High Prevalence Of Venous Thromboembolism Research Articles

Prevalence of risk factors for venous thromboembolism and aspirin resistance in Australian patients undergoing total hip and knee arthroplasty.

Aspirin is used for venous thromboembolism (VTE) prophylaxis after total hip and knee arthroplasty (THA/TKA). However, its efficacy is unclear in patients with multiple VTE risk factors and at risk of aspirin resistance (AR). To determine the prevalence of risk factors for VTE and AR in patients after THA/TKA and to determine the relationship between risk factors and drugs prescribed for thromboprophylaxis. A retrospective cohort study of elective-THA/TKA in six Australian hospitals over a 1-year period. Medical records were manually reviewed to determine demographics, thromboprophylaxis regimen and presence of risk factors. The relationship between individual and cumulative risk factors with the thromboprophylaxis regimen was determined. In total, 1011 patients were included with a mean (SD) age of 65.9 (±11.0) years, and 56.4% were female. The five most prevalent risk factors were obesity (59.1%), age ≥65 years (58.2%), hypertension (45.3%), dyslipidaemia (35.9%) and diabetes (19.7%). Most patients had ≥1 risk factor for VTE (93.6%) and AR (93.6%), with 49.0% and 35.0% having ≥3 concurrent VTE and AR risk factors, respectively. The only significant relationship between risk factors and drugs was diabetes (P < 0.01). Rivaroxaban was more commonly used as the number of concurrent VTE risk factors increased (P < 0.05). Patients had a high prevalence of VTE and AR risk factors, suggesting aspirin may not be beneficial in many patients. Only diabetes was linked to the selection of thromboprophylaxis. Patients who received rivaroxaban had a greater average number of VTE risk factors. Guidelines should promote individualised prescribing in higher-risk patients.

Direct oral anticoagulant agents might be safe for patients undergoing endovenous radiofrequency and laser ablation

ObjectiveStudies assessing the effect of the use of anticoagulant agents on endovenous thermal ablation (ETA) have been limited to patients taking warfarin. Thus, the aim of the present study was to assess the efficacy and safety of ETA for patients taking direct oral anticoagulants (DOACs). We hypothesized that the outcome of ETA for patients taking DOACs would not be superior to the outcomes for patients taking DOACs. MethodsWe performed a retrospective review to identify patients who had undergone radiofrequency ablation or endovenous laser ablation with 1470-nm diode laser fibers for symptomatic great or small saphenous venous reflux from 2018 to 2020. The patients were dichotomized into those who had received a therapeutic dose of DOACs periprocedurally and those who had not (control group). The outcomes of interest included the rates of treated vein closure at 7 days and 9 months and the incidence of deep vein thrombosis (DVT), endothermal heat-induced thrombosis (EHIT), and bleeding periprocedurally. ResultsOf the 301 patients (382 procedures), 69 patients (87 procedures) had received DOACs and 232 control patients (295 procedures) had not received DOACs. The patients receiving DOACs were more often older (mean age, 65 years vs 55 years; P < .001) and male (70% vs 37%; P < .001), with a higher prevalence of venous thromboembolism and more severe CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (5 or 6), than were the control patients. Those receiving DOACs were more likely to have had a history of DVT (44% vs 6%; P < .001), pulmonary embolism (13% vs 0%; P < .001), and phlebitis (32% vs 15%; P < .001). Procedurally, radiofrequency ablation had been used more frequently in the control group (92% vs 84%; P = .029), with longer segments of treated veins (mean, 38 mm vs 35 mm, respectively; P = .028). No major or minor bleeding events nor any EHIT had occurred in either group. Two patients in the control group (0.7%) developed DVT; however, no DVT was observed in those in the DOAC group (P = .441). At 9 months, the treated vein had remained ablated after 94.4% of procedures for patients receiving DOACs and 98.4% of the control group (P = .163). On multivariable analysis, DOAC usage was not associated with an increased risk of vein recanalization (hazard ratio, 5.76; 95% confidence interval, 0.57-58.64; P = .139). An increased preprocedural vein diameter and the use of endovenous laser ablation were associated with an increased risk of recanalization. ConclusionsIn our study of patients who had undergone ETA for symptomatic saphenous venous reflux, the periprocedural use of DOACs did not adversely affect the efficacy of endovenous ablation to ≥9 months. Furthermore, DOAC use did not confer an additional risk of bleeding, DVT, or EHIT periprocedurally. DOACs may be safely continued without affecting the efficacy and durability of ETA.

Renal insufficiency and venous thromboembolism

Venous thromboembolism (VTE) is of high incidence and prevalence worldwide. Renal insufficiency has high disease burden with insidious development and is accompanied with disorder of coagulation system. A higher prevalence of VTE has been observed among patients with renal insufficiency whereas VTE patient with renal insufficiency had higher rates of adverse outcomes. Recent evidence indicated that renal insufficiency was an important risk factor for both short and long-term prognosis for VTE. Renal function also affects the choice of anticoagulation therapy and dosage adjustment of drugs. We conducted a comprehensive review of the pathogenesis, mechanism, prognosis and treatment strategy for VTE patients who comorbid renal insufficiency by searching the latest and most advanced national and international articles, to provide integrated information for the prevention and treatment for VTE patients.

Pulmonary Embolism in Patients with COVID-19

Infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and the resulting syndrome, COVID-19, have been associated with inflammation and a prothrombotic state, with increases in fibrin, fibrinogen, fibrin degradation products and D-dimers. In some studies, elevations in these markers have been associated with worse clinical outcomes. Several studies have demonstrated a high prevalence of venous thromboembolism (VTE), and pulmonary embolism (PE), particularly in patients admitted to the intensive care unit (ICU), even in those receiving prophylactic anticoagulation. The high rate of thrombosis in COVID-19 is driven by at least two interrelated processes: a hypercoagulable state responsible for large-vessel thrombosis and thromboembolism and direct vascular and endothelial injury responsible for in situ microvascular thrombosis. The presence of PE and pulmonary thrombosis may explain why hypoxemia is out of proportion to impairment in lung compliance in some patients with COVID-19 pneumonia. Diagnosing PE in patients with COVID-19 pneumonia may be challenging, because the two pathologies share many signs and symptoms. It has been demonstrated that the administration of prophylactic anticoagulation within 24 h of admission in patients with COVID-19 was associated with decreased mortality when compared with no prophylactic anticoagulation. Given the antithrombotic, anti-inflammatory and possibly antiviral properties of heparins, it has been hypothesized that anticoagulation with heparin administered at doses higher than conventionally used for venous thromboprophylaxis may improve outcomes. In non-critically ill patients hospitalized with COVID-19, therapeutic-dose anticoagulants with heparin (most commonly, low-molecular-weight heparin) increased the probability of survival until hospital discharge with a reduced need for ICU-level organ support at 21 days as compared with usual-care thromboprophylaxis. In Critically ill patients with confirmed COVID-19, therapeutic-dose anticoagulation did not increase the probability of survival to hospital discharge or the number of days free of cardiovascular o respiratory organ support and had a 95% probability of being inferior to usual-care pharmacologic thromboprophylaxis. Currently, randomized trials evaluating the use of tissue plasminogen activator and Tenecteplase in patients with COVID-19 ARDS are underway.

Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study.

BackgroundAlthough venous thromboembolism (VTE) is a recognized side effect of some formulations of estrogen therapy, its impact in transgender people remains uncertain. The aim of this study was to define pooled prevalence estimate and correlates of VTE in Assigned Males at Birth (AMAB) trans people undergoing gender affirming hormone therapy.MethodsA thorough search of MEDLINE, COCHRANE LIBRARY, SCOPUS and WEB OF SCIENCE databases was carried out to identify suitable studies. Quality of the articles was scored using the Assessment Tool for Prevalence Studies. Data were combined using random effects models and the between-study heterogeneity was assessed by the Cochrane’s Q and I2.ResultsThe eighteen studies included gave information about 11,542 AMAB undergoing gender affirming hormone therapy. The pooled prevalence of VTE was 2% (95%CI:1-3%), with a large heterogeneity (I2 = 89.18%, P<0.0001). Trim-and-fill adjustment for publication bias produced a negligible effect on the pooled estimate. At the meta-regression analysis, a higher prevalence of VTE was significantly associated with an older age (S=0.0063; 95%CI:0.0022,0.0104, P=0.0027) and a longer length of estrogen therapy (S=0.0011; 95%CI:0.0006,0.0016, P<0.0001). When, according to the meta-regression results, the analysis was restricted to series with a mean age ≥37.5 years, the prevalence estimate for VTE increased up to 3% (95%CI:0-5%), but with persistence of a large heterogeneity (I2 = 88,2%, P<0.0001); studies on younger participants (<37.5 years) collectively produced a pooled VTE prevalence estimate of 0% (95%CI:0-2%) with no heterogeneity (I2 = 0%, P=0.97). Prevalence estimate for VTE in series with a mean length of estrogen therapy ≥53 months was 1% (95%CI:0-3%), with persistent significant heterogeneity (I2 = 84,8%, P=0.0006); studies on participants subjected to a shorter length of estrogen therapy (<53 months), collectively produced a pooled VTE prevalence estimate of 0% (95%CI:0-3%) with no heterogeneity (I2 = 0%, P=0.76).ConclusionsThe overall rate of VTE in AMAB trans people undergoing gender affirming hormone therapy was 2%. In AMAB population with <37.5 years undergoing estrogen therapy for less than 53 months, the risk of VTE appears to be negligible. Further studies are warranted to assess whether different types and administration routes of estrogen therapy could decrease the VTE risk in AMAB trans people over 37.5 years subjected to long-term therapy.Systematic Review Registration[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021229916].

The Higher Prevalence of Venous Thromboembolism in the Hungarian Roma Population Could Be Due to Elevated Genetic Risk and Stronger Gene-Environmental Interactions.

Background: Interactions between genetic and environmental risk factors (GxE) contribute to an increased risk of venous thromboembolism (VTE). Understanding how these factors interact provides insight for the early identification of at-risk groups within a population and creates an opportunity to apply appropriate preventive and curative measures.Objective: To estimate and compare GxE for VTE risk in the general Hungarian and Roma populations.Methods: The study was based on data extracted from a database consisting of results previously obtained from a complex health survey with three pillars (questionnaire-based, physical, and laboratory examinations) involving 406 general Hungarian and 395 Roma subjects. DNA was genotyped for rs121909567 (SERPINC1), rs1799963 (F2), rs2036914 (F11), rs2066865 (FGG), rs6025 (F5), and rs8176719 (ABO) polymorphisms. After allele frequency comparisons, the odds ratio (OR) was calculated for individual SNPs. Furthermore, genetic risk scores (weighted GRS, unweighted GRS) were computed to estimate the joint effect of the genetic factors. Multivariable linear regression analysis was applied to test the impact of GxE on VTE risk after interaction terms were created between genetic and VTE risk factors [diabetes mellitus (DM), cancer, chronic kidney diseases (CKD), coronary artery diseases (CAD), migraine, depression, obesity, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high density lipoprotein (HDL-C), triglyceride (TG), and smoking].Results: Interestingly, the rs121909567 (SERPINC1, ATBp3 mutation) SNP was not present in the general population at all. However, the risk allele frequency was 1% among the Roma population, which might suggest a founder effect in this minority. This polymorphism multiplicatively interacted with CAD, CKD, cancer, DM, depression, migraine, and obesity. Even though interactions were not statistically significant, the trend of interaction showed the probability of an incremental VTE risk among the Roma population. The risk of VTE was 4.7 times higher (p > 0.05) for Roma subjects who had ≥3 wGRS (median value) compared with individuals having lower wGRS values but lower for the general subjects (OR = 3.1 × 10−8). Additionally, the risk of VTE was 6.6 times higher in the Roma population that had ≥3 risk alleles (median value) than in individuals with the 0–1 risk allele, and the overall risk was much higher for the Roma population (OR = 6.6; p > 0.05) than for the general Hungarian population (OR = 1.5; p > 0.05). Five positive and significant GxE interactions were identified in the Roma population. The risk of VTE was higher among depressive Roma subjects who carried the risk variant rs2036914 (β = 0.819, p = 0.02); however, this interaction was not significant for the general subjects. The joint presence of high levels of LDL-C and rs2066865 (FGG) increased the VTE risk only among Roma individuals (β = 0.389, p = 0.002). The possibility of VTE risk increment, as a result of a multiplicative interaction between rs8176719 (ABO) and cancer, was identified, which was higher for the Roma population (β = 0.370, p < 0.001) than for the general population (β = −0.042, p = 0.6). The VTE risk increased in the Roma population (β = 0.280, p = 0.001), but was higher in the general population (β = 0.423, p = 0.001) as a result of the multiplicative interaction between CAD and rs2036914 (F11). The presence of a multiplicative interaction between rs2066865 (FGG) and CAD increased the VTE risk for the Roma population (β = 0.143, p = 0.046) but not for the general population (β = −0.329, p < 0.001).Conclusions: rs121909567 (SERPINC1, ATBp3) was confirmed as a founder mutation in the Roma population. Our study revealed some evidence on the burden of the joint presence of genetic and environmental risk factors on VTE, although the finding is highly subjected to the selection and observational biases due to the very small number of VTE cases and the observational nature of the study design, respectively. As a result of higher genetic load and GxE interactions, this minority Roma population is at higher risk of VTE than the general Hungarian population. Thus, our results suggest the need for an intensive search for the rs121909567 (SERPINC1; ATBp3) founder mutation, which might be an important factor for the assessment of thrombotic disease susceptibility among the Roma population. In addition, we strongly recommend further studies among a large number of VTE cases to explore the more precise impact of genetic and environmental risk factors on VTE in the study populations.

Venous thromboembolism and COVID-19: a single center experience from an academic tertiary referral hospital of Northern Italy

Preliminary evidence supports the notion that COVID-19 patients may have an increased susceptibility to develop venous thromboembolism (VTE). However, the magnitude of this association still needs to be defined. Furthermore, clinical predictors of thrombogenesis, and the relationship with the inflammatory status are currently unknown. On this basis, we conducted a retrospective, observational study on 259 consecutive COVID-19 patients admitted to an academic tertiary referral hospital in Northern Italy between March 19th and April 6th, 2020. Records of COVID-19 patients with a definite VTE event were reviewed for demographic information, co-morbidities, risk factors for VTE, laboratory tests, and anticoagulation treatment. Twenty-five cases among 259 COVID-19 patients developed VTE (9.6%), all of them having a Padua score > 4, although being under standard anticoagulation prophylaxis since hospital admission. In the VTE subcohort, we found a significant positive correlation between platelet count (PLT) and either C reactive protein (CRP) (p < 0.0001) or lactate dehydrogenase (LDH) (p = 0.0013), while a significant inverse correlation was observed between PLT and mean platelet volume (p < 0.0001). Platelet-to-lymphocyte ratio significantly correlated with CRP (p < 0.0001). The majority of VTE patients was male and younger compared to non-VTE patients (p = 0.002 and p = 0.005, respectively). No significant difference was found in d-dimer levels between VTE and non VTE patients, while significantly higher levels of LDH (p = 0.04) and IL-6 (p = 0.04) were observed in VTE patients in comparison to non-VTE patients. In conclusion, our findings showed a quite high prevalence of VTE in COVID-19 patients. Raised inflammatory indexes and increased serum levels of pro-inflammatory cytokines should raise the clinical suspicion of VTE.

COVID-19 and Venous Thromboembolism: A Meta-analysis of Literature Studies.

Coronavirus disease 2019 (COVID-19) may have a wide spectrum of clinical presentations, leading in some cases to a critical condition with poor long-term outcomes and residual disability requiring post-acute rehabilitation. A major concern in severe COVID-19 is represented by a concomitant prothrombotic state. However, contrasting data are available about the prevalence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and/or pulmonary embolism (PE). A detailed search on the association of COVID-19 with thromboembolic complications was conducted in the main electronic databases (PubMed, Web of Science, and Scopus) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The weighted mean prevalence (WMP) with 95% confidence interval (95% CI) was calculated with the random-effects model. Twenty studies enrolling 1,988 COVID-19 patients were included. The WMP of VTE was 31.3% (95% CI: 24.3–39.2%). The WMP of DVT was 19.8% (95% CI: 10.5–34.0%), whereas the WMP of PE was 18.9% (95% CI: 14.4–24.3%). Similar results were obtained when specifically analyzing studies on patients admitted to intensive care units and those on patients under antithrombotic prophylaxis. Regression models showed that an increasing age was associated with a higher prevalence of VTE (Z-score: 3.11, p = 0.001), DVT (Z-score: 2.33, p = 0.002), and PE (Z-score: 3.03, p = 0.002), while an increasing body mass index was associated with an increasing prevalence of PE (Z-score = 2.01, p = 0.04). Male sex did not impact the evaluated outcomes. The rate of thromboembolic complications in COVID-19 patients is definitely high. Considering the risk of fatal and disabling complications, adequate screening procedures and antithrombotic strategies should be implemented.

Venous Thromboembolism in Patients With Brain Cancer: Focus on Prophylaxis and Management.

Patients with primary and metastatic brain tumors are predisposed to thromboembolism. This review of the literature explores the high prevalence of venous thromboembolism and its negative impact on patients with brain cancer. It outlines the recommended prophylactic strategies to prevent venous thrombosis and analyzes the benefit versus risk of anticoagulation in this population, with a focus on the risk of intracranial bleeding associated with it. Additionally, it explores the exceedingly high prevalence of venous thromboembolism in the setting of brain cancer surgeries and provides guidance on the best methods used for prophylaxis in this setting and discusses the safety of each method perioperatively. Lastly, this review article provides guidance on how to manage venous thromboembolism in patients with brain cancer and discusses the use of vena cava filters in this population.

Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease?

IntroductionCOVID-19 infections are associated with a high prevalence of venous thromboembolism, particularly pulmonary embolism (PE). It is suggested that COVID-19 associated PE represents in situ immunothrombosis rather than venous thromboembolism, although the origin of thrombotic lesions in COVID-19 patients remains largely unknown. MethodsIn this study, we assessed the clinical and computed tomography (CT) characteristics of PE in 23 consecutive patients with COVID-19 pneumonia and compared these to those of 100 consecutive control patients diagnosed with acute PE before the COVID-19 outbreak. Specifically, RV/LV diameter ratio, pulmonary artery trunk diameter and total thrombus load (according to Qanadli score) were measured and compared. ResultsWe observed that all thrombotic lesions in COVID-19 patients were found to be in lung parenchyma affected by COVID-19. Also, the thrombus load was lower in COVID-19 patients (Qanadli score −8%, 95% confidence interval [95%CI] −16 to −0.36%) as was the prevalence of the most proximal PE in the main/lobar pulmonary artery (17% versus 47%; −30%, 95%CI −44% to −8.2). Moreover, the mean RV/LV ratio (mean difference −0.23, 95%CI −0.39 to −0.07) and the prevalence of RV/LV ratio >1.0 (prevalence difference −23%, 95%CI −41 to −0.86%) were lower in the COVID-19 patients. ConclusionOur findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19, fuelling the discussion on its pathophysiology.

Prevalence of Venous Thromboembolism in Ambulatory and Non-Ambulatory Patients with Cerebral Palsy

Introduction The prevalence of venous thromboembolism (VTE) in patients non-ambulatory from birth has not been well established. Available literature is unclear on the risk of VTE in patients with cerebral palsy (CP), both in the medical and post-surgical settings. Additionally, no large scale, population based studies of VTE rates in patients with severe disabilities have been done. Furthermore, assessing how the risk of VTE evolves with age in this patient population has not been assessed. Therefore, current guidelines regarding VTE prophylaxis do not take a stated position on patients with CP and recommend against thromboprophylaxis in chronically immobilized persons. Our study aims to assess the prevalence of VTE in patients with CP, both ambulatory and non-ambulatory, comparing them to the general population. Methods The Explorys platform provides aggregated patient data from many major integrated health systems incorporating tens of millions of patient lives since 1999. Explorys is an IBM database that draws on de-identified data that resides in a cloud-based, HIPAA-enabled, highly secure platform and houses over 63 million unique patients and allows customizable cohort selection as well as longitudinal patient-level data tracking. Patients were sorted based on coded diagnoses of cerebral palsy (CP), wheelchair dependence or wheelchair bound (WD) as a proxy for non-ambulatory status, and venous thrombosis (VTE). A control cohort representing the general population (GP) was generated using patients with a coded diagnosis for any disease excluding those above. Using these codes, we compared VTE prevalence among 4 primary cohorts: (1) general population with neither CP nor WD, (2) patients with CP but without WD, (3) patients with WD but without CP, and (4) patients with both CP and WD. A secondary analysis stratified patients by age decile and compared VTE prevalence between the four cohorts as well as compared rates after removing those with known risk factors for VTE. We also collected distributions of race, gender, and secondary diagnoses to characterize each cohort. Results We identified 42,566,360 unique patients, of whom 73,040 had CP but no WD, 65,390 had WD but no CP, and 5100 had both CP and WD (table 1). Among patients without WD, patients with a diagnosis of CP had higher prevalence of VTE than those without (figure 1; 9.36% vs 2.78%, RR 3.37, p &lt;0.0001). Among patients with WD, patients with CP had a lower rate of VTE (17.1% vs 24.1%, RR 0.71, p&lt;0.0001) compared to non-CP patients who were WD. When comparing CP WD to ambulatory non-CP we found that patients with WD and CP had a higher rate of VTE (17.1% vs 2.78%, RR 6.11, p &lt;0.0001). This observed relationship was consistent when stratified by age decile (figure 2), as well as in a secondary analysis of patients with a coded inpatient encounter but no diagnosis for malignancy or central venous catheter insertion with VTE prevalence 4.0% in GP, 4.8% CP no WD, 19.5% WD no CP, and 10.5% CP and WD; all relationships significant at p&lt;0.0001. Conclusion This study demonstrates that in non-wheelchair patients, ambulatory patients with CP had a higher rate of VTE compared to those without CP. And although wheelchair bound patients with CP had a higher rate of VTE vs ambulatory non-CP patients, this rate was lower than that observed among patients who are wheelchair dependent for reasons other than cerebral palsy. Our findings suggest that all patients with CP regardless of ambulatory status have a high prevalence of VTE but that in wheelchair bound patients, CP appears to be a protective factor in comparison to those who are wheelchair dependent for reasons other than CP. Both ambulatory and non-ambulatory patients with CP should be considered an at-risk group for VTE when calculating VTE risk scores and should be assessed accordingly when presenting with symptoms suggestive of venous thromboembolism. Finally, our data would suggest that patients who are wheelchair dependent may need to be considered a high-risk group when considering DVT prophylaxis during hospitalization, though further studies are needed to clarify risk in the hospital setting. Disclosures Ahuja: XaTexk Inc.: Consultancy, Patents &amp; Royalties, Research Funding; Rainbow Children's Foundation: Research Funding; Bayer: Consultancy; Biovertiv Sanofi: Consultancy; Genentech: Consultancy.

Venous thromboembolism among pediatric orthopedic trauma patients: a database analysis

Using the 2012 Kids Inpatient Database, we assessed records of pediatric patients (<21 years old) with fractures of the upper limb, lower limb, spine, pelvis, and multiple locations and calculated the overall prevalence of venous thromboembolism (VTE) and associated potential risk factors. 387 (0.68%) of 57 183 patients with one or more fractures were diagnosed with VTE. Children sustaining fractures of the axial skeleton and those with multiple fractures had a higher prevalence of VTE than those with isolated extremity fractures. Associated risk factors included the presence of a central venous catheter. A prospective, multicenter study is needed to confirm our findings.

Venous Thromboembolism Rates in Transferred Patients: A Cross-Sectional Study.

Patients undergoing a transfer during a hospitalization may be more likely to be diagnosed with a venous thromboembolism (VTE) than patients who are not transferred. To determine whether transferred patients have an increased prevalence of VTE diagnosis. This was a cross-sectional study comparing VTE diagnosis rates between transferred patients and non-transferred patients. For the years 2012-2014, the University HealthSystem Consortium database of multiple community and academic medical centers throughout the United States was parsed using ICD-9 VTE diagnosis codes and patient's point of origin. Patients were included in the analysis as transferred patients if their point of origin was a skilled nursing facility, another acute care facility or another facility. Non-transferred patients were those whose point of origin was a clinic or those with a non-facility point of origin. The primary comparison of VTE prevalence during hospitalization between transferred and non-transferred patients in the years 2012-2014. Subgroup analysis looked at level I trauma status and case mix index (CMI) to determine whether these had an effect on VTE prevalence. From 2012 to 2014, a total of 225 unique hospitals and 12,036,029 patients were analyzed, and the prevalence of VTE in transferred patients and non-transferred patients was 3.43% and 1.91% (RR 1.80; 95% CI 1.78-1.81; P<0.001), respectively. VTE prevalence in transferred versus non-transferred patients at level I trauma centers was 3.42% versus 1.88% (RR=1.82; 95% CI 1.80-1.85; P<0.001). The 3-year average CMI of transferred versus non-transferred patients was 3.53 versus 2.26 (P< 0.001). Transferred patients have a higher prevalence of VTE than non-transferred patients, regardless of level I trauma designation. Higher VTE rates in transferred versus non-transferred patients was minimally correlated with CMI.

C-reactive protein enhances activation of coagulation system and inflammatory response through dissociating into monomeric form in antineutrophil cytoplasmic antibody-associated vasculitis.

BackgroundC-reactive protein (CRP) exerts prothrombotic effects through dissociating from pentameric CRP (pCRP) into modified or monomeric CRP (mCRP). However, although the high prevalence of venous thromboembolism (VTE) in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been identified, it remains unclear whether the high levels of circulating pCRP potentially contribute to this hypercoagulable state in AAV. ANCA can induce the generation of neutrophil extracellular traps (NETs). In this study, the NETs-dependent generation of mCRP from pCRP and the influences of mCRP on the activation of coagulation system and inflammatory response in AAV were investigated.ResultsNETs were induced after TNF-α primed neutrophils were incubated with ANCA-containing IgG. After ANCA-induced netting neutrophils were incubated statically with platelet-rich plasma (PRP) containing mCRP (60 μg/mL), the proportion of platelets expressing CD62p increased significantly, while no increased CD62p expression of platelets was observed after static incubation with PRP containing pCRP (60 μg/mL). Under flow conditions, perfusing immobilized ANCA-induced netting neutrophils with pCRP-containing PRP caused platelets activation and mCRP deposition. The newly generated mCRP induced platelets activation on ANCA-induced netting neutrophils, enhanced D-dimer formation, and enhanced high mobility group box 1 secretion by platelets.ConclusionsUnder flow conditions, ANCA-induced netting neutrophils can activate platelets and then prompt the formation of mCRP on activated platelets. Then the newly generated mCRP can further enhance the activation of platelets, the process of thrombogenesis, and the inflammatory response. So the high level of circulating pCRP is not only a sensitive marker for judging the disease activity, but also a participant in the pathophysiology of AAV.

Venous thromboembolism in pregnant women with sickle cell disease: A retrospective database analysis

IntroductionThe risk of venous thromboembolism (VTE) is higher during pregnancy, with an incidence between 0.05 and 0.2%, and among persons with sickle cell disease (SCD), yet the rates and risk factors, such as pneumonia, vasooclusive crisis (VOC), and acute chest syndrome (ACS), associated with pregnancy-related VTE are not firmly established in SCD. MethodsInpatient hospital discharge data from 2007-2011 were obtained from the Pennsylvania Health Care Cost Containment Council to estimate the rate of VTE among African American delivery hospitalizations with SCD and to compare pregnancy complications and medical comorbidities among pregnant women with SCD. ResultsAmong 212 hospitalized deliveries in African-American women with SCD, 6 (2.8%, 95% CI 1.0%-5.9%) had VTE compared to 0.05 to 2.0% in the general population. Risk factors for VTE included pneumonia and diabetes mellitus. Overall, the prevalence of VTE, among hospitalized deliveries in SCD women with pneumonia, VOC, and/or ACS, 6.6%, was significantly greater than among those without these conditions, 2.2%, p<0.001. ConclusionPregnancy-related VTE in women with SCD appears to be 1.5 to 5 times greater than pregnancy-related VTE in the general population. The higher prevalence of VTE among pregnant women with pneumonia, VOC, and/or ACS, and their potential clinical overlap, suggests that VTE may be missed in such women. We conclude that VTE in pregnant women with SCD may be more common than previously reported, and such women might be candidates for thromboprophylaxis.

Venous thromboembolism after trauma

Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. Prospective, observational trial with waiver of consent. Level I trauma center intensive care unit. At admission, 534 patients were prescreened with a risk assessment profile. Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

Prevalence of venous thromboembolism (VTE) among patients (pts) with acute leukemia (AL) prior to treatment.

6595 Background: Cancer and cancer treatment increases the risk of VTE. However, the association of AL and VTE is unknown. Methods: We performed a retrospective chart review to determine the prevalence of VTE prior to treatment and recurrence of VTE. Medical records of 1295 pts [299 acute lymphoblastic leukemia (ALL) pts and 996 acute myelogenous leukemia (AML) pts] at MD Anderson Cancer Center between November 1999 and May 2005 were reviewed and analyzed. All computations were conducted using Stata version 11. Results: Of the 1295 pts with AL, the overall prevalence of VTE was 1.6% (22 VTE cases, median age: 63.5 yrs). The prevalence was 2.3 % (7/299) and 1.5% (15/996) among ALL and AML patients, respectively. Two of 14 AML pts were M3-AML. In the ALL group, 1 pt had VTE approximately 1 month prior to ALL diagnosis (dx), and 6 pts developed VTE at the time of ALL dx. In the AML group, 3 pts had VTE prior and 12 pts developed VTE at AML dx. Pulmonary embolism occurred in 4 pts [3 had associated lower extremity (LE) deep venous thrombosis (DVT)]. Nine pts (7 AML, 2 ALL) had upper extremity DVTs, and 9 pts (6 AML, 3 ALL) had LE DVTs. Recurrent VTE occurred in 5/22 (23%) pts. In a univariate model, pts with baseline platelet (plt) count ≤ 50 x 109/L or 50-99 x 109/L had a protective effect on VTE development, with 69% and 85% less likely to develop VTE than pts who had plt count 100-349x 109/L, respectively. Pts with prior history of VTE were 17.8 times (95%CI: 6.3-49.27) more likely to develop a VTE than pts without a prior VTE history. Pts with phlebitis were 4.8 times (95%CI: 1.07-21.9) more likely to develop VTE than pts without phlebitis. In a multivariate model, significant predictors of VTE were baseline plt count and prior history of VTE. Overall survival did not differ between pts who developed VTE prior to treatment versus others. Conclusions: Acute leukemia pts have a high prevalence of VTE. Occurrence of VTE prior to initiation of chemotherapy was not associated with poor prognosis. Further studies should be conducted to establish guidelines for the prevention and management of VTE in pts with leukemia.

Venous Thromboembolism in Hospitalized Inflammatory Bowel Disease Patients: The Magnitude of the Problem Is Staggering

There is evidence that thromboembolism as a disease-specific extraintestinal manifestation of inflammatory bowel disease (IBD) is developed as the result of multiple interactions between acquired and genetic risk factors. An imbalance of procoagulant, anticoagulant, and fibrinolitic factors predisposing to thrombosis has been reported by several studies in patients with IBD. The study by Nguyen and Sam demonstrates that hospitalized IBD patients have higher prevalence of venous thromboembolism and a more than two-fold excess of mortality compared with non-IBD hospitalized patients. When the findings from this large study are combined with previous data, they suggest that thromboembolism is a significant cause of extraintestinal morbidity and mortality in IBD patients with a higher risk during hospitalization.

Venous Thrombosis Trials at the Methodist Hospital in Houston

Venous thromboembolism continues to be a significant problem in hospitalized patients.1 According to Geerts et al., rationale for thromboprophylaxis is based on the high prevalence of venous thromboembolism among hospitalized patients, the clinically silent nature of the disease in the majority of patients, and the morbidity, costs and potential mortality associated with unprevented thrombi.2•3 Approximately two million Americans suffer from deep vein thrombosis (DVT) each year,4 but because most of these clots are silent, the true incidence is actually unknown. In addition to the acute thrombotic event with its inherent morbidity and time missed from work, the late sequelae from even properly treated thrombi can present as venous stasis and leg ulcers. Thromboembolic disease is responsible for approximately 200,000 deaths annually in the United States alone.5 The elderly are at highest risk, with a one-year mortality approaching 21%.6 Although excellent drugs are currently available to prevent and treat DVT, an investigation into new drugs with new targets and designer end points of anticoagulation seemed clinically relevant and timely. The following paper will discuss the different antithrombotic/anticoagulant agents that have been used in clinical trials at The Methodist Hospital in Houston, Texas. Several of the trials have been successfully completed and featured in medical publications such as the New England Journal of Medicine and The Lancet.

Current Perspectives on Primary Prophylaxis and Patient Risk Factors for Venous Thromboembolism in the Cancer Patient

The high prevalence of venous thromboembolism in cancer patients and the factors that increase the risk for this complication deserve emphasis.