Deep vein thrombosis: a clinical review

Effectiveness of non-instrumental early mobilization to reduce the incidence of deep vein thrombosis in hospitalized patients: A systematic review and meta-analysis

BACKGROUND

Deep vein thrombosis (DVT) poses a significant health risk, particularly in hospitalized patients with multiple risk factors (cigarette smoking, hypertension, diabetes and obesity). Despite advances in treatment, DVT remains a prevalent complication of hospitalization.

OBJECTIVE

To assess the effectiveness of non-instrumental mobilization in hospitalized patients at high risk of DVT, exploring the challenges and variations in intervention protocols.

DESIGN

Systematic review and meta-analysis.

SETTING(S)

Not applicable.

PARTICIPANTS

Hospitalized patients at risk of deep vein thrombosis.

METHODS

A systematic search of three databases was conducted from interception to September 2023 for randomized controlled trials. This study was registered in PROSPERO (CRD42023460485). This study was conducted according to PRISMA 2020 statement. Two authors independently screened the studies and extracted the data. The quality of the studies was evaluated using the Downs and Black checklist and GRADE system. The amount of evidence certainty was assessed using the Cochrane Risk of Bias Assessment tool. Meta-analysis was performed addressing the incidence of deep vein thrombosis during hospitalization.

RESULTS

7 studies were eligible for inclusion which included a total of 1774 participants. Interventions ranged from active and passive ankle exercises to walking. Meta-analysis demonstrated a significant overall effect in favor of non-instrumental early mobilization compared to usual care (RR = 0.55; 95 % CI = 0.41, 0.73; p < 0.0001). Subgroup analysis comparing type of mobilization revealed significant effects for global (RR = 0.54; 95 % CI = 0.38, 0.78; p = 0.001) and remote mobilization (RR = 0.25; 95 % CI = 0.07, 0.86; p = 0.03).

CONCLUSIONS

Non-instrumental early mobilization is beneficial in reducing the incidence of deep vein thrombosis in hospitalized patients.

REGISTRATION

PROSPERO, registration number: CRD42023460485.

A Comprehensive Review of Cardiovascular Disease Management: Cardiac Biomarkers, Imaging Modalities, Pharmacotherapy, Surgical Interventions, and Herbal Remedies

Cardiovascular diseases (CVDs) continue to be a major global health concern, representing a leading cause of morbidity and mortality. This review provides a comprehensive examination of CVDs, encompassing their pathophysiology, diagnostic biomarkers, advanced imaging techniques, pharmacological treatments, surgical interventions, and the emerging role of herbal remedies. The review covers various cardiovascular conditions such as coronary artery disease, atherosclerosis, peripheral artery disease, deep vein thrombosis, pulmonary embolism, cardiomyopathy, rheumatic heart disease, hypertension, ischemic heart disease, heart failure, cerebrovascular diseases, and congenital heart defects. The review presents a wide range of cardiac biomarkers such as troponins, C-reactive protein, CKMB, BNP, NT-proBNP, galectin, adiponectin, IL-6, TNF-α, miRNAs, and oxylipins. Advanced molecular imaging techniques, including chest X-ray, ECG, ultrasound, CT, SPECT, PET, and MRI, have significantly enhanced our ability to visualize myocardial perfusion, plaque characterization, and cardiac function. Various synthetic drugs including statins, ACE inhibitors, ARBs, β-blockers, calcium channel blockers, antihypertensives, anticoagulants, and antiarrhythmics are fundamental in managing CVDs. Nonetheless, their side effects such as hepatic dysfunction, renal impairment, and bleeding risks necessitate careful monitoring and personalized treatment strategies. In addition to conventional therapies, herbal remedies have garnered attention for their potential cardiovascular benefits. Plant extracts and their bioactive compounds, such as flavonoids, phenolic acids, saponins, and alkaloids, offer promising cardioprotective effects and enhanced cardiovascular health. This review underscores the value of combining traditional and modern therapeutic approaches to improve cardiovascular outcomes. This review serves as a vital resource for researchers by integrating a broad spectrum of information on CVDs, diagnostic tools, imaging techniques, pharmacological treatments and their side effects, and the potential of herbal remedies.

Aging of deep venous thrombosis in-vivo using polarization sensitive optical coherence tomography

Deep venous thrombosis (DVT) is a medical condition with significant post-event morbidity and mortality coupled with limited treatment options. Treatment strategy and efficacy are highly dependent on the structural composition of the thrombus, which evolves over time from initial formation and is currently unevaluable with standard clinical testing. Here, we investigate the use of intravascular polarization-sensitive optical coherence tomography (PS-OCT) to assess thrombus morphology and composition in a rat DVT model in-vivo, including changes that occur over the thrombus aging process. PS-OCT measures tissue birefringence, which provides contrast for collagen and smooth muscle cells that are present in older, chronic clots. Thrombi in the inferior vena cava of two cohorts of rats were imaged in-vivo with intravascular PS-OCT at 24 hours (acute, nrats = 3, 73 cross-sections) or 28 days (chronic, nrats = 4, 41 cross-sections) after thrombus formation. Co-registered histology was labelled by an independent pathologist to establish ground-truth clot composition. Automated analysis of OCT cross-sectional images differentiated acute and chronic thrombi with 97.6% sensitivity and 98.6% specificity using a linear discriminant model comprised of both polarization and conventional OCT metrics. These results support PS-OCT as a highly sensitive imaging modality for the assessment of DVT composition to differentiate acute and chronic thrombi. Intravascular PS-OCT imaging could be integrated with advanced catheter-based treatment strategies and serve to guide therapeutic decision-making and deployment, by offering an accurate assessment of DVT patients in real time.

Deep Vein Thrombosis in a 15-Year-Old Previously Restrained Psychiatric Patient: A Case Report

Deep vein thrombosis is a condition in which a thrombus forms in one of the deep veins of the body, most often in the legs. It may manifest with pain, swelling, redness, or increased temperature of the limb, potentially leading to fatal complications such as pulmonary embolism. This is a case of a 15-year-old psychiatric patient diagnosed with deep vein thrombosis of the left lower limb of uncertain etiology. The patient presented few risk factors associated with venous thromboembolism disorder such as immobilization, antipsychotic treatment, and obesity. Even though psychiatry deals primarily with the mind of a patient, somatic complications occur very often and should not be underestimated. One of those complications is deep vein thrombosis, which is worth remembering, especially when applying procedures during which patients are immobilized for a long period.

Development of an Aptamer-Based QCM-D Biosensor for the Detection of Thrombin Using Supported Lipid Bilayers as Surface Functionalization

Biosensors play an important role in numerous research fields. Quartz crystal microbalances with dissipation monitoring (QCM-Ds) are sensitive devices, and binding events can be observed in real-time. In combination with aptamers, they have great potential for selective and label-free detection of various targets. In this study, an alternative surface functionalization for a QCM-D-based aptasensor was developed, which mimics an artificial cell membrane and thus creates a physiologically close environment for the binding of the target to the sensor. Vesicle spreading was used to form a supported lipid bilayer (SLB) of 1-palmitoyl-2-oleoyl-glycero-3-phosphocholine (POPC) and 1,2-dipalmitoyl-sn-glycero-3-phosphethanolamine-N-(cap biotinyl) (biotin-PE). The SLB was then coated with streptavidin followed by applying a biotinylated aptamer against thrombin. SLB formation was investigated in terms of temperature and composition. Temperatures of 25 °C and below led to incomplete SLB formation, whereas a full bilayer was built at higher temperatures. We observed only a small influence of the content of biotinylated lipids in the mixture on the further binding of streptavidin. The functionalization of the sensor surface with the thrombin aptamer and the subsequent thrombin binding were investigated at different concentrations. The sensor could be reconstituted by incubation with a 5 M urea solution, which resulted in the release of the thrombin from the sensor surface. Thereafter, it was possible to rebind thrombin. Thrombin in spiked samples of human serum was successfully detected. The developed system can be easily applied to other target analytes using the desired aptamers.

Evaluating the Efficacy of ChatGPT in Navigating the Spanish Medical Residency Entrance Examination (MIR): Promising Horizons for AI in Clinical Medicine

The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician.

MATERIAL AND METHODS

We studied the 2022 Spanish MIR examination results after excluding those questions requiring image evaluations or having acknowledged errors. The remaining 182 questions were presented to the LLM GPT-4 and GPT-3.5 in Spanish and English. Logistic regression models analyzed the relationships between question length, sequence, and performance. We also analyzed the 23 questions with images, using GPT-4's new image analysis capability.

RESULTS

GPT-4 outperformed GPT-3.5, scoring 86.81% in Spanish (p < 0.001). English translations had a slightly enhanced performance. GPT-4 scored 26.1% of the questions with images in English. The results were worse when the questions were in Spanish, 13.0%, although the differences were not statistically significant (p = 0.250). Among medical specialties, GPT-4 achieved a 100% correct response rate in several areas, and the Pharmacology, Critical Care, and Infectious Diseases specialties showed lower performance. The error analysis revealed that while a 13.2% error rate existed, the gravest categories, such as "error requiring intervention to sustain life" and "error resulting in death", had a 0% rate.

CONCLUSIONS

GPT-4 performs robustly on the Spanish MIR examination, with varying capabilities to discriminate knowledge across specialties. While the model's high success rate is commendable, understanding the error severity is critical, especially when considering AI's potential role in real-world medical practice and its implications for patient safety.

Does COVID-19 infection increase the risk of pulmonary embolism in ambulatory patients with deep vein thrombosis

OBJECTIVES

Coronavirus disease 2019 (COVID-19) can lead to systemic coagulation activation and thrombotic complications including venous thromboembolism. This study compares the development of pulmonary embolism, post-thrombotic syndrome, and clinical outcomes of COVID-19 and non-COVID-19 patients with deep vein thrombosis (DVT).

METHODS

One hundred and eight patients diagnosed with acute deep vein thrombosis (DVT) between June 2020 and February 2021 in our institution were included in this retrospective study. Thirty-nine patients had been previously diagnosed with COVID-19 and specified as the COVID-19 group. Sixty-nine patients did not have COVID-19 and specified as the non-COVID-19 group. Mean ages of both groups were 64.3 ± 15.8 and 60.1 ± 19.7 years, respectively (p = .37).

RESULTS

The median duration from the onset of the COVID-19 to diagnosis of DVT was 22 (2-120) days in the COVID-19 group. The patients of two groups were mostly treated outpatient at rates of 94.9% vs 94.2%, respectively (p = .88). Pulmonary embolism was seen in six patients (15.4%) in the COVID-19 group and in three patients (4.3%) in the non-COVID-19 group (p = .04). Kaplan-Meir curves showed that patients with COVİD-19 had significantly higher pulmonary embolism than those without COVID-19 (p = .015). The recurrence rate of DVT was 2.6% in the COVID-19 group (n = 1), and 4.3% in the non-COVID-19 group (n = 3), indicating no statistically significant difference (p = .63). Mortality was seen in six patients (15.4%) in the COVİD-19 group, and in seven patients (10.1%) in the non-COVID-19 group. According to the Kaplan-Meir method, 10 months survival rates were 73.9 ± 10% in the COVID-19 group, and 66.3 ± 12.8% in the non-COVID-19 group with no statistical significance (p = .218).

CONCLUSIONS

Our data draw attention to the fact that deep vein thrombosis should not be considered a safe and self-limited condition. Efficient preventive measures such as mobilization and prophylactic drug use should be considered to prevent DVT during the management of COVID-19.

Rho GTPase Signaling in Platelet Regulation and Implication for Antiplatelet Therapies

Platelets play a vital role in regulating hemostasis and thrombosis. Rho GTPases are well known as molecular switches that control various cellular functions via a balanced GTP-binding/GTP-hydrolysis cycle and signaling cascade through downstream effectors. In platelets, Rho GTPases function as critical regulators by mediating signal transduction that drives platelet activation and aggregation. Mostly by gene targeting and pharmacological inhibition approaches, Rho GTPase family members RhoA, Rac1, and Cdc42 have been shown to be indispensable in regulating the actin cytoskeleton dynamics in platelets, affecting platelet shape change, spreading, secretion, and aggregation, leading to thrombus formation. Additionally, studies of Rho GTPase function using platelets as a non-transformed model due to their anucleated nature have revealed valuable information on cell signaling principles. This review provides an updated summary of recent advances in Rho GTPase signaling in platelet regulation. We also highlight pharmacological approaches that effectively inhibited platelet activation to explore their possible development into future antiplatelet therapies.

Thrombectomy of a Complex Deep Vein Thrombosis: A Case Report

A deep vein thrombosis (DVT) is a multifactorial condition characterized by a thrombus or blood clot developing in the deep veins of the upper or lower extremities. The presentation of DVT is characterized by unilateral peripheral edema and signs of inflammation in the affected extremity. The treatment of DVT is complex and case-dependent; however, most individuals are managed with oral anticoagulation therapy, while complex cases can be treated with advanced interventions. This report discusses a singular case of an atypical or complex DVT in a middle-aged woman with prior venous thromboembolic events undergoing a thrombectomy using an Inari FlowTriever system.

A decision support tool with health economic modelling for better management of DVT patients

BACKGROUND

Responding to the increasing demand for Deep Vein Thrombosis (DVT) treatment in the United Kingdom (UK) at times of limited budgets and resources is a great challenge for decision-makers. Therefore, there is a need to find innovative policies, which improve operational efficiency and achieve the best value for money for patients. This study aims to develop a Decision Support Tool (DST) that assesses the impact of implementing new DVT patients' management and care policies aiming at improving efficiency, reducing costs, and enhancing value for money.

METHODS

With the involvement of stakeholders from a number of DVT services in the UK, we developed a DST combining discrete event simulation (DES) for DVT pathways and the Socio Technical Allocation of Resources (STAR) approach, an agile health economics technique. The model was inputted with data from the literature, local datasets from DVT services, and interviews conducted with DVT specialists. The tool was validated and verified by various stakeholders and two policies, namely shifting more patients to community services (CSs) and increasing the usage of the Novel Oral Anticoagulant (NOAC) drug were selected for testing on the model.

RESULTS

Sixteen possible scenarios were run on the model for a period of 5 years and generated treatment activity, human resources, costing, and value for money outputs. The results indicated that hospital visits can be reduced by up to 50%. Human resources' usage can be greatly lowered driven mainly by offering NOAC treatment to more patients. Also, combining both policies can lead to cost savings of up to 50%. The STAR method, which considers both service and patient perspectives, produced findings that implementing both policies provide a significantly higher value for money compared to the situation when neither is applied.

CONCLUSIONS

The combination of DES and STAR can help decision-makers determine the interventions that have the highest benefits from service providers' and patients' perspectives. This is important given the mismatch between care demand and resources and the resulting need for improving operational and economic outcomes. The DST tool has the potential to inform policymaking in DVT services in the UK to improve performance.

A low-cost wearable device for portable sequential compression therapy

In 2020, cardiovascular diseases resulted in 25% of unnatural deaths in the United States. Treatment with long-term administration of medication can adversely affect other organs, and surgeries such as coronary artery grafts are risky. Meanwhile, sequential compression therapy (SCT) offers a low-risk alternative, but is currently expensive and unwieldy, and often requires the patient to be immobilized during administration. Here, we present a low-cost wearable device to administer SCT, constructed using a stacked lamination fabrication approach. Expanding on concepts from the field of soft robotics, textile sheets are thermally bonded to form pneumatic actuators, which are controlled by an inconspicuous and tetherless electronic onboard supply of pressurized air. Our open-source, low-profile, and lightweight (140 g) device costs $62, less than one-third the cost the least expensive alternative and one-half the weight of lightest alternative approved by the US Food and Drug Administration (FDA), presenting the opportunity to more effectively provide SCT to socioeconomically disadvantaged individuals. Furthermore, our textile-stacking method, inspired by conventional fabrication methods from the apparel industry, along with the lightweight fabrics used, allows the device to be worn more comfortably than other SCT devices. By reducing physical and financial encumbrances, the device presented in this work may better enable patients to treat cardiovascular diseases and aid in recovery from cardiac surgeries.

Perioperative Prevention of Venous Thromboembolism in Abdominal Surgery Patients Based on the Caprini or the Padua Risk Score-A Single Centre Prospective Observational Study

Surgical patients should receive perioperative thromboprophylaxis based on risk assessment, and the Caprini score is validated for this purpose. Whether the Padua score, originally devised for medical patients, can be useful in surgical patients remains to be fully clarified. This study aimed to evaluate perioperative thromboprophylaxis based on the Caprini or the Padua score in elective abdominal surgery. A total of 223 patients undergoing elective abdominal surgery for malignant or benign disease were prospectively evaluated. The patients were divided into two groups in which thromboprophylaxis was prescribed according to either the Caprini score (n = 122) or the Padua score (n = 101). Patients with high-risk scores in both groups received nadroparin. The alternate risk score in each group was calculated for evaluation purposes only. During a 3-month follow-up, we assessed patients for symptomatic venous thromboembolism (VTE), bleeding, or mortality. In the Caprini score group, 87 patients (71%) had a high risk for VTE (≥5 points), while 38 patients (38%) had a high risk for VTE (≥4 points) in the Padua score group; p < 0.00001. The overall correlation between the Caprini and Padua scores was moderate (r= 0.619), with 85 patients having high Caprini and discordant Padua scores. Ten patients died during follow-up (4.5%), and five developed non-fatal symptomatic VTE (2.2%). Among the five major bleeding incidents recorded (1.8%), two cases were possibly associated with pharmacological thromboprophylaxis. The incidence of adverse outcomes did not differ between the two groups. The odds ratio for adverse outcomes was significantly higher with a high Caprini or Padua risk score, malignant disease, age ≥65 years, and active smoking. We found no significant differences in adverse outcomes between abdominal surgical patients who received perioperative thromboprophylaxis based on either the Caprini or the Padua risk score. However, a discordant Padua score was noted in almost 40% of patients who had a high Caprini score, suggesting that the latter may be more sensitive than the Padua score in surgical patients.

Do we miss rare adverse events induced by COVID-19 vaccination?

Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has caused many complications, the invention of coronavirus disease 2019 (COVID-19) vaccines has also brought about several adverse events, from common side effects to unexpected and rare ones. Common vaccine-related adverse reactions manifest locally or systematically following any vaccine, including COVID-19 vaccines. Specific side effects, known as adverse events of particular interest (AESI), are unusual and need more evaluation. Here, we discuss some of the most critical rare adverse events of COVID-19 vaccines.

Recent Progresses in Development of Biosensors for Thrombin Detection

Thrombin is a serine protease with an essential role in homeostasis and blood coagulation. During vascular injuries, thrombin is generated from prothrombin, a plasma protein, to polymerize fibrinogen molecules into fibrin filaments. Moreover, thrombin is a potent stimulant for platelet activation, which causes blood clots to prevent bleeding. The rapid and sensitive detection of thrombin is important in biological analysis and clinical diagnosis. Hence, various biosensors for thrombin measurement have been developed. Biosensors are devices that produce a quantifiable signal from biological interactions in proportion to the concentration of a target analyte. An aptasensor is a biosensor in which a DNA or RNA aptamer has been used as a biological recognition element and can identify target molecules with a high degree of sensitivity and affinity. Designed biosensors could provide effective methods for the highly selective and specific detection of thrombin. This review has attempted to provide an update of the various biosensors proposed in the literature, which have been designed for thrombin detection. According to their various transducers, the constructions and compositions, the performance, benefits, and restrictions of each are summarized and compared.

The application of Caprini Risk Assessment Model in evaluation of deep vein thrombosis for patients with end-stage osteoarthritis before arthroplasty

Background

Deep vein thrombosis (DVT) was a fatal complication of knee arthroplasty. We had neglected the risk factors of preoperative DVT although patients undergoing knee arthroplasty were at high risk for VTE. This study was to determine the risk factors for preoperative DVT and application of Caprini Risk Assessment Model (RAM) in patients with end-stage knee osteoarthritis (OA).

Methods

We retrospectively analyzed 1808 cases with end-stage knee OA undergoing primary knee arthroplasty from May 2015 to December 2020. Based on the results of ultrasonography in lower extremities, all patients were divided into non-DVT group and DVT group. Distribution of risk factors and risk levels were compared using χ² test between two groups. Binary logistic regression analysis was used to determine the risk factors and relationship of risk levels and preoperative DVT.

Results

The incidence of preoperative DVT was 5.53% (n = 100). Distribution of the study population by risk level was low, 4.09%; moderate, 23.95%; high, 66.98%; and highest 4.98%. Female (P = 0.002), age (P = 0.012), swollen legs (P = 0.035) and history of blood clots (P < 0.001) was correlated with preoperative DVT. Difference among four risk levels was significant (P = 0.007). Patients with highest risk level had statistically significant association with preoperative DVT (P = 0.005, OR = 2.93, 95%CI [1.375–6.246]).

Conclusion

The incidence of preoperative DVT was 5.53% in end-stage knee OA patients. The gender (female) and age were independent risk factors for preoperative DVT. The risk group classification by Caprini RAM was significantly associated with preoperative DVT. The usage of Caprini RAM before knee arthroplasty may be beneficial for prophylaxis of DVT.

Management of Venous Thromboembolism in Morbid Obesity With Rivaroxaban or Warfarin

BACKGROUND

Rivaroxaban is a first-line option for the management of venous thromboembolism (VTE). However, limited data are available regarding its effectiveness in morbidly obese patients.

OBJECTIVE

To evaluate rates of thrombosis and bleeding in morbidly obese patients receiving rivaroxaban or warfarin for VTE.

METHODS

A multicenter, retrospective cohort study was conducted to compare rates of bleeding and thrombosis in patients receiving rivaroxaban versus warfarin for acute VTE. Patients were included if they were older than 18 years and had a body mass index (BMI) greater than 40 kg/m² or weight greater than 120 kg. The primary effectiveness outcome was hazard of VTE recurrence; the primary safety outcome was hazard of major bleeding. Patients were followed for up to 12 months.

RESULTS

A total of 1281 patients were identified for acute VTE and were included in this study with 487 patients receiving rivaroxaban and 785 receiving warfarin. The average cohort age was 57.6 ± 14.6 years, and the average weight was 136.4 ± 27.2 kg. After controlling for confounding factors, the use of rivaroxaban was not associated with an increased hazard of VTE events when compared with warfarin (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.42-1.08, P = 0.12) or major bleeding (HR = 1.29, 95% CI: 0.66-2.30, P = 0.52).

CONCLUSION AND RELEVANCE

No difference was observed in obese patients with weight >120 kg or BMI >40 kg/m² receiving rivaroxaban or warfarin for VTE treatment in hazard of VTE or major bleeding. Either agent may be considered an appropriate treatment option in this population.

Risk factors of pulmonary embolism in the elderly patients: a retrospective study

AIM

We aimed to summarize the clinical feature and risk factors of patients suffering from pulmonary embolism (PE) in the elderly patients, and explore the change in D-dimer after anti-coagulant therapy.

METHODS

A total of 426 patients with PE admitted from August 2012 to January 2019 in the Cangzhou Central Hospital were analyzed in this retrospective study. A comparison of clinical features and risk factors was conducted between the elderly group and non-elderly groups. Blood levels of D-dimer, C-reactive protein (CRP), tumor necrosis factor-α and interferon-γ were measured before and 3 days after anti-coagulant therapy in two groups.

RESULTS

The most important risk factor for the elderly patients was stroke, while for non-elderly patients was deep vein thrombosis (DVT). After anti-coagulant therapy, the decreasing level of D-dimer and CRP showed statistically significant differences between the two groups. Between the elderly and non-elderly groups, the main clinical manifestations were similar. The risk factors of elderly patients were chronic obstructive pulmonary disease, malignant tumor, DVT and stroke. After anti-coagulant therapy, the content of D-dimer was lower than 3 days ago.

CONCLUSION

Blood levels of D-dimer and CRP may be potent screening markers for PE especially among elderly patients.

Multimodal thrombectomy device for treatment of acute deep venous thrombosis

Deep vein thrombosis (DVT) is a potentially deadly medical condition that is costly to treat and impacts thousands of Americans every year. DVT is characterized by the formation of blood clots within the deep venous system of the body. If a DVT dislodges it can lead to venous thromboembolism (VTE) and pulmonary embolism (PE), both of which can lead to significant morbidity or death. Current treatment options for DVT are limited in both effectiveness and safety, in part because the treatment of the DVT cannot be confined to a defined sequestered treatment zone. We therefore developed and tested a novel thrombectomy device that enables the sequesteration of a DVT to a defined treatment zone during fragmentation and evacuation. We observed that, compared to a predicate thrombectomy device, the sequestered approach reduced distal DVT embolization during ex vivo thrombectomy. The sequestered approach also facilitated isovolumetric infusion and suction that enabled clearance of the sequestered treatment zone without significantly impacting vein wall diameter. Results suggest that our novel device using sequestered therapy holds promise for the treatment of high risk large-volume DVTs.

Central venous catheters are associated with thrombosis among adult inpatients undergoing therapeutic plasma exchange

BACKGROUND

For inpatients undergoing therapeutic plasma exchange (TPE) in the United States, the primary mode of venous access is the central venous catheter (CVC). To evaluate the impact of CVC on thrombosis outcomes of patients undergoing TPE, we analyzed the National Inpatient Sample (NIS) database.

STUDY DESIGN AND METHODS

In a cross-sectional analysis of the NIS, we identified hospital discharges of adult patients treated with TPE. Cases were classified into two groups based on CVC status. The primary outcome was thrombosis. Secondary outcomes were major bleeding, packed red blood cell (PRBC) transfusion, in-hospital mortality, hospital length of stay (LOS), and charges.

RESULTS

Among 9863 TPE-treated discharges, CVC was used in 5988 (60%). These numbers correspond to weighted national estimates of 49 315 and 29 940, respectively. There was a positive and significant association between CVC and thrombosis (OR = 1.23, 95% 1.04-1.46, P = 0.0174), PRBC transfusion (OR = 1.15, 95% 1.03-1.29, P = 0.0121), in-hospital mortality (OR = 1.36, 95% 1.10-1.68, P = 0.0043), hospital LOS (15.63 vs 12.45 days, P < 0.0001) and hospital charges ($166 387 vs. $132 655, P < 0.0001).

CONCLUSION

In hospitalized patients undergoing TPE, CVC use is associated with increased rates of thrombosis. Future studies are needed to investigate strategies to decrease CVC use and/or prevent CVC-associated complications in TPE-treated inpatients.

A diagnostic testing for people with appendicitis using machine learning techniques

Appendicitis is a common disease that occurs particularly often in childhood and adolescence. The accurate diagnosis of acute appendicitis is the most significant precaution to avoid severe unnecessary surgery. In this paper, the author presents a machine learning (ML) technique to predict appendix illness whether it is acute or subacute, especially between 10 and 30 years and whether it requires an operation or just taking medication for treatment. The dataset has been collected from public hospital-based citizens between 2016 and 2019. The predictive results of the models achieved by different ML techniques (Logistic Regression, Naïve Bayes, Generalized Linear, Decision Tree, Support Vector Machine, Gradient Boosted Tree, Random Forest) are compared. The covered dataset are 625 specimens and the total of the medical records that are applied in this paper include 371 males (60.22%) and 254 females (40.12%). According to the dataset, the records consist of 318 (50.88%) operated and 307 (49.12%) unoperated patients. It is observed that the random forest algorithm obtains the optimal result with an accurately predicted result of 83.75%, precision of 84.11%, sensitivity of 81.08%, and the specificity of 81.01%. Moreover, an estimation method based on ML techniques is improved and enhanced to detect individuals with acute appendicitis.

COVID-19 and the cardiovascular system: insights into effects and treatments

Coronavirus disease 2019 (COVID-19), an acute and highly transmissible infectious disease, has reached a pandemic level since 11 March 2020 and continues to challenge the healthcare system worldwide. The pathogenesis of COVID-19 is a complex process involving mechanisms that suppress the host antiviral and innate immune response, while triggering marked activation of coagulation and hyperinflammation leading to cytokine storm in severe COVID-19. This review summarizes current evidence related to COVID-19-associated cardiovascular severe illness and mortality, which encompasses life-threatening clinical manifestations, including myocardial injury, fulminant myocarditis, cardiac arrhythmia, and ischemic stroke. The onset of hypercoagulable state is consistent with increased venous thromboembolism including deep vein thrombosis and pulmonary embolism. Thromboembolic manifestations include arterial thrombotic events such as stroke, myocardial infarction, and limb ischemia. Several treatment strategies have been investigated to mitigate COVID-19-associated cardiovascular clinical manifestations. The prevalence of thrombo-inflammatory syndrome and subsequent cardiovascular dysfunction prompted the implementation of antithrombotic therapy and strategies targeting major pro-inflammatory cytokines involved in COVID-19 cytokine storm. The development of new guidelines for effective treatment strategies requires concerted efforts to refine our understanding of the mechanisms underlying cardiovascular disease and large-scale clinical trials to reduce the burden of COVID-19 hospitalization and mortality.

Optimal enoxaparin dosing strategies for venous thromboembolism prophylaxis and treatment of high body weight patients

OBJECTIVE

Obesity is a risk factor for developing venous thromboembolism (VTE). Optimal dosage of enoxaparin has not been established in the obese population. We aimed to study clinical outcomes and complications with enoxaparin in obese patients.

METHODS

A retrospective, single centre observational study of obese patients treated with enoxaparin for VTE (n = 47) using a body mass index (BMI)-stratified dosing, thromboprophylaxis (n = 46), and non-obese controls (n = 20) was performed. Anti-Xa was used to measure enoxaparin efficacy.

RESULTS

Patients with a median BMI of 36.3 kg/m2 (range 30-52.7) with a median weight of 136 kg (range 68-240) received therapeutic enoxaparin at median 120 mg BID (range 60-200). A median targeted anti-Xa level of 0.79 (95% CI 0.72-1.03) IU/mL was achieved in 58% of patients. Dose reduction, or increase was needed in 25%, and 16% patients respectively. Mild or major haemorrhage, or VTE occurred in 10%, 2% and 2% patients respectively. Patients with a median weight of 160 kg (range 130-245) received thromboprophylaxis with 40 mg BID enoxaparin. Targeted median anti-Xa of 0.22 IU/mL (95% CI 0.19-0.24) was achieved in 59% patients. Mild haemorrhage was seen in 2%, while none developed major haemorrhage or VTE. Control patients who received enoxaparin 40 mg daily did not develop VTE; 5% had minor bleeding events.

CONCLUSIONS

BMI-stratified therapeutic enoxaparin dosing regimen is safe and effective therapy in obese patients. Fixed dosing without monitoring may not be appropriate. Thromboprophylaxis with 40 mg BID in obese patients was efficacious in preventing VTE without excess bleeding compared to control patients.

Epidemiologic study of patients with thrombotic events referred to a tertiary hospital in Southern Iran

Background and aim

Thromboembolic events mainly occur in older age is related with high morbidity and mortality, and considerable health-care costs particularly in developing countries. Both arterial and venous thromboembolism has known risk factors such as hyperlipidemia, obesity, diabetes, cancer, major surgery, central catheter. We aimed to evaluate the occurrence of thrombotic events and related risk factors in a group of Iranian patients.

Methods

In this cross-sectional study, all patients (n = 99) who were complicated by thrombotic events referred to the Hematology Research Center of Shiraz University of Medical Sciences were investigated from 2015 to 2017, in Shiraz, Southern Iran. Data were collected from their medical records by a designed data gathering form.

Results

The median age of the occurrence of thrombosis was 51 (IQR: 31) years. From all thrombotic events 52.5% occurred in females. Venous thrombosis was more prevalent than arterial (61.6% vs. 38.4%). Hypertension, diabetes mellitus and ischemic heart disease were the most associated disease with thrombosis. Most of the patients (79.8%) had no episodes of relapse and the occurrence of relapse had no significant relationship with thrombophilia and underlying disease. Acceptable response rate for warfarin therapy was achieved in 46.5% with 5 mg and 43.4% with 5–7.5 mg.

Conclusion

Knowing the frequency and risk factors for thrombotic events lead to timely diagnosis and management of thrombosis. Atrial fibrillation and valvular rheumatic heart disease are the most common risk factors of thrombosis in our study showing prophylaxis is necessary in high-risk patients.

Potential Activity Mechanisms of Aesculus hippocastanum Bark: Antioxidant Effects in Chemical and Biological In Vitro Models

The bark of Aesculus hippocastanum is an herbal remedy used in conditions connected with vascular insufficiency; however, there is a lack of data concerning its mechanisms of action. The present work is a preliminary investigation into some of the potential directions of the bark activity. The phytochemically (qualitative UHPLC-PDA-MS/MS and quantitative UHPLC-PDA assays) characterized extract and its four main constituents (esculin, fraxin, (‒)-epicatechin and procyanidin A2) were first evaluated in terms of their antioxidant capacity. All analytes demonstrated dose-dependent scavenging potential towards the most common in vivo oxidants, with particularly advantageous capacity of the extract and its flavan-3-ol constituents against peroxynitrite (3.37–13.26 mmol AA/g), hydroxyl radical (5.03–8.91 mmol AA/g) and superoxide radical (3.50–5.50 mmol AA/g). Moreover, even at low concentrations (1–5 µg/mL), they protected components of human plasma against oxidative damage inflicted by peroxynitrite, preventing oxidation of plasma protein thiols and diminishing the tyrosine nitration and lipid peroxidation. High efficiency of the analytes was also demonstrated in preventing the peroxynitrite-induced nitrative changes of fibrinogen (up to 80% inhibition for (‒)-epicatechin at 50 µg/mL), an important protein of coagulation cascade. Additionally, the extract and its constituents had, at most, moderate inhibitory activity towards platelet aggregation induced by ADP and only negligible influence on clotting times. The results show that, among the investigated properties, the antioxidant activity might, to the highest extent, be responsible for the bark efficacy in vascular disorders, thus supporting its application in those conditions; they also indicate the directions for future research that would allow for better understanding of the bark activity.

Transcriptomic Profiling of Femoral Veins in Deep Vein Thrombosis in a Porcine Model

Deep vein thrombosis (DVT) is a severe disease affecting the human venous system, accompanied by high morbidity and mortality rates caused by early and late complications. The study aimed at analyzing the changes in the transcriptome of the femoral vein caused by DVT in the porcine model based on the formation of the thrombus in vivo. The study was performed on 11 castrated male pigs: A thrombus was formed in each left femoral vein in six animals; the remaining five served as a control group. Total RNA was isolated from the left femoral veins of the experimental and control animals. High-throughput RNA sequencing was used to analyze the global changes in the transcriptome of veins with induced DVT. Applied multistep bioinformatics revealed 1474 differentially expressed genes (DEGs): 1019 upregulated and 455 downregulated. Functional Gene Ontology annotated 1220 of DEGs into 225 biological processes, 30 molecular functions and 40 cellular components categories. KEGG analysis disclosed TNF, NF-κB and apoptosis pathways' overexpression in DVT samples. A thorough analysis of the detected DEGs indicated that a dysregulated inflammatory response and disturbed balance between clotting and anti-clotting factors play a crucial role in the process of DVT.

Effect of α2-plasmin inhibitor heterogeneity on the risk of venous thromboembolism

INTRODUCTION

Alpha2-plasmin inhibitor (α2-PI) has a heterogeneous composition in the plasma. Both N- and C-terminal cleavages occur that modify the function of the molecule. C-terminal cleavage converts the plasminogen-binding form (PB-α2-PI) to a non-plasminogen-binding form (NPB-α2-PI). N-terminal cleavage by soluble fibroblast activation protein (sFAP) results in a form shortened by 12 amino acids, which is more quickly cross-linked to fibrin. The p.Arg6Trp polymorphism of α2-PI affects N-terminal cleavage. In this work, we aimed to investigate the association between α2-PI heterogeneity and the risk of venous thromboembolism.

MATERIALS AND METHODS

Two hundred and eighteen patients with venous thromboembolism (VTE) and the same number of age and sex-matched healthy controls were enrolled. Total-α2-PI, PB-α2-PI and NPB-α2-PI antigen levels, α2-PI activity, sFAP antigen levels and p.Arg6Trp polymorphism were investigated.

RESULTS

Total-α2-PI and NPB-α2-PI levels were significantly elevated in VTE patients, while PB-α2-PI levels did not change. Elevated NPB-α2-PI levels independently associated with VTE risk (adjusted OR: 9.868; CI: 4.095-23.783). Soluble FAP levels were significantly elevated in the VTE group, however, elevated sFAP levels did not show a significant association with VTE risk. The α2-PI p.Arg6Trp polymorphism did not influence VTE risk, however, in the case of elevated sFAP levels the carriage of Trp6 allele associated with lower VTE risk.

CONCLUSION

Our results showed that the elevation of total-α2-PI levels in VTE is caused by the elevation of NPB-α2-PI levels. Elevated sFAP level or p.Arg6Trp polymorphism alone did not influence VTE risk. However, an interaction can be detected between the polymorphism and high sFAP levels.

Efficacy of modified pressure cuff for thrombolytic treatment on lower extremity deep venous thrombosis

ABSTRACT

To compare the effectiveness and patient comfort between two methods that block superficial venous blood flow during the thrombolytic treatment of lower extremity deep venous thrombosis (DVT) to provide evidence that informs clinical choice.One hundred twenty patients with lower extremity DVT were randomly divided into sphygmomanometer (group A, n = 40), tourniquet (group B, n = 40), and control group (no blocking, n = 40). All the patients were treated with a daily dosage of urokinase using a dial sphygmomanometer cuff and tourniquet to block lower extremity superficial vein blood flow. The pressure of the dial sphygmomanometer blocking lower extremity superficial vein blood flow was measured during lower extremity venography. Leg swelling reduction rate, venous patency, thrombus removal rate, and average comfort index were observed during the blocking process.The average pressure value for group A was 70  ± 10 mm Hg. The differences in the swelling reduction rate and venous patency were significant between the groups. Comparing the two groups at different time points, the average thrombus clearance rate of group A was higher than that of group B and control group. The leg pain scores of group A were lower than those of group B and control group. The postoperative comfort ratio of group A was higher than that of group B, and the proportion of severe discomfort in group A was lower than that in group B.Compared with the tourniquet, using a dial sphygmomanometer cuff to block lower extremity superficial vein blood flow achieved a better thrombolytic effect on DVT and provided higher patient comfort during treatment.

Safety and effectiveness of thromboprophylaxis use in hospitalized elderly medical patients at a Saudi tertiary care center

Introduction

Appropriate prescribing of thromboprophylaxis according to guidelines' recommendations can heighten over- or underutilization risk. The study intended to evaluate the safety and effectiveness of appropriate/inappropriate thromboprophylaxis use among hospitalized elderly medical patients.

Methods

A retrospective observational cohort study was conducted, including patients who were ≥60 years old, hospitalized for an acute medical illness that required hospitalization in a medical ward for >48 h, and received thromboprophylaxis. Against the American College of Chest Physicians guidelines, the thromboprophylaxis use appropriateness was assessed.

Results

A total of 370 patients met the inclusion criteria, in 71.9% of whom thromboprophylaxis use was appropriate. The mean age of the included patients was 75 years (±9.1), and 72.4% of them were at high risk of venous thromboembolism (VTE), and almost all these patients received appropriate thromboprophylaxis. The occurrence of bleeding was significantly higher in the appropriate use group during hospitalization than the inappropriate use group (11.7% vs. 2.9%, p = 0.009); the majority of these bleeding events were classified as major. There were no differences in VTE events during hospitalization or 90 days all-cause mortality between the two groups.

Conclusion

The study demonstrates high prescribers' compliance with recommendations in high-risk patients. In patients at low risk for VTE, the overutilization of thromboprophylaxis did not increase their bleeding risk. This study suggests that the benefits of thromboprophylaxis in elderly patients, regardless of their VTE risk, may outweigh the risk of bleeding.

Serological Parameters and Vascular Investigation for a Better Assessment in DVT during Pregnancy-A Systematic Review

Pregnancy and the postpartum period represent a condition characterized by a thrombotic predisposition. The majority of pregnant women do not face acute or severe thrombotic events. In general, mild inconveniences such as leg swelling or moderately painful thrombotic events (phlebitis) are encountered. However, when pregnancy is associated with inherited or acquired deficits that affect homeostasis, the risk of acute or even life-threatening events can increase significantly. The major consequence is the loss of the fetus or the venous thromboembolism that endangers the mother's life. Venous thromboembolism is caused by deep vein thrombosis, therefore timely detection and especially the assessment of the extent of the thrombotic event are crucial. In this paper we have summarized the most important paraclinical investigations. The study emphasizes the importance of selecting the methods of investigation. The right choice allows establishing a correct diagnosis and individualizing the treatment.

Increased deep vein thrombosis cases during the COVID-19 quarantine

OBJECTIVE

The aim of this study was to compare the number of deep vein thrombosis (DVT) cases during the quarantine period for COVID-19 to that of the last year.

METHODS

This study was conducted as a single-center and retrospective study. All hospital admissions during April 2020 and May 2020 were screened from the hospital records, and DVT cases were recorded. Likewise, all hospital admissions during April 2019 and May 2019 were screened, and DVT cases were noted. DVT cases of both years were compared.

RESULTS

Among 480931 patients admitted to our hospital in April 2019 and May 2019, DVT was detected in 82 patients (0.017%) (47 males, 35 females) with a mean age of 56.99 ± 9.1 years (ranges 39 to 79 years). Besides, among 145101 patients admitted to our hospital in April 2020 and May 2020, DVT was detected in 123 patients (0.084%) (51 males, 72 females) with a mean age of 58.64 ± 8.9 years (ranges 40 to 83 years). Despite the decrease in the total number of patients admitted to the hospital, there was a significant increase in the number of DVT patients. Interestingly, there were only two symptomatic pulmonary-embolism cases in the 2019 period, whereas there were seven symptomatic pulmonary embolisms secondary to DVT in the 2020 period. Unfortunately, one patient died due to pulmonary embolism secondary to DVT in 2020. The previous history of DVT was remarkable in patients admitted during the COVID-19 confinement.

CONCLUSION

In conclusion, COVID-19 confinement seems to be associated with increased rates of DVT. Strict preventive measures such as exercise training or prophylactic drug use should be considered to prevent immobility-related DVT during the COVID-19 quarantine.

Deep Vein Thrombosis Due to Fecal Impaction

BACKGROUND

Deep vein thrombosis (DVT) can occasionally be secondary to mechanical compressions, such as in May-Thurner syndrome. To our knowledge, no cases of DVT associated with mechanical compression by fecal impaction in a pediatric patient have been previously reported.

CASE PRESENTATION

An 18-year-old developmentally delayed female presented to the emergency department with swelling involving her left lower extremity. Cross-sectional imaging revealed a significant stool burden in the rectosigmoid colon compressing the left external iliac vein and causing secondary thrombosis. Thrombectomy successfully alleviated the clot burden.

CONCLUSION

This case underscores the potentially serious implications of severe fecal impaction in the pediatric and adolescent populations.

Incidence of deep vein thrombosis and pulmonary embolism in Asian patients after direct anterior total hip arthroplasty

Objective

Venous thromboembolism (VTE), comprising either deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most significant complications after Total Hip Arthroplasty (THA). The incidence of VTE after Direct Anterior Approach (DAA) hip arthroplasty is not known. Preceding studies have shown that internal femoral rotation used in the posterior approach leads to "scissoring" of the femoral vein and complete occlusion of flow. In contrast, external femoral rotation, utilized in an anterior approach, does not lead to any limitation in venous flow. We hypothesize that the rate of VTE post-operatively after DAA THA is comparable, if not lower, to other conventional approaches.

Methods

Retrospective analysis of medical records was examined to identify the incidence of symptomatic DVT within 6 months post-surgery, yielding 196 cases of elective primary DAA after THAs between 2015 and 2019. Aspirin was administered post-operatively. Corresponding imaging was performed for cases with high clinical suspicion of either DVT or PE based on Well's criteria.

Results

There were no cases of symptomatic DVT or fatal PE within 1 year of THA. There was 1 case of non-fatal subsegmental pulmonary embolism, treated with warfarin, which made an uneventful recovery. The overall incidence of symptomatic DVT and PE after DAA THA was 0% and 0.5% respectively in our study population.

Conclusion

Cumulative rate of symptomatic DVT and PE was less than 1%, demonstrating that incidence of VTE after DAA THA is low. DAA is a viable approach in Asian patients undergoing THA, in view of lower incidence of post-operative VTE compared values cited in other conventional surgical approaches. Further large scale studies involving use of routine post-operative venography for assessment will further validate our results.

Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity

BACKGROUND

People undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (e.g. heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT), but is associated with an increased risk of bleeding. Mechanical prophylaxis (e.g. antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has minimal side effects. However, mechanical prophylaxis is not always appropriate for people with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis for people undergoing major amputation and whether this is one treatment alone or in combination with another. This is an update of the review first published in 2013.

OBJECTIVES

To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2019. We planned to undertake reference checking of identified trials to identify additional studies. We did not apply any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised controlled trials which allocated people undergoing a major unilateral or bilateral amputation (e.g. hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed risk of bias. We resolved any disagreements by discussion. Outcomes of interest were VTE (DVT and pulmonary embolism (PE)), mortality, adverse events and bleeding. We used GRADE criteria to assess the certainty of the evidence. The two included studies compared different treatments, so we could not pool the data in a meta-analysis.

MAIN RESULTS

We did not identify any eligible new studies for this update. Two studies with a combined total of 288 participants met the inclusion criteria for this review. Unfractionated heparin compared to low molecular weight heparin One study compared unfractionated heparin with low molecular weight heparin and found no evidence of a difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35; 75 participants; very low-certainty evidence). No bleeding events occurred in either group. Deaths and adverse events were not reported. This study was open-label and therefore at a high risk of performance bias. Additionally, the study did not report the method of randomisation, so the risk of selection bias was unclear. Heparin compared to placebo In the second study, there was no evidence of a benefit from heparin use in preventing PE when compared to placebo (OR 0.84, 95% CI 0.35 to 2.01; 134 participants; low-certainty evidence). Similarly, no evidence of improvement was detected when the level of amputation was considered, with a similar incidence of PE between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97; 94 participants; low-certainty evidence); and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43; 40 participants; low-certainty evidence). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent PE, all of whom had been on placebo (low-certainty evidence). Bleeding events were reported in less than 10% of participants in both treatment groups, but the study did not present specific data (low-certainty evidence). There were no reports of other adverse events. This study did not report the methods used to conceal allocation of treatment, so it was unclear whether selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis.

AUTHORS' CONCLUSIONS

We did not identify any eligible new studies for this update. As we only included two studies in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in people undergoing lower limb amputation. Further large-scale studies of good quality are required.

The rational use of thromboprophylaxis therapy in hospitalized patients and the perspectives of health care providers in Northern Cyprus

Background

Despite the presence of effective strategies and standard guidelines for the prevention of deep vein thrombosis (DVT), a considerable proportion of patients at risk of developing thromboembolism did not receive prophylaxis during hospitalization, while others received it irrationally, thus led to unwanted side effects.

Aim

This study aimed to evaluate the current thromboprophylaxis practice and management of hospitalized patients at risk of developing DVT, along with the assessment of health care providers (HCPs) knowledge, and attitudes regarding DVT prevention.

Methods

An observational study was conducted in the general wards of two leading tertiary university hospitals in Northern Cyprus in which patients from multiple clinics were enrolled to investigate the rational use of DVT prophylaxis using the Caprini risk assessment tool. Patients were also followed for possible complications two weeks post-hospitalization. A cross-sectional study followed to assess the knowledge and attitude of HCPs regarding DVT risks and prophylaxis.

Results

Of the 180 patients enrolled, 47.7% were identified as irrationally managed, 52.3% were identified as rationally managed, 77.8% of patients were identified as having a high level of risk. Notably, Four of thirteen patients who received more thromboprophylaxis developed minor complications. Additionally, 73.3% of nurses had not received DVT education. Furthermore, more than 50% of physicians and nurses achieved a low knowledge score for DVT risks and prophylaxis.

Conclusions

A high degree of irrationality in the administration of thromboprophylaxis therapy to hospitalized patients was observed. The overall scores for HCPs indicated insufficient knowledge of DVT risk assessments and prophylaxis.

Anti-embolism stocking care protocol to prevent associated skin problems: A quasi-experimental study

AIM

The aim of this quasi-experimental study was to develop an anti-embolism stocking care protocol and assess its effectiveness in preventing associated skin problems on the legs.

MATERIALS AND METHODS

The study was conducted between 02 March and July 20, 2016 in the surgical clinics of a private university hospital in Ankara, Turkey. The sample consisted of 27 nurses and 162 patients (three different patients were fitted of anti-embolism stockings by each of the 27 nurses; pre-protocol 81 patients and post-protocol 81 patients). Data were collected using data collection forms developed by the researchers. An anti-embolism stocking care protocol was developed and used. Nurses and patients were evaluated using an observational method.

RESULTS

Following implementation of the protocol, nurses' mean knowledge (95.24 ± 5.60) and intervention skill (92.06 ± 10.42) scores were significantly higher than their pre-protocol knowledge (73.54 ± 14.26) and intervention skill (15.30 ± 6.84) scores. Nurses performed almost all steps of the care protocol correctly after the protocol was implemented. The rates of skin problems such as pressure ulcers, neurovascular problems and issues associated with wrinkles or creases in stockings were significantly reduced after implementation of the protocol.

CONCLUSIONS

This study demonstrates that nurses' knowledge and intervention skills are increased when a care protocol is used, together with the prevention of errors and improved patient outcomes. The use of care protocols guides nurses in practice, raises awareness and helps to achieve nursing care objectives by standardizing information.

Association between obesity and venous thromboembolism

Background and aims

Obesity is associated with numerous pathological conditions, including venous thromboembolism (VTE). VTE is a multifactorial disease; more than half of the hospitalized patients are at risk for VTE.

We aimed to assess the risk of VTE associated with obesity, taking into account the class of obesity (according to the body mass index), gender, age and the intervention of other acquired risk factors.

Methods

A case-control study including 732 patients was designed. Collected data included: age, gender, body mass index, pregnancy/postpartum state, use of hormonal therapy, personal and family history of VTE, smoking, prolonged immobilization and the presence of comorbidities - acquired risk factors for VTE. The risk of VTE was expressed as odds ratio (OR) with 95% confidence interval. Multiple logistic regression analysis was used to detect the independent risk factors. P value <0.05 was considered significant statistic.

Results

Obesity was associated with a 6.2-fold increased risk for VTE. The risk of VTE associated with obesity was highest in patients aged >50 years and in cases included in classes II and III of obesity. The interaction between obesity and another acquired risk factor has almost doubled the risk of VTE. Multivariate logistic regression analysis showed obesity as an independent risk factor for VTE for both female and male patients.

Conclusions

Obesity is an independent and moderate risk factor for VTE. The risk increases with body mass index, age and the presence of other acquired risk factors.

Treatment of distal deep vein thrombosis

BACKGROUND

The treatment of distal (below the knee) deep vein thrombosis (DVT) is not clearly established. Distal DVT can either be treated with anticoagulation, or monitored with close follow-up to detect progression to the proximal veins (above the knee), which requires anticoagulation. Proponents of this monitoring strategy base their decision to withhold anticoagulation on the fact that progression is rare and most people can be spared from potential bleeding and other adverse effects of anticoagulation.

OBJECTIVES

To assess the effects of different treatment interventions for people with distal (below the knee) deep vein thrombosis (DVT).

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 February 2019. We also undertook reference checking to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) for the treatment of distal DVT.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. We resolved disagreements by discussion. Primary outcomes of interest were recurrence of venous thromboembolism (VTE), DVT and major bleeding and follow up ranged from three months to two years. We performed fixed-effect model meta-analyses with risk ratio (RRs) and 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified eight RCTs reporting on 1239 participants. Five trials randomised participants to anticoagulation for up to three months versus no anticoagulation. Three trials compared anticoagulation treatment for different time periods. Anticoagulant compared to no intervention or placebo for distal DVT treatment Anticoagulation with a vitamin K antagonist (VKA) reduced the risk of recurrent VTE during follow-up compared with participants receiving no anticoagulation (RR 0.34, 95% CI 0.15 to 0.77; 5 studies, 496 participants; I² = 3%; high-certainty evidence), and reduced the risk of recurrence of DVT (RR 0.25, 95% CI 0.10 to 0.67; 5 studies, 496 participants; I² = 0%; high-certainty evidence). There was no clear effect on risk of pulmonary embolism (PE) (RR 0.81, 95% CI 0.18 to 3.59; 4 studies, 480 participants; I² = 0%; low-certainty evidence). There was little to no difference in major bleeding with anticoagulation compared to placebo (RR 0.76, 95% CI 0.13 to 4.62; 4 studies, 480 participants; I² = 26%; low-certainty evidence). There was an increase in clinically relevant non-major bleeding events in the group treated with anticoagulants (RR 3.34, 95% CI 1.07 to 10.46; 2 studies, 322 participants; I² = 0%; high-certainty evidence). There was one death, not related to PE or major bleeding, in the anticoagulation group. Anticoagulation for three months or more compared to anticoagulation for six weeks for distal DVT treatment Three RCTs of 736 participants compared three or more months of anticoagulation with six weeks of anticoagulation. Anticoagulation with a VKA for three months or more reduced the incidence of recurrent VTE to 5.8% compared with 13.9% in participants treated for six weeks (RR 0.42, 95% CI 0.26 to 0.68; 3 studies, 736 participants; I² = 50%; high-certainty evidence). The risk for recurrence of DVT was also reduced (RR 0.32, 95% CI 0.16 to 0.64; 2 studies, 389 participants; I² = 48%; high-certainty evidence), but there was probably little or no difference in PE (RR 1.05, 95% CI 0.19 to 5.88; 2 studies, 389 participants; I² = 0%; low-certainty evidence). There was no clear difference in major bleeding events (RR 3.42, 95% CI 0.36 to 32.35; 2 studies, 389 participants; I² = 0%; low-certainty evidence) or clinically relevant non-major bleeding events (RR 1.76, 95% CI 0.90 to 3.42; 2 studies, 389 participants; I² = 1%; low-certainty evidence) between three months or more of treatment and six weeks of treatment. There were no reports for overall mortality or PE and major bleeding-related deaths.

AUTHORS' CONCLUSIONS

Our review found a benefit for people with distal DVT treated with anticoagulation therapy using VKA with little or no difference in major bleeding events although there was an increase in clinically relevant non-major bleeding when compared to no intervention or placebo. The small number of participants in this meta-analysis and strength of evidence prompts a call for more research regarding the treatment of distal DVT. RCTs comparing different treatments and different treatment periods with placebo or compression therapy, are required.

Challenging Management of a Patient With Severe Bilateral Deep Vein Thrombosis

Among patients with proximal iliofemoral deep vein thrombosis (DVT) and an elevated Villalta score, anticoagulation therapy alone may not be a sufficient management strategy in select cases. In this article, we report a case of severe bilateral iliofemoral DVT that resisted the standard treatment for DVT, requiring catheter-directed thrombolysis and subsequent mechanical thrombectomy.

Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study

This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.

Proximal deep vein thrombosis among hospitalised medical and obstetric patients in Rwandan university teaching hospitals: prevalence and associated risk factors: a cross-sectional study

OBJECTIVES

To determine the prevalence of proximal deep vein thrombosis (DVT) by ultrasound scanning, as well as associated clinical features and known risk factors, among medical and obstetrics-gynaecology inpatients in two Rwandan tertiary hospitals.

DESIGN

Cross-sectional study.

SETTINGS

Rwanda teaching hospitals: Kigali and Butare University Teaching Hospitals.

PARTICIPANTS

901 adult patients admitted to the Departments of Internal Medicine and Obstetrics-Gynecology (O&G) who were at least 21 years of age and willing to provide a consent.

OUTCOMES

Prevalence of proximal DVT, clinical features and known risk factors associated with DVT.

METHODS

Between August 2015 and August 2016, participants were screened for DVT by compressive ultrasound of femoral and popliteal veins, conducted as a monthly cross-sectional survey of all consenting eligible inpatients. Patients completed a self-report survey on DVT risk factors. Prevalence of proximal DVT by compression ultrasonography was the primary endpoint, with univariate and multivariate regression analyses performed to assess associated clinical features and risk factors.

RESULTS

Proximal DVT was found in 5.5% of the study population, with similar rates in medical and O&G inpatients. The mean age was 41±16 SD (range, 21-91), 70% were female and 7% were pregnant. Univariate analysis showed active malignancy, immobilisation, prolonged recent travel and history of DVT to be significant risk factors for proximal DVT (all p values <0.05); while only active malignancy was an independent risk factor on multivariate regression (OR 5.2; 95% CI 2.0 to 13). Leg pain or tenderness, increased calf circumference, unilateral limb swelling or pitting oedema were predictive clinical features of DVT on both univariate analysis and multivariate regression (all p values <0.05).

CONCLUSION

Proximal DVT prevalence is high among hospitalised medical and O&G patients in two tertiary hospitals in Rwanda. For reducing morbidity and mortality, research to develop Africa-specific clinical prediction tools for DVT and interventions to increase thromboprophylaxis use in the region are urgently needed.

Acute Thrombolysis-Resistant Occlusive Left Femoral and Iliac Venous Thrombosis Treated with Mechanical Thrombectomy via the ClotTriever Device

BACKGROUND

Deep vein thrombosis (DVT) is frequently treated by anticoagulation, which helps to prevent new thrombus formation, but to restore venous flow, additional efforts might be needed. Thrombolytic agents can help clear acute thrombus, but increased bleeding risk is a concern; frequent contraindications are another. One lesser discussed potential limitation is thrombus age, which can affect efficiency of treatment.

CASE

A 62-year-old female patient with extensive DVT affecting the inferior vena cava (IVC) through the left femoral vein was initially treated with EKOS catheter directed thrombolysis (CDT) for 24 hr. Subsequent venogram revealed persistent, occlusive femoral and iliac thrombus. We decided on mechanical thrombectomy via the ClotTriever catheter (Inari Medical, Irvine, California), a nitinol coring element with an attached collection bag that can remove wall-adherent thrombus. We performed three passes with the device and removed large amounts of organized thrombus. Subsequent venography showed complete resolution of the occlusion. Finally, an underlying compression was treated via stenting.

CONCLUSIONS

ClotTriever was effective in removing subacute and chronic thrombus, as demonstrated in this case with persistent extensive thrombus after 24 h of CDT. The ClotTriever System adds a valuable option for vascular interventionalists to treat DVT.

Prevalence and Risk Factors of Preoperative Deep Vein Thrombosis in Patients with End-Stage Knee Osteoarthritis

BACKGROUND

The purpose of this study is to determine the prevalence and the risk factors of DVT in end-stage OA patients.

METHODS

From March 2015 to June 2017, 521 patients with knee degenerative osteoarthritis undergoing knee arthroplasty were enrolled; 458 patients (87.9%) were admitted for primary total knee arthroplasty and 63 patients (12.1%) were admitted for unicompartmental knee arthroplasty. Parameters were compared using χ² or t-test for both the groups. Binary logistic regression analysis was used to determine risk factors.

RESULTS

The incidence of preoperative DVT was 6.7% (n = 35). Age in preoperative DVT group was significantly more than the non-DVT group (72.54 ± 6.53 vs. 68.65 ± 7.35, P = 0.002). Preoperative D-dimer >0.5 μg/mL (P < 0.001) was also associated with preoperative DVT in knee osteoarthritis patients. The incidence increased with age significantly (2.17% in <65 years, 6.86% in ≥65 <75 years, and 12.26% in ≥75 years) (P = 0.008). Thus, age (P = 0.041, OR 1.075, 95% CI [1.002-1.110]) and D-dimer >0.5 μg/mL (P < 0.001, OR 4.441, 95% CI [1.942-10.153]) were the independent risk factors for preoperative DVT in knee osteoarthritis patients.

CONCLUSIONS

The incidence of DVT in end-stage osteoarthritis was 6.7%. The results suggest that older people aged over 75 and D-dimer > 0.5 μg/mL were risk factors for DVT among patients admitted to the hospital for total knee arthroplasty. Instrumental screening should be encouraged, especially in subgroups at higher risk for preoperative DVT.

Phospholipid-Coated Hydrophobic Mesoporous Silica Nanoparticles Enhance Thrombectomy by High-Intensity Focused Ultrasound with Low Production of Embolism-Inducing Clot Debris

Here we report the efficacy of a nanoparticle-assisted high-intensity focused ultrasound (HIFU) treatment that selectively destroys blood clots while minimizing generation of microparticles, or microemboli, that can cause further complications postsurgery. Treatment of malignant blood clots (thrombi) and the resulting emboli are critical problems for numerous patients, and treatments addressing these conditions would benefit from advancements in noninvasive procedures such as HIFU. While recanalization of occlusive blood clots is currently addressed with surgical intervention that seeks to minimize formation of large emboli, there is a danger of microemboli (micrometer-size particles) that have been theorized to be responsible for the poor correlation between apparent surgical success and patient outcome. Here, the addition of phospholipid-coated hydrophobically modified silica nanoparticles (P@hMSNs) improved the efficacy of HIFU treatment by serving as cavitation nuclei for mechanical disruption of thrombi. This treatment was evaluated for the ability to clear the HIFU focal area of a thick and dense thrombus within 10 min. Moreover, it was found that the use of P@hMSN+HIFU treatment generated a significantly smaller microembolic load as compared to comparison techniques, including a HIFU + microbubble contrast agent, HIFU alone, and direct mechanical disruption. This reduction in the microembolic load can occur either with primary removal of the clot by P@hMSN+HIFU or by insonation of the clot fragments after mechanical thrombectomy. Lastly, this method was evaluated in a flow model, where nonocclusive model thrombi and model emboli were mechanically ablated within the focal area within 15 s. Together, these results represent a combination therapy capable of resolving thrombi and microembolisms resulting from thrombectomy through localized destruction of clotted material.

Red flag rules for knee and lower leg differential diagnosis

Physical therapists can be frequently a patient's initial encounter after a lower extremity injury, as access to physical therapy services have become readily available without a physician's referral. In 2017, over 65% of physical therapy providers are treating via direct access in United States that allow unrestricted access. In addition to direct access, in an age when at least one of four Americans have multiple chronic medical conditions, it is vital to be able to perform a comprehensive examination, which includes a thorough patient history, systems review, and objective test and measures. Physical therapists should identify red flag symptoms and signs indicating possible pathological condition(s). Based on the findings, a clinical decision should be made to either treat the patient, refer the patient to an appropriate healthcare practitioner, or initiate both treatment and referral. If serious pathology is suspected, it is most prudent to refer the patient appropriately to a qualified medical practitioner.