Fatal Pulmonary Embolism Research Articles

Fatal pulmonary embolism related to anti-psychotics: forensic implications. About four autopsy cases with review of the literature

IntroductionThe association between the intake of antipsychotic drugs and the occurrence of thromboembolic complications is widely described in the literature. The occurrence of this complication may call into question the medical responsibility of the attending physician.ObjectivesThe objective of this work is to describe the physiopathological mechanisms involved in the occurrence of thromboembolic complications in a patient under antipsychotic treatment, whether or not associated with physical restraint and to discuss the forensic implications.MethodsOur study is retrospective on cases of fatal pulmonary embolism, discovered at autopsy, in connection with the taking of antipsychotics. The autopsies were carried out in the Department of Forensic Medicine of the Tahar Sfar University Hospital in Mahdia. The cases were collected over a period of 04 years. A review of the literature was carried out. We only selected articles published until February 2021 and dealing with cases of patients on antipsychotics, diagnosed with pulmonary embolism by performing a chest CT scan or during an autopsy.Results915 autopsy cases were performed during the study period. Twenty cases of pulmonary embolism, discovered at autopsy, were collected. Four cases were related to the taking of antipsychotics (incidence 0.004%), including two men and two women, aged between 25 and 52 years. They were all on antipsychotic treatment for at least 5 years, with the exception of one case who was put on 3 antipsychotics, 7 days before his death, with indication of physical restraint. After analysis of the memorial data, the external examination and the autopsy, the results of additional examinations, the death was attributed, in the 4 cases, to a massive fibrino-cruoric pulmonary embolism. A selection of 45 studies regarding thromboembolic complications associated with taking antipsychotics, was included in the final review.ConclusionsThe reported cases provided additional evidence on the involvement of antipsychotics in the occurrence of thromboembolic complications. Psychiatrists should be careful when prescribing these treatments. The establishment of therapeutic guidelines, taking into account the thromboembolic risk factors, becomes essential, in order to avoid the occurrence of a complication which could engage both the vital prognosis of patients and the responsibility of the physician.Disclosure of InterestNone Declared

Pulmonary fat embolism in non-survivors after cardiopulmonary resuscitation

BackgroundBlunt trauma acting against the human body presents the fundamental cause of pulmonary fat embolism (PFE) and fat embolism syndrome. The aim of the present study was to investigate PFE in non-survivors after cardiopulmonary resuscitation (CPR). MethodsThis was a prospective cohort study conducted in University Hospital Ostrava, Czech Republic. Within a 4-year study period, all non-survivors after CPR because of out-of-hospital cardiac arrest were assessed for the study eligibility. The presence/seriousness of PFE was determined by microscopic examination of cryo-sections of lung tissue (staining with Oil Red O). ResultsIn total, 106 persons after unsuccessful CPR were enrolled in the study. The most frequent cause of death in the study population (63.2% of cases) was cardiac disease (ischemic heart disease); PFE was not determined as the cause of death in any of our study cases. Sternal fractures were identified 66.9%, rib fractures (usually multiple) in 80.2% of study cases; the median number of rib fractures was 10.2 fractures per person. Serious intra-thoracic injuries were found in 34.9% of cases.Microscopic examination of lung cryo-sections revealed PFE in 40 (37.7%) study cases; PFE was most frequently evaluated as grade I or II. Occurrence of sternal and rib fractures was significantly higher in persons with PFE than between persons without PFE (p = 0.033 and p = <0.001). Number of rib fractures was also significantly higher in persons with PFE. The occurrence of serious intra-thoracic injuries was comparable in both our study groups (p = 0.089). ConclusionsPFE presents a common resuscitation injury which can be found in more than 30% of persons after CPR. Persons with resuscitation skeletal chest fractures have significantly higher risk of PFE development. During autopsy of persons after unsuccessful CPR, it is necessary to distinguish CPR-associated injuries including PFE from injuries that arise from other mechanisms.

Extended Post Discharge Prophylaxis for Venous Thromboembolism Prevention After Bariatric Surgery.

The utility of routine post-discharge VTE prophylaxis after bariatric surgery remains a matter of debate. While inpatient chemical prophylaxis decreases the risk of fatal pulmonary embolism, most thromboembolic events occur after discharge and carry high morbidity and mortality. To address this risk, apixaban was introduced as extended prophylaxis for 30days after surgery. The study ranges between 1/2014 and 7/2022. Apixaban was incorporated as routine extended prophylaxis protocol in 05/2017 and is dosed at 2.5mg BID for 30days. There were two study groups: those who received apixaban on discharge (n = 1443; 60%) and those who did not (n = 953; 40%). Patients with concern for postoperative bleeding (hypotension, unexplained tachycardia with hematocrit drop > 6%, hematocrit drop > 9%), or on preoperative anticoagulant/antiplatelet therapy (except aspirin), were not discharged on apixaban. Post-discharge VTE, readmission, transfusion, and reoperation rates were compared between groups. There were 2396 consecutive primary bariatric operations: sleeve gastrectomy (1949; 81%), Roux-en-Y gastric bypass (419; 18%), and duodenal switch (28; 1%). There were no post-discharge VTEs in patients treated with apixaban vs. five (0.5%) VTEs in patients who did not receive treatment; p = 0.02. There was a higher incidence in post-discharge bleeding events in the apixaban group (0.5 vs 0.3%; p = 0.75), mostly requiring readmission for monitoring without intervention or transfusion. In the apixaban group, one patient underwent EGD for bleeding while another required blood transfusion; there were no reoperations for bleeding. There were no post-discharge VTEs in patients who received apixaban. Treatment was associated with a higher risk of self-resolving bleeding events. This study adds to the increasing body of evidence supporting the benefit of routine, extended oral chemoprophylaxis after bariatric surgery.

Venous Thrombosis and Thromboembolism of Pulmonary Artery in Plastic Surgery: Risk Factors, Course Options and Therapeutic Strategies

A detailed analysis of the literature was carried out and an analysis of our own clinical case of managing a patient with thrombosis of the veins of the lower extremities and thromboembolism of the pulmonary arteries, which developed after the procedure of abdominoplasty and liposuction, is presented. There are limited descriptions of thromboembolic events and their treatment after abdominoplasty and/or liposuction in the literature. The article summarizes modern mechanisms of development and variants of the course of venous thrombosis, pulmonary embolism and pulmonary fat embolism in plastic surgery, as well as approaches to the management of such patients, with special attention paid to the interdisciplinary approach.

Dissecting the rationale for thromboprophylaxis in challenging surgical cases

Pulmonary embolism (PE) is a leading preventable cause of death in surgical patients, and rates of fatal PE are increasing. Individual assessment, to balance the risks of thrombosis and bleeding, is the key to providing appropriate prophylaxis. The risk assessment process includes use of evidence-based guidelines, literature published since the latest guidelines, large registries, and risk scoring systems together with clinical experience and judgment. Risk assessment is a dynamic process and needs to be updated both during the hospital stay and just prior to discharge since clinical events may change the level of risk. The final assessment may identify patients who require ongoing anticoagulant prophylaxis after discharge. The Caprini risk score is widely used in surgical patients and is a composite of the number of risk factors and their relative weights. The Caprini risk score set point for risk levels requiring anticoagulant prophylaxis varies depending on the type of surgical procedure, surgical population, and number of risk factors. Mandatory implementation of evidence-based care pathways is helpful in lowering PE-related mortality. This review presents several challenging cases, emphasizing the importance of employing all available assessment tools, including dynamic assessment of risk during hospitalization. Finally, the limitations of evidence-based guidelines in complex scenarios and the need to employ all available tools to properly protect very high–risk patients are emphasized.

Augmented Safety Profile of Ultrasound-Guided Gluteal Fat Transfer: Retrospective Study With 1815 Patients.

Gluteal augmentation with autologous fat transfer is one of the fastest growing aesthetic surgical procedures worldwide over the past decade. However, this procedure can be associated with high mortality from fatal pulmonary fat embolism events caused by intramuscular injection of fat. Ultrasound-guided fat grafting allows visualization of the transfer in the subcutaneous space, avoiding intramuscular injection. The aim of this study was to assess the safety and efficacy of gluteal fat grafting performed with ultrasound-guided cannulation. A retrospective chart review of all patients undergoing ultrasound-guided gluteal fat grafting at the authors' center between 2019 and 2022 was performed. All cases were performed by board-certified and board-eligible plastic surgeons under general anesthesia in ASA Class I or II patients. Fat was only transferred to the subcutaneous plane when over the gluteal muscle. Patients underwent postoperative follow-up from a minimum of 3 months up to 2 years. Results were analyzed with standard statistical tests. The study encompassed 1815 female patients with a median age of 34 years. Controlled medical comorbidities were present in 14%, with the most frequent being hypothyroidism (0.7%), polycystic ovarian syndrome (0.7%), anxiety (0.6%), and asthma (0.6%). Postoperative complications occurred in 4% of the total cohort, with the most common being seroma (1.2%), local skin ischemia (1.2%), and surgical site infection (0.8%). There were no macroscopic fat emboli complications or mortalities. These data suggest that direct visualization of anatomic plane injection through ultrasound guidance is associated with a low rate of complications. Ultrasound guidance is an efficacious adjunct to gluteal fat grafting and is associated with an improved safety profile that should be considered by every surgeon performing this procedure.

Fat embolism syndrome in Duchenne muscular dystrophy: Report on a novel case and systematic literature review

We report a non-ambulatory 13-year-old boy with Duchenne muscular dystrophy who experienced severe acute respiratory distress syndrome and cerebral fat embolism following elective soft tissue surgery. Post-surgery radiological examination revealed bilateral femoral fractures and marked osteopenia that were believed to have caused disseminated pulmonary and cerebral fat embolism. The patient had never been on glucocorticoid treatment. Five months post-surgery, he remained in a state of minimal consciousness.A literature review was performed and eleven publications included, providing case reports of a total number of 23 patients with Duchenne muscular dystrophy with fat embolism syndrome. The most common causes were falls from the wheelchair that predominantly resulted in femoral fractures. Median age at the event was around 14 years. Seven patients succumbed to complications of fat embolism. No event was described in the context of surgery. We want to raise awareness that spontaneous unnoticed fractures may occur especially in adolescents with DMD from traumatic injury of large bones and also during elective surgery with a high risk of causing fat embolism with severe sequelae.

Fatal Pulmonary Embolism, Fatal Bleeding and Intracranial Hemorrhage with Systemic and Catheter-Directed Thrombolysis in Intermediate-High and High-Risk Pulmonary Embolism: A Systematic Review with Meta-Analysis

Background: Thrombolysis, either systemic (ST) or catheter-directed (CDT), may reduce mortality in patients with intermediate-high and high-risk pulmonary embolism (PE), but with an increased risk of major bleeding (MB). Moreover, uncertainties remain for other efficacy and safety outcomes, such as fatal PE, fatal bleeding, and intracranial hemorrhage (ICH). Aims: To evaluate fatal PE, fatal bleeding and ICH with ST and CDT in patients with intermediate-high and high-risk PE. Methods: We performed a systematic search in MEDLINE, EMBASE and Cochrane from inception to December 2022. Randomized trials and cohort/observational studies of patients with intermediate-high and high-risk PE were included. We report fatal PE, fatal bleeding and ICH; mortality and MB have been previously reported. Pooled proportions with their 95% confidence interval (CI) were calculated for each treatment group. Results: One hundred and fifty-eight studies (87,874 patients) were included. In patients treated with ST, 30-day mortality and MB occurred in 10.4% (95%CI 6.6%-14.8%; I 2=99%) and in 8.0% (95%CI 5.8%-10.5%; I 2=96%), respectively. Fatal PE occurred in 3.9% (95%CI 2.1%-6.3%; I 2=88%), fatal bleeding in 1.7% (95%CI 1.3%-2.3%; I 2=8%) and ICH in 1.6% (95%CI 1.3%-1.9%; I 2=17%). In patients treated with CDT, 30-day mortality and MB occurred in 5.3% (95%CI 3.6%-7.3%; I 2=93%) and in 5.4% (95%CI 3.8%-7.2%; I 2=87%), respectively. Fatal PE occurred in 1.5% (95%CI 1.0%-2.0%; I 2=2%), fatal bleeding in 1.2% (95%CI 0.8%-1.6%; I 2=0%) and ICH in 0.6% (95%CI 0.4%-0.9%; I 2=7%). In patients treated with anticoagulation alone, 30-day mortality and MB occurred in 9.9% (95%CI 7.1%-13.1%; I 2=97%) and in 3.8% (95%CI 2.6%-5.4%; I 2=66%), respectively. Fatal PE occurred in 3.3% (95%CI 1.9%-5.2%; I 2=65%), fatal bleeding in 0.5% (95%CI 0.2%-0.9%; I 2=0%) and ICH in 0.7% (95%CI 0.3%-1.3%; I 2=64%). Conclusion: In patients with intermediate-high and high-risk PE, fatal PE was non-negligeable in all treatment modalities and must be balanced with equally important fatal bleeding event rates. Additional studies are needed to further assess these efficacy and safety parameters of thrombolytics in patients with intermediate-high and high risk PE.

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.

A diagnostic strategy for pulmonary fat embolism based on routine H&E staining using computational pathology.

Pulmonary fat embolism (PFE) as a cause of death often occurs in trauma cases such as fractures and soft tissue contusions. Traditional PFE diagnosis relies on subjective methods and special stains like oil red O. This study utilizes computational pathology, combining digital pathology and deep learning algorithms, to precisely quantify fat emboli in whole slide images using conventional hematoxylin-eosin (H&E) staining. The results demonstrate deep learning's ability to identify fat droplet morphology in lung microvessels, achieving an area under the receiver operating characteristic (ROC) curve (AUC) of 0.98. The AI-quantified fat globules generally matched the Falzi scoring system with oil red O staining. The relative quantity of fat emboli against lung area was calculated by the algorithm, determining a diagnostic threshold of 8.275% for fatal PFE. A diagnostic strategy based on this threshold achieved a high AUC of 0.984, similar to manual identification with special stains but surpassing H&E staining. This demonstrates computational pathology's potential as an affordable, rapid, and precise method for fatal PFE diagnosis in forensic practice.

Enoxaparin for Long-Term Therapy of Venous Thromboembolism in Patients with Cancer and Renal Insufficiency.

The optimal therapy of venous thromboembolism (VTE) in cancer patients with renal insufficiency (RI) is unknown. Current guidelines recommend to use low-molecular-weight heparin over direct oral anticoagulants to treat VTE in cancer patients at high risk of bleeding. We used the Registro Informatizado Enfermedad Tromboemb00F3lica (RIETE) registry to compare the 6-month incidence rates of (1) VTE recurrences versus major bleeding and (2) fatal pulmonary embolism (PE) versus fatal bleeding in three subgroups (those with mild, moderate, or severe RI) of cancer patients receiving enoxaparin monotherapy. From January 2009 through June 2022, 2,844 patients with RI received enoxaparin for ≥6 months: 1,432 (50%) had mild RI, 1,168 (41%) moderate RI, and 244 (8.6%) had severe RI. Overall, 68, 62, and 12%, respectively, received the recommended doses. Among patients with mild RI, the rates of VTE recurrences versus major bleeding (4.6 vs. 5.4%) and fatal PE versus fatal bleeding (1.3 vs. 1.2%) were similar. Among patients with moderate RI, VTE recurrences were half as common as major bleeding (3.1 vs. 6.3%), but fatal PE and fatal bleeding were close (1.8 vs. 1.2%). Among patients with severe RI, VTE recurrences were threefold less common than major bleeding (4.1 vs. 13%), but fatal PE was threefold more frequent than fatal bleeding (2.5 vs. 0.8%). During the first 10 days, fatal PE was fivefold more common than fatal bleeding (2.1 vs. 0.4%). Among cancer patients with severe RI, fatal PE was fivefold more common than fatal bleeding. The recommended doses of enoxaparin in these patients should be revisited.

Clinical effectiveness and safety of aspirin versus anticoagulation for venous thromboembolism prevention following orthopedic trauma and surgery: a meta-analysis of randomized controlled trials

Abstract Background The risk for venous thromboembolism (VTE) following orthopedic trauma and surgery is high. When preventive measures are not used, the odds of DVT can reach 60% within 90 days from surgery and 1.5% for fatal pulmonary embolism. Until now, consensus is not yet reached for the best pharmacologic prevention given the clinical situation. Guidelines on VTE prophylaxis vary across expert societies. Objective To compare the clinical effectiveness and safety between aspirin and anticoagulation in preventing venous thromboembolism (VTE) following an orthopedic trauma or surgery Study Selection Only randomized controlled trials (RCT) comparing aspirin and any anticoagulants as VTE prophylaxis following an orthopedic trauma or surgery were selected for review. Methods Pubmed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) reporting clinical outcomes of aspirin versus any anticoagulants for VTE prevention. Primary endpoint was composite of venous thromboembolism (VTE) events. Secondary endpoints were mortality, bleeding events, and wound complications. Results Eleven RCTs with 17,963 patients were included in the analysis. Patients receiving aspirin as VTE prophylaxis have no significant difference in terms of reducing venous thromboembolism (VTE) events (RR 1.03; 95% CI, 0.71-1.48; p = 0.88), mortality (RR 1.01; 95% CI, 0.68-1.49; p = 0.97), bleeding events (RR 0.97; 95% CI, 0.80-1.05; p = 0.38), and wound complications (RR 0.76; 95% CI, 0.50-1.16; p = 0.21), as compared to anticoagulation after orthopedic trauma or surgery. Conclusion There are no significant differences between aspirin and anticoagulation in terms of reducing venous thromboembolism events, mortality, bleeding events, and wound complications following orthopedic trauma or surgery.

Retrievable Inferior Vena Cava Filter Trapped Embolus: A Risk Factor of Detachment of Thrombus Analysis Based on a Multicenter Prospective Observational Study.

Up to now, the indications of inferior vena cava filter placement still remain controversial in the academic field. The aim of this study was to determine the risk factors of detachment of thrombus and to evaluate the necessity of inferior vena cava filter placement to prevent fatal pulmonary embolism. A total of 2892 patients participated in the multicenter prospective observational study from January 1, 2018, to December 31, 2018, and underwent retrievable inferior vena cava filter (RIVCF) placement in 103 centers in China. The primary endpoint of the study was RIVCF trapped embolus detected by inferior vena cava venography/ultrasound/computed tomography scanning or visible macroscopic thrombus before or during RIVCF retrieval. The relative factors of RIVCF trapped embolus were analyzed accordingly. The average age of the patients was 61.0 (50.0-71.0) years. Retrievable inferior vena cava filter trapped embolus occurred in 308 patients (10.65%). The fracture location, surgery location, and endovascular intervention differed between RIVCF trapped embolus and non-RIVCF trapped embolus groups (p<0.001, respectively). By multivariate analysis, RIVCF trapped embolus were less common in older patients (odds ratio [OR]=0.998; p<0.001) and more common in patients with below-the-knee fracture (OR=1.093, p=0.038), thigh fracture (OR=1.118, p=0.007), and pelvis surgery (OR=1.067, p=0.016). In addition, compared with patients without endovascular intervention, patients with percutaneous mechanical thrombectomy (PMT) + catheter-directed thrombolysis (CDT) were more prone to develop RIVCF trapped embolus (OR=1.060, p=0.010). However, RIVCF trapped embolus was less common in patients with CDT (OR=0.961, p=0.004). Lower limb fracture, pelvis surgery, and PMT + CDT are prone to cause trapped embolus. As a trapped embolus often represents the possibility of severe pulmonary embolism, lower limb fracture, pelvis surgery, and PMT + CDT could be risk factors of fatal pulmonary embolism. Due to the low incidence of trapped embolus, it is not necessary to place filters in elderly patients and CDT-only patients. The purpose of this paper is to standardize the use of inferior vena cava filter and avoid unnecessary filter implantation through the summary and analysis of a large number of clinical data. At the same time, more attention should be paid to and active treatment should be given to high-risk groups of pulmonary embolism.

FRI111 Venous Thromboembolism In Cushing Syndrome - A Call For Standardized Anticoagulation Regimen In Hypercortisolism

Abstract Disclosure: M. Minasyan: None. A. Bryk-Wiazania: None. E. Rzepka: None. A. Bogusławska: None. A. Hubalewska-Dydejczyk: None. A. Gilis-Januszewska: None. Venous thromboembolism in Cushing Syndrome - a call for standardized anticoagulation regimen in hypercortisolism. Cushing Syndrome (CS) is associated with a 18-fold higher risk of venous thromboembolism (VTE) when compared to the general population with the similar demographic characteristics. Despite numerous studies on hypercoagulability in CS, the unequivocal recommendations regarding timing and dosing of thromboprophylaxis in hypercortisolism are still lacking. We present a case series of patients with CS and VTE, hospitalized in the Endocrinology Department of University Hospital in Krakow. Among 135 patients with CS, we found 7cases of VTE (5.19%), aged 35-65 years, mostly females (n=6). The etiology of CS was predominately pituitary (n=3), the other tissue origins of CS were: adrenal (n=2), ectopic(n=1) and adrenal carcinoma (n=1). Pulmonary embolism (PE) was found in 3 patients, deep venous thrombosis (DVT) in 2 patients, while 2 patients suffered from concomitant DVT and PE. We found that one patient had VTE 5 months before inducing the biochemical remission by a transsphenoidal surgery, while 2 patients within the 30 days after inducing the biochemical remission by either a transsphenoidal surgery in one, or metyrapone treatment in 2nd case. In the remaining 4 patients, VTE episode preceded the diagnosis of CS, ranging from 1 year to 2 months prior to the diagnosis. Among them, 2 PE episodes were associated with other predisposing factors, such as (1) postpartum PE in a 36-year-old women, who was subsequently diagnosed with Cushing disease, and (2) combined oral contraceptive in a 35-year-old woman, who suffered from the peripheral PE, and was eventually diagnosed with adrenal CS. Of note, at the time of VTE episode, 1 patient was treated with warfarin (international normalized ratio at the time of VTE, 1.66), another one took apixaban. One fatal PE occurred on the thromboprophylaxis with low molecular weight heparin, in the hypocortisolemia following metyrapone implementation. To summarize, VTE episode: 1. may be the first, life-threatening presentation of CS; 2. may occur after treatment of hypercortisolism; 3. may happen in patients on thromboprophylaxis or anticoagulant treatment; 4. should be included in the differential diagnosis of a thrombotic event despite coexisting transient factor (e.g. oral contraceptive, delivery). 5. Further multicenter studies are essential to understand the hypercoagulability in CS, and to create the recommendations on this topic. Presentation: Friday, June 16, 2023

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli. This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures. An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform. The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality. Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

Gossypin mitigates oxidative damage by downregulating the molecular signaling pathway in oleic acid-induced acute lung injury.

One of the leading causes of acute lung injury, which is linked to a high death rate, is pulmonary fat embolism. Increases in proinflammatory cytokines and the production of free radicals are related to the pathophysiology of acute lung injury. Antioxidants that scavenge free radicals play a protective role against acute lung injury. Gossypin has been proven to have antioxidant, antimicrobial, and anti-inflammatory properties. In this study, we compared the role of Gossypin with the therapeutically used drug Dexamethasone in the acute lung injury model caused by oleic acid in rats. Thirty rats were divided into five groups; Sham, Oleic acid model, Oleic acid+Dexamethasone (0.1 mg/kg), Oleic acid+Gossypin (10 and 20 mg/kg). Two hours after pretreatment with Dexamethasone or Gossypin, the acute lung injury model was created by injecting 1 g/kg oleic acid into the femoral vein. Three hours following the oleic acid injection, rats were decapitated. Lung tissues were extracted for histological, immunohistochemical, biochemical, PCR, and SEM imaging assessment. The oleic acid injection caused an increase in lipid peroxidation and catalase activity, pathological changes in lung tissue, decreased superoxide dismutase activity, and glutathione level, and increased TNF-α, IL-1β, IL-6, and IL-8 expression. However, these changes were attenuated after treatment with Gossypin and Dexamethasone. By reducing the expression of proinflammatory cytokines and attenuating oxidative stress, Gossypin pretreatment provides a new target that is equally effective as dexamethasone in the treatment of oleic acid-induced acute lung injury.

Pulmonary fat embolism: a potentially new fatal complication of SARS-CoV-2 infection. A case report

BackgroundSo far, there have been more than 761 million confirmed cases of SARS-CoV-2 worldwide, with more than 6.8 million deaths. The most common direct causes of death for COVID-19 are diffuse alveolar injury and acute respiratory distress syndrome. Autopsy results have shown that 80-100% of COVID-19 patients have microthrombi which is 9 times higher than in patients with influenza. There are reported cases of fat embolism associated with Covid-19, but relevant epidemiological investigations and fatal cases of pulmonary fat embolism are lacking. In this report, we describe the first COVID-19 patient to die from pulmonary fat embolism.Case presentationA 54-year-old woman suddenly felt unwell while at work. She had difficulty breathing for 40 min and lost consciousness for 20 min before being taken to the hospital. On admission, her temperature was 36 ℃, but her respiration, heart rate, and blood pressure were undetectable. Laboratory examination revealed C-reactive protein, 26.55 mg/L; D-dimer, 11,400 µg/L; and procalcitonin, 0.21 ng/mL. She was declared clinically dead 2 h after admission due to ineffective rescue efforts. At autopsy, both lungs were highly oedematous with partial alveolar haemorrhage. The presence of microthrombi and pulmonary fat embolism in small interstitial pulmonary vessels was confirmed by phosphotungstic acid haematoxylin staining and oil red O staining. The immunohistochemical results of spike protein and nucleocapsid protein in laryngeal epithelial cells confirmed SARS-CoV-2 infection.ConclusionsPulmonary fat embolism may be another fatal complication of COVID-19 infection, and clinicians should pay more attention to it.

Clinicians' interpretation of ventilation/perfusion lung scan reports: Where are we today?

Clinicians' interpretation of lung scan reports will determine which further management decisions are taken when potentially fatal pulmonary embolism (PE) is suspected. To assess current referring clinicians' interpretation of the terminology used in ventilation/perfusion (V/Q) scan reports, whether this interpretation is affected by experience level, and how it affects clinical management decisions. This was a questionnaire-based cross-sectional study. Between September 2020 and May 2021, 300 questionnaires were distributed among clinicians who refer patients for V/Q scans. Of the 162 clinicians who responded, 94% thought that there is >85% likelihood of PE or definitely PE present when a scan is reported as 'high probability of PE'; 87% interpreted 'low probability of PE' as <10% likelihood of PE or definitely no PE present. Overall, >70% of clinicians across all experience levels correctly interpreted the intended meaning of probability categories according to the Modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II criteria. Of the respondents, 77% agreed that clinically significant PE is ruled out by a normal scan. Further investigation for inconclusive findings, features of parenchymal lung disease and cardiomegaly were selected by 72%, 93% and 98% of clinicians, respectively. The findings of this study regarding high-probability scan results were in line with existing literature on lung scan report interpretation. However, our findings regarding low-probability scan results and negative V/Q scan specificity contrasted with the findings in these articles, suggesting that clinicians are now more familiar with lung scan interpretation guidelines. Experience level did not significantly affect interpretation of reports. Although most clinicians agreed that a negative scan excludes clinically significant PE, two-thirds of them would still subject the patient to further unnecessary investigations to exclude PE. What the study adds. Our findings regarding a low-probability ventilation/perfusion (V/Q) scan and the specificity of a negative V/Q scan contrasted with previous articles on lung scan interpretation, suggesting that clinicians are now more familiar with lung scan interpretation guidelines.Implications of the findings. Although most clinicians understood the negative predictive value of a V/Q scan, 20% would still investigate further with computed tomography pulmonary angiography or treat as confirmed pulmonary embolism. Education of clinicians about the negative predictive value of V/Q scans is important to avoid unnecessary radiation or anticoagulation.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Effective VTE prophylaxis with enoxaparin after elective THR or TKR: a retrospective observational study.

Orthopedic patients are at the highest risk for venous thromboembolism (VTE). Nowadays, with VTE prophylaxis as a routine in patients undergoing total hip replacement (THR) and total knee replacement (TKR), fatal pulmonary embolism (PE) is rare and the rates of symptomatic VTE within 3 months dropped to 1.3%-10%, compared with the rates of 50%-70% before VTE prophylaxis implementation. In this study, we aim to evaluate the VTE prophylaxis and incidence in patients who underwent THR and TKR in Centro Hospitalar Universitário de Santo António (CHUdSA). We included 483 patients who underwent elective THR or TKR in CHUdSA from March 2019 to February 2020 and who were under enoxaparin as a VTE prophylaxis drug. All data related to prescribed enoxaparin were collected from the nationwide common electronic drug prescription system (PEM). Of the 483 eligible patients, 192 (39.75%) underwent elective THR and 291 (60.25%) underwent TKR. Enoxaparin was prescribed for 31.86 ± 5.98 and 30.28 ± 5.97 days, on average, for the THR and TKR groups, respectively (P = .005). Patients completed, on average, 29.38 ± 8.12 days and 28.20 ± 7.32 days of VTE prophylaxis with enoxaparin in the THR and TKR groups, respectively (P = .098). The incidence of VTE was approximately 3.13% and 0.69% in the THR and TKR groups, respectively (P = .064). In CHUdSA, we usually prescribe enoxaparin 40 mg once daily for up to 35 days for VTE prophylaxis after THR or TKR. High therapeutic compliance rates resulted in very few events.