Pulmonary embolism and deep vein thrombosis

The Role of Zinc and Copper in Platelet Activation and Pathophysiological Thrombus Formation in Patients with Pulmonary Embolism in the Course of SARS-CoV-2 Infection

To date, many studies have proved that COVID-19 increases the incidence of thrombus formation and coagulopathies but the exact mechanism behind such a disease outcome is not well known. In this review we collect the information and discuss the pathophysiology of thrombus formation in patients with pulmonary embolism in the course of COVID-19 disease and the role of zinc and copper in the process. Supplementation of zinc and copper may be beneficial for COVID-19 patients due to its anti-inflammatory and anti-oxidative properties. On the other hand, excess of those microelements in the organism may be harmful, that is why marking the level of those micronutrients should be done at first. We also propose further investigation of diagnostic and therapeutic options of zinc and copper in course of COVID-19 thrombus formation to their potential in patient care, with particular emphasis on the dosage and the duration of their misbalance.

Atherosclerosis and Its Impact on the Outcomes of Patients with Deep Venous Thrombosis

Introduction: Atherosclerosis and pulmonary embolism (PE) affect cardiovascular mortality substantially. We aimed to investigate the impact of atherosclerosis on the outcomes of patients with deep venous thrombosis (DVT) and to identify the differences in DVT patients with and without PE. Methods: Patients with DVT with and without symptomatic atherosclerosis (defined as coronary artery disease, myocardial infarction and/or peripheral artery disease) as well as with and without PE under oral anticoagulation were enrolled during January 2011−April 2013 and compared. The impact of symptomatic atherosclerosis on several outcomes was analyzed. Results: Overall, 509 DVT patients (70.0 [56.0−77.0] years, 51.9% females) were included in this study. Among them, 179 (36.3%) had symptomatic atherosclerosis and 204 (40.1%) a concomitant PE. DVT patients with symptomatic atherosclerosis were older (74.0 [IQR 65.0−80.0] vs. 63.0 [48.0−75.0] years, p < 0.0001), more often male (56.4% vs. 43.9%, p = 0.0087) and had a higher prevalence of classical CVRF and a higher Charlson comorbidity index (7.00 [5.00−8.00] vs. 4.00 [2.00−6.00], p < 0.001). Symptomatic atherosclerosis was associated with increased mortality (HR 1.98 [95%CI 1.12−3.49], p = 0.018) and hospitalizations (HR 1.64 [95%CI 1.21−2.21], p = 0.0012) and primary long-term outcome (HR 1.99 [95%CI 1.31−3.04], p = 0.0013) during the 2 years follow-up-period in DVT patients. DVT patients without PE had diabetes mellitus (28.2% vs. 16.3%, p < 0.01) and symptomatic atherosclerosis (42.9% vs. 26.4%, p < 0.001) more often compared to DVT patients with PE, and symptomatic atherosclerosis was associated with isolated DVT (without PE) (OR 2.01 [95%CI 1.28−3.16], p < 0.01). Conclusions: Atherosclerosis was associated with isolated DVT (without PE) and increased mortality in DVT patients under oral anticoagulation. The profile of CVRF and comorbidities differed between DVT patients with and without a concomitant PE. In the case of DVT or PE, patients should be screened for concomitant atherosclerotic disease. Clinical Trial Registration: at clinicaltrials with Unique identifier NCT01809015.

Large-scale genetic correlation scanning and causal association between deep vein thrombosis and human blood metabolites

Deep vein thrombosis (DVT) refers to the abnormal coagulation of blood in a deep vein. Recently, some studies have found that metabolites are related to the occurrence of DVT and may serve as new markers for the diagnosis of DVT. In this study, we used the GWAS summary dataset of blood metabolites and DVT to perform a large-scale genetic correlation scan of DVT and blood metabolites to explore the correlation between blood metabolites and DVT. We used GWAS summary data of DVT from the UK Biobank (UK Biobank fields: 20002) and GWAS summary data of blood metabolites from a previously published study (including 529 metabolites in plasma or serum from 7824 adults from two European population studies) for genetic correlation analysis. Then, we conducted a causal study between the screened blood metabolites and DVT by Mendelian randomization (MR) analysis. In the first stage, genetic correlation analysis identified 9 blood metabolites that demonstrated a suggestive association with DVT. These metabolites included Valine (correlation coefficient = 0.2440, P value = 0.0430), Carnitine (correlation coefficient = 0.1574, P value = 0.0146), Hydroxytryptophan (correlation coefficient = 0.2376, P value = 0.0360), and 1-stearoylglycerophosphoethanolamine (correlation coefficient = - 0.3850, P value = 0.0258). Then, based on the IVW MR model, we analysed the causal relationship between the screened blood metabolites and DVT and found that there was a suggestive causal relationship between Hydroxytryptophan (exposure) and DVT (outcome) (β = - 0.0378, se = 0.0163, P = 0.0204). Our study identified a set of candidate blood metabolites that showed a suggestive association with DVT. We hope that our findings will provide new insights into the pathogenesis and diagnosis of DVT in the future.

Survival Prediction in Patients with Hypertensive Chronic Kidney Disease in Intensive Care Unit: A Retrospective Analysis Based on the MIMIC-III Database

Objective

Disease prediction is crucial to treatment success. The aim of this study was to accurately and explicably predict, based on the first laboratory measurements, medications, and demographic information, the risk of death in patients with hypertensive chronic kidney disease within 1 and 3 years after admission to the Intensive Care Unit (ICU).

Methods

Patients with hypertensive chronic kidney disease who had been registered in the Medical Information Mart for Intensive Care (MIMIC-III) database of critical care medicine were set as the subject of study, which was randomly divided into a training set and a validation set in a ratio of 7 : 3. Univariate Cox regression analysis and stepwise Cox regression analysis were applied in the training set to identify the predictive factors of prognosis of patients with hypertensive chronic kidney disease in ICU, and the predictive nomogram based on Cox regression model was constructed. We internally validated the model in the training set and externally validated that in the validation model. The efficacy was assessed primarily through area under the receiver operating characteristic (ROC) curve, clinical decision curves, and calibration curves.

Results

A total of 1762 patients with hypertensive chronic kidney disease were finally included. During the 3-year follow-up, 667 patients (37.85%) died, with a median follow-up time of 220 days (1-1090). The data set were randomly divided into a training set (n = 1231) and a validation set (n = 531). It was identified in the training set that insurance, albumin, alkaline phosphatase, the mean corpuscular hemoglobin concentration, mean corpuscular volume, history of coronary angiogram, hyperlipemia, medication of digoxin, acute renal failure, and history of renal surgery were the most relevant features. Taking 1 year and 3 years as the cut-off points, the AUC of participants were 0.736 and 0.744, respectively, in the internal validation and were 0.775 and 0.769, respectively, in the external validation, suggesting that the model is of favorable predictive efficacy.

Conclusion

We trained and validated a model using data from a large multicenter cohort, which has considerable predictive performance on an individual scale and could be used to improve treatment strategies.

Hospitalizations for pulmonary embolism in Brazil (2008-2019): an ecological and time series study

Objective

To assess the temporal trends of hospitalizations for pulmonary embolism (PE) in Brazil, its regions, and states between 2008 and 2019.

Methods

An ecological and time series study was conducted. Data were obtained from the Hospital Information System (SIH) of the Brazilian Ministry of Health. The inflection point regression model was applied for temporal trend analyses. Trends were classified as increasing, decreasing, or stationary according to the slope of the regression line. The Annual Percent Charge (APC) and the Average Annual Percent Change (AAPC) were calculated considering a confidence interval of 95% and p-value <0.05. Furthermore, spatial distribution maps of epidemiological indicators related to PE in Brazil were elaborated.

Results

There was an increasing trend in the hospitalization rate for PE in Brazil, ranging from 2.57 in 2008 to 4.44/100,000 in 2019 (AAPC=5.6%; p<0.001). Total and average hospitalizations costs also showed increasing trend in the country (AAPC=9.2% and 3.0%, respectively). Still, there was a decrease in the in-hospital mortality rate (from 21.21% to 17.11%; AAPC=-1.9%; p<0.001). Similar trends were observed in most regions. The average hospitalization time in Brazil showed a stationary trend. The hospitalization rate has also increased in 18 states (66.67%). Seven states showed a decrease in the mortality rate (25.93%), except for Roraima, which showed an increasing trend.

Conclusion

Hospitalizations for PE represent a serious public health problem in Brazil and the temporal patterns observed herein demonstrate an increasing trend in all regions and states of the country.

Thrombotic and Cardiovascular Events and Treatment Patterns Among Patients Hospitalized with COVID-19 in Japan: An Analysis of a Nationwide Medical Claims Database

Introduction

Limited data are available regarding the prevalence of thrombotic/cardiovascular disease and treatment patterns for patients with coronavirus disease 2019 (COVID-19) in Japan. In this study we describe patients hospitalized for COVID-19 in Japan.

Methods

This retrospective database study analyzed the Japan Medical Data Vision database (416 acute care hospitals) for patients hospitalized for COVID-19 during the identification period from 1 January 1 to 30 September 2020.

Results

Among 9282 eligible patients, 832 (9%) had developed thrombotic disease including myocardial infarction, ischemic stroke, deep vein thromboembolism and pulmonary embolism. Intriguingly, 171(1.8%) had two thrombotic events and 25 (0.3%) had three or four thrombotic events at the same time. The data also showed that arterial thrombotic events accounted for 77% of total thrombotic events. Anticoagulant and/or antiplatelet medication was provided to 3312 patients. Even with antithrombotic medication, 21.2% of patients suffered from thrombotic diseases.

Conclusions

Patients with COVID-19 could experience thrombotic complications in every blood vessel. Further optimization of medication is crucial for preventing thrombotic complications and improving prognosis.

Efficacy of CRP in combination with D-dimer in predicting adverse postoperative outcomes of patients with acute Stanford type A aortic dissection

Purpose

The present study evaluated the efficacy of C-reactive protein (CRP) and D-dimer and the combination of them as prognostic indicators for patients with acute type A aortic dissection (ATAAD).

Methods

This is a retrospective cohort study. From January 2019 to December 2021, patients with ATAAD admitted to the emergency medicine center of our hospital within 24 h after symptoms (chest pain, back pain, abdominal pain and so on) onset were enrolled in our study. Serum concentration of CRP and D-dimer were measured during hospitalization. Logistic regression was used to evaluate the association between these two biomarkers and in-hospital adverse outcomes (IAO) by adjusting confounding factors. Predictive efficacy was assessed by area under the curve (AUC) of receiver operating characteristic curve.

Results

A total of 199 patients with ATAAD were finally enrolled. They were categorized as Non-IAO group (n = 146) and IAO group (n = 53) according to postoperative outcomes. After controlling for potentially confounding variables, we found categorized variables that admission CRP > 54.28 mg/L, admission D-dimer > 8.45 mg/L and peak D-dimer > 24.89 mg/L were independent predictors of in-hospital adverse outcomes. Multiple Logistic regression analysis revealed that the odd ratios were 2.9 for admission D-dimer > 8.45 [95% Confidence Interval (CI) 1.11–7.5, p = 0.03], 4.9 for admission CRP > 54.28 (95% CI 1.6–14.9, p = 0.005) and 5.7 for peak D-dimer > 24.89 (95% CI 2.49–13, p < 0.001). The predictive accuracy of the combination of three categorized variables (AUC: 0.867, 95% CI 0.813–0.921, p < 0.001) was superior to that of any other one alone.

Conclusion

Admission D-dimer > 8.45 mg/L, peak D-dimer > 24.89 mg/L and admission CRP > 54.28 mg/L are independent predictors of in-hospital adverse outcomes in patients with ATAAD. Combination of these three markers will improve the predictive efficacy.

Current Knowledge on Factor V Leiden Mutation as a Risk Factor for Recurrent Venous Thromboembolism: A Systematic Review and Meta-Analysis

Background

Thrombophilia screening is widely done in clinical practice, and it is claimed that the extent of venous thromboembolism (VTE) recurrence risk in patients with common defects is still not fully understood.

Aim

We aimed to summarize data of all observational studies prospectively assessing the association of heterozygous factor V Leiden (FVL) mutation and recurrent VTE in patients with VTE, and to calculate pooled relative risks (RR), overall and in various subgroups.

Methods

We searched MEDLINE and EMBASE databases for cohort studies prospectively assessing VTE recurrence in patients with and without FVL mutation (PROSPERO: CRD42021182800). Data were extracted on cohort and study-level. The methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). RR were calculated overall and in subgroups using a random-effects model.

Results

From 31 cohorts, 24 studies were finally included summarizing 13,571 patients. Heterozygous FVL mutation was identified in 2,840 individuals (21%). The methodological quality was estimated to be high in 20 studies (83%). The overall RR was 1.46 (95% CI: 1.31, 1.64), consistent across subgroups.

Conclusions

Pooling all high-quality epidemiological data, the risk of recurrent VTE was increased by 46% in patients with heterozygous FVL mutation. Against the background of established risk factors, the FVL mutation plays only a marginal role in the risk assessment for recurrent VTE.

A new method of monitoring catheter-directed thrombolysis for deep venous thrombosis-application of D-dimer and fibrinogen testing

BACKGROUND

Catheter-directed thrombolysis (CDT) is one of the main treatment methods for acute deep venous thrombosis (DVT), which has the characteristics of long treatment time and large dosage of thrombolytic drugs. In the absence of good monitoring methods, problems such as low thrombolytic efficiency and high risk of bleeding are easy to occur.

OBJECTIVE

To evaluate the value of D-dimer (D-D) and fibrinogen (FIB) testing as a thrombolysis-monitoring method during CDT for acute DVT.

METHODS

Twenty patients with acute DVT were divided into group A and group B. During CDT, the D-D and FIB testing every 8 h were used in group A, and the venography and FIB testing every 24 h in group B. The thrombolysis rate, thrombolysis time, urokinase dosage, and X-ray radiation dose were compared.

RESULTS

The thrombolysis rate in group A was significantly higher than that in group B (p < 0.05), but the number of venography and radiation dose were significantly lower than those in group B (p < 0.05).

CONCLUSION

D-D and FIB testing can improve the thrombolysis rate, reduce the risk of bleeding, and decrease the number of angiograms and X-ray radiation dose during CDT.

The Interaction Effect between Comorbidity Burden and Venous Thromboembolism on Mortality: A Nationwide Cohort Study

BACKGROUND

Comorbidity influences venous thromboembolism (VTE) mortality, but it is unknown whether this is due to comorbidity alone or whether biological interaction exists.

OBJECTIVES

We examined whether comorbidity and VTE interact to increase VTE mortality beyond their individual effects.

METHODS

This nationwide population-based cohort study included all VTE patients ≥18 years during 2000 to 2016, and an age-, sex-, and comorbidity-matched comparison cohort of individuals without VTE. We computed age-standardized mortality rates and examined interaction on the additive scale using interaction contrasts (difference in rate differences).

RESULTS

After 30-day follow-up, the mortality rate per 1,000 person-years among individuals with no comorbidity was 419 (95% confidence interval [CI]: 391-447) in the VTE and 16 (95% CI: 13-18) in the comparison cohort (rate difference: 403). The corresponding mortality rate increased to 591 (95% CI: 539-643) in the VTE cohort and 38 (95% CI: 33-44) in the comparison cohort among individuals with low comorbidity (rate difference: 553). The interaction contrast (150) showed that 25% (150/591) of mortality was explained by the interaction in individuals with low comorbidity. This percentage increased to 56% for moderate and 63% for severe comorbidity. Interaction effects were largest within 30-day follow-up, for provoked VTE, in young individuals, and in individuals noncompliant to anticoagulant therapy. Dose-response patterns for interaction effects were also observed after 31-365-day and >1-5-year follow-up (p < 0.0001). Interaction effects varied between individual comorbidities.

CONCLUSION

Biological interaction between comorbidity and VTE explained a substantial proportion of VTE mortality. The interaction effect increased with comorbidity burden.

Non-vitamin K antagonist oral anticoagulants in venous thromboembolism patients: a meta-analysis of real-world studies

BACKGROUND

The real-world studies on recurrent venous thromboembolism (VTE) and bleeding events of non-vitamin K antagonist oral anticoagulants (NOACs) in VTE patients have reported conflicting findings. Our study aimed to provide the direct comparison evidence of different NOACs for VTE patients in clinical practice settings.

METHODS

Search of the medical literature was conducted using PubMed, Web of Science, EMBASE, Clinical Trials.gov, and the Cochrane Library from inception to March 22, 2021. Among the 19,996 citations retrieved, a total of 63,144 patients from 6 studies were analyzed. Clinical outcomes included recurrent VTE, death, and different bleeding events.

RESULTS

Adjusted hazard ratio (HR) analysis suggested that apixaban had significant lower bleeding riskthan rivaroxaban (major, minor and any bleeding: HR = 0.61, 0.56, 0.70; p = 0.008, < 0.0001, 0.006, respectively), but no statistics difference found in recurrent VTE events (HR = 1.02, 95% confidence interval (CI) 0.71-1.47, p = 0.93). There was no significant difference of major bleeding between dabigatran and rivaroxaban (odds ratios (OR) = 0.41, 95% CI 0.09-1.90, p = 0.25), apixaban and dabigatran (OR 0.64, 95% CI 0.15-2.72, p = 0.83). No significant difference was found in the comparison of edoxaban and other NOACs in VTE recurrence, major bleeding and composite outcome.

CONCLUSIONS

In the prevention of bleeding events, apixaban was associated with a lower risk than rivaroxaban, but equivalent efficacy for different NOACs in prevention of recurrent VTE. Evidence generated from the meta-analysis based on real-world data can help to guide selection between apixaban and rivaroxaban in routine clinical practice.

TRIAL REGISTRATION

This systematic review and meta-analysis were conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology statements and was registered with PROSPERO (CRD42019140553).

Vena Cava Filters: Toward Optimal Strategies for Filter Retrieval and Patients' Follow-Up

Mortality rates associated with venous thromboembolism (VTE) are high. Inferior vena cava filters (IVCFs) have been frequently placed for these patients as part of their treatment, albeit the paucity of data showing their ultimate efficacy and potential risk of complications. Issues regarding long-term filter dwell time are accounted for in society guidelines. This topic has led to an FDA mandate for filter retrieved as soon as protection from pulmonary embolism is no longer needed. However, even though most are retrievable, some were inadvertently left as permanent, which carries an incremental lifetime risk to the patient. In the past decade, attempts have aimed to determine the optimal time interval during which filter needs to be removed. In addition, distinct strategies have been implemented to boost retrieval rates. This review discusses current conflicts in indications, the not uncommon complications, the rationale and need for timely retrieval, and different quality improvement strategies to fulfill this aim.

Upconversion nanoparticles regulated drug & gas dual-effective nanoplatform for the targeting cooperated therapy of thrombus and anticoagulation

Thromboembolism is the leading cause of cardiovascular mortality. Currently, for the lack of targeting, short half-life, low bioavailability and high bleeding risk of the classical thrombolytic drugs, pharmacological thrombolysis is usually a slow process based on micro-pumping. In addition, frequently monitoring and regulating coagulation functions are also required during (and after) the process of thrombolysis. To address these issues, a targeted thrombolytic and anticoagulation nanoplatform (UCATS-UK) is developed based on upconversion nanoparticles (UCNPs) that can convert 808 or 980 nm near-infrared (NIR) light into UV/blue light. This nanoplatform can target and enrich in the thrombus site. Synergistic thrombolysis and anticoagulation therapy thus could be realized through the controlled release of urokinase (UK) and nitric oxide (NO). Both in vitro and in vivo experiments have confirmed the excellent thrombolytic and anticoagulative capabilities of this multifunctional nanoplatform. Combined with the unique fluorescent imaging capability of UCNPs, this work is expected to contribute to the development of clinical thrombolysis therapy towards an integrated system of imaging, diagnosis and treatment.

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This work is not only the first application of UCNPs in the thrombolysis therapy, but also the first attempt to develop a dual effective drug & gas nanoplatform for thrombolytic & anticoagulation therapy.

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Besides conventional in vitro and animal experiments, a 3D printed vascular model is also constructed to further verify the feasibility of UCATS-UK.

•

Through surface chemical modification, the nanoplatform possesses the capabilities of targeting thrombus, as well as light-controlled NO release for drug-free anticoagulation therapy.

Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics

The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P= .001), and tachypnea (58.9% vs. 42.1%, P= .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P= .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P= .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P= .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P= .000), RV dysfunction (45.8% vs. 22%, P= .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P= .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P= .864) and hypoxemia (41.1% vs. 34.3%, P= .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.

Conversion from dose-length product to effective dose in computed tomography venography of the lower extremities

For radiation dose assessment of computed tomography (CT), effective dose (ED) is often estimated by multiplying the dose-length product (DLP), provided automatically by the CT scanner, by a conversion factor. We investigated such conversion in CT venography of the lower extremities performed in conjunction with CT pulmonary angiography. The study subjects consisted of eight groups imaged using different scanners and different imaging conditions (five and three groups for the GE and Siemens scanners, respectively). Each group included ten men and ten women. The scan range was divided into four anatomical regions (trunk, proximal thigh, knee and distal leg), and DLP was calculated for each region (regional DLP). Regional DLP was multiplied by a conversion factor for the respective region, to convert it to ED. The sum of the ED values for the four regions was obtained as standard ED. Additionally, the sum of the four regional DLP values, an approximate of the scanner-derived DLP, was multiplied by the conversion factor for the trunk (0.015 mSv mGy cm^-1), as a simplified method to obtain ED. When using the simplified method, ED was overestimated by 32.3%-70.2% and 56.5%-66.2% for the GE and Siemens scanners, respectively. The degree of overestimation was positively and closely correlated with the contribution of the middle and distal portions of the lower extremities to total radiation exposure. ED/DLP averaged within each group, corresponding to the conversion factor, was 0.0089-0.0114 and 0.0091-0.0096 mSv mGy cm^-1for the GE and Siemens scanners, respectively. In CT venography of the lower extremities, ED is greatly overestimated by multiplying the scanner-derived DLP by the conversion factor for the trunk. The degree of overestimation varies widely depending on the imaging conditions. It is recommended to divide the scan range and calculate ED as a sum of regional ED values.

Preventing Venous Thromboembolism after elective total hip arthroplasty surgery - are the current guidelines appropriate? Venous thromboembolism prophylaxis in elective total hip arthroplasty surgery

INTRODUCTION

Venous Thromboembolism after elective Total Hip Arthroplasty surgery is a well-recognised complication, resulting in fatal pulmonary embolism, post thrombotic syndrome and recurrent thrombotic episodes. Guidelines developed by clinical organisations attempt to provide evidence-based recommendations to clinicians.

METHODS

This narrative review evaluated the current available literature in relation to the available guidelines, to evaluate whether the current major guidelines reflect the evidence base. All major clinical guidelines were collated through database searching, alongside the relevant clinical studies.

PRINCIPAL FINDINGS

The promotion of a multi-modal approach, combining mechanical and chemical prophylaxis, does appear to be well validated, with mechanical prophylaxis offering positive clinical effects with little negative clinical consequence. Within the current guidelines surrounding VTE prevention in the elective-THA patient, there does appear to be a lack of prescription in relation to risk stratification and adopting personalised approaches for specific patient subsets.

CONCLUSION

We suggest moving away from protocolisation of VTE prevention, given the evidence base is not fully developed to allow a 'one-size-fits-all' approach.

Dysregulation of Biomarkers of Hemostatic Activation and Inflammatory Processes are Associated with Adverse Outcomes in Pulmonary Embolism

Introduction

The pathophysiology of pulmonary embolism (PE) represents complex, multifactorial processes involving blood cells, vascular endothelium, and the activation of inflammatory pathways. Platelet (P), endothelial (E), and leukocyte (L)-selectin molecules may play an important role in PE pathophysiology. We aimed to profile the biomarkers of inflammation, including selectins in PE patients, and compare them to healthy individuals.

Materials and methods

100 acute PE patients and 50 controls were included in this case control study. ELISA methods were used to quantify levels of selectins, inflammatory, and hemostatic biomarkers.

Results

In PE patients, levels of selectin molecules as compared to controls convey increased P-selectin levels (95 ng/mL vs 40 ng/mL, p < .0001) and decreased L-selectin levels (1468 ng/mL vs 1934 ng/mL, p < .0001). Significant correlations were found between selectins and Plasminogen Activating Inhibitor-1 (PAI-1), Tumor Necrosis Factor-a (TNFa), and D-dimer. Fold change between selectins and controls is compared to other biomarkers, illustrating degrees of change comparable to TNFa, alpha-2-antiplasmin, and microparticles. L-selectin levels are inversely associated with all-cause-mortality in PE patients, (p = .040).

Conclusion

These studies suggest that various thrombo-inflammatory biomarkers are elevated in PE patients. Furthermore, L-selectin levels are inversely associated with mortality outcomes.

Impact of dedicated outpatient pulmonary follow‐up for hospitalized patients with acute pulmonary embolism

Pulmonary embolism (PE) response teams are the standard of care for the management of acute PE. The complications of PE extend far beyond the initial hospitalization period. In this study, we examined the role and potential benefits of dedicated pulmonary follow‐up after hospital discharge for patients with PE.

miRNA-130 Promotes Migration and Angiogenesis of Endothelial Progenitor Cells Through PI3K/AKT/mTOR Pathways

<sec> <title>Aim:</title> In this study, we aimed to investigate the effects and mechanisms of miRNA-130a in human endothelial progenitor cells (EPCs) involved in Deep vein thrombosis (DVT). </sec> <sec> <title>Methods:</title> EPCs were isolated and identified by cell morphology and surface marker detection. The effect of miR-130a on the migration, invasion and angiogenesis of EPCs in vitro were also detected. In addition, whether miR-130a is involved in the MMP-1 expression and Akt/PI3K/mTOR signaling pathway was also demonstrated. </sec> <sec> <title>Results:</title> Results suggested that miRNA-130a promotes migration, invasion, and tube formation of EPCs by positively regulating the expression of MMP-1 through Akt/PI3K/mTOR signaling pathway. </sec> <sec> <title>Conclusion:</title> Thus, as a potential therapeutic target, miRNA-130a may play an important role in the treatment of DVT. </sec>

Serum Metabolic Profiles Based on Nuclear Magnetic Resonance Spectroscopy among Patients with Deep Vein Thrombosis and Healthy Controls

Deep venous thrombosis (DVT) is associated with significant morbidity and mortality. Studies on changes in the level of metabolites could have the potential to reveal biomarkers that can assist in the early detection, diagnosis, monitoring of DVT progression, response to treatment, or recurrence of DVT. In this scenario, the metabolomic analysis can provide a better understanding of the biochemical dysregulations of thrombosis. Using an untargeted metabolomic approach through magnetic resonance spectroscopy and multi- and univariate statistical analysis, we compared 40 patients with previous venous thrombosis and 40 healthy individuals, and we showed important serum differences between patients and controls, especially in the spectral regions that correspond to glucose, lipids, unsaturated lipids, and glycoprotein A. Considering the groups depending on risk factors and the local of the previous episode (lower limbs or cerebral system), we also noticed differences in metabolites linked to lipids and lactate. Comparative analyses pointed to altered ratios of glucose/lactate and branched-chain amino acids (BCAAs)/alanine, which might be associated with the fingerprints of thrombosis. Although samples for metabolomic analysis were collected months after the acute episode, these results highlighted that, alterations can still remain and may contribute to a better understanding of the complications of the disease.

Identification of four hub genes in venous thromboembolism via weighted gene coexpression network analysis

Background

The pathogenic mechanisms of venous thromboembolism (VT) remain to be defined. This study aimed to identify differentially expressed genes (DEGs) that could serve as potential therapeutic targets for VT.

Methods

Two human datasets (GSE19151 and GSE48000) were analyzed by the robust rank aggregation method. Gene ontology and Kyoto encyclopedia of genes and genomes pathway enrichment analyses were conducted for the DEGs. To explore potential correlations between gene sets and clinical features and to identify hub genes, we utilized weighted gene coexpression network analysis (WGCNA) to build gene coexpression networks incorporating the DEGs. Then, the levels of the hub genes were analyzed in the GSE datasets. Based on the expression of the hub genes, the possible pathways were explored by gene set enrichment analysis and gene set variation analysis. Finally, the diagnostic value of the hub genes was assessed by receiver operating characteristic (ROC) analysis in the GEO database.

Results

In this study, we identified 54 upregulated and 10 downregulated genes that overlapped between normal and VT samples. After performing WGCNA, the magenta module was the module with the strongest negative correlation with the clinical characteristics. From the key module, FECH, GYPA, RPIA and XK were chosen for further validation. We found that these genes were upregulated in VT samples, and high expression levels were related to recurrent VT. Additionally, the four hub genes might be highly correlated with ribosomal and metabolic pathways. The ROC curves suggested a diagnostic value of the four genes for VT.

Conclusions

These results indicated that FECH, GYPA, RPIA and XK could be used as promising biomarkers for the prognosis and prediction of VT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02409-4.

Acoustics at the nanoscale (nanoacoustics): A comprehensive literature review.: Part II: Nanoacoustics for biomedical imaging and therapy

In the past decade, acoustics at the nanoscale (i.e., nanoacoustics) has evolved rapidly with continuous and substantial expansion of capabilities and refinement of techniques. Motivated by research innovations in the last decade, for the first time, recent advancements of acoustics-associated nanomaterials/nanostructures and nanodevices for different applications are outlined in this comprehensive review, which is written in two parts. As part II of this two-part review, this paper concentrates on nanoacoustics in biomedical imaging and therapy applications, including molecular ultrasound imaging, photoacoustic imaging, ultrasound-mediated drug delivery and therapy, and photoacoustic drug delivery and therapy. Firstly, the recent developments of nanosized ultrasound and photoacoustic contrast agents as well as their various imaging applications are examined. Secondly, different types of nanomaterials/nanostructures as nanocarriers for ultrasound and photoacoustic therapies are discussed. Finally, a discussion of challenges and future research directions are provided for nanoacoustics in medical imaging and therapy.

Role of multidetector CT in predicting patient outcome in cases of pulmonary embolism: correlation between imaging findings, ICU admissions and mortality rate

Background

Pulmonary embolism (PE) is a critical medical condition that requires prompt diagnosis and treatment to avoid serious morbidity and mortality risk. Multidetector CT pulmonary angiography (CTPA) is considered the first-line imaging modality for suspected acute PE. The presence of right heart strain, which supports the diagnosis, requires special attention. The aim of our retrospective study is to assess the reliability of CTPA hemodynamic indices in predicting patients’ outcome in cases of PE.

Results

Sixty patients were included in our study. CTPA parameters including main pulmonary artery (MPA) diameter, left ventricle (LV) diameter, right ventricle (RV)/LV ratio, and septal deviation had a clinical prognostic value for short-term 30-day mortality and ICU admission. Statistically significant relationship between MPA diameter > 29 mm, LV diameter, RV/LV ratio > 1, left-sided septal deviation and contrast reflux into the IVC/distal hepatic veins with ICU admission was observed with p values 0.031, 0.000, 0.000, 0.005 and 0.028 respectively. There was a statistically significant correlation between MPA diameter > 29 mm, LV diameter, RV/LV > 1 ratio and septal deviation with 30-day mortality with p values of < 0.001, 0.001, < 0.001 and 0.015 respectively. No significant correlation was found between 30-day mortality and contrast reflux to IVC with p value of 0.070.

Conclusions

CTPA measurements including MPA diameter, RV/LV ratio and septal deviation were found to be significantly correlated to ICU admission and 30-day mortality as predictors for PE severity. CT contrast reflux was found to be correlated to ICU admission; however, it was not significantly correlated to 30-day mortality.

In Vivo Porcine Aged Deep Vein Thrombosis Model for Testing Ultrasound-based Thrombolysis Techniques

As blood clots age, many thrombolytic techniques become less effective. To fully evaluate these techniques for potential clinical use, a large animal aged-clot model is needed. Previous minimally invasive attempts to allow clots to age in an in vivo large animal model were unsuccessful because of the clot clearance associated with relatively high level of cardiac health of readily available research pigs. Prior models have thus subsequently used invasive surgical techniques with the associated morbidity, animal stress and cost. We propose a method for forming sub-acute venous blood clots in an in-vivo porcine model. The age of the clots can be controlled and varied. By using an intravenous scaffold to anchor the clot to the vessel wall during the aging process, we can show that sub-acute clots can consistently be formed with a minimally invasive, percutaneous approach. The clot formed in this study remained intact for at least 1 wk in all subjects. Therefore, we established a new minimally invasive, large animal aged-clot model for evaluation of thrombolytic techniques.

Dual-Frequency Intravascular Sonothrombolysis: An In Vitro Study

Thrombo-occlusive disease is one of the leading causes of death worldwide. There has been active research on safe and effective thrombolysis in preclinical and clinical studies. Recently, the dual-frequency transcutaneous sonothrombolysis with contrast agents [microbubbles (MBs)] has been reported to be more efficient in trigging the acoustic cavitation, which leads to a higher lysis rate. Therefore, there is increasing interest in applying dual-frequency technique for more significant efficacy improvement in intravascular sonothrombolysis since a miniaturized intravascular ultrasound transducer typically has a limited power output to fully harness cavitation effects. In this work, we demonstrated this efficacy enhancement by developing a new broadband intravascular transducer and testing dual-frequency sonothromblysis in vitro. A broadband intravascular transducer with a center frequency of 750 kHz and a footprint size of 1.4 mm was designed, fabricated, and characterized. The measured -6-dB fractional bandwidth is 68.1%, and the peak negative pressure is 1.5 MPa under the driving voltage of 80 V_pp. By keeping one frequency component at 750 kHz, the second frequency component was selected from 450 to 650 kHz with an interval of 50 kHz. The in vitro sonothrombolysis tests were conducted with a flow model and the results indicated that the MB-mediated, dual-frequency (750+500 kHz) sonothrombolysis yields an 85% higher lysis rate compared with the single-frequency treatment, and the lysis rate of dual-frequency sonothrombolysis increases with the difference between the two frequency components. These findings suggest a dual-frequency excitation technique for more efficient intravascular sonothrombolysis than conventional single-frequency excitation.

Development of a machine learning model using electrocardiogram signals to improve acute pulmonary embolism screening

Aims

Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to computed tomography pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection.

Methods and results

We create a retrospective cohort of 21 183 patients at moderate- to high suspicion of PE and associate 23 793 CTPAs (10.0% PE-positive) with 320 746 ECGs and encounter-level clinical data (demographics, comorbidities, vital signs, and labs). We develop three machine learning models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating clinical data and an embedded representation of the ECG waveform. We find that a Fusion model [area under the receiver-operating characteristic curve (AUROC) 0.81 ± 0.01] outperforms both the ECG model (AUROC 0.59 ± 0.01) and EHR model (AUROC 0.65 ± 0.01). On a sample of 100 patients from the test set, the Fusion model also achieves greater specificity (0.18) and performance (AUROC 0.84 ± 0.01) than four commonly evaluated clinical scores: Wells' Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score (AUROC 0.50-0.58, specificity 0.00-0.05). The model is superior to these scores on feature sensitivity analyses (AUROC 0.66-0.84) and achieves comparable performance across sex (AUROC 0.81) and racial/ethnic (AUROC 0.77-0.84) subgroups.

Conclusion

Synergistic deep learning of ECG waveforms with traditional clinical variables can increase the specificity of PE detection in patients at least at moderate suspicion for PE.

Expert Consensus on the Contraindications and Cautions of Foam Rolling-An International Delphi Study

Background: Foam rolling is a type of self-massage using tools such as foam or roller sticks. However, to date, there is no consensus on contraindications and cautions of foam rolling. A methodological approach to narrow that research gap is to obtain reliable opinions of expert groups. The aim of the study was to develop experts’ consensus on contraindications and cautions of foam rolling by means of a Delphi process. Methods: An international three-round Delphi study was conducted. Academic experts, defined as having (co-) authored at least one PubMed-listed paper on foam rolling, were invited to participate. Rounds 1 and 2 involved generation and rating of a list of possible contraindications and cautions of foam rolling. In round 3, participants indicated their agreement on contraindications and cautions for a final set of conditions. Consensus was evaluated using a priori defined criteria. Consensus on contraindications and cautions was considered as reached if more than 70% of participating experts labeled the respective item as contraindication and contraindication or caution, respectively, in round 3. Results: In the final Delphi process round, responses were received from 37 participants. Panel participants were predominantly sports scientists (n = 21), physiotherapists (n = 6), and medical professionals (n = 5). Consensus on contraindications was reached for open wounds (73% agreement) and bone fractures (84%). Consensus on cautions was achieved for local tissue inflammation (97%), deep vein thrombosis (97%), osteomyelitis (94%), and myositis ossificans (92%). The highest impact/severity of an adverse event caused by contraindication/cautions was estimated for bone fractures, deep vein thrombosis, and osteomyelitis. Discussion: The mechanical forces applied through foam rolling can be considered as potential threats leading to adverse events in the context of the identified contraindications and cautions. Further evaluations by medical professionals as well as the collection of clinical data are needed to assess the risks of foam rolling and to generate guidance for different applications and professional backgrounds.

Psoriasis and its impact on the clinical outcome of patients with pulmonary embolism

BACKGROUND

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients. The impact of psoriasis on prognosis of VTE patients is widely unknown.

METHODS

Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005-2017.

RESULTS

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0-80.0] years) were recorded in Germany 2005-2017. Among these, 3145 patients had psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0-76.0] vs. 72.0 [60.0-80.0] years,P < 0.001) and more often male (64.1% vs. 46.3%,P < 0.001). The prevalence of VTE risk factors, traditional cardiovascular risk factors and cardiovascular comorbidities was higher in psoriatic than in non-psoriatic individuals. Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%,P < 0.001), confirmed by logistic regressions showing an independent association of psoriasis with reduced case-fatality rate (OR 0.73 [95%CI 0.65-0.82],P < 0.001), despite higher prevalence of pneumonia (24.8% vs. 23.2%,P = 0.029). Psoriasis was an independent predictor for gastro-intestinal bleeding (OR 1.35 [95%CI 1.04-1.75],P = 0.023) and transfusion of blood constituents (OR 1.23 [95%CI 1.11-1.36],P < 0.001).

CONCLUSIONS

PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis.

TRANSLATIONAL PERSPECTIVE

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients, but the impact of psoriasis on prognosis of VTE patients is widely unknown. PE patients with psoriasis were younger and psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile. In-hospital mortality was lower in psoriatic PE patients, which might be mainly driven by younger age. Our findings improve the clinical management of PE patients and contribute evidence for relevant systemic manifestation of psoriasis.

ONE SENTENCE SUMMARY

Psoriasis with chronic inflammation promotes PE development, is associated with an unfavorable cardiovascular and VTE-risk profile, but lower in-hospital mortality.

The Function of microRNAs in Pulmonary Embolism: Review and Research Outlook

Pulmonary embolism (PE) is a common pathologic condition that frequently occurs in patients with deep venous thrombosis. Severe PE may critically suppress cardiopulmonary function, thereby threatening the life of patients. Chronic pulmonary hypertension caused by PE may lead to deterioration of respiratory dysfunction, resulting in complete disability. MicroRNAs (miRNAs) are a group of abundantly expressed non-coding RNAs that exert multiple functions in regulating the transcriptome via post-transcriptional targeting of mRNAs. Specifically, miRNAs bind to target mRNAs in a matching mechanism between the miRNA seed sequence and mRNA 3ʹ UTR, thus modulating the transcript stability or subsequent translation activity by RNA-induced silencing complex. Current studies have reported the function of miRNAs as biomarkers of PE, revealing their mechanism, function, and targetome in venous thrombophilia. This review summarizes the literature on miRNA functions and downstream mechanisms in PE. We conclude that various related miRNAs play important roles in PE and have great potential as treatment targets. For clinical application, we propose that miRNA biomarkers combined with traditional biomarkers or miRNA signatures generated from microchips may serve as a great predictive tool for PE occurrence and prognosis. Further, therapies targeting miRNAs or their upstream/downstream molecules need to be developed more quickly to keep up with the progress of routine treatments, such as anticoagulation, thrombolysis, or surgery.

Establishment of a risk assessment score for deep vein thrombosis after artificial liver support system treatment

BACKGROUND

The artificial liver support system (ALSS) is an effective treatment method for liver failure, but it requires deep venous intubation and long-term indwelling catheterization. However, the coagulation mechanism disorder of basic liver failure diseases, and deep venous thrombosis (DVT) often occur.

AIM

To evaluate the risk factors for DVT following use of an ALSS and establish a risk assessment score.

METHODS

This study was divided into three stages. In the first stage, the risk factors for DVT were screened and the patient data were collected, including ALSS treatment information; biochemical indices; coagulation and hematology indices; complications; procoagulant use therapy status; and a total of 24 indicators. In the second stage, a risk assessment score for DVT after ALSS treatment was developed. In the third stage, the DVT risk assessment score was validated.

RESULTS

A total of 232 patients with liver failure treated with ALSS were enrolled in the first stage, including 12 with lower limb DVT. Logistic regression analysis showed that age [odds ratio (OR), 1.734; P = 0.01], successful catheterization time (OR, 1.667; P = 0.005), activity status (strict bed rest) (OR, 3.049; P = 0.005), and D-dimer level (≥ 500 ng/mL) (OR, 5.532; P < 0.001) were independent risk factors for DVT. We then established a scoring system for risk factors. In the validation group, a total of 213 patients with liver failure were treated with ALSS, including 14 with lower limb DVT. When the cutoff value of risk assessment was 3, the specificity and sensitivity of the risk assessment score were 88.9% and 85.7%, respectively.

CONCLUSION

A simple risk assessment scoring system was established for DVT patients with liver failure treated with ALSS and was verified to have good sensitivity and specificity.

Patients with right lower extremity deep vein thrombosis have a higher risk of symptomatic pulmonary embolism: a retrospective study of 1585 patients

OBJECTIVE

To determine the risk for pulmonary embolism (PE) and explore the relationship between the site of thrombosis and PE in patients with acute lower extremity deep vein thrombosis (DVT).

METHODS

1585 hospitalized patients first diagnosed with acute lower extremity DVT were investigated retrospectively. The patients were divided into two groups: the non-PE group (Group 1) and the PE group (Group 2). Then, Group 2 was divided into two subgroups: asymptomatic pulmonary embolism (asPE, Group 2a) and symptomatic pulmonary embolism (sPE, Group 2b). Kaplan-Meier curves and logistic regression analysis were used to explore the relevant risk factors for PE.

RESULTS

Among 1585 patients, 458 patients suffered from PE, accounting for 28.9%. 102 (22.3%) of them had the typical clinical manifestations of PE and were defined as sPE, and the remaining 356 (77.7%) patients were classified as asPE. Patients with proximal lower extremity DVT were significantly more predominant in the PE group than in the non-PE group (92.8% vs. 86.2%, p<0.001). Moreover, in Group 2, patients with typical PE manifestations showed a higher proportion of patients with right lower extremity DVT than left lower extremity DVT (26.7% vs. 17.7%, P=0.035), and bilateral lower extremity DVT than unilateral DVT (44.1% vs. 20.5%, p<0.001). By multivariate analysis, alcohol consumption (OR, 1.824; 95% CI, 1.194-2.787; p=0.005), heart failure (OR, 2.345; 95% CI, 1.560-3.526; p<0.001), proximal DVT (OR, 2.096; 95% CI,1.407-3.123; p<0.001) were independent risk factors for PE.

CONCLUSION

Patients with proximal acute lower extremity DVT were more likely to suffer from PE than those with distal DVT. Patients with right acute lower extremity DVT had a higher risk of sPE than patients with left acute lower extremity DVT. Alcohol consumption and heart failure were associated with the occurrence of PE in patients with acute lower extremity DVT.

Venous Thromboembolism for the Practicing Cardiologist

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.

Bioactive Natural Compounds with Antiplatelet and Anticoagulant Activity and Their Potential Role in the Treatment of Thrombotic Disorders

Natural anticoagulant drugs can be obtained from plants, rich in secondary bioactive metabolites which, in addition to being effective antioxidants, also possess anticoagulant and antiplatelet properties and, for this reason, can be excellent candidates for the treatment of thrombotic diseases. This review reports an overview of the hemostatic process and thrombotic disorders together with data on plants, more and less common from around the world, containing bioactive compounds characterized by antiplatelet and anticoagulant activity. The reported literature was obtained from Medline, PubMed, Elsevier, Web of Science, Google Scholar considering only articles in the English language, published in peer-reviewed journals. The number of citations of the articles and the impact factor of the journals were other parameters used to select the scientific papers to be included in the review. The analysis of the literature data selected demonstrates that many plants' bioactive compounds show antiplatelet and anticoagulant activity that make them potential candidates to be used as new natural compounds able to interfere with both primary and secondary hemostasis. Moreover, they could be used together with anticoagulants currently administered in clinical practice to increase their efficacy and to reduce complications in the treatment of thrombotic disorders.

Could VEGF-D level have a role in clinical risk scoring, estimation of thrombus burden, and treatment in acute pulmonary thromboembolism?

OBJECTIVE

Pulmonary embolism (PE) is usually a complication of deep vein thrombosis and is an important cause of mortality and morbidity. Vascular endothelial growth factor D (VEGF-D) is a secretory protein that plays a role in the remodelling of blood vessels and the lymphatic system. This study aimed to determine the relationship between VEGF-D level and clinical risk scoring in patients with PE.

METHODS

The study included 117 patients admitted for PE that were divided into four groups: high-risk patients (n = 35), high-intermediate-risk patients (n = 30), low-intermediate-risk patients (n = 24), and low-risk patients (n = 28). Plasma VEGF-D was measured from peripheral venous blood samples (5 mL) using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Pulmonary Artery Obstruction Index (PAOI) was calculated from CT angiography imaging.

RESULTS

There was no significant difference in troponin-I and NT-proBNP levels between the high-intermediate-risk and high-risk PE patients (P = .134, .146). VEGF-D and PAOI levels were found to be statistically significantly higher in high-risk patients compared with high-intermediate-risk patients (P = .016, .001). VEGF-D level was moderately correlated with mean pulmonary artery pressure and PAOI (r = .481, P = .01; r = .404, P = .01). In ROC curve analysis, a cut-off of 370.1 pg/mL for VEGF-D had 91.4% sensitivity and 67% specificity in the differentiation of high-intermediate-risk and high-risk PE patients.

CONCLUSION

This study showed that plasma VEGF-D level was more reliable than troponin-I and NT-proBNP in clinical risk scoring and demonstrating thrombus burden. VEGF-D can be used as a biomarker in clinical risk scoring and estimation of thrombus burden in patients with acute PE.

Prescribing Errors With Low-Molecular-Weight Heparins

BACKGROUND

Low-molecular-weight heparins (LMWHs) are used in the prevention and treatment of venous thromboembolism (VTE). Bleeding is the primary major complication of LMWH therapy, which is associated with dose. The administration of appropriate dosages of LMWHs depends on the patient's risk of VTE, risk of bleeding, bodyweight, and renal function. Therefore, LMWH prescribing is prone to errors. However, no earlier study has explored the frequency of prescribing errors with LMWH.

PURPOSE

The aim of the study was to determine the frequency and determinants of in-hospital LMWH-prescribing errors.

METHODS

A cross-sectional study was conducted to examine the frequency and determinants of LMWH prescribing errors between April and August 2014. We randomly selected 500 patients 18 years and older with at least one LMWH prescription during inpatient hospitalization. A prescribing error was a deviation from the internal hospital guidelines. Logistic regression estimated determinants of prescribing error.

RESULTS

A prescribing error was present with 34% of all LMWH users. The most frequently recorded error was a dose that was not adjusted to body weight and/or renal function (85%). Prophylactic LMWH prescribing in medical wards was associated with a higher risk of prescribing error as compared with surgical wards.

CONCLUSIONS

The frequency of prescribing errors was 34% in a tertiary care hospital. Being a patient with prophylactic LMWH use on a medical ward is a determinant for LMWH prescribing error. Interventions that will lead to better electronic recording of body weight and more awareness among medical doctors may reduce the total number of prescribing errors.

Risk of venous thromboembolism associated with Janus kinase inhibitors for rheumatoid arthritis: case presentation and literature review

Janus kinase (JAK) inhibitors have been developed as disease-modifying antirheumatic drugs. Despite the positive therapeutic impacts of JAK inhibitors, concerns have been raised regarding the risk of venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE). A recent post hoc safety analysis of placebo-controlled trials of JAK inhibitors in rheumatoid arthritis (RA) reported an imbalance in the incidence of VTE for a 4-mg daily dose of baricitinib versus placebo. In a recent postmarketing surveillance trial for RA, a significantly higher incidence of PE was reported in treatment with tofacitinib (10 mg twice daily) compared with tofacitinib 5 mg or tumor necrosis factor inhibitors. We also experienced a case of massive PE occurring 3 months after starting baricitinib (4 mg once daily) for multiple biologic-resistant RA. Nevertheless, the evidence to support the role of JAK inhibitors in VTE risk remains insufficient. There are a number of predisposing conditions and risk factors for VTE. In addition to the known risk factors that can provoke VTE, advanced age, obesity, diabetes mellitus, hypertension, hyperlipidemia, and smoking can also contribute to its development. Greater VTE risk is noted in patients with chronic inflammatory conditions, particularly RA patients with uncontrolled disease activity and any comorbidity. Prior to the initiation of JAK inhibitors, clinicians should consider both the number and strength of VTE risk factors for each patient. In addition, clinicians should advise patients to seek prompt medical help if they develop clinical signs and symptoms that suggest VTE/PE.

Key Points • Patients with rheumatoid arthritis (RA) are at increased risk of venous thromboembolism (VTE), especially those with uncontrolled, high disease activity and those with comorbidities. • In addition to the well-known risk factors that provoke VTE events, advanced age and cardiovascular risk factors, such as obesity, diabetes mellitus, hypertension, hyperlipidemia, and smoking, should be considered risk factors for VTE. • Although a signal of VTE/pulmonary embolism (PE) risk with JAK inhibitors has been noted in RA patients who are already at high risk, the evidence is currently insufficient to support the increased risk of VTE during RA treatment with JAK inhibitors. • If there are no suitable alternatives, clinicians should prescribe JAK inhibitors with caution, considering both the strength of individual risk factors and the cumulative weight of all risk factors for each patient.

Impact of Systemic Atherosclerosis on Clinical Characteristics and Short-term Outcomes in Patients with Deep Venous Thrombosis or Thrombophlebitis

BACKGROUND

Venous thromboembolism (VTE) and atherosclerosis are accompanied by substantial cardiovascular mortality; links between both disease entities were reported. We aimed to investigate the impact of systemic atherosclerosis on adverse outcomes in patients with deep venous thrombosis or thrombophlebitis (DVT) and to identify differences in DVT patients with and without systemic atherosclerosis.

METHODS

The German nationwide inpatient sample was used for this analysis. Patients admitted for DVT were included in this study and stratified by systemic atherosclerosis (composite of coronary artery disease, myocardial infarction, ischemic stroke, and/or atherosclerotic arterial diseases). We compared DVT patients with (DVT+Athero) and without (DVT-Athero) systemic atherosclerosis and analysed the impact of systemic atherosclerosis on adverse outcomes.

RESULTS

Overall, 489,679 patients with DVT (55.7% females) were included in this analysis. Among these, 53,309 (10.9%) were coded with concomitant systemic atherosclerosis with age-dependent incline. Concomitant PE (4.1% vs.3.8%, P=0.001) was more frequently in DVT-Athero and risk for PE in DVT patients was independently associated with absence of systemic atherosclerosis (OR 0.87 [95%CI 0.83-0.91], P<0.001). In-hospital mortality (3.4% vs.1.4%, P<0.001) and adverse in-hospital events (2.2% vs.0.8%,P<0.001) were more prevalent in DVT+Athero compared to DVT-Athero; both, in-hospital mortality (OR 1.52 [95%CI 1.41-1.63], P<0.001) and adverse in-hospital events (OR 1.49 [95%CI 1.40-1.58], P<0.001) were affected independently of sex, age and comorbidities by systemic atherosclerosis.

CONCLUSIONS

Systemic atherosclerosis in DVT patients was accompanied by poorer outcomes. Systemic atherosclerosis was associated with higher bleeding rate and with isolated DVT (without concomitant PE).

Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used.

ELIGIBILITY CRITERIA AND DATA ANALYSIS

Eligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I² was used to assess the study heterogeneity.

MAIN OUTCOME MEASURES

The primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism.

RESULTS

6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell's sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)).

CONCLUSION

Several ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging.

PROSPERO REGISTRATION NUMBER

CRD42020184313.

Association Between Black Race, Clinical Severity, and Management of Acute Pulmonary Embolism: A Retrospective Cohort Study

Background

Existing evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood.

Methods and Results

We retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02).

Conclusions

Black patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.

In-hospital mortality of acute pulmonary embolism: Predictive value of shock index, modified shock index, and age shock index scores

OBJECTIVE

The shock index (SI), modified shock index (MSI), and age shock index (ASI) have been reported to predict adverse outcomes in patients with different acute cardiovascular conditions. This study aimed to investigate the association between these indexes and in-hospital mortality in patients with acute pulmonary embolism.

METHODS

The medical records of all adult patients who were hospitalized with acute pulmonary embolism between June 2014 and June 2019, were examined. Collected data included vital signs, demographic characteristics, comorbidities, and laboratory values on presentation. The predictive value of SI, MSI, ASI, and pulmonary embolism severity index (PESI) for predicting in-hospital mortality were compared by C-statistics.

RESULTS

A total of 602 consecutive patients (mean age 66.7±13.2 years, 55% female) were included, and 62 (10.3%) of the patients died during their in-hospital course. The admission SI, MSI, ASI, and PESI were significantly higher in the deceased patients. After adjusting for other factors, the SI, MSI, PESI, and ASI were independent predictors of in-hospital mortality. The prognostic performance of ASI (C-statistics 0.74) was better than MSI (C-statistics 0.71), SI (C-statistics 0.68), and PESI (C-statistics 0.65).

CONCLUSION

The ASI may be used to identify patients at risk for in-hospital mortality following acute pulmonary embolism.

Ultrasound-Responsive Nanopeptisomes Enable Synchronous Spatial Imaging and Inhibition of Clot Growth in Deep Vein Thrombosis

Deep vein thrombosis (DVT) is a life-threatening blood clotting condition that, if undetected, can cause deadly pulmonary embolisms. Critical to its clinical management is the ability to rapidly detect, monitor, and treat thrombosis. However, current diagnostic imaging modalities lack the resolution required to precisely localize vessel occlusions and enable clot monitoring in real time. Here, we rationally design fibrinogen-mimicking fluoropeptide nanoemulsions, or nanopeptisomes (NPeps), that allow contrast-enhanced ultrasound imaging of thrombi and synchronous inhibition of clot growth. The theranostic duality of NPeps is imparted via their intrinsic binding to integrins overexpressed on platelets activated during coagulation. The platelet-bound nanoemulsions can be vaporized and oscillate in an applied acoustic field to enable contrast-enhanced Doppler ultrasound detection of thrombi. Concurrently, nanoemulsions bound to platelets competitively inhibit secondary platelet-fibrinogen binding to disrupt further clot growth. Continued development of this synchronous theranostic platform may open new opportunities for image-guided, non-invasive, interventions for DVT and other vascular diseases.

In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease

Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.

Effectiveness and safety of oral anticoagulation treatment beyond 1 year after venous thromboembolism in patients at intermediate recurrence risk

Effectiveness and safety of long-term anticoagulation treatment are uncertain in venous thromboembolism (VTE) patients at intermediate risk of recurrence. We examined the association between treatment beyond 1 year and outcomes in a Danish nationwide register-based study. VTE patients at intermediate risk of recurrence, that is, non-cancer patients with a first-time unprovoked VTE, who started oral anticoagulation treatment within 30 days and were alive 365 days after the index VTE were included and followed between 2007 and 2015. Exposure was extended (>365 days) or intermediate (91-365 days) treatment. Analyses were done using Cox regression on a propensity score weighted population. We included 18 609 patients with 7232 (38.9%) receiving extended treatment. Mean duration of follow-up was 2.6 years. Compared with intermediate treatment, treatment beyond 365 days was associated with a lower weighted risk of recurrent VTE (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.49-0.65) and all-cause mortality (HR 0.81, 95% CI 0.72-0.90) and an increased risk of major bleeding (HR 1.87, 95% CI 1.58-2.22). In conclusion, extended anticoagulation treatment (predominantly warfarin) beyond 1 year was in real-life settings associated with a lower risk of recurrent VTE and all-cause mortality among VTE patients with an intermediate risk of recurrence. However, an increased bleeding risk should be considered.

Impact of a Smartphone App Reminder on Adherence to Aspirin Prescribed as Antithrombotic Therapy

BACKGROUND

Many patients are discharged with aspirin (ASA) as an anticoagulant after joint replacement surgery. In studies in which ASA was prescribed, doses were frequently missed. Adherence to postoperative ASA regimen is critical to preventing thrombotic complications. This randomized controlled study evaluated the impact of an existing medication adherence smartphone application (app) on adherence to twice daily ASA 81 mg for 35 days after knee or hip arthroplasty.

METHODOLOGY

Patients were randomized to either the app (intervention) group or the usual care (control) group. All patients received a baseline interview with a survey and demographics collected prior to randomization, a 36-day follow-up call for phone pill count, and a 6-week in-office interview with surveys and an in-person pill count. A convenience sample of 195 patients enrolled; 122 completed pill counts at both baseline and end of study. Ages ranged from 29 to 89 (mean: 60.4, SD: 10.1) years. The majority had a bachelor's degree or higher (59.3%), made more than $75,000 (or were retired; 51.9%), were of White race (75.9%), and female (53.8%). There were no significant demographic differences between the groups.

RESULTS

There were no significant group differences in final pill counts, adherence (reasons for missed pills), or ASA Medication self-efficacy scores. However, the intervention group scored significantly higher on the ASA Adherence measure (general ease in and ability to take ASA; p = .020). Higher ASA Adherence scores were associated with lower pill counts at the end of study (better adherence) in the intervention group. There was a high rate of attrition related to failure to bring the ASA to hospital or to the follow-up appointment.

CONCLUSIONS

Although there were no significant differences in final pill counts between groups, the app group reported more ease in taking pills. With smartphone use virtually ubiquitous, this project provided an opportunity to educate patients and nurses about how technology can support medication adherence. It was also an excellent opportunity to involve clinical nurses in a funded research project.