Deep Vein Research Articles

Venous thromboembolism in patients with liver cancer: a retrospective study

Abstract Background Little is known about the association between venous thromboembolism (VTE) and tumors. In this study, we identified the clinical features of patients with liver cancer who presented with at least 1 VTE episode. Methods This was a retrospective case-control study of a single-institution database with univariate and multivariate analyses using χ 2 and Fisher exact tests. Statistical significance was set at P < 0.05. Results The overall incidence of VTE in the patients with liver cancer was 1.2%. More than half (53.8%) of the 13 patients with liver cancer and venous thrombosis died within 2 months. The thrombus in 12 patients (92.3%) was located within the deep veins, whereas the other patient (7.7%) was diagnosed with a pulmonary embolism. Of the 11 patients, 9 (69.2%) had swelling and/or pain symptoms. All 6 patients with peripherally inserted central catheters (PICCs) had thrombosis, accounting for 46.2% of all patients with liver cancer and venous thrombosis. Compared with the controls, liver cancer patients with PICC tubes, thrombosis-related symptoms such as swelling and pain, traumatic stimulation such as fracture, acute respiratory distress syndrome, and interventional therapy or hemostasis drugs were prone to be diagnosed with VTE (P < 0.05). Conclusions Liver cancer and thrombosis are rare and have poor prognoses. Liver cancer with thrombosis may be associated with PICC catheterization, traumatic stimulation, or hemostatic drugs. Patients with liver cancer and thrombosis often present with swelling and pain.

CHRONIC VENOUS INSUFFICIENCY AND TROPHIC ULCERS OF THE LOWER EXTREMITIES

Chronic venous hypertension (CVH) triggers a whole cascade of pathological reactions, the ultimate result of which is gross changes in the trophism of soft tissues of the lower extremities. The main hemodynamic factor leading to hypertension in the superficial venous system and, subsequently, to trophic changes in the lower limb, is blood reflux from deep veins, and it is associated with valve insufficiency at the mouth of the great and small saphenous veins (vertical reflux), as well as incompetency of perforators (horizontal reflux). Moreover, 90% of the latter are localized in the calf region, of which 87% belong to the veins ofthe Cockett I-III zone.

Bleeding and Thrombosis in Patients with Cancer and Acute Venous Thromboembolism Requiring Urgent Procedures

BACKGROUND There are limited data of outcomes in patients who require anticoagulation interruption for a surgical procedure shortly after an acute VTE, especially in patients with cancer who are at higher risk for both hemorrhage and recurrent thrombosis. Our goal was to assess the incidence of recurrent thrombosis or major hemorrhage at 60-days following an urgent surgical procedure in patients with acute VTE (within one month prior to surgery). METHODS We performed a retrospective cohort study of patients with cancer at Memorial Sloan Kettering Cancer Center (from January 1 st 2021 to December 31 st 2022). Patients were eligible for inclusion if they were diagnosed with a new acute deep vein thrombosis or pulmonary embolism and underwent surgical procedure within 30-days following the acute VTE diagnosis. Recurrent VTE was defined as symptomatic new deep-vein thrombosis or pulmonary embolism, incidental new deep-vein thrombosis or pulmonary embolism involving segmental or more proximal pulmonary arteries, or fatal pulmonary embolism or unexplained death for which pulmonary embolism could not be ruled out as the cause. Major hemorrhage was characterized according to ISTH definition. Competing risk framework was used to estimate cumulative incidences of major hemorrhage, VTE and death at 30 and 60-days. RESULTS A total of 90 patients were included in this analysis. The median age was 73 years and 62% were female (Table 1). Surgical procedures were classified by their risk of bleeding with 64 patients undergoing lower bleeding risk procedures and 26 high-risk procedures (Table 1). There were 10 recurrent or new VTE within 60-days of surgery (60-day cumulative incidence of 8.9%, 95% CI 4.1-16%). The recurrent sites were deep venous (N=7) and new PE (N=3). There were 12 major hemorrhagic events within 60 days (cumulative incidence of 12%, 95% CI 6.5-20%). The most common sites of hemorrhage were the lower gastrointestinal tract and genitourinary system. The competing risk framework is shown graphically in Figure 1. Among patients who received IVC filters the incidence of recurrent VTE was 1.1% and major hemorrhage was 2.2%. The 60-day cumulative incidence of death following surgical procedure was 19% (95% 12-28%). There were no fatal VTE and 3 fatal hemorrhagic events. CONCLUSION Among patients with cancer undergoing surgical procedures within 30-days of an acute VTE, the rates of recurrent VTE and major hemorrhage are substantively higher than reported in non-surgical acute VTE cohorts. Placement of temporary IVC filters may improve short-term bleeding and thrombotic outcomes.

NDUFB11 and NDUFS3 regulate arterial atherosclerosis and venous thrombosis: Potential markers of atherosclerosis and venous thrombosis.

Atherosclerosis is a chronic disease that thickens the blood vessel walls and narrows the lumen. Venous thrombosis is a blood clot that forms in the body's deep veins or pulmonary arteries. However, the relationship between NDUFB11 and NDUFS3 and atherosclerosis and venous thrombosis is unclear. We employed data files that combined atherosclerosis and chronic stress groups. Subsequently, we conducted differential gene expression analysis (DEGs) and performed weighted gene co-expression network analysis (WGCNA). We constructed and analyzed a protein-protein interaction (PPI) network. Further analyses included functional enrichment analysis, gene set enrichment analysis (GSEA), gene expression heatmaps, immune infiltration analysis, and mRNA analysis. By comparing our findings with the Comparative Toxicogenomics Database (CTD), we identified the most relevant diseases associated with the core genes. Additionally, we utilized TargetScan to screen for miRNAs regulating the central DEGs. To validate our results, we conducted Western Blot experiments at the cellular level. A total of 1747 DEGs were co-identified. According to the Gene Ontology (GO) analysis of differentially expressed genes, they were primarily enriched in mitochondrial gene expression, mitochondrial envelope, organelle membrane, and mitochondrial inner membrane categories. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis revealed that the target cells were mainly enriched in metabolic pathways, ribosomes, and histidine metabolism. The intersection of enriched terms from both GO and KEGG analyses showed significant enrichment in mitochondrial gene expression, mitochondrial envelope, organelle inner membrane, ribosomal structural constituents, histidine metabolism, and oxidative phosphorylation. Eight core genes were identified, including NDUFS5, UQCRQ, COX6C, COX7B, ATP5ME, NDUFS3, NDUFA3, and NDUFB11. The gene expression heatmap demonstrated that core genes (NDUFB11 and NDUFS3) were downregulated in atherosclerosis with venous thrombosis samples and upregulated in normal samples. CTD analysis revealed that the core genes NDUFB11 and NDUFS3 were associated with pain, arterial diseases, atherosclerosis, arteritis, venous thrombosis formation, and venous thromboembolism. We added Western Blot basic cell experiment for verification. NDUFB11 and NDUFS3 are downregulated in atherosclerosis and venous thrombosis, associated with poorer prognosis, and may serve as potential biomarkers for both diseases.

Gender disparities, causes and predictors of immediate and short-term cardiovascular readmissions following COVID-19-related hospitalisations in the USA

ObjectivesIn this study, we aimed to identify the causes, predictors and gender disparities of 30-day and 90-day cardiovascular readmissions after COVID-19-related hospitalisations using National Readmission Database (NRD) 2020.SettingWe used the...

The Paramedian Supracerebellar Infratentorial Approach: 2-Dimensional Operative Video.

The supracerebellar-infratentorial approach uses the plane between the tentorium and the superior surface of the cerebellum to expose the pineal region. The bone opening is just underneath the level of the transverse sinus, and so its position must be noted preoperatively. The anatomy of the internal cerebral veins and the veins of Galen and Rosenthal should be examined as well. The sitting position allows gravity-assisted expansion of the supracerebellar corridor, and a paramedian approach provides the biggest working space in the TIGER triangle, delineated by the tentorial surface of the cerebellum, the internal cerebral vein/Galen complex, and the vein of Rosenthal. The veil of arachnoid beyond the triangle must be carefully opened to expose the pineal region. For the sitting position, the operative team must be careful about air emboli. A patent foramen ovale is a contraindication for the position. The deep veins must be handled delicately to avoid complications. Several variations are shown in this video. For visualization, augmented reality is helpful, but since current augmented reality technology is microscope-based, its use can be ergonomically challenging if the tentorium is steep.1 Our current preference is to use the exoscope for the major portion of the procedure until most of the tumor is out and then switch to hand-held endoscopes with various angles to finish the operation.The patients consented to the surgery, and all relevant participants consented to publication of their images.

Student Competition (Technology Innovation) ID 1985239

Background Deep vein thrombosis (DVT) is a blood clot that forms in the deep veins and is the third most common cardiovascular disease today. One of the causes of DVT is venous stasis. Current methods of DVT prevention include anticoagulants and mechanical prophylaxis. Anticoagulant use is contraindicated in individuals with bleeding risks and mechanical interventions are often cumbersome and uncomfortable. Objective The overall goal of this project is to investigate a novel method for DVT prevention, termed intermittent electrical stimulation (IES). The current study investigated the effects of IES on healthy typical as well as post-stroke persons. Method Of the 32 participants, 22 were healthy subjects from Edmonton, and 10 were inpatient post-stroke subjects at the Glenrose Rehabilitation Hospital, Edmonton. A two-channel stimulator was used to administer IES through electrodes placed on the posterior and anterior sides of the leg and was applied in increasing stimulation amplitudes to the gastrocnemius muscle and the resulting plantar flexion force and changes in popliteal and femoral venous velocities were recorded for each stimulation respectively using B-mode ultrasound. Results IES-induced contractions produced significant increases in venous flow compared to baseline. Small contractions induced by comfortable levels of stimulation in typical and in post-stroke persons were sufficient to increase flow in the popliteal and femoral veins. Conclusion The results indicate that IES can sufficiently increase venous flow to prevent venous stasis and is comfortable for end users. Incorporation of IES into a clinical device could provide a feasible and effective alternative for DVT prophylaxis.

Effect of Diosmin on Selected Parameters of Oxygen Homeostasis.

Chronic venous disease (CVD) is a condition characterized by functional disturbances in the microcirculation of the superficial and deep veins, affecting up to 30% of the global population. Diosmin, a phlebotropic drug, is commonly used in the treatment of CVD, and its beneficial effects have been described in numerous clinical studies. However, the precise molecular mechanism underlying the activity of diosmin is not yet fully understood. Therefore, the objective of our study was to investigate whether diosmin has an impact on oxygen management, as cardiovascular diseases are often associated with hypoxia. In our study, patients were administered a daily dosage of 2 × 600 mg of diosmin for 3 months, and we evaluated several factors associated with oxygen management, angiogenesis, and inflammation using biochemical assays. Our findings indicate that diosmin reduced the levels of fibroblast growth factors (FGF) and vascular endothelial growth factor (VEGF-C), while increasing endostatin and angiostatin levels, suggesting a potential influence on angiogenesis regulation. Furthermore, diosmin exhibited anti-inflammatory properties by suppressing the levels of tumor necrosis factor-alpha (TNF-α), interleukin 1-beta (IL-1β), and interleukin 6 (IL-6), while promoting the production of interleukin 12 (IL-12). Additionally, diosmin significantly decreased the levels of hypoxia-inducible factor (HIF), anion gap (AG), and lactate, indicating its potential influence on the hypoxia-inducible factor pathway. These findings suggest that diosmin may play a crucial role in modulating oxygen management and inflammation in the context of chronic venous disease.

AN INVESTIGATION INTO THE IMPACT OF CONTINUING OR TERMINATING PREGNANCY ON THE MATERNAL, FETAL AND DISEASE PROGRESSION OUTCOMES IN PREGNANT WOMEN WITH COVID-19

Abstract Introduction: There is limited evidence regarding the potential impact of COVID-19 on pregnancy, fetuses, and its outcomes. Evaluating population-level data on these outcomes as soon as they become available will be crucial for identifying trends related to the COVID-19 pandemic and managing the disease in pregnant women and their offspring. Material and methods: This study employed a descriptive-analytical approach based on the recorded hospital files. All pregnant mothers who presented to the hospitals and tested positive for COVID-19 were included. Data included background and initial information such as age, gender, maternal PCR positivity, COVID-19 vaccination, number of vaccinations, pregnancy count, number of deliveries after 20 weeks of gestation, miscarriage, gestational age at sonography, COVID-19 symptoms, pulmonary involvement, preterm labor, premature rupture of membranes, high blood pressure, preeclampsia, intrauterine fetal demise, deep vein thrombosis/pulmonary embolism, maternal death, pregnancy termination, age at pregnancy termination, reasons for pregnancy termination, method of pregnancy termination, hospitalization duration, maternal recovery, neonatal PCR positivity, Apgar score, neonatal weight, neonatal intensive care unit admission, and neonatal death. Blood factors at admission and discharge were also recorded. Results: A total of 401 pregnant women were enrolled in the study, among whom 282 individuals underwent delivery due to labor pain, previous cesarean section, pain, and labor. Among the pregnant women with COVID-19, 385 (96%) tested positive for PCR. White blood cells, hemoglobin, platelet, alanine aminotransferase, serum ferritin levels, and D-dimer levels showed statistically significant differences before and after discharge. Maternal PCR positivity was significantly associated with first-trimester termination, and the number of COVID-19 vaccinations had a significant relationship with third-trimester termination. In cases of moderate to severe pulmonary involvement, white blood cells, hemoglobin, alanine aminotransferase, aspartate aminotransferase, serum ferritin levels, D-dimer levels, and thrombocytopenia showed a noticeable increase, statistically significant compared to mild cases. Conclusion: This study suggests that the most common time for COVID-19 infection in pregnancy is the first and third trimesters, with clinical symptoms of fever and cough. Pregnancy termination during the inflammatory phase of COVID19 in patients with severe involvement was associated with unfavorable outcomes for both the mother and fetus.

Diffuse generalized venulitis as the primary pathology of Behçet's disease: A comprehensive magnetic resonance venography study

ObjectiveBehçet's Disease (BD) is a chronic multisystem vasculitis that manifests with destructive inflammation affecting the eyes, central nervous system, and blood vessels. The pathology of vein involvement in BD is poorly characterized. Magnetic resonance (MR) venography gives more comprehensive information about deep veins and adjacent tissues. In this study, we aimed to characterize vein involvement and evaluate the diagnostic utility of MR venography in BD. MethodsSixty-five BD patients who fulfilled the International Study Group (ISG) criteria and 20 healthy control subjects were enrolled. Inferior vena cava (IVC), common iliac veins (CIV), external (EIV) and internal iliac veins (IVV), common femoral veins (CFV), femoral veins (FV), and greater saphenous veins (GSV) of BD patients and healthy controls were evaluated with MR venography and ultrasonography for the presence pathologic features, luminal thrombi, vessel wall changes, and perivascular abnormalities. Results33 vascular and 32 non-vascular BD patients (mean age 39.3 ± 11.3 years and 48 [73.8%] male) were enrolled. MR venography revealed diffuse concentric thickening of the walls of IVC, CIV, EIV, IIV, CFV, FV, and GSV in BD (healthy controls vs. BD p<0.05 for all vein segments). MR venography provided additional information about veins and perivascular tissues like contrast enhancement, enlarged lymph nodes, and seminal vesicle vascularization, which were remarkably more frequent in vascular BD than non-vascular BD and healthy controls. ConclusionThe results of our study suggest that the involvement of the venous system is diffuse and generalized in BD, and demonstration of venulitis might help diagnose the disease.

The selection of the suitable long peripheral catheter in DIVA patients: The significance of ultrasonography.

There are several types of LPC (long peripheral catheters) that vary in length, size, insertion method, and cost. The aim of the study was to evaluate whether ultrasonography can be useful for the selection of the suitable LPC in DIVA (difficult intravenous access) patients. Based on the ultrasonographic examination, a long peripheral catheter was selected. A 6.4 cm LPC into a vein at a depth of up to 0.5 cm, a 8.5 cm LPC into a vein at a depth up to 1.5 cm, and a 9.8 cm catheter at a depth up to 2 cm using the cannula over needle method. A 12 cm catheter was inserted into the deeper veins using the direct Seldinger method. The catheter diameter was no more than 33% vein diameter. Dwell time and the number of complications of four vascular devices were recorded and compared. One thousand one hundred fifty-six patients, average age 76 years (19-102), 501 men and 655 women, were included in the study. Average dwelling time was 10 days (1-30), there were 136 complications (11.7%). A catheter 6.4 cm long was inserted in 346 (29.8%), 8.5 cm in 140 (12.1%), 9.8 cm in 320 (27, 5%), and 12 cm in 356 (30.6%) patients. There were no significant differences in dwelling time, rate, and type of complications among the four catheters used. Our results confirm that ultrasound examination can be useful for the selection of the suitable long peripheral catheter in DIVA patients.

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis.

Systematic Review and Meta-analysis. To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States. PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients. 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included. AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

Right heart thrombus in transit and peripherally inserted central catheters

Right heart thrombus in transit or “free-floating right heart thrombus” is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.

Incidence and Risk Factors for Pregnancy-Associated Venous Thromboembolism: Are There Differences between East and West?

Venous thromboembolism (VTE) manifests as thrombus formation in deep vein usually in lower legs which subsequently embolizes to pulmonary artery causing pulmonary embolism and increased risk of morbidity and mortality.[1] Even in this journal there has been much interest in the epidemiology, prognosis, and risk factors for VTE, as well as the pathophysiological mechanisms underlying the propensity to develop this common condition.[2] [3] [4] [5] [6] [7]

Neurologic manifestations in hospitalized patients with COVID‐19

AbstractBackgroundTo investigate the effect of pre‐existing neurological symptoms and disease in coronavirus disease 2019 (COVID‐19) health outcomes in a large Illinois‐based cohort.MethodA multicenter retrospective study analyzed differences in a cohort of COVID‐19 positive patients with and without baseline neurological symptoms or disease admitted to RUSH University Systems for Health from March to November 2020. We measured sex and health outcome differences in hospitalization rates, symptoms during initial admission, complications, readmissions, and mortality of the two groups.ResultOf the total of 1708 hospitalized COVID‐19 positive patients (mean age: 58.04, 930 males) — 31% [527] patients had a history of neurological symptoms and/or disease, 9% [140] with dementia. Nonspecific symptoms during hospitalization including myalgia (19%), headache (11%), epilepsy (0.8%), tremors (3%), and abdominal pain (11%) were reported more frequently in patients with a neurologic history. Female patients with pre‐existing neurological conditions were hospitalized more than their male counterparts (40% versus 24%). Compared to those with no neurological conditions, patients with neurological conditions had higher rates of complications, such as acute myocardial infarction (13% vs. 8%; p = 0.002) and deep vein thrombosis/pulmonary embolism (14% vs. 10%; p = 0.02). Multivariate analysis showed that history of stroke and migraines are independently associated with readmission to a hospital floor (generalized linear model, z = 2.092, z = 3.320, p = 0.036, p &lt; 0.001, respectively); of those readmitted, 13% had a history of dementia. Of the patients that died in hospital, 6% had a history of dementia.ConclusionNeurologic manifestations are common in hospitalized COVID‐19 positive patients and are associated with higher rates of complications during hospitalization. The increasing evidence for SARS CoV‐2’s impact on the central nervous system raises important questions on the long‐term consequences of this virus to patients with pre‐existing brain injury.

Abstract 555: Technique For Testing Drug-coated Balloons In Deep Veins In Vivo

Background: Chronic deep venous occlusions, leading to outflow obstruction in dialysis patients and post thrombotic syndrome (PTS) in DVT patients, are often treated with balloon venoplasty and stenting to restore flow and improve limb outcomes. In stent restenosis and occlusion are primary reasons for late intervention failure. mTOR inhibitors might impact thrombotic and fibrotic pathways on venous endothelial cells (VEC). Methods: Immortalized murine VEC (EOMA, ATTC #CRL-2586) were stimulated with sirolimus (1ng) and vehicle (DMSO) performing quantitative real-time PCR (qRT-PCR). Sprague Dawley rats (n=4, 250-400g) were anesthetized (isoflurane). IVC diameter measured by ultrasound. Infrarenal IVC was exposed using a midline laparotomy, side branches ligated, posterior venous branches cauterized, and micro-clips temporarily placed. A 0.014 sharpened guidewire with a DCB back-loaded was inserted retrograde into the infrarenal IVC. After DCB inflation/deflation, the entire system was removed and U-stitch tightened for hemostasis. Results: Sirolimus blunted transcription of cellular adhesion molecules (CAMs) and mediators of EndMT. (Fig 1) We achieved total stasis to replicate a vein wall reaction to thrombosis and further EndMT changes, with 75% survival in initial proof-of-concept experiments. (Fig 2) Conclusion: IVC retrograde cannulation via U-stitch and sharpened guidewire is a viable animal model for testing venous DCBs. Sirolimus inhibits VEC CAMs critical for thrombus initiation and EndMT mediators involved in PTS remodeling. Future DCB research on adhesive and fibrotic phenotypes is required.

Comparing Adherence with Best Practices in End-of-Life Care After Implementing the End-of-Life Order Set: A Quality Improvement Project in an Ottawa Academic Hospital.

Physicians in acute care require tools to assist them in transitioning patients from a "life prolonging" approach to "end-of-life care," and standardized order sets can be a useful strategy. The end-of-life order set (EOLOS) was developed and implemented in the medical wards of a community academic hospital. To compare adherence with best practices in end-of-life care after implementing the EOLOS. We conducted a retrospective chart review of admitted patients with expected deaths in the year preceding EOLOS implementation ("before EOLOS" group), and in the 12 to 24 months following EOLOS implementation ("after EOLOS" group). A total of 295 charts were included: 139 (47%) in the "before EOLOS" group and 156 (53%) in the "after EOLOS" group, of which 117/156 charts (75%) had a completed EOLOS. The "after EOLOS" group demonstrated more "do not resuscitate" orders and more written communication to team members about comfort goals of care. There was a decrease in nonbeneficial interventions in the last 24 hours of life in the "after EOLOS" group: high-flow oxygen, intravenous antibiotics, and deep vein thrombosis/venous thromboembolism prophylaxis. The "after EOLOS" group demonstrated increased prescription of all common end-of-life medications, except for opioids, which had a high preexisting rate of prescription. Patients in the "after EOLOS" group showed a higher rate of spiritual care and palliative care consult team consultation. Findings support standardized order sets as a good framework allowing generalist hospital staff to improve adherence to established palliative care principles and improve end-of-life care of hospital inpatients.

Predictors and outcomes of acute pulmonary embolism in COVID-19; insights from US National COVID cohort collaborative

ObjectivesTo investigate whether COVID-19 patients with pulmonary embolism had higher mortality and assess the utility of d-dimer in predicting acute pulmonary embolism.Patients and methodsUsing the National Collaborative COVID-19 retrospective cohort, a cohort of hospitalized COVID-19 patients was studied to compare 90-day mortality and intubation outcomes in patients with and without pulmonary embolism in a multivariable cox regression analysis. The secondary measured outcomes in 1:4 propensity score-matched analysis included length of stay, chest pain incidence, heart rate, history of pulmonary embolism or DVT, and admission laboratory parameters.ResultsAmong 31,500 hospitalized COVID-19 patients, 1117 (3.5%) patients were diagnosed with acute pulmonary embolism. Patients with acute pulmonary embolism were noted to have higher mortality (23.6% vs.12.8%; adjusted Hazard Ratio (aHR) = 1.36, 95% CI [1.20–1.55]), and intubation rates (17.6% vs. 9.3%, aHR = 1.38[1.18–1.61]). Pulmonary embolism patients had higher admission D-dimer FEU (Odds Ratio(OR) = 1.13; 95%CI [1.1–1.15]). As the d-dimer value increased, the specificity, positive predictive value, and accuracy of the test increased; however, sensitivity decreased (AUC 0.70). At cut-off d-dimer FEU 1.8 mcg/ml, the test had clinical utility (accuracy 70%) in predicting pulmonary embolism. Patients with acute pulmonary embolism had a higher incidence of chest pain and history of pulmonary embolism or deep vein thrombosis.ConclusionsAcute pulmonary embolism is associated with worse mortality and morbidity outcomes in COVID-19. We present d-dimer as a predictive risk tool in the form of a clinical calculator for the diagnosis of acute pulmonary embolism in COVID-19.

Automatic cerebral computed tomography venographic imaging based on the prior knowledge of cerebral blood circulation

Background and purposeCurrent clinical computed tomography venographic (cCTV) images present limited cerebral venous profiles. Therefore, this study aimed to develop an automatic cerebral CTV imaging technique using computed tomographic perfusion (CTP) images in a cohort of patients with stroke. Materials and MethodsWe retrospectively evaluated 10 (intracerebral hemorrhage) and 2 (acute ischemic stroke) patients who underwent institutional CTP imaging. CTV images were processed with the proposed CTV (pCTV) technique, and pCTV and cCTV images were then independently evaluated by two experienced neuroradiologists blinded to all clinical information using a novel scoring method that considered overall image quality, venous visibility, and arterial mis-segmentation. Venous visibility was separately evaluated for the dural sinus, superficial vein, and deep vein. Then, statistical analysis was performed to determine whether the pCTV technique was superior to the cCTV technique. ResultsIn total, 14 sets of pCTV images were generated and compared with cCTV images. The overall image quality and venous visibility scores of pCTV images were significantly higher than those of cCTV images (all values of p<0.05), especially for the dural sinus (median [25th, 75th percentiles], 14.00 [13.63, 15.50] vs. 7.50 [7.00, 10.88]), and superficial vein (9.00 [8.88, 10.00] vs. 3.25 [1.63, 8.25]), while the difference in arterial mis-segmentation was not statistically significant (p= 0.164). ConclusionsThis study proposed an automatic cerebral CTV imaging technique to eliminate residual bone and soft tissues, minimize the impact of the cerebral arterial system, and present a relatively comprehensive cerebral venous system, which would help physicians assess cerebral venous outflow profiles after stroke and seek imaging markers associated with clinical outcomes.

Management of a Large Endometriotic Nodule of the Right Parametrium Involving the Sacral Roots, Vagina, Rectum, and Sigmoid Colon, with Intraoperative Bleeding

Deep endometriotic lesions may involve the deep parametrium which is highly vascular and includes numerous somatic and autonomous nerves (1,2). Surgeons who dissect in this area, must always be prepared to deal with major bleeding, and to master the different techniques of hemostasis. The goal of this video is to show the steps of laparoscopic excision of deep endometriotic lesion of the parametrium and the steps taken to control the bleeding encountered from one of the venous branches. Surgical educational video. Endometriosis referral center. Excision of the endometriotic parametrial nodule and the release of the sacral plexus, with excision of the vaginal involvement, rectal disc excision, and segmental resection of the sigmoid colon. The video shows the excision of a deep endometriosis involving the right parametrium, the mid rectum, the sigmoid colon, and the vagina. The excision of deep endometriosis of the parametrium followed the 10 steps previously described (1). During this procedure, careful dissection of arteries and veins branching from the internal iliac vessels is a crucial step. However, injury of one or more of the vessels can still occur. The movie presents the different techniques used to control the bleeding from a venous injury faced during the dissection around the nodule in the parametrium, including energy use, clips, hem-o-loks, and direct continuous pressure. Of note, hemostatic agents are available, however we have not yet successfully employed them in these circumstances in which large veins were injured. The ultimate solution in our case was the clamping of the injured vessels, allowing meticulous dissection and sectioning of all the feeding vessels, while taking care not to injure the sacral roots which were just beneath these veins. Total operative time was 4 hours. Surgery of deep endometriosis involving the sacral plexus may be successfully done laparoscopically. Thorough knowledge of the deep pelvis anatomy is mandatory, and the surgeon should master various techniques of hemostasis, particularly on deep veins.