Diabetes increases the risk of deep-vein thrombosis and pulmonary embolism. A population-based cohort study

Glycemia and Coagulation in Patients with Glioblastomas

BACKGROUND

Glioblastomas are among the most malignant tumors which, despite aggressive treatment, currently have an abysmal prognosis. These lesions are known to cause local and systemic perturbations in the coagulation system, leading to neoangiogenesis and a high risk of venous thromboembolism. Indeed, there have been multiple proposals of the coagulation system being a possible target for future treatment of these patients. However, nonselective anticoagulant therapy has proven suboptimal and leads to a significant increase of intracranial hemorrhage. Thus, recognizing factors that lead to hypercoagulation is considered paramount. Hyperglycemia is a well-known prothrombotic factor, a fact that has received little attention in neuro-oncology. We previously hypothesized that patients with brain tumors could be highly susceptible to iatrogenic glycemia dysregulation. Here, we analyzed the connection between glycated hemoglobin (HbA1c) and the routine coagulation markers (D-dimers, prothrombin time and activated partial thromboplastin time [aPTT]) in patients with de novo intracranial glioblastomas.

METHODS

Included in this study were 74 patients who were operated on in 2 hospitals: Clinical Hospital Dubrava, Zagreb, Croatia; University Hospital Center Split, Split, Croatia; and University Hospital de la Princesa, Madrid, Spain.

RESULTS

We found a significant inverse correlation between HbA1c and aPTT (ρ = -0.379; P = 0.0009). We also found a significant inverse correlation between Ki67 immunoreactivity and aPTT (ρ = -0.211; P = 0.0082). No connection was found between HbA1c and D-dimers or prothrombin time.

CONCLUSIONS

Our results suggest that patients with hyperglycemia, with a more proliferative glioblastoma, could in fact have their coagulation profile significantly disrupted, primarily through the intrinsic coagulation pathway. Such findings could have great clinical importance. Further research in this area could help to elucidate the vicious connection between glioblastomas and coagulation and to combat this deadly disease.

Prevalence and risk factors for proximal deep vein thrombosis at admission in patients with traumatic fractures: a multicenter retrospective study

Objective

This study aimed to determine the associated risk factors for proximal deep vein thrombosis (DVT) in patients with lower extremity and pelvic-acetabular fractures.

Methods

The medical records of 4,056 patients with lower extremity and pelvic-acetabular fractures were retrospectively reviewed. The patients were classified into proximal or non-proximal DVT groups. Logistic regression models were used to determine the independent risk variables for proximal DVT. The predictive value of the related risk factors was further analyzed using receiver operating characteristic curves.

Results

The prevalence of proximal DVT was 3.16%. Sex, body mass index (BMI), fracture site, injury mechanism, diabetes, coronary heart disease (CHD), injury-to-admission interval, hematocrit, platelet counts, and D-dimer levels differed significantly between the two groups. BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT. CHD decreased the risk of proximal DVT. The platelet and D-dimer had high negative predictive value for predicting proximal DVT formation, with cut-off values of 174 × 109/L and 2.18 mg/L, respectively.

Conclusion

BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT in patients with lower extremity and pelvic-acetabular fractures. Platelet count and D-dimer level were effective indicators for excluding proximal DVT occurrence. CHD decreased the risk of proximal DVT.

The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study

OBJECTIVE

To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain.

METHODS

Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results.

RESULTS

The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP.

CONCLUSION

Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.

The Inhibition of Serine Proteases by Serpins Is Augmented by Negatively Charged Heparin: A Concise Review of Some Clinically Relevant Interactions

Serine proteases are members of a large family of hydrolytic enzymes in which a particular serine residue in the active site performs an essential role as a nucleophile, which is required for their proteolytic cleavage function. The array of functions performed by serine proteases is vast and includes, among others, the following: (i) the ability to fight infections; (ii) the activation of blood coagulation or blood clot lysis systems; (iii) the activation of digestive enzymes; and (iv) reproduction. Serine protease activity is highly regulated by multiple families of protease inhibitors, known collectively as the SERine Protease INhibitor (SERPIN). The serpins use a conformational change mechanism to inhibit proteases in an irreversible way. The unusual conformational change required for serpin function provides an elegant opportunity for allosteric regulation by the binding of cofactors, of which the most well-studied is heparin. The goal of this review is to discuss some of the clinically relevant serine protease-serpin interactions that may be enhanced by heparin or other negatively charged polysaccharides. The paired serine protease-serpin in the framework of heparin that we review includes the following: thrombin-antithrombin III, plasmin-anti-plasmin, C1 esterase/kallikrein-C1 esterase inhibitor, and furin/TMPRSS2 (serine protease Transmembrane Protease 2)-alpha-1-antitrypsin, with the latter in the context of COVID-19 and prostate cancer.

A Case Report of Urinary Tract Infection and Fungemia Due to Pichia ohmeri Complicated with Pulmonary Thromboembolism

Pichia ohmeri (P. ohmeri) is a rare human pathogen known to cause severe conditions such as sepsis, fungemia, endocarditis, and peritonitis, often resulting in high mortality rates. This report presents a case of a febrile 66-year-old male with a urinary tract infection and fungemia caused by P. ohmeri. The patient had additional complications of pulmonary thromboembolism (PTE) and deep venous thrombosis (DVT) in the left lower extremity. Notably, the pathogen was isolated in both urine and blood cultures, an uncommon finding in immunocompetent patients. Treatment with fluconazole was initiated based on the antifungal susceptibility testing (AFST) results. Following treatment, the patient experienced a gradual resolution of fever and urinary tract infection symptoms. Concurrently, anticoagulant therapy was administered for the management of PTE and DVT. The patient was eventually discharged in a stable condition.

Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery

Diabetics are a highly comorbid population with an elevated risk profile when undergoing surgery. Proper preparation and management of modifiable risk factors can optimize outcomes in diabetics. A multidisciplinary approach to preoperative optimization, including surgeons, primary care providers, and anesthesiologists, ensures diabetic patients receive comprehensive evaluation before elective surgery. Orthopedic surgeons must understand preoperative optimization goals as they pertain to nutrition, glycemic control, and cardiovascular disease in diabetic patients.

Diabetes as one of the long-term COVID-19 complications: from the potential reason of more diabetic patients' susceptibility to COVID-19 to the possible caution of future global diabetes tsunami

According to recent researches, people with diabetes mellitus (type 1 and 2) have a higher incidence of coronavirus disease 2019 (COVID-19), which is caused by a SARS-CoV-2 infection. In this regard, COVID-19 may make diabetic patients more sensitive to hyperglycemia by modifying the immunological and inflammatory responses and increasing reactive oxygen species (ROS) predisposing the patients to severe COVID-19 and potentially lethal results. Actually, in addition to COVID-19, diabetic patients have been demonstrated to have abnormally high levels of inflammatory cytokines, increased virus entrance, and decreased immune response. On the other hand, during the severe stage of COVID-19, the SARS-CoV-2-infected patients have lymphopenia and inflammatory cytokine storms that cause damage to several body organs such as β cells of the pancreas which may make them as future diabetic candidates. In this line, the nuclear factor kappa B (NF-κB) pathway, which is activated by a number of mediators, plays a substantial part in cytokine storms through various pathways. In this pathway, some polymorphisms also make the individuals more competent to diabetes via infection with SARS-CoV-2. On the other hand, during hospitalization of SARS-CoV-2-infected patients, the use of some drugs may unintentionally lead to diabetes in the future via increasing inflammation and stress oxidative. Thus, in this review, we will first explain why diabetic patients are more susceptible to COVID-19. Second, we will warn about a future global diabetes tsunami via the SARS-CoV-2 as one of its long-term complications.

An Overview of Specific Considerations in Chronic Venous Disease and Iliofemoral Venous Stenting

Unlike arterial disease, chronic venous disease (CVD) is rarely life-threatening or limb-threatening. However, it can impose substantial morbidity on patients by influencing their lifestyle and quality of life (QoL). The aim of this nonsystematic narrative review is to provide an overview of the most recent information on the management of CVD and specifically, iliofemoral venous stenting in the context of personalized considerations for specific patient populations. The philosophy of treating CVD and phases of endovenous iliac stenting are also described in this review. Additionally, the use of intravascular ultrasound is described as the preferred operative diagnostic procedural tool for iliofemoral venous stent placement.

Race does matter: venous thromboembolism in trauma patients with isolated severe pelvic fractures

PURPOSE

Studies in non-trauma populations have shown that Black patients have a higher risk of venous thromboembolism (VTE) compared to other races. We sought to determine whether this association exists in trauma patients. The incidence of VTE is particularly high following severe pelvic fractures. To limit confounding factors associated with additional injuries, we examined patients with isolated blunt severe pelvic fractures.

METHODS

The TQIP database (2013-2017) was queried for all patients who sustained isolated blunt severe pelvic fractures (AIS ≥ 3) and received VTE prophylaxis (VTEp) with either unfractionated heparin or low molecular weight heparin. The study groups were Asian, Black, and White race as defined by TQIP. The primary outcome was differences in the rate of thromboembolic events.

RESULTS

A total of 9491 patients were included in the study. Of these, 232 (2.4%) were Asian, 1238 (13.0%) Black, and 8021 (84.5%) White. There was no significant difference in the distribution of pelvis AIS 3,4,5 between the groups. Black patients had a significantly higher incidence of VTE, DVT and PE compared to Asians and Whites. After adjusting for differences between the groups, Black patients had higher odds of developing pulmonary embolism (OR 1.887, 95% CI 1.101-3.232, p = 0.021) compared to White patients.

CONCLUSIONS

In this nationwide study of trauma patients with severe pelvic fractures, Black patients were more likely to develop pulmonary embolism compared to White patients. Further research to identify the determinants of racial disparities in trauma-related VTE is warranted, to target interventions that can improve VTE outcomes for all patients.

Machine learning-based prediction of the post-thrombotic syndrome: Model development and validation study

Background

Prevention is highly involved in reducing the incidence of post-thrombotic syndrome (PTS). We aimed to develop accurate models with machine learning (ML) algorithms to predict whether PTS would occur within 24 months.

Materials and methods

The clinical data used for model building were obtained from the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis study and the external validation cohort was acquired from the Sun Yat-sen Memorial Hospital in China. The main outcome was defined as the occurrence of PTS events (Villalta score ≥5). Twenty-three clinical variables were included, and four ML algorithms were applied to build the models. For discrimination and calibration, F scores were used to evaluate the prediction ability of the models. The external validation cohort was divided into ten groups based on the risk estimate deciles to identify the hazard threshold.

Results

In total, 555 patients with deep vein thrombosis (DVT) were included to build models using ML algorithms, and the models were further validated in a Chinese cohort comprising 117 patients. When predicting PTS within 2 years after acute DVT, logistic regression based on gradient descent and L1 regularization got the highest area under the curve (AUC) of 0.83 (95% CI:0.76–0.89) in external validation. When considering model performance in both the derivation and external validation cohorts, the eXtreme gradient boosting and gradient boosting decision tree models had similar results and presented better stability and generalization. The external validation cohort was divided into low, intermediate, and high-risk groups with the prediction probability of 0.3 and 0.4 as critical points.

Conclusion

Machine learning models built for PTS had accurate prediction ability and stable generalization, which can further facilitate clinical decision-making, with potentially important implications for selecting patients who will benefit from endovascular surgery.

Prevalence of Hemorrhagic Complications in Hospitalized Patients with Pulmonary Embolism

Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System “ASKLIPIOS™ HOSPITAL” implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population’s mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages.

The Interplay of Race/Ethnicity and Obesity on the Incidence of Venous Thromboembolism

INTRODUCTION

Factors predisposing asymptomatic individuals within the community to venous thromboembolism are not fully understood. This study characterizes the incidence and determinants of venous thromboembolism among the Multiethnic Study of Atherosclerosis cohort with a focus on race/ethnicity and obesity.

METHODS

This study (analyzed in 2020-2021) used the Multiethnic Study of Atherosclerosis cohort (2000-2017), which included participants with diverse ethnic/racial backgrounds aged 45-84 years without cardiovascular disease at baseline. The primary endpoint was time to diagnosis of venous thromboembolism defined using International Classification of Diseases codes (415, 451, 453, 126, 180, and 182). Multivariable-adjusted hazard ratios of the predictors of venous thromboembolism were calculated with a focus on the interaction between obesity and race/ethnicity categories.

RESULTS

Over a median follow-up period of 14 years, 233 individuals developed venous thromboembolism. Incidence rates (per 1,000 person-years) varied across racial/ethnic groups with the highest incidence among Black (4.02) followed by White (2.98), Hispanic (2.08), and Chinese (0.79) participants. There was a stepwise increase in the incidence rate of venous thromboembolism with increasing BMI regardless of race/ethnicity: normal (1.95), overweight (2.52), obese (3.63), and morbidly obese (4.55). The association between BMI and venous thromboembolism was strongest among non-White women with the highest incidence rate for obese (4.8) compared with non-obese (1.6). The interaction among obesity, gender, and race was statistically significant (p=0.01) in non-White obese women. Risk of venous thromboembolism increased with age for all race/ethnicities.

CONCLUSIONS

This study finds that obesity may confer an increased risk for venous thromboembolism among non-White women compared with other groups-White men, White women, and non-White men.

Impact of Type 2 Diabetes Mellitus on the Incidence and Outcomes of COVID-19 Needing Hospital Admission According to Sex: Retrospective Cohort Study Using Hospital Discharge Data in Spain, Year 2020

(1) Background: To analyze incidence and in-hospital mortality (IHM) of COVID-19 needing hospital admission in Spain (2020) in patients with T2DM. (2) Methods: We conducted a retrospective cohort study. Using the Spanish Register of Specialized Care-Basic Minimum Database we estimated age-adjusted incidence rates (IR). (3) Results: We included 203,488 patients (56.77% men), of whom 45,620 (22.41%) had T2DM. Age-adjusted IRs/1000 for men with and without T2DM was 12.90 and 5.87, respectively (IRR 2.20; 95% CI 2.18−2.22; p < 0.001), and for women with and without T2DM was 9.23 and 4.27, respectively (IRR 2.16; 95% CI 2.13−2.19; p < 0.001). Crude IHM was 23.86% in people with T2DM, and 15.94% in non-T2DM people (p < 0.001). After matching, intensive-care admission (7.37% vs. 6.15%; p < 0.001) and IHM (23.37% vs. 20.41%; p < 0.001) remained higher in women with T2DM. After matching, IHM among T2DM men was 1.5% higher than among non-T2DM men (24.27% vs. 22.72%; p < 0.001). Men with T2DM had a 34% higher IHM than women with T2DM. Prevalent T2DM increased IHM among women (1.09; 95% 1.03−1.16) and men (1.05; 95% 1.01−1.10). (4) Conclusions: Incidence rates of COVID-19 needing hospital admission were higher in men vs. women, and for people with T2DM vs. non-T2DM. Men had higher IHM beside T2DM status. Prevalent T2DM was associated with higher IHM for both sexes.

Predictive value of admission glycemia in diabetics with pulmonary embolism compared to non-diabetic patients

AIMS

To examine the relationship between admission glucose (AG) level and short-term in-hospital mortality and to investigate the association between hyperglycemia and major bleeding in PE patients with and without DMT2.

METHODS

We evaluated 1165 patients with diagnosed acute PE with multi-detector computed tomography pulmonary angiography (MDCT-PA) enrolled in the Regional multicenter PE registry (REPER). The study population was classified to patients with diabetes mellitus type 2 (DMT2) and those without diabetes. According to quartiles of AG patients, both groups separately were categorized into four subgroups (DMT2 I: < 7.5 mmol/L; II: 7.5-10.0 mmol/L; III: 10.0-15.7 mmol/L; IV: > 15.7 mmol/L and (non-DMT2 I: < 5.5 mmol/L; II: 5.5-6.3 mmol/L; III: 6.3-7.9 mmol/L; IV: > 7.9 mmol/L).

RESULTS

All-cause mortality was higher in the DMT2 group (9.5% vs. 18.2%, p < 0.001), and PE-cause mortality was 6% for the patients without DMT2 and 12.4% for DMT2 patients (p = 0.02). The patients in the fourth AG quartiles in both groups, without DMT2 and with DMT2, had significantly higher all-cause and PE-cause in-hospital mortality compared with the first quartile. Rates of major bleeding were similar between the groups. On the multivariable analysis, after adjusting for age, gender and mortality risk, the adherence in the fourth AG quartile had an independent predictive value for all-cause death (HR 2.476, 95% CI 1.017-6.027) only in DM patients.

CONCLUSION

In our cohort of patients with acute PE, diabetes was associated with increased rates for all-cause and PE-cause mortality.

Diabetes mellitus and its impact on mortality rate and outcome in pulmonary embolism

AIMS/INTRODUCTION

In patients with pulmonary embolism (PE), the impact of diabetes mellitus on patient profile and outcome is not well investigated.

MATERIAL AND METHODS

The German nationwide inpatient sample of the years 2005-2018 was analyzed. Hospitalized PE patients were stratified for diabetes, and the impact of diabetes on in-hospital events was investigated.

RESULTS

Overall, 1,174,196 PE patients (53.8% aged ≥70 years, 53.5% women) and, among these, 219,550 (18.7%) diabetes patients were included. In-hospital mortality rate amounted to 15.8%, and was higher in diabetes patients than in non-diabetes patients (19.8% vs 14.8%, P < 0.001). PE patients with diabetes had a higher prevalence of cardiovascular risk factors, comorbidities, right ventricular dysfunction (31.8% vs 27.7%, P < 0.001), prolonged in-hospital stay (11.0 vs 9.0 days, P < 0.001) and higher rates of adverse in-hospital events. Remarkably, diabetes was independently associated with increased in-hospital mortality (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.20-1.23, P < 0.001) when adjusted for age, sex and comorbidities. Within the observation period of 2005-2018, a relevant decrease of in-hospital mortality in PE patients with diabetes was observed (25.5% to 16.8%). Systemic thrombolysis was more often administered to diabetes patients (OR 1.18, 95% CI 1.01-3.49, P < 0.001), and diabetes was associated with intracerebral (OR 1.19, 95% CI 1.12-1.26, P < 0.001), as well as gastrointestinal bleeding (OR 1.11, 95% CI 1.07-1.15, P < 0.001). Type 1 diabetes mellitus was shown to be a strong risk factor in PE patients for shock, right ventricular dysfunction, cardiopulmonary resuscitation and in-hospital death (OR 1.75, 95% CI 1.61-1.90, P < 0.001).

CONCLUSIONS

Despite the progress in diabetes treatments, diabetes is still associated with an unfavorable clinical patient profile and higher risk for adverse events, including substantially increased in-hospital mortality in acute PE.

Association between Hyperosmolar Hyperglycemic State and Venous Thromboembolism in Diabetes Patients: A Nationwide Analysis in Taiwan

Background: Previous studies in Western countries have shown that a hyperosmolar hyperglycemic state (HHS) is associated with an increased risk of venous thromboembolism (VTE); in these cases, prophylactic anticoagulant treatment is suggested. However, the association between HHS and VTE in Asian populations remains undetermined. Therefore, we aimed to evaluate whether HHS is associated with an increased risk of VTE in diabetic Taiwanese patients. Methods: This nationwide, population-based, retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. We enrolled a total of 4,723,607 admission records of patients with diabetes diagnosed with one or more of seven common diseases (pneumonia, urinary tract infection, sepsis, heart disease, stroke, malignancy, and respiratory tract disease) between 2001 and 2018 in Taiwan. The patients were divided into two groups based on the presence (n = 46,000) or absence (n = 4,677,607) of HHS. We estimated the adjusted odds ratio (aOR) for developing VTE within 90 days after the index hospitalization using multivariable logistic regression with generalized estimating equations accounting for repeated measures. Results: Overall, patients admitted with HHS had a similar risk of VTE compared with those admitted without HHS (408/46,000 vs. 39,345/4,677,607; aOR = 1.06, 95% CI: 0.97–1.17, p = 0.190). A similar non-significant association between HHS and VTE was found regardless of age and sex subgroups. Conclusions: There was no significant association between HHS and overall VTE risk in patients with diabetes in Taiwan. The results of our study may not support the use of prophylactic anticoagulant therapy in diabetic Taiwanese patients with HHS.

Glycemia and venous thromboembolism in patients with primary brain tumors - A speculative review

Venous thromboembolism (VTE) is a significant public health issue causing severe morbidity and mortality. One of the most vulnerable populations for VTE development are cancer patients. And among them, patients with brain tumors have arguably the highest risk of developing this often fatal complication. Hyperglycemia is a well-known factor which leads to a wide variety of pro-thrombotic changes. In this article, we review the current literature on the topic of VTE in brain tumor patients. We also discuss the known correlation between VTE and glycemia, as well as the importance and frequency of glycemia dysregulation in brain tumor patients. Based on the already well-known importance of glucose metabolism in cancer patients, as well as the previous research of our group, we hypothesize that there is a significant number of brain tumor patients who have chronically elevated glycemia, a fact that so-far hasn't been reported. We argue that these patients carry a significantly higher risk of VTE development and would benefit greatly from strict glycemic control. We present our hypothesis, the ways in which to test it, as well as the possible counter-arguments against it. Our hope is that other investigators will be inspired by our article to continue this type of research, since we consider the topic of VTE in brain tumor patients highly important and urgent, primarily due to its prevalence and severity.

Short- and Long-Term Outcomes of Catheter-Directed Thrombolysis versus Pulmonary Artery Embolectomy in Pulmonary Embolism: A National Population-Based Study

OBJECTIVES

This study aimed to compare the short-term and long-term follow-up outcomes of catheter-directed thrombolysis (CDT) with those of pulmonary artery embolectomy (PAE) for patients with acute pulmonary embolism (PE) included in a nationwide cohort.

BACKGROUND

Data allowing direct comparisons between CDT and PAE are lacking in the literature, and the optimal management of high-risk and intermediate-risk PE is still debated.

METHODS

A retrospective cohort study was conducted with data for 2001 through 2013 collected from the Taiwan National Health Insurance Research Database (NHIRD). Patients who were first admitted for PE and treated with either CDT or PAE were included and compared. In-hospital outcomes included in-hospital death and safety (bleeding and cardiac arrhythmias) outcomes. Follow-up outcomes included all-cause mortality and recurrent PE during the 1- and 2-year follow-up periods and through the last follow-up. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to minimize possible selection bias, including indices for multimorbidity such as the Charlson's Comorbidity Index (CCI) and HAS-BLED scores.

RESULTS

A total of 389 patients treated between January 1, 2001, and December 31, 2013, were identified; 169 underwent CDT and 220 underwent PAE. After IPTW, there were no significant differences in in-hospital mortality (18.2% vs 21.3%; odds ratio 1.07, 95% confidence interval [CI]: 0.70-1.62) or the incidence of safety outcomes between the CDT and PAE groups. The risks of all-cause mortality (30% vs 29.5%; hazard ratio 1.16, 95% CI: 0.89-1.53), recurrent PE (7.2% vs 8.7%; subdistribution hazard ratio [SHR] 0.68, 95% CI: 0.39-1.21) and new-onset pulmonary hypertension (SHR 0.25, 95% CI: 0.05-1.32) were also not significantly different between the CDT and PAE groups at 2 years of follow-up. Subgroup analysis indicated that PAE may be associated with a more favorable 2-year mortality in patients <65 years old, patients with CCI scores of <3, patients with HAS-BLED scores of 1 to 2, and patients without cardiogenic shock (all P for interaction <.05).

CONCLUSIONS

In patients with PE who required reperfusion therapy, CDT and PAE resulted in similar in-hospital and long-term all-cause mortality rates and long-term rates of recurrent PE. Bleeding risks were also comparable in the 2 groups.

Interactions between diabetes and COVID-19: A narrative review

Diabetes, whether due to pancreatic beta cells insufficiency or peripheral resistance to insulin, has been suggested as a risk factor of developing severe acute respiratory disease coronavirus-2 (SARS-CoV-2) infections. Indeed, diabetes has been associated with a higher risk of infections and higher risk of developing severe forms of coronavirus disease 2019 (COVID-19) related pneumonia. Diabetic patients often present associated comorbidities such as obesity, hypertension and cardiovascular diseases, and complications of diabetes, including chronic kidney disease, vasculopathy and relative immune dysfunction, all of which make them more susceptible to infectious complications. Moreover, they often present low-grade inflammation with increased circulating interleukin levels, endothelial susceptibility to inflammation and dysfunction, and finally, hyperglycemia, which increases this risk. Additionally, corticosteroids, which count among the few medications which showed benefit on survival and mechanical ventilation requirement in COVID-19 pneumonia in large randomized controlled trials, are associated to new onsets of diabetes, and metabolic disorders in patients with previous history of diabetes. Finally, SARS-CoV-2 via the alternate effects of the renin-angiotensin system, mediated by the angiotensin-converting-enzyme 2, was also associated with insulin resistance in key tissues involved in glucose homeostasis, such as liver, skeletal muscles, and adipose tissue; and also, with impaired insulin secretion by pancreatic β-cells. In this work, we reviewed all elements which may help understand how diabetes affects patients with COVID-19, how treatments affect outcomes in patients with COVID-19, how they may cause new onsets of diabetes, and finally review how SARS-CoV-2 may inherently be a risk factor of developing diabetes, through immune-mediated diabetogenic mechanisms.

Contemporary Rates of Inferior Vena Cava Filter Thrombosis and Risk Factors

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Higher admission activated partial thromboplastin time, neutrophil-lymphocyte ratio, serum sodium, and anticoagulant use predict in-hospital COVID-19 mortality in people with Diabetes: Findings from Two University Hospitals in the U.K

AIMS

To create and compare survival models from admission laboratory indices in people hospitalized with coronavirus disease 2019 (COVID-19) with and without diabetes.

METHODS

Retrospective observational study of patients with COVID-19 with or without diabetes admitted to Sheffield Teaching Hospitals from 29 February to 01 May 2020. Predictive variables for in-hospital mortality from COVID-19 were explored using Cox proportional hazard models.

RESULTS

Out of 505 patients, 156 (30.8%) had diabetes mellitus (DM) of which 143 (91.7%) had type 2 diabetes. There were significantly higher in-hospital COVID-19 deaths in those with DM [DM COVID-19 deaths 54 (34.6%) vs. non-DM COVID-19 deaths 88 (25.2%): P < 0.05]. Activated partial thromboplastin time (APPT) > 24 s without anticoagulants (HR 6.38, 95% CI: 1.07-37.87: P = 0.04), APTT > 24 s with anticoagulants (HR 24.01, 95% CI: 3.63-159.01: P < 0.001), neutrophil-lymphocyte ratio > 8 (HR 6.18, 95% CI: 2.36-16.16: P < 0.001), and sodium > 136 mmol/L (HR 3.27, 95% CI: 1.12-9.56: P = 0.03) at admission, were only associated with in-hospital COVID-19 mortality for those with diabetes.

CONCLUSIONS

At admission, elevated APTT with or without anticoagulants, neutrophil-lymphocyte ratio and serum sodium are unique factors that predict in-hospital COVID-19 mortality in patients with diabetes compared to those without. This novel finding may lead to research into haematological and biochemical mechanisms to understand why those with diabetes are more susceptible to poor outcomes when infected with Covid-19, and contribute to identification of those most at risk when admitted to hospital.

Comparison of 2013 and 2009 versions of Caprini risk assessment models for predicting VTE in Chinese cancer patients: a retrospective study

This study aimed to compare the predictive value of 2009 and 2013 version of Caprini risk assessment models (RAM) for venous thromboembolism (VTE) in cancer patients by receiver operating characteristic (ROC) analysis. This retrospective study reviewed a total of 1439 VTE and 1439 non-VTE Chinese cancer inpatients. The baseline demographic data of these patients were recorded. 2009 and 2013 versions Caprini RAMs were applied, and cumulative risk scores were obtained by adding the scores of each risk factor. The specificity, sensitivity, positive predictive value and negative predictive value of these two models were analyzed. ROC curve was drawn to calculate the area under the curve (AUC) and the Youden index. Significant differences were observed in the risk factors between VTE and non-VTE Group. The specificity and negative predictive value of 2013 version were higher than those of 2009 version (P < 0.05). No significant differences were found in the sensitivity or positive predictive value between 2009 and 2013 versions of the Caprini RAM (P > 0.05). The AUC and Youden index of 2013 Caprini RAM were significantly higher than those of 2009 Caprini RAM (P < 0.001), whereas the Youden index of the 2009 Caprini RAM at critical point 4 was higher than that at critical point 3 (0.362 vs 0.067, P < 0.05). Compared with 2009 version, 2013 version of the Caprini RAM provides a more accurate and efficacious method for the risk assessment of VTE in Chinese cancer patients.

Midterm Prognosis of Patients With Pulmonary Embolism Receiving Catheter-Directed Thrombolysis or Systemic Thrombolysis: A Nationwide Population-Based Study

Background This study compared the efficacy and safety between catheter-directed thrombolysis (CDT) and systemic thrombolysis for patients with acute pulmonary embolism (PE) with midterm follow-up. Methods and Results We conducted a prospective open cohort study by using data from the Taiwan National Health Insurance Research Database for 2001 to 2013. Patients who were first admitted for PE and were treated by either systemic thrombolysis or CDT were included and compared. Inverse probability of treatment weighting, based on the propensity score, was used to mitigate possible selection bias. A total of 145 CDT-treated and 1158 systemic thrombolysis-treated patients with PE were included. The in-hospital mortality rate was significantly lower in the CDT group (12.7% versus 21.4%; odds ratio, 0.49; 95% CI, 0.36-0.67) after inverse probability of treatment weighting. No significant differences between the groups were observed for the safety (bleeding) outcomes. In patients who survived the index PE admission, the 1-year all-cause mortality rate was significantly lower in the CDT group after inverse probability of treatment weighting (12.2% versus 13.2%; hazard ratio [HR], 0.73; 95% CI, 0.56-0.94). Treatment with CDT was also associated with lower risks of recurrent PE (9.3% versus 17.5%; subdistribution HR, 0.52; 95% CI, 0.41-0.66). The difference remained through the last follow-up. Conclusions Among patients with PE requiring reperfusion therapy, those accepting CDT had lower all-cause mortality and recurrent PE over both short-term and midterm follow-up periods than those receiving systemic thrombolysis. The bleeding risk was similar for both groups. These findings should be cautiously validated in future randomized trials.

Study on the Risk Factors of Preoperative Deep Vein Thrombosis (DVT) in Patients With Lower Extremity Fracture

Objective:

The objective of this work is to discuss and analyze the related factors of lower extremity fracture complicated by preoperative deep vein thrombosis (DVT).

Methods:

A total of 11,891 patients with closed fractures of lower extremities were selected. By analyzing each patient’s gender, age, presence or absence of diabetes and hypertension, preoperative plasma D-dimer level, and color Doppler ultrasound of the lower extremity vein, the pertinent factors of the patients with lower extremity fractures complicated by preoperative DVT were analyzed.

Results:

A total of 578 with preoperative DVT were detected, displaying a total incidence of 4.86%. All patients were categorized into either the DVT group or non-DVT group. The results demonstrate that there were statistically significant differences between the 2 groups in age, the presence of diabetes and hypertension, the fracture site, and the preoperative plasma D-dimer level (P < 0.05). Logistic multivariate analysis revealed that age, the presence of diabetes, and the preoperative plasma D-dimer level of patients were independent risk factors for lower extremity fracture complicated by DVT.

Conclusion:

Age, the presence of diabetes, the fracture site, and increased D-dimer levels were found to be potential risk factors and indicators for preoperative DVT in patients with lower extremity fractures. In addition, the preoperative plasma D-dimer level has certain guiding significance for the prediction of venous thrombosis after lower extremity fracture, which is conducive to the early prediction and diagnosis of DVT, but it often must be followed with good clinic acumen and examinations.

COVID-19 and diabetes mellitus: from pathophysiology to clinical management

Initial studies found increased severity of coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in patients with diabetes mellitus. Furthermore, COVID-19 might also predispose infected individuals to hyperglycaemia. Interacting with other risk factors, hyperglycaemia might modulate immune and inflammatory responses, thus predisposing patients to severe COVID-19 and possible lethal outcomes. Angiotensin-converting enzyme 2 (ACE2), which is part of the renin-angiotensin-aldosterone system (RAAS), is the main entry receptor for SARS-CoV-2; although dipeptidyl peptidase 4 (DPP4) might also act as a binding target. Preliminary data, however, do not suggest a notable effect of glucose-lowering DPP4 inhibitors on SARS-CoV-2 susceptibility. Owing to their pharmacological characteristics, sodium-glucose cotransporter 2 (SGLT2) inhibitors might cause adverse effects in patients with COVID-19 and so cannot be recommended. Currently, insulin should be the main approach to the control of acute glycaemia. Most available evidence does not distinguish between the major types of diabetes mellitus and is related to type 2 diabetes mellitus owing to its high prevalence. However, some limited evidence is now available on type 1 diabetes mellitus and COVID-19. Most of these conclusions are preliminary, and further investigation of the optimal management in patients with diabetes mellitus is warranted.

Translational insight into prothrombotic state and hypercoagulation in nonalcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is an emerging and threatening pathological condition, ranging from fatty liver (FL) to chronic steatohepatitis (NASH), liver cirrhosis, and eventually to hepatocellular carcinoma (HCC). Recent findings suggest that patients with NAFLD have a higher risk of cardiovascular events and thromboembolism and that this risk is independent of metabolic diseases that are frequently associated with NAFLD, such as diabetes, hyperlipidaemia, and obesity. The vascular involvement of NAFLD might be considered its systemic burden, conditioning higher mortality in patients affected by the disease. These clinical findings suggested the existence of a prothrombotic state in NAFLD, which is partially unexplored and whose underlying mechanisms are to date not completely understood. Here, we review the mechanisms involved in the pathogenesis of the prothrombotic state in NAFLD across the progression from the healthy liver through the different stages of the disease. We focused on the possible role of several metabolic features of NAFLD possibly leading to hypercoagulation other than endothelial and platelet activation, such as insulin-resistance, nitric oxide production regulation, and gut microbiota homeostasis. Also, we analysed the involvement of plasminogen activator inhibitor-1 (PAI-1) and thromboinflammation taking place in NAFLD. Finally, we described factors striking a prothrombotic imbalance in NASH cirrhosis, with a particular focus on the pathogenesis of portal vein thrombosis.

Type 2 Diabetes Is a Risk Factor for Suffering and for in-Hospital Mortality with Pulmonary Embolism. A Population-Based Study in Spain (2016-2018)

(1) Background: The relationship between type 2 diabetes (T2DM) and pulmonary embolism (PE) has not been well stablished so far. We aim to analyze incidence, clinical conditions and in-hospital mortality (IHM) according to the presence of T2DM among patients hospitalized for suffering from PE. The factors associated with IHM were identified. (2) Methods: Patients aged ≥40 years hospitalized for PE from 2016 to 2018 included in the Spanish National Health System Hospital Discharge Database were analyzed. Dependent variables included incidence, IHM and length of hospital stay. Independent variables were age, sex, diagnosed comorbidities, thrombolytic therapy and inferior vena cava filter placement. Poisson and logistic regression models were constructed for multivariable analysis. (3) Results: Of the 47,190 hospitalizations for PE recorded, 16.52% had T2DM. Adjusted incidence of PE was higher among T2DM women (IRR 1.83; 95% CI: 1.58-1.96) and men (IRR 1.22; 95% CI: 1.18-1.27) than among non-diabetic subjects. Crude IHM in T2DM patients with PE was similar in both sexes but higher than in non-diabetic patients. Among T2DM patients with PE, risk factors for IHM included older age, comorbidity, atrial fibrillation and massive PE. Obesity was associated with lower IHM. Suffering T2DM was a risk of IHM (OR 1.15; 95% CI 1.05-1.26) after PE. (4) Conclusions: The incidence of PE is higher in T2DM men and women than in non-diabetic patients. T2DM was a risk factor for IHM after PE.

Determining Risk Factors for Endovenous Heat-induced Thrombosis after Radiofrequency Ablation

BACKGROUND

The objective of this study was to evaluate risk factors, incidence, management, and outcome of endovenous heat-induced thrombosis (EHIT) related to radiofrequency ablation (RFA).

METHODS

This was a single-center retrospective analysis of patients over the age of 18 who underwent RFA between 2016 and 2019. Demographics, comorbidities, medications, severity scores, vascular anatomy, procedural details, and outcome data were collected. EHIT-related data included occurrence, grade, laterality, management, and outcome.

RESULTS

During the study period, 672 RFA procedures were performed at our institution. Of these, 642 (median age 57 (21-93), 62.3% female) met study inclusion criteria. EHIT was observed in 43 (6.6%) cases. Concurrent left common femoral vein (CFV) or right femoral vein (FV) incompetence was found to be more prevalent in the EHIT group (P = 0.024 and P = 0.011, respectively). Compared with performing RFA alone, concurrent performance of stab phlebectomy and sclerotherapy with RFA on the left side was found to be associated with possible increased risk for EHIT (P = 0.021). Furthermore, patients with diabetes mellitus (DM) (P = 0.05) and those with median diameter of the treated left vein of 1.2 cm (P = 0.02) were more likely to have a higher EHIT grade (III and IV) than those without DM and those with smaller vein diameter, respectively. Management included aspirin (44%), anticoagulant (28%), both (10%), or neither (18%). EHIT either resolved or regressed (64%), did not change (5%), or propagated (8%) at follow-up.

CONCLUSIONS

Left CFV or right FV incompetence was found to be more prevalent in the total EHIT group. Furthermore, DM and the median size of the treated vein on the left (1.2 cm) were more prevalent in the high (III-IV) versus low grade (I-II) EHIT group. More than 50% of EHIT improved (regressed or resolved) at follow-up regardless of the management option. Further analysis with larger patient samples are needed to confirm the association between these variables and the development of EHIT.

Deep vein thrombosis in the lower extremities after femoral neck fracture: A retrospective observational study

PURPOSE

The actual incidence of deep vein thrombosis (DVT) in femoral neck fractures is underestimated. This study aimed to investigate the incidence of DVT in the lower extremities after femoral neck fracture before and after operation.

METHODS

The clinical data of patients with femoral neck fractures treated at Xi'an Honghui Hospital between July 1, 2016, and December 31, 2018, were collected. The patients were examined with ultrasonography before and after operation and divided into thrombosis and non-thrombosis groups according to their ultrasonographic results. The incidence of DVT was reported as a percentage.

RESULTS

The incidence rates of preoperative and postoperative DVT were 32% and 56%, respectively. DVT on the uninjured side constituted 45% of all preoperative DVT and 43% of all postoperative DVT. Peripheral DVT constituted 90% and 84% of all preoperative and postoperative DVT, respectively. Diabetes was an independent risk factor of preoperative DVT. Blood loss was an independent risk factor of postoperative DVT, and open reduction and internal fixation surgical procedure was independent protective factor of postoperative DVT as compared with hemiarthroplasty and total hip replacement.

CONCLUSIONS

The incidence rates of preoperative and postoperative DVT in the patients with femoral neck fracture were high, and orthopedists should pay more attention to DVT as a complication.

Type 1 Diabetes Induces Hearing Loss: Functional and Histological Findings in An Akita Mouse Model

The relationship between type 1 diabetes and hearing loss is not well known, although based on many pathological studies, type 2 diabetes induced hearing loss is associated with microcirculation problems in the inner ear. The purpose of this study was to investigate the correlation between type 1 diabetes and hearing loss through hearing function and immunohistochemical analyses using type 1 diabetic Akita or wild-type (WT) mice. The Akita mice had a significant increase in hearing thresholds, blood glucose, and insulin tolerance compared to WT mice. Histological analysis showed that the loss of cells and damage to mitochondria in the spiral ganglion neurons of Akita mice were significantly increased compared to WT. Also, the stria vascularis showed decreased thickness, loss of intermediate cells, and disturbance in blood capillary shape in the Akita mice. Moreover, a reduction in type I, II, and IV fibrocytes and Na⁺/K⁺-ATPase α1 expression in spiral ligament was also observed. Cleaved caspase-3 expression was highly expressed in spiral ganglion neurons. In conclusion, hearing loss in type 1 diabetes is caused not only by ion imbalance and blood flow disorders of cochlear endolymph, but through the degenerative nervous system via apoptosis-mediated cell death.

Perioperative management of antithrombotic treatment

End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.

Association between venous thromboembolism and acute pancreatitis: An analysis from the nationwide inpatient sample

BACKGROUND AND AIMS

Acute inflammation of the pancreas may trigger a systemic inflammatory response and initiate coagulation. Few studies have been conducted on the association between venous thromboembolism (VTE) and acute pancreatitis (AP). We investigated the incidence and risk of VTE in patients with AP.

METHODS

We conducted a retrospective cohort analysis for the nationwide AP cohort. We identified 91 786 patients with AP and 183 557 controls who were frequency-matched according to sex, age (5-y interval), and index year from the National Health Insurance Research Database between 2000 and 2008. The patients and controls were followed until diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE), death or the end of 2011.

RESULTS

The nationwide cohort study showed that patients with AP exhibited a higher incidence of VTE (13.1 vs 5.65 per 10 000 person-y) than did the controls. After covariates were controlled for, the patients with AP had a 1.88-fold higher risk of VTE than did the controls (adjusted hazard ratios [aHR] = 1.88; 95% confidence intervals [CI] = 1.68-2.10). The incidence rates of DVT and PE were higher in the patients with AP than in the controls, irrespective of sex, age or comorbidity. The patients with AP exhibited a 1.86-fold higher aHR of DVT (95% CI = 1.63-2.12) and a 1.92-fold higher aHR of PE (95% CI = 1.59-2.31) than did the controls.

CONCLUSION

Patients with AP exhibited a significantly higher risk of VTE than did the controls.

Anticoagulation in pulmonary arterial hypertension: a decision analysis

Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43-0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66-1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.

The comparative analysis of non-thrombotic internal jugular vein stenosis and cerebral venous sinus stenosis

Internal jugular vein (IJV) stenosis and cerebral venous sinus (CVS) stenosis belong to cerebral venous outflow insufficiency. This study aimed to analyze the similarities and differences between IJV stenosis and CVS stenosis. Patients with either IJV stenosis or CVS stenosis confirmed by contrast-enhanced magnetic resonance venography between October 2017 and July 2018 were enrolled in this retrospective study. The similarities and differences between IJV stenosis and CVS stenosis on the aspects of clinical and imaging features were compared. A total of 82 eligible patients entered into the final analysis. The similarities of the two subsets of cerebral venous outflow insufficiency mainly included headache, head noises or tinnitus, visual disorders, and sleeping disorders, as well as cloud-like white matter hyperintensity in T2WI and FLAIR sequences of MRI. However, there were differences in between, the ratio of patients with higher intracranial pressure (ICP) was common in CVS stenosis (p < 0.001). Namely, higher ratios of papilledema (p = 0.001) and visual damage (p = 0.029), as well as poor Frisen papilledema grade scores were more commonly observed in CVS stenosis (p = 0.004), while abnormal collateral-vessels appeared more frequently in IJV stenosis (100.00%) than CVS stenosis (28.57%). Continuous head noises, tinnitus and cloud-like white matter hyperintensity in MRI are the features of both IJV stenosis and CVS stenosis. Whereas, severe headache, visual damage, papilledema, and intracranial hypertension (IH) were more common in CVS stenosis, and the appearance of collateral-vessels is a key feature of IJV stenosis.

Deep vein thrombosis: a less noticed complication in hematologic malignancies and immunologic disorders

Deep vein thrombosis (DVT) is a common complication in hematologic malignancies and immunologic disorders that coagulation and inflammatory factors play a crucial role in its occurrence. The content used in this article has been obtained by PubMed database and Google Scholar search engine of English-language articles (1980-2019) using the "Deep vein thrombosis," "Hematologic malignancies," "Immunologic disorders" and "Treatment." Increased levels of coagulation factors, the presence of genetic disorders, or the use of thrombotic drugs that stimulate coagulation processes are risk factors for the development of DVT in patients with hematologic malignancies. Inflammatory and auto-anti-inflammatory factors, along with coagulant factors, play an essential role in the formation of venous thrombosis in patients with immunological disorders by increasing the recruitment of inflammatory cells and adhesion molecules. Therefore, anti-coagulants in hematologic malignancies and immunosuppressants in immune disorders can reduce the risk of developing DVT by reducing thrombotic and inflammatory activity. Considering the increased risk of DVT due to impaired coagulation and inflammation processes, analysis of coagulation and inflammatory factors have prognostic values in patients with immunologic deficiencies and hematologic malignancies. Evaluation of these factors as diagnostic and prognostic biomarkers in the prediction of thrombotic events could be beneficial in implementing effective treatment strategies for DVT.

Probable factors affecting clinical outcomes of internal jugular vein stenosis

Background

Internal jugular vein stenosis (IJVS) has recently aroused increasing interests, whereas, the factors affecting its clinical outcomes are not clear. This study aims to explore the probable factors affected clinical prognosis by evaluating the IJVS with different etiologies and strategies.

Methods

Patients with IJVS confirmed by contrast-enhanced magnetic resonance venography (CE-MRV) were enrolled from October 2017 through October 2018. One-year clinical outcomes of the IJVS cases enrolled in this study were assessed by outpatient and telephone follow-up using the Patient Global Impression of Change (PGIC) scores. According to the etiologies, patients were divided into thrombotic IJVS and non-thrombotic IJVS groups. And further, non-thrombotic IJVS group was divided into external compression and non-external compression subgroups. Outcomes of IJVS with different etiologies and strategies were compared and the probable prognostic factors were analyzed.

Results

A total of 118 eligible patients enrolled in this study, including 76 females and 42 males, mean aged 55.07±14.61 years. The average follow-up duration after discharge was 13.22±3.80 months. According to the PGIC scores, we categorized patients as good outcome and poor outcome groups. For thrombotic IJVS, patients underwent standard anticoagulant obtained remarkable PGIC improvement (100.0% vs. 33.3%, P=0.038). For non-thrombotic IJVS, stenting showed benefit in non-external compression subgroup (26.9% vs. 3.3%, P=0.019) but not in external compression subgroup. In addition, we found that in this Chinese IJVS cohort, poor outcomes involved old age (P=0.004), type 2 diabetes mellitus (P=0.036), previous hepatitis B virus (HBV) infection (P=0.027), and head noises (P=0.002). Multivariate logistic regression analysis indicated that continuous head noises [P=0.045, odds ratio (OR): 2.412, 95% confidence interval (CI): 1.019-5.711], as a unique symptom of IJVS may be significantly related to poor outcomes.

Conclusions

In this Chinese cohort, elderly degenerative bone compression, type 2 diabetes mellitus, and previous HBV infection are the top-three probable etiologies of non-thrombotic IJVS and may involve poor outcome. Long-term head noises may predict IJVS and with poor outcome. Thrombosis-induced IJVS may get benefit from standard anticoagulation. Non-external compression IJVS can be corrected by stenting.

Assessing the Rate of Antipsychotic Use in Ambulatory Care Patients With a Venous Thromboembolism

Background: Evidence regarding the use of antipsychotics and associated venous thromboembolism (VTE) risk is inconclusive. Studies finding a relationship lack in-depth analysis; thus, the VTE risk among those treated with antipsychotic remains largely unknown. Objectives: The primary objective of this investigation was to compare the incidence of antipsychotic use in patients who developed a VTE versus those who did not. Methods: Data were collected via retrospective chart review from an ambulatory care clinic between January 2012 and August 2017. All active clinic patients within the study period were included unless they met the following criteria: age <18 years, pregnancy within the study period, and/or current or historical malignancy. The odds ratio (OR) of developing a VTE was determined using multivariate regression analysis controlling for age, gender, obesity, and smoking. Secondary end points were reviewed for participants who were exposed to an antipsychotic and subsequently developed a VTE within the study period. Results: A total of 7079 patients were included in the analysis, of whom 314 developed a VTE. Of these, 45 were exposed to an antipsychotic prior to VTE development. Nearly 25% of patients receiving an antipsychotic did not have a primary psychiatric diagnosis. Results suggest that antipsychotic use was significantly associated with increased risk of VTE development (OR = 1.481 [95% CI = 1.067 to 2.055]). Conclusion and Relevance: The results of this study suggest an association between antipsychotic use and VTE development. This association should be considered when prescribing antipsychotics and treating patients who develop a VTE after antipsychotic exposure.

Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis

Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk assessment. We compared the results of our prospective department protocol to the Caprini risk assessment model (RAM) retrospectively in this study group. Our goal was to determine whether the department protocol or the Caprini score would identify venous thromboembolism (VTE) events after total joint replacement. A secondary purpose was to validate the 2013 Caprini RAM in joint arthroplasty and determine whether patients with VTE would be accurately identified using the Caprini score. A total of 1078 patients met inclusion criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or less is considered low risk. The 2013 version of the Caprini RAM retrospectively stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the prospective department protocol. This tool provided a consistent, accurate, and efficacious method for risk stratification and selection of chemoprophylaxis.

Completion of the Updated Caprini Risk Assessment Model (2013 Version)

The Caprini risk assessment model (RAM) has been validated in over 250 000 patients in more than 100 clinical trials worldwide. Ultimately, appropriate treatment options are dependent on precise completion of the Caprini RAM. As the numerical score increases, the clinical venous thromboembolism rate rises exponentially in every patient group where it has been properly tested. The 2013 Caprini RAM was completed by specially trained medical students via review of the presurgical assessment history, medical clearances, and medical consults. The Caprini RAM was completed for every participant both preoperatively and predischarge to ensure that any changes in the patient’s postoperative course were captured by the tool. This process led to the development of completion guidelines to ensure consistency and accuracy of scoring. The 2013 Caprini scoring system provides a consistent, thorough, and efficacious method for risk stratification and selection of prophylaxis for the prevention of venous thrombosis.

Incidence and risk of venous thromboembolism in patients following appendectomy: a nationwide cohort study

Surgery may lead to poor blood flow and hypercoagulation. Few studies have investigated the incidence of venous thromboembolism (VTE) in Asian patients following appendectomy. We conducted a nationwide cohort study to investigate the risk of VTE in patients who underwent appendectomy compared with those who did not in Taiwan. We studied the entire hospitalized population in Taiwan from 2000 to 2012, with a follow-up period extending to the end of 2013. We identified patients who underwent appendectomy in Taiwan's National Health Insurance Research Database as the appendectomy cohort, and selected a nonappendectomy cohort from the general population that was 4:1 frequency-matched by age (5-year interval), sex, and index year for each appendectomy case. We used Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for symptomatic VTE in the appendectomy cohort for comparison with the nonappendectomy cohort. The appendectomy cohort exhibited a higher incidence of symptomatic VTE than the nonappendectomy cohort (5.90 vs. 3.29 per 10,000 person-years). After adjustment for covariates, a 1.68-fold HR for symptomatic VTE was observed in the appendectomy cohort (95% CI 1.56-1.81). Compared with the nonappendectomy cohort, the patients who underwent open appendectomy had a 1.73-fold increased adjusted HR for symptomatic VTE (95% CI 1.61-1.87). Laparoscopic appendectomy was not significantly associated with symptomatic VTE. An 8.15-fold higher adjusted HR for VTE was observed in patients who underwent appendectomy within the first month after surgery compared with the nonappendectomy cohort. Open appendectomy carried an increased risk of symptomatic VTE. Laparoscopic appendectomy was not significantly associated with symptomatic VTE.

Clinical Manifestations and Prognostic Factors of Pulmonary Embolism in Adult Patients Visiting the Emergency Department: A Single Institute Experience

BACKGROUND AND PURPOSE

To investigate the clinical manifestations of a pulmonary embolism (PE) in patients visiting the Emergency Department (ED) and to identify possible prognostic factors among the patients.

METHODS

Patients who suspected as PE and presented to the ED with chest tightness, chest pain, or syncope were enrolled. Wells score, revised Geneva score, and PE severity Index (PESI) were all recorded for analysis. Twelve patients who were diagnosed with a PE after a serial work-up were further analyzed for possible prognostic factors. The demographic characteristics, serum lab data, clinical presentations, management strategies, computed tomography (CT) angiography findings, and final outcomes were analyzed retrospectively. Chi-squared tests with Fisher's exact tests, and t-test analyses were applied to evaluate the prognostic factors.

RESULTS

Among the 763 patients enrolled, poor prediction effectiveness of Geneva score and Wells score were noticed, and PESI was also found with no significant predictive value in our study group. The initial vital signs, syncope, chest pain, leg edematous changes, dyspnea, D-dimer levels, CT angiography-measured thrombus diameter, the presence of a right atrium (RA) or right ventricular (RV) thrombus, and presence of lung consolidations all revealed no predictive values in this study (p > 0.05). Notably, the presence of a cardiac disease history showed possible prognostic factors for satisfactorily predicting patient outcomes (p = 0.02). The presence of left atrium (LA) thrombus showed a border significant differences in comparison (p = 0.05).

CONCLUSIONS

Although the number of patients analyzed was relatively low, our findings suggest that a history of cardiac disease is predictive of a relatively lethal or severe condition in patients with a PE. The diagnosis and prediction of outcomes for patients with a PE remains a challenge and further study is necessary in the future.

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.

Mortality after pulmonary embolism in patients with diabetes. Findings from the RIETE registry

BACKGROUND

Among patients presenting with pulmonary embolism (PE), those with diabetes are at increased risk to die than those without diabetes. The reasons have not been identified. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to compare the mortality rate and the causes of death during anticoagulation in patients with PE according to the presence or absence of diabetes.

METHODS

A matched retrospective cohort study from consecutively enrolled patients in RIETE, from 179 hospitals in 24 countries. For each patient with diabetes we selected two patients with no diabetes matched by age, sex and year of diagnosis of the PE.

RESULTS

As of September 2017, there were 2010 PE patients with diabetes and two age-and-gender matched controls. Mean age was 74 ± 11 years, 46% were men. Patients with diabetes were more likely to have co-morbidities, to be using antiplatelets and to have more severe PE. During anticoagulation (median, 219 days), patients with diabetes had a higher mortality (hazard ratio [HR]: 1.45; 95% confidence intervals [CI]: 1.25-1.67) and a higher rate of arterial ischemic events (HR: 2.89; 95%CI: 1.71-4.94) than those without diabetes. On multivariable analysis, diabetes was not associated with an increased risk for death (HR: 1.26; 95%CI: 0.97-1.63). We also failed to find differences according to the use of antiplatelet drugs concomitantly.

CONCLUSIONS

In our cohort of patients with PE, diabetes was not an independent predictor for death. The influence of arterial events or antiplatelet drugs (if any) was low.

Prophylaxis of Postoperative Venous Thromboembolism Using Enoxaparin After Esophagectomy: A Prospective Observational Study of Effectiveness and Safety

BACKGROUND

The incidence of venous thromboembolism (VTE) after esophagectomy is higher than in other gastroenterological cancer surgery. Although the effectiveness and safety of thromboprophylaxis using enoxaparin have been established in orthopedic, abdominal, and pelvic surgeries, no studies regarding esophagectomy are available.

METHODS

A prospective observational study was conducted to elucidate the usefulness of enoxaparin for VTE prophylaxis after esophagectomy. The study enrolled 30 patients who underwent elective esophagectomy for esophageal cancer between April 2015 and October 2016. During postoperative days 2-11, the patients received a subcutaneous injection of enoxaparin (2000 IU) twice daily. The primary end point for the study was the incidence of postoperative VTE. In addition, the incidence of all enoxaparin treatment- and operation-related adverse events was investigated. The study identified VTE by VTE protocol-enhanced computed tomography, performed routinely during and after enoxaparin treatment.

RESULTS

One pulmonary embolism (PE) (3.3%) and two deep vein thromboses (DVTs) (6.7%) were observed during enoxaparin treatment. In addition, one PE (3.6%) and four DVTs (14.3%) (one patient experienced both) were observed after treatment. All VTEs were asymptomatic. Regarding enoxaparin-related adverse events, four minor bleeds occurred but did not require discontinuation of enoxaparin. The incidence of postoperative morbidity was acceptable. In blood tests related to coagulation, no significant differences were observed between patients with and without VTE.

CONCLUSIONS

The authors believe that thromboprophylaxis using enoxaparin is safe and can prevent VTE after esophagectomy. However, its effectiveness is limited to the period of treatment, so additional prophylaxis may be recommended.

Saliva Proteomics Analysis Offers Insights on Type 1 Diabetes Pathology in a Pediatric Population

The composition of the salivary proteome is affected by pathological conditions. We analyzed by high resolution mass spectrometry approaches saliva samples collected from children and adolescents with type 1 diabetes and healthy controls. The list of more than 2000 high confidence protein identifications constitutes a comprehensive characterization of the salivary proteome. Patients with good glycemic regulation and healthy individuals have comparable proteomic profiles. In contrast, a significant number of differentially expressed proteins were identified in the saliva of patients with poor glycemic regulation compared to patients with good glycemic control and healthy children. These proteins are involved in biological processes relevant to diabetic pathology such as endothelial damage and inflammation. Moreover, a putative preventive therapeutic approach was identified based on bioinformatic analysis of the deregulated salivary proteins. Thus, thorough characterization of saliva proteins in diabetic pediatric patients established a connection between molecular changes and disease pathology. This proteomic and bioinformatic approach highlights the potential of salivary diagnostics in diabetes pathology and opens the way for preventive treatment of the disease.