1
|
Yao W, Tang W, Wang W, Lv Q, Ding W. Association between hyperglycemia on admission and preoperative deep venous thrombosis in patients with femoral neck fractures. BMC Musculoskelet Disord 2022; 23:899. [PMID: 36203137 PMCID: PMC9535957 DOI: 10.1186/s12891-022-05862-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/30/2022] [Indexed: 11/28/2022] Open
Abstract
Background Elevated blood glucose is the most frequent electrolyte disturbance in acutely ill patients. This study aimed to determine whether admission hyperglycemia is associated with the incidence of preoperative deep venous thrombosis (DVT) in patients with femoral neck fractures. Methods This retrospective study was conducted on consecutive patients with femoral neck fractures admitted to our institution from March 2018 to March 2022. Blood glucose levels were measured within 24 h of admission and categorized into quartiles (Q1 = 5.30; Q2 = 5.70; Q3 = 6.60). Patients were divided into four groups (Group1-4) based on the quartiles. Preoperative DVT was diagnosed using venous compression ultrasonography. Multivariable logistic regression models and propensity score matching analysis evaluated the association between blood glucose and preoperative DVT in patients. Results Of 217 patients included in this study, 21(9.7%) had preoperative DVT in hospital, and admission hyperglycemia was observed in 83 (38.2%). Preoperative DVT was higher in patients with hyperglycemia (n = 15) than patients without hyperglycemia (n = 6) in the multivariable logistic regression models (OR 3.03, 95% CI 0.77–11.87). Propensity scores matching analyses manifested that compared with patients with group 2 (5.30 – 5.70 mmol/L) of glucose levels, the odds of preoperative DVT were slightly higher (OR 1.94, 95% CI 0.31–12.12) in patients with group 3 (5.70 – 6.60 mmol/L), substantially higher (OR 6.89, 95% CI 1.42–33.44, P trend < 0.01) in patients with the group 4 (> 6.60 mmol/L) of glucose levels. Conclusions In patients hospitalized for femoral neck fracture, markedly elevated blood glucose is associated with increased preoperative DVT in patients. The development of this biomarker could help in guiding patient counseling, risk assessment, and future management decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05862-0.
Collapse
Affiliation(s)
- Wei Yao
- Department of Orthopedics, Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China
| | - Wanyun Tang
- Department of Orthopedics, Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China
| | - Wei Wang
- Department of Orthopedics, Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China
| | - Qiaomei Lv
- Department of Oncology, Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China.
| | - Wenbo Ding
- Department of Orthopedics, Dandong Central Hospital, China Medical University, No. 338 Jinshan Street, Zhenxing District, Dandong, Liaoning Province, 118002, P.R. China.
| |
Collapse
|
2
|
Wu Y, Zhou L, Yao M, Zhu Y, Ni J, Cui L, Peng B. Elevated fasting blood glucose is predictive of the severity and poor outcome in nondiabetic patients with cerebral venous thrombosis. J Neurol Sci 2020; 417:117017. [DOI: 10.1016/j.jns.2020.117017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 06/16/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022]
|
3
|
van der Toorn FA, de Mutsert R, Lijfering WM, Rosendaal FR, van Hylckama Vlieg A. Glucose metabolism affects coagulation factors: The NEO study. J Thromb Haemost 2019; 17:1886-1897. [PMID: 31325222 DOI: 10.1111/jth.14573] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/11/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND It is insufficiently understood if there is an association between diabetes and VT, and what the underlying mechanism would be. OBJECTIVES We aimed to study the association between glucose concentrations with several coagulation factors in the general population. METHODS This is a cross-sectional analysis of baseline measurements within 5778 participants of the Netherlands Epidemiology of Obesity (NEO) study, a population-based cohort study of individuals 45 to 65 years. Associations between fasting glucose and HbA1c concentrations, and postprandial glucose response and factor (F) VIII, FIX, FXI, and fibrinogen levels were examined using linear regression analyses and by calculating mean levels per category of glucose concentrations while adjusting for confounding factors. RESULTS Per each mmol/L higher fasting glucose concentration we observed higher levels of fasting FVIII (5.33%, 95% CI: 4.00-6.65), FIX (6.19%, 95% CI: 5.15-7.23), and FXI (2.11%, 95% CI: 1.20-3.02). Results for fasting HbA1c and postprandial glucose response were similar. Participants with an impaired fasting glucose, high fasting glucose, and diabetes mellitus had higher mean levels of FVIII, FIX, and FXI than those with a normal glucose metabolism, with the highest differences in the levels of FVIII, FIX, and FXI between a high fasting glucose and a normal glucose metabolism. All associations attenuated after adjustment for total body fat, yet all of the above associations remained after adjustment for the confounding factors, except for fibrinogen when contrasted to glucose. CONCLUSION Concentrations of fasting glucose and HbA1c and postprandial glucose response were positively associated with FVIII, FIX, and FXI, and to some extent also with fibrinogen.
Collapse
Affiliation(s)
| | - Renée de Mutsert
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | |
Collapse
|
4
|
Li‐Gao R, Morelli VM, Lijfering WM, Cannegieter SC, Rosendaal FR, van Hylckama Vlieg A. Glucose levels and diabetes are not associated with the risk of venous thrombosis: results from the MEGA case-control study. Br J Haematol 2019; 184:431-435. [PMID: 30478992 PMCID: PMC6587875 DOI: 10.1111/bjh.15599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/14/2018] [Indexed: 01/29/2023]
Abstract
It is unclear whether hyperglycaemia or diabetes mellitus are risk factors for a first venous thrombosis (VT). Self-reported diabetes status and fasting glucose (FG) measures were collected from the Multiple Environmental and Genetic Assessment (MEGA) study to confirm these associations. FG levels were categorized based on the World Health Organization criteria [<6·1 (reference), 6·1-7·0 (2nd), ≥7·0 (3rd) mmol/l]. Logistic regression was performed to quantify the associations. Neither increased FG levels [Odds ratio (95% confidence interval): 0·98 (0·69-1·37) 2nd vs. reference, 0·97 (0·58-1·63) 3rd vs. reference] nor self-reported diabetes [1·12 (0·80-1·58)] were associated with an increased risk of a first VT.
Collapse
Affiliation(s)
- Ruifang Li‐Gao
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenthe Netherlands
| | - Vânia M. Morelli
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenthe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenthe Netherlands
- Einthoven Laboratory for Experimental Vascular MedicineLeiden University Medical CentreLeidenthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenthe Netherlands
- Einthoven Laboratory for Experimental Vascular MedicineLeiden University Medical CentreLeidenthe Netherlands
- Department of Internal MedicineSection of Thrombosis and HaemostasisLeiden University Medical CentreLeidenThe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CentreLeidenthe Netherlands
- Einthoven Laboratory for Experimental Vascular MedicineLeiden University Medical CentreLeidenthe Netherlands
- Department of Internal MedicineSection of Thrombosis and HaemostasisLeiden University Medical CentreLeidenThe Netherlands
| | | |
Collapse
|
5
|
Rudy MD, Ahuja NK, Aaronson AJ. Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty. JBJS Rev 2018; 6:e10. [DOI: 10.2106/jbjs.rvw.17.00146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
6
|
Bollig CA, Spradling CS, Dooley LM, Galloway TL, Jorgensen JB. Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction. Head Neck 2018; 40:1196-1206. [PMID: 29498137 DOI: 10.1002/hed.25097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 10/07/2017] [Accepted: 01/10/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The effects of perioperative hyperglycemia on complications and outcomes in microvascular reconstruction have not been reported in the literature. METHODS A retrospective cohort of 203 patients undergoing microvascular reconstruction was generated. Perioperative glucose levels and clinical factors were tested for associations with complications using simple and multivariate analyses. RESULTS Hyperglycemia (blood glucose ≥ 180 mg/dL) occurred in 91 patients (44.8%) perioperatively, and was associated with increased rates of surgical complications, medical complications, surgical site infections, fistulas, and wound dehiscence. On univariate analysis, a more strict definition of hyperglycemia (blood glucose ≥ 165 mg/dL) was significantly associated with greater rates of venous thrombosis, although this lost statistical significance on multivariate analysis. CONCLUSION Perioperative hyperglycemia occurs commonly in patients undergoing microvascular reconstruction and is associated with higher rates of complications, independent of a preexisting diagnosis of diabetes mellitus. Further research is needed to define the ideal glycemic target in this population.
Collapse
Affiliation(s)
- Craig A Bollig
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | | | - Laura M Dooley
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Tabitha L Galloway
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Jeffrey B Jorgensen
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri
| |
Collapse
|
7
|
Mi Y, Yan S, Lu Y, Liang Y, Li C. Venous thromboembolism has the same risk factors as atherosclerosis: A PRISMA-compliant systemic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4495. [PMID: 27512866 PMCID: PMC4985321 DOI: 10.1097/md.0000000000004495] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Previous studies have shown that idiopathic pulmonary embolism is positively associated with other cardiovascular events, such as myocardial infarction and stroke, suggesting a potentially important association between atherosclerosis risk factors and venous thromboembolism (VTE). We performed a meta-analysis to evaluate the correlation between risk factors for atherosclerosis and VTE. METHODS In December 2014, we searched MEDLINE and EMBASE for studies evaluating the associations between VTE and risk factors for atherosclerosis and pooled outcome data using random-effects meta-analysis. In addition, we analyzed publication bias. RESULTS Thirty-three case-control and cohort studies with a total of 185,124 patients met the inclusion criteria. We found that participants with body mass index (BMI) ≥30 kg/m had a significantly higher prevalence of VTE than those with BMI <30 kg/m in both case-control studies (odds ratio [OR] = 2.45, 95% confidence interval [CI]: 1.78-3.35) and cohort studies (relative risk [RR] = 2.39, 95% CI: 1.79-3.17). VTE was more prevalent in patients with hypertension than without hypertension (OR = 1.40, 95% CI: 1.06-1.84; RR = 1.36, 95% CI: 1.11-1.67). The findings were similar for VTE prevalence between patients with and without diabetes (OR = 1.78, 95% CI: 1.17-2.69; RR = 1.41, 95% CI: 1.20-1.66). Current smoking was significantly associated with VTE prevalence in case-control studies (OR = 1.34, 95% CI: 1.01-1.77), but not in cohort studies (RR = 1.29, 95% CI: 0.96-1.72). In addition, we found that total cholesterol and triglyceride concentrations were significantly higher in patients with VTE than without VTE (weighted mean differences [WMD] = 8.94 mg/dL, 95% CI: 3.52-14.35 mg/dL, and WMD = 14.00 mg/dL, 95% CI: 8.85-19.16 mg/dL, respectively). High-density lipoprotein cholesterol concentrations were significantly lower in patients with VTE than without VTE (WMD = -2.03 mg/dL, 95% CI: -3.42 to -0.63 mg/dL). Higher quality studies were more homogeneous, but confirmed the same significant associations. CONCLUSIONS Based on our systematic review and meta-analysis, we observed a significant association between VTE and the risk factors for atherosclerosis. These results may make an important contribution to clinical practice regarding VTE treatment.
Collapse
Affiliation(s)
- Yuhong Mi
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Disease, Beijing, China
| | - Shufeng Yan
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Disease, Beijing, China
| | - Yanhui Lu
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Disease, Beijing, China
| | - Ying Liang
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vascular Disease, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
8
|
Forster R, Stewart M. Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair. Cochrane Database Syst Rev 2016; 3:CD004179. [PMID: 27027384 PMCID: PMC10332795 DOI: 10.1002/14651858.cd004179.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal duration of thromboprophylaxis after total hip or knee replacement, or hip fracture repair remains controversial. It is common practice to administer prophylaxis using low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) until discharge from hospital, usually seven to 14 days after surgery. International guidelines recommend extending thromboprophylaxis for up to 35 days following major orthopaedic surgery but the recommendation is weak due to moderate quality evidence. In addition, recent oral anticoagulants that exert effect by direct inhibition of thrombin or activated factor X lack the need for monitoring and have few known drug interactions. Interest in this topic remains high. OBJECTIVES To assess the effects of extended-duration anticoagulant thromboprophylaxis for the prevention of venous thromboembolism (VTE) in people undergoing elective hip or knee replacement surgery, or hip fracture repair. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Specialised Register (last searched May 2015) and CENTRAL (2015, Issue 4). Clinical trials databases were searched for ongoing or unpublished studies. SELECTION CRITERIA Randomised controlled trials assessing extended-duration thromboprophylaxis (five to seven weeks) using accepted prophylactic doses of LMWH, UFH, vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) compared with short-duration thromboprophylaxis (seven to 14 days) followed by placebo, no treatment or similar extended-duration thromboprophylaxis with LMWH, UFH, VKA or DOACs in participants undergoing hip or knee replacement or hip fracture repair. DATA COLLECTION AND ANALYSIS We independently selected trials and extracted data. Disagreements were resolved by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity. MAIN RESULTS We included 16 studies (24,930 participants); six compared heparin with placebo, one compared VKA with placebo, two compared DOAC with placebo, one compared VKA with heparin, five compared DOAC with heparin and one compared anticoagulants chosen at investigators' discretion with placebo. Three trials included participants undergoing knee replacement. No studies assessed hip fracture repair.Trials were generally of good methodological quality. The main reason for unclear risk of bias was insufficient reporting. The quality of evidence according to GRADE was generally moderate, as some comparisons included a single study, low number of events or heterogeneity between studies leading to wide CIs.We showed no difference between extended-duration heparin and placebo in symptomatic VTE (OR 0.59, 95% CI 0.35 to 1.01; 2329 participants; 5 studies; high quality evidence), symptomatic deep vein thrombosis (DVT) (OR 0.73, 95% CI 0.39 to 1.38; 2019 participants; 4 studies; moderate quality evidence), symptomatic pulmonary embolism (PE) (OR 0.61, 95% CI 0.16 to 2.33; 1595 participants; 3 studies; low quality evidence) and major bleeding (OR 0.59, 95% CI 0.14 to 2.46; 2500 participants; 5 studies; moderate quality evidence). Minor bleeding was increased in the heparin group (OR 2.01, 95% CI 1.43 to 2.81; 2500 participants; 5 studies; high quality evidence). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration VKA and placebo (one study, 360 participants) for symptomatic VTE (OR 0.10, 95% CI 0.01 to 1.94; moderate quality evidence), symptomatic DVT (OR 0.13, 95% CI 0.01 to 2.62; moderate quality evidence), symptomatic PE (OR 0.32, 95% CI 0.01 to 7.84; moderate quality evidence) and major bleeding (OR 2.89, 95% CI 0.12 to 71.31; low quality evidence). Clinically relevant non-major bleeding and minor bleeding were not reported.Extended-duration DOAC showed reduced symptomatic VTE (OR 0.20, 95% CI 0.06 to 0.68; 2419 participants; 1 study; moderate quality evidence) and symptomatic DVT (OR 0.18, 95% CI 0.04 to 0.81; 2459 participants; 2 studies; high quality evidence) compared to placebo. No differences were found for symptomatic PE (OR 0.25, 95% CI 0.03 to 2.25; 1733 participants; 1 study; low quality evidence), major bleeding (OR 1.00, 95% CI 0.06 to 16.02; 2457 participants; 1 study; low quality evidence), clinically relevant non-major bleeding (OR 1.22, 95% CI 0.76 to 1.95; 2457 participants; 1 study; moderate quality evidence) and minor bleeding (OR 1.18, 95% CI 0.74 to 1.88; 2457 participants; 1 study; moderate quality evidence).We showed no difference between extended-duration anticoagulants chosen at investigators' discretion and placebo (one study, 557 participants, low quality evidence) for symptomatic VTE (OR 0.50, 95% CI 0.09 to 2.74), symptomatic DVT (OR 0.33, 95% CI 0.03 to 3.21), symptomatic PE (OR 1.00, 95% CI 0.06 to 16.13), and major bleeding (OR 5.05, 95% CI 0.24 to 105.76). Clinically relevant non-major bleeding and minor bleeding were not reported.We showed no difference between extended-duration VKA and heparin (one study, low quality evidence) for symptomatic VTE (OR 1.64, 95% CI 0.85 to 3.16; 1279 participants), symptomatic DVT (OR 1.36, 95% CI 0.69 to 2.68; 1279 participants), symptomatic PE (OR 9.16, 95% CI 0.49 to 170.42; 1279 participants), major bleeding (OR 3.87, 95% CI 1.91 to 7.85; 1272 participants) and minor bleeding (OR 1.33, 95% CI 0.64 to 2.76; 1279 participants). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration DOAC and heparin for symptomatic VTE (OR 0.70, 95% CI 0.28 to 1.70; 15,977 participants; 5 studies; low quality evidence), symptomatic DVT (OR 0.60, 95% CI 0.11 to 3.27; 15,977 participants; 5 studies; low quality evidence), symptomatic PE (OR 0.91, 95% CI 0.43 to 1.94; 14,731 participants; 5 studies; moderate quality evidence), major bleeding (OR 1.11, 95% CI 0.79 to 1.54; 16,199 participants; 5 studies; high quality evidence), clinically relevant non-major bleeding (OR 1.08, 95% CI 0.90 to 1.28; 15,241 participants; 4 studies; high quality evidence) and minor bleeding (OR 0.95, 95% CI 0.82 to 1.10; 11,766 participants; 4 studies; high quality evidence). AUTHORS' CONCLUSIONS Moderate quality evidence suggests extended-duration anticoagulants to prevent VTE should be considered for people undergoing hip replacement surgery, although the benefit should be weighed against the increased risk of minor bleeding. Further studies are needed to better understand the association between VTE and extended-duration oral anticoagulants in relation to knee replacement and hip fracture repair, as well as outcomes such as distal and proximal DVT, reoperation, wound infection and healing.
Collapse
Affiliation(s)
- Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Marlene Stewart
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | | |
Collapse
|
9
|
Hogan C, Bucknell AL, King KB. The Effect of Diabetes Mellitus on Total Joint Arthroplasty Outcomes. JBJS Rev 2016; 4:01874474-201602000-00003. [PMID: 27490133 DOI: 10.2106/jbjs.rvw.o.00044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Diabetes has negative effects on the outcomes of total joint arthroplasty, including increased numbers of complications, decreased function, early revision, and higher costs. The prevalence of diabetes is increasing rapidly worldwide; therefore, the orthopaedic surgeon should have an understanding of how diabetes affects surgical outcomes.
Collapse
|
10
|
Zuurbier SM, Hiltunen S, Tatlisumak T, Peters GM, Silvis SM, Haapaniemi E, Kruyt ND, Putaala J, Coutinho JM. Admission Hyperglycemia and Clinical Outcome in Cerebral Venous Thrombosis. Stroke 2015; 47:390-6. [PMID: 26670083 DOI: 10.1161/strokeaha.115.011177] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Admission hyperglycemia is associated with poor clinical outcome in ischemic and hemorrhagic stroke. Admission hyperglycemia has not been investigated in patients with cerebral venous thrombosis. METHODS Consecutive adult patients with cerebral venous thrombosis were included at the Academic Medical Center, The Netherlands (2000-2014) and the Helsinki University Central Hospital, Finland (1998-2014). We excluded patients with known diabetes mellitus and patients without known admission blood glucose. We defined admission hyperglycemia as blood glucose ≥7.8 mmol/L (141 mg/dL) and severe hyperglycemia as blood glucose ≥11.1 mmol/L (200 mg/dL). We used logistic regression analysis to determine if admission hyperglycemia was associated with modified Rankin Scale (mRS) score of 3 to 6 or mortality at last follow-up. We adjusted for: age, sex, coma, malignancy, infection, intracerebral hemorrhage, deep cerebral venous thrombosis, and location of recruitment. RESULTS Of 380 patients with cerebral venous thrombosis, 308 were eligible. Of these, 66 (21.4%) had admission hyperglycemia with 8 (2.6%) having severe admission hyperglycemia. Coma (31.3% versus 5.0%, P<0.001) and intracerebral hemorrhage (53.0% versus 32.6%, P=0.002) at presentation were more common among patients with admission hyperglycemia than normoglycemic patients. Patients with admission hyperglycemia had a higher risk of mRS score of 3 to 6 (adjusted odds ratio, 3.10; 95% confidence interval, 1.35-7.12) and mortality (adjusted odds ratio, 4.13; 95% confidence interval, 1.41-12.09). Severe hyperglycemia was even more strongly associated with mRS score of 3 to 6 (adjusted odds ratio, 11.59; 95% confidence interval, 1.74-77.30) and mortality (adjusted odds ratio, 33.36; 95% confidence interval, 3.87-287.28) compared with normoglycemic patients. CONCLUSIONS Admission hyperglycemia is a strong predictor of poor clinical outcome in patients with cerebral venous thrombosis.
Collapse
Affiliation(s)
- Susanna M Zuurbier
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Sini Hiltunen
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Turgut Tatlisumak
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Guusje M Peters
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Suzanne M Silvis
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Elena Haapaniemi
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Nyika D Kruyt
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Jukka Putaala
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.)
| | - Jonathan M Coutinho
- From the Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands (S.M.Z., G.M.P., S.M.S, J.M.C.); Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands (N.D.K.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (S.H., T.T., E.H., J.P.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).
| |
Collapse
|
11
|
Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications. J Minim Invasive Gynecol 2015; 22:1049-58. [DOI: 10.1016/j.jmig.2015.05.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/24/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022]
|
12
|
Jämsen E, Nevalainen PI, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop 2015; 86:175-82. [PMID: 25409255 PMCID: PMC4404767 DOI: 10.3109/17453674.2014.987064] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 09/08/2014] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Perioperative hyperglycemia has been associated with adverse outcomes in several fields of surgery. In this observational study, we identified factors associated with an increased risk of hyperglycemia following hip and knee replacement. PATIENTS AND METHODS We prospectively monitored changes in glucose following primary hip and knee replacements in 191 patients with osteoarthritis. Possible associations of patient characteristics and operation-related factors with hyperglycemia (defined as glucose > 7.8 mmol/L in 2 consecutive measurements) and severe hyperglycemia (glucose > 10 mmol/L) were analyzed using binary logistic regression with adjustment for age, sex, operated joint, and anesthesiological risk score. RESULTS 76 patients (40%) developed hyperglycemia, and 48 of them (25% of the whole cohort) had severe hyperglycemia. Glycemic responses were similar following hip replacement and knee replacement. Previously diagnosed diabetes was associated with an increased risk of hyperglycemia and severe hyperglycemia, compared to patients with normal glucose metabolism, whereas newly diagnosed diabetes and milder glucose metabolism disorders had no effect. In patients without previously diagnosed diabetes, increased values of preoperative glycosylated hemoglobin (HbA1c) and fasting glucose on the day of operation were associated with hyperglycemia. Higher anesthesiological risk score-but none of the operation-related factors analyzed-was associated with an increased risk of hyperglycemia. INTERPRETATION Perioperative hyperglycemia is common in primary hip and knee replacements. Previously diagnosed diabetes is the strongest risk factor for hyperglycemia. In patients with no history of diabetes, preoperative HbA1c and fasting glucose on the day of operation can be used to stratify the risk of hyperglycemia.
Collapse
Affiliation(s)
- Esa Jämsen
- Coxa, Hospital for Joint Replacement, Tampere
| | | | | | | | | |
Collapse
|
13
|
Best practices for centers of excellence in addressing periprosthetic joint infection. J Am Acad Orthop Surg 2015; 23 Suppl:S12-7. [PMID: 25808965 DOI: 10.5435/jaaos-d-14-00380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection is a rare and devastating complication. Management of this complication often requires a multidisciplinary approach similar to that used for the care of patients with cancer. Several studies have reported better outcomes following total joint arthroplasties performed at specialized hospitals than those performed at general hospitals. Specialized institutions use care pathways that aid the multidisciplinary team in decision making. During the recent Musculoskeletal Infection symposium, specific issues were discussed with regard to the treatment of periprosthetic joint infection, including medical optimization, systematic approaches to infection management, and the importance of establishing registries to aid in the creation of Centers of Excellence. A Center of Excellence in periprosthetic infection could provide better overall outcomes with lower financial, physical, and emotional costs to patients.
Collapse
|
14
|
Sechterberger MK, Hermanides J, Poolman RW, Kal JE, Meijers JCM, Hoekstra JBL, Hans DeVries J. Lowering blood glucose during hip surgery does not influence coagulation activation. BBA CLINICAL 2015; 3:227-32. [PMID: 26675337 PMCID: PMC4661563 DOI: 10.1016/j.bbacli.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 11/18/2022]
Abstract
Background Hyperglycaemia during and after hip surgery is associated with coagulation activation and an increased risk of venous thromboembolism. Whether lowering of glucose levels during hip surgery diminishes coagulation activation is unknown. We investigated the efficacy of the human GLP-1 analogue liraglutide to lower glucose during and after hip surgery and studied its influence on coagulation activation. Methods A total of 37 obese subjects who underwent hip surgery were randomized to subcutaneous liraglutide or placebo for 4 consecutive days, starting one day prior to surgery. Glucose levels and coagulation indices at three fixed time-points (pre-operative, 2 h post-operative and 3 days post-operative) were measured. Results Liraglutide reduced glucose at day three post-surgery (median glucose (IQR) liraglutide 5.5 (5.2–5.7) vs. placebo 5.8 (5.5–6.2); difference 0.3 mmol/L, P = 0.04). Changes in 6 out of 8 coagulation indices studied did not differ between the two groups. Only D-dimer levels were significantly lower in the liraglutide group at day three post-surgery and FVIII levels were significantly higher in the liraglutide group 2 h post-surgery. Conclusion Although the human GLP-1 analogue liraglutide moderately reduced post-operative blood glucose levels in non-diabetic and prediabetic obese patients undergoing elective hip surgery, no changes were observed with respect to coagulation activation. Hyperglycaemia during hip surgery is associated with venous thromboembolism. We examined the effect of perioperative glucose lowering on coagulation. Perioperative glucose lowering was realized using the GLP-1 antagonist liraglutide. Liraglutide moderately reduced glucose levels in non-diabetic and prediabetic hip surgery patients. No effect of glucose lowering therapy on coagulation was found.
Collapse
Affiliation(s)
| | - Jeroen Hermanides
- Dept of Anaesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rudolf W Poolman
- Dept of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Jasper E Kal
- Dept of Anaesthesiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Joost C M Meijers
- Dept of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands ; Dept of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - Joost B L Hoekstra
- Dept of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J Hans DeVries
- Dept of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Tala JA, Silva CT, Pemira S, Vidal E, Faustino EVS. Blood glucose as a marker of venous thromboembolism in critically ill children. J Thromb Haemost 2014; 12:891-6. [PMID: 24708410 PMCID: PMC4055532 DOI: 10.1111/jth.12583] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND The ability to predict the development of venous thromboembolism is highly desirable. OBJECTIVE We aim to determine the association between hyperglycemia and venous thromboembolism in non-diabetic critically ill children. PATIENTS/METHODS We conducted a retrospective cohort study that included children in the pediatric intensive care unit on a vasopressor or mechanical ventilator and without history of diabetes mellitus or prior diagnosis of thrombosis. Based on maximum blood glucose > 150 mg dL(-1) while admitted to the unit, children were categorized as hyperglycemic or non-hyperglycemic. The primary outcome was development of venous thromboembolism while admitted to the unit. We determined the association between hyperglycemia and venous thromboembolism using logistic regression models adjusting for selected subject characteristics. RESULTS Of the 789 subjects analyzed, 34 subjects developed venous thromboembolism (incidence, 4.3%; 95% confidence interval, 3-6%). Venous thromboembolism was more likely to develop in hyperglycemic subjects compared with non-hyperglycemic subjects. A total of 31 subjects (6.2%; 95% confidence interval, 4.2-8.7%) developed venous thromboembolism after becoming hyperglycemic compared with three non-hyperglycemic subjects with venous thromboembolism (1%; 95% confidence interval, 0.2-3%). When adjusted for age, diagnosis, presence of central venous catheter, prophylactic antithrombotic use and severity of illness, the odds ratio of venous thromboembolism with hyperglycemia was 4.1 (95% confidence interval, 1.2-14.1). For every 10 mg dL(-1) increase in maximum blood glucose, the adjusted odds ratio of venous thromboembolism was 1.04 (95% confidence interval, 1.01-1.06). CONCLUSION Hyperglycemia is associated with venous thromboembolism in critically ill non-diabetic children. Maximum blood glucose is a potential predictor of venous thromboembolism in this population.
Collapse
Affiliation(s)
- J A Tala
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | | | | | | | | |
Collapse
|
16
|
Zhao Z, Wang S, Ma W, Kong G, Zhang S, Tang Y, Zhao Y. Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg 2014; 134:79-83. [PMID: 24276361 DOI: 10.1007/s00402-013-1894-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Many patients undergoing total knee arthroplasty (TKA) have diabetes mellitus, which may increase the risk of deep vein thrombosis (DVT) after TKA. We therefore assessed whether diabetes mellitus increased the incidence of DVT within 14 days after TKA. MATERIALS AND METHODS The incidence of DVT within 14 days of surgery was compared in diabetic and non-diabetic patients undergoing TKA in our hospital between June 2011 and February 2013. The relationships between diabetes mellitus and DVT were analyzed. RESULTS Of the 358 enrolled patients, 70 (19.6%) had diabetes and 288 (80.4%) did not. DVT occurred within 14 days in 198 patients, 52 of 70 (74.3%) in the diabetes group and 146 of 288 (50.7%) in the non-diabetes group (p = 0.012). DVT of the contralateral leg was observed in 16 and 50 patients, respectively (p = 0.452). Logistic regression analysis showed that the risk of DVT was 2.71-fold higher in patients with than without diabetes mellitus (95% CI 1.183-6.212, p = 0.018). There were no significant differences in age, gender, hypertension, BMI, duration of surgery, intra-operative blood loss, and duration of tourniquet between the two groups. CONCLUSIONS The incidence of DVT 14 days after TKA was significantly higher in patients with than without diabetes.
Collapse
Affiliation(s)
- Zhongyuan Zhao
- Department of the Joint and Bone Surgery, Yantaishan Hospital, No. 91, Jiefang Road, Yantai, 264001, Shandong, China,
| | | | | | | | | | | | | |
Collapse
|
17
|
Rambachan A, Mioton LM, Saha S, Fine N, Kim JYS. The impact of surgical duration on plastic surgery outcomes. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013. [DOI: 10.1007/s00238-013-0851-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
18
|
Wang S, Zhao Y. Diabetes mellitus and the incidence of deep vein thrombosis after total knee arthroplasty: a retrospective study. J Arthroplasty 2013; 28:595-7. [PMID: 23153599 DOI: 10.1016/j.arth.2012.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 06/04/2012] [Accepted: 07/18/2012] [Indexed: 02/01/2023] Open
Abstract
We explored if there was an increased risk of DVT in patients with diabetes mellitus undergoing total knee arthroplasty within 14days followup. We reviewed 245 patients undergoing total knee arthroplasty in our hospital between 2003 and 2011. The incidence of DVT within 14days after operations was compared between diabetic patients and non-diabetic patients. There were 37 patients with DVT in the diabetes group and 88 in the non-diabetes group within 14days followup (p=0.002). The risk of DVT in patients with diabetes mellitus was 2.76 times the risk in patients without diabetes mellitus using logistic regression modeling (OR=2.76, p=0.003). Although it is still controversial, patients with diabetes had a higher incidence rate of DVT after total knee arthroplasty in our study.
Collapse
Affiliation(s)
- Shijun Wang
- Department of the Joint and Bone Surgery, Yantaishan Hospital, Yantai, Shandong Province, China
| | | |
Collapse
|
19
|
Sechterberger MK, Hutten BA, Hermanides J, Cohn DM, Hoekstra JBL, Kamphuisen PW, DeVries JH. The incidence of diabetes mellitus following pulmonary embolism: a retrospective cohort study. J Thromb Haemost 2012; 10:2628-30. [PMID: 23082916 DOI: 10.1111/jth.12029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
20
|
Iba T, Aihara K, Kawasaki S, Yanagawa Y, Niwa K, Ohsaka A. Formation of the venous thrombus after venous occlusion in the experimental mouse model of metabolic syndrome. Thromb Res 2012; 129:e246-50. [PMID: 22459906 DOI: 10.1016/j.thromres.2012.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/29/2012] [Accepted: 03/05/2012] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The metabolic syndrome is considered to be a risk factor for the venous thromboembolism (VTE) as well as arterial thrombosis. Although obesity, hyperglycemia and dyslipidemia are considered to be important triggering factors, it is difficult to evaluate the relationship between VTE and the metabolic syndrome in a clinical study. Furthermore the mechanism of venous thrombosis initiation still remains elusive. MATERIALS AND METHODS 20 min clamp of superior mesenteric vein was applied to 7 w, 16 w-old KK-A(y) mouse and 16 w-old B6J mouse (n = 6 in each group), after de-clamp, the view of the mesenteric vein and intestinal submucosal venule were observed by the intravital microscopy. RESULTS Massive thrombi formed in the mesenteric vein in 16 w-old KK-A(y) mice, moderate thrombi formation was observed in 7 w-old KK-A(y) mice, while very few thrombi were observed in B6 J mice. The first event in submucosal venule after de-clamp was the adhesion of leukocytes to the endothelium. Subsequently, leukocytes assembled and platelets covered the leukocyte cluster. These leukocyte-platelet aggregates move from the venule to the vein and finally formed a venous thrombus. CONCLUSION Metabolic syndrome is a risk factor for venous thrombosis. Intravital microscopic examination revealed leukocyte and platelet recruitment to the venule in the early stages of venous thrombosis formation.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan.
| | | | | | | | | | | |
Collapse
|