in the hazard period than in the control periods. A one-unit increase in ln-C-reactive protein was associated with increased risk of venous thromboembolism (OR 1.79, 95% CI 1.48-2.16). The risk estimates were only slightly attenuated after adjustment for immobilization and infection. In stratified analyses, ln-C-reactive protein was associated with increased risk of venous thromboembolism in cases with (OR 1.55, 95% CI 1.01-2.38) and without infection (OR 1.77, 95% CI 1.22-2.57). In conclusion, we found that acute inflammation, assessed by C-reactive protein, was a trigger for venous thromboembolism.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

BACKGROUND AND PURPOSE

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.

METHODS

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.

RESULTS

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.

CONCLUSIONS

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and Purpose

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version.

Methods

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members.

Results

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.

Conclusions

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

More than an anticoagulant: Do heparins have direct anti-inflammatory effects?

The heparins, well-known for their anticoagulant properties, may also have anti-inflammatory effects that could contribute to their effectiveness in the treatment of venous thromboembolism and other vascular diseases. This review focuses on the inflammatory pathophysiology that underlies the development of thrombosis and the putative effects of heparin on these pathways. We present evidence supporting the use of heparin for other indications, including autoimmune disease, malignancy, and disseminated intravascular coagulation. These considerations highlight the need for further research to elucidate the mechanisms of the possible pleiotropic effects of the heparins, with a view to advancing treatments based upon heparin derivatives.

Epidemiology and pathophysiology of venous thromboembolism: similarities with atherothrombosis and the role of inflammation

Venous thromboembolism (VTE) is a multifactorial disease. Major provoking factors (e. g. surgery, cancer, major trauma, and immobilisation) are identified in 50–60 % of patients, while the remaining cases are classified as unprovoked. However, minor predisposing conditions may be detectable in these patients, possibly concurring to the pathophysiology of the disease, especially when co-existing. In recent years, the role of chronic inflammatory disorders, infectious diseases and traditional cardiovascular risk factors has been extensively investigated. Inflammation, with its underlying prothrombotic state, could be the potential link between these risk factors, as well as the explanation for the reported association between arterial and venous thromboembolic events.

Optimal long-term pharmacological treatment of patients with venous thromboembolism that was unprovoked or associated with weak risk factors

INTRODUCTION

Unprovoked venous thromboembolism (VTE) tend to recur. Many factors, patient- or event-related, influence the individual risk of recurrence. After initial and long-term (usually for 3-6 months) anticoagulant therapy, extended anticoagulation has been recommended in patients at high risk of recurrence, provided they do not have a high risk of bleeding. Areas covered: The effect of different risk factors on the risk of recurrence is discussed, as well as risk factors for bleeding. The estimation of individual balance between these two risks is crucial to decide which can be the best treatment duration in single patients. The use of direct oral anticoagulants, with likely less risk of bleeding, may influence the balance. D-dimer assessment during and after anticoagulation is stopped is also commented for its role to help identifying the individual risk of recurrence. Expert commentary: All patients with a first VTE should be reconsidered after the initial 3-6 months of treatment. Anticoagulation can then be stopped or continued in relation to low or very high risk of recurrence, respectively. Serial D-dimer assessment during the first 2 or 3 months after anticoagulation is stopped is useful in patients with uncertain risk evaluation (especially after unprovoked events).

Venous thrombotic events in patients admitted to a tuberculosis centre

BACKGROUND

Considering the relationship between inflammation and thrombosis, patients with tuberculosis (TB) patients might be at high risk of venous thrombosis.

AIM

To evaluate the risk of venous thromboembolism in patients admitted to the Beatrixoord Tuberculosis Centre (BTBC), a tertiary centre for TB. We specifically explored which cofactors elevate the risk of venous thrombosis (VTE), and whether the timing of venous thrombotic events would justify extended primary prophylaxis.

DESIGN

retrospective cohort study.

METHODS

We performed a retrospective chart review of all patients with TB discharged from BTBC between 2000 and 2010. We excluded patients who were already on therapeutic anticoagulation before their TB episode, below the age of 18 years and patients in which TB diagnosis was withdrawn. For evaluating the timing of venous thrombosis, we calculated the time between commencement of anti TB therapy and the VTE.

RESULTS

Of 750 included in the final analysis, 18 (2.4%) suffered a venous thrombotic event. 3 of these events were not related to classic risk factors or hospitalization. Most (13/18) VTE's occurred in the time window of two weeks before starting TB medication.

In the multivariate analysis, only Human Immunodeficiency Virus (HIV) infection was strongly associated with risk of VTE (adjusted Odds ratio 8.2 (95% confidence interval: 2.9-22.7)).

CONCLUSIONS

This high risk in HIV co-infected TB patients suggests that standard thrombo-prophylaxis should be routinely considered in this group. However, our findings might not be generalizable due to referral bias. Further prospective studies in unselected HIV co-infected TB patients are needed to corroborate our findings.

Thrombosis and platelets: an update

Haemostasis and thrombosis are complex, multifactorial processes. There is an evolving understanding of the mechanisms influencing vascular occlusion and the role of inflammation and immunity. Despite major advances in elucidating the mechanistic pathways mediating platelet function and thrombosis, challenges in the treatment of vascular occlusive diseases persist. Pharmacological advances have greatly affected thrombotic outcomes, but this has led to the unwanted side effect of bleeding. Detailed assessment of the impact of non-thrombotic diseases on haemostasis and thrombosis is necessary to better evaluate thrombotic risk and establish optimal treatment. This review will focus on recent advances in understanding the contribution of evolving risk factors to thrombosis.

Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care: a retrospective observational study

OBJECTIVES

To evaluate the extent of delay in the diagnosis of pulmonary embolism (PE) in primary care, and to identify determinants that are associated with such diagnostic delay.

DESIGN

Retrospective observational study.

SETTING

6 primary care practices across the Netherlands.

PARTICIPANTS

Data from patients with an objectively confirmed diagnosis of PE (International Classification of Primary Care (ICPC) code K93) up to June 2015 were extracted from the electronic medical records. For all these PE events, we reviewed all consultations with their general practitioner (GP) and scored any signs and symptoms that could be attributed to PE in the 3 months prior to the event. Also, we documented actual comorbidity and the diagnosis considered initially.

PRIMARY AND SECONDARY OUTCOME MEASURES

Delay was defined as a time gap of >7 days between the first potentially PE-related contact with the GP and the final PE diagnosis. Multivariable logistic regression analysis was performed to identify independent determinants for delay.

RESULTS

In total, 180 incident PE cases were identified, of whom 128 patients had 1 or more potential PE-related contact with their GP within the 3 months prior to the diagnosis. Based on our definition, in 33 of these patients (26%), diagnostic delay was observed. Older age (age >75 years; OR 5.1 (95% CI 1.8 to 14.1)) and the absence of chest symptoms (ie, chest pain or pain on inspiration; OR 5.4 (95% CI 1.9 to 15.2)) were independent determinants for diagnostic delay. A respiratory tract infection prior to the PE diagnosis was reported in 13% of cases without delay, and in 33% of patients with delay (p=0.008).

CONCLUSIONS

Diagnostic delay of more than 7 days in the diagnosis of PE is common in primary care, especially in the elderly, and if chest symptoms, like pain on inspiration, are absent.

Hospitalization with infection and incident venous thromboembolism: The ARIC study

BACKGROUND AND OBJECTIVES

Acute triggers for VTE, which may include infection, are understudied, as is the timing and duration of VTE risk after infection. We hypothesized that there is an association between hospitalization with infection and short-term VTE risk that exceeds the known association between hospitalization and VTE.

METHODS

VTE cases and infections were identified in the Atherosclerosis Risk in Communities (ARIC) cohort. A case-crossover design and conditional logistic regression were used to compare hospitalized infections among VTE cases (14, 30, 42, and 90days before VTE) with corresponding control periods 1year and 2years prior. Since hospitalization is a known VTE trigger, study design and analytical techniques were used to isolate the impact of infection.

RESULTS

There were 845 adjudicated incident VTE cases. Hospitalization with infection was more common in all case periods compared to equivalent control periods: 14day OR (95% CI)=1.7 (0.5, 5.8), 30day OR (95% CI)=2.7 (1.1, 6.4), 42day OR (95% CI)=2.2 (1.1, 4.7), and 90day OR (95% CI)=1.2 (0.7, 2.0). The association was generally strongest in exposure periods closest to the VTE event and decreased as the time window before VTE increased.

CONCLUSIONS

These results support the hypothesis that hospitalized infection is a trigger of VTE. VTE preventive measures may prevent VTE events if used in the peri-infection period but clinical trials are needed.

Elevated risk of venous thromboembolic events in patients with inflammatory myopathies

Venous thromboembolism (VTE) is a multifactorial disease manifesting as either deep vein thrombosis or pulmonary embolism. Its prevalence makes VTE a significant issue for both the individual – as a negative factor influencing the quality of life and prognosis – and the society due to economic burden. VTE is the third most common vascular disorder in Western countries, after myocardial infarction and stroke, making it a major cause of in-hospital mortality, responsible for 5%–10% of hospital deaths. Despite many studies conducted, only 50%–60% provoking factors have been identified, while the remaining 40%–50% have been classified as idiopathic or unprovoked. Chronic inflammatory disorders, with their underlying prothrombotic state, reveal an increased risk of VTE (six to eight times) compared with the general population. Among the inflammatory disorders, we can identify inflammatory myopathies – a group of rare, chronic diseases featuring weakness and inflammation of muscles with periods of exacerbation and remission; their main classes are polymyositis and dermatomyositis. The objective of this review is to emphasize the need of VTE prophylaxis in individuals with inflammatory myopathies in order to reduce morbidity and mortality rates among those patients and improve their quality of life and prognosis.

Deep Vein Thrombosis in the Lower Extremities in Comatose Elderly Patients with Acute Neurological Diseases

PURPOSE

Comatose elderly patients with acute neurological illness have a great risk of deep vein thrombosis (DVT). In this study, the incidence of DVT and the effectiveness of early initiation of treatment were evaluated in those patients.

MATERIALS AND METHODS

Total 323 patients were admitted to our ward due to neurological diseases in one year, and 43 patients, whose Glasgow Coma Scale was ≤ 11 and who was older than ≥ 60 years, were included in this study. D-dimer was measured on admission and day 7, and lower-extremity ultrasonography was performed on day 7. When DVT was positive, heparin treatment was initiated, and further evaluation of pulmonary embolism (PE) was conducted. Vena cava filter protection was inserted in PE-positive patients. Incidence of DVT and PE, alteration of D-dimer value, and effect of heparin treatment were analyzed.

RESULTS

DVT was positive in 19 (44.2%) patients, and PE was in 4 (9.3%). D-dimer was significantly higher in DVT-positive group on day 7 (p<0.01). No DVT were identified in patients with ischemic disease, while 66.7% of intracerebral hemorrhage and 53.3% of brain contusion patients were DVT positive. Surgery was a definite risk factor for DVT, with an odds ratio of 5.25. DVT and PE disappeared by treatment in all cases, and no patients were succumbed to the thrombosis.

CONCLUSION

Patients with hemorrhagic diseases or who undergo operation possess high risk of DVT, and initiation of heparin treatment in 7 days after admission is an effective prophylaxis for DVT in comatose elderly patients without causing bleeding.

Autoinflammatory diseases: a possible cause of thrombosis?

Autoinflammatory diseases are a group of disorders due to acquired or hereditary disfunction of innate immune system and characterized by systemic or localized manifestations. The prototype is Familial Mediterranean Fever, a monogenic hereditary disorder, whose causing gene (MeFV gene) was identified in 1997 and opened the way to a new fascinanting chapter of rheumatology. A growing body of monogenic and poligenic autoinflammatory disorders has been described since then.

Arterial and venous thrombosis is a common medical problem, with significant morbidity and mortality. Strong evidences from basic research and clinical epidemiological studies support the theory that inflammation and thrombosis can be associated.

Because of their recurrent/chronic inflammatory nature, autoinflammatory diseases are a putative cause of thrombotic manifestations. In the present work, we reviewed the available evidences about monogenic autoinflammatory disorders, complicated by thrombotic manifestations.

Thrombosis in inflammatory bowel diseases: what's the link?

Inflammatory bowel disease affects more than 2 million people in Europe, with almost 20% of patients being diagnosed in pediatric age. Patients with inflammatory bowel disease are at increased risk of thromboembolic complications which may affect patients’ morbidity and mortality. The risk of the most common thromboembolic events, such as deep venous thrombosis and pulmonary embolism, are estimated to be three-fold increased compared to controls, but many other districts can be affected. Moreover, patients with ulcerative colitis and Crohn’s disease experience thromboembolic events at a younger age compared to general population. Many factors have been investigated as determinants of the pro-thrombotic tendency such as acquired risk factors or genetic and immune abnormalities, but a unique cause has not been found. Many efforts have been focused on the study of abnormalities in the coagulation cascade, its natural inhibitors and the fibrinolytic system components and both quantitative and qualitative alterations have been demonstrated. Recently the role of platelets and microvascular endothelium has been reviewed, as the possible link between the inflammatory and hemostatic process.

Long-term risk of mesenteric ischemia in patients with inflammatory bowel disease: a 13-year nationwide cohort study in an Asian population

BACKGROUND

It is unclear whether patients with inflammatory bowel disease (IBD) have higher risks of developing mesenteric ischemia.

METHODS

We enrolled 9,363 patients who had been hospitalized because of IBD between January 1998 and December 2010, along with 37,452 control patients who were matched at a 1:4 proportion for age, sex, and index year. We accounted the cumulative incidences and hazard ratios (HRs) of developing mesenteric ischemia during the 13-year study period.

RESULTS

Patients with IBD had a considerably higher incidence rate of subsequent mesenteric ischemia compared with the controls (22.7 vs 3.09 per 10,000 person-years), with adjusted HR of 6.33 (95% confidence interval: 4.75 to 8.43). A multivariate stratified analysis showed that the mesenteric ischemia risk after adjustment for comorbidities is significantly higher in patients of all age groups, particularly in patients younger than 44 years (adjusted HR: 48.0; 95% confidence interval: 11.3 to 203.9). Moreover, patients with IBD were at highest risk of developing mesenteric ischemia within the first year of follow-up.

CONCLUSIONS

Careful follow-up and effective therapy are necessary to reduce the excessive risk in these patients.

Acute brachial artery thrombosis in a neonate caused by a peripheral venous catheter

This case describes the diagnostic testing and management of an acute thrombosis of the brachial artery in a female neonate. On day seven of life, clinical signs of acutely decreased peripheral perfusion indicated an occlusion of the brachial artery, which was confirmed by high-resolution Doppler ultrasound. Imaging also showed early stages of collateralization so that surgical treatment options could be avoided. Unfractionated heparin was used initially and then replaced by low-molecular-weight heparin while coagulation parameters were monitored closely. Within several days, brachial artery perfusion was completely restored. Acetylsalicylic acid was given for additional six weeks to minimize the risk of recurring thrombosis. If inadequately fixated in a high-risk location, a peripheral venous catheter can damage adjacent structures and thus ultimately cause arterial complications.

Key advances in the clinical approach to ANCA-associated vasculitis

The updated nomenclature for vasculitis defines this varied group of disorders by aetiology, specific features of pathogenesis and clinical symptoms; diagnostic and classification criteria for clinical practice are in development. Here, I review some important advances in the management of vasculitis within the category of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), which encompasses microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The clinical approach to the management of the patient with AAV should include testing for ANCA specificity; proteinase 3 (PR3)-specific ANCAs are most often associated with GPA, whereas myeloperoxidase (MPO)-ANCAs are usually associated with MPA. Also important to the management of AAV is an assessment of the disease stage and severity, to enable tailored treatment based on an algorithm derived from controlled-trial data. Remaining questions pertain to the dosage and duration of corticosteroid treatment, the selection of patients for, and duration of, maintenance treatment after induction of remission, and the identification of safer and more effective therapies than are currently in use. Outcome measures should assess not only disease activity, but also damage and quality of life. Infections, cardiovascular events and malignancies also contribute to outcome, and their prevention should therefore be part of the clinical approach to managing patients with AAV.

Venous thrombosis and prothrombotic factors in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) may have an increased risk of venous thrombosis (VTE). PubMed, ISI Web of Knowledge and Scopus were searched to identify studies investigating the risk of VTE and the prevalence of acquired and genetic VTE risk factors and prothrombotic abnormalities in IBD. Overall, IBD patients have a two- to fourfold increased risk of VTE compared with healthy controls, with an overall incidence rate of 1%-8%. The majority of studies did not show significant differences in the risk of VTE between Crohn’s disease and ulcerative colitis. Several acquired factors are responsible for the increased risk of VTE in IBD: inflammatory activity, hospitalisation, surgery, pregnancy, disease phenotype (e.g., fistulising disease, colonic involvement and extensive involvement) and drug therapy (mainly steroids). There is also convincing evidence from basic science and from clinical and epidemiological studies that IBD is associated with several prothrombotic abnormalities, including initiation of the coagulation system, downregulation of natural anticoagulant mechanisms, impairment of fibrinolysis, increased platelet count and reactivity and dysfunction of the endothelium. Classical genetic alterations are not generally found more often in IBD patients than in non-IBD patients, suggesting that genetics does not explain the greater risk of VTE in these patients. IBD VTE may have clinical specificities, namely an earlier first episode of VTE in life, high recurrence rate, decreased efficacy of some drugs in preventing further episodes and poor prognosis. Clinicians should be aware of these risks, and adequate prophylactic actions should be taken in patients who have disease activity, are hospitalised, are submitted to surgery or are undergoing treatment.

Venous thromboembolism after community-acquired bacteraemia: a 20-year danish cohort study

Background

Infections may increase the risk for venous thromboembolism (VTE), but little is known about VTE risk associated with community-acquired bacteraemia (CAB). We examined the risk for VTE within one year of CAB in comparison to that in matched controls.

Methods

We conducted a population-based cohort study in North Denmark 1992–2011, using data from high-quality health-care databases. We included 4,213 adult CAB patients who had positive blood cultures drawn on the day of hospital admission, 20,084 matched hospitalised controls admitted for other acute medical illness, and 41,121 matched controls from the general population. We computed 0–90 and 91–365 day absolute risks for hospital-diagnosed VTE and used regression analyses with adjustment for confounding factors to compare the risk for VTE in bacteraemia patients and controls.

Results

Among CAB patients, 1.1% experienced VTE within 90 days of admission and 0.5% during 91–365 days after admission. The adjusted 90-day odds ratio (OR) for VTE was 1.9 (95% CI 1.4–2.7) compared with hospitalised controls, and 23.4 (95% CI 12.9–42.6) compared with population controls. During 91–365 days after CAB admission, the VTE risk remained moderately increased (adjusted hazard ratio vs. hospitalised controls, 1.4; 95% CI 0.8–2.5, and vs. population controls, 1.9; 95% CI 1.0–3.3). Compared to hospitalised controls, the 90-day VTE risk increase was greater for Gram-positive infection (adjusted OR 2.5; 95% CI 1.6–4.1) than for Gram-negative infection (adjusted OR, 1.2; 95% CI 0.7–2.1), partly due to a high risk after Staphylococcus aureus infection (3.6%).

Conclusion

The risk for VTE is substantially increased within 90 days after community-acquired bacteraemia when compared to hospitalised controls and population controls. However, the absolute risk of VTE following CAB is low.

Mechanisms of thrombosis in obesity

PURPOSE OF REVIEW

Obesity has become a worldwide epidemic that is driving increased morbidity and mortality from thrombotic disorders such as myocardial infarction, stroke, and venous thromboembolism. Effective prevention and treatment of thrombosis in obese patients is limited by an incomplete understanding of the underlying prothrombotic mechanisms and by uncertainties about risks, benefits, and dosing of anticoagulant drugs in this patient population.

RECENT FINDINGS

This review summarizes our current understanding of established and emerging mechanisms contributing to the obesity-induced prothrombotic state. The mechanistic impact of chronic inflammation and impaired fibrinolysis in mediating obesity-associated thrombosis is highlighted. Recent data demonstrating the aberrant expression of adipokines and microRNAs, which appear to function as key modulators of proinflammatory and prothrombotic pathways in obesity, are also reviewed. Finally, some challenges and new approaches to the prevention and management of thrombotic disorders in obese and overweight patients are discussed.

SUMMARY

Obesity-driven chronic inflammation and impaired fibrinolysis appear to be major effector mechanisms of thrombosis in obesity. The proinflammatory and hypofibrinolytic effects of obesity may be exacerbated by dysregulated expression and secretion of adipokines and microRNAs, which further increase the risk of thrombosis and suggest new potential targets for therapy.

Extraintestinal manifestations and complications in IBD

More than one-third of patients with IBD are affected by extraintestinal manifestations or extraintestinal complications beyond the intestinal manifestation of the disease. The most common manifestations include arthropathies, mucocutaneous and ophthalmological manifestations, as well as conditions affecting the hepatobiliary system, both in Crohn's disease and ulcerative colitis. However, less frequent manifestations, such as pulmonary or neurological manifestations, should also be considered in patients with IBD. Several extraintestinal manifestations follow the course of the underlying intestinal activity, whereas others are independent from the intestinal inflammation. Extraintestinal complications such as iron-deficiency anaemia and osteoporosis are consequences of the intestinal disease or of disease-specific treatment. As extraintestinal manifestations and complications strongly influence quality of life, and to avoid severe complications, adequate treatment is mandatory in affected patients. We provide a comprehensive overview of different extraintestinal manifestations and complications, including their management, in patients with IBD.

Tumour necrosis factor in infectious disease

TNF signals through two distinct receptors, designated TNFR1 and TNFR2, which initiate diverse cellular effects that include cell survival, activation, differentiation, and proliferation and cell death. These cellular responses can promote immunological and inflammatory responses that eradicate infectious agents, but can also lead to local tissue injury at sites of infection and harmful systemic effects. Defining the molecular mechanisms involved in TNF responses, the effects of natural and experimental genetic diversity in TNF signalling and the effects of therapeutic blockade of TNF has increased our understanding of the key role that TNF plays in infectious disease.

Atorvastatin favorably modulates proinflammatory cytokine profile in patients following deep vein thrombosis

BACKGROUND

Venous thromboembolism (VTE) has been shown to be associated with inflammation. Statins that might reduce VTE risk have been found to exert anti-inflammatory properties in patients at cardiovascular risk. We sought to investigate whether anti-inflammatory effects of atorvastatin can be observed in VTE patients.

MATERIALS AND METHODS

Atorvastatin 40 mg/d was given for 3 days to 26 consecutive VTE patients following discontinuation of anticoagulant therapy and 25 controls. We evaluated interleukin (IL)-1b, IL-6, IL-8, IL-10, soluble P-selectin and von Willebrand factor (vWF) antigen in peripheral venous blood.

RESULTS

The VTE patients displayed higher C-reactive protein (p=0.013), IL-1b (p=0.03), IL-8 (p=0.03) and vWF (p<0.0001) compared with the controls. In VTE patients atorvastatin decreased IL-6 (p=0.0003), IL-8 (p=0.003) and P-selectin (p<0.0001), but increased IL-10 (p=0.001), with no association with C-reactive protein or cholesterol-lowering effects. Atorvastatin reduced IL-1b (p=0.01), IL-6 (p=0.03) and P-selectin (p=0.002) in controls. Residual venous thrombosis was associated with elevated IL-6 and P-selectin, whereas patients with proximal deep vein thrombosis showed elevated P-selecitn prior to and following statin administration (all p<0.05).

CONCLUSION

A 3-day administration of atorvastatin reduces inflammation without decrease in C-reactive protein in VTE patients.

Peptidylarginine deiminase inhibition is immunomodulatory and vasculoprotective in murine lupus

Recent evidence suggests that enhanced neutrophil extracellular trap (NET) formation activates plasmacytoid dendritic cells and serves as a source of autoantigens in SLE. We propose that aberrant NET formation is also linked to organ damage and to the premature vascular disease characteristic of human SLE. Here, we demonstrate enhanced NET formation in the New Zealand mixed 2328 (NZM) model of murine lupus. NZM mice also developed autoantibodies to NETs as well as the ortholog of human cathelicidin/LL37 (CRAMP), a molecule externalized in the NETs. NZM mice were treated with Cl-amidine, an inhibitor of peptidylarginine deiminases (PAD), to block NET formation and were evaluated for lupus-like disease activity, endothelial function, and prothrombotic phenotype. Cl-amidine treatment inhibited NZM NET formation in vivo and significantly altered circulating autoantibody profiles and complement levels while reducing glomerular IgG deposition. Further, Cl-amidine increased the differentiation capacity of bone marrow endothelial progenitor cells, improved endothelium-dependent vasorelaxation, and markedly delayed time to arterial thrombosis induced by photochemical injury. Overall, these findings suggest that PAD inhibition can modulate phenotypes crucial for lupus pathogenesis and disease activity and may represent an important strategy for mitigating cardiovascular risk in lupus patients.

Optimal treatment duration of venous thrombosis

Randomized controlled trials have shown that patients with venous thromboembolism benefit from a minimum of three months of anticoagulant therapy. After this period, it was suggested that patients with an expected annual recurrence rate of < 5% could safely discontinue treatment. Using a population-based approach for stratification, these patients are those with major transient risk factors, and represent the minority. For all other patients, including those with previous episodes of venous thromboembolism, cancer, or unprovoked events, this treatment duration may not be sufficiently protective. Because extending anticoagulation for additional three to nine months does not result in further, long-term reduction of recurrences, indefinite treatment duration should be considered. However, case-fatality rate for major bleeding in patients taking warfarin for more than three months is higher than case-fatality rate of recurrent venous thromboembolism. Thus, an individual patient approach to improve and increase the identification of those who can safely discontinue treatment at three months becomes necessary. Clinical prediction rules or management strategies based on D-dimer levels or residual vein thrombosis have been proposed and need further refinement and validation. Specific bleeding scores are lacking. Meanwhile, the oral direct inhibitors have been proposed as potential alternatives to the vitamin K antagonists, and aspirin may provide some benefit in selected patients who discontinue anticoagulation. Deep vein thrombosis in unusual sites is associated with less, but potentially more severe recurrences, in particular in patients with splanchnic vein thrombosis who also face an increased risk of bleeding complications while on treatment.