Effects of older age on fibrin D-dimer, C-reactive protein, and other hemostatic and inflammatory variables in men aged 60-79 years

C-reactive protein is a predictor for lower-extremity deep venous thrombosis in patients with primary intracerebral hemorrhage

OBJECTIVE

Our study aimed to determine whether there exists an association between low-grade systemic inflammation, as measured by serum C-reactive protein (CRP), and the risk of lower-extremity deep venous thrombosis (LEDVT) in patients with primary intracerebral hemorrhage (ICH).

METHODS

This observational study was retrospectively conducted on patients with primary ICH who were presented to two tertiary medical centers between January 2021 and August 2022. The primary outcome was detecting LEDVT occurrence within 14 days from the onset of the acute ICH episode. Weighted logistic regression and restricted cubic spline models were employed to estimate the association between CRP and LEDVT following 1:1 propensity score matching (PSM).

RESULTS

Of the 538 patients with primary ICH who met the inclusion criteria, 76 (14.13%) experienced LEDVT. Based on the cut-off levels of CRP measured upon admission from the receiver operating characteristic (ROC) curve, patients with primary ICH were categorized into two groups: (i) CRP < 1.59 mg/L and (ii) CRP ≥ 1.59 mg/L. After 1:1 PSM, the LEDVT events occurred in 24.6% of patients with CRP ≥ 1.59 mg/L and 4.1% of patients with CRP < 1.59 mg/L (P < 0.001). ROC curve revealed the area under the ROC curve of 0.717 [95% confidence interval (CI) 0.669-0.761, P < 0.001] for CRP to predict LEDVT with a sensitivity of 85.71% and specificity of 56.29%. After adjusting for all confounding variables, the occurrence of LEDVT in ICH patients with higher CRP levels (≥ 1.59 mg/L) was 10.8 times higher compared to those with lower CRP levels (95% CI 4.5-25.8, P < 0.001). A nonlinear association was observed between CRP and an increased risk of LEDVT in the fully adjusted model (P for overall < 0.001, P for nonlinear = 0.001). The subgroup results indicated a consistent positive link between CRP and LEDVT events following primary ICH.

CONCLUSIONS

Higher initial CRP levels (CRP as a dichotomized variable) in patients with primary ICH are significantly associated with an increased risk of LEDVT and may help identify high-risk patients with LEDVT. Clinicians should be vigilant to enable early and effective intervention in patients at high risk of LEDVT.

A nomogram model based on the combination of the systemic immune-inflammation index, body mass index, and neutrophil/lymphocyte ratio to predict the risk of preoperative deep venous thrombosis in elderly patients with intertrochanteric femoral fracture: a retrospective cohort study

OBJECTIVES

Deep vein thrombosis (DVT) has been considered as a frequent and serious consequence of intertrochanteric femoral fractures in the elderly. Several negative repercussions of DVT can be considerably mitigated by its timely recognition and treatment. The current work was aimed at exploring the factors independently predicting DVT among cases suffering from intertrochanteric femoral fractures and validate their predictive usefulness in diagnosing DVT.

METHODS

Between April 2017 and July 2022, clinical information from 209 cases showing preoperative DVT for femoral intertrochanteric fractures were retrospectively evaluated. In patients with femoral intertrochanteric fractures, logistic regression analysis with a backward stepwise method was adopted for detecting independent predictors for the diagnosis of preoperative DVT. Using multivariate logistic regression, a nomogram prediction model was developed and verified with the testing group.

RESULTS

According to multivariate logistic regression model, body mass index (BMI) (OR 0.79, 95% CI 0.63-0.99, P = 0.042), neutrophil/lymphocyte ratio (NLR) (OR 7.29, 95% CI 1.53, 34.64, P = 0.0012), and systemic immune-inflammation index (SII) (OR 6.61, 95% CI 2.35, 18.59, P = 0.001) were independent predictors for DVT before surgery among cases developing intertrochanteric femoral fracture. AUC values were 0.862 and 0.767 for training and testing groups, separately, while their mean errors in the calibration curve were 0.027 and 0.038 separately. Decision curve analysis (DCA) curve revealed a high value of clinical application for both groups.

CONCLUSION

Upon admission, BMI, NLR, and SII are independent predictors of DVT before surgery among cases developing intertrochanteric femoral fractures. Additionally, the nomogram based on the BMI, NLR, and SII can assist clinicians in determining if preventive and symptomatic therapies are required to improve DVT prognosis and reduce its associated mortality.

Incidence and risk factors of admission deep venous thrombosis in nonagenarians and centenarians with intertrochanteric fracture: a retrospective study

PURPOSE

The objective of this study was to identify the risk factors for admission deep venous thrombosis (aDVT) and proximal aDVT in nonagenarians and centenarians with intertrochanteric fracture (IF).

METHODS

We collected statistics on nonagenarians and centenarians with IF admitting from January 2010 to October 2022. Patients with aDVT were considered as the aDVT group and those without aDVT as the non-aDVT group. Additionally, we also conducted a subgroup analysis based on the location of aDVT to investigate the predictors of proximal aDVT. The demographics, comorbidities and admission laboratory examinations of patients were computed by univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis.

RESULTS

In our study, the rate of aDVT (109 of 318) was 34.3%, and 5.7% (18 of 318) of patients had proximal aDVT. Logistic regression analysis showed that female patients and a high level of D-dimer were risk factors for aDVT. Similarly, hypoproteinemia and a high level of D-dimer were found to be risk factors for proximal aDVT. ROC curve analysis indicated the cut-off values of D-dimer to predict the aDVT and proximal aDVT were 1.28 mg/L and 1.485 mg/L, respectively.

CONCLUSIONS

Our findings investigated the risk factors of aDVT and proximal aDVT in nonagenarians and centenarians with IF and identified the cut-off values of D-dimer, helping us assess the risk of aDVT and proximal aDVT to manage early targeted interventions.

LEVEL OF EVIDENCE III

A nomogram for prediction of deep venous thrombosis risk in elderly femoral intertrochanteric fracture patients: A dual-center retrospective study

Objective

Deep venous thrombosis (DVT) of the lower extremity is a common perioperative complication of femoral intertrochanteric fracture. This study aimed to identify the risk factors of lower extremity deep vein thrombosis (DVT) in elderly femoral intertrochanteric fracture patients and establish a nomogram model.

Methods

From August 2014 to June 2021, a total of 1,652 femoral intertrochanteric fracture patients over the age of 65 were enrolled in our study. We distinguished independent risk factors by univariate and multivariate Cox analyses. A nomogram model was then built, and the discriminative and calibration of the model was evaluated through receiver operating characteristics (ROC) and calibration plots.

Results

A total of 378 patients developed DVT (292 in the training group, 86 in the validation group) while the remaining patients did not. According to the univariate and multivariate Cox analyses results, age (OR = 1.07, 95% CI: 1.04-1.10), fibrinogen (OR = 2.09, 95% CI: 1.68-2.60), D-dimer (OR = 1.33, 95% CI: 1.27-1.40), time from injury to admission (OR = 1.78, 95% CI: 1.55-2.05), functional status (OR = 4.21, 95% CI: 2.86-6.20), and diabetes (OR = 1.65, 95% CI: 1.10-2.48) were identified as independent risk factors of DVT. The ROC values for DVT of the training and validation group were 0.862 and 0.912, and the P-value of the Hosmer-Lemeshow calibration test was 0.767.

Conclusion

This nomogram model can be used to predict the probability of preoperative DVT in elderly patients with femoral intertrochanteric fracture and guide physician in perioperative thrombosis management.

Demographic, behavioral, dietary, and clinical predictors of high-sensitivity C-reactive protein: The National Health and Nutrition Examination Surveys (NHANES)

Aims

High-sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is associated with atherosclerosis, and recent studies indicate that therapies targeting inflammation are associated with reductions in cardiovascular risk. However, factors predictive of elevated hs-CRP in the general population have not been elucidated.

Methods

In this cross-sectional study, multivariable logistic regression analysis was used to identify independent predictors of elevated hs-CRP (≥3 mg/L) utilizing the National Health and Nutrition Examination Survey (NHANES) 2015-2016 cycle. The model was verified using the independent NHANES 2017-2018 cycle. Candidate variables comprised demographic, behavioral, dietary, and clinical factors. The study included 5412 adults from the 2015-2016 cohort and 5856 adults from the 2017-2018 cohort.

Results

Significant independent predictors of elevated hs-CRP included: older age (OR 1.09 per decade; 95 % CI 1.03-1.14; P = 0.024), female sex (OR 1.57; 95 % CI 1.36-1.80; P = 0.003), Black vs White race (OR 1.31; 95 % CI 1.10-1.56; P = 0.037), increased BMI (OR 1.12 per kg/m2; 95 % CI 1.10-1.14; P < 0.001), elevated white blood cell count (OR 1.21 per 1000 white blood cells/μL; 95 % CI 1.15-1.28; P = 0.002), and self-reported poor vs excellent health (OR 1.73; 95 % CI 1.04-2.22; P = 0.012). The model had excellent discrimination with a c-statistic of 0.77 in the 2015-2016 cycle and 0.76 in the 2017-2018 cycle.

Conclusion

Older age, female sex, Black race, increased BMI, higher white blood cell count, and self-reported poor health were independent predictors of elevated hs-CRP levels. Additional studies are needed to determine if behavioral modifications can lower hs-CRP and whether this translates to reduced risk for cardiovascular disease and other conditions associated with chronic inflammation.

Haematological variables and risk of future venous thromboembolism in the British Regional Heart Study on men. Combined D-dimer and APTT as a predictive test for thromboembolism?

We examined the associations between haematological and inflammatory variables with future venous thromboembolism (VTE), in 3494 men aged 60-79 years, with no previous history of VTE or myocardial infarction, who were not receiving oral anticoagulants. After a mean follow-up period of 18 years, there were 149 confirmed cases of fatal or non-fatal VTE (deep vein thrombosis and/or pulmonary embolism). Among classical cardiovascular risk factors, only obesity and cigarette smoking were associated with VTE risk. After adjustment for age, obesity and smoking, VTE risk was associated with coagulation factor VIII, factor IX, von Willebrand factor (VWF), activated partial thromboplastin time (APTT), and fibrin D-dimer. Hazard ratios (95% CI) for top to bottom quarters (bottom to top for APTT), were respectively 2.17 (1.37, 3.44), 2.15 (1.30, 3.53), 2.02 (1.27, 3.22), 2.43 (1.47, 4.02) and 3.62 (2.18, 6.08). The 11% of men with both the shortest APTT and highest D-dimer combined had a 5.02 (2.37, 10.62) higher risk of VTE. VTE risk was not associated with fibrinogen, factor VII or activated protein C resistance; full blood count variables or with inflammatory markers, plasma viscosity, C-reactive protein or interleukin-6. The combination of D-dimer and APTT merits evaluation as an adjunct to VTE risk prediction scores.

Computational Analysis of the Related Factors of Deep Vein Thrombosis (DVT) Formation in Patients Undergoing Hip Fracture Surgery

A retrospective study was conducted on 51 patients undergoing hip fracture surgery to investigate the factors associated with the formation of deep venous thrombosis (DVT). The independent sample t-test and correlation analysis were used to sort out and analyze the data. The findings are as follows. (1) Different gender samples showed significant differences in the Caprini score and thrombus location. Most DVTs in females are located in the posterior tibial vein and intermuscular veins. The Caprini score of females was significantly higher than that of males. (2) Age displays a positive correlation with DVT, coronary heart disease, hypertension, and different surgical types, respectively. (3) There is a correlation between age and operation duration. (4) Hyperlipidemia and cerebrovascular disease show a positive correlation with DVT. (5) There was a significant negative correlation between the Caprini score and the quantification of D-dimer. This indicates that in this sample, the higher the patients' Caprini score is, the lower the quantitation of D-dimer will be. (6) Hyperlipidemia and cardiac insufficiency show a positive correlation with cerebrovascular disease. Patients with hyperlipidemia and cardiac insufficiency may also suffer from cerebrovascular diseases.

Analysis of high-risk factors for preoperative DVT in elderly patients with simple hip fractures and construction of a nomogram prediction model

BACKGROUND

Hip fractures are anatomically classified in relation to femoral neck, intertrochanteric or subtrochanteric fractures. Simple hip fractures discussed in this study are femoral neck fractures or intertrochanteric fractures, which are the most common types of hip fractures. Controversy remains regarding the value of biochemical indices of thrombosis in elderly patients with fractures. A retrospective study was conducted to investigate the index admission data in blood draws of elderly patients with hip fractures and their high-risk factors for deep venous thrombosis (DVT). A nomogram prediction model for DVT was established to facilitate a rapid, accurate, and effective prediction based on the results.

METHODS

The data were based on 562 elderly patients undergoing hip fracture surgery, from whom 274 patients were selected for enrollment. The 274 patients were divided into two groups using preoperative vascular color Doppler ultrasonography. Chi-square tests, t-tests, and U tests were conducted, and logistic regression analysis was conducted showing different factors between the two groups. Independent risk factors with statistical significance (P < 0.05) were obtained, and the logistic regression equation and the new variable prediction probability_1 (PRE_1) were constructed. The receiver operating characteristic (ROC) curve of risk factors and PRE_1 was drawn to obtain the area under the curve (AUC) and truncation value of each risk factor. Finally, a nomogram prediction model was constructed using the R programming language to calculate the concordance index (C-index).

RESULTS

Time from injury to hospitalization, platelet (PLT) count, D-dimer level, fibrinogen (FIB) level, and systemic immune-inflammatory index (SII) score were independent risk factors for preoperative DVT in elderly patients with hip fractures. The logistic regression equation and PRE_1 were constructed by combining the above factors. ROC analysis showed that the area under the curve for PRE_1 (AUC = 0.808) was greater than that of the other factors. The sensitivity of PRE_1 (sensitivity = 0.756) was also higher than that of the other factors, and the specificity of PRE_1 (specificity = 0.756) was higher than that of two other factors. Moreover, a predictive nomogram was established, and the results showed a high consistency between the actual probability and the predicted probability (C-index = 0.808), indicating a high predictive value in fractures accompanied by DVT.

CONCLUSIONS

This study confirmed that SII score could be used as a risk factor in the prediction of DVT occurrence. A nomogram prediction model was constructed by combining 5 independent risk factors: time from injury to admission, PLT count, D-dimer level, FIB level, and SII score, which had high predictive values for fractures accompanied by DVT. This model use is limited to simple hip fracture.

Risk factors for preoperative deep venous thrombosis in hip fracture patients: a meta-analysis

Study design

A meta-analysis.

Background

Hip fracture (HF), as common geriatric fracture, is related to increased disability and mortality. Preoperative deep vein thrombosis (DVT) is one of the most common complications in patients with hip fractures, affecting 8–34.9% of hip fracture patients. The study aimed to assess the risk factors of preoperative DVT after hip fractures by meta-analysis.

Methods

An extensive search of the literature was performed in the English databases of PubMed, Embase, and the Cochrane Library; and the Chinese databases of CNKI and WAN FANG. We collected possible predictors of preoperative DVT from included studies, and data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

A total of 26 English articles were included, and the rate of DVT was 16.6% (1627 of 9823 patients) in our study. Our findings showed that advanced age [p = 0.0003, OR = 0.13 95% CI (0.06, 0.21)], female patients [p = 0.0009, OR = 0.82 95% CI (0.72, 0.92)], high-energy injury [p = 0.009, OR = 0.58 95% CI (0.38, 0.87)], prolonged time from injury to admission [p < 0.00001, OR = 0.54 95% CI (0.44, 0.65)], prolonged time from injury to surgery [p < 0.00001, OR = 2.06, 95% CI (1.40, 2.72)], hemoglobin [p < 0.00001, OR = − 0.32 95% CI (− 0.43, − 0.21)], coronary heart disease [p = 0.006, OR = 1.25 95% CI (1.07, 1.47)], dementia [p = 0.02, OR = 1.72 95% CI (1.1, 2.67)], liver and kidney diseases [p = 0.02, OR = 1.91 95% CI (1.12, 3.25)], pulmonary disease [p = 0.02, OR = 1.55 95% CI (1.07, 2.23)], smoking [p = 0.007, OR = 1.45 95% CI (1.11, 1.89)], fibrinogen [p = 0.0005, OR = 0.20 95% CI (0.09, 0.32)], anti-platelet drug [p = 0.01, OR = 0.51 95% CI (0.30, 0.85)], C-reactive protein [p = 0.02, OR = 5.95 95% CI (1.04, 10.85)], < 35 g/l albumin [p = 0.006, OR = 1.42 95% CI (1.1, 1.82)], and thrombosis history [p < 0.00001, OR = 5.28 95% CI (2.85, 9.78)] were risk factors for preoperative DVT.

Conclusions

Many factors, including advanced age, female patients, high-energy injury, prolonged time from injury to admission, prolonged time from injury to surgery, patients with a history of coronary heart disease, dementia, liver and kidney diseases, pulmonary disease, smoking, and thrombosis, fibrinogen, C-reactive protein, and < 35 g/l albumin, were found to be associated with preoperative DVT. Our findings suggested that the patient with above characteristics might have preoperative DVT.

Level of evidence: Level III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10195-022-00639-6.

A nationwide study of air pollution from particulate matter and daily hospitalizations for respiratory diseases in Italy

BACKGROUND/AIM

The relationship between air pollution and respiratory morbidity has been widely addressed in urban and metropolitan areas but little is known about the effects in non-urban settings. Our aim was to assess the short-term effects of PM10 and PM2.5 on respiratory admissions in the whole country of Italy during 2006-2015.

METHODS

We estimated daily PM concentrations at the municipality level using satellite data and spatiotemporal predictors. We collected daily counts of respiratory hospital admissions for each Italian municipality. We considered five different outcomes: all respiratory diseases, asthma, chronic obstructive pulmonary disease (COPD), lower and upper respiratory tract infections (LRTI and URTI). Meta-analysis of province-specific estimates obtained by time-series models, adjusting for temperature, humidity and other confounders, was applied to extrapolate national estimates for each outcome. At last, we tested for effect modification by sex, age, period, and urbanization score. Analyses for PM_2.5 were restricted to 2013-2015 cause the goodness of fit of exposure estimation.

RESULTS

A total of 4,154,887 respiratory admission were registered during 2006-2015, of which 29% for LRTI, 12% for COPD, 6% for URTI, and 3% for asthma. Daily mean PM₁₀ and PM_2.5 concentrations over the study period were 23.3 and 17 μg/m³, respectively. For each 10 μg/m³ increases in PM₁₀ and PM_2.5 at lag 0-5 days, we found excess risks of total respiratory diseases equal to 1.20% (95% confidence intervals, 0.92, 1.49) and 1.22% (0.76, 1.68), respectively. The effects for the specific diseases were similar, with the strongest ones for asthma and COPD. Higher effects were found in the elderly and in less urbanized areas.

CONCLUSIONS

Short-term exposure to PM is harmful for the respiratory system throughout an entire country, especially in elderly patients. Strong effects can be found also in less urbanized areas.

Acute Effects of Particulate Matter on All-Cause Mortality in Urban, Rural, and Suburban Areas, Italy

Background: Short-term exposure to particulate matter (PM) has been related to mortality worldwide. Most evidence comes from studies conducted in major cities, while little is known on the effects of low concentrations of PM and in less urbanized areas. We aim to investigate the relationship between PM and all-cause mortality at national level in Italy. Methods: Daily numbers of all-cause mortality were collected for all 8092 municipalities of Italy, from 2006 to 2015. A satellite-based spatiotemporal model was developed to estimate daily PM₁₀ (inhalable particles) and PM_2.5 (fine particles) concentrations at 1-km resolution. Multivariate Poisson regression models were fit to estimate the association between daily PM and mortality at province level, and then, results were pooled with a random-effects meta-analysis. Associations were estimated by combination of age and sex and degree of urbanization of the municipalities. Flexible functions were estimated to explore the shape of the associations at low PM concentrations. Results: We analyzed 5,884,900 deaths (40% among subjects older than 85 years, 60% occurring outside the main urban areas). National daily mean (interquartile range) PM₁₀ and PM_2.5 concentrations were 23 (14) μg/m³ and 15 (11) μg/m³, respectively. Relative increases of mortality per 10 μg/m³ variation in lag 0–5 (average of last six days since death) PM₁₀ and PM_2.5 were 1.47% (95% Confidence Intervals (CI): 1.15%, 1.79%) and 1.96% (1.33%, 2.59%), respectively. Associations were highest among elderly and women for PM₁₀ only, similar between rural and urbanized areas, and were present even at low concentrations, e.g., below WHO guidelines. Conclusions: Air pollution was robustly associated with peaks in daily all-cause mortality in Italy, both in large cities and in less urbanized areas of Italy. Current WHO Air Quality Guidelines (2021) for PM₁₀ and PM_2.5 are not sufficient to protect public health.

Contemporary Rates of Inferior Vena Cava Filter Thrombosis and Risk Factors

OBJECTIVE

Inferior vena cava thrombosis is an uncommon complication associated with inferior vena cava filters (IVCF), with literature citing rates ranging from 1% to 31%. Few observational studies describe risk factors associated with IVCF thrombosis, despite the significant clinical sequelae such as post-thrombotic syndrome, venous claudication, and venous ulceration. To better describe IVCF thrombosis and risk factors, data were queried from VQI-participating centers.

METHODS

IVCF data were obtained through the international VQI database from 2013 - 2019. Patients included in this analysis had two-year follow-up. Baseline demographics, medical comorbidities, medication, procedural, anatomical, and post-operative variables were assessed using Kaplan-Meier survival curves with log-rank tests, Student's t-tests, or Mann-Whitney U tests for IVCF thrombosis at two years. Cox regression analyses identified independent predictors of IVCF thrombosis. A subgroup analysis of those who presented with a venous thromboembolism (VTE) was also performed.

RESULTS

There were 62 US and Canadian VQI-participating centers, including 12,874 cases of IVCF placement. There 78 cases (1.3%) of IVCF thrombosis identified out of a total of 5,780 cases with two-year follow up. Those who experienced IVCF thrombosis had significantly lower rates of diabetes, coronary artery disease, pre-operative antiplatelet medications, pre-operative statins, as well as lower rates of discharge and follow up antiplatelet medications. On univariable analysis, cases of IVCF thrombosis also had higher rates of pulmonary emboli (PE) and VTE on admission, internal jugular venous access (versus femoral vein access), temporary IVCF use, follow up anticoagulation, follow up IVCF complication, follow up access site thrombosis, and rates of new or propagated DVT at follow up, and longer post-operative hospital stays. Multivariable analysis demonstrated independent predictors of IVCF thrombosis included new or propagated DVT at follow up (hazard ratio [HR]=16.3, 95% confident interval (CI) = 9.8 - 27.3, P<.001), no antiplatelet at follow up (HR=4.8, 95% CI= 1.9 - 12.5, P=.001), internal jugular venous access (HR=2.2, 95% CI=1.4 - 3.5, P=.001), VTE on admission (HR=2.7, 95% CI=1.4 - 5.1, P=.002), and temporary IVCF placement (HR=2.5, 95% CI = 1.1 - 5.6, P=.031). In an analysis of the subgroup of patients with VTE on admission, similar predictive factors were identified in a multivariable model, in addition, massive PE was also predictive of IVCF thrombosis in this subgroup.

CONCLUSION

The rate of IVCF thrombosis remained low in a contemporary international database. This study of over 5,000 patients with IVCFs suggests that antiplatelet therapy should be administered after IVCF placement to decreased risk of IVCF thrombosis.

The Role of Oxidative Stress in Cardiovascular Aging and Cardiovascular Diseases

Aging can be seen as process characterized by accumulation of oxidative stress induced damage. Oxidative stress derives from different endogenous and exogenous processes, all of which ultimately lead to progressive loss in tissue and organ structure and functions. The oxidative stress theory of aging expresses itself in age-related diseases. Aging is in fact a primary risk factor for many diseases and in particular for cardiovascular diseases and its derived morbidity and mortality. Here we highlight the role of oxidative stress in age-related cardiovascular aging and diseases. We take into consideration the molecular mechanisms, the structural and functional alterations, and the diseases accompanied to the cardiovascular aging process.

Clinical Frailty Scale and Biomarkers for Assessing Frailty in Elder Inpatients in China

OBJECTIVE

This study aimed to assess the feasibility of the Clinical Frailty Scale (CFS) and clinical biomarkers in assessing the frailty in elder inpatients in China.

DESIGN

The study was a cross-sectional study.

SETTING AND PARTICIPANTS

The study included 642 elder inpatients (295 females and 347 males) aged ≥65 years, from the Department of Geriatrics of Zhejiang Hospital between January 2018 and December 2019.

MEASUREMENTS

All participants underwent a comprehensive geriatric assessment and blood tests. Univariate and multivariate logistic regression was used to analyze the association between risk factors and frailty.

RESULTS

The average age of the participants was 82.72±8.06 years (range: 65-95 years) and the prevalence of frailty was 39.1% according to the CFS. Frail participants showed significantly lower short physical performance battery (SPPB), basic activities of daily living (ADL) and instrumental activities of daily living (IADL) scores (all p<0.001), and lower hemoglobin, total protein and albumin levels (all P<0.05) than nonfrail participants. Frail participants had higher CRP, D-dimer and fibrinogen levels than nonfrail participants (all p<0.05). Univariate logistic regression analysis showed a significant association between frailty and age, comorbidity, polypharmacy, fall history, SPPB, ADL, and IADL scores, D-dimer, fibrinogen, hemoglobin, total protein and albumin levels (all P<0.05). Multivariate logistic regression analysis indicated that age (odds ratio (OR), 95% confidence interval (CI)= 1.151(1.042-1.272), P=0.006), SPPB scores (OR, 95% CI=0.901(0.601-1.350), P<0.001), and D-dimer (OR, 95% CI=4.857(2.182-6.983), P<0.001), fibrinogen (OR, 95% CI=2.665(0.977-4.254), P<0.001), hemoglobin (OR, 95% CI=0.837(0.725-0.963), P= 0.044), and albumin (OR, 95% CI=0.860 (0.776-1.188), P<0.001) levels were independently associated with frailty in all participants.

CONCLUSION

Frailty in elder inpatients in China is characterized by older age, a lower SPPB scores, higher D-dimer and fibrinogen levels and lower hemoglobin and albumin levels. Functional decline and malnutrition may be the targets of frailty interventions.

Influence of lipid metabolism disorders on venous thrombosis risk

Background: To investigate the influence of lipid metabolism disorders on the risk of deep vein thrombosis. Methods: A total of 200 subjects participated in the study, 100 of whom experienced DVT with or without PTE, and 100 healthy subjects representing the control group. We classified patients and controls in terms of serum concentrations of chylomicrons, LDL, IDL, VLDL, and HDL particles, as those with or without hyperlipoproteinemia and in terms of serum Lp (a) lipoprotein levels, as those with hyperLp (a) lipoproteinemia (serum Lp (a) values >0.3 g/L) and those without hyperLp (a) lipoproteinemia (serum Lp (a) values <0.3 g/L). Based on the modified and supplemented Fredrickson classification, participants with verified existences of hyperlipoproteinemia were classified into subgroups based on the type of hyperlipoproteinemia. Unconditional logistic regression was used to calculate ORs with 95% CIS as a measure of the relative risks for venous thrombosis in participants with hyperlipoproteinemia compared with those without hyperlipoproteinemia. The analysis was adjusted for all potential confounders (age, sex, obesity) related to the functionality of the lipid metabolism, and at the same time, may have an impact on the risk of venous thrombosis. Results: The results of the comparison of the mean values of individual lipid status parameters between the patient group and the control group clearly indicate higher concentrations of total cholesterol (5.93 mmol/L vs. 5.52 mmol/L), total triglycerides (1.58 mmol/L vs. 1.50 mmol/L), and LDL-cholesterol (3.83 mmol/L vs. 3.44 mmol/L) in the patient group relative to the control group, with a statistically significant difference observed only in the case of LDL-cholesterol concentrations. We have found that type IIa hyperlipoproteinemia is associated with a nearly double increased risk for deep vein thrombosis (OR 1.99; Cl 1.01-3.90), while type IIb, IV, or hyperLp (a) lipoproteinemia did not influence the risk (OR 1.22; 95% Cl 0.79-1.84; OR 0.89; 95% Cl 0.52-1.54 OR 1.85; 95% CI 0.84-4.04). Conclusions: Hypercholesterolemia doubles the risk of deep vein thrombosis development.

Diagnostic Accuracy of D-Dimer Testing and the Revised Geneva Score in the Prediction of Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) diagnosis can sometimes be challenging due to the disease having nonspecific signs and symptoms at the time of presentation. The present study aimed to evaluate the validity of the D-dimer in combination with the revised Geneva score (RGS) in the prediction of pulmonary embolism.

PATIENTS AND METHODS

This is a retrospective study of 2010 patients with suspected PE who had undergone both D-dimer testing followed by chest CT angiography (CTPA), irrespective of the D-dimer test results, at King Abdulaziz Medical City, Riyadh, Saudi Arabia, over 3 years, from Jan. 2016 to Jan. 2019. The predictive accuracy of D-dimer, adjusted D-dimer, and RGS was calculated. The receiver operating characteristic "ROC" curve was applied to allocate the optimum RGS cutoff for PE prediction.

RESULTS

The overall prevalence of PE was 16%. It was 0%, 25.8%, and 88.9% in low, intermediate, and high clinical probability categories of RGS, respectively. Both conventional and age-adjusted D-dimer thresholds showed significant level of agreement (kappa=0.81, p<0.001), high sensitivity (94% and 92.8%), high negative predictive value "NPV" (91.2% and 91.4%), low specificity (12.3% and 15.3%), and low positive predictive value "PPV" (17.5% and 17.8%), respectively. Combination of the age-adjusted D-dimer threshold and RGS at a cut-off of 5 points would provide 100% sensitivity and 61.7% specificity 34.1% PPV, 100% NPV, and 0.87 area under the curve "AUC". At an RGS cutoff <5 points, PE could have been ruled out in more than one-half (1036, 51.5%) of all suspected cases, and would have saved the cost of CTPA.

CONCLUSION

Conventional and age-adjusted D-dimer tests showed high levels of agreement in the prediction of PE, high sensitivity, and low specificity. RGS has a good performance in PE prediction. Using the revised Geneva score alone rules out PE for more than one-half of all suspected without further imaging.

Age over 65 years and high levels of C-reactive protein are associated with the risk of preoperative deep vein thrombosis following closed distal femur fractures: a prospective cohort study

Background

In this study, we investigated the epidemiological characteristics and predictors of preoperative new-onset deep vein thrombosis (DVT) in adult patients with closed distal femur fractures (DFFs).

Methods

The study was designed as a prospective cohort trial at the Third Hospital of Hebei Medical University. From October 2018 to June 2020, a total of 160 patients with closed DFFs were enrolled to assess the location and prognosis of preoperative DVT. The patients were followed up for 2 months. Duplex ultrasonography (DUS) was used to diagnose patients with DVT. The patients were divided into two groups (DVT group and non-DVT group). The DVT was then classified into proximal, distal, and mixed thromboses. The Mann-Whitney U test or t test, receiver operating characteristic (ROC) analyses, univariate Chi-square analyses, and multiple logistic regression analyses were used to analyze the adjusted predictors of DVT.

Results

The overall incidence of preoperative DVTs was 52.5% (n = 84), which was diagnosed at a mean period of 3.1 days after injury. Among patients diagnosed with DVTs, 50.0% (n = 42) had distal thrombosis while 47.6% (n = 40) had mixed thrombosis. The calf muscle veins were the most common sites of DVTs (90.5%, n = 76). Of note, 45.2% (n = 38) of diagnosed DVTs were completely recanalized at a mean period of 12.0 days after the initial (first) diagnosis. Multivariate analysis revealed that age of ≥ 65 years of age (odds ratio [OR], 4.390; 95% confidence interval [CI] 1.727–11.155; p = 0.002), C-reactive protein (CRP) levels exceeding 11 mg/L (OR 4.158; 95% CI 1.808–11.289; p = 0.001), platelet (PLT) levels over 217 × 109/L (OR, 2.55; 95% CI 1.07–6.07; p = 0.035), D-dimer levels over 1.0 mg/L (OR 3.496; 95% CI 1.483–8.237; p = 0.004), and an American Society of Anesthesiologists (ASA) score of III-V (OR 2.753; 95% CI 1.216–6.729; p = 0.026) were the independent risk factors of preoperative DVT.

Conclusions

High levels of CRP, PLT, D-dimer, ASA, and ≥ 65 years of age increase the risk of preoperative DVTs in adult patients with closed DFFs. Thus, the prediction of preoperative DVTs can significantly be improved by identifying older patients over the age of 65, and establishing the biochemical cut-off values of CRP, PLT, ASA, and D-dimer.

Trial registration

No. 2018-026-1, 24 October 2018, prospectively registered.

This trial was registered prospectively on 24 October 2018 before the first participant was enrolled. This study protocol conformed to the Declaration of Helsinki and approved by the Institutional Review Board. The ethics committee approved the study on the factors of prognosis for patients with fractures. Data used in this study were obtained from the patients who underwent orthopedic surgery between October 2018 and June 2020.

Coarse particles (PM2.5-10) and cause-specific hospitalizations in southwestern China: Association, attributable risk and economic costs

The short-term morbidity effects of the coarse particle (diameter in 2.5-10 μm, PM_2.5-10), as well as the corresponding morbidity burden and economic costs, remain understudied, especially in developing countries. This study aimed to examine the associations of PM_2.5-10 with cause-specific hospitalizations in a multi-city setting in southwestern China and assess the attributable risk and economic costs. City-specific associations were firstly estimated using generalized additive models with quasi-poisson distribution to handle over-dispersion, and then combined to obtain the regional average association. City-specific and pooled concentration-response (C-R) associations of PM_2.5-10 with cause-specific hospitalizations were also modeled. Subgroup analyses were performed by age, sex, season and region. The health and economic burden of hospitalizations for multiple outcomes due to PM_2.5-10 were further evaluated. A total of 4,407,601 non-accidental hospitalizations were collected from 678 hospitals. The estimates of percentage change in hospitalizations per 10 μg/m³ increase in PM_2.5-10 at lag01 was 0.68% (95%CI: 0.33%-1.03%) for non-accidental causes, 0.86% (95% CI: 0.36%-1.37%) for circulatory diseases, 1.52% (95% CI: 1.00%-2.05%) for respiratory diseases, 1.08% (95% CI: 0.47%-1.69%) for endocrine diseases, 0.66% (95% CI: 0.12%-1.21%) for nervous system diseases, and 0.84% (95% CI: 0.42%-1.25%) for genitourinary diseases, respectively. The C-R associations of PM_2.5-10 with cause-specific hospitalizations suggested some evidence of nonlinearity, except for endocrine diseases. Meanwhile, the adverse effects were modified by age and season. Overall, about 0.70% (95% CI: 0.35%-1.06%) of non-accidental hospitalizations and 0.78% (95% CI: 0.38%-1.17%) of total hospitalization expenses could be attributed to PM_2.5-10. The largest morbidity burden and economic costs were observed in respiratory diseases. Our findings indicate that PM_2.5-10 exposure may increase the risk of hospitalizations for multiple outcomes, and account for considerable morbidity and economic burden.

Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors

Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO).

Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design.

Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke.

Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.

Oxidative Stress and Thrombosis during Aging: The Roles of Oxidative Stress in RBCs in Venous Thrombosis

Mid-life stage adults are at higher risk of developing venous thrombosis (VT)/thromboembolism (VT/E). Aging is characterized by an overproduction of reactive oxygen species (ROS), which could evoke a series of physiological changes involved in thrombosis. Here, we focus on the critical role of ROS within the red blood cell (RBC) in initiating venous thrombosis during aging. Growing evidence has shifted our interest in the role of unjustifiably unvalued RBCs in blood coagulation. RBCs can be a major source of oxidative stress during aging, since RBC redox homeostasis is generally compromised due to the discrepancy between prooxidants and antioxidants. As a result, ROS accumulate within the RBC due to the constant endogenous hemoglobin (Hb) autoxidation and NADPH oxidase activation, and the uptake of extracellular ROS released by other cells in the circulation. The elevated RBC ROS level affects the RBC membrane structure and function, causing loss of membrane integrity, and decreased deformability. These changes impair RBC function in hemostasis and thrombosis, favoring a hypercoagulable state through enhanced RBC aggregation, RBC binding to endothelial cells affecting nitric oxide availability, RBC-induced platelet activation consequently modulating their activity, RBC interaction with and activation of coagulation factors, increased RBC phosphatidylserine exposure and release of microvesicles, accelerated aging and hemolysis. Thus, RBC oxidative stress during aging typifies an ultimate mechanism in system failure, which can affect major processes involved in the development of venous thrombosis in a variety of ways. The reevaluated concept of the critical role of RBC ROS in the activation of thrombotic events during aging will help identify potential targets for novel strategies to prevent/reduce the risk for VT/E or VT/E recurrences in mid-life stage adults.

Predictive value of admission D-dimer for contrast-induced acute kidney injury and poor outcomes after primary percutaneous coronary intervention

BACKGROUND

DD was found to be associated with acute myocardial infarction (AMI) and renal insufficiency. However, it is uncertain whether DD is an independent risk factor of CI-AKI in patients undergoing pPCI.

METHODS

We prospectively enrolled 550 consecutive patients with STEMI undergoing pPCI between January 2012 and December 2016. The predictive value of admission DD for CI-AKI was assessed by receiver operating characteristic (ROC) and multivariable logistic regression analysis. CI-AKI was defined as an absolute serum creatinine increase ≥0.3 mg/dl or a relative increase in serum creatinine ≥50% within 48 h of contrast medium exposure.

RESULTS

Overall, the incidence of CI-AKI was 13.1%. The ROC analysis showed that the cutoff point of DD was 0.69 μg/ml for predicting CI-AKI with a sensitivity of 77.8% and a specificity of 57.3%. The predictive value of DD was similar to the Mehran score for CI-AKI (AUC_DD = 0.729 vs AUC_Mehran = 0.722; p = 0.8298). Multivariate logistic regression analysis indicated that DD > 0.69 μg/ml was an independent predictor of CI-AKI (odds ratio [OR] = 3.37,95% CI:1.80-6.33, p < 0.0001). Furthermore, DD > 0.69 μg/ml was associated with an increased risk of long-term mortality during a mean follow-up period of 16 months (hazard ratio = 3.41, 95%CI:1.4-8.03, p = 0.005).

CONCLUSION

Admission DD > 0.69 μg/ml was a significant and independent predictor of CI-AKI and long-term mortality in patients undergoing pPCI.

Prevalence and determinants of elevated D-dimer in patients with hypertrophic cardiomyopathy

Aim: To evaluate D-dimer levels in patients with hypertrophic cardiomyopathy (HCM). Patients & methods: A total of 346 patients with HCM were recruited. Plasma D-dimer was determined by clinical laboratory of our hospital. Left ventricular mass, stroke volume, cardiac output and cardiac index were assessed with cardiovascular magnetic resonance. Results: A total of 36 (10.4%) patients had elevated D-dimer levels. Age, female patients and statin therapy were independently associated with increasing D-dimer levels, and predictors of elevated D-dimer. Conclusion: Patients with HCM may have higher plasma D-dimer levels than subjects without HCM. D-dimer levels in patients with HCM are influenced by age, sex, atrial fibrillation, statin therapy and diastolic blood pressure.

Admission prevalence of deep vein thrombosis in elderly Chinese patients with hip fracture and a new predictor based on risk factors for thrombosis screening

BACKGROUND

Elderly hip fracture (HF) patients are at very high risk of developing deep vein thrombosis (DVT), which increases their perioperative mortality. However, data focusing on the admission prevalence of DVT in elderly Chinese patients with hip fracture are limited. Venography and ultrasonography are not suitable for most elderly HF patients; there is also controversy about the prognostic value of D-dimer in elderly patients. Thus, our primary goal was to clarify the prevalence of and risk factors for DVT in elderly Chinese HF patients at admission. Our secondary goal was to evaluate the diagnostic value of a new predictor of DVT based on the risk factors for elderly HF patients.

METHODS

This retrospective study was conducted in the West China Hospital, Sichuan University. Between January 2015 and January 2017, 248 elderly Chinese HF patients (> 60 years) were enrolled in this study. The subjects were diagnosed with DVT using ultrasonography or venography. All the patients' clinical data were obtained, including demographic variables, medical history, comorbidities, and laboratory results. A stepwise multiple logistic regression analysis was used to identify the risk factors contributing to the occurrence of DVT. The value of the new DVT predictor was calculated using a formula based on the coefficient regression and independent variables. A receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic value of different factors.

RESULTS

Of the study patients, 74 (29.8%) were diagnosed with DVT, including sixty-five (87.8%) with distal peripheral, five (6.8%) with proximal central and four (5.4%) with mixed DVT. A multivariate logistic regression analysis showed that five risk factors increased the occurrence of DVT at admission, including gender, age, time from injury to admission, fibrinogen, and D-dimer. The new DVT predictor was calculated using the following formula: 1.131× (female = 1, male = 0) + 0.071 × age (years) + 0.571 × time from injury to admission (days) + 1.028 × fibrinogen(g/L) + 0.123 × D-dimer(g/L). The diagnostic value of the new predictor was highest among those risk predictors whose AUC (area under the ROC curves) value was 0.852.

CONCLUSIONS

The results of this study revealed a high prevalence of DVT in elderly Chinese HF patients at admission. Moreover, the new predictor, based on risk factors, was a good method to improve the diagnosis of DVT.

Biomarker Profiling of Neurovascular Diseases in Patients with Stage 5 Chronic Kidney Disease

Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk of developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD) are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Eleven plasma biomarker levels in patients with CKD5D (n = 97) and healthy controls (n = 17-50) were measured using sandwich enzyme-linked immunosorbent assay (ELISA) method. Of the 97 patients with CKD5D, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Elevations in NACHT, LRR, and PYD domains-containing protein 3 (NALP3) levels in patients with CKD5D (+)CCAD (1.80 ± 0.11 ng/mL) compared to patients with (−)CCAD (1.55 ± 0.08 ng/mL) were statistically significant (P = .0299). Differences in D-dimer levels were also found to be statistically significant (P = .0258) between CKD5D (+)stroke (1.83 ± 0.42 μg/mL) and (−)stroke (0.89 ± 0.13 μg/mL) groups. The ages of the (+) neurovascular disease groups were found to be significantly elevated compared to the (−) neurovascular disease groups (P = .0002 carotid AD; P < .0001 ICAD; P = .0157 stroke). D-dimer levels were positively correlated with age in CKD5D (P = .0375). With the possible exception of NALP3 for CCAD, profiling levels of specific biomarkers for risk stratification of neurovascular diseases in the CKD5D population warrants further investigation.

Still reduced cardiovascular mortality 12 years after supplementation with selenium and coenzyme Q10 for four years: A validation of previous 10-year follow-up results of a prospective randomized double-blind placebo-controlled trial in elderly

BACKGROUND

Selenium and coenzyme Q10 are both necessary for optimal cell function in the body. The intake of selenium is low in Europe, and the endogenous production of coenzyme Q10 decreases as age increases. Therefore, an intervention trial using selenium and coenzyme Q10 for four years as a dietary supplement was performed. The main publication reported reduced cardiovascular mortality as a result of the intervention. In the present sub-study the objective was to determine whether reduced cardiovascular (CV) mortality persisted after 12 years, in the supplemented population or in subgroups with diabetes, hypertension, ischemic heart disease or reduced functional capacity due to impaired cardiac function.

METHODS

From a rural municipality in Sweden, four hundred forty-three healthy elderly individuals were included. All cardiovascular mortality was registered, and no participant was lost to the follow-up. Based on death certificates and autopsy results, mortality was registered.

FINDINGS

After 12 years a significantly reduced CV mortality could be seen in those supplemented with selenium and coenzyme Q10, with a CV mortality of 28.1% in the active treatment group, and 38.7% in the placebo group. A multivariate Cox regression analysis demonstrated a reduced CV mortality risk in the active treatment group (HR: 0.59; 95%CI 0.42-0.81; P = 0.001). In those with ischemic heart disease, diabetes, hypertension and impaired functional capacity we demonstrated a significantly reduced CV mortality risk.

CONCLUSIONS

This is a 12-year follow-up of a group of healthy elderly participants that were supplemented with selenium and coenzyme Q10 for four years. Even after twelve years we observed a significantly reduced risk for CV mortality in this group, as well as in subgroups of patients with diabetes, hypertension, ischemic heart disease or impaired functional capacity. The results thus validate the results obtained in the 10-year evaluation. The protective action was not confined to the intervention period, but persisted during the follow-up period. The mechanisms behind this effect remain to be fully elucidated, although various effects on cardiac function, oxidative stress, fibrosis and inflammation have previously been identified. Since this was a small study, the observations should be regarded as hypothesis-generating.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01443780.

Impact of a negative D-dimer result on the initial assessment of acute aortic dissection

BACKGROUND

D-dimer shows high sensitivity but low specificity for the diagnosis of acute aortic dissection (AAD). Previous reports indicated that negative D-dimer patients have shorter dissection length. However, whether patients with negative D-dimer results have a good prognosis is unknown. This study aimed to elucidate the clinical characteristics and implications of a negative D-dimer result on AAD diagnosis.

METHODS

The study group comprised 126 patients (71 males, 55 females; mean age, 69 ± 11 years) with AAD admitted to our hospital between April 2009 and March 2015. Blood samples on presentation were used for D-dimer measurement. Clinical characteristics and outcomes were assessed.

RESULTS

Nine (7.1%) and 117 (92.9%) exhibited negative and positive D-dimer results, respectively. The negative group showed a significantly lower extension score and a higher platelet count than the positive group. Multivariate analysis demonstrated that platelet count (odds ratio, 1.31 (1.09-1.58), p = 0.003) and extension score (odds ratio, 0.56 (0.33-0.96), p = 0.03) were significantly related to a negative result. Notably, 44% of patients in the negative group had type A dissection and 33% underwent an emergency operation due to cardiac tamponade.

CONCLUSION

We found that high platelet count and low extension score were independent factors related to a negative D-dimer result. Even if the length of the dissection is short, an emergency operation is necessary in some patients with a negative D-dimer result. Physicians should recognize that a negative D-dimer result alone cannot exclude patients with fatal AAD conditions.

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

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

Serum C-reactive protein increases the risk of venous thromboembolism: a prospective study and meta-analysis of published prospective evidence

Evolving debate suggests that C-reactive protein (CRP) might be associated with the development of venous thromboembolism (VTE); however, the evidence is conflicting. We aimed to assess the prospective association of CRP with VTE risk. C-reactive protein was measured in serum samples at baseline from 2420 men aged 42–61 years, from the Kuopio Ischemic Heart Disease study. Within-person variability in CRP levels was corrected for using repeat measurements of CRP taken 11 years after baseline. Incident VTE events (n = 119) were recorded during a median follow-up of 24.7 years. The age-adjusted regression dilution ratio for log_e CRP was 0.57 [95% confidence interval (CIs): 0.51–0.64]. In age-adjusted Cox regression analysis, the hazard ratio (95% CIs) for VTE per 1 standard deviation (SD) increase in log_e baseline CRP was 1.17 (0.98–1.40). Further adjustment for several established and emerging risk factors did not alter the association. In a meta-analysis of nine population-based studies (including the current study) comprising 81,625 participants and 2225 VTE cases, the fully-adjusted risk estimate for VTE was 1.14 (1.08–1.19) per SD increase in log_e baseline CRP. In a pooled dose–response analysis, a linear association between CRP and VTE risk was suggested (P for nonlinearity = 0.272). The pooled risk estimate for VTE per 5 mg/l increment in CRP levels was 1.23 (1.09–1.38). C-reactive protein was only modestly associated with VTE risk in the primary analysis. Pooled evidence, however, suggests that elevated CRP is associated with greater VTE risk, consistent with a linear dose–response relationship.

Smoking exposure, loss of forced expiratory volume in one second and the risk of lung cancer among patients with malignant disease who present with cardiac or pulmonary symptoms: a cross-sectional study

BACKGROUND

Smokers with airway obstruction are at a higher risk of lung cancer than smokers without airway obstruction. Inflammation plays a key role in lung carcinogenesis. This single-center study prospectively assessed (i) the relationship between smoking exposure and the loss of forced expiratory volume in 1 s (FEV1) in determining lung cancer risk and (ii) the effect of lung cancer on systemic inflammation.

METHODS

The study group comprised 475 consecutively enrolled patients with cancer who presented with pulmonary or cardiac symptoms. The effects of smoking exposure and FEV1 loss on the predicted lung cancer risk were assessed using multiple logistic regression analysis. C-reactive protein (CRP) was used as a marker of inflammation.

RESULTS

The prevalence of lung cancer was 0.23. The lung cancer risk increased with the number of pack years and FEV1 loss (p < 0.01). Moving from the 5^th (-22% of the predicted value) to the 95^th percentile of FEV1 loss (56% of the predicted value) increased lung cancer risk from 0.07 to 0.23 (Δ = 0.16) at 0 pack years and from 0.39 to 0.73 (Δ = 0.34) at 70 pack years (95^th percentile). The values for Δ peaked at 61 pack years (0.34) and then decreased with a further increase in smoking exposure, without reaching the zero mark. Patients with lung cancer were more likely to have a CRP level above the median (4.05 mg/L) than patients with other cancers (adjusted odds ratio = 2.67).

CONCLUSIONS

Systemic inflammation is more pronounced in patients with lung cancer than in patients with other cancers. The effect of FEV1 loss on the patients' predicted risks of lung cancer increases with increasing smoking exposure. Measurements of FEV1 loss are useful to identify patients facing an increased risk of developing lung cancer.

How to use D-dimer in acute cardiovascular care

D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.

Elevated risk of venous thromboembolic events in patients with inflammatory myopathies

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

Air pollution exposure, cause-specific deaths and hospitalizations in a highly polluted Italian region

BACKGROUND

The Lombardy region in northern Italy ranks among the most air polluted areas of Europe. Previous studies showed air pollution short-term effects on all-cause mortality. We examine here the effects of particulate matter with aerodynamic diameter ≤10µm (PM10) and nitrogen dioxide (NO2) exposure on deaths and hospitalizations from specific causes, including cardiac, cerebrovascular and respiratory diseases.

METHODS

We considered air pollution, mortality and hospitalization data for a non-opportunistic sample of 18 highly polluted and most densely populated areas of the region in the years 2003-2006. We obtained area-specific effect estimates for PM10 and NO2 from a Poisson regression model on the daily number of total deaths or cause-specific hospitalizations and then combined them in a Bayesian random-effects meta-analysis. For cause-specific mortality, we applied a case-crossover analysis. Age- and season-specific analyses were also performed. Effect estimates were expressed as percent variation in mortality or hospitalizations associated with a 10µg/m(3) increase in PM10 or NO2 concentration.

RESULTS

Natural mortality was positively associated with both pollutants (0.30%, 90% Credibility Interval [CrI]: -0.31; 0.78 for PM10; 0.70%, 90%CrI: 0.10; 1.27 for NO2). Cardiovascular deaths showed a higher percent variation in association with NO2 (1.12%, 90% Confidence Interval [CI]: 0.14; 2.11), while the percent variation for respiratory mortality was highest in association with PM10 (1.64%, 90%CI: 0.35; 2.93). The effect of both pollutants was more evident in the summer season. Air pollution was also associated to hospitalizations, the highest variations being 0.77% (90%CrI: 0.22; 1.43) for PM10 and respiratory diseases, and 1.70% (90%CrI: 0.39; 2.84) for NO2 and cerebrovascular diseases. The effect of PM10 on respiratory hospital admissions appeared to increase with age. For both pollutants, effects on cerebrovascular hospitalizations were more evident in subjects aged less than 75 years.

CONCLUSIONS

Our study provided a sound characterization of air pollution exposure and its potential effects on human health in the most polluted, and also most populated and productive, Italian region, further documenting the need for effective public health policies.

Assessment of health status by molecular measures in adults ranging from middle-aged to old: Ready for clinical use?

In addition to measures already used in clinical practice, molecular measures have been proposed to assess health status, but these have not yet been introduced into clinical practice. We aimed to test the association of functional capacity measures used in current practice and molecular measures with age and health status. The cohort consisted of 178 middle-aged to old participants of the Leiden Longevity Study (range 42-82years). We tested associations between functional capacity measures (physical tests: grip strength, 4-meter walk, chair stand test; cognitive tests: Stroop test, digit symbol substitution test and 15-picture learning test) with age and with cardiovascular or metabolic disease as a measure of the health status. These associations with age and health status were also tested for molecular measures (C reactive protein (CRP), numbers of senescent p16INK4a positive cells in the epidermis and dermis and putative immunosenescence (presence of CD57+ T cells)). All functional capacity measures were associated with age. CRP and epidermal p16INK4a positivity were also associated with age, but with smaller estimates. Grip strength and the Stroop test were associated with cardiovascular or metabolic disease, as was epidermal p16INK4a positivity. All associations with cardiovascular or metabolic disease attenuated when adjusting for age. In conclusion, in middle-aged to old persons, the molecular measures tested here were more weakly associated with age and health status than functional capacity measures. Whether these molecular measures associate more closely with health status in the elderly or in specific groups of patients needs to be explored further.

Initial evidence for the link between activities and health: Associations between a balance of activities, functioning and serum levels of cytokines and C-reactive protein

Growing evidence shows interrelations of psychological factors, neurological and immunological processes. Therefore, constructs like a balance of activities, the so called "occupational balance", could also have biological correlates. The aim of this study was to investigate potential associations between occupational balance, functioning, cytokines and C-reactive protein (CRP) in patients suffering from a chronic inflammatory disease like rheumatoid arthritis (RA) and healthy people. Moreover, we wanted to explore potential differences in gender and employment status. A descriptive study in patients with RA and healthy people was conducted using the Occupational Balance-Questionnaire (OB-Quest) and the Short-Form 36 Health Survey (SF-36). Serum levels of cytokines, such as interleukin 6 (IL-6) and 8 (IL-8), interferon alpha (INFα), tumour necrosis factor alpha (TNFα), rheumatoid factor (RF) and of CRP were measured. Descriptive statistics, as well as Mann-Whitney U tests and Spearmen's rank correlation coefficients (rs) were calculated. One-hundred-thirty-two patients with RA and 76 healthy people participated. Occupational balance was associated with functioning, cytokines and CRP. The strongest associations were identified in the unemployed healthy-people sample with cytokines and CRP being within the normal range. For example, the OB-Quest item challenging activities was associated with IL-8 (rs=-0.63, p=0.04) and the SF-36 sub-scale bodily pain was associated with IFNα (rs=-0.69, p=0.02). The items rest and sleep (rs=-0.71, p=0.01) and variety of different activities (rs=-0.74, p<0.01) correlated with the SF-36 sub-scale social functioning. Employed and unemployed people differed in their age and CRP levels. Additionally, gender differences were found in two OB-Quest items in that fewer women were able to adapt their activities to changing living conditions and fewer men were overstressed. In conclusion, we found preliminary biological evidence for the link between occupation and health in that the concepts encompassed in the construct of occupational balance were associated with functioning, cytokines and CRP.

Reduced Cardiovascular Mortality 10 Years after Supplementation with Selenium and Coenzyme Q10 for Four Years: Follow-Up Results of a Prospective Randomized Double-Blind Placebo-Controlled Trial in Elderly Citizens

Background

Selenium and coenzyme Q10 are important antioxidants in the body. As the intake of selenium is low in Europe, and the endogenous production of coenzyme Q10 decreases as age increases, an intervention trial using selenium and coenzyme Q10 for four years was performed. As previously reported, the intervention was accompanied by reduced cardiovascular mortality. The objective of the present study was to analyze cardiovascular mortality for up to 10 years after intervention, to evaluate if mortality differed in subgroups differentiated by gender, diabetes, ischemic heart disease (IHD), and functional class.

Methods

Four-hundred forty-three healthy elderly individuals were included from a rural municipality in Sweden. All cardiovascular mortality was registered, and no participant was lost to the follow-up. Based on death certificates and autopsy results mortality was registered.

Findings

Significantly reduced cardiovascular mortality could be seen in those on selenium and coenzyme Q10 intervention. A multivariate Cox regression analysis demonstrated a reduced cardiovascular mortality risk in the active treatment group (HR: 0.51; 95%CI 0.36–0.74; P = 0.0003). The reduced mortality could be seen to persist during the 10-year period. Subgroup analysis showed positive effects in both genders. An equally positive risk reduction could be seen in those with ischemic heart disease (HR: 0.51; 95%CI 0.27–0.97; P = 0.04), but also in the different functional classes.

Conclusions

In a 10-year follow-up of a group of healthy elderly participants given four years of intervention with selenium and coenzyme Q10, significantly reduced cardiovascular mortality was observed. The protective action was not confined to the intervention period, but persisted during the follow-up period. The mechanism explaining the persistency remains to be elucidated. Since this was a small study, the observations should be regarded as hypothesis-generating.

Increase in the Inflammatory Marker GlycA over 13 Years in Young Adults Is Associated with Poorer Cognitive Function in Midlife

Background

Inflammatory markers are elevated in patients with dementia. Evidence for an association between inflammation and cognitive function in dementia-free individuals is sparse, inconsistent, and predominantly restricted to the elderly. Assessment of inflammatory markers in young adults as predictors of cognitive function in midlife, well before the onset of overt dementia, is lacking. Furthermore, rarely has the relation with longitudinal change in inflammatory markers been examined.

Objective

To examine the association of the inflammatory markers C-reactive protein (CRP), fibrinogen, white blood cell count (WBC) and GlycA, a novel NMR-determined biomarker of systemic inflammation, measured in young adulthood and of GlycA change over 13 years follow-up with cognitive function in midlife.

Methods

507 participants of the Jerusalem Lipid Research Clinic (LRC) study were assessed at 3 time points over 18–22 years. First, the inflammatory variables GlycA, CRP, fibrinogen, and WBC were measured in blood samples drawn at ages 28–32. Then, in blood samples drawn a mean 13 years later (range, 12–16 years) at ages 41–46, GlycA was again measured (in 484 individuals). Subsequently at ages 48–52, on average 7 years later, global cognitive function and its five specific component domains were assessed with a NeuroTrax computerized test battery. Multiple regression and multivariable logistic models were applied.

Results

Inverse unadjusted associations were shown for baseline levels and longitudinal change in inflammatory markers and measures of cognition. Multiple regression models were adjusted for age at cognitive assessment, sex, socio-demographic characteristics, baseline measures of leisure-time vigorous activity, smoking status and body mass index (BMI) at ages 28–32, change in smoking status and BMI between ages 28–32 and 41–46, and depression assessed at the time of cognitive testing. The highest quintile of GlycA change, but not the baseline inflammation measures, was inversely related to global cognition (standardized β = -.109, p = .011) as well as to the information processing speed and memory domains (standardized β = -.124, p = .008 and-.117, p = .014, respectively). The multivariable-adjusted odds ratio for low ranked global cognitive function (lowest fifth) comparing the extreme quintiles of GlycA change was 4.8 (95%CI, 1.7–13.5, p = .003; p for trend = .031).

Conclusions

In this longitudinal study of a novel systemic inflammatory marker in a population-based cohort of young adults, GlycA increase over 13 years, but not baseline measures of inflammation, was associated with poorer cognitive function in midlife.

Pulmonary embolism in Bradford, UK: role of end-tidal CO2 as a screening tool

End-tidal CO2 (ETCO2) can represent dead space ventilation. The authors aimed to define the optimum ETCO2 to conclusively exclude a pulmonary embolic event. One hundred consecutive patients with suspected pulmonary embolisms (PEs) were enrolled over 6 months in 2012. Symptoms, demographic date, Wells' score, D-dimer levels and the gold standard computed tomography pulmonary angiogram (CTPA) results were collated for analysis. ETCO2 was measured within 24 hours of presentation in all 100 patients. Patient ages ranged from 18 years to 93 years. PE was diagnosed in 38% of cases. The average ETCO2 in patients with a positive CTPA was 3.35 kPa (range 2.4-4.2 kPa, SD 0.50). The average ETCO2 in patients without a PE was 4.41 kPa (range 1.3-6.6 kPa, SD 1.10). All patients positive for a PE obtained an ETCO2 <4.3 kPa (32.3 mmHg). This point (4.3 kPa) had a sensitivity and specificity (100% and 68% respectively), with a negative predictive value of 100% and positive predictive value of 66%. ETCO2 may reliably be used to screen and exclude patients with suspected PEs. If used in combination with D-dimer with clinical probability as a screening tool, CTPA will be required in only a minority of patients.

Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort

BACKGROUND

The public health burden of venous thromboembolism, which includes deep vein thrombosis and pulmonary embolism, is not fully known, and contemporary incidence and mortality estimates are needed. We determined the incidence and case fatality of venous thromboembolism in a general population.

METHODS

Using the administrative health care databases of the Canadian province of Québec, we identified all incident cases of deep vein thrombosis or pulmonary embolism between 2000 and 2009 and classified them as definite or probable venous thromboembolism. We formed 2 patient cohorts, one with definite cases and the other including cases with definite or probable venous thromboembolism that were followed until December 31, 2009.

RESULTS

We identified 67,354 definite and 35,123 probable cases of venous thromboembolism. The age- and sex-adjusted incidence rates of definite or probable venous thromboembolism, deep vein thrombosis, and pulmonary embolism were 1.22 (95% confidence interval [CI], 1.22-1.23), 0.78 (95% CI, 0.77-0.79), and 0.45 (95% CI, 0.44-0.45) per 1000 person-years, respectively, while for definite venous thromboembolism it was 0.90 (95% CI, 0.89-0.90) per 1000 person-years. The 30-day and 1-year case-fatality rates after definite or probable venous thromboembolism were 10.6% (95% CI, 10.4-10.8) and 23.0% (95% CI, 22.8-23.3), respectively, and were slightly higher among definite cases. The 1-year survival rate was 0.47 (95% CI, 0.46-0.48) for cases with definite or probable venous thromboembolism and cancer, 0.93 (95% CI, 0.93-0.94) for cases with unprovoked venous thromboembolism, and 0.84 (95% CI, 0.83-0.84) for cases with venous thromboembolism secondary to a major risk factor. Similar survival rates were seen for cases with definite venous thromboembolism.

CONCLUSION

The risk of venous thromboembolism in the general population remains high, and mortality, especially in cancer patients with venous thromboembolism, is substantial.

Association between venous and arterial thrombosis: clinical implications

Venous and arterial thromboses have traditionally been regarded as separate diseases with different causes. However, recent epidemiological studies have documented an association between these vascular complications, probably due to the presence of more overlapping risk factors than previously recognized. This narrative review first focuses on the risk factors associated with both arterial and venous thrombotic events. In addition, it summarizes the more recent data on the risk of incident venous thromboembolism in patients with asymptomatic atherosclerosis or clinical manifestations of atherothrombosis, as well as on the risk of incident atherothrombotic events in patients with previous manifestation of venous thromboembolism. The potential clinical implications are also discussed.

Fibrin D-dimer, tissue-type plasminogen activator, von Willebrand factor, and risk of incident stroke in older men

BACKGROUND AND PURPOSE

Abnormalities in blood coagulation and the fibrinolytic system have been associated with increased risk of stroke, but few prospective studies have studied the associations in older adults. We have examined the associations between fibrin D-dimer, tissue-type plasminogen activator, and von Willebrand factor (vWF) and risk of stroke in older men and examined their predictive roles separately in normotensive and hypertensive men.

METHODS

Prospective study of 3358 men aged 60 to 79 years with no previous diagnosis of myocardial infarction or stroke and without atrial fibrillation followed-up for an average of 9 years, during which there were 187 incident stroke events.

RESULTS

Increased levels of D-dimer and vWF were associated with significantly increased risk of major stroke events after adjustment for potential confounders, including systolic blood pressure (adjusted hazard ratios and 95% confidence interval per standard deviation increase in D-dimer and vWF were 1.24 [95% confidence interval, 1.08-1.44] and 1.25 [95% confidence interval, 1.09-1.45], respectively). No associations were seen with tPA after adjustment. The positive associations between D-dimer and vWF and incident stroke remained after additional adjustment for markers of inflammation (C-reactive protein, IL-6). D-dimer was associated with stroke in both normotensive and hypertensive men; vWF showed stronger associations in normotensive than in hypertensive men (test for interaction: P=0.52 for D-dimer; P<0.01 for vWF).

CONCLUSIONS

Fibrin D-dimer and vWF are associated with increased risk of stroke in older men. These associations were not explained by their associations with inflammation. D-dimer may be a useful marker to identify those at high risk for stroke among hypertensive men.

C-reactive protein and sociodemographic parameters in Moscow residents aged 55 years and older

Aim.High-sensitive C-reactive protein (hsCRP) is currently regarded as an important marker of cardiovascular disease (CVD). The aim of the study was to assess the population characteristics of hsCRP in the sample of Moscow residents aged 55 years and older.Material and methods.The analysis included 1851 people (response rate 65 %), who participated in the SAHR (Stress, Aging, and Health in Russia) study.Results.The hsCRP levels were similar in men and women, with the right-skewed distribution. The hsCRP values ranged from 0,5 to 69,5 mg/dl in men (median 1,5 mg/l), and from 0,5 to 75 mg/l in women (median 1,5 mg/l). The mean hsCRP levels were slightly higher in men than in women (3,4±0,19 vs. 3,1±0,15, respectively;р=0,36). Overall, there was no marked age-related dynamics of hsCRP levels in men or women. The prevalence of high hsCRP levels (>3 mg/l) non-significantly increased from 31,2 % in the youngest age group to 36,2 % in those aged 75 years and older. Acute inflammation (hsCRP levels >10 mg/l) was registered in 85 participants (4,5 %), including 42 men and 43 women. After adjustment for age and gender, the lower education level remained a significant predictor of hsCRP elevation.Conclusion.No clear associations between hsCRP and age or gender were observed. However, participants with university and secondary education had significantly lower hsCRP concentrations, compared to their peers with education level lower than secondary.