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

Shared genetic etiology of vessel diseases: A genome-wide multi-traits association analysis

BACKGROUND

The comorbidity among vascular diseases has been widely reported, however, the contribution of shared genetic components remains ambiguous.

METHODS

Based on genome-wide association study summary statistics, we employed statistical genetics methodologies to explore the shared genetic basis of eight vascular diseases: coronary artery disease, abdominal aortic aneurysm, ischemic stroke, peripheral artery disease, thoracic aortic aneurysm, phlebitis, varicose veins, and venous thromboembolism. We assessed global and local genetic correlations among these disorders by linkage disequilibrium score regression, high-definition likelihood, and local analysis of variant association. Cross-trait analyses conducted with CPASSOC identified pleiotropic variants and loci. Further, biological pathways at the multi-omics level were explored using multimarker analysis of genomic annotation, transcriptome-wide and proteome-wide association studies. Causal associations among the vascular diseases were evaluated by mendelian randomization and latent causal variable to assess vertical pleiotropic effects.

RESULTS

We found significant global genetic associations in 18 pairs of vascular diseases. Additionally, we discovered 317 unique genomic regions where at least one pair of traits demonstrated significant correlation. Multi-trait association analysis identified 19,361 significant potential pleiotropic variants in 274 independent pleiotropic loci. Multi-trait colocalization analysis revealed 56 colocalized loci in specific disease sets. Gene-based analysis identified 700 potential pleiotropic genes, which were subsequently validated at both transcriptome and protein levels. Gene-set enrichment analysis supports the role of biological pathways such as vessel wall structure, coagulation and lipid transport in vascular disease. Additionally, 7 pairs of vascular diseases have a causal relationship.

CONCLUSIONS

Our study indicates a shared genetic basis and the presence of common risk genes among vascular diseases. These findings offer novel insights into potential mechanisms underlying the association between vascular diseases, as well as provide guidance for interventions and treatments of multi-vascular conditions.

Construction of a Prediction Model for Post-Thrombotic Syndrome After Deep Vein Thrombosis Incorporating Novel Inflammatory Response Parameter Scoring

OBJECTIVE

To investigate the independent predictive factors for post-thrombotic syndrome (PTS) and to construct a risk prediction model for PTS by incorporating a novel inflammatory response parameter scoring.

METHODS

A retrospective study analyzed patients diagnosed with lower extremity deep vein thrombosis (LEDVT) at the Affiliated Hospital of Chengde Medical College from January 2018 to January 2022. The Villalta scale was used to assess the occurrence of PTS 6-24 months after discharge. Patients were randomly divided into a training set and a validation set at a ratio of 7:3. In the training set, univariate analysis was performed on meaningful continuous variables, and those with differences were converted into dichotomous variables based on optimal cutoff values. Variable selection was performed using Log-Lambda and LASSO 10-fold cross-validation, followed by multivariable logistic regression analysis on selected variables for model construction. The model underwent internal validation in the validation set and external validation in an independent external cohort, including discriminative analysis, calibration analysis, and clinical decision curve analysis, with the model's rationale being evaluated lastly.

RESULTS

A total of 356 patients with lower extremity DVT were included, with 249 in the training set for model construction and 107 in the validation set for internal validation, along with 37 external patients for external validation. A composite score of inflammatory response parameters, including the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to high-density lipoprotein cholesterol ratio (MHR) (NLR-PLR-MHR score, NPMscore), was developed, showing a significantly higher NPMscore in the PTS group compared to the non-PTS group (p<0.05). Predictive factors related to the risk of PTS occurrence included stage (OR=6.83, 95%CI: 2.74-18.04), varicose veins (OR=7.30, 95%CI: 2.29-25.75), homocysteine (Hcy) (OR=1.12, 95%CI: 1.04-1.22), NPMscore (OR=3.13, 95%CI: 1.94-5.36), standardized anticoagulant therapy (OR=5.77, 95%CI: 1.25-27.62), and one-stop treatment (OR=0.04, 95%CI: 0.00-0.35) were incorporated into the Nomogram model. The model showed good discrimination with a concordance index of 0.918 (95%CI: 0.876-0.959) for model construction, 0.843 (95%CI: 0.741-0.945) for internal validation, and 0.823 (95%CI: 0.667-0.903) for external validation. The Nomogram model, internal and external validation calibration curves showed good agreement between observed and predicted values. Decision curve analysis (DCA) indicated the Nomogram model predicted PTS risk probability thresholds ranging from 3%-98% for model construction, 5%-97% for internal validation, and 10%-80% for external validation, demonstrating better net benefit for predicting PTS risk in the model, internal, and external validation. Rationality analysis showed the model and internal validation had higher discrimination and clinical net benefit than other clinical indices.

CONCLUSION

The novel inflammatory response parameter score (NPMscore) combined with stage, varicose veins, homocysteine (Hcy), standardized anticoagulant therapy, and one-stop treatment in the Nomogram model provides a practical tool for healthcare professionals to assess the risk of PTS in DVT patients, enabling early identification of high-risk patients for effective PTS prevention.

Circulating Blood Biomarkers and Risk of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

 Cancer patients have an increased risk of venous thromboembolism (VTE). Currently, the availability of highly discriminatory prediction models for VTE in cancer patients is limited. The implementation of biomarkers in prediction models might lead to refined VTE risk prediction. In this systematic review and meta-analysis, we aimed to evaluate candidate biomarkers and their association with cancer-associated VTE.

METHODS

 We searched Medline, EMBASE, and Cochrane Central for studies that evaluated biomarkers in adult cancer patients from inception to September 2022. We included studies reporting on VTE after a cancer diagnosis with biomarker measurements performed at a defined time point. Median/mean differences (for continuous measures) and odds ratios (for dichotomous measures) with 95% confidence intervals were estimated and pooled using random-effects models.

RESULTS

 We included 113 studies in the systematic review. Of these, 50 studies were included in the meta-analysis. We identified two biomarkers at cancer diagnosis (factor VIII and time to peak thrombin), three biomarkers pre-chemotherapy (D-dimer, fibrinogen, and mean platelet volume), and one biomarker preoperatively (platelet count) that had significant median or mean differences. Additionally, we found that hemoglobin <100 g/L and white blood count >11 × 109/L were significantly associated with future VTE risk only when measured at cancer diagnosis. Pre-chemotherapy neutrophil-to-lymphocyte ratio ≥3 and preoperative platelet count ≥400 × 109/L were also found to be associated with future VTE risk.

CONCLUSION

 In conclusion, this study identified nine candidate blood biomarkers that may help in optimizing VTE prediction in cancer patients that should be further explored in future studies.

Under the dual effect of inflammation and pulmonary fibrosis, CTD-ILD patients possess a greater susceptibility to VTE

As an autoimmune disease, the persistent systemic inflammatory response associated with connective tissue disease (CTD) is involved in the development of venous thromboembolism (VTE). However, clinical data showed that the risk of VTE in patients differed between subtypes of CTD, suggesting that different subtypes may have independent mechanisms to promote the development of VTE, but the specific mechanism lacks sufficient research at present. The development of pulmonary fibrosis also contributes to the development of VTE, and therefore, patients with CTD-associated interstitial lung disease (CTD-ILD) may be at higher risk of VTE than patients with CTD alone or patients with ILD alone. In addition, the activation of the coagulation cascade response will drive further progression of the patient's pre-existing pulmonary fibrosis, which will continue to increase the patient's risk of VTE and adversely affect prognosis. Currently, the treatment for CTD-ILD is mainly immunosuppressive and antirheumatic therapy, such as the use of glucocorticoids and janus kinase-inhibitors (JAKis), but, paradoxically, these drugs are also involved in the formation of patients' coagulation tendency, making the clinical treatment of CTD-ILD patients with a higher risk of developing VTE challenging. In this article, we review the potential risk factors and related mechanisms for the development of VTE in CTD-ILD patients to provide a reference for clinical treatment and prevention.

Clinical disease activity is a major determinant of plasma D-dimer elevation in outpatients with rheumatoid arthritis: A hospital-based cross-sectional study

OBJECTIVES

To identify factors associated with plasma D-dimer levels in outpatients with rheumatoid arthritis (RA).

METHODS

We consecutively recruited 460 RA patients who visited our hospital for routine follow-ups between June and October 2021. Plasma D-dimer, RA-related characteristics, comorbidities, and cardiovascular and venous thromboembolism (VTE) risk factors were examined at enrolment. Patients with elevated D-dimer levels underwent whole-leg venous ultrasonography to diagnose deep vein thrombosis (DVT).

RESULTS

Participants had no DVT signs or symptoms. Among them, 252 (54.8%) were positive for plasma D-dimer (≥0.5 μg/ml) and 40 (8.7%) had high D-dimer levels (≥3 μg/ml). The mean was 1.07 μg/ml. After adjustments, age [odds ratio (OR) 1.88 per additional 10 years, P = .003], high and moderate clinical disease activity index (OR 8.79, P < .001), and the presence of comorbidities or cardiovascular/VTE risk factors (OR 2.94, P = .017) were identified as the factors independently associated with high D-dimer levels. Among patients with D-dimer levels ≥3 μg/ml, 10 (25%) had DVT in their lower limbs, and D-dimer levels were significantly higher in patients with DVT compared with those without it (mean 6.0  vs. 4.1 μg/ml, P < .001).

CONCLUSIONS

Clinical disease activity is a major contributor to plasma D-dimer elevation in RA outpatients.

Factors Influencing Venous Remodeling in the Development of Varicose Veins of the Lower Limbs

One of the early symptoms of chronic venous disease (CVD) is varicose veins (VV) of the lower limbs. There are many etiological environmental factors influencing the development of chronic venous insufficiency (CVI), although genetic factors and family history of the disease play a key role. All these factors induce changes in the hemodynamic in the venous system of the lower limbs leading to blood stasis, hypoxia, inflammation, oxidative stress, proteolytic activity of matrix metalloproteinases (MMPs), changes in microcirculation and, consequently, the remodeling of the venous wall. The aim of this review is to present current knowledge on CVD, including the pathophysiology and mechanisms related to vein wall remodeling. Particular emphasis has been placed on describing the role of inflammation and oxidative stress and the involvement of extracellular hemoglobin as pathogenetic factors of VV. Additionally, active substances used in the treatment of VV were discussed.

Unravelling Surface Modification Strategies for Preventing Medical Device-Induced Thrombosis

The use of biomaterials in implanted medical devices remains hampered by platelet adhesion and blood coagulation. Thrombus formation is a prevalent cause of failure of these blood-contacting devices. Although systemic anticoagulant can be used to support materials and devices with poor blood compatibility, its negative effects such as an increased chance of bleeding, make materials with superior hemocompatibility extremely attractive, especially for long-term applications. This review examines blood-surface interactions, the pathogenesis of clotting on blood-contacting medical devices, popular surface modification techniques, mechanisms of action of anticoagulant coatings, and discusses future directions in biomaterial research for preventing thrombosis. In addition, this paper comprehensively reviews several novel methods that either entirely prevent interaction between material surfaces and blood components or regulate the reaction of the coagulation cascade, thrombocytes, and leukocytes.

Evaluating the impact of sickle cell disease on COVID-19 susceptibility and severity: a retrospective cohort study based on electronic health record

Background

Sickle cell trait/disease (SCT/SCD) are enriched among Black people and associated with various comorbidities. The overrepresentation of these characteristics prevents traditional regression approach obtaining convincing evidence for the independent effect of SCT/SCD on other health outcomes. This study aims to investigate the association between SCT/SCD and COVID-19-related outcomes using causal inference approaches that balance the covariate.

Methods

We leveraged electronic health record (EHR) data from the University of Chicago Medicine between March 2020 and December 2021. Demographic characteristics were retrieved. Medical conditions were identified using ICD-10 codes. Five approaches, including two traditional regression approaches (unadjusted and adjusted) and three causal inference approaches [covariate balancing propensity score (CBPS) matching, CBPS weighting, and CBPS adjustment], were employed.

Results

A total of 112,334 patients were included in the study, among which 504 had SCT and 388 SCD. Patients with SCT/SCD were more likely to be non-Hispanic Black people, younger, female, non-smokers, and had a diagnosis of diabetes, heart failure, asthma, and cerebral infarction. Causal inference approaches achieved a balanced distribution of these covariates while traditional approaches failed. Across these approaches, SCD was consistently associated with COVID-19-related pneumonia (odds ratios (OR) estimates, 3.23 (95% CI: 2.13-4.89) to 2.57 (95% CI: 1.10-6.00)) and pain (OR estimates, 6.51 (95% CI: 4.68-9.06) to 2.47 (95% CI: 1.35-4.49)). While CBPS matching suggested an association between SCD and COVID-19-related acute respiratory distress syndrome (OR = 2.01, 95% CI: 0.97-4.17), this association was significant in other approaches (OR estimates, 2.96 (95% CI: 1.69-5.18) to 2.50 (95% CI: 1.43-4.37)). No association was observed between SCT and COVID-19-related outcomes in causal inference approaches.

Conclusion

Using causal inference approaches, we provide comprehensive evidence for the link between SCT/SCD and COVID-19-related outcomes.

Association between inflammatory biomarkers and venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common thrombotic vascular disease that has a significant impact on people's well-being and quality of life. A plethora of clinical studies explore the relationship between inflammatory biomarkers and VTE but yield conflicting results. This article proposed to pool these studies to draw a more convincing conclusion.

METHODS

We searched several databases for studies before April 2023. Available data was processed using Stata software (version 15.0 SE) and R (version 4.1.2). This meta-analysis has been registered in PROSPERO (CRD42022321815). The VTE in this review encompassed pulmonary embolism, deep vein thrombosis, and cerebral venous thrombosis.

RESULTS

A total of 25 articles were finally involved in this study. Our results revealed that higher levels of high-sensitivity C-reactive protein (hs-CRP, MD, 0.63, 95%CI, 0.21-1.05) and C-reactive protein (CRP)> 3ug/ml (OR, 1.52, 95%CI, 1.18-1.96) might be regarded as risk factors for future VTE occurrence. The elevated levels of monocyte (MD, 0.03, 95%CI, 0.00-0.05), hs-CRP (0.85, 0.61-1.08), CRP (0.66, 0.20-1.13) and IL-6 (0.47, 0.25-0.70) might represent the previous VTE; a series of markers such as white blood cell (1.43, 0.88-1.98), neutrophil (1.79, 1.02-2.56), monocyte (0.17, 0.14-0.21), hs-CRP (3.72, 1.45-5.99), IL-6 (5.99, 4.52-7.46), platelet-lymphocyte ratio (33.1, 24.45-41.78) and neutrophil-lymphocyte ratio (1.34, 0.95-1.73) increased during the acute phase of VTE.

CONCLUSIONS

In general, activated inflammatory biomarkers might not only be correlated with an increased risk of VTE, but may also give a hint of the occurrence of VTE in clinical settings.

Risk of Venous Thromboembolism Among Adults With Atopic Dermatitis

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

The Effect of Diosmin, Escin, and Bromelain on Human Endothelial Cells Derived from the Umbilical Vein and the Varicose Vein-A Preliminary Study

In this study, we investigated the properties of human varicose vein (VV) endothelial cells (HVVEC) in comparison to the human umbilical vein endothelial cells (HUVEC). The cells were treated with three bioactive compounds with proven beneficial effects in the therapy of patients with VV, diosmin, escin, and bromelain. Two concentrations of tested drugs were used (1, 10 mg/mL), which did not affect the viability of either cell type. Escin led to a slight generation of reactive oxygen species in HUVEC cells. We observed a slight release of superoxide in HVVEC cells upon treatment with diosmin and escin. Diosmin and bromelain showed a tendency to release nitric oxide in HUVEC. Using membrane fluorescent probes, we demonstrated a reduced fluidity of HVVEC, which may lead to their increased adhesion, and, consequently, a much more frequent occurrence of venous thrombosis. For the first time, we show the mechanism of action of drugs used in VV therapy on endothelial cells derived from a VV. Studies with HVVEC have shown that tested drugs may lead to a reduction in the adhesive properties of these cells, and thus to a lower risk of thrombosis.

Development of Personalized Thrombogenesis and Thrombin Generation Assays to Assess Endothelial Dysfunction in Cardiovascular Diseases

The study of endothelial dysfunction (ED) is crucial to identify the pathogenetic mechanism(s) and provide indications for patient management in cardiovascular diseases. It is currently hindered by the limited availability of patient-specific primary endothelial cells (ECs). Endothelial colony-forming cells (ECFCs) represent an optimal non-invasive tool to overcome this issue. Therefore, we investigated the use of ECFCs as a substrate in thrombogenesis and thrombin generation assay (TGA) to assess ED. Both assays were set up on human umbilical vein endothelial cells (HUVECs) and then tested on ECFCs obtained from healthy donors. To prove the ability of the assays to detect endothelial activation, ECs stimulated with TNFα were compared with unstimulated ECs. EC activation was confirmed by the upregulation of VCAM-1 and Tissue Factor expression. Both assays discriminated between unstimulated and activated HUVECs and ECFCs, as significantly higher platelet deposition and fibrin formation in thrombogenesis assay, and thrombin generation in TGA, were observed when TNFα-activated ECs were used as a substrate. The amount of fibrin and thrombin measured in the two assays were directly correlated. Our results support the combined use of a thrombogenesis assay and TGA performed on patient-derived ECFCs to provide a personalized global assessment of ED relevant to the patient's hemostatic profile.

Combination of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio with plasma D-dimer level to improve the diagnosis of deep venous thrombosis (DVT) following ankle fracture

PURPOSE

To investigate the relationship between neutrophil to lymphocyte ratio (NLR)/platelet to lymphocyte ratio (PLR) with deep venous thrombosis (DVT) following ankle fracture and the diagnostic ability of combination model.

METHOD

This retrospective study included patients with a diagnosis of ankle fracture who had undergone preoperative Duplex ultrasound (DUS) examination for detecting the possible deep venous thrombosis (DVT). The variables of interest, the calculated NLR and PLR and others (demographics, injury, lifestyles and comorbidities) were extracted from the medical records. Two independent multivariate logistics regression models were used to detect the relationship between NLR or PLR and DVT. If any, combination diagnostic model was constructed and its diagnostic ability was evaluated.

RESULTS

There were 1103 patients included, and 92 (8.3%) were found to have preoperative DVT. The NLR and PLR, which had respective optimal cut-off point of 4 and 200, were significantly different between patients with and without DVT either in continuous or categorical variable. After adjustment for covariates, both NLR and PLR were identified as independent risk factors associated with DVT, with odd ratio of 2.16 and 2.84, respectively. The combination diagnostic model, including NLR, PLR and D-dimer, demonstrated to significantly improved the diagnostic performance than any one alone or combined (all P < 0.05), and the area under the curve was 0.729 (95% CI 0.701-0.755).

CONCLUSION

We concluded the relatively low incidence rate of preoperative DVT after ankle fracture, and both NLR and PLR were independently associated with DVT. The combination diagnostic model can be considered as a useful auxiliary tool for identifying high-risk patients for DUS examination.

Venous thromboembolism: Why is it still a significant health problem?

BACKGROUND

Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis.

METHODS

We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed.

RESULTS

For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research.

CONCLUSIONS

Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.

Association of neutrophil to lymphocyte ratio and D-dimer with functional outcome in patients with cerebral venous sinus thrombosis

BACKGROUND

Investigations on the risk factors for the prognosis of cerebral venous sinus thrombosis (CVST) are limited. This study aimed to explore whether specific inflammatory factors and coagulation indictors are associated with functional outcome in patients treated for CVST.

METHODS

This retrospective study included 137 patients admitted to our hospital between January 2010 and October 2021. The functional outcome was assessed with the modified Rankin Scale (mRS) score at discharge. Patients were divided into two groups, 102 patients with favorable outcomes (mRS 0-1) and 35 patients with poor outcomes (mRS 2-6). The clinical indexes were compared between two groups. Multivariable logistic regression was performed to identify the independent influencing factors for poor outcomes of CVST patients. The prognostic indicators were analyzed using the receiver operating characteristic (ROC) curve.

RESULTS

Compared with the favorable outcome group, the incidence of impaired consciousness and brain lesion, the levels of D-dimer, RDW, neutrophil count, neutrophil to lymphocyte ratio (NLR) and red blood cell distribution width to platelet ratio (%) on admission were significantly higher in the poor outcome group, while the level of lymphocyte count was significantly lower. After multivariable logistic regression analysis, baseline D-dimer level (odds ratio (OR), 1.180; 95% confidence interval (CI), 1.019-1.366, P = 0.027) and NLR (OR, 1.903; 95%CI, 1.232-2.938, P = 0.004) were significantly associated with unfavorable outcome at discharge. The ROC curve analysis showed that the areas under the curve of D-dimer, NLR and their combined detection for predicting worse outcome were 0.719, 0.707 and 0.786, respectively.

CONCLUSIONS

Elevated D-dimer level and NLR on admission were associated with an increased risk of poor functional outcome in patients with CVST.

[Clinical characteristics of patients with rheumatoid arthritis complicated with venous thrombosis of lower extremities]

OBJECTIVE

To analyze the clinical characteristics of patients with rheumatoid arthritis (RA) complicated with venous thrombosis of lower extremities, and to improve the awareness of this condition.

METHODS

The clinical and laboratory data of 502 RA patients hospitalized in Department of Rheumatology and Immunology Peking University Third Hospital from November 1, 2013 to December 31, 2020 were collected, retrospective analysis was made on the RA patients who were diagnosed with lower limb vein thrombosis on discharge but hadn't on admission, the patients in this group were defined as thrombosis group, and the other patients without lower limb vein thrombosis were taken as control group. Single factor analysis was conducted between the two groups. Then multivariate Logistic regression analysis was used to analyze the independent risk factors of RA complicated with lower limb venous thrombosis with statistical significance in univariate analysis.

RESULTS

There were 34 patients (6.77%) in the thrombosis group and 468 patients (93.23%) in the control group. The age of thrombosis group was 34-86 years (median age was 71 years); 23 were female and 11 were male; there were 20 cases with unilateral lower limb vein thrombosis and 14 cases with bilateral lower limb vein thrombosis; pulmonary embolism in 3 cases (low risk).In the thrombosis group 17 (50.0%) patients were bedridden for more than one week or needed crutches/wheelchairs before admission. 29 cases(85.3%)had large joint involvement of lower extremities, including 22 cases of knee joint involvement, 1 case of hip joint involvement, 2 cases of ankle joint involvement, and 4 cases with both knee and hip joint involvement. In the thrombosis group, the high, middle and low disease activity scores 28(DAS28) were 23 (67.6%), 9 (26.5%) and 2 (5.9%), respectively. There were 21 patients in the thrombosis group had completed thrombosis related examinations, only 4 patients were positive for anti-cardiolipin antibody or anti-β2 glycoprotein 1 antibody or lupus anticoagulant, the rests were all negative. In the thrombosis group, age and platelet (PLT) level were significantly higher than those in the control group [71 (60, 77) years vs. 60 (51, 68) years, Z=-3.873, P < 0.01, (328.53× 10⁹±119.06 × 10⁹) /L vs.(278.68 × 10⁹±104.50 × 10⁹)/L, t=2.660, P < 0.01, respectively]. The proportion of D-Dimer increased in the thrombosis group as well as the positivity rheumatoid factor (RF) was much higher than those in the control group (94.1% vs.66.4%, χ²=11.192, P < 0.01; 85.3% vs.67.1%, χ²=4.852, P < 0.05, respectively). Multivariate Logistic regression analysis showed that age (OR=1.063, 95%CI: 1.026-1.101, P=0.001), D-Dimer increased (OR=4.968, 95%CI: 1.136-21.730, P=0.033) and PLT level (OR=1.004, 95%CI: 1.001-1.007, P=0.022) were the independent risk factors for RA complica-ted with lower extremity venous thrombosis.

CONCLUSION

RA patients have potential risk of thrombosis of lower extremities. For the older age, D-Dimer and PLT elevated, especially those who were bedridden, RF positive and had high disease activity, should be alert to the risk.

Venous Thromboembolism in Sepsis: From Bench to Bedside

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

Added value of computed tomography venography in the identification of abnormities in veins of lower extremities

OBJECTIVE

To investigate the efficacy of direct computed tomography venography (CTV) in early and accurate detection of lower extremity venous (LEV) abnormalities.

METHODS

Cross-sectional research was conducted in Hebei General Hospital of China. A total of 211 CTV reports of both lower extremities from January 2017 to September 2019, 75 color Doppler ultrasound (DUS) examinations, and eight intravascular angiography records of these patients over the same period were collected from the hospital. Comparisons were made for the reported number and percentage of LEV abnormalities (thrombosis, stenosis including severe stenosis, and varicosities). Chi-square test and t-test were applied to compare the rates and means, respectively. Significance level α was 0.05. Individual interviews were performed to understand the perceptions of medical staff and patients on the application of CTV, and the interview results were analyzed.

RESULTS

Of the 75 cases with both CTV and DUS reports, 159 abnormalities occurring in the lower extremity deep veins (LEDV) were reported, among which 125 (79%) and 18 (11%) were reported by CTV and DUS on a single basis, respectively, whereas 16 (10%) were reported by CTV and DUS simultaneously. A statistically significant greater number of abnormalities in LEDV were identified by CTV than DUS in both males and females (χ²_males = 78.449, χ²_females = 27.574, χ²_total = 104.164, p < .05). In the 211 CTV reports, among the 383 abnormalities reported in total, the common iliac vein (CIV) had the highest number of reported abnormalities (132, 34.5%), followed by the femoral vein (93, 24.3%). The ratios between LEDV abnormality and patient numbers were 1.055 and 0.688 for left and right sides in males, and 0.892 and 0.461 for left and right sides in females, respectively, with that for the left side statistically significantly higher than the right one (t_male = 2.896, t_female = 4.347, p < .05). The incidence of thrombosis was 10.9% (95% CI = 6.7 ∼ 15.1%). Reported abnormities in CIV by CTV were in agreement with those by intravascular angiography. The medical staff believed that CTV could guide the performance of surgeries for LEV and the patients perceived CTV acceptable.

CONCLUSIONS

Application of CTV for early and accurate detection of LEDV abnormalities including thrombosis has been proven to be efficient. Corresponding benefit in early intervention and reduction of severe complications of such abnormalities is of important value. CTV earned good recognition from medical staff and patients. Hence, it could be considered as part of global health assistance cooperation with developing countries to facilitate enhanced medical services.

Ruscogenin alleviates deep venous thrombosis and pulmonary embolism induced by inferior vena cava stenosis inhibiting MEK/ERK/Egr-1/TF signaling pathway in mice

BACKGROUND

Ruscogenin (RUS) has anti-inflammatory and antithrombotic effects, while its potential effects on deep venous thrombosis (DVT) and pulmonary embolism (PE) remain unclear.

OBJECTIVE

We aimed to elucidate the effects of RUS on DVT and PE induced by the inferior vena cava stenosis (IVCS) model and investigate the underlying mechanism.

METHODS

Male C57/BL6 mice were used to explore whether IVCS model could be complicated with deep venous thrombosis and pulmonary embolism. Then, Effects of RUS on DVT and PE related inflammatory factors and coagulation were examined using H&E staining, ELISA, and real-time PCR. Western blot analysis was used to examine the effects of RUS on MEK/ERK/Egr-1/TF signaling pathway in PE.

RESULTS

IVCS model induced DVT and complied with PE 48 h after surgery. Administration of RUS (0.01, 0.1, 1 mg/kg) inhibited DVT, decreased biomarker D-Dimer, cardiac troponin I, N-Terminal probrain natriuretic peptide in plasma to ameliorate PE induced by IVCS model. Meanwhile, RUS reduced tissue factor and fibrinogen content of lung tissue, inhibited P-selectin and C-reactive protein activity in plasma, and suppressed the expressions of interleukin-6 and interleukin-1β in mice. Furthermore, RUS suppressed the phosphorylation of ERK1/2 and MEK1/2, decreasing the expressions of Egr-1 and TF in the lung.

CONCLUSION

IVCS model contributed to the development of DVT and PE in mice and was associated with increased inflammation. RUS showed therapeutic effects by inhibiting inflammation as well as suppressing the activation of MEK/ERK/Egr-1/TF signaling pathway.

Association between varicose vein and atrial fibrillation-a population-based study in Taiwan

OBJECTIVE

This study retrospectively explores the association between varicose vein and atrial fibrillation (AF).

METHODS

The data are from Taiwan National Health Insurance Research Database. The univariate and multivariable-adjusted hazard ratios (HR), with corresponding 95% confidence intervals (CI), for the occurrence of AF between the varicose vein cohort and comparison cohort were estimated using cox proportional hazards models after adjustment for age, sex, and comorbidities.

RESULTS

The incidence rates of AF in the varicose vein and the comparison cohort were 4.82 per 1000 person-years and 3.47 per 1000-person years, respectively. After controlling for all the confounding variables, subjects with varicose vein were associated with a significantly higher risk of AF (adjusted HR = 1.23, 95% CI = 1.04-1.45) compared with the comparison cohort.

CONCLUSIONS

Our study is the first to show that varicose vein correlates to AF.

Assessment of Association Between Venous Occlusion and Infection of Cardiac Implantable Electronic Devices

The increasing number of patients treated with cardiac implantable electronic devices (CIEDs) and indications for complex pacing requires system revisions. Currently, data on venous patency in repeat CIED surgery involving lead (re)placement or extraction are largely missing. This study aimed to assess venous patency and risk factors in patients referred for repeat CIED lead surgery, emphasizing CIED infection. All consecutive patients requiring extraction, exchange, or additional placement of ≥1 CIED leads during reoperative procedures from January 2015 to March 2020 were evaluated in this retrospective study. Venography was performed in 475 patients. Venous patency could be assessed in 387 patients (81.5%). CIED infection with venous occlusion was detected in 74 patients compared with venous occlusion without infection in 14 patients (P < .05). Concerning venous patency, novel oral anticoagulant medication appeared to be protective (P < .05; odds ratio [OR]: .35). Infection of the CIED appeared to be strongly associated with venous occlusion (OR: 16.0). The sensitivity was only 64.15%, but the specificity was 96.1%. Number of leads involved and previous CIED procedures were not associated with venous occlusion. In conclusion, in patients with CIED, venous occlusion was strongly associated with device infection, but not with the number of leads or previous CIED procedures.

Dabigatran: its protective effect against endothelial cell damage by oxysterol

Recent data showed that dabigatran can reduce not only procoagulatory effects but also block proinflammatory stimuli by inhibiting the expression of cytokines and chemokines and reducing thrombin-induced endothelial permeability. The aim of our study was to assess the effect of dabigatran on the integrity and inflammatory properties of endothelial cells stimulated by 25-hydroxycholesterol (25-OHC, oxysterol). HUVECs (Human Umbilical Vein Endothelial Cells) were stimulated with 25-hydroxycholesterol 10 µg/ml, dabigatran 100 ng/ml or 500 ng/ml and 25-hydroxycholesterol + dabigatran (100 ng/ml, 500 ng/ml). HUVEC integrity and permeability was measured in the RTCA-DP xCELLigence system and by the paracellular flux system. The mRNA expression of ICAM-1, VEGF, IL-33, MCP-1 and TNF-α was analyzed by Real-time PCR. Cell apoptosis and viability was measured by flow cytometry. VEGF protein concentration was assessed in supernatants by ELISA. VE-cadherin expression in endothelial cells was evaluated by confocal microscopy. Pre-stimulation of HUVECs with 25-OHC decreased endothelial cell integrity (p < 0.001) and increased the expression of IL-33, ICAM-1, MCP-1, VEGF, TNF-α mRNA (p < 0.01) compared to unstimulated controls. Following stimulation of HUVECs with dabigatran 100 ng/ml or 500 ng/ml restored HUVEC integrity interrupted by 25-OHC (p < 0.001). In HUVECs pre-stimulated with oxysterol, dabigatran stimulation decreased mRNA expression of the proinflammatory cytokines IL-33 and TNF-α, chemokines MCP-1 ICAM-1 and VEGF (p < 0.01). Dabigatran 500 mg/ml+ 25-OHC increased the endothelial expression of VE-cadherin as compared to 25-OHC (p < 0.01). Our findings suggest that dabigatran stabilizes the endothelial barrier and inhibits the inflammation caused by oxysterol.

Association between obstructive sleep apnea and venous thromboembolism recurrence: results from a French cohort

Background

Growing evidence suggests the relationship between obstructive sleep apnea (OSA) and venous thromboembolism (VTE). Few studies focused on VTE recurrence risk associated with OSA after anticoagulation cessation.

Methods

In a prospective cohort study, patients with documented VTE, were followed for an indefinite length of time and VTE recurrence were documented and adjudicated. The primary outcome was recurrent VTE after anticoagulation discontinuation. Secondary outcomes included all-cause mortality and the clinical presentation of VTE. Univariable and multivariable analyses were performed to identify risk factors for recurrence and mortality.

Results

Among the 2109 patients with documented VTE included, 74 patients had moderate to severe OSA diagnosis confirmed by home sleep test or polysomnography. During a median follow-up of 4.8 (interquartile range 2.5–8.0) years recurrent VTE occurred in 252 patients (9 with OSA and 243 without OSA). The recurrence risk in the univariable and multivariable analysis was not increased in patients with OSA, regardless of the time of diagnosis (before or after index VTE or pooled). VTE phenotype was significantly more often PE with or without associated deep vein thrombosis in the first event and recurrence for OSA patients compared to non-OSA patients. The risk of death was not increased in the OSA population compared to non-OSA patients in multivariable analysis.

Conclusions

In patients with OSA and VTE, the risk of all-cause mortality and VTE recurrence after anticoagulation discontinuation was not increased compared to non-OSA patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-021-00358-8.

Differential Presentations of Arterial Thromboembolic Events Between Venous Thromboembolism and Atrial Fibrillation Patients

Objective: Atrial fibrillation (AF) and venous thromboembolism (VTE) share several risk factors related to arterial thromboembolism. No study has reported the differential contribution to arterial thromboembolic events and mortality between these two conditions in the same population. We therefore assessed the differential arterial thromboembolic events between AF and VTE.

Methods: We included AF and VTE national cohorts derived from Taiwan National Health Insurance Research Database between 2001 and 2013. The eligible population was 314,861 patients in the AF cohort and 41,102 patients in the VTE cohort. The primary outcome was arterial thromboembolic events, including ischemic stroke, extracranial arterial thromboembolism (ECATE) and myocardial infarction (MI). Secondary outcomes were all-cause mortality and cardiovascular death.

Results: After a 1:1 propensity matching, 32,688 patients in either group were analyzed. The risk of arterial thromboembolic events was lower in the VTE cohort than that in the AF cohort (subdistribution hazard ratio [SHR], 0.60; 95% confidence interval [CI], 0.57–0.62). The risk of ischemic stroke (SHR, 0.44; 95% CI, 0.42–0.46) and MI (SHR, 0.80; 95% CI, 0.72–0.89) were lower in the VTE cohort, while the risk of ECATE (SHR, 1.23; 95% CI, 1.14–1.33; particularly lower extremities) was higher in the VTE cohort. All-cause mortality rate was higher in the VTE cohort (HR, 1.18; 95% CI, 1.15–1.21) while the risk of cardiovascular death was lower in the VTE cohort (HR, 0.96; 95% CI, 0.93–0.995).

Conclusions: Patients with AF had higher risks of arterial thromboembolic events compared to patients with VTE, despite having risk factors in common. The VTE cohort had higher risks of all-cause mortality and ECATE, particularly lower extremity events, compared to AF patients. The differential manifestations of thromboembolism sequelae and mortality between AF and VTE patients merit further investigation.

Association of Psoriasis With Incident Venous Thromboembolism and Peripheral Vascular Disease: A Systematic Review and Meta-analysis

Importance

Psoriasis, venous thromboembolism (VTE), and peripheral vascular disease (PVD) share similar mechanisms involving chronic inflammation. However, the associations between psoriasis and VTE or PVD are unclear.

Objective

To determine the association of psoriasis with incident VTE and PVD.

Data Sources

MEDLINE, Embase, Cochrane Library, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were systematically searched for relevant publications from their respective inception through May 21, 2021. No restrictions on language or geographic locations were imposed.

Study Selection

Two authors independently selected cohort studies that investigated the risk for incident VTE or PVD in patients with psoriasis. Any discrepancy was resolved through discussion with 2 senior authors until reaching consensus. Only 13 initially identified studies met the selection criteria for qualitative review, and only 9 of these for quantitative analysis.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed. Two authors independently extracted data and assessed the risk of bias of included studies by using the Newcastle-Ottawa Scale. Disagreements were resolved by discussion with 2 other authors. A random-effects model meta-analysis was conducted to calculate the pooled hazard ratios (HRs) with the corresponding confidence intervals for incident VTE and PVD. Subgroup analyses based on arthritis status, psoriasis severity, sex, and geographic location were also performed.

Main Outcomes and Measures

Hazard ratios for incident VTE and PVD associated with psoriasis.

Results

A total of 13 cohort studies with 12 435 982 participants were included. The meta-analysis demonstrated a significantly increased risk for incident VTE (pooled HR, 1.26; 95% CI, 1.08-1.48) and PVD (pooled HR, 1.27; 95% CI, 1.16-1.40) among patients with psoriasis. Subgroup analyses illustrated increased risk for incident VTE among participants with psoriatic arthritis (pooled HR, 1.24; 95% CI, 1.01-1.53), women (pooled HR, 1.89; 95% CI, 1.36-2.61), and those in Asia (pooled HR, 2.02; 95% CI, 1.42-2.88) and Europe (pooled HR, 1.28; 95% CI, 1.06-1.53).

Conclusions and Relevance

This systematic review and meta-analysis found an increased risk for incident VTE and PVD among patients with psoriatic disease. Typical presentations of VTE or PVD should not be overlooked in patients with psoriasis. Risk factors, such as obesity, physical inactivity, smoking, and varicose veins, should be identified and treated in patients with psoriasis, and medications like hormone-related therapies should be prescribed with caution.

Inflammatory Markers and Thromboembolic Risk in Patients with Non-Muscle-Invasive Bladder Cancer

Introduction: Patients with bladder cancer have a high risk of venous thrombosis that represents a key challenge for physicians in the decision-making for initiating anticoagulation therapy. Non-muscle-invasive bladder cancer (NMIBC) represents more than 70% of all diagnosed bladder malignancies; therefore, we aimed to evaluate the relationship of the neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), and risk of thrombosis by using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score as well as the risk of bleeding by using the IMPROVE Bleeding Risk Assessment Score in a study cohort. Material and Methods: This was a retrospective observational study involving 130 patients who met the inclusion criteria: age > 18 years, stage pTa-pT1 NMIBC. The exclusion criteria were age < 18 years; stage pT2 or higher; or a presentation of metastasis, inflammatory, liver or autoimmune diseases, or other systemic neoplasms. In order to evaluate the risk of thromboembolic events as well as those of bleeding, the IMPROVE scores were calculated for each patient. Subjects were categorized in a Low IMPROVE group (< 4 points) or a High IMPROVE group. By using uni- and multivariate regression models, we analyzed CBC-derived parameters which could be associated with a higher risk of venous thrombosis in subjects with low or high IMPROVE scores. Results: Patients with IMPROVE score greater than 4 were associated with higher NLR, LMR and lymphocyte values (p < 0.05). In a multivariate regression model, the IMPROVE score was significantly influenced by lymphocyte count (p = 0.007) as well as the NLR value (p < 0.0001). Conclusions: In our study population, subjects with NMIBC with low lymphocytes and NLR > 3 were at a higher risk of developing venous thromboembolic events, reflected by an IMPROVE score of greater than 4. The IMPROVE and IMPROVE Bleeding Risk Assessment Scores are easy to use, and, complemented with the CBC-derived lymphocyte to monocyte ratio as a prothrombotic marker, could aid in the decision of prophylactic anticoagulation therapy during admission.

Association between body mass index, waist circumference, and relative fat mass with the risk of first unprovoked venous thromboembolism

BACKGROUND AND AIMS

Obesity defined by body mass index (BMI) is independently associated with venous thromboembolism (VTE). Abdominal obesity, defined by waist circumference, is a predictor of cardiovascular events. Recently, relative fat mass (RFM) was proposed as a marker of cardiovascular risk. We assessed the role of three different measures of obesity to predict unprovoked VTE in a longitudinal study.

METHODS AND RESULTS

Moli-sani is a prospective cohort study carried out in the general population of the Molise region, Italy. A total of 23,538 individuals (48% men, age 55.4 years) enrolled between 2005 and 2010 were eligible. Patients on anticoagulant treatment were excluded. BMI ≥30 kg/m² defined obesity, waist circumference >102 cm for men or 88 cm for women defined abdominal obesity, tertiles of RFM were compared. The long-term incidence of first unprovoked VTE during follow-up was assessed. Overall, 29.6% individuals were obese and 44.2% had abdominal obesity. A total of 66 first unprovoked VTE events were diagnosed during a median follow-up of 8.2 years. After multivariable Cox regression analysis, the risk of unprovoked VTE was significantly higher in obese participants (HR 1.89, 95% CI 1.16-3.07) than in participants with BMI <30; in subjects with abdominal obesity than with normal waist circumference (HR 2.19, 1.26-3.81); and in subjects with third vs first RFM tertile index (HR 2.46, 1.15-5.28). The areas under the curves for the models including the three obesity indexes were comparable.

CONCLUSIONS

Three indexes of obesity based on BMI, waist circumference or RFM similarly predict first occurrence of unprovoked VTE.

A PSGL-1 glycomimetic reduces thrombus burden without affecting hemostasis

Events mediated by the P-selectin/PSGL-1 pathway play a critical role in the initiation and propagation of venous thrombosis by facilitating the accumulation of leukocytes and platelets within the growing thrombus. Activated platelets and endothelium express P-selectin, which binds P-selectin glycoprotein ligand-1 (PSGL-1) that is expressed on the surface of all leukocytes. We developed a pegylated glycomimetic of the N terminus of PSGL-1, PEG40-GSnP-6 (P-G6), which proved to be a highly potent P-selectin inhibitor with a favorable pharmacokinetic profile for clinical translation. P-G6 inhibits human and mouse platelet-monocyte and platelet-neutrophil aggregation in vitro and blocks microcirculatory platelet-leukocyte interactions in vivo. Administration of P-G6 reduces thrombus formation in a nonocclusive model of deep vein thrombosis with a commensurate reduction in leukocyte accumulation, but without disruption of hemostasis. P-G6 potently inhibits the P-selectin/PSGL-1 pathway and represents a promising drug candidate for the prevention of venous thrombosis without increased bleeding risk.

Risk of venous thromboembolism associated with Janus kinase inhibitors for rheumatoid arthritis: case presentation and literature review

Janus kinase (JAK) inhibitors have been developed as disease-modifying antirheumatic drugs. Despite the positive therapeutic impacts of JAK inhibitors, concerns have been raised regarding the risk of venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE). A recent post hoc safety analysis of placebo-controlled trials of JAK inhibitors in rheumatoid arthritis (RA) reported an imbalance in the incidence of VTE for a 4-mg daily dose of baricitinib versus placebo. In a recent postmarketing surveillance trial for RA, a significantly higher incidence of PE was reported in treatment with tofacitinib (10 mg twice daily) compared with tofacitinib 5 mg or tumor necrosis factor inhibitors. We also experienced a case of massive PE occurring 3 months after starting baricitinib (4 mg once daily) for multiple biologic-resistant RA. Nevertheless, the evidence to support the role of JAK inhibitors in VTE risk remains insufficient. There are a number of predisposing conditions and risk factors for VTE. In addition to the known risk factors that can provoke VTE, advanced age, obesity, diabetes mellitus, hypertension, hyperlipidemia, and smoking can also contribute to its development. Greater VTE risk is noted in patients with chronic inflammatory conditions, particularly RA patients with uncontrolled disease activity and any comorbidity. Prior to the initiation of JAK inhibitors, clinicians should consider both the number and strength of VTE risk factors for each patient. In addition, clinicians should advise patients to seek prompt medical help if they develop clinical signs and symptoms that suggest VTE/PE.

Key Points • Patients with rheumatoid arthritis (RA) are at increased risk of venous thromboembolism (VTE), especially those with uncontrolled, high disease activity and those with comorbidities. • In addition to the well-known risk factors that provoke VTE events, advanced age and cardiovascular risk factors, such as obesity, diabetes mellitus, hypertension, hyperlipidemia, and smoking, should be considered risk factors for VTE. • Although a signal of VTE/pulmonary embolism (PE) risk with JAK inhibitors has been noted in RA patients who are already at high risk, the evidence is currently insufficient to support the increased risk of VTE during RA treatment with JAK inhibitors. • If there are no suitable alternatives, clinicians should prescribe JAK inhibitors with caution, considering both the strength of individual risk factors and the cumulative weight of all risk factors for each patient.

An Association between Inflammation and Cerebral Venous Thrombosis: A Retrospective Study

OBJECTIVES

Evidence is currently accumulating for the role of inflammation in cerebral venous thrombosis (CVT). Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/high-density lipoprotein ratio (MHR), and systematic immune-inflammation index (SII) are easily obtainable indicators of systemic inflammations. However, there were few studies on the relationship between them and CVT. Therefore, we aimed to evaluate the connection between the occurrence of CVT and the inflammatory markers described.

MATERIALS AND METHODS

The samples from 150 participants (including 90 CVT and 60 primary headaches as controls) with similar baseline characteristics were collected in this retrospective study. The NLR, PLR, MHR, SII and file records were employed to compare CVT patients with the control group.

RESULTS

The levels of NLR (3.93 [2.27, 7.87] vs. 1.65 [1.31, 2.06], P < 0.001), PLR (149.52 [98.39, 198.82] vs. 107.34 [83.31, 129.47], P < 0.001), SII (896.84 [559.89, 1591.87] vs. 382.45 [273.51, 520.92], P < 0.001) and MHR (0.51 [0.40, 0.64] vs. 0.41 [0.29, 0.53], P = 0.001) were significantly higher in the CVT group. After multivariate logistic regression analysis, the SII degree (13.136, [5.675, 30.407], P < 0.001) and MHR degree (2.620, [1.123, 6.113], P < 0.01) were found as independent predictors of CVT.

CONCLUSIONS

NLR, PLR, SII, and MHR may be able to assist in the diagnosis of CVT which confirmed that inflammation played an important role in CVT.

Vitamin D levels and C-reactive protein/albumin ratio in pregnant women with cerebral venous sinus thrombosis

Changes in coagulation system during pregnancy have been put forth as risk factors for cerebral venous sinus thrombosis (CVT), yet we still have limited knowledge on markers for predicting the risk of CVT in pregnant women. Therefore, we aimed to investigate the significance of vitamin D (VD) levels and C-reactive protein (CRP)/albumin ratio (CAR), an inflammation marker, as risk factors for CVT in pregnant women. 23 pregnant women who were followed up for CVT, 26 healthy pregnant women who had no pregnancy complications, and 31 non-pregnant fertile women were included in the study. CAR and VD levels were compared between groups. CAR was significantly higher in the pregnant CVT group compared to the other two groups (p < 0.001). CAR was also significantly higher in the healthy pregnant group than the non-pregnant fertile group (p < 0.001). VD levels were determined to be statistically significantly lower in the pregnant CVT group compared to the other two groups (p < 0.001). However, VD levels did not significantly differ between healthy pregnant group and non-pregnant fertile group (p > 0.05). We found no significant correlation between CAR and VD levels in any of the three groups. Pregnant women with CVT were found to have a high rate of severe VD deficiency. Low VD levels and high CAR levels in pregnant women may be associated with an increased risk of CVT.

Predictive Value of Inflammation Biomarkers in Patients with Portal Vein Thrombosis

BACKGROUND AND AIMS

To investigate the usefulness of inflammation biomarkers to serve as a predictors of portal vein thrombosis (PVT) postoperatively (post) in patients with portal hypertension after splenectomy and periesophagogastric devascularization.

METHODS

A total of 177 liver cirrhosis patients were recruited from January 2013 to December 2017. They were divided into a PVT group (n=71) and a non-PVT group (n=106), according to ultrasound examination findings at 7-day post. Inflammation biomarkers involving platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), red blood cell distribution width-to-platelet ratio(RPR), mean platelet volume-to-platelet ratio (MPR) preoperatively (pre) and at 1, 3, 7-days post were recorded.

RESULTS

The univariate logistic regression analysis indicated that PLR (pre) (odds ratio (OR)=3.963, 95% confidence interval (CI)=2.070-7.587, p<0.000), MLR (pre) (OR=2.760, 95% CI=1.386-5.497, p=0.004), PLR (post-day 7) (OR=3.345, 95% CI=1.767-6.332, p=0.000) were significantly associated with the presence of PVT. The multivariate logistic regression analysis results indicated that PLR (pre) (OR=3.037, 95% CI=1.463-6.305, p=0.003), MLR (pre) (OR=2.188, 95% CI=1.003-4.772, p=0.049), PLR(post-day 7) (OR=2.166, 95% CI=1.053-4.454, p=0.036) were independent factors for predicting PVT.

CONCLUSIONS

The PLR (pre), MLR (pre), and PLR (post-day 7) are predictors of portal vein thrombosis post in patients with portal hypertension after splenectomy and periesophagogastric devascularization.

Combined effects of plasma von Willebrand factor and platelet measures on the risk of incident venous thromboembolism

Plasma von Willebrand factor (VWF) and platelet reactivity are both risk factors for venous thromboembolism (VTE), and VWF can promote hemostasis by interaction with platelets. In this study, we explored the combined effects of plasma VWF and platelet measures on the risk of incident VTE. A population-based nested case-control study with 403 cases and 816 controls was derived from the Tromsø Study. VWF, platelet count and mean platelet volume (MPV) were measured in blood samples drawn at baseline. Odds ratios (ORs) with 95% confidence intervals (CIs) for VTE were estimated across VWF tertiles, within predefined MPV (<8.5, 8.5-9.5, ≥9.5 fL) and platelet count (<230, 230-299, ≥300·109 L-1) strata. Here, participants with VWF levels in the highest tertile and MPV ≥9.5 fL had an OR of 1.98 (95% CI 1.17-3.36) for VTE compared with those in the lowest VWF tertile and with MPV <8.5 fL in the age- and sex-adjusted model. In the joint exposure group, 48% (95% CI 15% to 96%) of VTEs were attributable to the biological interaction between VWF and MPV. Similarly, individuals with VWF in the highest tertile and platelet count ≥300·109 L-1 had an OR of 2.91 (95% CI 1.49-5.67) compared with those with VWF in the lowest tertile and platelet count <230, and 39% (95% CI -2% to 97%) of VTEs in the joint exposure group were explained by the interaction. Our results suggest that both platelet reactivity and platelet count interact biologically with high plasma VWF, resulting in an increased risk of incident VTE.

Plasma levels of von Willebrand factor and future risk of incident venous thromboembolism

Several case-control studies have reported elevated plasma von Willebrand factor (VWF) levels in patients with venous thromboembolism (VTE) compared with controls. However, because few studies have investigated the association in a prospective design, it is unclear whether elevated plasma VWF is a risk factor or a consequence of the VTE event. Therefore, we aimed to investigate the prospective association between plasma VWF levels and risk of VTE, as well as to perform subgroup analyses of deep vein thrombosis (DVT) and pulmonary embolism. We established a population-based nested case-control study of 414 VTE cases and 843 age- and sex-matched controls based on the Tromsø study cohort (1994-2007). Blood samples were collected at cohort baseline (1994-1995). Odds ratios (ORs) with 95% confidence intervals (CIs) for VTE were estimated across quartiles of VWF levels. We found that the risk of VTE increased linearly across quartiles of VWF levels (P for trend = .023). Participants with VWF in the highest quartile had an OR of 1.45 (95% CI, 1.03-2.03) for VTE compared with those in the lowest quartile. The association was strongest for unprovoked VTE (OR, 2.74; 95% CI, 1.66-4.54) and unprovoked DVT in particular (OR, 6.73; 95% CI, 3.07-14.76). Further adjustment for body mass index, C-reactive protein, hypertension, estrogen use, and smoking had a modest effect on the risk estimates. To conclude, we found a dose-dependent relationship between plasma VWF levels and future risk of incident VTE, and unprovoked events in particular. Our findings suggest that VWF may represent a promising biomarker for future risk of incident VTE.

Treatment of Varicose Veins Affects the Incidences of Venous Thromboembolism and Peripheral Artery Disease

[Figure: see text].

Multifunctional surfaces through synergistic effects of heparin and nitric oxide release for a highly efficient treatment of blood-contacting devices

Thrombosis and inflammation after implantation remain unsolved problems associated with various medical devices with blood-contacting applications. In this study, we develop a multifunctional biomaterial with enhanced hemocompatibility and anti-inflammatory effects by combining the anticoagulant activity of heparin with the vasodilatory and anti-inflammatory properties of nitric oxide (NO). The co-immobilization of these two key molecules with distinct therapeutic effects is achieved by simultaneous conjugation of heparin (HT) and copper nanoparticles (Cu NPs), an NO-generating catalyst, via a simple tyrosinase (Tyr)-mediated reaction. The resulting immobilized surface showed long-term, stable and adjustable NO release for 14 days. Importantly, the makeup of the material endows the surface with the ability to promote endothelialization and to inhibit coagulation, platelet activation and smooth muscle cell proliferation. In addition, the HT/Cu NP co-immobilized surface enhanced macrophage polarization towards the M2 phenotype in vitro, which can reduce the inflammatory response and improve the adaptation of implants in vivo. This study demonstrated a simple but efficient method of developing a multifunctional surface for blood-contacting devices.

The Association between Blood-Based Global DNA Methylation and Venous Thromboembolism

Alterations in DNA methylation patterns have been associated with many diseases. However, the role of DNA methylation in venous thromboembolism (VTE) is not well established. The aim of this study was to investigate a possible association between global DNA methylation and VTE. The study participants consisted of 168 individuals including 74 patients with primary VTE from the Malmö Thrombophilia Study (MATS) and 94 healthy controls. Among 74 primary VTE patients, 37 suffered VTE recurrence during the follow-up period; 37 nonrecurrent VTE patients were included for comparison. Blood-based global DNA methylation was assessed by an enzyme-linked immunosorbent assay. Global DNA methylation was significantly higher in primary VTE patients compared with the healthy controls (median: 0.17 vs. 0.08%; p < 0.001). After stratification of data from primary VTE patients according to sex, the association between higher global DNA methylation and shorter recurrence-free survival time was of borderline statistical significance in males (β = -0.2; p = 0.052) but not in females (β = 0.02; p = 0.90). Our results show that global DNA methylation is associated with primary VTE and that higher levels of global DNA methylation may be associated with early VTE recurrence in males but not in females. Further investigation on the role of DNA methylation as a diagnostic or preventive biomarker in VTE is warranted.

Correlation Study of the Long-Term Prognosis of Venous Thromboembolism and Inflammatory Gene Polymorphisms

Background

Venous thromboembolism (VTE) is the third most common cause of cardiovascular death worldwide, following coronary heart disease and stroke, and many risk factors for VTE are not yet clear. Our study investigated the association between multiple inflammatory gene polymorphisms and VTE prognosis, aiming to find a new predictor of VTE prognosis.

Methods

Based on our previous studies, we detected the plasma levels of serum amyloid A protein (SAA), interleukin-1 (IL-1) and tumor necrosis factor-a (TNF-a) and their 8 gene polymorphisms by ELISA and a multiplex ligation detection reaction (iMLDR) method in 284 patients with VTE. All subjects were followed up for 5 years.

Results

The 5-year follow-up results of this study showed that 62 of the 284 patients (21.83%) had reached the endpoint (all-cause death). Kaplan–Meier survival analyses revealed that the mortality rate of VTE patients with a high Simplified Pulmonary Embolism Severity Index (SPESI) score and carrying IL-1 rs1800587 mutation genotypes was significantly increased (log-rank p=0.000 and 0.034 respectively). The multifactor Cox regression results confirmed that the mortality rate of patients who carrying IL-1 rs1800587 mutation genotypes was significantly increased (HR=2.982; 95% CI: 1.681–5.100). The mortality rate of those carrying IL-1 rs1143634 mutation genotypes was significantly decreased (HR=0.294; 95% CI: 0.132–0.652). There were no significant differences in mortality rates between wild-type and mutant genotypes of IL-1 rs1143634, IL-1 rs2234650, SAA rs11603089, and TNF-α rs1800629 (P>0.05).

Conclusion

A high SPESI score and the presence of the IL-1 rs1800587 mutant genotype predict shorter survival in patients with VTE, whereas the IL-1 rs1143634 genotype is associated with a lower mortality rate. Screening for mutations in inflammation-related genes has prognostic value in the clinical management of VTE.

Venous thromboembolism in anti-neutrophil cytoplasmic antibody-associated vasculitis: an underlying prothrombotic condition?

Objectives

We investigated the incidence and potential underlying risk factors of venous thromboembolism (VTE) in patients with AAV. We assessed haemostatic disturbances and factors that might contribute to the risk of development of VTE.

Methods

ANCA-positive AAV patients (n = 187) were included. Previously identified risk factors for VTE and current medication were retrieved from the medical records. We assessed haemostasis using different methods [endogenous thrombin potential (ETP), overall haemostatic potential (OHP), overall coagulation potential (OCP) and overall fibrinolysis potential (OFP)] in patients with active AAV (n = 19), inactive AAV (n = 15) and healthy controls (n = 15).

Results

Twenty-eight VTEs occurred in 24 patients over a total follow-up time of 1020 person-years. A majority of VTEs occurred within the first year after diagnosis. Old age (P < 0.01), ongoing prednisolone treatment and recent rituximab administration were more common in the VTE group (P < 0.05 for all). ETP and OHP were significantly increased and OFP significantly decreased in plasma from active compared with inactive AAV patients (P < 0.05, P < 0.01 and P < 0.05, respectively) and healthy controls (P < 0.001). We could not confirm previously reported risk factors for VTE development.

Conclusion

A high prevalence of VTE in AAV patients was seen within the first year after diagnosis, suggesting that disease activity contributes to development of VTE. Old age and concurrent treatment should also be taken into account when estimating VTE risk. The results also indicate disturbances in the haemostatic balance towards pro-thrombotic conditions in AAV patients, where ETP and OHP might be useful markers for identifying patients at high risk.

Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor

Background

The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis.

Methods

A case-control study was performed of patients with PE admitted to our hospital [2010–2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus.

Results

A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95–3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27–2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24–2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02–7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82–34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25–51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06–49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance.

Conclusions

A relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.

Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review

IMPORTANCE

Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event.

OBSERVATIONS

PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin.

CONCLUSIONS AND RELEVANCE

Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.

Direct oral anticoagulant treatment of deep vein thrombosis reduces IL-6 expression in peripheral mono-nuclear blood cells

Multiple factors play a pathophysiologic role for the venous thromboembolism (VTE) as a multi-factorial disease. Inflammation might play a peculiar role in shifting towards a pro-thrombotic state. Anticoagulant drugs are the first cure line for VTE. The low-molecular-weight heparins (LMWH) show anti-coagulant capability as well as reducing levels of inflammatory factors, including interleukin (IL)-6. The direct oral anticoagulants (DOACs) have shown efficacy in threating VTE, additionally to the anti-activated factor X these drugs seem able to reduce the abnormal release of pro-inflammatory agents. The present study evaluated the capability of DOACs in reducing plasma level of IL-6 in patients suffered from deep vein thrombosis (DVT) of the lower limbs. Our results showed reduced IL-6 expression levels in the peripheral lymphocytes of DVT compared to controls (fold-change, 2.8; P<0.05). We postulate that lowered IL-6 expression in the lymphocytes of DVT patients may mediate the anti-inflammatory action of DOACs. The present study is the first evidence concerning the anti-inflammatory properties of DOACs in specific setting of VTE patients such as DVT.

Blood biomarkers associated with inflammation predict poor prognosis in cerebral venous thrombosis:: a multicenter prospective observational study

BACKGROUND AND PURPOSE

Experimental studies suggest inflammation can contribute to blood barrier disruption and brain injury in cerebral venous thrombosis (CVT). We aimed to determine whether blood biomarkers of inflammation were associated with the evolution of brain lesions, persistent venous occlusion or functional outcome in patients with CVT.

METHODS

Pathophysiology of Venous Infarction-Prediction of Infarction and Recanalization in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Evaluation of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) concentrations in peripheral blood samples was performed at admission in 62 patients. Additional quantification of interleukin (IL)-6 was performed at day 1, 3 and 8 in 35 patients and 22 healthy controls. Standardized magnetic resonance imaging was performed at day 1, 8 and 90. Primary outcomes were early evolution of brain lesion, early recanalization and functional outcome at 90 days.

RESULTS

Interleukin-6 levels were increased in patients with CVT with a peak at baseline. IL-6, NLR and CRP levels were not related with brain lesion outcomes or early recanalization but had a significant association with unfavourable functional outcome at 90 days (IL-6: OR = 1.28, 95% CI: 1.05-1.56, P = 0.046; NLR: OR = 1.39, 95% CI: 1.4-1.87, P = 0.014; CRP: OR = 1.756, 95% CI: 1.010-3.051, P = 0.029). Baseline IL-6 had the best discriminative capacity, with an area under the receiver operating characteristic curve to predict unfavourable functional outcome of 0.74 (P = 0.031).

CONCLUSIONS

Increased baseline levels of NLR, CRP and IL-6 may serve as new predictive markers of worse functional prognosis at 90 days in patients with CVT. No association was found between inflammatory markers and early evolution of brain lesion or venous recanalization.

Influence of dabigatran on pro-inflammatory cytokines, growth factors and chemokines - Slowing the vicious circle of coagulation and inflammation

AIMS

Blood coagulation is one of the most important host-defending mechanisms in vivo by maintaining the blood pressure after injury. However, besides maintaining homeostasis, blood coagulation and the contributing factors are directly linked to pathological conditions, such as thromboembolism and inflammation, leading to cardiovascular diseases, among others. As anti-inflammatory drugs may reduce cardiovascular events, we hypothesized in this study that the direct thrombin inhibitor dabigatran may reduce cytokine, growth factor and chemokine expression in vitro.

MAIN METHODS

Initially, human whole blood was incubated in tubes for serum, EDTA plasma, and heparinized plasma. Furthermore, human PBMCs were isolated and incubated under different culture conditions, including the treatment with human serum or thrombin, respectively. The effect of the oral anticoagulant dabigatran on pro-inflammatory cytokines, growth factors and chemokines was investigated by ELISA.

KEY FINDINGS

Conditioned serum resulted in a significant alteration of the secretome's protein levels after 24 h. However, solely ANG showed a dose-dependent increment by the addition of serum (79.8 ± 9.2 ng/mL) in comparison to baseline (0.2 ± 0.2 ng/mL), as it was in trend for thrombin treatment. Furthermore, the pre-treatment of PBMCs with different doses of dabigatran significantly lowered supernatant protein levels measured. Moreover, dabigatran was shown to decrease most notably the growth factor and chemokine levels in the PBMC's secretome that were treated with 200 ng/mL thrombin in a dose-dependent manner.

SIGNIFICANCE

In conclusion, novel oral anticoagulants, such as dabigatran, could help to reduce not only procoagulatory effects in inflammatory conditions but could also reduce proinflammatory stimuli via reduced expression of cytokines and chemokines.

Head, Neck, and Abdominopelvic Septic Thrombophlebitis: Current Evidence and Challenges in Diagnosis and Treatment

Septic thrombophlebitis (STP) is a complex, cross-disciplinary clinical condition that combines a localized infection with a neighboring venous thrombosis. STP can occur at several possible anatomic sites, such as dural sinuses, jugular vein (Lemierre syndrome), portal vein (pylephlebitis), and pelvic veins. Its high mortality in the preantibiotic era improved considerably with the introduction of modern antibiotics. However, little evidence exists to date to guide its clinical management. The incidence of STP or its risk factors may be increasing, and its mortality may still be considerable. These trends would have far-reaching implications, especially in the setting of increasing resistance to antimicrobial agents. No clinical assessment tools exist to support patient screening or guide treatment in STP. Few interventional studies exist on the efficacy and safety of anticoagulation. Recommendations on its indications, duration, and the agents of choice are mostly based on evidence derived from small observational studies. While all forms of STP pose similar challenges, future research may benefit from the distinction between bacteria-associated, virus-associated, and mycosis-associated thrombophlebitis. Addressing these gaps in evidence would enhance our ability to diagnose this condition and treat patients effectively.

Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging Findings

Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality. In recent decades, US, CT, and MRI have surpassed catheter-based angiography as the imaging examinations of choice for evaluation of vascular structures and identification of thrombus owing to their ready availability, noninvasive nature, and, in the cases of US and MRI, lack of exposure to ionizing radiation. As a result, VTE and associated complications are commonly identified in day-to-day radiologic practice across a variety of clinical settings. A wide range of hereditary and acquired conditions can increase the risk for development of venous thrombosis, and many patients with these conditions may undergo imaging for unrelated reasons, leading to the incidental detection of VTE or one of the associated complications. Although the development of VTE may be an isolated occurrence, the imaging findings, in conjunction with the clinical history and vascular risk factors, may indicate a predisposing condition or underlying diagnosis. Furthermore, awareness of the many clinical conditions that result in an increased risk of venous thrombosis may aid in detection of thrombus and any concomitant complications. For these reasons, it is important that practicing radiologists be familiar with the multimodality imaging findings of thrombosis, understand the spectrum of diseases that contribute to the development of thrombosis, and recognize the potential complications of hypercoagulable states and venous thrombosis. Online DICOM image stacks and supplemental material are available for this article. ^©RSNA, 2020.

Thrombogenic and Inflammatory Reactions to Biomaterials in Medical Devices

Blood-contacting medical devices of different biomaterials are often used to treat various cardiovascular diseases. Thrombus formation is a common cause of failure of cardiovascular devices. Currently, there are no clinically available biomaterials that can totally inhibit thrombosis under the more challenging environments (e.g., low flow in the venous system). Although some biomaterials reduce protein adsorption or cell adhesion, the issue of biomaterial associated with thrombosis and inflammation still exists. To better understand how to develop more thrombosis-resistant medical devices, it is essential to understand the biology and mechano-transduction of thrombus nucleation and progression. In this review, we will compare the mechanisms of thrombus development and progression in the arterial and venous systems. We will address various aspects of thrombosis, starting with biology of thrombosis, mathematical modeling to integrate the mechanism of thrombosis, and thrombus formation on medical devices. Prevention of these problems requires a multifaceted approach that involves more effective and safer thrombolytic agents but more importantly the development of novel thrombosis-resistant biomaterials mimicking the biological characteristics of the endothelium and extracellular matrix tissues that also ameliorate the development and the progression of chronic inflammation as part of the processes associated with the detrimental generation of late thrombosis and neo-atherosclerosis. Until such developments occur, engineers and clinicians must work together to develop devices that require minimal anticoagulants and thrombolytics to mitigate thrombosis and inflammation without causing serious bleeding side effects.

Inflammatory markers are beneficial in the early stages of cerebral venous thrombosis

BACKGROUND

Cerebral vein thrombosis (CVT) is a rare but serious cause of acute stroke. Inflammation is a hypothetical etiological factor in CVT.

OBJECTIVE

The aim of this study was to evaluate inflammatory marker levels in CVT patients and compare these with healthy individuals.

METHODS

This prospective case-control study was conducted with 36 newly-diagnosed CVT patients age- and sex-matched with 40 healthy individuals. The laboratory investigations included a serum hemogram, full biochemistry profiles, high sensitivity C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-HDL cholesterol ratio (MHR) values were calculated and compared between the patients and healthy participants.

RESULTS

The mean age was 41.4 ± 11.8 years for patients, and 39.3 ± 12.5 for controls. Lymphocyte, total bilirubin, indirect bilirubin, and HDL levels were significantly lower in CVT patients (p < 0.05), while CRP, and ESR values were significantly higher. In the CVT patients the mean NLR and PLR values were significantly higher than in the control individuals. Smoking rates, alcohol consumption, white blood cell, neutrophil, platelet, and MHR values were similar in both groups (p 0.05).

CONCLUSIONS

We suggest that NLR, PLR, CRP, ESR, and bilirubin can be used in clinical practice for prediction of CVT in suspected patients as they are inexpensive parameters and widely available. However, further large-scale studies are required to confirm this relationship.

The immunosuppressed traveler: infection risks with autoimmunity and immunosuppression, vaccinations, and general travel advice

The travel-related infection risks in the significantly immunocompromised traveler are complex and comprise vaccine preventable, vector-borne, and other nonvaccine preventable infections. A thorough risk assessment should be performed before travel and advice sought from relevant specialists. Immunosuppression used to treat autoimmune diseases and their mechanisms of action need particular consideration.This risk assessment needs to take the patient's beliefs and preferences into account. It is also important not to neglect noninfectious travel considerations.