Diagnosis Of Venous Thromboembolism Research Articles

Diagnostic value of systematic compression ultrasonography for the detection of unrecognized venous thromboembolism in patients admitted to an internal medicine ward for dyspnea.

The diagnosis of venous thromboembolism (VTE) is complex, and many cases of pulmonary embolism (PE) and deep vein thrombosis (DVT) go undetected despite validated diagnostic algorithms. This study evaluated the diagnostic performance of compression ultrasound (CUS) when systematically performed in patients admitted to an internal medicine department for dyspnea and/or respiratory failure. We conducted a prospective observational cohort study of consecutive adult hospitalized patients admitted for dyspnea and/or respiratory failure with at least one of the following: tachycardia (> 100bpm), tachypnea (> 20/min), chest pain, cough, syncope, or hemoptysis. Patients with a previous diagnosis of VTE or who underwent computed tomography pulmonary angiography (CTPA) or CUS during evaluation in the emergency department were excluded. The study included 263 patients (50.2% women, average age 84years). CUS was positive in 31 patients (11.8%); Bilateral DVT was diagnosed in two patients and unilateral DVT in 29 patients. Of these, 10 underwent CT scan, with PE confirmed in 9 cases. Using the Wells score for DVT (cut-off ≥ 2), only 8 patients (25.8%) were at high risk. The accuracy of the Wells score in identifying PE was suboptimal, as 5 of 9 patients (55.5%) with confirmed PE were in the low-risk group (three-level interpretation) and 8 (89.9%) were in the "EP unlikely" group (two-level interpretation). The systematic use of CUS as a point-of-care tool can improve the diagnostic accuracy for VTE in patients admitted to internal medicine departments with dyspnea/respiratory failure.

The association between steroid use and recurrent venous thromboembolism: from the COMMAND VTE Registry-2

Abstract Background It is well known that use of oral steroids is a risk factor for development of venous thromboembolism (VTE). However, the impact of use of oral steroids on VTE recurrence has not been fully evaluated in the era of direct oral anticoagulants (DOAC), which has been a clinically relevant issue in the decision-making of anticoagulation strategies for patients who need oral steroids after VTE diagnosis. Purpose We aimed to investigate long-term clinical outcomes in VTE patients treated with oral steroids after VTE diagnosis in the DOAC era. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. The current study population were divided into 2 groups according to the use of oral steroids after VTE diagnosis; the steroid group and the non-steroid group. We compared clinical characteristics, management strategies, and outcomes including recurrent VTE, major bleeding and all-cause death, between the 2 groups. Results Patients with steroids and those without accounted for 693 (13%) and 4,504 (87%), respectively. Patients with steroids more often had chronic kidney disease (29% vs. 18%, P<0.001), autoimmune disease (50% vs. 5.4%, P<0.001), thrombocytopenia (7.7% vs 4.9%, P=0.002), and anemia (64.4% vs 54.1%, P<0.001), whereas there was no significant difference in the mean age (68.5 vs. 67.6 years old, P=0.16), the prevalence of women (62% vs 58%, P=0.06), active cancer (30% vs. 29%, P=0.42), and history of VTE (8.4% vs 6.8%, P=0.12) between the 2 groups. The cumulative 5-year incidence of discontinuation of anticoagulation therapy were not significantly different between the 2 groups (61.5% vs. 58.5%, log-rank P=0.16). The cumulative 5-year incidences of recurrent VTE nor major bleeding were not significantly different between the 2 groups (10.4% vs. 9.4%, log-rank P=0.55; 16.9% vs. 13.3%, log-rank P=0.16, respectively). Even after adjusting confounders, the risks of recurrent VTE nor major bleeding were not significantly different (adjusted hazard ratio = 0.97, 95% confidence interval = 0.65-1.45, P = 0.89; adjusted hazard ratio = 1.12, 95% confidence interval = 0.84-1.50, P = 0.44). The cumulative 5-year incidences of all-cause death was significantly different between the 2 groups (44.2% vs. 30.2%, log-rank P<0.001). Even after adjusting confounders, the risk of all-cause death remained significantly different (adjusted hazard ratio = 1.82, 95% confidence interval = 1.56-2.12, P<0.001). Conclusions Use of oral steroids after VTE diagnosis was not significantly associated with an increased risk of VTE recurrence in the DOAC Era, which might suggest that there could be no major concerns on an increased risk of recurrent VTE with oral steroids after VTE diagnosis under appropriate anticoagulation therapy.

Incidence, patient characteristics, and treatment patterns of U.S. active-duty service members diagnosed with COVID-19-associated VTE in the outpatient setting

Abstract Background Venous Thromboembolism (VTE) is a well-established complication of acute coronavirus disease 2019 (COVID-19) infection. We sought to clarify the incidence, patient characteristics, and treatment patterns of VTE within United States active-duty service members (ADSM) diagnosed with COVID-19 infection in the outpatient setting. Methods Our team conducted a multicenter retrospective review of the outpatient healthcare records for all U.S. ADSM diagnosed COVID-19-associated VTE between January 1, 2020, and April 30, 2022. The data was obtained from the COVID-19 surveillance case list maintained by the Armed Services Health Surveillance Division (ASHSD) of the U.S. Defense Health Agency (DHA). The Defense Medical Surveillance System (a database containing inpatient and outpatient electronic medical records for active-duty service members) was used to capture all appropriate medical encounters using ICD-10 coding for venous thromboembolic events within 365 days of COVID-19 diagnosis. Chart review for data adjudication was performed by the physician investigator team. Results Among 365,788 ADSM who were diagnosed with COVID-19 in the outpatient setting, a total of 159 patients were identified as having COVID-19-associated VTE. The overall incidence rate of VTE was 43.47 per 100,000 people within 365 days of diagnosis (90-day incidence rate of 32.5/100,000). The median time from COVID-19 diagnosis to VTE was 23 days (IQR 13-87). Of 159 patients, 33 (20.7%) were diagnosed with DVT, 143 (90%) with PE, and 20 (12.5%) with both PE and DVT. The median age was 30 years old (IQR 23-38). The majority of patients were male (85%). 49% were white. The most common medical comorbidity was obesity (33%), 11% had a history of active tobacco use, and 9.4% of patients had a prior VTE diagnosis. Only 34% of patients were vaccinated for COVID-19 prior to their diagnosis (35 Pfizer–BioNTech, 13 Moderna, and 4 other). 148 (93%) of patients were treated with a direct oral anticoagulant, 10 (6.2%) were treated with low molecular weight heparin, and 1 (0.8%) was treated with a vitamin K antagonist. 96 (60.3%) required hospitalization with 4 (2.5%) requiring subsequent thrombectomy. None experienced major bleeding events. Only 2 (1.3%) of the patients died within 22 days from VTE diagnosis. The remaining 98.7% were alive at 875 days (SD 230) of follow-up. Conclusion The incidence of venous thromboembolism in active-duty military patients with COVID-19 was rare, affecting mostly unvaccinated, minority men in their 30s with risk factors such as obesity, prior VTE, and prior tobacco use. Of the women with VTE, 54% were non-white minorities. While VTE diagnosis was associated with a low mortality rate, the majority of patients required hospitalization.

A novel dynamic risk score to predict venous thromboembolism (VTE) recurrences after 3 months of anticoagulation in patients with incident VTE and without active cancer

Abstract Background Predicting the risk of recurrent venous thromboembolism (rVTE) during and following anticoagulation is complex. Current models lack the ability to adapt to changing patient conditions over time and fail to account for the direct impact of anticoagulation in real-world clinical settings. Purpose To develop a dynamic risk prediction model for rVTE to help clinicians decide on the duration of anticoagulant therapy in conjunction with a model for bleeding (also submitted to the conference). Methods UK Clinical Practice Research Datalink data (2001-2020) was used to generate a retrospective cohort with first VTE who had received 3 months of anticoagulation. Patient episodes of rVTE were evaluated. Covariates were collected at baseline and subsequently as time-varying data to capture changes post-VTE. Hazards with 95% confidence intervals (CI) were estimated and covariates included in a Fine & Gray model used as predictors of rVTE. An additive (logarithmic) scoring scheme was developed from subdistribution hazard ratios, discrimination (expressed by the C-statistic) estimated from 10-fold cross-validation. Results 51,465 patients with a first VTE were included; 4041 rVTE were identified in 200,698 person-years of observation. Incidence rates for rVTE were 2.01 per 100 person-years. Nineteen independent predictors of rVTE (recorded before or after the VTE diagnosis) were included in the model, 13 associated with increased risk and 6 with decreased risk, Table 1. Patients recognised as lower-risk, medium and higher-risk (10.5%, 37% and 52.5% of the population, respectively, at 90 days after first VTE, assuming no anticoagulation treatment) had an annualised rVTE incidence rate of 2.20, 3.84, and 7.44 per 100 person-years. The C-statistic for rVTE was 0.65 (95%CI, 0.64-0.66). The points scored can be added or subtracted to predict risk (Table 2). Conclusions Our dynamic risk score effectively identifies patients at risk of rVTE three months post their initial VTE diagnosis. It allows for continuous monitoring of risk, and modelling of treatment impact, providing clinicians with a pragmatic tool to help determine treatment duration, and adapt their strategies in response to evolving patient conditions.Table 1:Predictors for VTE recurrenceTable 2:VTE recurrence risk score

A novel dynamic risk score to predict Clinically Significant Bleeding (CSB) after 3 months of anticoagulation in patients with incident Venous ThromboEmbolism (VTE) and without active cancer

Abstract Background Predicting the risk of clinically significant bleeding (CSB), bleeding requiring hospitalisation or fatal bleeding, during and following anticoagulation is complex. Current models lack the ability to adapt to changing patient conditions over time and fail to account for the direct impact of anticoagulation in real-world clinical settings. Purpose To develop a dynamic risk prediction model for CSB to help clinicians decide on the duration of anticoagulant therapy in conjunction with a model for recurrences of VTE (also submitted to the conference). Methods UK Clinical Practice Research Datalink data (2001-2020) was used to generate a retrospective cohort with first VTE who had received 3 months of anticoagulation. Patient episodes of CSB and recurrent VTE were evaluated. Covariates were collected at baseline and subsequently as time-varying data to capture changes post-VTE. Hazards with 95% confidence intervals (CI) were estimated and covariates included in a Fine & Gray model used as predictors of CSB. An additive (logarithmic) scoring scheme was developed from subdistribution hazard ratios, discrimination (expressed by the C-statistic) estimated from 10-fold cross-validation. Results 51,621 patients with a first VTE were included; 3307 CSB were identified in 206,292 person-years of observation. Incidence rates for CSB were 1.60 per 100 person-years. 18 independent predictors of CSB (recorded before or after the VTE diagnosis) were included in the model, Table 1. Patients recognised as lower-risk, medium and higher-risk (67.5 %, 15.9 % and 16.7 % of the population, respectively, at 90 days after first VTE, assuming no anticoagulation treatment) had an annualised incidence rate of 0.84, 2.94, and 9.45 per 100 person-years. The C-statistic for CSB was 0.78 (95%CI, 0.77-0.79). The points scored can be added to predict risk (Table 2). Conclusions Our dynamic score effectively identifies patients at risk of CSB three months post their initial VTE diagnosis. It allows for continuous monitoring of risk, and modelling of treatment impact, providing clinicians with a pragmatic tool to help determine treatment duration, and adapt their strategies in response to evolving patient conditions.Table 1:Predictors for CSBTable 2:CSB risk score

Duration of Anticoagulation for Venous Thromboembolism in Pediatric Patients: Kids-DOTT Trial Outcomes at Two Years

The Kids-DOTT multinational randomized clinical trial (RCT) revealed non-inferiority of a six-week versus three-month duration of anticoagulation for the treatment of provoked venous thromboembolism (VTE) in patients <21 years old, in regard to net clinical benefit at one year. To evaluate non-inferiority at two years. Patients whose repeat imaging six weeks after VTE diagnosis did not show complete veno-occlusion were randomized to discontinue anticoagulation versus receive a total three-month course and followed for two years for the occurrence of symptomatic recurrent (SR-) VTE (efficacy outcome) and clinically-relevant bleeding (CRB, safety outcome). Outcomes were centrally adjudicated and net clinical benefit was compared between treatment arms via a pre-specified bivariate non-inferiority boundary, using 95% confidence intervals (CIs) in absolute risk differences (ARDs) between treatment arms. Kaplan-Meier estimates of two-year cumulative incidences in the six-week and three-months arms of the intention-to-treat (ITT) population (n=417) were 1.7% (95% CI: 0%, 3.7%) and 2.9% (95% CI: 0.3%, 5.4%) for SR-VTE and 1.1% (95% CI: 0%, 2.5%) and 3.2% (95% CI: 0.6%, 5.7%) for CRB. Bivariate analysis of the ARDs in the ITT population demonstrated that a six-week anticoagulation duration was non-inferior to a three-month course. These findings support durability of the Kids-DOTT RCT findings of net clinical benefit at two years.

Association Between White Blood Cell Counts at Diagnosis and Clinical Outcomes in Venous Thromboembolism - From the COMMAND VTE Registry-2.

White blood cell (WBC) counts were reported to be a risk factor for acute adverse events in patients with venous thromboembolism (VTE). However, there are limited data on VTE patients without active cancer. The COMMAND VTE Registry-2 was a multicenter study enrolling 5,197 consecutive patients with acute symptomatic VTE. We divided 3,668 patients without active cancer into 4 groups based on WBC count quartiles (Q1-Q4) at diagnosis: Q1, ≤5,899 cells/μL; Q2, 5,900-7,599 cells/μL, Q3, 7,600-9,829 cells/μL; and Q4, ≥9,830 cells/μL. Patients in Q4 more often presented with pulmonary embolism (PE) than patients in Q1, Q2, and Q3 (68% vs. 37%, 53%, and 61%, respectively; P<0.001). The proportion of massive PEs among all PEs was higher in Q4 than in Q1, Q2, and Q3 (21% vs. 3.4%, 5.8%, and 11%, respectively; P<0.001). Compared with Q1, Q2, and Q3, patients in Q4 had a higher cumulative 5-year incidence of all-cause death (17.0%, 15.2%, 16.1%, and 22.8%, respectively; P<0.001) and major bleeding (10.9%, 11.0%, 10.3%, and 14.4%, respectively; P=0.002). The higher mortality risk of Q4 relative to Q2 was consistent regardless of the presentations of VTEs. An elevated WBC count on VTE diagnosis was associated with a higher risk of mortality and major bleeding regardless of VTE presentation, suggesting the potential usefulness of WBC counts for further risk stratification.

Thrombotic complications in pregnancy: a case-based review of the evidence

Pregnancy is a prothrombotic state due to an estrogen-driven shift in the coagulation system, increased venous stasis, and external restriction of blood flow caused by the gravid uterus. Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in pregnancy. Preventing, recognizing, and treating thrombosis in pregnancy, as well as the postpartum period, often challenges decision making in the clinical setting. In early pregnancy, guidance with respects to thrombophilia testing and anticoagulation in increasing the likelihood of live birth among patients with recurrent miscarriages is evolving. This review explores emerging data that support clinical decision making in thrombosis care in women with common thrombotic complications in pregnancy. The first case outlines VTE diagnosis in pregnancy, initial anticoagulation management, management around delivery and postpartum, and subsequent long-term anticoagulation treatment. The second case examines testing for inherited and acquired thrombophilia in the setting of recurrent miscarriage and the management of obstetric antiphospholipid syndrome. Lastly, the third case reviews VTE risk assessment and prevention in pregnancy and the postpartum period, as well as duration and dose of postpartum thromboprophylaxis. Review of these common clinical scenarios surrounding thrombotic complications in pregnancy demonstrates recent advances in high-quality data, current gaps in knowledge, and variation in expert opinion. Ultimately, multidisciplinary discussion and teamwork remain key to optimal, safe care. Clinicians must prioritize collaborative, high-quality trials and prospective clinical management studies to better understand and define best practice in this population.

7119 Klinefelter Syndrome in a Tertiary Referral Clinic: A Case Series and Clinical Audit

Abstract Disclosure: J. Luo: None. S. Sarlos: None. R. Giri: None. I. Sim: None. R.I. McLachlan: None. C.A. Allan: None. R. Upreti: None. Background: Klinefelter syndrome, the most common chromosomal disorder in men, remains underdiagnosed in many of those affected. Klinefelter syndrome is associated with hypogonadism and infertility, as well as an increased risk for venous thromboembolism (VTE), cardiometabolic disease, osteoporosis and gynaecomastia in adults. We studied the clinical features and disease associations in a tertiary referral cohort, and audited the care provided. Methods: Following ethics approval, adult patients with Klinefelter syndrome attending a Clinical Andrology Service in a tertiary Australian institution since 1 January 2011 were recruited. A database was established and demographics, aspects of initial diagnosis, ongoing treatments and comorbidities were documented. We audited our care using the European Academy of Andrology 2021 Guidelines for Klinefelter Syndrome. Results: Of 94 patients eligible, 57 patients consented to participation. The median age of diagnosis was 28 years, with the most common karyotype being 47,XXY (74%), followed by mosaic (20%) and higher degree polysomy (6%). Infertility (44%) and hypogonadism (33%) were the most common reasons for diagnosis. Most patients (88%) were treated with testosterone. Five men (11%) had genetic children with seven (18%) having previously attempted surgical sperm extraction. VTE occurred in seven patients (12%), with five on long-term anticoagulation following VTE diagnosis. Cardiovascular risk factor prevalence assessed at a median age of 42 years included increased BMI (72%), hypertension (25%), dyslipidaemia (70%), tobacco use (26%), impaired fasting glucose (11%) and type 2 diabetes (22%), though only one patient had a previous cardiovascular event. Osteopenia and osteoporosis were present in 28% and 4% of patients respectively, though only two patients had minimal trauma fractures. The audit of longitudinal care showed that gynaecomastia status was underreported (42%) in our clinic, whilst assessment and management of other health domains were mostly in keeping with the current recommendations. Conclusions: Klinefelter syndrome diagnosis continues to be delayed until adulthood in many men, with presentations most commonly involving infertility and/or hypogonadism. Our tertiary cohort demonstrates low rates of fertility treatment and success, which is likely multifactorial. There is a high burden of VTE, cardiovascular risk factors and reduced bone density despite testosterone treatment. Low rates of cardiovascular events and fracture may be reflective of a younger cohort as well as more aggressive risk factor management in a sub-specialist service. Gynaecomastia identification, documentation and management are areas for potential improvement. Increased awareness of Klinefelter syndrome and research into its associated risks are essential for standardising care and improving long-term outcomes. Presentation: 6/1/2024

7119 Klinefelter Syndrome in a Tertiary Referral Clinic: A Case Series and Clinical Audit

Abstract Disclosure: J. Luo: None. S. Sarlos: None. R. Giri: None. I. Sim: None. R.I. McLachlan: None. C.A. Allan: None. R. Upreti: None. Background: Klinefelter syndrome, the most common chromosomal disorder in men, remains underdiagnosed in many of those affected. Klinefelter syndrome is associated with hypogonadism and infertility, as well as an increased risk for venous thromboembolism (VTE), cardiometabolic disease, osteoporosis and gynaecomastia in adults. We studied the clinical features and disease associations in a tertiary referral cohort, and audited the care provided. Methods: Following ethics approval, adult patients with Klinefelter syndrome attending a Clinical Andrology Service in a tertiary Australian institution since 1 January 2011 were recruited. A database was established and demographics, aspects of initial diagnosis, ongoing treatments and comorbidities were documented. We audited our care using the European Academy of Andrology 2021 Guidelines for Klinefelter Syndrome. Results: Of 94 patients eligible, 57 patients consented to participation. The median age of diagnosis was 28 years, with the most common karyotype being 47,XXY (74%), followed by mosaic (20%) and higher degree polysomy (6%). Infertility (44%) and hypogonadism (33%) were the most common reasons for diagnosis. Most patients (88%) were treated with testosterone. Five men (11%) had genetic children with seven (18%) having previously attempted surgical sperm extraction. VTE occurred in seven patients (12%), with five on long-term anticoagulation following VTE diagnosis. Cardiovascular risk factor prevalence assessed at a median age of 42 years included increased BMI (72%), hypertension (25%), dyslipidaemia (70%), tobacco use (26%), impaired fasting glucose (11%) and type 2 diabetes (22%), though only one patient had a previous cardiovascular event. Osteopenia and osteoporosis were present in 28% and 4% of patients respectively, though only two patients had minimal trauma fractures. The audit of longitudinal care showed that gynaecomastia status was underreported (42%) in our clinic, whilst assessment and management of other health domains were mostly in keeping with the current recommendations. Conclusions: Klinefelter syndrome diagnosis continues to be delayed until adulthood in many men, with presentations most commonly involving infertility and/or hypogonadism. Our tertiary cohort demonstrates low rates of fertility treatment and success, which is likely multifactorial. There is a high burden of VTE, cardiovascular risk factors and reduced bone density despite testosterone treatment. Low rates of cardiovascular events and fracture may be reflective of a younger cohort as well as more aggressive risk factor management in a sub-specialist service. Gynaecomastia identification, documentation and management are areas for potential improvement. Increased awareness of Klinefelter syndrome and research into its associated risks are essential for standardising care and improving long-term outcomes. Presentation: 6/1/2024

Incidence and Risk factors of Ischemic Stroke in Patients with Cancer-associated Venous Thromboembolism: From the COMMAND VTE Registry-2

BackgroundIschemic stroke is a serious complication in patients with cancer-associated venous thromboembolism (VTE), although data remain scarce in the direct oral anticoagulant (DOAC) era. ObjectiveTo investigate the incidence and identify predictive risk factors of ischemic stroke in patients with cancer-associated VTE (CAVTE). MethodsFrom the COMMAND VTE Registry-2 enrolling 5197 VTE patients across 31 centers in Japan between January 2015 and August 2020, we selected 1507 patients with active cancer. We calculated the cumulative incidence function of ischemic stroke accounting for the competing risk of death, and investigated risk factors of ischemic stroke in a subdistribution hazard model of multivariable analysis. ResultsDuring a median follow-up period of 1020 days, 71 patients (4.7%) developed ischemic stroke, and the cumulative incidence of ischemic stroke was 4.0% at 1 year and 4.7% at 3 years. Independent risk factors of ischemic stroke included pancreatic cancer (HR: 4.24 [95%CI: 2.13-8.43]), ovarian cancer (HR: 2.82 [95%CI: 1.31-6.08]), lung cancer (HR: 2.35 [95%CI: 1.20-4.57]), dyslipidemia (HR: 1.76 [95%CI: 1.01-3.09]), metastasis (HR: 1.70 [95%CI: 1.02-2.82]), higher D-dimer level at VTE diagnosis (HR: 1.09 [95%CI: 1.04-1.14]), and younger age (HR: 0.84 [95%CI: 0.71-0.999]). ConclusionsIn this large VTE registry in the DOAC era, the cumulative incidence of ischemic stroke was 4.0% at 1 year and 4.7% at 3 years in patients with CAVTE, and several independent risk factors of ischemic stroke were identified, including pancreatic cancer, ovarian cancer, lung cancer, dyslipidemia, metastasis, higher D-dimer levels at VTE diagnosis, and younger age.

Incidence of and risk factors for post-operative venous thromboembolism after free flap breast reconstruction in a London teaching hospital: A retrospective cohort study

The objective of this study was to determine the incidence of venous thromboembolism (VTE) following autologous breast reconstruction, assess risk factors that may predict incidence and assess the accuracy of the Caprini risk assessment model. VTE is a rare, but potentially lethal complication of autologous breast reconstruction. An accurate preoperative risk-stratification strategy is essential to improve patient outcomes by determining the patients who would benefit from extended thromboprophylaxis after surgery. Patients who underwent autologous free flap breast reconstruction at a London teaching hospital from 2019-2021 were included. Risk factors for VTE were analysed. VTE incidence was assessed, and the risk factors were identified using multivariate analysis. Overall, 368 patients were included in the study. Among them, 10 (2.72%) had a confirmed diagnosis of post-operative VTE, at an average of 23 days after surgery (range 3-64 days). All VTEs occurred in deep, inferior epigastric artery perforator flap patients with a history of breast cancer. Multivariate regression analysis revealed a statistically significant correlation between the incidence of VTE and Caprini score (p=0.030) and length of hospital stay (p=0.007). Tamoxifen use was individually significant for VTE (p=0.043) but non-significant (p=0.106) when confounded for length of hospital stay (LOS) and Caprini score. Current VTE risk assessment tools do not accurately identify patients who are at risk of developing VTE following free flap breast reconstruction. The Caprini risk assessment model and LOS may be useful in predicting post-operative VTE in this cohort. These patients may benefit from extended chemoprophylaxis. Larger prospective studies are required to optimise risk prediction models in this cohort.

Venous thromboembolism during pregnancy and postpartum period: an updated review.

Venous thromboembolism (VTE) is a leading cause of maternal mortality. The risk of VTE in pregnant and postpartum women is ~ five times higher compared with non-pregnant women. There is a physiological tendency to a hypercoagulable state, from conception to the postpartum period. Several non-obstetric risk factors independently increase the risk of VTE. Since most signs and symptoms of VTE might mimic those of a normal pregnancy, a high index of suspicion is warranted to establish the diagnosis. D-dimer, ultrasonography and computed tomography pulmonary angiography are the primary tools for VTE diagnosis. Management mainly revolves around systemic anticoagulation with heparin. Advanced therapy options exist, but these can be considered for selected high-risk cases.

Trends in the Diagnosis of Pediatric Venous Thromboembolism and Arterial Ischemic Stroke during the COVID-19 Pandemic: An Administrative Database Study

To investigate trends in the diagnosis of venous thromboembolism (VTE) and arterial ischemic stroke (AIS), and examine the use of pharmacological thromboprophylaxis during the COVID-19 pandemic. This retrospective cohort study used the Pediatric Health Information Systems database to investigate patients admitted to a participating hospital between January 1, 2018, and December 31, 2021. International Classification of Diseases, 10th edition codes were used to identify VTE, AIS, and COVID-19. Pharmacy billing codes were used to investigate pharmacological thromboprophylaxis use. 1 759 701 unique patients underwent 2 234 135 inpatient admissions. Rate of VTE increased from 84 cases per 10 000 admissions in 2018-2019 to 108 cases per 10 000 admissions in 2020-2021, representing a 28.6% increase (P<.001). In contrast, the rate of AIS remained stable through the study period. When compared with 2018-2019, children diagnosed with VTE during 2020-2021 had longer hospitalizations and were more likely to be admitted to the intensive care unit. When analysis was limited to 2020-2021, a diagnosis code of COVID-19 was associated with a 1.35-fold (95% CI: 1.24-1.45) increase in the odds of VTE diagnosis, but not AIS. Use of pharmacologic thromboprophylaxis increased from 1.5% of hospitalizations in 2018-2019 to 3.0% of hospitalizations in 2020-2021 (P<.001). When evaluating thromboprophylaxis during 2020-2021, a diagnosis code for COVID-19 was associated with an 11-fold (95% CI: 10.86-11.49; P<.001) increase in the utilization of pharmacological thromboprophylaxis. This study found an increase in the rate of VTE among hospitalized children during the pandemic. A diagnosis of COVID-19 was associated with a modest increase in odds of VTE diagnosis, which occurred despite increased use of pharmacological thromboprophylaxis.

Outcomes in children with provoked venous thrombosis and antiphospholipid antibodies: findings from the Kids-DOTT trial

AbstractFew studies have prospectively evaluated the incidence and outcomes in children with provoked venous thromboembolism (VTE) and transient or persistent antiphospholipid antibodies (aPLs). We compared outcomes of patients aged <21 years with a first-episode acute provoked VTE and positive aPL at diagnosis, enrolled in the Multicenter Evaluation of the Duration of Therapy for Thrombosis in Children trial. aPLs were tested at enrollment and, when positive, repeated at 6 weeks after VTE diagnosis. Subsequent testing was performed at the discretion of the treating hematologist. Of 524 patients, 116 (22%) had positive aPLs at enrollment. At follow-up, 70 (60%) had transient (n = 66) or low-titer aPLs (n = 4), 11 (10%) had persistent aPLs meeting the criteria for antiphospholipid antibody syndrome (APS), and 35 (30%) had no repeat testing. Patients with APS were older (15.8 vs 9.9 years; P = .014) and had a statistically significant higher risk of symptomatic recurrent VTE (18% vs 1%; odds ratio [OR], 12.2; 95% confidence interval [CI], 1.4-108; P = .025) and a statistically nonsignificant but clinically meaningful difference in the risk of anticoagulant-related clinically relevant bleeding (9% vs 0%; OR, 20.1; 95% CI, 0.7-558; P = .077) compared with those in the transient or low-titer aPL group. In conclusion, aPLs are common in young patients with acute provoked VTE and are mostly transitory and clinically insignificant. Patients with APS and provoked VTE appear to have an increased risk of recurrent VTE compared with patients with transitory or low-titer aPLs. Future collaborative studies should investigate the optimal VTE management for children with provoked VTE who meet the criteria for APS. The trial was registered at www.ClinicalTrials.gov as #NCT00687882.

Venous Thromboembolism Prophylaxis in Maxillofacial Surgery.

The aim of this article is to conduct a literature review concerning the need for venous thromboembolism (VTE) prophylaxis among patients undergoing maxillofacial surgery. This article addresses the diagnosis of VTE, patient risk stratification, and prophylactic measures suitable for the various groups of interest in maxillofacial surgery. From a pool of 44 articles identified, nine were chosen as the most pertinent to the aims of this review.Despite limited data on this topic, individuals undergoing oral and maxillofacial surgery generally exhibit a low risk of VTE. This review emphasizes the importance of implementing prophylactic measures tailored to individual risk factors. Pharmacological prophylaxis merits consideration, particularly when the Caprini score is ≥7. However, further research is needed to optimize prophylactic strategies in maxillofacial surgery.

Prediction model for major bleeding in anticoagulated patients with cancer-associated venous thromboembolism using machine learning and natural language processing.

We developed a predictive model to assess the risk of major bleeding (MB) within 6 months of primary venous thromboembolism (VTE) in cancer patients receiving anticoagulant treatment. We also sought to describe the prevalence and incidence of VTE in cancer patients, and to describe clinical characteristics at baseline and bleeding events during follow-up in patients receiving anticoagulants. This observational, retrospective, and multicenter study used natural language processing and machine learning (ML), to analyze unstructured clinical data from electronic health records from nine Spanish hospitals between 2014 and 2018. All adult cancer patients with VTE receiving anticoagulants were included. Both clinically- and ML-driven feature selection was performed to identify MB predictors. Logistic regression (LR), decision tree (DT), and random forest (RF) algorithms were used to train predictive models, which were validated in a hold-out dataset and compared to the previously developed CAT-BLEED score. Of the 2,893,108 cancer patients screened, in-hospital VTE prevalence was 5.8% and the annual incidence ranged from 2.7 to 3.9%. We identified 21,227 patients with active cancer and VTE receiving anticoagulants (53.9% men, median age of 70years). MB events after VTE diagnosis occurred in 10.9% of patients within the first six months. MB predictors included: hemoglobin, metastasis, age, platelets, leukocytes, and serum creatinine. The LR, DT, and RF models had AUC-ROC (95% confidence interval) values of 0.60 (0.55, 0.65), 0.60 (0.55, 0.65), and 0.61 (0.56, 0.66), respectively. These models outperformed the CAT-BLEED score with values of 0.53 (0.48, 0.59). Our study shows encouraging results in identifying anticoagulated patients with cancer-associated VTE who are at high risk of MB.

Impact of clinically unsuspected venous thrombotic events on CVC removal and survival in pediatric cancer patients: A population-based study from the Maritimes, Canada.

Venous thromboembolism (VTE) is a well-recognized complication in pediatric cancer patients. We aimed to determine the frequency of central venous catheter (CVC) removal and survival impact of children with cancer who develop VTE. After ethics approval, a retrospective population-based study of cancer patients less than 21 years between 2005 and 2020, in the Maritime Provinces Nova Scotia, New Brunswick, and Prince Edward Island was conducted. Clinical data was collected from hospital charts and online medical records. Data on demographics, cancer diagnosis and treatment, diagnosis of VTE, use of CVC, were assessed. Kaplan-Meier survival curves were computed and compared among study groups. This study included 770 patients with a male to female ratio of 1.1:1. There were 49 patients with symptomatic VTE, 49 patients with clinically unsuspected VTE, and 671 patients with no VTE. There were 15 (1.9%) non-CVC-symptomatic (ncsVTE), 34 (4.4%) CVC-symptomatic (csVTE), 40 (5.2%) non-CVC-clinically unsuspected (ncuVTE), 9 (1.2%) CVC-clinically unsuspected (cVTE), and 671 (87%) no VTE patients. The mean number of CVCs required during treatment was significantly higher among patients with VTE (p < 0.001). Both symptomatic and clinically unsuspected VTE required significantly more CVCs compared to no VTE patients (p < 0.001 and p = 0.049 respectively). Kaplan-Meier survival curves showed ncsVTE patients' survival was significantly reduced compared to all other patients (p < 0.001). This study demonstrates that pediatric oncology patients with ncsVTE have significantly lower survival. This suggests that ncsVTE may be a biomarker for increased disease burden. This study also demonstrated that clinically unsuspected VTE had significantly more CVCs placed during treatment compared to patients without a VTE, indicating the need for better screening.

Accurately identifying incident cases of venous thromboembolism in the electronic health record: Performance of a novel phenotyping algorithm

BackgroundAccurate identification of incident venous thromboembolism (VTE) for quality improvement and health services research is challenging. The purpose of this study was to evaluate the performance of a novel incident VTE phenotyping algorithm defined using standard terminologies, requiring three key indicators documented in the electronic health record (EHR): VTE diagnostic code, VTE-related imaging procedure code, and anticoagulant medication code. MethodsRetrospective chart reviews were conducted to assess the performance of the algorithm using a random sample of phenotype(+) and phenotype(−) diagnostic encounters from primary care practices and acute care sites affiliated with five hospitals across a large integrated care delivery system in Massachusetts. The performance of the algorithm was evaluated by calculating the positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity, using the phenotype(+) and phenotype(−) diagnostic encounters sample and target population data. ResultsBased on gold-standard manual chart review, the algorithm had a PPV of 95.2 % (95 % CI: 93.1–96.8 %), NPV of 97.1 % (95 % CI: 95.3–98.4 %), sensitivity of 91.7 % (95 % CI: 90.8–92.6 %), and specificity of 98.4 % (95 % CI: 98.1–98.6 %). The algorithm systematically misclassified a low number of specific types of encounters, highlighting potential areas for improvement. ConclusionsThis novel phenotyping algorithm offers an accurate approach for identifying incident VTE in general populations using EHR data and standard terminologies, and accurately identifies the specific encounter and date of diagnosis of the incident VTE. This approach can be used for measurement of incident VTE to drive quality improvement, research to expand the evidence, and development of quality metrics and clinical decision support to improve the diagnostic process.

Venous thromboembolism in transgender and gender non-binary youth is rare and occurs in the setting of secondary risk factors: A retrospective cohort study.

The risk of venous thromboembolism (VTE) with gender-affirming hormone therapy (GAHT) in transgender and gender non-binary (TNB) youth is unclear. To identify the rate of VTE in a cohort of TNB youth followed in the transgender health clinic at Boston Children's Hospital, and to investigate the impact of congenital thrombophilia diagnosis on the use of GAHT. ICD-9 and ICD-10 codes were used to identify eligible individuals, defined as (i) having a diagnosis of gender dysphoria and (ii) venous thromboembolism (VTE). Data were abstracted from a review of medical records. A second data query assessed TNB individuals who had an associated thrombophilia diagnosis. The primary analysis included 1860 individuals. Total 942 individuals (50.6%) had started GAHT at the time of data analysis. Mean age (±SD) at GAHT initiation was 16.8 (±1.9) years. Five thrombotic events were identified in three (0.13%) individuals, all in the setting of additional VTE risk factors. Only two of five thrombotic events occurred while receiving GAHT. The rate of VTE in the GAHT cohort did not statistically differ from the rate of VTE in the non-GAHT cohort (0.1% vs. 0.2%, p=.62). Of the 10 individuals diagnosed with a congenital thrombophilia, two transmasculine individuals received prophylactic anticoagulation prior to GAHT. No VTE has been reported to date in this cohort. In our cohort, VTE was rare in the TNB youth and was not associated with GAHT use. TNB youth with congenital thrombophilia have not developed VTE in the setting of GAHT use to date.