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Qiu YH, Yang Z, Yang FJ, Su X, Chen BC, Ni HZ. Prophylactic Dose of Rivaroxaban Versus Warfarin for the Treatment of Isolated Calf Muscle Vein Thrombosis: A Retrospective Propensity Score-Matched Analysis. Ann Vasc Surg 2024; 108:508-518. [PMID: 39025209 DOI: 10.1016/j.avsg.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/14/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Prophylactic dose of rivaroxaban is often used in treatment of isolated calf muscle vein thrombosis (ICMVT); nevertheless, its effect is less reported. This study aims to evaluate short-term outcomes in patients with ICMVT who received prophylactic dose of rivaroxaban or warfarin therapy. METHODS A retrospective analysis of 472 ICMVT patients who received 2 different treatment regimens was undertaken. Propensity score matching method was used to balance the confounding effect of baseline clinical data. Chi-squared test and logistic regression analysis were used to compare outcomes (venous thromboembolism events, bleeding events, complete clot resolution) according to the type of treatment regimens before and after propensity score matching. Univariate and multivariable analysis were used to investigate risk factors for incomplete clot resolution of ICMVT after propensity score matching. RESULTS 242 ICMVT patients received prophylactic dose of rivaroxaban (rivaroxaban group, RG), and 230 received warfarin (warfarin group, WG). After propensity score matching, 156 patients were included in each group; Venous thromboembolism (VTE) events occurred in 14 (9.0%) patients in the RG and 10 (6.4%) in the WG (P = 0.395); no major bleeding events occurred in each group, and clinically relevant nonmajor bleeding events occurred in 5 (3.2%) patients in the RG and 10 (6.4%) in the WG (P = 0.186); complete clot resolution at 3 months occurred in 80 (51.3%) patients in the RG and 100 (64.1%) in the WG (P = 0.022). Logistic regression analysis showed that there were no significant differences between RG and WG in VTE events (odds ratio 1.439, 95% confidence interval 0.619-3.347, P = 0.397) and clinically relevant nonmajor bleeding events (odds ratio 0.483, 95% confidence interval 0.161-1.449, P = 0.194); it revealed that complete clot resolution rate at 3 months was different in the 2 groups (odds ratio 0.589, 95% confidence interval 0.375-0.928, P = 0.022). Treatment regimens (prophylactic dose of rivaroxaban), thrombosis (maximum diameter >7 mm), and risk factors for VTE (nonsurgery risk factors, mainly referring to active malignancy) were risk factors for incomplete clot resolution of ICMVT (P < 0.05). CONCLUSIONS In this retrospective study with a short-term follow-up, ICMVT patients who received prophylactic dose of rivaroxaban had no significant differences in VTE and bleeding events compared to those who received warfarin therapy (the overall INR >2.0 for >50% of the time); but it was not conducive to complete clot resolution.
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Affiliation(s)
- Yi-Hui Qiu
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhe Yang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fa-Jing Yang
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiang Su
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Bi-Cheng Chen
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
| | - Hai-Zhen Ni
- Department of Vascular Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Wang Z, Lu Y, Wang P, Fei C, Li S, Xue H, Li Z, Wang Q, Zhang K, Ma T. Suboptimal Use of DOACs Post-Discharge for Geriatric Hip Fractures with Isolated Calf Deep Vein Thrombosis: Do Clinician Prescribing Preferences and Patient Compliance Alters Clinical Outcomes? Clin Interv Aging 2023; 18:1423-1436. [PMID: 37663122 PMCID: PMC10473050 DOI: 10.2147/cia.s421422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/06/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction This study aimed to examine the impacts of DOACs compliance and prescribing preferences on clinical outcomes in elderly hip fracture patients with isolated calf deep vein thrombosis (ICDVT). Methods We conducted a retrospective cohort study that evaluated 702 patients who underwent surgical treatment combined with ICDVT in an academic university hospital between January 2016 and October 2021. DOACs compliance was investigated through telephone and outpatient follow-up, and ICDVT clinical outcomes were collected 30 and 90 days post-discharge, respectively. Variables of interest were collected through the electronic medical record system, and data were analyzed after adjusting for predictors of non-completely dissolved (CD) of ICDVT. Results The DOACs compliance survey revealed that 375 (53.42%) patients were fully adherent, 270 (38.46%) were fairly adherent, and 57 (8.12%) were poorly adherent. Approximately 62% of patients had ICDVT dissipation within 30 days after discharge, reaching 94% within 90 days. DOACs QD/BID regimen is often based on economic status, activity capacity, discharge destination and post-operative weight-bearing activities (p<0.05).The mechanism of injury, ASA classification, surgical technique and timing of ICDVT formation were significantly correlated with DOACs 14/28 days regimen (p<0.05).Multivariate analysis revealed that rural patients [OR 1.518 (95% CI, 1.117-2.236)], pre-operative ICDVT[OR 2.816 (95% CI, 1.862-4.259)] and thrombus length [OR 1.157 (95% CI, 1.263-1.821)] were ICDVT risk factors for non-CD. Furthermore, DOACs fair compliance [OR 0.087 (95% CI, 0.042-0.178)], DOACs full compliance [OR 0.283 (95% CI, 0.139-0.579)], and hospitalization duration [OR 0.793 (95% CI, 0.694-0.907)] were ICDVT protective factors for CD. Conclusion Better compliance with DOACs benefits early ICDVT dissipation, but final clinical outcomes have to be validated with longer follow-up periods. When managing elderly patients with hip fractures, indications for anticoagulation should be considered and individualized protocols should be used.
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yao Lu
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Pengfei Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Chen Fei
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Shuhao Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Hanzhong Xue
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhong Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qian Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Kun Zhang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Teng Ma
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
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Liu L, Zhou J, Zhang Y, Lu J, Gan Z, Ye Q, Wu C, Xu G. A Nomogram for Individualized Prediction of Calf Muscular Vein Thrombosis in Stroke Patients During Rehabilitation: A Retrospective Study. Clin Appl Thromb Hemost 2022; 28:10760296221117991. [PMID: 35942697 PMCID: PMC9373120 DOI: 10.1177/10760296221117991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: To develop a nomogram for predicting calf muscle veins thrombosis (CMVT) in stroke patients during rehabilitation. Methods: We enrolled 360 stroke patients from the Rehabilitation Medicine Center from December 2015 to February 2019. Of the participants, 123 were included in the CMVT group and 237 in the no CMVT group. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize feature selection for the model. Multivariable logistic regression analysis was applied to construct a predictive model. Performance and clinical utility of the nomogram were generated using the Harrell's concordance index, calibration curve, and decision curve analysis (DCA). Results: Age, Brunnstrom stage (lower extremity), D-dimer, and antiplatelet therapy were associated with the occurrence of CMVT. The prediction nomogram showed satisfactory performance with a concordance index of 0.718 (95% CI: 0.663-0.773) in internal verification. The Hosmer-Lemeshow test, P = .217, suggested that the model was of goodness-of-fit. In addition, the DCA demonstrated that the CMVT nomogram had a good clinical net benefit. Conclusions: We developed a nomogram that could help clinicians identify high-risk groups of CMVT in stroke patients during rehabilitation for early intervention.
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Affiliation(s)
- Lingling Liu
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Zhou
- 74734Department of Ultrasonography, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - YiQing Zhang
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Lu
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhaodan Gan
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qian Ye
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chuyan Wu
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guangxu Xu
- 74734School of Rehabilitation Medicine, Nanjing Medical University, Rehabilitation Medicine Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ren Z, Yuan Y, Qi W, Li Y, Wang P. The incidence and risk factors of deep venous thrombosis in lower extremities following surgically treated femoral shaft fracture: a retrospective case-control study. J Orthop Surg Res 2021; 16:446. [PMID: 34243792 PMCID: PMC8268537 DOI: 10.1186/s13018-021-02595-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background There is still a lack of data on deep vein thrombosis (DVT) following surgically treated femoral shaft fracture (FSF). The goal of this study was to investigate the characteristics of postoperative DVT and the association between the occurrence of DVT and risk factors in patients undergoing surgical treatment for FSF. Methods This observational retrospective case-control study reviewed 308 patients who received surgical treatment of FSF between January 2016 and October 2020 at a university hospital. Univariate analyses were performed on the data of demographics, comorbidities, laboratory biomarkers, and operation-related indexes. The receiver operating characteristic (ROC) curve analysis, univariate analyses, and multivariate logistic regression analysis were employed to identify the independent risk factors associated with DVT. Results In total, 308 patients with surgically treated FSF were included, among whom 48 (15.6%) patients had postoperative DVTs. The univariate analyses showing significant differences regarding DVT were American Society of Anesthesiologists (ASA) classification, diabetes mellitus, current smoking, aspartate transaminase (AST), and very-low-density lipoprotein (VLDL) level among the 34 factors. According to the ROC results, the optimal cutoff values for intraoperative blood loss, d-dimer, and age were 350 ml, 1.08 μg/ml, and 35 years, respectively. The multivariable model demonstrated 4 significantly independent associations with postoperative DVT, including current smoking, intraoperative blood loss (> 550 ml), age (> 35 years), and d-dimer > 1.09 μg/ml. Conclusion These risk factors as screening tools contribute to risk stratification of the occurrence of thromboembolic events. In addition, our findings would help orthopedic surgeons make a cross-specialty decision and implement targeted precaution measures for patients with FSF.
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Affiliation(s)
- Zhixin Ren
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yufei Yuan
- Department of Orthopaedic Surgery, Handan Central Hospital, Handan, 056000, Hebei, People's Republic of China
| | - Wei Qi
- Department of Orthopaedic Surgery, The First People's Hospital of Taian, Tai'an, 271000, Shandong, People's Republic of China
| | - Yanbao Li
- Department of Orthopaedic Surgery, Handan Central Hospital, Handan, 056000, Hebei, People's Republic of China
| | - Pengcheng Wang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Chen C, Liu Y, Wu H, Feng J, Li A, Wu Z. The outcome of isolated calf muscle vein thrombosis after open reduction and internal fixation for closed intra-articular distal femur fractures: a prospective cohort study. BMC Musculoskelet Disord 2021; 22:397. [PMID: 33910542 PMCID: PMC8082779 DOI: 10.1186/s12891-021-04289-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 04/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background To observe the outcome of isolated calf muscle vein thrombosis (ICMVT) undergoing open reduction and internal fixation (ORIF) for closed intra-articular distal femur fractures (DFFs) and to analyze related factors. Methods The study was designed as a prospective clinical cohort study at our hospital. From August 2018 to August 2020,a total of 140 patients with flesh ICMVT after ORIF for closed intra-articular DFFs were collected during hospitalization. After the administration of antithrombotic agents immediately after diagnosis, the location and prognosis of postoperative ICMVT were examined by Duplex ultrasonography (DUS) with a three-month follow-up. There were 29 males and 111 females with the average age of 70.16 ± 8.75 years old. Sonography was used to evaluate the resolution of muscular vein thrombosis at the time point of the third month postoperatively and the results were compared between the two time points. Multivariable analysis was performed to evaluate the relationship between the resolution of ICMVT three months postoperatively and risk factors including age, Body Mass Index (BMI), gender, thrombosis length (> 5 / ≤5 cm), thrombosis diameter(> 0.6/≤0.6 cm), and thrombosis-related biochemistry indices. Results The postoperative ICMVTs was diagnosed at 5.47 ± 2.46 days after ORIF for closed intra-articular DFFs. At the follow up of 3 months,120 cases was tending to disappear with 88 cases(62.9 %) completely dissolved and 32 cases(22.9 %) partly dissolved. There existed 14 cases (10.0 %) without change on the size and 6 cases (4.2 %) with proximal propagation. Multivariate analysis revealed that thrombus diameter over 0.6 cm (odds ratio [OR], 8.900; 95 % confidence interval [CI]: 3.623–21.865), thrombus length over 5.0 cm (OR, 3.904; 95 % CI, 1.121–13.603), FIB over 3.0 g/L (OR, 3.627; 95 % CI, 1.356–9.689), and D-dimer over 1.0 mg/L (OR, 2.602; 95 % CI, 1.075–6.296) were four independent risk factors of non-completely dissolved ICMVTs. Conclusions 85.8 % of ICMVT was tending to disappear at the third months after ORIF for closed intra-articular DFFs. Thrombus diameter, thrombus length, FIB, and D-dimer were four independent risk factors of non-completely dissolved ICMVTs. The Thrombus diameter has a significant effect on the natural course of ICMVTs, especially with diameter larger than 0.6 cm.
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Affiliation(s)
- Chen Chen
- Department of Nuclear Medicine, the People's Hospital of Yuxi City, the Sixth Affiliated Hospital of Kunming Medical University, 653100, Yuxi, Yunnan, People's Republic of China
| | - Ying Liu
- Department of Nuclear Medicine, the Second Affiliated Hospital of Guangzhou Medicine University, No. 250 Changgang East Road, Guangdong, 510260, Guangzhou, People's Republic of China
| | - Hengfu Wu
- Department of Nuclear Medicine, the Second Affiliated Hospital of Guangzhou Medicine University, No. 250 Changgang East Road, Guangdong, 510260, Guangzhou, People's Republic of China
| | - Jingmin Feng
- Department of Nuclear Medicine, the Second Affiliated Hospital of Guangzhou Medicine University, No. 250 Changgang East Road, Guangdong, 510260, Guangzhou, People's Republic of China
| | - Ao Li
- Department of Nuclear Medicine, the Second Affiliated Hospital of Guangzhou Medicine University, No. 250 Changgang East Road, Guangdong, 510260, Guangzhou, People's Republic of China
| | - Zhaozhong Wu
- Department of Nuclear Medicine, the Second Affiliated Hospital of Guangzhou Medicine University, No. 250 Changgang East Road, Guangdong, 510260, Guangzhou, People's Republic of China.
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Zhu Y, Chen W, Li J, Zhao K, Zhang J, Meng H, Zhang Y, Zhang Q. Incidence and locations of preoperative deep venous thrombosis (DVT) of lower extremity following tibial plateau fractures: a prospective cohort study. J Orthop Surg Res 2021; 16:113. [PMID: 33546695 PMCID: PMC7863261 DOI: 10.1186/s13018-021-02259-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022] Open
Abstract
Background There is still lack of data on deep vein thrombosis (DVT) following bone trauma. This study aimed to determine the epidemiologic characteristics of deep venous thrombosis (DVT) of lower extremities following tibial plateau fractures. Methods Retrospective analysis of prospectively collected data on patients presenting with tibial plateau fractures between October 2014 and December 2018 was conducted. Duplex ultrasonography (DUS) was routinely used to screen for preoperative DVT of bilateral lower extremities. Data on demographics, comorbidities, injury-related data, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors associated with DVT. Results A total of 1179 patients were included, among whom 192 (16.3%) had a preoperative DVT, with incidence rate of 1.0% for proximal and 15.3% for distal DVT. The average interval between fracture occurrence and diagnosis of DVT was 3.5 days (median, 2 days), ranging from 0 to 19 days. DVT involved the injured extremity in 166 (86.4%) patients, both the injured and uninjured extremities in 14 patients (7.3%) and only the uninjured extremity in 12 patients (6.3%). Six risk factors were identified to be associated with DVT, including gender (male vs female), hypertension, open fracture, alkaline phosphatase > 100 u/L, sodium concentration < 135 mmol/L, and D-dimer > 0.5 mg/L. Conclusion These epidemiologic data are conducive to the individualized assessment, risk stratification, and development of targeted prevention programs.
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Affiliation(s)
- Yanbin Zhu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Junyong Li
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Junzhe Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Hongyu Meng
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Chinese Academy of Engineering, Beijing, 100088, People's Republic of China. .,NHC Key Laboratory of Intelligent Orthopeadic Equipment, Shijiazhuang, Hebei, 050051, P.R. China.
| | - Qi Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Li J, Zhu Y, Chen W, Zhao K, Zhang J, Meng H, Jin Z, Ye D, Zhang Y. Incidence and locations of deep venous thrombosis of the lower extremity following surgeries of tibial plateau fractures: a prospective cohort study. J Orthop Surg Res 2020; 15:605. [PMID: 33317585 PMCID: PMC7735415 DOI: 10.1186/s13018-020-02136-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/30/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To investigate the incidence of deep venous thrombosis (DVT) of the lower extremities following surgeries of tibial plateau fractures. METHODS Retrospective analysis of the prospectively collected data on patients undergoing surgeries of tibial plateau fractures between October 2014 and December 2018 was conducted. Duplex ultrasonography (DUS) was used to screen for postoperative DVT of the bilateral lower extremities. Data on demographics, comorbidities, injury, surgery, and laboratory biomarkers at admission were collected. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors associated with DVT. RESULTS Among 987 patients included, 46 (4.7%) had postoperative DVT, with incidence rate of 1.0% for proximal and 3.7% for distal DVT. The average interval between operation and DVT was 8.3 days (median, 5.8 days), ranging from 2 to 42 days. DVT involved the injured extremity in 39 (84.8%) patients, both the injured and uninjured extremity in 2 patients (4.3%) and only the uninjured extremity in 5 patients (10.9%). Five risk factors were identified to be associated with postoperative DVT, including age (≥ 41 vs < 41 years) (OR 3.08; 95% CI 1.43-6.61; p = 0.004), anesthesia (general vs regional) (OR 2.08; 95% CI 1.12-3.85; p = 0.021), hyponatremia (OR 2.21; 95% CI 1.21-4.06; p = 0.010), prolonged surgical time (OR 1.04; 95% CI 1.01-1.07; p = 0.017) and elevated D-dimer level (OR 2.79; 95% CI 1.34-4.83; p = 0.004). CONCLUSION These epidemiologic data may be helpful in individualized assessment, risk stratification, and development of targeted prevention programs.
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Affiliation(s)
- Junyong Li
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- The Second Hospital of Shijiazhuang City, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Junzhe Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Hongyu Meng
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Zhucheng Jin
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Dandan Ye
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051 Hebei PR China
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051 Hebei PR China
- NHC Key Laboratory of Intelligent Orthopeadic Equipment, Hebei 050051 Shijiazhuang, People’s Republic of China
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Zixuan L, Chen W, Li Y, Wang X, Zhang W, Zhu Y, Zhang F. Incidence of deep venous thrombosis (DVT) of the lower extremity in patients undergoing surgeries for ankle fractures. J Orthop Surg Res 2020; 15:294. [PMID: 32736663 PMCID: PMC7393865 DOI: 10.1186/s13018-020-01809-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/22/2020] [Indexed: 12/23/2022] Open
Abstract
Objective To investigate the incidence of postoperative deep venous thrombosis (DVP) in patients undergoing surgeries for ankle fractures and identify the associated risk factors. Methods This was a retrospective study. A total of 1451 patients undergoing surgery of ankle fractures from January 2016 to June 2019 were included. The inpatient medical record system was inquired for data collection, including demographics, comorbidities, injury, and surgery-related data, and laboratory biomarkers. DVT of the lower extremity was diagnosed by routine Doppler examination. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Results Among the 1451 patients, DVT was confirmed in 38 cases, indicating an incidence of 2.6%. DVT involved both the operated and non-operated limbs in 8 patients (21.1%). DVT involved superficial femoral vein in 4 cases (6.6%), deep femoral vein in 2 (3.3%), popliteal vein in 5 (8.2%), posterior tibial vein in 11 (18.0%), and peroneal vein in 39 (63.9%). The median interval between operation and diagnosis of DVT was 7 days. Six risk factors were identified to be independently associated with DVT, including age (10-year increase) (OR, 1.44), preoperative stay (delay of each day) (OR, 1.11), anesthesia (general vs regional) (OR, 3.51), lower hemoglobin level (OR, 2.02), total cholesterol > 5.2 mmol/L (OR, 3.20), and reduced lymphocyte count (OR, 3.16). Conclusion These identified factors, although not easily modifiable, do help counsel patients about the risk of DVT and help individualized assessment of the risk factors and accordingly the risk stratification.
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Affiliation(s)
- Luo Zixuan
- Department of Foot and Ankle Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yansen Li
- Department of Foot and Ankle Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xiaomeng Wang
- Department of Foot and Ankle Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Weili Zhang
- Department of Foot and Ankle Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Fengqi Zhang
- Department of Foot and Ankle Surgery, The 3rd Hospital of Hebei Medical University, NO.139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Liu D, Zhu Y, Chen W, Li J, Zhao K, Zhang J, Meng H, Zhang Y. Relationship between the inflammation/immune indexes and deep venous thrombosis (DVT) incidence rate following tibial plateau fractures. J Orthop Surg Res 2020; 15:241. [PMID: 32616051 PMCID: PMC7331237 DOI: 10.1186/s13018-020-01765-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/26/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To determine the relationship between inflammation/immune-based indexes and deep venous thrombosis (DVT) incidence rate following tibial plateau fractures Methods Retrospective analysis of a prospectively collected data on patients undergoing surgeries of tibial plateau fractures between October 2014 and December 2018 was performed. Duplex ultrasonography (DUS) was routinely used to screen for preoperative DVT of bilateral lower extremities. Data on biomarkers (neutrophil, lymphocyte, monocyte, and platelet counts) at admission were collected, based on which neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), monocyte/lymphocyte (MLR), and systemic immune-inflammation index (SII, neutrophil* platelet/lymphocyte) were calculated. Receiver operating characteristic (ROC) was used to determine the optimal cutoff value for each variable. Multivariate logistic regression analysis was used to evaluate the independent relationship of each biomarker or index with DVT, after adjustment for demographics, co-morbidities, and injury-related variables. Results Among 1179 patients included, 16.3% (192/1179) of them had a preoperative DVT. Four factors were identified to be significantly associated with DVT, including open fracture, increased D-dimer level. Among the biomarkers and indexes, only platelet and neutrophil were identified to be independently associated with DVT, and the significance remained after exclusion of open fracture. The other independent variables were elevated D-dimer level (> 0.55 mg/L), male gender, and hypertension in the sensitivity analysis with open fractures excluded. Conclusion These identified factors are conducive to the initial screening for patients at risk of DVT, individualized risk assessment, risk stratification, and accordingly, development of targeted prevention programs.
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Affiliation(s)
- Dawei Liu
- Department of Orthopaedic Surgery, Tianjin Nankai Hospital, Tianjin, 300100, P. R. China
| | - Yanbin Zhu
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Wei Chen
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Junyong Li
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Junzhe Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Hongyu Meng
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China.,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The 3rd Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, P. R. China. .,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China. .,Orthopaedic Institution of Hebei Province, Shijiazhuang, 050051, Hebei, P. R. China. .,Chinese Academy of Engineering, Beijing, 100088, P. R. China.
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11
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Preoperative incidence and locations of deep venous thrombosis (DVT) of lower extremity following ankle fractures. Sci Rep 2020; 10:10266. [PMID: 32581237 PMCID: PMC7314767 DOI: 10.1038/s41598-020-67365-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/04/2020] [Indexed: 11/18/2022] Open
Abstract
This retrospective study aimed to investigate the preoperative incidence and locations of deep venous thrombosis (DVT) in patients undergoing surgeries for ankle fractures and identify the associated risk factors. From January 2016 to June 2019, 1,532 patients undergoing surgery of ankle fractures were included. Their inpatient medical records were inquired for data collection, including demographics, comorbidities, injury-related data and preoperative laboratory biomarkers. DVT of bilateral lower extremities was diagnosed by routine preoperative Doppler examination. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors. Totally, 98 patients had a preoperative DVT, indicating an incidence rate of 6.4%. A total of 164 clots for 6 veins were found, representing an average of 1.7 for each patient. The detailed DVTs involving veins were as follows: 2 in femoral common vein, 7 in superficial femoral vein, 2 in deep femoral vein, 16 in popliteal vein, 49 in posterior tibial vein, and 88 in peroneal vein. In the multivariate model, 5 risk factors were identified to be associated with DVT, including age (10-year increase), gender, lower ALB level, reduced LYM count and elevated D-dimer level. There was a tendency for diabetes mellitus to increase the risk of DVT, although there was no statistical significance (p = 0.063). These epidemiologic data on DVT may help counsel patients about the risk of DVT, individualized risk assessment and accordingly the risk stratification.
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12
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Verde F, Alabi O, Prokopowicz G, Steele KE. Imaging Modalities for Detecting Deep Venous Thrombosis After Bariatric Surgery. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0219-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Xia ZN, Xiao K, Zhu W, Feng B, Zhang BZ, Lin J, Qian WW, Jin J, Gao N, Qiu GX, Weng XS. Risk assessment and management of preoperative venous thromboembolism following femoral neck fracture. J Orthop Surg Res 2018; 13:291. [PMID: 30458869 PMCID: PMC6245713 DOI: 10.1186/s13018-018-0998-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Limited studies are available to investigate the prevalence of preoperative venous thromboembolism (VTE) in elderly patients with femoral neck fractures. Our primary aim was to determine the incidences of VTE and its risk or protective factors in such patient population. The secondary objective was to evaluate the need of therapeutic anticoagulation for isolated calf muscular venous thrombosis (ICMVT) prior to femoral neck fracture surgery. METHODS This is a retrospective case-control study, including 301 femoral neck fracture patients who were admitted to our institution between January 2014 and March 2017. Bilateral Doppler ultrasonography was performed in each of the patients as a preoperative VTE screening. The event rate of VTE was calculated, and significant risk or protective factors were determined by using a multivariate logistic regression model. Patients with ICMVT were divided into anticoagulation and no anticoagulation groups to assess the efficacy and safety of preoperative therapeutic anticoagulation. Intraoperative blood loss, drainage volume, blood transfusion, perioperative hemoglobin change, and rate of thrombosis extension were compared between the two groups. RESULTS The overall preoperative incidence of VTE in patients with femoral neck fracture was 18.9% (57/301), in which deep vein thrombosis (DVT) was 18.9% and pulmonary embolism (PE) was 1%. Among the DVT cases, 77.2% (44/57) were ICMVTs. Multiple fractures (odds ratio [OR] = 9.418; 95% confidence interval [CI] = 2.537 to 34.96), coexisting movement disorder (OR = 3.862; 95% CI = 1.658 to 8.993), bed rest for more than 7 days (OR = 2.082; 95% CI = 1.011 to 4.284) as well as elevated levels of D-dimer (OR = 1.019; 95% CI = 1.002 to 1.037) and fibrinogen (OR = 1.345; 95% CI = 1.008 to 1.796) led to an increase in the risk of VTE, while the recent use of antiplatelet drug (OR = 0.424; 95% CI = 0.181 to 0.995) and prophylactic anticoagulation (OR = 0.503; 95% CI = 0.263 to 0.959) decreased the risk of VTE. For the 39 patients with ICMVT undergoing femoral neck fracture surgery, there were no significant differences in the rate of thrombosis extension between anticoagulation and no anticoagulation groups, but significantly decreased postoperative hemoglobin was observed in the anticoagulation group. CONCLUSION Our findings showed a high prevalence of preoperative VTE in elderly patients with femoral neck fracture, with risk factors identified. We found that the most detected VTE were ICMVTs. Our study suggested that a direct surgery without preoperative use of therapeutic anticoagulation for ICMVT would not reduce the risk of thrombus extension, and the therapeutic use of anticoagulation may worsen postoperative anemia.
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Affiliation(s)
- Ze-Nan Xia
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Ke Xiao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wei Zhu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Bin Feng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Bao-Zhong Zhang
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Jin Lin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Wen-Wei Qian
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Jin Jin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Na Gao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Gui-Xing Qiu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xi-Sheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Wangfujing, Dongcheng District, Beijing, 100730, People's Republic of China.
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