Risk factors for venous thromboembolism

Full-dose rivaroxaban in patients with a history of bariatric surgery: bridging the knowledge gap through a phase 1 study

BACKGROUND

Bariatric surgery (BS) induces significant changes in gastrointestinal anatomy, potentially influencing the pharmacokinetics of orally administered drugs such as rivaroxaban.

OBJECTIVES

This phase 1 study aimed to assess the pharmacokinetics and safety of full-dose rivaroxaban in post-BS patients.

METHODS

The ABSORB (Rivaroxaban Pharmacokinetics and Pharmacodynamics After Bariatric Surgery and in Morbid Obesity) study was a single-center, nonrandomized, multiple-dose, parallel-design bioequivalence trial. Adult patients with stable weight after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with subjects with class III obesity and healthy controls. Participants received 20 mg of rivaroxaban daily for 8 days.

RESULTS

Post-BS patients exhibited altered rivaroxaban pharmacokinetics, suggesting reduced absorption. Mean area under the concentration-time curve from time 0 to 24 hours after the first dose (RYGB, 1806.8 ng.h/mL; SG, 1648.9 ng.h/mL) was lower compared with that in controls (1893.5 ng.h/mL). At steady state, the area under the concentration-time curve values remained lower in BS groups (RYGB, 2129.9 ng.h/mL; SG, 1946.4 ng.h/mL) than in controls (2224.8 ng.h/mL). The maximum concentration after the first dose was lower in post-RYGB subjects (214.9 ng/mL) than in controls (264.1 ng/mL). This difference was less pronounced at steady state (RYGB, 256.9 ng/mL vs controls, 288.8 ng/mL). Neither BS group met bioequivalence criteria compared with controls, whereas the group with class III obesity met bioequivalence criteria compared with controls at steady state.

CONCLUSION

Rivaroxaban displayed minor pharmacokinetic variations in post-BS patients. Given reported interindividual variability in the general population, these variations are unlikely to be of clinical significance. Our findings support rivaroxaban use in BS patients, emphasizing the need for further research in this area.

Association of Cardiovascular Health with the Incidence of Venous Thromboembolism: A Prospective Study of 275,149 Participants from the UK Biobank

BACKGROUND

 The Life's Essential 8 (LE8) score, recently proposed by the American Heart Association, represents a new paradigm for evaluating cardiovascular health (CVH). We aimed to explore the association between CVH, estimated using LE8, and venous thromboembolism (VTE) incidence.

METHODS

 A total of 275,149 participants were recruited from the UK Biobank and divided into high (LE8 score ≥ 80), moderate (LE8 score < 80 but ≥ 50), and low (LE8 score < 50) CVH groups. Restricted cubic spline analysis, the Kaplan-Meier method, and the Cox proportional hazards model were used to explore the association between CVH and VTE. The genetic predisposition to VTE was assessed with a polygenic risk score. Sensitivity analyses were performed to validate the results.

RESULTS

 During a median follow-up of 12.56 years, VTE developed in 506 (4.09%), 6,069 (2.78%), and 720 (1.66%) participants with low, moderate, and high CVH levels, respectively. Compared with the low CVH group, participants in the moderate and high CVH groups had a 23% (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.71-0.85) and 41% (HR: 0.59; 95% CI: 0.52-0.66) lower risk of VTE, respectively, after adjusting for demographic characteristics, medical history, socioeconomic status, and genetic predisposition. This association remained robust in multiple sensitivity analyses. Higher CVH levels led to a more pronounced reduction in the risk of VTE in females and could appreciably offset the genetic risk of VTE.

CONCLUSION

 Higher CVH levels were significantly associated with a lower incidence of VTE, encouraging efforts to increase LE8 scores in individuals.

Evaluating the risk of venous thromboembolism in transfeminine and gender diverse people: A retrospective analysis

OBJECTIVE

The risk of venous thromboembolism (VTE) with feminizing gender-affirming hormone therapy (GAHT) is an area of concern. This analysis aimed to assess whether GAHT and other potential risk factors are associated with VTE in transfeminine and gender diverse (TGD) individuals.

METHODS

We conducted a chart review of 2,126 TGD adults receiving care within a large urban health system. The primary outcomes were the prevalence of VTE and odds ratios for the association of VTE with insurer, use of estrogen, and select comorbidities.

RESULTS

A history of VTE was documented in 0.8% of the cohort. Those with a history of VTE were older (p<.001), more often self-identified as Hispanic or Black compared to white or Asian (p<.05) and were more likely to have Medicaid or Medicare (p<.01) when compared to those without a history of VTE. The prevalence of hyperlipidemia (p<.001), diabetes mellitus (p<.05), and hypercoagulable conditions (p<.001) were all greater in the +VTE group. Hyperlipidemia (p<.001), diabetes mellitus (p<.05), and insurer (p<.05) were associated with increased odds of VTE in univariate analyses. None of the exposure variables analyzed were associated with VTE when controlling for age, race, and the number of comorbidities.

CONCLUSIONS

The prevalence of VTE in our cohort was lower than previously observed. VTE was not associated with any one risk factor, including estrogen use, when controlling for age, race, and the number of comorbidities. Those of advanced age and those with multiple cardiometabolic comorbidities may benefit from increased surveillance and mitigation of modifiable risk factors.

Utilization of the Caprini risk assessment model(RAM) to predict venous thromboembolism after primary hip and knee arthroplasty: an analysis of the Healthcare Cost and Utilization Project(HCUP)

PURPOSE

This study aims to investigate the potential role of Caprini risk assessment model (RAM) in predicting the risk of venous thromboembolism (VTE) in patients undergoing total hip or knee arthroplasty (THA/TKA). No national study has investigated the role of Caprini RAM after primary THA/TKA.

METHODS

Data from The National Sample of Healthcare Cost and Utilization Project (HCUP) in 2019 were utilized for this study. The dataset consisted of 229,134 patients who underwent primary THA/TKA. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were considered as VTE. The incidence of thrombosis was calculated based on different Caprini scores, and the risk of the Caprini indicator for VTE events was evaluated using a forest plot.

RESULTS

The prevalence of VTE after primary THA/TKA in the U.S. population in 2019 was found to be 4.7 cases per 1000 patients. Age, body mass index (BMI), and Caprini score showed a positive association with the risk of VTE (P < 0.05). The receiver operating characteristic (ROC) curve analysis indicated that a Caprini score of 9.5 had a sensitivity of 47.2% and a specificity of 82.7%, with an area under the curve (AUC) of 0.693 (95% CI, 0.677-0.710). The highest Youden index was 0.299. Multivariate logistic regression analysis revealed that malignancy, varicose vein, positive blood test for thrombophilia, history of thrombosis, COPD, hip fracture, blood transfusion, and age were significant risk factors for VTE. Based on these findings, a new risk stratification system incorporating the Caprini score was proposed.

CONCLUSIONS

Although the Caprini score does not seem to be a good predictive model for VTE after primary THA/TKA, new risk stratification for the Caprini score is proposed to increase its usefulness.

Outcomes of deep venous thrombosis management and associated factors among patients in tertiary hospitals in Addis Ababa, Ethiopia: a multicenter retrospective cohort study

BACKGROUND

Pulmonary embolism (PE) and deep venous thrombosis (DVT) are the two most important manifestations of venous thromboembolism (VTE). DVT remains a significant condition since associated morbidity is significant and has elevated healthcare-related costs.

METHODS

A retrospective cohort study was conducted among DVT patients admitted to Tikur Anbessa Specialized Hospital, Zewditu Memorial Hospital and St. Paul's Hospital Millennium Medical College on follow-up from July 1, 2017, to July 01, 2020. Data on sociodemographic characteristics, types of DVT, laboratory findings, medications, risk factors of DVT, complications and outcomes of DVT were collected. The data were analyzed using SPSS version 25. Multivariate logistic regression analysis was conducted to determine predictors of DVT recurrence and major bleeding. A P value < 0.05 was considered to identify significant predictors.

RESULTS

The mean age of the participants was 45.2 years, with SD of 15.36. The major causes of DVT included immobilization (29.9%), previous surgery (27.5%) and cancer (21.1%). The DVT recurrence rate was 22.5%. Nine (2.2%) of the participants died, and 19.9% developed complications. Bilateral DVT (Adjusted odds ratio (AOR) = 2.8, 95% Confidence interval (CI) = 1.14, 6.66), obesity (AOR = 3.3, 95% CI = 1.15, 9.59), hypertension (AOR = 6.5, 95% CI = 2.90, 14.70) and retroviral infection (AOR = 6.3, 95% CI = 2.34, 16.94) were predictors of recurrent DVT. Nineteen (4.7%) patients had major bleeding, and patients with bilateral DVT, active cancer and terminal age had an increased risk of major bleeding.

CONCLUSIONS

The overall DVT recurrence rate was alarmingly high and further complicated by PE, post thrombotic syndrome and chronic vein insufficiency, resulting in a 2.2% death rate. Major bleeding after DVT and PE remained high. Close monitoring should be performed for patients with advanced age, active cancer, bilateral DVT, retroviral infection, obesity and hypertension to prevent the recurrence of DVT and major bleeding.

Inconsistency in UK Biobank Event Definitions From Different Data Sources and Its Impact on Bias and Generalizability: A Case Study of Venous Thromboembolism

The UK Biobank study contains several sources of diagnostic data, including hospital inpatient data and data on self-reported conditions for approximately 500,000 participants and primary-care data for approximately 177,000 participants (35%). Epidemiologic investigations require a primary disease definition, but whether to combine data sources to maximize statistical power or focus on only 1 source to ensure a consistent outcome is not clear. The consistency of disease definitions was investigated for venous thromboembolism (VTE) by evaluating overlap when defining cases from 3 sources: hospital inpatient data, primary-care reports, and self-reported questionnaires. VTE cases showed little overlap between data sources, with only 6% of reported events for persons with primary-care data being identified by all 3 sources (hospital, primary-care, and self-reports), while 71% appeared in only 1 source. Deep vein thrombosis-only events represented 68% of self-reported VTE cases and 36% of hospital-reported VTE cases, while pulmonary embolism-only events represented 20% of self-reported VTE cases and 50% of hospital-reported VTE cases. Additionally, different distributions of sociodemographic characteristics were observed; for example, patients in 46% of hospital-reported VTE cases were female, compared with 58% of self-reported VTE cases. These results illustrate how seemingly neutral decisions taken to improve data quality can affect the representativeness of a data set.

Prevalence of Venous Thromboembolism after Immediate Screening in Hip Fracture Patients

Purpose

Venous thromboembolism (VTE) is a major complication for hip fracture patients, and may exist preoperatively. This study aimed to examine the prevalence of VTE after immediate screening in hip fracture patients.

Materials and Methods

Hip fracture patients with an elevated level of D-dimer underwent screening for VTE using computed tomography (CT) angiography. Anticoagulation treatments were administered preoperatively to patients diagnosed with VTE, followed by administration of additional anticoagulation postoperatively. Medical records were reviewed to identify risk factors for preoperative VTE and determine the prognosis of the patients.

Results

Among 524 hip fracture patients, 66 patients (12.6%) were diagnosed with VTE, including 42 patients with deep vein thrombosis (DVT), 17 patients with pulmonary thromboembolism (PTE), and 7 patients with both DVT and PTE. Of the patients with VTE, 68.2% were diagnosed within 24 hours of injury, and 33.3% of these patients had PTE. VTE patients showed a tendency toward being overweight (P<0.01) and not on anticoagulant medication (P=0.02) compared to patients without VTE. The risk of VTE was higher for femur shaft fractures (odds ratio [OR] 4.83, 95% confidence interval [CI] 2.18-10.69) and overweight patients (OR 2.12, 95% CI 1.17-3.85), and lower for patients who were previously on anticoagulants (OR 0.36, 95% CI 0.18-0.74). Patients with preoperatively diagnosed VTE were asymptomatic before and after surgery.

Conclusion

Clinicians should be aware that VTE may be present within 24 hours of injury, and screening for VTE or prophylactic measures should be considered for high-risk patients.

Thromboembolic Disease

Venous thromboembolism (VTE) encompasses deep vein thrombosis and pulmonary embolism, both of which can present on a spectrum from subtle symptoms to life- and limb-threatening emergencies. Some risk factors for VTE overlap cardiovascular risk factors and statin therapy can somewhat reduce the VTE risk. When presentations are not life-threatening, clinical prediction scores using the Well's criteria are best used to determine diagnostic testing. The mainstay of VTE treatment is anticoagulant therapy, although life- and limb-threatening presentations can also require thrombolytic therapy.

Venous Thromboembolism: Review of Clinical Challenges, Biology, Assessment, Treatment, and Modeling

Venous thromboembolism (VTE) is a massive clinical challenge, annually affecting millions of patients globally. VTE is a particularly consequential pathology, as incidence is correlated with extremely common risk factors, and a large cohort of patients experience recurrent VTE after initial intervention. Altered hemodynamics, hypercoagulability, and damaged vascular tissue cause deep-vein thrombosis and pulmonary embolism, the two permutations of VTE. Venous valves have been identified as likely locations for initial blood clot formation, but the exact pathway by which thrombosis occurs in this environment is not entirely clear. Several risk factors are known to increase the likelihood of VTE, particularly those that increase inflammation and coagulability, increase venous resistance, and damage the endothelial lining. While these risk factors are useful as predictive tools, VTE diagnosis prior to presentation of outward symptoms is difficult, chiefly due to challenges in successfully imaging deep-vein thrombi. Clinically, VTE can be managed by anticoagulants or mechanical intervention. Recently, direct oral anticoagulants and catheter-directed thrombolysis have emerged as leading tools in resolution of venous thrombosis. While a satisfactory VTE model has yet to be developed, recent strides have been made in advancing in silico models of venous hemodynamics, hemorheology, fluid-structure interaction, and clot growth. These models are often guided by imaging-informed boundary conditions or inspired by benchtop animal models. These gaps in knowledge are critical targets to address necessary improvements in prediction and diagnosis, clinical management, and VTE experimental and computational models.

Venous Thromboembolism in Burn Patients: A 5-Year Retrospective Study

Background and Objectives: Burn patients manifest all components of Virchow's triad, amplifying the concern for venous thromboembolism (VTE). Routine prophylaxis for VTE remains a subject of debate, with the central concern being the occurrence of associated adverse events. Materials and Methods: We conducted a five-year retrospective study on burn patients admitted to our burn center. Demographic data, comorbidities, burn lesions characteristics, surgical interventions, anticoagulant medication, the need for transfusions, the presence of a central venous catheter, length of stay, complications, and mortality were recorded. Results: Of the overall number of patients (494), 2.63% (13 patients) developed venous thromboembolic complications documented through paraclinical investigations. In 70% of cases, thrombosis occurred in a limb with central venous catether (CVC). Every patient with VTE had a Caprini score above 8, with a mean score of 12 points in our study group. Conclusions: Considering each patient's particularities and burn injury characteristics, individualized approaches may be necessary to optimize thromboprophylaxis effectiveness. We suggest routinely using the Caprini Risk Assessment Model in burn patients. We recommend the administration of pharmacologic thromboprophylaxis in all patients and careful monitoring of patients with Caprini scores above 8, due to the increased risk of VTE. Additionally, ongoing research in this field may provide insights into new strategies for managing thrombotic risk in burn patients.

In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Non-steroidal anti-inflammatory drugs and risk of pulmonary embolism in patients with inflammatory joint disease-results from the nationwide Norwegian Cardio-rheuma registry

AIMS

Patients with inflammatory joint diseases (IJD), including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) have increased rates of pulmonary embolism (PE). Non-steroidal anti-inflammatory drugs (NSAIDs) use is associated with PE in the general population. Our aim was to evaluate the association between NSAIDs use and PE in IJD patients.

METHODS AND RESULTS

Using individual-level registry data from the whole Norwegian population, including data from the Norwegian Patient Registry and the Norwegian Prescription Database, we: (1) evaluated PE risk in IJD compared to non-IJD individuals, (2) applied the self-controlled case series method to evaluate if PE risks were associated with use of traditional NSAIDs (tNSAIDs) and selective cox-2 inhibitors (coxibs). After a one-year wash-out period, we followed 4 660 475 adults, including 74 001 with IJD (RA: 39 050, PsA: 20 803, and axSpA: 18 591) for a median of 9.0 years. Crude PE incidence rates per 1000 patient years were 2.02 in IJD and 1.01 in non-IJD individuals. Age and sex adjusted hazard ratios for PE events were 1.57 for IJD patients compared to non-IJD. Incidence rate ratios (IRR) [95% confidence interval (CI)] for PE during tNSAIDs use were 0.78 (0.64-0.94, P = 0.010) in IJD and 1.68 (1.61-1.76, P < 0.001) in non-IJD. IRR (95% CI) for PE during coxibs use was 1.75 (1.10-2.79, P = 0.018) in IJD and 2.80 (2.47-3.18, P < 0.001) for non-IJD.

CONCLUSION

Pulmonary embolism rates appeared to be higher in IJD than among non-IJD subjects in our study. Traditional NSAIDs may protect against PE in IJD patients, while coxibs may associated with increased PE risk.

Factors Associated with Hospital Length of Stay among VTE Cases: Insights from the i-RegVed Registry

INTRODUCTION

Venous thromboembolism (VTE) is a multifactorial condition and one of the leading causes of mortality and disability. The present study explores the factors associated with hospitalization duration among different types of venous thromboembolism diagnoses, such as deep vein thrombosis (DVT), pulmonary embolism (PE), and other forms of thrombosis.

METHODS

The data included participants with VTE admitted to 13 hospitals within pan-India from June 2022 to December 2023 to the i-RegVed registry, where socio-demographic data, clinical history, and various factors associated with hospital length of stay (LOS) were included for analyses. Multilinear regression was performed to explore the factors associated with hospital LOS among VTE conditions such as DVT, PE, forms of thrombosis other than PE and DVT, and all VTE diagnoses.

RESULTS

A total of 633 participants were included in the study, with 55% being males, and 28.9% being homemakers. Longer hospital LOS was significantly associated with age (β = -.09, P < .05), sex (β = 3.21, P < .05), and non-communicable diseases (β = 3.51, P < .05) among participants with DVT and among participants with at least one of the VTE diagnoses, age (β = -.12, P < .001) and anticoagulant use (β = -2.49, P < .05) was significantly associated.

CONCLUSION

The findings provide insights into the factors influencing hospital outcomes among participants with different types of VTE, highlighting the importance of age and comorbidities in predicting the hospital LOS.

Risk assessment scales to predict risk of lower extremity deep vein thrombosis among multiple trauma patients: a prospective cohort study

BACKGROUND

Deep vein thrombosis (DVT) is a common complication in orthopedic patients. Previous studies have focused on major orthopedic surgery.There are few studies with multiple trauma. We aimed to describe the prevalence of DVT and compare the predictive power of the different risk assessment scales in patients with multiple trauma.

METHODS

This prospective cohort study involved multiple trauma patients admitted to our hospital between October 2021 and December 2022. Data were prospectively collected for thrombotic risk assessments using the Risk Assessment Profile for thromboembolism(RAPT), the DVT risk assessment score (DRAS), and the Trauma Embolic Scoring System (TESS), respectively. The receiver operation characteristic (ROC) curve and the area under the curve (AUC) were evaluated to compare the predictive power. The whole leg duplex ultrasound of both lower extremities Doppler ultrasound was used to determine DVT incidence.

RESULTS

A total of 210 patients were included, and the incidence of DVT was 26.19%. Distal DVT accounted for 87.27%; postoperative DVT, 72.73%; and bilateral lower extremity thrombosis, 30.91%. There were significant differences in age, education degree, pelvic fracture, surgery, ISS, D-dimer level, length of hospital stay and ICU stay between the thrombosis group and the non-thrombosis group. The AUCs for RAPT, DRAS, and TESS were 0.737, 0.710, and 0.683, respectively. There were no significant differences between the three ROC curves.

CONCLUSIONS

The incidence of DVT was relatively high during hospitalization. We prospectively validated the tests to predict risk of DVT among patients with multiple trauma to help trauma surgeons in the clinical administration of DVT prophylaxis.

Evaluation of choroidal thickness and choroidal vascular index in patients using combined oral contraceptive pills

PURPOSE

To evaluate the choroidal thickness and choroidal vascular index (CVI) in healthy women using the combined oral contraceptive pill (COCp).

METHODS

This prospective study included 30 women using COCp (3 mg drospirenone/0.03 mg ethinylestradiol) for contraception for at least 1 year and 30 healthy women who did not use COCp. Intraocular pressure (IOP), axial length (AL) and body mass index (BMI) values of all participants were recorded. Subfoveal choroidal thickness (SCT) and choroidal thickness at 1500 micron distance in nasal and temporal regions (NCT, TCT) were measured through optical coherence tomography (OCT) images. Luminal, stromal and total choroidal area values were evaluated by binarization method. The ratio of the luminal choroidal area to the total choroidal area was determined as the CVI value.

RESULTS

There was no statistically significant difference in IOP and AL values between the two groups at no significant difference in age and BMI index (p > 0.05, for all). SCT, NCT and TCT values were no significant difference in the two groups (p > 0.05, for all). Luminal and stromal choroidal area values were found to be lower in the group using COCp (p = 0.01, p = 0.02 respectively). The CVI value was 62.1 ± 3.6% in the COCp group and 65.6 ± 4.3% in the control group. There was a significant difference between the two groups in terms of CVI value (p = 0.002).

CONCLUSION

To our knowledge, this is the first study to evaluate CVI in women using COCp, and CVI was found to be lower in individuals using COCp. Therefore, CVI can be used in the follow-up of possible ocular pathologies that may develop in individuals using COCp.

Limited Effect of Prevention Strategies on Incidence of Clinically Detectable Venous Thromboembolism After Lung Transplantation

BACKGROUND

Thromboembolic complications are common post-lung transplant, leading to significant morbidity. We instituted multiple interventions because of an observed 36.8% incidence of venous thromboembolism (VTE) (Incidence rate (IR) 5.74/1000 pt days) in our recipients.

METHODS

Our initiative commenced January 2015 with enoxaparin initiation within 6-8 hours of intensive care unit arrival and continuation for 4-6 weeks. We evaluated the IR of VTE in lung transplant recipients within 90 days of transplant. In 2017, the protocol was modified to extend the time to initiation of prophylaxis to within 72 hours of ICU arrival. In 2019, we further amended our intraoperative vascular access strategy.

RESULTS

Eighteen of 26 lung transplant recipients (LTR) met inclusion criteria in the 2015 cohort. Six of 18 (33.3%) developed VTE, 50% of which were upper extremity (UE), line associated. Fifty two of 75 LTR were eligible for enoxaparin prophylaxis in the 2017 cohort. Fifteen of 52 subjects (28.8%) developed VTE, 77.8% of which were UE and line associated. Despite improved adherence in 2017, there was little change in VTE IR (3.90/1000 pt days compared with 3.85/1000 pt days). Twenty six of 43 LTR met protocol inclusion criteria in the 2019 cohort. Ten subjects (38.5%) developed VTE, 67% of which were UE and line associated (IR 5.18/1000 pt days).

CONCLUSION

Our prospective study found that LTR remain at high risk for VTE despite aggressive prophylaxis with 4-6 weeks of enoxaparin and adjustment of vascular access approach. Alternative interventions should be investigated to minimize VTE development in this vulnerable population.

Clinical profile, risk factors, and clinical outcomes in patients of venous thromboembolism at a tertiary care center

Background

Venous thromboembolism (VTE) commonly presents as either deep-vein thrombosis (DVT) or pulmonary embolism (PE). Despite rapid advances in its diagnostic and therapeutic modalities, it still leads to significant morbidity and mortality.

Objectives

Our study predominantly aims at studying the clinical profile, risk factors, and the clinical outcomes in VTE patients presenting to a single tertiary care center to rapidly detect the disease and use appropriate thrombo-prophylaxis.

Materials and Methods

This was an prospective observational study involving 40 patients of confirmed cases of VTE who presented to this tertiary care hospital during a period from June 2017 to May 2019. Data collected included the age, sex, clinical presentation, risk factors, diagnostic modalities, and their clinical outcomes. Descriptive analysis was carried out by mean and standard deviation for quantitative variables; frequency and proportion for the categorical variables.

Results

Among the study groups, 30 (74%) had DVT, 4 (11%) had PE, and 6 (15%) had both. Major risk factors detected included smoking history (44%), recent surgery (15%), malignancy (11%), history of immobility (10%), and past history of DVT (15%). The clinical presentation mainly included leg pain (62%) and leg swelling (87%).The outcomes were predominantly re-canalization (31%), recurrent DVT (21%), recurrent PE (1%), chronic DVT (27%), chronic venous insufficiency (36%), chronic venous ulcer (7%), pulmonary hypertension (16%), and death (5%). In our study population, the most common pro-thrombotic state was found to be hyperhomocysteinemia.

Conclusions

In our study of VTE patients, we have highlighted the possible risk factors, clinical presentation, and clinical outcomes to identify the disease early and help us initiate appropriate thromboprophylaxis to reduce morbidity.

Risk of Incident Venous Thromboembolism Among Patients With Bullous Pemphigoid or Pemphigus Vulgaris: A Nationwide Cohort Study With Meta-Analysis

Background Bullous pemphigoid (BP) and pemphigus vulgaris (PV) share similar pathophysiology with venous thromboembolism (VTE) involving platelet activation, immune dysregulation, and systemic inflammation. Nevertheless, their associations have not been well established. Methods and Results To examine the risk of incident VTE among patients with BP or PV, we performed a nationwide cohort study using Taiwan's National Health Insurance Research Database and enrolled 12 162 adults with BP or PV and 12 162 controls. A Cox regression model considering stabilized inverse probability weighting was used to calculate the hazard ratios (HRs) for incident VTE associated with BP or PV. To consolidate the findings, a meta-analysis that incorporated results from the present cohort study with previous literature was also conducted. Compared with controls, patients with BP or PV had an increased risk for incident VTE (HR, 1.87 [95% CI, 1.55-2.26]; P<0.001). The incidence of VTE was 6.47 and 2.20 per 1000 person-years in the BP and PV cohorts, respectively. The risk for incident VTE significantly increased among patients with BP (HR, 1.85 [95% CI, 1.52-2.24]; P<0.001) and PV (HR, 1.99 [95% CI, 1.02-3.91]; P=0.04). In the meta-analysis of 8 studies including ours, BP and PV were associated with an increased risk for incident VTE (pooled relative risk, 2.17 [95% CI, 1.82-2.62]; P<0.001). Conclusions BP and PV are associated with an increased risk for VTE. Preventive approaches and cardiovascular evaluation should be considered particularly for patients with BP or PV with concomitant risk factors such as hospitalization or immobilization.

Sodium-glucose cotransporter 2 inhibitors and the risk of venous thromboembolism: A population-based cohort study

AIMS

The cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2Is) result from their complex impact on coronary and arterial vessels. However, their effect on veins and the risk of venous thromboembolism (VTE) remains unclear. Meta-analysis of trials has suggested no significant change in risk, but observational studies on the topic are scarce. Our objective was to determine if the use of SGLT2Is, compared to the use of dipeptidyl peptidase 4 inhibitors (DPP-4Is), is associated with the risk of VTE among patients with type 2 diabetes.

METHODS

Using the Clinical Practice Research Datalink linked to hospitalization and vital statistics databases, we conducted a retrospective cohort study using a prevalent new-user design. SGLT2Is were matched to DPP-4I users on calendar time, diabetes treatment intensity, duration of previous DPP-4I use and time-conditional high-dimensional propensity score. Cox proportional hazard models estimated the hazard ratio (HR) for VTE with SGLT2Is versus DPP-4Is.

RESULTS

SGLT2I use was not associated with an increased risk of VTE (HR 0.65, 95% confidence interval [CI] 0.34 to 1.25). This finding was consistent among prevalent (HR 0.47, 95% CI 0.16 to 1.42) and incident (HR 0.75, 95% CI 0.33 to 1.72) new users.

CONCLUSIONS

We found that SGLT2Is were not associated with an increased risk of VTE compared to DPP-4Is. Although we observed a numerically decreased risk of VTE with SGLT2Is, estimates were accompanied by wide 95% CIs. Nonetheless, given the morbidity associated with VTE, our results provide some reassurance regarding the safety of SGLT2Is with respect to VTE.

Fabry-Perot Interferometric Fiber-Optic Sensor for Rapid and Accurate Thrombus Detection

We present a fiber-optic sensor based on the principles of a Fabry-Perot interferometer (FPI), which promptly, sensitively, and precisely detects blood clot formation. This sensor has two types of sensor tips; the first was crafted by splicing a tapered fiber into a single-mode fiber (SMF), where fine-tuning was achieved by adjusting the tapered diameter and length. The second type is an ultra-compact blood FPI situated on the core of a single-mode fiber. The sensor performance was evaluated via clot-formation-indicating spectrum shifts induced by the varied quantities of a thrombin reagent introduced into the blood. The most remarkable spectral sensitivity of the micro-tip fiber type was approximately 7 nm/μL, with a power sensitivity of 4.1 dB/μL, obtained with a taper fiber diameter and length of 55 and 300 μm, respectively. For the SMF type, spectral sensitivity was observed to be 8.7 nm/μL, with an optical power sensitivity of 0.4 dB/μL. This pioneering fiber-optic thrombosis sensor has the potential for in situ applications, healthcare, medical monitoring, harsh environments, and chemical and biological sensing. The study underscores the scope of optical technology in thrombus detection, establishing a platform for future medical research and application.

Revisiting Anticoagulation in Spine Surgery: Balancing Venous Thromboembolic Events and Epidural Hematoma

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH.

METHODS

We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH.

RESULTS

From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage.

CONCLUSIONS

The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.

A Mendelian randomization study of serum uric acid with the risk of venous thromboembolism

BACKGROUND

Observational studies have linked hyperuricemia with venous thromboembolism (VTE). We aimed to investigate whether there are causal relationships between uric acid levels and VTE and its subtypes, including deep venous thrombosis (DVT) of the lower extremities and pulmonary embolism (PE).

METHODS

We utilized Mendelian randomization (MR) analysis to estimate the causal association in European individuals. We extracted two sets of polygenic instruments strongly associated (p < 5 × 10^-8) with uric acid from the CKDGen consortium and UK biobank, respectively. Genetic associations with the risk of VTE, DVT, and PE were obtained from the FinnGen biobank. We used the inverse-variance weighted method as the preliminary estimate. Additionally, we employed MR-Egger, weighted median, and Mendelian randomization pleiotropy residual sum and outlier method as complementary assessments. Sensitivity analyses were performed to test for pleiotropic bias.

RESULTS

The genetically instrumented serum uric acid levels had no causal effects on VTE, DVT, and PE. Two sets of polygenic instruments used for exposure, along with three complementary MR methods, also yielded no significant association.

CONCLUSIONS

Our MR analysis provided no compelling evidence for a causal relationship of serum uric acid with the risk of VTE. This suggests that uric acid-lowering therapies in patients with hyperuricemia may not be effective in reducing the likelihood of developing VTE.

Risk of Venous Thromboembolism Among Adults With Atopic Dermatitis

Importance

The associations of atopic dermatitis (AD) with multiple cardiovascular comorbidities have been investigated because of its pathomechanisms regarding chronic systemic inflammation and potential vascular effects. Nevertheless, the association between AD and incident venous thromboembolism (VTE) in adulthood is largely unknown. This study aimed to investigate the association of AD with incident VTE.

Objective

To examine the risk of incident VTE among patients with AD.

Design, Setting, and Participants

This population-based nationwide cohort study included adults 20 years or older (adults with AD newly diagnosed between 2003 and 2017 and matched controls) from the National Health Insurance Research Database. Patients with AD were subgrouped according to the severity of the disease. A Cox regression model was used to estimate hazard ratios (HRs) for VTE. Stratified analyses according to age and sex, and a sensitivity analysis excluding systemic steroid users were performed.

Main Outcomes and Measures

Hazard ratios (HRs) for incident VTE associated with AD.

Results

This analysis included a total of 284 858 participants, with 142 429 participants each in the AD (mean [SD] age, 44.9 [18.3] years; 78 213 women) and non-AD cohorts (mean [SD] age, 44.1 [18.1] years; 79 636 women). During the follow-up, 1066 patients (0.7%) in the AD cohort and 829 patients (0.6%) in the non-AD cohort developed VTE, with incidence rates of 1.05 and 0.82 per 1000 person-years, respectively. Adults with AD had a significantly increased risk of incident VTE (HR, 1.28; 95% CI, 1.17-1.40) compared with adults without AD. Individual outcome analyses suggested that AD was associated with higher risks of deep vein thrombosis (HR, 1.26; 95% CI, 1.14-1.40) and pulmonary embolism (HR, 1.30; 95% CI, 1.08-1.57).

Conclusions and Relevance

The results of this cohort study suggest that AD in adulthood is associated with an increased risk of VTE; however, the absolute risk difference of VTE between adults with and without AD appears small. Nevertheless, cardiovascular examination and imperative management may be considered for adults with AD who present with symptoms suggestive of VTE. Future research is warranted to elucidate the pathophysiology underlying the association between AD and VTE.

Elevated plasma complement factor H related 5 protein is associated with venous thromboembolism

Venous thromboembolism (VTE) is a common, multi-causal disease with potentially serious short- and long-term complications. In clinical practice, there is a need for improved plasma biomarker-based tools for VTE diagnosis and risk prediction. Here we show, using proteomics profiling to screen plasma from patients with suspected acute VTE, and several case-control studies for VTE, how Complement Factor H Related 5 protein (CFHR5), a regulator of the alternative pathway of complement activation, is a VTE-associated plasma biomarker. In plasma, higher CFHR5 levels are associated with increased thrombin generation potential and recombinant CFHR5 enhanced platelet activation in vitro. GWAS analysis of ~52,000 participants identifies six loci associated with CFHR5 plasma levels, but Mendelian randomization do not demonstrate causality between CFHR5 and VTE. Our results indicate an important role for the regulation of the alternative pathway of complement activation in VTE and that CFHR5 represents a potential diagnostic and/or risk predictive plasma biomarker.

Clinical manifestations of cancer in patients with acute pulmonary embolism

BACKGROUND

Neoplasmatic disease increases the risk of acute pulmonary embolism (APE) by different pathophysiological mechanisms that favor thrombosis in patients with cancer. Recently, the role of cancer (active and occult) in the prevalence of venous thromboembolism has been discussed more thoroughly in the subject literature.

MATERIAL

Medical records of 366 consecutive patients with a diagnosis of APE (aged: mean = 65.0 ± 16.6, median = 68, range = 19-94; men = 41%/women = 59%) were collected with a wide range of demographic data, medical history of coexisting diseases, computer examination, and laboratory tests.

METHODS

The APE patients were analyzed in two groups: negative cancer cases (83%), i.e. without concomitant active malignancy or a history of cancer, and positive ones (17%), i.e. those hospitalized with concomitant active cancer disease or a history of cancer within the past 5 years.

RESULTS

Based on the application of the Student's t-test for independent samples and the χ2 test of independence, a statistically significant difference (P < 0.05) between cancer (-) and cancer(+) groups of patients was calculated for the following selected risk factors: BMI, smoking status, hemoglobin, hematocrit, red blood cell, urea, glomerular filtration rate, high-sensitivity troponin T, C-reactive protein (CRP), D-dimer, and NT-proBNP. Using univariate Cox regression and a discrete-time hazard model, the estimated hazard ratios and odds ratios, respectively, for the risk of an earlier death from cancer as well as for a secondary APE episode in APE patients with malignancy are more than three times higher than in cancer-free patients and they are statistically significant (P < 0.05). Moreover, the modeled discrete-time hazard curves show a constant excess risk of death and a secondary APE episode in patients diagnosed with malignancy over the period of observation.

CONCLUSION

Cancer and APE seem to go 'hand in hand'. Attention should be paid to many factors, primarily clinical, differentiating patients with cancer from those with an APE incident. The patients with cancer after a primary APE should receive anticoagulants to prevent a secondary APE episode and to reduce the risk of mortality.

Impact of venous thromboembolism on incidence of arterial thromboembolism - An analysis of German outpatient claims data

BACKGROUND

Venous thromboembolism (VTE) and arterial thromboembolism (ATE) are considered as two separate disease-entities. In recent years, studies have reported clear associations between VTE and atherosclerosis. We aimed to evaluate the long-term risk of ATE in VTE patients in comparison to controls without VTE.

METHODS

Nationwide outpatient claims data of all inhabitants with statutory health insurance in Germany were used for secondary data analysis between the years 2011 and 2020. Patients treated in 2013 were stratified by VTE event, and groups were 1:2-matched by age and sex. The hazard for an ATE event in a 5-year follow-up period between patients with and without VTE was calculated with multivariable Cox regression adjusted for age, sex, cardiovascular risk factors, and comorbidities.

RESULTS

Of 69,699,277 individuals treated in the year 2013 by German physicians in outpatient care, in total 686,382 individuals (age 59.8 ± 17.5 years, 65.4 % females) were included comprising 228,794 patients with VTE and 457,588 controls without VTE. VTE patients more often had cardiovascular risk factors (81.6 % vs. 62.2 %) and traditional VTE risk factors. The occurrence of ATE events during follow-up was 1.8 %-points higher in VTE patients in comparison to the controls (9.7 % vs. 7.9 %). VTE events were independently associated with increased occurrence of ATE events within follow-up (HR_adjusted 1.19 [99%CI 1.16-1.23], p < 0.0001).

CONCLUSIONS

Patients with a VTE event have an increased long-term risk for subsequent arterial cardiovascular events. Large prospective cohorts are needed to identify patient subgroups with a very high ATE risk after VTE.

Is Circulating Vitamin D Status Associated with the Risk of Venous Thromboembolism? A Meta-Analysis of Observational Studies

BACKGROUND

Although vitamin D is antithrombotic, associations between serum vitamin D status and the risk of venous thromboembolism (VTE) remain inconsistent.

METHODS

We searched the EMBASE, MEDLINE, Cochrane Library, and Google Scholar databases from inception to June 2022 to identify observational studies examining associations between vitamin D status and VTE risk in adults. The primary outcome presented as odds ratio (OR) or hazard ratio (HR) was the association of vitamin D levels with the risk of VTE. Secondary outcomes included the impacts of vitamin D status (i.e., deficiency or insufficiency), study design, and the presence of neurological diseases on the associations.

RESULTS

Pooled evidence from a meta-analysis of sixteen observational studies, including 47648 individuals published from 2013 to 2021, revealed a negative relationship between vitamin D levels and the risk of VTE either based on OR (1.74, 95% confidence interval (CI): 1.37 to 2.20, p < 0.00001; I² = 31%, 14 studies, 16074 individuals) or HR (1.25, 95% CI: 1.07 to 1.46, p = 0.006; I² = 0%, 3 studies, 37,564 individuals). This association remained significant in subgroup analyses of the study design and in the presence of neurological diseases. Compared to individuals with normal vitamin D status, an increased risk of VTE was noted in those with vitamin D deficiency (OR = 2.03, 95% CI: 1.33 to 3.11) but not with vitamin D insufficiency.

CONCLUSIONS

This meta-analysis demonstrated a negative association between serum vitamin D status and the risk of VTE. Further studies are required to investigate the potential beneficial effect of vitamin D supplementation on the long-term risk of VTE.

Gout and risk of venous thromboembolism: A systematic review and meta-analysis of cohort studies

BACKGROUND

The association between gout and venous thromboembolism (VTE) remains ambiguous, and the results of current studies are inconsistent. A systematic review and meta-analysis of cohort studies were conducted to comprehensively assess the associations between gout and VTE and its subtypes, deep venous thrombosis (DVT) and pulmonary embolism (PE).

METHODS

PubMed, Web of Science, Embase, Scopus, and the Cochrane Library databases were searched up to June 2021, to identify eligible cohort studies, reporting the association of gout with VTE and its subtypes. We pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Subgroup analysis, sensitivity analysis, and publication bias tests were also conducted.

RESULTS

Five studies involving 642 632 individuals were included. Patients with gout had a statistically significantly higher risk of VTE (HR: 1.33; 95% CI: 1.21, 1.46; P < .001) compared with non-gout controls, and significant associations were also found between gout and DVT (HR: 1.40; 95% CI: 1.22, 1.62; P < .001) and PE (HR: 1.18; 95% CI: 1.07, 1.30; P = .001). Subgroup analysis showed this association in men (HR: 1.37; 95% CI: 1.14, 1.65; P = .001) and women (HR: 1.36; 95% CI: 1.21, 1.53; P < .001) were consistent (P = .980). Meta-regression analysis revealed publication year (P = .005) and quality of study (P = .006) contributed to heterogeneity.

CONCLUSIONS

In conclusion, our study provided evidence that gout was associated with the risk of VTE and its subtypes DVT and PE. However, more prospective and high-quality clinical evidence is required to confirm our findings.

Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap.

METHODS

We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe.

RESULTS

From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays.

CONCLUSIONS

ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.

Asymptomatic pulmonary thromboembolism due to hemodialisys catheter thrombosis: case series and literature review

Right atrial thrombus is commonly associated to catheters. Catheter-related right atrial thrombus (CRAT) in hemodialysis patients frequently presents as pulmonary embolism. Although CRAT is sometimes asymptomatic, even in these cases it is associated with worse prognosis. The management strategy for CRAT is not well established, however, along with catheter removal, anticoagulation, thrombolysis, and surgical thrombectomy may be performed. Suspicion of asymptomatic pulmonary embolism associated to CRAT is important in order to perform proper treatment. The authors of this article report two cases of asymptomatic pulmonary thromboembolism due to CRAT in hemodialysis patients and perform a review of the literature.

Risk factors and potential predictors of pulmonary embolism in cancer patients undergoing thoracic and abdominopelvic surgery: a case control study

BACKGROUND

Postoperative pulmonary embolism (PE) is a severe complication leading to death and poor prognosis. The present study investigated the risk factors and potential predictors of PE in cancer patients undergoing thoracic and abdominopelvic surgery.

METHODS

A retrospective study was conducted on the patients with cancer who underwent thoracic and abdominopelvic surgery in Sichuan Cancer Hospital from December 2016 to January 2022. A total of 189 patients were included, in which 63 patients diagnosed PE after operation were collected as PE group, and 126 patients matched by age, type of cancer and cancer location were enrolled as control group. Conditional logistic regression was conducted to analyze the association between PE and risk factors. Predictive values of key factors were compared by the area under the curve (AUC) in receiver operating characteristic curve (ROC) curve.

RESULTS

Conditional multivariate logistic regression showed that BMI (odds ratio [OR] 4.065, 95% confidence interval [CI] 1.138-14.527; p = 0.031), intraoperative hypotension time (OR 4.095, 95% CI 1.367-12.266; p = 0.009), same day fluid balance (OR 0.245, 95% CI 0.061-0.684; p = 0.048), and postoperative D-Dimer (OR 1.693, 95% CI 1.098-2.611; p = 0.017) were significantly related to the occurrence of postoperative PE. Postoperative D-Dimer had the maximal AUC value 0.8014 (95% CI: 0.7260-0.8770) for predicting PE, with a cutoff value of 1.505 μg/ml.

CONCLUSIONS

BMI, intraoperative hypotension time, lower same day fluid balance and postoperative D-dimer are independent risk factors associated with PE in cancer patients undergoing thoracic and abdominopelvic surgery. Postoperative D-Dimer seems to be a good indicator to predict postoperative PE for cancer patients.

Postoperative statin therapy is not associated with reduced incidence of venous thromboembolic events following kidney transplantation

BACKGROUND

The pleiotropic effects of statin therapy on inflammation and coagulation may reduce the risk of venous thromboembolism. This study evaluated whether statin therapy is associated with decreased venous thromboembolic (VTE) events following kidney transplantation.

METHODS

We performed a retrospective analysis of all primary kidney transplants performed between January 2014 and December 2019 at Mayo Clinic Arizona. Patients were divided into two groups depending on sustained statin therapy during the first year following transplantation. Recipient and donor clinical and demographic data were collected. The primary outcome was admission for symptomatic VTE events (deep vein thrombosis [DVT] or pulmonary embolism [PE]).

RESULTS

Sustained statin therapy in the first year following transplant was observed in 16.1% (n = 223) of 1384 kidney transplants. The overall incidence of VTE events in the year following kidney transplant was 3.8%. VTE occurred in 4.1% of recipients treated with statins and 3.8% of the controls - (hazard ratio [HR] .92, 95% confidence interval [95% CI] .39, 2.21, p = .86). However, there were significant differences between the groups in terms of age, sex, race/ethnicity, body mass index, indication for transplant, diagnosis of diabetes and discharge antiplatelet or anticoagulant therapy. Following sensitivity analysis in which cohort matching was performed to account for these differences, there was no difference in VTE event-free survival (HR .89, 95% CI .41, 1.96, p = .78) or overall survival (HR .54, 95% CI .15, 1.94, p = .35) between patients treated with statins compared to controls.

CONCLUSION

Statin therapy in the year following successful kidney transplant was not associated with a reduction in risk of VTE.

Venous Thromboembolism in Cancer Patients Undergoing Chemotherapy: A Systematic Review and Meta-Analysis

Objective: Venous thromboembolism (VTE) is a life-threatening complication that may exacerbate cancer prognosis. Whilst some studies indicate an increased risk of VTE in cancer patients undergoing chemotherapy, the prevalence estimates on the pooled prevalence of VTE in cancer patients undergoing chemotherapy are not known. This study aims to calculate the pooled prevalence of VTE in chemotherapy-treated cancer patients. Methods: Studies on VTE occurrence in cancer patients undergoing chemotherapy were retrieved after database search. The terms used included “cancer”, “chemotherapy”, and “venous thromboembolism”. A random-effects meta-analysis was conducted to obtain a pooled estimate of VTE prevalence in cancer patients undergoing chemotherapy. Results: A total of 102 eligible studies involving 30,671 patients (1773 with VTE, 28,898 without) were included in the meta-analysis. The pooled estimate of VTE prevalence was found to be 6%, ranging from 6% to 7% (ES 6%; 95% CI 6−7%; z = 18.53; p < 0.001). Conclusions: The estimated pooled prevalence rate of VTEs was 6% in cancer patients undergoing CRT, which was higher than the overall crude prevalence rate (5.78%). Comprehensive cancer care should consider stratified VTE risk assessment based on cancer phenotype, given that certain phenotypes of cancer such as bladder, gastric and ovarian posing particularly high risks of VTE.

Glucocorticoid in Combination with a TNF-α Inhibitor: Treatment of Deep Vein Thrombosis in a Patient with Behçet's Disease

A 38-year-old man with deep vein thrombosis associated with Behçet's disease (BD) was admitted to our hospital due to worsening symptoms despite the initiation of direct oral anticoagulants (DOACs). Administration of oral prednisolone and an intravenous anti-tumor necrosis factor-alpha (TNF-α) monoclonal antibody dramatically improved his symptoms. In addition, he was incidentally diagnosed with autosomal dominant polycystic kidney disease, which increases the risk of aortic aneurysms. BD also increases the risk of aortic aneurysms. This case suggests that immunosuppressive treatment is effective in patients with inflammation-related DOAC-refractory venous thrombosis who also suffer from BD.

Association of Combined Lifestyle and Polygenetic Risk with Incidence of Venous Thromboembolism: A Large Population-Based Cohort Study

As one of the fatal complications, venous thromboembolism (VTE) is associated with increased mortality. However, the combined effects of adopting multiple healthy lifestyles have not been firmly demonstrated. This study was to evaluate the association of combined healthy lifestyles and genetic risk factors with VTE and to investigate their interaction. A prospective cohort study from UK Biobank with a total of 442,963 men and women aged between 38 to 73 years were recruited from 2006 to 2010 and followed up through 2017 or 2018. A polygenic risk score was constructed and a weighted healthy lifestyle score, including no current smoking, regular physical exercises, healthy diet, and healthy body mass index, was categorized. During a median follow-up 9.0 years (3,912,396 person-years), there were 6,736 (172 per 100,000 person-years) incident VTE cases recorded. Among the participants with an unfavorable lifestyle, 1.80% developed VTE, versus 1.03% of the participants with a favorable lifestyle (hazard ratio [HR]: 1.58; 95% confidence interval [CI]: 1.48-1.68). Of the participants with high genetic risk, 2.42% developed VTE, versus 0.97% of the participants with low genetic risk (HR: 2.60; 95% CI: 2.39-2.81). Moreover, of the participants with high genetic risk and unfavorable lifestyle, 2.90% developed VTE, versus 0.66% of the participants with low genetic risk and favorable lifestyle (HR: 4.09; 95% CI: 3.48-4.79). No significant interaction between genetic risk and lifestyle factors was observed (p for interaction = 0.727). An unfavorable lifestyle was associated with a substantially higher risk of VTE, regardless of the genetic risk strata.

Warfarin Failure in a Patient With Chronic Thromboembolic Pulmonary Hypertension: A Case Report and Literature Review

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension caused by chronic venous thromboembolism (VTE). Venous thromboembolism (VTE) manifests as deep vein thrombosis (DVT), progressing to pulmonary embolism (PE). Pulmonary endarterectomy (PEA) is the preferred therapeutic option as it provides vascular disobliteration. Long-term anticoagulation with warfarin or direct oral anticoagulants (DOACs) is recommended for patients at risk for recurrent DVT in poor surgical candidates. However, treatment failure remains a concern. We present a patient who had VTE despite long-term anticoagulation with warfarin who had failed treatment and developed VTE with a therapeutic dilemma to continue anticoagulation despite supratherapeutic international normalized ratio (INR).

Pulmonary embolism and deep vein thrombosis—comorbidities and temporary provoking factors in a register‐based study of 1.48 million people

Background

Knowledge on differences in patients who present with deep vein thrombosis (DVT) and those with pulmonary embolism (PE) is incomplete.

Objective

To determine comorbidities and temporary provoking factors in patients with a first‐time PE or DVT.

Methods

This was a nationwide Swedish registry‐based, retrospective, case‐control study including 298 172 patients with first‐time venous thromboembolism (VTE) and 1 185 079 controls matched for age, sex, and county of residence, free of VTE at the time of matching.

Results

Patients with PE were older than those with DVT (mean age, 69 vs 66 years) and included slightly more women (PE, 53.4% vs DVT, 52.1%). After multivariable adjustment for comorbidities (within 7 years) and temporary provoking factors (within 3 months), heart failure (PE: adjusted odds ratio [aOR], 2.64 [99% confidence interval [CI], 2.55‐2.73]; DVT: aOR, 1.66 [99% CI, 1.60‐1.72]), ischemic heart disease (PE: aOR, 1.51 [99% CI, 1.47‐1.56]; DVT: aOR, 1.01 [99% CI, 0.98‐1.04]), and chronic obstructive pulmonary disease (PE: aOR, 2.51 [99% CI, 2.40‐2.63]; DVT, 1.54 [99% CI, 1.47‐1.62]) were among diseases that showed higher odds ratios in patients with PE than in those with DVT, compared with controls. Comorbidities registered within 6 months were associated with higher aORs than those within 7 years. The highest population attributable risks for PE were for cancer (13.0%) and heart failure (11.7%).

Conclusion

Cardiopulmonary diseases, particularly with recent onset, imply a higher risk for PE, whereas orthopedic surgery and lower‐extremity fractures carry a higher risk of DVT.

Hereditary Thrombophilia in the Era of COVID-19

Thrombophilia, also called hypercoagulability or prothrombotic condition, usually reflects a certain imbalance that occurs either in the coagulation cascade or in the anticoagulation/fibrinolytic system. A similar imbalance may be induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thrombotic complications are associated with multiorgan failure and increased mortality. In this context, activation of coagulation and thrombocytopenia appeared as prognostic markers in COVID-19. Our work provides a structured and updated analysis of inherited thrombophilia and its involvement in COVID-19, emphasizing the importance of diagnosing and initiating thromboprophylaxis. Since the state of hypercoagulation is directly correlated with COVID-19, we consider that studies on the genetic profiles of proteins involved in thrombophilia in patients who have had COVID-19 and thrombotic events are of great importance, both in treating and in preventing deaths due to COVID-19.

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.

Invasive and Pharmacological Treatment of Deep Vein Thrombosis: a Scoping Review

The annual occurrence of venous thromboembolism (VTE) is 300,000-600,000 cases in the United States and 700,000 in Europe. VTE includes deep venous thrombosis (DVT) of upper or lower extremities, superior and inferior vena cava thrombosis, and pulmonary embolism (PE) as well. The primary treatment of DVT includes oral anticoagulation to prevent the progression of the thrombus and decrease the risk of pulmonary embolism. Depending on the symptoms, more invasive treatments can be applied to target the iliofemoral thrombus and its removal. However, less emphasis is given to acute symptomatology, early recovery of function, quality of life improvement, and the individualized likelihood of developing post-thrombotic syndrome. While invasive therapy has been used to enhance the acute management of iliofemoral DVT, our knowledge about the overall outcomes associated with the invasive treatment of VTE is still limited. In this review, we illustrate the available data on pharmacological and endovascular management of iliofemoral VTE, including therapies such as catheter-directed thrombolysis (CDT), mechanical thrombectomy (PMT), and pharmacomechanical catheter-directed thrombolysis (PCDT).

Characteristics and outcomes of cancer patients who develop pulmonary embolism: A cross‑sectional study

Pulmonary embolism (PE), along with deep vein thrombosis, are collectively known as venous thromboembolism (VTE). Predisposing factors for PE include post-operative conditions, pregnancy, cancer and an advanced age; of note, a number of genetic mutations have been found to be associated with an increased risk of PE. The association between cancer and VTE is well-established, and cancer patients present a higher risk of a thrombotic event compared to the general population. In addition, PE is a significant cause of morbidity and mortality among cancer patients. The aim of the present study was to illustrate the clinical characteristics, laboratory findings, radiology features and outcomes of cancer patients who developed PE, collected from an anticancer hospital. For this purpose, adult cancer patients diagnosed with PE by imaging with computed tomography pulmonary angiography were enrolled. The following data were recorded: Demographics, comorbidities, type of cancer, time interval between cancer diagnosis and PE occurrence, the type of therapy received and the presence of metastases, clinical signs and symptoms, predisposing factors for PE development, laboratory data, radiological findings, electrocardiography findings, and the type of therapy received for PE and outcomes in a follow-up period of 6 months. In total, 60 cancer patients were enrolled. The majority of the cancer patients were males. The most common type of cancer observed was lung cancer. The majority of cases of PE occurred within the first year from the time of cancer diagnosis, while the majority of patients had already developed metastases. In addition, the majority of cancer patients had received chemotherapy over the past month, while they were not receiving anticoagulants and had central obstruction. A large proportion of patients had asymptomatic PE. The in-hospital mortality rate was 13.3% and no relapse or mortality were observed during the follow-up period. The present study demonstrates that elevated levels of lactic acid and an increased platelet count, as well as low serum levels of carcinoembryonic antigen, albumin and D-dimer, may be potential biomarkers for asymptomatic PE among cancer patients.

Evaluation of the modified Wells score in predicting venous thromboembolic disease in patients with tuberculosis or HIV in a South African setting

Background

There is paucity of data on the modified Wells score (MWS) utility on patients with venous thromboembolism (VTE) in a South African setting where there is a high burden of HIV and tuberculosis (TB). This study analyses the performance of this score in HIV/TB-infected patients compared with non-infected patients.

Objectives

To assess the performance of the MWS as an additional risk factor for VTE in hospitalised patients with a high burden of HIV/TB infections.

Method

This study was a retrospective cross-sectional cohort analysis of the utility of the MWS in 156 HIV/TB-infected and non-infected adult patients diagnosed with VTE on compression ultrasonography (CUS) or computed tomography pulmonary angiography (CTPA) in a medical inpatient setting over six months. Patients with HIV and/or TB were assessed as having an additional risk factor (1 point for each), and this was compared with the MWS. A McNeymar’s paired sample chi-squared test was used to compare the sensitivity of this score against the MWS.

Results

Of the 156 patients with VTE who were enrolled, HIV was the commonest risk factor (42.31%) with TB accounting for 10.90% of cases. When the MWS adjusted for HIV/TB was used, the sensitivity increased from 25% to 100% for the HIV–/TB+ category, it increased from 77.36% to 98.11% in the HIV+/TB– category and it increased from 84.62% to 92.95% in the HIV+/TB+ category. These differences were statistically significant at P < 0.05 in all categories.

Conclusion

The MWS performs better when the infectivity of HIV/TB is included as an additional risk factor in the score.

Epidemiological status and risk factors of deep vein thrombosis in patients with femoral neck fracture

Objectives

The purpose of this study was to investigate the incidence of deep vein thrombosis (DVT) and clarify the risk factors of DVT in patients with femoral neck fracture.

Methods

A self-designed questionnaire was used to collect the clinical data of 1209 patients with femoral neck fracture in our hospital from January 2019 to December 2019. The content of the questionnaire mainly includes general information, past medical history, history of present illness, operation related information, occurrence of DVT. The collected data were entered into Excel to analyze the incidence and risk factors of DVT in patients with femoral neck fracture. Chi square test and binary logistic regression model was used to screen the risk factors of DVT.

Results

1209 cases of femoral neck fracture were included in this study. The incidence of DVT was 28.0% (339 patients). Among them, 71.7% (243 patients) were preoperative DVT and 28.3% (96 patients) were postoperative DVT. For the risk-factor analysis, gender, age, time from injury to hospitalization, operative method, anesthesia method and intraoperative blood loss were independent risk factors for DVT.

Conclusion

The incidence of DVT in patients with femoral neck fracture is relatively high, and there are many related risk factors.

Glucocorticoids and Risk of Venous Thromboembolism in Asthma Patients Aged 20-59 Years in the United Kingdom's CPRD 1995-2015

BACKGROUND

Glucocorticoids, the class of steroids used in management of asthma, have been observed to be associated with adverse events such as increased coagulation and inhibition of fibrinolysis. This study evaluated the risk of VTE in relation to the use of glucocorticoids in patients with asthma.

METHODS

We conducted a nested case-control study among patients aged 20-59 years with asthma who received at least one glucocorticoid prescription during 1995-2015 in the UK-based Clinical Practice Research Datalink GOLD. We used descriptive analyses and conditional logistic regression to evaluate the risk of VTE associated with glucocorticoid use.

RESULTS

The adjusted ORs (aORs) (95% CI) for VTE in patients exposed to glucocorticoids were 1.9 (1.6-2.3), 1.4 (1.1-1.8), and 1.2 (0.9-1.5) for current, recent, and past glucocorticoid users, respectively, compared to the unexposed. The aORs (95% CI) for VTE in patients exposed to systemic glucocorticoid and inhaled glucocorticoids, compared to the unexposed, were 3.5 (2.7-4.5) and 1.5 (1.3-1.8), respectively.

CONCLUSION

Current and systemic glucocorticoid use was associated with a dose-response increased risk of incident idiopathic VTE.

Awareness and Perception of Hospitalized Patients on Thromboembolism and Thromboprophylaxis: A Cross-Sectional Study in Sana'a-Yemen

PURPOSE

Patients' awareness toward VTE and thromboprophylaxis is critical for medication adherence. This study aimed to evaluate the patient's awareness and perception towards VTE and its prophylaxis and to assess patient's satisfaction towards the information given by the medical staff.

PARTICIPANTS AND METHODS

A cross-sectional survey was conducted among hospitalized patients who received VTE prophylaxis in public and private hospitals in Sana'a, Yemen. Besides sociodemographic variables, participants' awareness and perception of VTE and its prophylaxis were evaluated. Variables' association with VTE awareness were analyzed using univariable and multivariable logistic regression using SPSS.

RESULTS

A total of 396 of the hospitalized patients agreed to participate in the study, with 31% (n = 121) have ever heard about VTE. The multivariable logistic regression findings revealed that the participants who did not have a profession had OR = 17.182 (P < 0.001) of being unaware of VTE compared with those who had one. Participants who did not have a personal history of VTE had OR = 7.580 (P < 0.001) of being unaware of DVT/PE compared with the participants who had a personal history of VTE. Male participants had OR = 2.839 (P < 0.005) of being unaware of DVT/PE compared with female participants. Participants who were illiterate had OR = 2.832 (P < 0.022) of being unaware of DVT/PE compared with participants with a higher level of education.

CONCLUSION

The study revealed lack of awareness and perception of VTE and its prophylaxis among hospitalized patients in Yemen. The patients who are unaware of the disease have wrong perception about their role in DVT prophylaxis. Patient's education must be considered in healthcare setting to improve patient's health outcomes.

Exosomal myeloperoxidase as a biomarker of deep venous thrombosis

BACKGROUND

Deep vein thrombosis (DVT) often occurs following major orthopedic surgery. In this study, we investigated specific exosomal proteins as potential diagnostic biomarkers of DVT.

METHODS

Proteomic analysis of exosomes from four DVT patients and healthy controls (n=4) was performed by mass spectrometry. The model animals were evaluated at 1 inferior vena cava ligation [(IVCL)-1D], 3 (IVCL-3D), and 7 (IVCL-7D) days after IVCL. Endothelial cells in the thrombus segment were examined using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assays and hematoxylin and eosin (HE) staining. Myeloperoxidase (MPO) expression in the damaged vessel was detected by immunofluorescence staining. Exosomes were co-cultured with human umbilical vein endothelial cells (HUVECs) and cell proliferation was estimated using Cell Counting Kit-8 (CCK-8) assays.

RESULTS

A total of 78 differentially expressed proteins (DEPs; 38 downregulated and 40 upregulated) were identified in the DVT group. In the rat DVT model, endothelial cells were damaged continuously after thrombosis, with the most serious injury in the IVCL-3D group, after which signs of endothelial repair were apparent. The IVCL-1D group showed the highest levels of vascular endothelial cell apoptosis and MPO increased sharply in the IVCL-1D and IVCL-3D groups, but had almost disappeared in the IVCL-7D group. In co-culture, plasma exosomes isolated from DVT model rats were efficiently absorbed by HUVECs, with markedly lower HUVECs growth and higher levels of apoptosis in the IVCL-1D and IVCL-3D groups compared with the control group.

CONCLUSIONS

Our findings suggest that exosomes may be involved in endothelial cell injury during DVT. The exosomal protein MPO is a potential biomarker of early stage DVT.