Cases Of PE Research Articles

Venous thromboembolism: exploring incidence and utility of screening in individuals with dual diagnosis.

The development of venous thromboembolism (VTE) is a common complication following spinal cord injury (SCI) and brain injury (BI), leading to significant morbidity and mortality. The purpose of this study was to explore the incidence of VTE in patients with the dual diagnosis (DD) of SCI and concomitant BI using ultrasonography. Retrospective study. Acute rehabilitation hospital. Thirty-one individuals admitted for DD rehabilitation who were routinely screened for VTE with ultrasound on admission. Not applicable. Retrospective chart review was performed to identify whether patients were found to have DVT or PE at the following three time points: in acute care prior to admission to rehabilitation, at time of admission diagnosed via screening examination, and after admission to rehabilitation during the inpatient stay via post screening examinations. Retrospective chart review was also performed to identify incidence of bleeding. 67.7% of individuals were found to have DVTs at any timepoint. Of these DVTs, 22.6% were identified in acute care, 48.4% on admission to rehabilitation, and 16.1% during the course of rehabilitation stay. Of those who were placed on therapeutic anticoagulation due to admission diagnosis of VTE, 25% developed recurrent DVT and 12.5% had bleeding complications. No cases of PE were observed in this study population. This study found a high incidence of DVT for the DD population at all three timepoints with a high proportion identified via screening ultrasonography on admission to rehabilitation. Further research is needed to investigate the incidence of VTE and utility of screening ultrasonography in this population.

STUDY OF IMMUNOHISTOCHEMICAL EXPRESSION OF BETA-CATENIN IN ENDOMETRIAL BIOPSY SPECIMENS AMONG PATIENTS OF ABNORMAL UTERINE BLEEDING IN A TERTIARY CARE HOSPITAL

Context The primary role of endometrial sampling in patients with AUB is to determine whether carcinoma or premalignant lesions are present by evaluating histologically. β-catenin has been one among the important markers studied to differentiate between benign EH and premalignant EIN. 1) To analyse the expression of Aims: β-catenin in various endometrial lesions 2) To dene the diagnostic accuracy of β-catenin in differentiating benign EH from premalignant EAH/EIN. Settings and Design: Prospective study conducted at Department of Pathology in a tertiary care hospital over a period of two years. Methods and Materials: β-catenin immunoexpressions were evaluated using immunohistochemical staining in 150 histopathologically diagnosed cases of endometrial lesions from AUB cases. Statistical analysis used: The statistical analysis was done using Pearson's Chi-squared test. Results: This study included Proliferative endometrium (22 cases), Benign endometrial hyperplasia (57 cases), Endometrial atypical hyperplasia/ Endometrioid intraepithelial neoplasia (56 cases) and Endometrioid carcinoma (15 cases). 50% cases of PE showed β-catenin membranous expression, 56% cases of BEH showed cytoplasmic expression, 27% cases of EAH/EIN and 60% of EMC showed nuclear expression. Statistically signicant association was seen between the location of β-catenin expression and different endometrial lesions (p<0.001). Diagnostic accuracy in differentiating benign EH from premalignant EAH/EIN was high with considering only nuclear β-catenin as aberrant expression and was low by considering cytoplasmic and /or nuclear βcatenin as aberrant expression.Conclusion Nuclear expression of β-catenin strongly correlates with increasing grades of endometrial pathology, namely endometrial atypical hyperplasia/ endometrioid intraepithelial neoplasia and endometrioid carcinoma. Also nuclear expression of β-catenin appears as a little sensitive, but perfectly specic marker of endometrial precancer (EAH/EIN).

P-790 Mode of conception and pregnancy outcomes: systematic review and meta-analysis of 110 studies and 33,655,021 singleton pregnancies

Abstract Study question Does mode of conception such as in-vitro fertilisation (IVF), ovulation induction (OI), intra-uterine insemination (IUI) affect singleton pregnancy outcomes when compared to spontaneous conception (SC)? Summary answer Singleton pregnancies resulting from OI, IUI, IVF are associated with higher risks of adverse pregnancy outcomes compared to spontaneous pregnancies. What is known already Several meta-analysis have shown singleton pregnancies resulting from IVF have adverse pregnancy outcomes However, these studies had much smaller sample size and did not compare OI or IUI to SC. Additionally, when matched studies were analysed, the pooled events used were not adjust for medical conditions such as polycystic ovaries (PCO) and chronic hypertension which predispose patients to gestational diabetes(GDM) and pre-eclampsia (PET).he lack of consensus on how PET and GDM was defined was also a cause of bias. Our study is the largest meta-analysis to date and aims to provide clinician with the latest evidence when offering fertility treatment. Study design, size, duration Literature search in MEDLINE, COCHRANE Library, and Scopus was performed, up to November 2021. Randomised controlled trials (RCTs), non-randomised studies, cohort and case control studies, reporting on any association between pregnancy outcome, such as pre-eclampsia (PET), gestational diabetes mellitus (GDM), preterm birth, (<37 weeks (TB), very preterm birth , (<32 weeks (vVPTB), low birthweight (<2500g,LBW), very low birth weight (<1500g,VLBW) and small gestational age (SGA) in relation to mode of conception were included. Participants/materials, setting, methods 110 studies consisting of 31 cohort studies and 79 case control were included comprising a total of 32,463,058spontaneous singleton conception compared to 1,191,963 singleton pregnancies following OI, IUI and IVF treatment .Matching criteria used for adjustment were also identified For PET and GDM, only studies which defined the condition according to international agreed consensus were included Any inconsistency between studies was quantified through Higgins’ Chi-square (Chi2) and I-squared (I2) using statistical software R. Main results and the role of chance Singleton pregnancies following, OI, IUI, or IVF had a higher odds of PET compared to SC (odds ratio [OR]1.95,, 95% confidence interval [CI]1.61-2.31; I2=97%), OR 1.53, 95%CI 1.36 -1.71,, I2=84% and OR1.62, 95%CI 0.94-2.78, I2=11%).respectively. For GDM, pregnancies following, OI, IUI, or IVF had a higher odds compared to SC (OR1.59, 95%CI 1.59 -1.71, I2=83%, OR 1.62, 95%CI 0.94-2.78, I2=11% and OR1.72, 95% CI 1.49–1.98; I2=13%). Higher odds of TB and vPTB were seen in pregnancies following OI and IVF compared to SC (PTB: OR1.80, 95% CI 1.76–1.85; I2=94% and , (OR 1.47, 95% CI 1.22-1.77 I2=66% and vPTB OR 2.92, 95% CI 2.76-3.09; I2=91%). Only one study reported PTB when comparing IUI to SC (OR 1.88, 95% CI 1.40-2.53) and comparing vPTB in OI vs SC (OR 1.73 95% CI 0.71-4.18). Singleton pregnancies following, OI or IVF had a higher odds of LBW and vLBW compared to SC (OR1.98, 95% CI 1.93–2.04; I2=96%),OR1.72, 95% CI 1.49–1.98 I2=13% and OR4.57, 95% CI 4.34–4.81; I2=98% and OR2.32, 95% CI 1.60–3.37; I2=56% respectively. The rate of SGA was comparable in IVF (OR 0.91, 95% CI 0.90–0.93; I2=99%), OI (OR 0.96, 95% CI 0.95-0.97; I2=100%) and IUI (RR 0.92, 95% CI 0.90–0.94; I2=31%). Limitations, reasons for caution In cases of PE and GDM, published definitions differed in various studies and there was limited information given past medical history which increase the risk of such conditions. This made it impossible to separate the baseline confounders which may increase the risk of PE and consequently PTB, SGA and LBW. Wider implications of the findings Our meta-analysis confirmed that IVF/ICSI pregnancies are at higher odds of adverse pregnancy outcomes. This is the largest systematic review to date analysing pregnancy outcomes and mode of conception comparing OI, IUI and IVF respectively. It provides the latest evidence possible for clinicians to choose the safest fertility treatment, Trial registration number Not applicable

Expression of lncRNA MIR193BHG in serum of preeclampsia patients and its clinical significance

BackgroundPreeclampsia (PE) represents a salient complication of late pregnancy. Long noncoding RNAs (LncRNAs) are critical biological regulators in PE. This study investigated lncRNA MIR193BHG expression and clinical significance in PE. MethodsSerum samples were collected from 116 PE patients, including 62 cases of mild PE (mPE) and 54 cases of severe PE (sPE), with another 50 normal pregnant women as controls. LncRNA MIR193BHG expression in serum was detected by RT-qPCR. The correlation between MIR193BHG expression and clinical indicators was determined using Pearson analysis. The downstream microRNAs (miRNAs) and genes of MIR193BHG were predicted and verified through the database and dual-luciferase assay. Expressions of miR-345–3p and SASH1 in serum of PE patients were detected using RT-qPCR. ResultsLncRNA MIR193BHG was upregulated in the serum of PE patients, and MIR193BHG expression in mPE patients was lower than that in sPE patients. MIR193BHG expression was positively correlated with systolic and diastolic blood pressure, and urine protein. miR-345–3p was poorly expressed and SASH was highly expressed in serum of PE patients. There existed a binding relationship between MIR193BHG and miR-345–3p or between miR-345–3p and SASH. ConclusionLncRNA MIR193BHG was upregulated in the serum of PE patients. Moreover, MIR193BHG might play a role in PE by competitively binding to SASH1 with miR-345–3p.

Effects of Coronavirus on Human Cardiovascular System

SARS-CoV-2 has many biological traits, the pathogenic virus that caused the acute respiratory syndrome (SARS) epidemic in 2002. Clinical investigations have also discovered a link between CORONAVIRUS and cardiovascular illness. The coronavirus disease is caused by binding the viral spike protein to angiotensin-converting enzyme 2. It has spread around the world, affecting millions and millions of people. CORONAVIRUS looks to be connected to even worse results and an elevated risk of mortality in individuals before cardiovascular illness, even though CORONAVIRUS can cause myocardial damage, arrhythmia, acute coronary syndrome, and venous thromboembolism. Possible drug-disease interactions are becoming more concern for individuals with CORONAVIRUS and associated cardiac and vascular esses. By integrating our expertise of the virus's genetic makeups with clinical findings, we can better grasp the possible processes causing CO VID-19. This might pave the door for creating medicinal and pharmaceutical products. Pulmonary embolism is one of the most common acquired conditions in generalized hospitalized patients but an uncommon finding in patients with Covid. It has a penchant for thrombosis fueled by at least two separate yet interconnected processes i)A state of hypercoagulability and is Large vessel thrombosis and thromboembolism. ii)Direct vascular and endovascular damage. In situ microvascular thrombosis is caused by endothelial damage.PE can be presented in patients admitted to the ICU despite standard prophylactic anticoagulation. Deep vein thrombosis is present in significant cases of PE.

Real-World Patient Characteristics, Treatment Patterns and Outcomes for Patients with Atypical Hemolytic Uremic Syndrome Who Have Switched from Eculizumab to Ravulizumab in the USA

IntroductionAtypical hemolytic uremic syndrome (aHUS) is a rare disease that can cause irreversible organ damage or death. Ravulizumab is a long-acting complement C5 inhibitor approved in the USA, Europe, and Japan for the treatment of aHUS. Ravulizumab was engineered from eculizumab to leverage its clinical benefits and safety profile while reducing dosing frequency. This study assessed real-world patient characteristics, treatment patterns, and clinical outcomes for adult and pediatric patients with aHUS in the USA who switched from eculizumab to ravulizumab.MethodsThis retrospective, non-interventional study evaluated the period from January 1, 2012 to March 22, 2021, using US claims data from the Decision Resources Group Real World Data repository. Eligible patients had ≥ 1 medical claim with an aHUS-related International Classification of Diseases 9/10 diagnosis code and ≥ 1 medical or pharmacy claim for treatment with eculizumab or ravulizumab. Patients with evidence of paroxysmal nocturnal hemoglobinuria, myasthenia gravis, neuromyelitis optical spectrum disorder or Shiga toxin Escherichia coli-related hemolytic uremic syndrome in the 3 months prior to their first aHUS-related treatment were excluded. A patient was classified as ‘switched’ if they had ≥ 1 claim for eculizumab followed by an initial claim for ravulizumab from 14 to 30 days after the last eculizumab claim. Patients were required to have ≥ 3 months of continuous enrollment in the database prior to their first ravulizumab claim. Ravulizumab treatment was considered to be continuous if all treatment intervals were ≤ 63 days.Data extracted included: demographics and clinical characteristics at the time of switching to ravulizumab; treatment patterns (including service setting, treatment history before switching to ravulizumab, and subsequent adherence); and clinical outcomes (dialysis, plasma exchange [PE], kidney transplant, and utilization of other end-stage renal disease [ESRD] services) in the 6 months before and after switching to ravulizumab. Data were summarized using descriptive statistics.ResultsOverall, 2101 patients had ≥ 1 eculizumab or ravulizumab claim and an aHUS-related diagnosis. Of these patients, 227 had claims for both eculizumab and ravulizumab with ≥ 3 months of continuous enrollment data before the first ravulizumab claim. The median (lower quartile, upper quartile) treatment interval between the last eculizumab claim and the first ravulizumab claim was 15 (14, 41) days.In total, 131 patients met the ‘switched’ criteria. Table 1 presents patient characteristics at the time of switching from eculizumab to ravulizumab. Outpatient facilities were the most common places of service for initiation of switch to ravulizumab (n = 41/89 patients [46%]); private practice facilities were the most common sites for administration of ravulizumab maintenance treatment (n = 84/213 claims [39%]).Prior to switching to ravulizumab, the median (lower quartile, upper quartile) duration between the first and last eculizumab claim was 788 (252, 1719) days. Among the 95 patients with ≥ 6 months of continuous enrollment after switching to ravulizumab, 73 (77%) patients were treated with ravulizumab continuously for ≥ 6 months. Selected clinical outcomes in the 6 months before and after switching to ravulizumab treatment are presented in Table 2. Although no inferential statistical comparisons were made, data show that fewer switched patients underwent dialysis or utilized other ESRD services in the 6-month post-switch period (with no recorded cases of PE or kidney transplant) compared with the 6-month pre-switch period.Discussion and conclusionsThis study provides real-world data on clinical characteristics and treatment patterns for patients with aHUS who have switched from eculizumab to ravulizumab. The majority of patients switching to ravulizumab were treated continuously for ≥ 6 months according to the treatment schedule in the prescribing information. Ongoing analyses with longer follow-up time will provide inferential assessment of the clinical and economic impacts of switching to ravulizumab. [Display omitted] DisclosuresWang: Alexion: Current Employment; AstraZeneca: Current Employment. Al-Dakkak: Alexion: Current Employment; AstraZeneca: Current Employment. Garlo: Alexion: Current Employment; AstraZeneca: Current Employment. Ong: Alexion: Current Employment; AstraZeneca: Current Employment. Tomazos: Alexion, AstraZeneca Rare Disease: Current Employment. Mahajerin: Alexion: Consultancy; AstraZeneca: Current Employment.

S2594 Between a Clot and a Hard Place: Unusual COVID-19 Thromboses in Patients With Liver Disease

Introduction: It is established that COVID-19 predisposes patients to arterial and venous thrombotic disease,1 though the exact mechanism is unknown. Cases of PE and DVT are well described, while arterial and multi-vessel thromboses are rare.2 We report COVID-19 associated hepatic artery thrombosis (HAT) and portal and superior mesenteric vein (PV; SMV) thrombosis, both resulting in compromised liver function. Case Description/Methods: A 47-year-old man with a history of remote orthotopic liver transplantation (OLT) for HBV cirrhosis presented to the ED with two days of RUQ pain and vomiting. Physical exam revealed tenderness to palpation in the RUQ. Labs were normal, including liver synthetic function. COVID-19 nasopharyngeal swab was positive. CT of the abdomen and pelvis with IV contrast revealed complete acute thrombosis of the aortohepatic conduit near its origin, new from imaging six months prior. He received remdesivir and methylprednisolone and was discharged on a DOAC. A 57-year-old man with a history of Lynch syndrome and decompensated alcoholic cirrhosis presented to the ED with 3 days of LUQ pain, melena, coffee ground emesis and subjective fever. Physical exam and vital signs were normal. Labs showed Hgb 5.4 and WBC 15.2. COVID-19 nasopharyngeal swab was positive. CT of the abdomen and pelvis with IV contrast revealed extensive PV and SMV thrombosis. The patient was treated with pRBC, PPI, octreotide, and empiric antibiotics. He was given IV heparin and bridged to warfarin. Discussion: Thrombosis is a serious complication of COVID-19 infection. While there are known macrovascular thrombotic events associated with COVID-19, there are no reports of HAT, and one reported case of PV and SMV thrombosis. It is important to evaluate for thromboses in patients with cirrhosis or prior OLT and COVID-19 due to elevated thrombotic risk. Thromboses in these patients can compromise blood supply and further worsen liver function.

Two-Stage TURP as an Option for Treatment of Large Prostates in Resource Poor Environments

Transurethral resection of the prostate (TURP) is the gold standard of surgical therapy of benign prostatic hyperplasia (BPH) for prostates <100 ml. This study was carried out to describe our experience with and outcome of staged TURP for large prostates (>100 ml). A review of the records of all the patients who underwent staged TURP for large BPH at a specialist urology center. They had two-stage monopolar resection using a size 26F continuous flow resectoscope and 5% Dextrose water irrigation. Staged-TURP were performed by a single Consultant Urologist under spinal anesthesia. Patients’ age, Co-morbidities, Prostate-specific Antigen (PSA), Abdominal Ultrasound scan (USS) estimated prostate volume, Pre-operative Packed Cell Volume (Pre-op PCV), Post-operative Packed Cell Volume (Post-op PCV), Resection Weight for 1st stage (RW I), Resection Weight for 2nd stage (RW II), Resection Time for 1st stage (RT I), Resection Time for 2nd stage (RT II), blood transfusion were obtained and analyzed. Follow up was for a minimum of 9 months and the outcome and development of complications noted. Statistical analysis was done using the IBM Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM, Chicago, USA). Means and percentages were calculated, and paired sample T test was used to compare variables between 1st stage and 2nd stage. P value < 0.05 was considered significant. Twenty-five patients with a mean age of 72.32±7.98 years were analyzed. Most (88%) were on indwelling Foley’s urethral catheter before surgery. The mean PSA and prostate volume were 25.61±22.08 ng/ml and 221.56±62.78 cm3. There were significant differences between Pre-op PCV and Post-op PCV (p<0.001); RWI and RWII (p<0.001); and RTI and RTII (p<0.001). Nineteen patients (76%) received perioperative transfusion. Most patients voided satisfactorily following catheter removal except one who developed acute urinary retention (AUR). No cases of TUR syndrome, post-operative sepsis, DVT or PE and urethral stricture were recorded. Staged TURP is safe and effective treatment modality for patients with large prostates in the absence of more recent endoscopic options.

Pulmonary embolism in coronavirus disease 2019: the silent killer

BackgroundPulmonary embolism (PE) has been identified as one of the deadliest complications of coronavirus disease 2019 (COVID-19), especially in patients admitted to the intensive care unit (ICU). Western literature reminds us of the high prevalence of PE in COVID. Here, we report a series of 13 cases of PE diagnosed and managed at our hospital. MethodsRetrospective analysis of medical records of 13 cases of PE admitted at our hospital from February 1, 2020, to September 31, 2020, were done. Their clinical, laboratory, and radiologic data were assessed in detail. ResultsComputed tomography pulmonary arteriography was used to make the diagnosis in eight patients (61.53%), and clinical findings with corroborative ultrasound and laboratory parameters were used to label PE in five patients (38.46%). Five patients were hemodynamically unstable, requiring thrombolysis with recombinant tissue plasminogen activator, and four patients (30.76%) suffered a fatal outcome. ConclusionCOVID-19 is a highly prothrombotic state, and all physicians should keep a high vigilance for PE. All hospitalized patients with COVID-19, especially those admitted in ICU, should be on prophylactic anticoagulation and, if there is any worsening, should be started on therapeutic regimen. Patients at the time of discharge should be switched to oral anticoagulation, which should be continued for at least 3–6 months.

Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review.

BackgroundPulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE.MethodsWe retrospectively reviewed confirmed ischemic stroke cases to identify patients presented with simultaneous PE from June 2018 to May 2019. Additionally, a literature review was performed. Two reviewers assessed the manuscripts' quality, and relevant data regarding clinical course and management was extracted.ResultsWe reviewed 439 patient charts, identifying two cases of concomitant AIS and PE. Additionally, twelve articles (n = 15 subjects) fulfilled our literature review criteria for a total of 17 cases, including ours. Intravenous anticoagulation (70.5%) was the most frequent intervention targeting both disorders. Therapies such as intravenous thrombolysis (23.53% (n = 4)) and mechanical thrombectomy (23.53% (n = 4)) were specific in AIS. Catheter-directed thrombolysis (5.88%) was used for PE. Clinical outcomes were favorable (asymptomatic or mild disable symptoms) in 47.05% (N = 8) of patients, while 41.17% had poor outcomes (severe disable symptoms or death).ConclusionsAIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis

ObjectiveTo determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. MethodsCohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35–40 and 60mg/day for BMI 40–60. Results675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010−2015 and 321 with Enoxaparin-Clexane® during the period 2016−2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. ConclusionsThe combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Automated calculation of the right ventricle to left ventricle ratio on CT for the risk stratification of patients with acute pulmonary embolism.

To assess the feasibility and reliability of the use of artificial intelligence post-processing to calculate the RV:LV diameter ratio on computed tomography pulmonary angiography (CTPA) and to investigate its prognostic value in patients with acute PE. Single-centre, retrospective study of 101 consecutive patients with CTPA-proven acute PE. RV and LV volumes were segmented on 1-mm contrast-enhanced axial slices and maximal ventricular diameters were derived for RV:LV ratio using automated post-processing software (IMBIO LLC, USA) and compared to manual analysis in two observers, via intraclass coefficient correlation analysis. Each CTPA report was analysed for mention of the RV:LV ratio and compared to the automated RV:LV ratio. Thirty-day all-cause mortality post-CTPA was recorded. Automated RV:LV analysis was feasible in 87% (n = 88). RV:LV ratios ranged from 0.67 to 2.43, with 64% (n = 65) > 1.0. There was very strong agreement between manual and automated RV:LV ratios (ICC = 0.83, 0.77-0.88). The use of automated analysis led to a change in risk stratification in 45% of patients (n = 40). The AUC of the automated measurement for the prediction of all-cause 30-day mortality was 0.77 (95% CI: 0.62-0.99). The RV:LV ratio on CTPA can be reliably measured automatically in the majority of real-world cases of acute PE, with perfect reproducibility. The routine use of this automated analysis in clinical practice would add important prognostic information in patients with acute PE. • Automated calculation of the right ventricle to left ventricle ratio was feasible in the majority of patients and demonstrated perfect intraobserver variability. • Automated analysis would have added important prognostic information and altered risk stratification in the majority of patients. • The optimal cut-off value for the automated right ventricle to left ventricle ratio was 1.18, with a sensitivity of 100% and specificity of 54% for the prediction of 30-day mortality.

Riesgo trombótico y hemorrágico en cirugía bariátrica con programas de rehabilitación multimodal comparando 2 pautas reducidas de profilaxis farmacológica

Objectiveto determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. MethodsCohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60. Results675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. ConclusionsThe combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

INPATIENT MANAGEMENT OF PULMONARY EMBOLISM: CLINICAL CHARACTERISTICS AND MORTALITY IN A HIGH-VOLUME TERTIARY REFERRAL CARE CENTER

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Many institutions have implemented pulmonary embolism response teams (PERT) as a means to standardize approach to management and in hopes of improving outcomes. Some at our institution have also called for the development of a PERT. To explore whether there is a need for a PERT, we first wanted to review our experience in the inpatient setting, including outcomes. METHODS: A single-center retrospective observational study was conducted at the Mayo Clinic in Rochester, MN where cases of PE are managed without the use of a PERT. All adult inpatient admissions between 8/1/2018 and 8/1/2019 with an encounter diagnosis of pulmonary embolism were reviewed. Mortality was considered PE-specific if determined by autopsy or if the treating clinician deemed it definitely or probably due to PE. RESULTS: 430 inpatient cases of PE were identified. Active malignancy was present in 36.7% of cases. The mean PESI score at presentation was 112. All cause in-hospital mortality was 2.6%, 30 day mortality 7.5%, 3-month mortality 15.4%, and 6-month mortality 21.8%. Of the 88 patients dead at the 6-month point, 76% had active cancer. 47 of the 88 had elected hospice care as outpatients. Overall in-hospital PE cause-specific mortality was 0.7%. At the 6-month point, PE cause-specific mortality was 1.4%. 238 cases (55.3%) were classified as intermediate risk PE (submassive) at the time of diagnosis with a mean PESI score of 120. Nine in-hospital deaths (3.8%) occurred in this group; only one was cause-specific to PE. Six of the nine patients elected comfort care while clinically stable due to advanced cancer or advanced age with multiple comorbidities. Treatment was largely limited to anticoagulation alone in the submassive group. Only five patients (2.1%) had hemodynamic decompensation 12-34 hours after admission and received systemic alteplase with resultant improvement. Four of the five survived to discharge. Ten cases (2.3%) were classified as high risk (massive) PE at the time of diagnosis, of which two died. 90% were treated with systemic alteplase. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was used in three patients and ultrasound-assisted catheter directed thrombolysis in one patient. In-hospital mortality in this group was 20%; all deaths were cause-specific to PE. Eight of the ten survivors were alive at six months. CONCLUSIONS: Despite the high overall acuity of PE cases at our institution, in-hospital all-cause mortality was low and PE cause-specific mortality was rare. Malignancy was a major factor in the 6-month mortality of these patients. The oft-feared scenario of a patient presenting with a submassive PE and subsequently decompensating occurred in only five out of 238 cases. CLINICAL IMPLICATIONS: PE is rarely the direct cause of mortality. Hence a therapeutic strategy biased towards more aggressive intervention and greater adverse effects may not be ideal. DISCLOSURES: No relevant relationships by Sumera Ahmad, source=Web Response No relevant relationships by Sean Caples, source=Web Response No relevant relationships by Harsha Mudrakola, source=Web Response

VenaTech Convertible Vena Cava Filter 6 Months after Conversion Follow-up

PurposeTo report device-related adverse events 6 months after placement or conversion of the VenaTech convertible vena cava filter (VTCF). Materials and MethodsA review of 6-month follow-up data of an investigational device exemption multicenter, prospective, single-arm study was performed. The VTCF was implanted in 149 patients. Conversion was attempted in 64.4% of those patients (n = 96) and successfully in 96.9% of the patients (n = 93). A total of 76 patients completed imaging evaluation at 6 months after filter conversion. Patients who required continued venous thromboembolism prophylaxis at 6 months did not undergo a conversion attempt and were designated as nonconverted filter subjects. A total of 28 nonconverted filter subjects completed imaging evaluation at 6 months after implantation. ResultsEvaluation of patients at 6 months after conversion demonstrated 1 of 76 (1.3%) inferior vena cava (IVC) perforations with a filter strut greater than 3 mm outside of the caval lumen. No cases of recurrent PE, clinically significant filter migration, filter fracture, or IVC thrombosis were reported in the converted subjects. In the nonconverted filter subjects, there was a 14.3% (4 of 28) complete or nearly complete rate of IVC thromboses. There were no cases of recurrent pulmonary embolism, penetration, fracture, or spontaneous conversion in the nonconverted filter subjects. There was a significant reduction in the rate of IVC thrombosis and migration in the converted cohort compared to that in the nonconverted cohort. ConclusionsAt 6 months, the VTCF demonstrated low adverse event rates in the converted configuration, whereas a minority of patients with the nonconverted configuration demonstrated a high risk of IVC thrombosis.

Rate of venous thromboembolism after surgical treatment of proximal humerus fractures.

The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established. A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE. 131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245). The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.

Prevalence and Outcomes of Thrombophilia in Patients with Acute Pulmonary Embolism.

BackgroundWe aimed to study the prevalence and outcomes of thrombophilia in acute pulmonary embolism.MethodsA retrospective observational study was conducted to include patients with a radiologically confirmed diagnosis of PE screened for thrombophilia from May 2011 to February 2015. Data included patients’ demographics; clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed and compared in patients with and without thrombophilia.ResultsA total of 227 cases of PE were included in the study, of which 108 (47.6%) had thrombophilia. The most frequent coagulopathic abnormality included deficiency of protein S, protein C, and antithrombin III and hyperhomocysteinemia. Only seven out of 79 patients were found to have factor V Leiden. PE patients diagnosed with thrombophilia were 10 years younger in age and peaked in the age range 30–39 years. Prior history of DVT (p=0.001) and PE (p=0.001) were the main significant risk factors in the thrombophilia group. The frequency of different risk categories of clinical probability scores did not differ significantly among those with and without thrombophilia. Pulmonary hypertension was a common complication in the thrombophilia group (P=0.009). Medications used included warfarin (74.7%), enoxaparin (73.9%), and heparin (55.4%). The overall mortality rate was 8.4%, and was non-significantly higher in the non-thrombophilia group.ConclusionDeficiencies of protein S, protein C, and antithrombin III are the leading causes of thrombophilic defects. Patients with hereditary thrombophilia are at increased risk of acute PE, particularly among young individuals. Therefore, early detection of thrombophilic defects together with other unprovoked risk factors could reduce the risk of recurrent VTE.

The predictive value of 11-14 week uterine artery Doppler indices for hypertensive pregnancy complications

Introduction. Hypertensive complications of pregnancy can often lead to serious, even life-threatening situations for the mother and fetus. First-trimester uterine artery Doppler can be a predictive tool for such complications. Materials and method. At the Department of Obstetrics and Gynecology of the Arad County Emergency Clinical Hospital, we examined 305 pregnant patients, from 11 weeks to 13 weeks+6 days gestational age, by ultrasound, both as inpatients and outpatients, and we have assessed the evolution of their pregnancy. Results. There were 21 patients with hypertensive pregnancy complications (6.89%) and 284 patients with normal outcome (93.11%). Three patients had pregnancy-induced hypertension (0.98%), and 18 had preeclampsia (PE; 5.9%), with 12 cases of mild PE (3.95%) and six cases of severe PE (1.97%). The sensitivity for uterine artery PI above the 95th percentile, for uterine artery RI above the 95th percentile, and for uterine artery PI/RI above the 95th percentile was 0%, 0-33.33% and 0%, respectively. The specificity was 94.72-95.03%, 94.98-95.42% and 94.98-95.03%, respectively. The positive predictive value was 0%, 0-13.33% and 0%, respectively. The negative predictive value was 92.76-98.97%, 93.45-99.31% and 92.76-98.97%, respectively. Odds ratios were 0.453-3.966, 1.147-10.286 and 0.453-3.966, respectively. Conclusions. Uterine artery Doppler indices above the 95th percentile during the 11-14 week gestational age offers low to medium detection rates, the best index being the resistivity index.

The dating of thrombus organization in cases of pulmonary embolism: an autopsy study

BackgroundPulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time.MethodsPulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values.ResultsThe 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h.ConclusionsAfter a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death.Clinical trial numberNCT03887819.Trial registrationThe trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was “Retrospectively registered”.

Rationale for catheter-based therapies in acute pulmonary embolism.

Pulmonary embolism (PE) is a common disease resulting in significant morbidity and mortality. High-risk features of PE are hypotension or shock, and early reperfusion is warranted to unload the strained right ventricle and improve clinical outcomes. Currently, systemic thrombolysis (ST) is the standard of care but is associated with bleeding complications. Catheter-based therapies (CDT) have emerged as a promising alternative having demonstrated to be equally effective while having a lower risk of bleeding. Several CDT are currently available, some combining mechanical properties with low-dose thrombolytics. Recent guidelines suggest that CDT may be considered in patients with high-risk PE who have high bleeding risk, after failed ST, or in patients with rapid haemodynamic deterioration as bail-out before ST can be effective, depending on local availability and expertise. In haemodynamically stable patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT may be considered if clinical deterioration occurs after starting anticoagulation and relative contraindications for ST due to bleeding risk exist. Decision on treatment modality should follow a risk-benefit analysis on a case by case base, weighing the risk of PE-related complications; i.e. haemodynamic deterioration vs. bleeding. As timely initiation of treatment is warranted to prevent early mortality, bleeding risk factors should be assessed at an early stage in all patients with acute PE and signs of RV dysfunction. To ensure optimal management of complex cases of PE and assess a potential CDT strategy, a multidisciplinary approach is recommended. A dedicated Pulmonary Embolism Response Team may optimize this process.