Venous thromboembolism

The High Expression of Adhering and Circulating Integrin Serves as a Diagnostic Marker in Venous Thromboembolism

Objective

To investigate the diagnostic value of circulating integrins β1, 2, and 3 in venous thrombosis (VTE).

Materials and Methods

A total of 474 VTE patients and 306 patients with nonhigh risk for VTE as the control group were studied. Levels of adhering integrins β1, 2, and 3 were detected by flow cytometry. Levels of circulating integrins β1, 2, and 3 in serum were measured by enzyme-linked immunosorbent assay.

Results

We found that integrins β1, 2, and 3 were expressed highly both in serum and on the surface of leukocytes and platelets in venous thromboembolism. The levels of circulating integrins β1, 2, and 3 are positively correlated with adhering integrins. It showed excellent clinical diagnostic performance of circulating integrins β1, 2, and 3 in venous thromboembolism.

Conclusions

Integrin subunit β can be used as a diagnostic marker with high sensitivity and specificity for venous thromboembolism.

Silent Pulmonary Embolism in Deep Vein Thrombosis: Relationship and Risk Factors

PURPOSE

This study aimed to evaluate risk factors for silent pulmonary embolism (PE) in symptomatic deep vein thrombosis (DVT) and investigate the relationship between DVT and silent PE.

METHODS

This was a single-centre, retrospective cohort study. Between 5 January 2015 and 31 December 2021, consecutive patients with symptomatic DVT received CT pulmonary angiography and CT venography were analyzed. Patient demographics, comorbidities, risk factors, and image findings were analyzed. The group differences were compared using a Chi-square test, Fisher's exact test, independent t test, or Mann-Whitney U test. Multivariant regression was used to determine predictive factors for silent PE.

RESULTS

A total of 355 patients (mean age, 60.5 ± 16.6 years) were included. The incidence of silent PE was 43.1%. The main or lobar pulmonary arteries were affected in 53.6% of patients, which is more often found in iliofemoral DVTs (56.6% vs 26.7%, p = .027). The multivariant analysis showed male patients (p = .042; OR 1.59; 95% CI, 1.02-2.50), inferior vena cava involvement (p = .043; OR 1.81; 95% CI, 1.02-3.20) and D-dimer value > 3.82 μg/ml (p < .001; OR 2.32; 95% CI, 1.43-3.77) were risk factors for silent PE. Unilateral DVT patients with ipsilateral iliac vein compression had a lower incidence of silent PE (28.8% vs 52.9%, p < .001).

CONCLUSION

Iliofemoral DVT was associated with a more proximal PE. The male patients, inferior vena cava involvement, and D-dimer > 3.82 μg/ml were risk factors for silent PE. Ipsilateral iliac vein compression reduced the incidence of silent PE.

Association Between Blood Lipid Levels and Lower Extremity Deep Venous Thrombosis: A Population-Based Cohort Study

ObjectsTo investigate the potential clinical significance between blood lipid levels and lower extremity deep venous thrombosis (LEDVT). Methods: This cohort study included 500 participants, contains 246 patients with LEDVT and 254 patients without LEDVT. The characteristics including age, sex, body mass index (BMI), disease course, ill position, smoking history, history of current illness, drug administration were collected. And blood lipid levels and other clinical parameters including triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (ApoA1), apolipoprotein B (ApoB), activated partial thromboplastin time (APTT), thromboplastin time (TT), prothrombin time (PT), and fibrinogen (FIB), neutrophils (NEUT), platelet (PLT), lymphocyte count (LY) were observed. Univariate and multivariate logistic regression analyses were applied. In the present study we particularly focused on the potential associations between blood lipid levels and LEDVT. Results: The risk of LEDVT in participants with HDL-C levels of 0.965 to 1.14 mmol/L, 1.14 to 1.36 mmol/L, and >1.36 mmol/L were 0.366, 0.183, 0.203 times than in controls (<0.965 mmol/L), respectively. Compared to individuals with ApoA1 <1.06 mmol/L, individuals with ApoA1 levels of 1.06 to 1.22 mmol/L, 1.22 to 1.38 mmol/L, and >1.38 mmol/L were related to a decreased risk of LEDVT. The risk of LEDVT in patients with TG levels of 0.985 to 1.37 mmol/L, 1.37 to 1.91 mmol/L, and >1.91 mmol/L were 2.243, 2.224, and 2.540 times higher than that of those with TG <0.985 mmol/L, respectively. The risk of LEDVT in subjects with 4.57< TC <5.17 mmol/L was 0.471-fold than that of those with TC <3.97 mmol/L. Conclusion: The present study indicates that higher levesl of HDL-C and ApoA1 could be associated with a decreased risk of LEDVT, while higher TG levels might be associated with an increased risk of LEDVT. In addition, within the normal range, high TC levels were associated with decreased risk of LEDVT. These findings may help clinicals to identify early and treat those patients with a high-risk of LEDVT at proper time, which could improve patients’ life quality.

Precautions When Performing Pericardiocentesis in Patients with Cardiac Tamponade-complicated Malignancy: A Case Report and Review of the Literature

A 51-year-old woman who had previously undergone left mastectomy for left breast cancer accompanied by multiple metastasis experienced worsening dyspnea. Physical and imaging assessments of the hemodynamics suggested cardiac tamponade, and emergency pericardiocentesis was successfully performed. However, immediately after the procedure, the patient's condition deteriorated rapidly and showed pulseless electrical activity. Contrast-enhanced computed tomography with continuous mechanical support demonstrated massive thrombi in both pulmonary arteries. An abrupt decrease in the central venous pressure and an increase in the venous return following pericardiocentesis might result in the migration of a deep venous thrombus and fatal acute pulmonary thromboembolism.

Muscular Calf Vein Thrombosis Is Associated With Increased 30-Day Mortality But Not 90-Day Mortality in Older Patients With Hip Fracture

Calf deep vein thrombosis (DVT) is common in patients with hip fractures. However, studies on whether calf DVT has an impact on the prognosis are limited. This retrospective cohort study explored the association between calf DVT and 30-day and 90-day all-cause mortality in older patients with hip fractures. A total of 564 consecutive patients who underwent ultrasound examination were identified from our hip fracture database and categorized into patients with calf DVT (axial DVT, muscular DVT) and no DVT. Of these, 86 patients (15.2%) had ultrasound-confirmed calf DVT, including 66 patients with muscular DVT, and 20 patients with axial DVT. The 30-day and 90-day all-cause mortality were 2.5% and 6.0%, respectively. Multivariate Cox analysis showed that calf DVT was significantly associated with an increased risk of 30-day mortality (hazard ratio [HR] 3.21, 95% confidence interval [CI] 1.05 to 9.84, p = 0.04), but this risk relationship did not persist at 90-day follow-up (HR 1.59, 95% CI 0.69 to 3.71, p = 0.28). When calf DVT was further categorized, muscular DVT remained an independent risk factor for 30-day mortality (HR 3.95, 95% CI 1.18 to 13.15, p = 0.03), whereas this relationship was not found in axial DVT (HR 1.79, 95% CI 0.21 to 15.02, p = 0.59). In conclusion, calf DVT, especially muscular calf DVT but not axial DVT, is independently associated with an increased risk of 30-day mortality in older patients with hip fracture, but this risk relationship did not persist at 90-day follow-up.

Obesity as a Risk Factor for Venous Thromboembolism Recurrence: A Systematic Review

Background and Objectives: Venous thromboembolism (VTE) encompasses Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE). The duration of anticoagulant therapy following a VTE event partly relies on the risk of recurrent VTE which depends on the clinical setting where VTE occurred and the VTE risk factors present. Obesity is considered a minor risk factor and studies in the literature have provided conflicting results on whether obesity influences the development of recurrences. The aim of the present study is to assess the effect of obesity on VTE recurrence in patients that suffered from a previous VTE event. Materials and Methods: We conducted systematic research for English language studies in Medline, Scopus and ProQuest databases in order to identify publications that assess the risk of VTE recurrence in obesity. Inclusion criteria were: 1. Diagnosis of VTE, 2. Definition of obesity as a body mass index ≥30 kg/m², 3. Report of the risk of obesity on VTE recurrence, 4. Adult human population. We did not include case reports, review studies or studies that assessed other forms of thrombosis and/or used other definitions of obesity. We used the Newcastle-Ottawa scale to address the quality of the studies. Results: Twenty studies were included in the analysis, of which 11 where prospective cohort studies, 6 were retrospective cohort studies, 1 was a cross-sectional study, and 2 were post-hoc analysis of randomized clinical trials. Obesity was significantly associated with recurrences in 9 studies and in 3 of them the association was significant only in females. Conclusions: There is heterogeneity between the studies both in their design and results, therefore the effect of obesity on VTE recurrence cannot be adequately estimated. Future randomized clinical studies with appropriately selected population are needed in order to streamline the effect of obesity on VTE recurrence.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Preoperative and postoperative clinical signatures of postgastrectomy venous thromboembolism (VTE) in patients with gastric cancer: A retrospective cohort study

BACKGROUND

This study aimed to identify preoperative and postoperative risk factors of venous thromboembolism (VTE) after gastrectomy in gastric cancer (GC) patients.

METHODS

757 GC patients underwent gastrectomy at our institution and 246 patients with elevated postoperative D-dimer levels who received Doppler ultrasonography of lower/upper extremity veins were enrolled. Clinicopathological factors data were collected, and the differences in clinicopathological factors between postoperative VTE (+) and VTE (-) groups were analyzed. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors of postgastrectomy VTE.

RESULTS

Of 246 patients with elevated postgastrectomy D-dimer concentrations, 74 patients showed thrombosis in lower/upper extremity veins. Among preoperative factors, age, WBC level, D-dimer concentration, and blood glucose level were significantly higher in the postoperative VTE (+) group. Among the postoperative factors, hemoglobin level was significantly lower in the postoperative VTE (+) group. Among the pathological factors, tumor stage, depth of invasion and TNM classification indicated higher malignancy in the postoperative VTE (+) group. Univariate logistic regression analysis indicated age, preoperative blood glucose level, postoperative hemoglobin level, tumor stage, depth of invasion, and TNM classification as the independent risk factors for postgastrectomy VTE, whereas multivariate logistic regression analysis revealed age and tumor stage as independent risk factors for postgastrectomy VTE.

CONCLUSION

Our study revealed that age, preoperative blood glucose level, postoperative anemia, and tumor malignancy were independent risk factors for GC patients exhibiting postgastrectomy VTE. Therefore, the perioperative monitoring, assessment and management of risk factors are important in achieving better outcomes after gastrectomy.

One-Year Incidences of Venous Thromboembolism, Bleeding, and Death in Patients With Lung Cancer (Cancer-VTE Subanalysis)

Introduction

This subanalysis aimed to provide real-world data on venous thromboembolism (VTE) from patients with lung cancer in the Cancer-VTE Registry.

Methods

The primary outcome was the number of baseline VTE events in patients with lung cancer. The 1-year cumulative incidences of symptomatic VTE; composite VTE (symptomatic and incidental VTE requiring treatment); bleeding; cerebral infarction, transient ischemic attack, and systemic embolic events; and all-cause death were calculated. Clinical trial registration: UMIN000024942.

Results

The study enrolled a total of 2377 patients with lung cancer; of these, 119 (5.0%) had VTE (six [0.3%], symptomatic, and 113 [4.8%], asymptomatic) and 14 (0.6%) had pulmonary embolism at baseline. During the follow-up period (mean, 337.7 d), the incidence was 0.6% for symptomatic VTE, 1.8% for composite VTE, 1.5% for bleeding events, 1.3% for cerebral infarction, transient ischemic attack, and systemic embolism, and 19.1% for all-cause death. Composite VTE frequency did not vary by anticancer drug type. Patients with (versus without) VTE at baseline had higher hazard ratios (HRs) for composite VTE (unadjusted HR: 5.29; Gray test p < 0.001) and symptomatic VTE (unadjusted HR: 4.89; Gray test p = 0.007). Patients with VTE at baseline had higher HRs for bleeding events (unadjusted HR: 3.27; Gray test p = 0.010) and all-cause death (unadjusted HR: 2.73; log-rank test p < 0.001) than patients without. In multivariable analysis, patients with baseline VTE prevalence and Eastern Cooperative Oncology Group Performance Status of 2 had increased composite VTE risk during cancer therapy. There were no other risk factors for composite VTE.

Conclusions

Our findings emphasize the importance of VTE screening at cancer diagnosis.

The combination of EGCG with warfarin reduces deep vein thrombosis in rabbits through modulating HIF-1α and VEGF via the PI3K/AKT and ERK1/2 signaling pathways

Deep venous thrombosis (DVT) poses a major challenge to public health worldwide. Endothelial cell injury evokes inflammatory and oxidative responses that contribute to thrombus formation. Tea polyphenol (TP) in the form of epigallocatechin-3-gallate (EGCG) has anti-inflammatory and oxidative effect that may ameliorate DVT. However, the precise mechanism remains incompletely understood. The current study was designed to investigate the anti-DVT mechanism of EGCG in combination with warfarin (an oral anticoagulant). Rabbits were randomly divided into five groups. A DVT model of rats was established through ligation of the inferior vena cava (IVC) and left common iliac vein, and the animals were orally administered with EGCG, warfarin, or vehicle for seven days. In vitro studies included pretreatment of human umbilical vein endothelial cells (HUVECs) with different concentrations of EGCG for 2 h before exposure to hydrogen peroxide. Thrombus weight and length were examined. Histopathological changes were observed by hematoxylin-eosin staining. Blood samples were collected for detecting coagulation function, including thrombin and prothrombin times, activated partial thromboplastin time, and fibrinogen levels. Protein expression in thrombosed IVCs and HUVECs was evaluated by Western blot, immunohistochemical analysis, and/or immunofluorescence staining. RT-qPCR was used to determine the levels of AGTR-1 and VEGF mRNA in IVCs and HUVECs. The viability of HUVECs was examined by CCK-8 assay. Flow cytometry was performed to detect cell apoptosis and ROS generation was assessed by 2',7'-dichlorofluorescein diacetate reagent. In vitro and invivo studies showed that EGCG combined with warfarin significantly reduced thrombus weight and length, and apoptosis in HUVECs. Our findings indicated that the combination of EGCG and warfarin protects HUVECs from oxidative stress and prevents apoptosis. However, HIF-1α silencing weakened these effects, which indicated that HIF-1α may participate in DVT. Furthermore, HIF-1α silencing significantly up-regulated cell apoptosis and ROS generation, and enhanced VEGF expression and the activation of the PI3K/AKT and ERK1/2 signaling pathways. In conclusion, our results indicate that EGCG combined with warfarin modifies HIF-1α and VEGF to prevent DVT in rabbits through anti-inflammation via the PI3K/AKT and ERK1/2 signaling pathways.

Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors

Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m², p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.

The Impact of Fine Particulate Matter 2.5 on the Cardiovascular System: A Review of the Invisible Killer

Air pollution exerts several deleterious effects on the cardiovascular system, with cardiovascular disease (CVD) accounting for 80% of all premature deaths caused by air pollution. Short-term exposure to particulate matter 2.5 (PM_2.5) leads to acute CVD-associated deaths and nonfatal events, whereas long-term exposure increases CVD-associated risk of death and reduces longevity. Here, we summarize published data illustrating how PM_2.5 may impact the cardiovascular system to provide information on the mechanisms by which it may contribute to CVDs. We provide an overview of PM_2.5, its associated health risks, global statistics, mechanistic underpinnings related to mitochondria, and hazardous biological effects. We elaborate on the association between PM_2.5 exposure and CVD development and examine preventive PM_2.5 exposure measures and future strategies for combating PM_2.5-related adverse health effects. The insights gained can provide critical guidelines for preventing pollution-related CVDs through governmental, societal, and personal measures, thereby benefitting humanity and slowing climate change.

Risk factors for portal vein thrombosis or venous thromboembolism in a large cohort of hospitalized cirrhotic patients

BACKGROUND

Portal vein thrombosis (PVT) and venous thromboembolism (VTE) are fearsome complications of liver cirrhosis.

OBJECTIVES

To assess the prevalence and the main risk factors for venous thrombotic complications in hospitalized cirrhotic patients.

PATIENTS/METHODS

We retrospectively reviewed electronic administrative discharge data of 19461 cirrhotic patients hospitalized over a 35-year period; univariate and multivariate logistic regression was used to asses risk factors for PVT or VTE and their impact on hospital stay and mortality.

RESULTS

382 out of 7445 patients (5.1%) were diagnosed with PVT and 95 (1.3%) with VTE. Liver cirrhosis complications were observed in 45% of patients. Hepatic encephalopathy (HE) (OR 13.88 [10.76-17.98] p < 0.0001), endoscopic signs of portal hypertension (OR 1.33 [1.02-1.75] p = 0.02), hepatocellular carcinoma (HCC) (OR 4.59 [3.6-5.84] p < 0.0001), diabetes (OR 1.68 [1.27-2.22] p = 0.0001), abdominal surgery/invasive procedures (OR 2.03 [1.56-2.64] p < 0.0001) emerged as independent predictors of PVT. Higher risk of VTE was observed in patients with HE (OR 3.21 [1.78-5.79] p < 0.0001), HCC (OR 1.98 [1.23-3.19] p = 0.002) or other tumors (OR 2.48 [1.42-4.32] p = 0.001), acute illnesses (infections OR 3.01 [1.84-5.05] p = 0.0001; cardiac/respiratory insufficiency OR 2.4 [1.27-4.53] p = 0.003; acute myocardial infarction/stroke OR 7.86 [1.76-35.12] p = 0.003). VTE was the only independent predictor of in-hospital mortality (OR 4.45 [1.05-18.81] p = 0.042).

CONCLUSIONS

Liver disease complications related to portal hypertension, HCC or other tumors, diabetes, acute illnesses (i.e. infections, cardiac/pulmonary insufficiency, acute myocardial infarction/stroke) and abdominal interventions are associated with increased risk of PVT or VTE in hospitalized cirrhotic patients, and should be considered to define personalized preemptive approaches.

Neutrophil extracellular traps participate in the development of cancer-associated thrombosis in patients with gastric cancer

BACKGROUND

The development of venous thromboembolism (VTE) is associated with high mortality among gastric cancer (GC) patients. Neutrophil extracellular traps (NETs) have been reported to correlate with the prothrombotic state in some diseases, but are rarely reported in GC patients.

AIM

To investigate the effect of NETs on the development of cancer-associated thrombosis in GC patients.

METHODS

The levels of NETs in blood and tissue samples of patients were analyzed by ELISA, flow cytometry, and immunofluorescence staining. NET generation and hypercoagulation of platelets and endothelial cells (ECs) in vitro were observed by immunofluorescence staining. NET procoagulant activity (PCA) was determined by fibrin formation and thrombin–antithrombin complex (TAT) assays. Thrombosis in vivo was measured in a murine model induced by flow stenosis in the inferior vena cava (IVC).

RESULTS

NETs were likely to form in blood and tissue samples of GC patients compared with healthy individuals. In vitro studies showed that GC cells and their conditioned medium, but not gastric mucosal epithelial cells, stimulated NET release from neutrophils. In addition, NETs induced a hypercoagulable state of platelets by upregulating the expression of phosphatidylserine and P-selectin on the cells. Furthermore, NETs stimulated the adhesion of normal platelets on glass surfaces. Similarly, NETs triggered the conversion of ECs to hypercoagulable phenotypes by downregulating the expression of their intercellular tight junctions but upregulating that of tissue factor. Treatment of normal platelets or ECs with NETs augmented the level of plasma fibrin formation and the TAT complex. In the models of IVC stenosis, tumor-bearing mice showed a stronger ability to form thrombi, and NETs abundantly accumulated in the thrombi of tumor-bearing mice compared with control mice. Notably, the combination of deoxyribonuclease I, activated protein C, and sivelestat markedly abolished the PCA of NETs.

CONCLUSION

GC-induced NETs strongly increased the risk of VTE development both in vitro and in vivo. NETs are potential therapeutic targets in the prevention and treatment of VTE in GC patients.

Comparison of the Efficacy and Safety of Rivaroxaban and Enoxaparin as Thromboprophylaxis Agents for Orthopedic Surgery—Systematic Review and Meta-Analysis

Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The current guidelines for VTE prophylaxis in postoperative patients recommend the use of LMWHs, one of which is enoxaparin. Another recommendation for use in pharmacological VTE prophylaxis is rivaroxaban, which has better efficacy than enoxaparin but a higher bleeding risk. The aim of this systematic review is to provide an update on the profile of rivaroxaban for VTE prophylaxis after orthopedic surgery. PubMed, SCOPUS, EMBASE, and EBSCOhost were searched up until May 2022. The outcome sought was efficacy and safety, described by the incidence of VTE and incidence of bleeding, respectively. Five randomized controlled trials (RCT) were finally included. Rivaroxaban was confirmed to have better efficacy by significantly reducing the risk of VTE and all-cause mortality (RR = 0.38; 95% CI = 0.27–0.54) compared to enoxaparin. However, regarding the safety variable, no significant difference was found between the incidence of major bleeding in rivaroxaban and enoxaparin (RR = 0.97; 95% CI = 0.56–1.68). The results of the analysis show that rivaroxaban has better efficacy than enoxaparin but the same safety profile, so when used, the bleeding of patients should still be monitored.

Leukocyte as an Independent Predictor of Lower-Extremity Deep Venous Thrombosis in Elderly Patients With Primary Intracerebral Hemorrhage

Objective

Due to the interaction of leukocytes with platelets and coagulation factors, they may in turn play a role in hemostasis or the formation of thrombi. This study aimed to investigate the association of leukocytosis on admission with an increased risk of acute lower-extremity deep venous thrombosis (LEDVT) in elderly patients with primary intracerebral hemorrhage (ICH).

Methods

This was a single-center, retrospective observational study of consecutive patients observed with spontaneous ICH aged 60 years or above at Lanzhou University Second Hospital from January 2017 to September 2021. Clinical data and demographic information were collected and analyzed. Univariate and multivariate analyses were conducted to identify independent risk factors of acute LEDVT. One-to-one matching was implemented to balance important patient characteristics by the groups' propensity score matching (PSM) analysis.

Results

A total of 371 elderly patients with primary ICH fulfilled requirements for inclusion and exclusion, of whom 33 (8.89%) experienced LEDVT. Leukocyte counts were statistically higher in the LEDVT group compared to the non-LEDVT group [12.89 (8.80–14.61) × 10⁹ cells/L vs. 8.31 (6.60–10.75) × 10⁹ cells /L, p < 0.001]. Multivariate logistic regression models adjusted for several potential confounding factors were performed, and leukocytes were consistently a significant independent predictor of LEDVT. The optimal cut-off value of leukocyte counts calculated from the receiver operating characteristic (ROC) curve to predict LEDVT was 10.22 × 10⁹ cells /L (area under the curve:0.714, 95%CI 0.665–0.759; the sensitivity was 72.73%; the specificity was 71.01%) in elderly patients with primary ICH. After one-to-one PSM, compared to the matched non-LEDVT group, the matched LEDVT group had significantly higher leukocyte counts [11.98 (8.40–13.94) × 10⁹ cells/L vs. 6.12 (4.68–12.00) × 10⁹ cells/L, p = 0.003]. After PSM, the ROC curve was plotted for leukocytes as a predictor of LEDVT, with an AUC of 0.722 (95%CI 0.593–0.828, p = 0.001; the sensitivity was 87.10%, and the specificity was 61.29%). Elevated leukocytes remained independently significant as predictors of LEDVT in elderly patients with primary ICH.

Conclusion

Leukocyte at admission is an independent risk factor of LEDVT in elderly patients with primary ICH.

Blood Cells and Venous Thromboembolism Risk: A Two-Sample Mendelian Randomization Study

Background

Previous studies have shown that various cell indices are associated with a higher risk of venous thromboembolism (VTE), however, whether these findings reflect a causal relationship remains unclear. Therefore, we performed a two-sample Mendelian randomization (MR) analysis to assess the causal association of various blood cells with VTE risk.

Study Design and Methods

Summary statistics of genetic instruments representing cell indices for erythrocytes, leukocytes, and platelets were extracted from genome-wide association studies of European ancestry, by Two-Sample Mendelian Randomization. Inverse variance weighting (IVW) was used as the primary analytical method for MR. Sensitivity analyses were performed to detect horizontal pleiotropy and heterogeneity.

Results

Genetically predicted red blood cell distribution width, mean reticulocyte volume, and mean red blood cell volume were positively associated with VTE, with odds ratio (OR) of 1.002 [CI 1.000-1.003, P = 0.022), 1.003 (CI 1.001-1.004, P = 0.001, respectively)] and 1.001 (CI 1.000-1.002, P = 0.005). Genetically predicted monocyte count was negatively correlated with VTE, with OR = 0.998 (CI 0.996-0.999, P = 0.041).

Conclusion

Genetically liability to high- red blood cell distribution width, mean reticulocyte volume, mean red blood cell volume, and low monocyte count are associated with the higher risk of VTE. Targeting these factors might be a potential strategy to prevent VTE.

Venous Thromboembolism in Sepsis: From Bench to Bedside

Septic patients were commonly affected by coagulation disorders; thus, they are at high risk of thrombotic complications. In the last decades, novel knowledge has emerged about the interconnected and reciprocal influence of immune and coagulation systems. This phenomenon is called immunothrombosis, and it indicates an effective response whereby immune cells and the coagulation cascade cooperate to limit pathogen invasion and endothelial damage. When this network becomes dysregulated due to a systemic inflammatory activation, as occurs during sepsis, it can result in pathological thrombosis. Endothelium, platelets and neutrophils are the main characters involved in this process, together with the TF and coagulation cascade, playing a critical role in both the host defense and in thrombogenesis. A deeper understanding of this relationship may allow us to answer the growing need for clinical instruments to establish the thrombotic risk and treatments that consider more the connection between coagulation and inflammation. Heparin remains the principal therapeutical response to this phenomenon, although not sufficiently effective. To date, no other significant alternatives have been found yet. In this review, we discuss the role of sepsis-related inflammation in the development and resolution of venous thromboembolism and its clinical implications, from bench to bedside.

Management of Contraception in Adolescent Females With Hormone-Related Venous Thromboembolism

PURPOSE

Management of contraception in adolescent females with hormone-related venous thromboembolism (VTE) is challenging. We examined the characteristics of this patient population and outcomes, including recurrent VTE, heavy menstrual bleeding, and pregnancy.

METHODS

We performed a single-institution retrospective cohort study of adolescents with a new diagnosis of VTE and concurrent use of estrogen- and/or progestin-containing medication (N = 89). We collected data on additional risk factors for thrombosis, management of hormone therapy, and anticoagulation. We compared outcomes between patients with prescribed contraception within the year after their VTE diagnosis (n = 52) with those without (n = 37).

RESULTS

At least one additional risk factor for thrombosis was identified in 92% of patients, and 73% had two or more. The most common additional thrombosis risk factors were obesity (35%), family history (33%), and recent immobility (33%). Ninety-seven percent of patients were receiving combined hormonal medications, and 42% of patients had their medication stopped and not replaced with an alternative. Heavy menstrual bleeding was reported while on anticoagulation in 46% of patients with a documented menstrual history. Recurrent VTE occurred in 9.0% of patients. The group without prescribed contraception had a significantly higher rate of pregnancy in the two years after VTE diagnosis (18% vs. 1.9%, p = .04). Two pregnancies occurred while on warfarin.

DISCUSSION

Early assessment of contraceptive needs and menstrual bleeding symptoms are needed after diagnosis of hormone-related VTE in adolescent females. Access to contraceptive methods associated with low thrombosis risk is important for the prevention of unplanned pregnancy in this patient population.

Case Report: A Mysterious Giant Thrombus in the Right Atrium in a Patient With Dilated Cardiomyopathy

An isolated right atrial thrombus is a life-threatening entity that is extremely rare in patients with dilated cardiomyopathy (DCM), which is characterized by a reduced left ventricular function and consequent left ventricular thrombosis. Here, we present the case of a mysterious isolated giant right atrial thrombus in a male patient with DCM. The presence of deep vein thrombosis prompted us to investigate for other underlying diseases for his right atrial thrombus. Interestingly, the elevation of two tumor markers indicated the likelihood of cancer-associated thrombosis. Further, the computed tomography demonstrated a spiculated mass in the lower right lung that was confirmed by an endobronchial biopsy as lung squamous cell carcinoma. Consequently, the giant thrombus in the right atrium should be attributed principally to lung squamous cell carcinoma on the background of DCM. After 3 weeks of enoxaparin, the echocardiogram indicated partial resolution of the thrombus. However, the patient suffered sudden death due to pulmonary embolism.

Fondaparinux sodium and low molecular weight heparin for venous thromboembolism prophylaxis in Chinese patients with major orthopedic surgery or trauma: a real-world study

Background

The present real-world study aimed to compare the efficacy and safety between fondaparinux sodium (FPX) and low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis in Chinese patients with major orthopedic surgery or trauma.

Methods

A total of 2429 patients, with major orthopedic surgery or trauma, underwent FPX (n = 1177) or LMWH (n = 1252) for VTE prophylaxis and were retrospectively reviewed. Primary outcomes, including in-hospital VTE and in-hospital major bleeding incidences, as well as the secondary outcomes, including in-hospital minor bleeding, in-hospital death, and VTE/bleeding/death within 2 months after discharge, were analyzed. Inverse probability of treatment weighting (IPTW) was conducted.

Results

FPX group exhibited lower in-hospital VTE (0.1% vs. 0.8%; P = 0.032, crude OR = 0.11 before IPTW; P = 0.046, weighted OR = 0.12 after IPTW) and in-hospital minor bleeding (17.8% vs. 26.8%; P < 0.001, crude OR = 0.59 before IPTW; P < 0.001, weighted OR = 0.67 after IPTW) compared to LMWH group. Furthermore, no difference of in-hospital major bleeding, in-hospital death, and VTE/bleeding/death within 2 months after discharge was observed between FPX group and LMWH group (all P > 0.05). Further subgroup analyses identified, in specific cluster of patients such as older age, renal function impairment, hypertension and so on, in-hospital VTE was declined in FPX group compared to LMWH group (all P < 0.001).

Conclusions

FPX is probable to exhibit a superior thromboprophylaxis efficacy compared with LMWH in in-hospital patients with major orthopedic surgery or trauma, especially in some special patients such as older age, renal function impairment, hypertension, etc.

The effect of balloon-assisted pharmacomechanical catheter-directed thrombolysis on the patency and post-thrombotic syndrome in patients with acute iliofemoral deep vein thrombosis: Is it really necessary or not?

OBJECTIVES

The objective of this study was to describe the contribution and advantage of balloon-dilatation of iliac and femoral veins following pharmacomechanical catheter-directed thrombolysis (PCDT) on the development of post-thrombotic syndrome (PTS).

METHODS

From October 2018 and January 2022, 85 patients with acute total occlusion of the iliac and femoral veins were treated with PCDT. The cohort was divided into two groups depending on the utilization of concomitant balloon dilatation of iliac and femoral veins (Group 1, n=34, 40.0%) or not (Group 2, n=51, 60.0%) during the PCDT. All patients underwent duplex ultrasound scanning for evaluating the patency of iliac veins and recanalization rates at 3, 6, and 12 months postoperatively. the Villalta score was used to score the severity of PTS at 12 months postoperatively.

RESULTS

Patients who underwent balloon-assisted PCDT (group 1) exhibited significantly higher primary patency rates in CIV (recanalization 84.3 ± 14.6%, p = 0.003) , EIV (recanalization 82.8 ± 17.2, p = 0.003) and CFV (recanalization 88.1 ± 12.1%, p = 0.038) compared with the group 2 at the end of 12 months follow-up. Only 2 patients underwent venous stenting in follow-up due to severe venous claudication, however, 13 patients were required iliac vein stenting due to severe PTS proved with a high Villalta score at 12-month follow-up. The d-dimer level at 1-year follow-up had also significantly lower in Group 1 due to higher rates of patency and lower thrombosis burden. The most common bleeding events were hematuria (n =4) or oozing in the puncture site (n = 4).

CONCLUSIONS

This study showed that balloon-assisted PCDT reduces the risk of PTS, is more successful in common iliac vein recanalization, reduces the need for the venous stent, and even lowers the D-dimer levels of the patients compared to routine PCDT alone.

Predicting major bleeding during extended anticoagulation for unprovoked or weakly provoked venous thromboembolism

No clinical prediction model has been specifically developed or validated to identify patients with unprovoked venous thromboembolism (VTE) who are at high risk of major bleeding during extended anticoagulation. In a prospective multinational cohort study of patients with unprovoked VTE receiving extended anticoagulation after completing ≥3 months of initial treatment, we derived a new clinical prediction model using a multivariable Cox regression model based on 22 prespecified candidate predictors for the primary outcome of major bleeding. This model was then compared with modified versions of 5 existing clinical scores. A total of 118 major bleeding events occurred in 2516 patients (annual risk, 1.7%; 95% confidence interval [CI], 1.4-2.1). The incidences of major bleeding events per 100 person-years in high-risk and non–high-risk patients, respectively, were 3.9 (95% CI, 3.0-5.1) and 1.1 (0.8-1.4) using the newly derived creatinine, hemoglobin, age, and use of antiplatelet agent (CHAP) model; 3.3 (2.6-4.1) and 1.0 (0.7-1.3) using modified ACCP score, 5.3 (0.6-19.2) and 1.7 (1.4-2.0) using modified RIETE score, 3.1 (2.3-3.9) and 1.1 (0.9-1.5) using modified VTE-BLEED score, 5.2 (3.3-7.8) and 1.5 (1.2-1.8) using modified HAS-BLED score, and 4.8 (1.3-12.4) and 1.7 (1.4-2.0) using modified outpatient bleeding index score. Modified versions of the ACCP, VTE-BLEED, and HAS-BLED scores help identify patients with unprovoked VTE who are at high risk of major bleeding and should be considered for discontinuation of anticoagulation after 3 to 6 months of initial treatment. The CHAP model may further improve estimation of bleeding risk by using continuous predictor variables, but external validation is required before its implementation in clinical practice.

Fibrinogen and Factor XIII in Venous Thrombosis and Thrombus Stability

As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombogenesis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.

Disease activity as a risk factor for venous thromboembolism in rheumatoid arthritis analysed using time-averaged DAS28CRP: a nested case-control study

The objective of this study is to clarify the clinical features and risk factors of venous thromboembolism (VTE) in patients with rheumatoid arthritis (RA). We retrospectively reviewed the prevalence of VTE in RA patients who visited Hokkaido University Hospital from 2010 to 2019 and had more than 2 years of follow-up. To explore the risk to develop VTE, we selected 260 RA patients without VTE (non-VTE) via density sampling and identified the risk factors for VTE by multivariate logistic regression analysis. Univariate conditional logistic regression analysis showed older age (p < 0.0001, Odds Ratio [OR] 1.08, 95% Confidence Interval [CI] 1.04-1.14), increase of the body mass index (BMI) (p = 0.001, OR 1.17, 95% CI 1.06-1.31), higher prevalence of RA-associated lung disease (p = 0.002, OR 2.10, 95% CI 1.33-3.30) and more frequent glucocorticoid usage (p = 0.001, OR 2.09, 95% CI 1.34-3.51) in RA patients was associated with the development of VTE significantly. Furthermore, patients with higher time-averaged disease activity score 28 (DAS28) CRP were at elevated risk (p < 0.0001, OR 3.25, 95% CI 1.94-6.12). In conditional multivariate logistic regression analysis, time averaged DAS28CRP was significantly associated with the development of VTE (p = 0.0001, adjusted OR 3.40, 95% CI 1.77-7.85). Disease activity was identified as a major risk factor of VTE in patients with RA, suggesting that sustained clinical remission could be beneficial for decrease the risk of VTE.

A Fibrin Site-Specific Nanoprobe for Imaging Fibrin-Rich Thrombi and Preventing Thrombus Formation in Venous Vessels

Venous thromboembolism (VTE) is a prevalent public health issue worldwide. Before treatment, spatiotemporally accurate thrombus detection is essential. However, with the currently available imaging technologies, this is challenging. Herein, the development of a novel fibrin-specific nanoprobe (NP) based on the conjugation of poly(lactic-co-glycolic acid) with the pentapeptide Cys-Arg-Glu-Lys-Ala (CREKA) for selective and semiquantitative imaging in vivo is presented. By integrating Fe₃ O₄ and NIR fluorochrome (IR780), the NP can function as a highly sensitive sensor for the direct analysis of thrombi in vivo. The fibrin-specific NP distinguishes fibrin-rich thrombi from collagen-rich or erythrocyte-rich thrombi, which can be beneficial for future individually tailored therapeutic strategy. Furthermore, loading NPs with the ketotifen fumarate results in mast cell degranulation inhibition, and hence, NPs can prevent thrombosis without the risk of excessive bleeding. Thus, the use of fibrin-specific NPs may serve as a safe alternative approach for the detection and prevention of VTEs in susceptible populations in the future.

Cardio-Oncology: A Myriad of Relationships Between Cardiovascular Disease and Cancer

Cardiovascular disease (CVD) and cancer are the leading causes of death worldwide. With an increasing number of the elderly population, and early cancer screening and treatment, the number of cancers cases are rising, while the mortality rate is decreasing. However, the number of cancer survivors is increasing yearly. With the prolonged life span of cancer patients, the adverse effects of anti-tumor therapy, especially CVD, have gained enormous attention. The incidence of cardiovascular events such as cardiac injury or cardiovascular toxicity is higher than malignant tumors' recurrence rate. Numerous clinical studies have also shifted their focus from the study of a single disease to the interdisciplinary study of oncology and cardiology. Previous studies have confirmed that anti-tumor therapy can cause CVD. Additionally, the treatment of CVD is also related to the tumors incidence. It is well established that the increased incidence of CVD in cancer patients is probably due to an unmodified unhealthy lifestyle among cancer survivors or cardiotoxicity caused by anti-cancer therapy. Nevertheless, some patients with CVD have a relatively increased cancer risk because CVD and malignant tumors are highly overlapping risk factors, including gender, age, hypertension, diabetes, hyperlipidemia, inflammation, and obesity. With advancements in the diagnosis and treatment, many patients simultaneously suffer from CVD and cancer, and most of them have a poor prognosis. Therefore, clinicians should understand the relationship between CVD and tumors, effectively identify the primary and secondary prevention for these diseases, and follow proper treatment methods.

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.

•

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.

Negative Venous Leg Ultrasound in Acute Pulmonary Embolism: Prevalence, Clinical Characteristics, and Predictors

The purpose of this study was to investigate the prevalence, clinical characteristics, and predictors of negative venous leg ultrasound in acute pulmonary embolism (PE). We retrospectively analyzed a cohort of 168 patients with acute PE (median age 73 years, 44% women) evaluated with complete venous leg ultrasound. A multivariate logistic regression analysis was performed to identify the independent predictors of negative venous ultrasound in acute PE. Venous leg ultrasound was negative for deep venous thrombosis (DVT) in 78 patients (46.4%). Patients with negative venous ultrasound were less likely to have a history of DVT (7.7% vs. 20.0%, p = 0.0273) and had significantly lower D-dimer levels (median 2.5 vs. 6.2 mg/dL p < 0.0001). Negative venous ultrasound was more frequent in PE diagnosed with V/P-SPECT than in PE diagnosed with CT (66.2% vs. 34.0%, p < 0.0001). The prevalence of negative venous ultrasound increased with more peripherally located PE (29.5% for central/lobar, 43.1% for segmental, and 60.6% for subsegmental PE, p = 0.0049). For the multivariate analysis, a diagnosis of PE with V/P-SPECT rather than CT (OR 3.2, p = 0.0056) and lower D-dimer levels (OR 0.94, p = 0.0266) were independent predictors of negative venous ultrasound. In conclusion, venous leg ultrasound was negative for DVT in almost half of patients with acute PE. Negative venous ultrasound was more common in patients with no history of DVT, lower D-dimer levels, PE diagnosed with V/P-SPECT rather than CT, and more peripherally located PE.

Prevention and management of thrombosis in hospitalised patients with COVID-19 pneumonia

A proportion of people infected with SARS-CoV-2 develop moderate or severe COVID-19, with an increased risk of thromboembolic complications. The inflammatory response to SARS-CoV-2 infection can cause an acute-phase response and endothelial dysfunction, which contribute to COVID-19-associated coagulopathy, the clinical and laboratory features of which differ in some respects from those of classic disseminated intravascular coagulation. Understanding of the pathophysiology of thrombosis in COVID-19 is needed to develop approaches to management and prevention, with implications for short-term and long-term health outcomes. Evidence is emerging to support treatment decisions in patients with COVID-19, but many questions remain about the optimum approach to management. In this Viewpoint, we provide a summary of the pathophysiology of thrombosis and associated laboratory and clinical findings, and highlight key considerations in the management of coagulopathy in hospitalised patients with severe COVID-19, including coagulation assessment, identification of thromboembolic complications, and use of antithrombotic prophylaxis and therapeutic anticoagulation. We await the results of trials that are underway to establish the safety and benefits of prolonged thromboprophylaxis after hospital discharge.

Incidence and risk factors for venous thromboembolism during an acute attack in patients with neuromyelitis optica spectrum disorders

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) patients may be at increased risk of venous thromboembolism (VTE) during the acute attack, but evidence is limited.

OBJECTIVE

To investigate the incidence of venous thromboembolism (VTE) in Neuromyelitis optica spectrum disorders (NMOSD) patients with an acute attack and to identify the potential risk factors for the development of VTE.

METHODS

We conducted a retrospective study of NMOSD patients with an acute attack between January 1, 2015, and June 31, 2021. Diagnosis of DVT or PE was objectively confirmed by doppler ultrasound or computed tomographic pulmonary angiography (CTPA) during their acute hospital stay.

RESULTS

We identified 184 attacks in 128 NMOSD patients with the mean age of 46.9 years at the time of the attack and female predominance (152/184, 83.2%). VTE occurred in 22 (12.0%) attacks. Among the 22 attacks, 20 presented with transverse myelitis (TM), 1 cerebral syndrome (CS), and 1 simultaneous TM and brainstem syndrome (BS). Multivariable logistic regression analysis showed that advanced age [odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.04-1.12, p = 0.000], Nadir Expanded Disability Status Scale (EDSS)>6.5(OR = 3.39, 95% CI = 1.22-10.10, p = 0.029) and intravenous immunoglobulin (IVIG) treatment (OR = 3.21, 95% CI = 1.15-8.91, p = 0.025) were independent risk factors for the development of VTE in the total NMOSD cohort. In the subgroup analysis of the NMOSD patients with TM, age at attack (OR = 1.07, 95% CI = 1.03-1.11, p = 0.002) and IVIG treatment (OR = 4.23, 95% CI = 1.44-12.45, p = 0.009) were independent risk factors for the development of VTE in the total NMOSD cohort, but Nadir EDSS>6.5 was not an independent risk factor.

CONCLUSIONS

VTE is a frequent complication in NMOSD patients, especially in patients with TM. Advanced age and IVIG are independent risk factors for VTE. Immobilization is an independent risk factor for VTE in the total NMOSD cohort but not in the subgroup analysis of the patients with TM.

Effectiveness and safety of oral anticoagulants in the treatment of acute venous thromboembolism: A nationwide comparative cohort study in France

INTRODUCTION

Data from clinical trials indicate that direct oral anticoagulants (DOACs) are non-inferior and safer than conventional therapy (low-molecular weight heparin followed by a vitamin K antagonist [VKA]) for treating venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism (PE). This study compared the effectiveness and safety of DOACs and conventional therapy in a real-world setting.

MATERIALS AND METHODS

This observational study used French national claims data of adult, treatment-naïve patients diagnosed with VTE (majority PE) who were hospitalized and treated for VTE with a DOAC (apixaban or rivaroxaban) or VKAs during 2013-2018. Patients with active cancer were excluded. After propensity score matching for each DOAC-VKA comparison, risks of bleeding, recurrent VTE, and all-cause mortality were compared at 6 months. Cox proportional-hazards regression was used to estimate adjusted hazard ratios of the endpoints.

RESULTS

58137 patients were included (10775 VKAs, 10440 apixaban, 36922 rivaroxaban). Propensity score-matched cohort sizes were 7503 for apixaban and 9179 for rivaroxaban. The hazard ratio (95% confidence interval) was significantly lower for apixaban than VKAs for bleeding requiring hospitalization (0.43 [0.32-0.59]), all-cause death (0.61 [0.51-0.74]), and first-recurrent VTE (0.67 [0.52-0.85]). The hazard ratio was also significantly lower for rivaroxaban than VKAs for all-cause death (0.63 [0.53-0.74]) but not for bleeding requiring hospitalization (0.86 [0.69-1.07]) or first-recurrent VTE (0.91 [0.74-1.13]).

CONCLUSIONS

Apixaban was associated with superior safety and effectiveness than VKAs. All-cause mortality was lower in both DOACs than VKAs. Our results support recommendations to use DOACs over VKAs for the treatment of VTE.

Association Between Monocyte Count and Preoperative Deep Venous Thrombosis in Older Patients with hip Fracture: A Retrospective Study

Purpose

To analyze the relationship between monocyte count and preoperative deep venous thrombosis (DVT) in older patients with hip fracture.

Methods

Consecutive older patients with hip fracture undergoing surgery were included from January 2014 to December 2021. Monocyte count was measured on admission, and Doppler ultrasonography was performed for DVT screening prior to surgery. Univariate and multivariate logistic regression analyses were used to assess the association between monocyte count and DVT.

Results

A total of 674 patients were finally included, and 128 patients (19.0%) were diagnosed with preoperative DVT. Patients with DVT exhibited a higher monocyte count than patients without DVT [0.55 (0.43-0.72) × 10⁹/L versus 0.49 (0.38-0.63) × 10⁹/L, P = 0.007]. Multivariate logistic regression analysis showed that a high monocyte count (> 0.6 × 10⁹/L) was independently associated with a higher risk of DVT (OR = 1.705, 95% CI: 1.121-2.593, P = 0.013), and for every 0.1 × 10⁹/L increase in monocyte count, the risk of DVT increased by 8.5% (OR = 1.085, 95% CI: 1.003-1.174, P = 0.041). Other risk factors associated with DVT included intertrochanteric fracture (OR = 1.596, 95% CI: 1.022-2.492, P = 0.040), and elevated fibrinogen level (OR = 1.236, 95% CI: 1.029-1.484, P = 0.023).

Conclusion

A high monocyte count is associated with an increased risk of DVT in older patients with hip fracture. Future studies should evaluate the potential role of monocyte in the prevention and treatment of thrombosis.

Immune-mediated inflammatory diseases and risk of venous thromboembolism: A Mendelian randomization study

Introduction

Immune-mediated inflammatory diseases (IMIDs) have been associated with an increased risk of venous thromboembolism (VTE) in multiple observational studies. However, a direct causally relation between IMIDs and VTE remains unclear to date. Here, we used Mendelian randomization (MR) analysis to investigate causal associations between IMIDs and VTE.

Methods

We collected genetic data from published genome-wide association studies (GWAS) for six common IMIDs, specifically inflammatory bowel disease (IBD), Crohn's disease (CD), ulcerative colitis (UC), rheumatoid arthritis (RA), psoriasis (PSO), and systemic lupus erythematosus (SLE); and summary-level data for VTE, pulmonary embolism (PE), and deep vein thrombosis (DVT) from the FinnGen database. Two-sample MR analysis using inverse variance weighting (IVW) was performed to identify causal associations between IMIDs and VTE/DVT/PE, and sensitivity analyses were implemented for robustness.

Results

IVW analysis showed a causal relationship between genetically predicted UC (one type of IBD) and the risk of VTE (OR = 1.043, 95% CI: 1.013-1.073, p = 0.004) and DVT (OR = 1.088, 95% CI: 1.043-1.136, p < 0.001), but we found no evidence of causality between UC and PE (OR = 1.029, 95% CI: 0.986-1.074, p = 0.19). In addition, no associations were observed between total IBD, CD, RA, SLE, or PSO and VTE/DVT/PE. Sensitivity analysis found no evidence for horizontal pleiotropy.

Conclusion

This MR study provides new genetic evidence for the causal relationship between IMIDs and the risk of VTE. Our findings highlight the importance of active intervention and monitoring to mitigate VTE risk in patients with IBD, in particular those presenting with UC.

Effects of Hyperthyroidism on Venous Thromboembolism: A Mendelian Randomization Study

Objective

Observational studies show the correlation between thyroid dysfunction and risk of venous thromboembolism. However, the causal effects remain uncertain. Our study was conducted to evaluate whether thyroid function and dysfunction were causally linked to the risk of venous thromboembolism.

Methods

Publicly available summary data of thyrotropin (TSH) and free thyroxine (FT4), hypothyroidism, and hyperthyroidism were obtained from the ThyroidOmics Consortium and the UK Biobank. With single nucleotide polymorphisms (SNPs) as instrumental variables, the casual effects of genetically predicted TSH and FT4 and hypo- and hyperthyroidism on venous thromboembolism outcome were estimated through Mendelian randomization analysis methods (inverse variance weighted (IVW), MR-Egger, weighted median, simple mode, and weighted mode). Cochran's Q test was performed to evaluate the heterogeneity and horizontal pleiotropy.

Results

Our study selected 15 FT4-, 36 TSH-, 3 hyperthyroidism-, and 79 hypothyroidism-associated SNPs as instrumental variables. The IVW analysis results showed that the odds ratio of venous thromboembolism for hyperthyroidism was 1.124 (95% confidence interval: 1.019-1.240; p = 0.019), demonstrating the casual effect of hyperthyroidism not FT4, TSH, and hypothyroidism on venous thromboembolism. No heterogeneity or horizontal pleiotropy was observed according to Cochran's Q test.

Conclusion

Our Mendelian randomization analysis supports the causal effect of hypothyroidism on risk of venous thromboembolism. There is no evidence that genetically predicted TSH, FT4, and hypothyroidism have casual effects on venous thromboembolism. Future studies should be conducted to elucidate the underlying pathophysiological mechanisms.

Predictive factors for differentiating thrombohemorrhagic disorders in high-risk acute promyelocytic leukemia

INTRODUCTION

Acute promyelocytic leukemia (APL) is often accompanied by potentially fatal coagulopathy, especially in high-risk APL. Bleeding, particularly severe bleeding is the leading cause of early death (ED). Meanwhile, thrombosis, the other major coagulopathic complication, is being increasingly recognized. However, predictors of thrombohemorrhagic disorders are still not well investigated.

MATERIALS AND METHODS

In this study, we retrospectively studied 83 patients with high-risk APL and categorized them into severe bleeding, thrombosis and no evident events groups.

RESULTS

Severe bleeding was observed in 15 patients, nearly half of whom died of hemorrhage, while thrombosis was observed in 12 patients. Risk factor analysis showed that high WBC (>58.76 × 10⁹/L) (p = 0.001) and prolonged PT (>17.7 s) (p = 0.015) could be independent predictors for severe bleeding, while high WBC/D-dimer>5.12 (p = 0.002) and low D-dimer/FIB<5.14 (p = 0.03) could be independent predictors for thrombosis in high-risk APL patients. Moreover, there are significant differences in WBC/D-dimer and D-dimer/FIB between DIC and Non-DIC groups (p < 0.001). Notably, we found that the WBC/D-dimer was dramatically higher in the thrombotic group than in the other two groups at the time of admission or during the first week of induction therapy.

CONCLUSIONS

High WBC and prolonged PT could predict severe bleeding in high-risk APL patients, while high WBC/D-dimer and low D-dimer/FIB could be independent predictors for thrombosis. For high-risk APL, WBC/D-dimer and D-dimer/FIB are also beneficial in the diagnosis of DIC. WBC/D-dimer might help early identification of thrombosis at the time of admission or during the first week of induction therapy.

Chronic hypersensitivity pneumonitis is associated with an increased risk of venous thromboembolism: a retrospective cohort study

Background

Idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis share commonalities in pathogenesis shifting haemostasis balance towards the procoagulant and antifibrinolytic activity. Several studies have suggested an increased risk of venous thromboembolism in IPF. The association between venous thromboembolism and chronic hypersensitivity pneumonitis has not been studied yet.

Methods

A retrospective cohort study of IPF and chronic hypersensitivity pneumonitis patients diagnosed in single tertiary referral center between 2005 and 2018 was conducted. The incidence of symptomatic venous thromboembolism was evaluated. Risk factors for venous thromboembolism and survival among those with and without venous thromboembolism were assessed.

Results

A total of 411 (259 IPF and 152 chronic hypersensitivity) patients were included (mean age 66.7 ± 8.4 vs 51.0 ± 13.3 years, respectively). There were 12 (4.6%) incident cases of venous thromboembolism in IPF and 5 (3.3%) in chronic hypersensitivity pneumonitis cohort. The relative risk (RR) of venous thromboembolism in chronic hypersensitivity pneumonitis was not significantly different to that found in patients with IPF (7.1 vs 11.8/1000 person-years, RR 1.661 95% CI 0.545–6.019, respectively).

The treatment with systemic steroids (OR 5.38; 95% CI 1.65–18.8, p = 0.006) and GAP stage 3 (OR 7.85; 95% CI 1.49–34.9; p = 0.037) were significant risk factors for venous thromboembolism in IPF. Arterial hypertension and pulmonary hypertension significantly increased risk of venous thromboembolism in chronic hypersensitivity pneumonitis. There were no significant differences in survival between patients with and without venous thromboembolism.

Conclusions

The patients with chronic hypersensitivity pneumonitis have a marked increase in the risk of venous thromboembolism, similar to the patients with IPF. Venous thromboembolism does not affect the survival of patients with IPF and chronic hypersensitivity pneumonitis.

Usability barriers and facilitators of a human factors engineering-based clinical decision support technology for diagnosing pulmonary embolism

BACKGROUND

Health IT, such as clinical decision support (CDS), has the potential to improve patient safety. However, poor usability of health IT continues to be a major concern. Human factors engineering (HFE) approaches are recommended to improve the usability of health IT. Limited evidence exists on the actual impact of HFE methods and principles on the usability of health IT.

OBJECTIVE

To identify and describe the usability barriers and facilitators of an HFE-based CDS prior to implementation in the emergency department (ED).

METHODS

We conducted debrief interviews with 32 emergency medicine physicians as a part of a scenario-based simulation study evaluating the usability of the HFE-based CDS. We performed a deductive content analysis of the interviews using the usability criteria of Scapin and Bastien as a framework.

RESULTS

We identified 271 occurrences of usability barriers (94) and facilitators (177) of the HFE-based CDS. For instance, we found a facilitator relating to the usability criteria prompting as the PE Dx helps the physician order diagnostic tests following the risk assessment. We found the most facilitators relating to the criteria, minimal actions, e.g. as the PE Dx automatically populates vitals signs (e.g., heart rate) from the chart into the CDS. The majority of the usability barriers related to the usability criteria, compatibility (i.e., workflow integration), which was not explicitly considered in the HFE design of the CDS. For example, the CDS did not support resident and attending physician teamwork in the PE diagnostic process.

CONCLUSION

The systematic use of HFE principles in the design of CDS improves the usability of these technologies. In order to further reduce usability barriers, workflow integration should be explicitly considered in the design of health IT.

Risk Factors for Venous Thromboembolism in Severe COVID-19: A Study-Level Meta-Analysis of 21 Studies

Venous thromboembolism (VTE) in patients with COVID-19 in intensive care units (ICU) is frequent, but risk factors (RF) remain unidentified. In this meta-analysis (CRD42020188764) we searched for observational studies from ICUs reporting the association between VTE and RF in Medline/Embase up to 15 April 2021. Reviewers independently extracted data in duplicate and assessed the certainty of the evidence using the GRADE approach. Analyses were conducted using the random-effects model and produced a non-adjusted odds ratio (OR). We analysed 83 RF from 21 studies (5296 patients). We found moderate-certainty evidence for an association between VTE and the D-dimer peak (OR 5.83, 95%CI 3.18–10.70), and length of hospitalization (OR 7.09, 95%CI 3.41–14.73) and intubation (OR 2.61, 95%CI 1.94–3.51). We identified low-certainty evidence for an association between VTE and CRP (OR 1.83, 95% CI 1.32–2.53), D-dimer (OR 4.58, 95% CI 2.52–8.50), troponin T (OR 8.64, 95% CI 3.25–22.97), and the requirement for inotropic drugs (OR 1.67, 95% CI 1.15–2.43). Traditional VTE RF (i.e., history of cancer, previous VTE events, obesity) were not found to be associated to VTE in COVID-19. Anticoagulation was not associated with a decreased VTE risk. VTE RF in severe COVID-19 correspond to individual illness severity, and inflammatory and coagulation parameters.

Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain.

OBJECTIVES

To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE.

METHODS

We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies.

RESULTS

Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%).

CONCLUSIONS

Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.

Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain.

OBJECTIVES

To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE.

METHODS

MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results.

RESULTS

Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%).

CONCLUSIONS

In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.

Extended thromboprophylaxis post gynaecological cancer surgery; the effect of weight adjusted and fixed dose LMWH (Tinzaparin)

OBJECTIVE

Gynaecological cancer surgery is associated with high rates of venous thromboembolism (VTE) despite recommended prophylaxis. We sought to investigate the impact of extended prophylaxis with fixed dose and weight based LMWH in patients undergoing gynaecological cancer surgery.

METHODS

VTE rates were recorded in patients who received LMWH prophylaxis (4500 IU Tinzaparin once daily) for the duration of hospital stay (2006-2012) (n = 610) and were compared with VTE rates in patients who underwent surgery after the introduction of extended prophylaxis (3500/4500 IU Tinzaparin for patients with BMI < 40kg/m2 and 75 IU/kg for BMI > 40 kg/m2) (2012-2017) (n = 651). Peak (4 h) anti-Xa levels in a subset of patients were also evaluated.

RESULTS

73 (5.7%) cases of VTE were recorded during 1 year of follow-up. 20 cases occurred during hospital stay. There was no significant difference in the rate of VTE between the extended prophylaxis cohort and the standard prophylaxis cohort. 23/24 patients who developed VTE in the extended prophylaxis cohort received a fixed (4500 units) dose of Tinzaparin. 63% of patients who received a fixed LMWH dose had peak anti-Xa levels below the target range (0.2-0.4 IU/ml). Peak anti-Xa was lower in patients who subsequently developed VTE compared with those who received either fixed dose (P = 0.041) and weight adjusted Tinzaparin (P = 0.0006).

CONCLUSIONS

Extended prophylaxis with Tinzaparin does not significantly reduce VTE rates in gynaecological cancer patients post surgery. Peak anti-Xa levels may be suboptimal in many patients receiving a fixed LMWH dose. Further studies are required to determine whether weight adjusted doses of Tinzaparin may provide more effective prophylaxis following gynaecological cancer surgery.

Integrated Analysis of Microbiome and Transcriptome Data Reveals the Interplay Between Commensal Bacteria and Fibrin Degradation in Endometrial Cancer

The gut-uterus axis plays a pivotal role in the pathogenesis of endometrial cancer (EC). However, the correlations between the endometrial microbiome and endometrial tumor transcriptome in patients with EC and the impact of the endometrial microbiota on hematological indicators have not been thoroughly clarified. In this prospective study, endometrial tissue samples collected from EC patients (n = 30) and healthy volunteers (n = 10) were subjected to 16S rRNA sequencing of the microbiome. The 30 paired tumor and adjacent nontumor endometrial tissues from the EC group were subjected to RNAseq. We found that Pelomonas and Prevotella were enriched in the EC group with a high tumor burden. By integrating the microbiome and hematological indicators, a correlation was observed between Prevotella and elevated serum D-dimer (DD) and fibrin degradation products (FDPs). Further transcriptome analysis identified 8 robust associations between Prevotella and fibrin degradation-related genes expressed within ECs. Finally, the microbial marker of Prevotella along with DD and FDPs showed a high potential to predict the onset of EC (AUC = 0.86). Our results suggest that the increasing abundance of Prevotella in endometrial tissue combined with high serum DD and FDP contents may be important factors associated with tumor burden. The microbe-associated transcripts of host tumors can partly explain how Prevotella promotes DD and FDPs.

Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis

BACKGROUND

The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain.

PURPOSE

To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021.

STUDY SELECTION

Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment.

DATA EXTRACTION

Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies.

DATA SYNTHESIS

Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs.

LIMITATION

Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs.

CONCLUSION

In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).