History Of Thromboembolic Disease Research Articles

Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation

BackgroundAtrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib. MethodsIn this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant. ResultsOf the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (β = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001). ConclusionApart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.

COMPARISON BETWEEN INTRA-ARTICULAR AND INTRAVENOUS TRANEXAMIC ACID APPLICATION IN PRIMARY UNILATERAL KNEE JOINT ARTHROPLASTY

To compare the efficacy of intra-articular and intravenous modes of administration of tranexamic acid in primary total knee arthroplasty in terms of blood loss and fall in haemoglobin level.Study Design: Randomized controlled trial.Duration of Study: Six months, from May 2019 to Nov 2019.Seventy-eight patients were included in the study. All patients undergoing unilateral primary total knee replacement were included in the study. Exclusion criteria were patients with hepatitis B and C, history of previous knee replacement, bilateral total knee replacement, allergy to TXA, Hb less than 11g/dl in males and less than 10g/dl in females, renal dysfunction, use of anticoagulants for 7 days prior to surgery and history of thromboembolic diseases. Patients were randomly divided into group A and B. Group A patients undergoing unilateral primary total knee replacement (TKR) were given intravenous tranexamic acid (TXA) while group B were infiltrated with intra-articular TXA. Volume of drain output, fall in haemoglobin (Hb) level and need for blood transfusion were measured immediately after surgery and at 12 and 24 hours post operatively in both groups.The study included 35 (44.87%) male and 43 (55.13%) female patients. Mean age of patients was 61 ± 6.59 years. The mean drain output calculated immediately after surgery in group A was 45.38 ± 20.75 ml compared with 47.95 ± 23.86 ml in group B (p=0.73). At 24 hours post operatively, mean drain output was 263.21 ± 38.50 ml in intravenous group versus 243.59 ± 70.73 ml in intra-articular group (p=0.46). Regarding fall in Hb level, both groups showed no significant difference (p&gt;0.05). About 12.82% (n=5) patients in group A compared to 10.26% (n=4) patients required blood transfusion post operatively (p=0.72).Intra-articular and intravenous TXA are equally effective in patients undergoing primary total knee arthroplasty in reducing post-operative blood loss.

Association of Clinical and Laboratory Findings in COVID-19 Patients with Thromboembolic Complications

Background: COVID-19 is associated with dangerous thromboembolic complications, such as stroke, heart attack, pulmonary embolism, and arterial and venous thromboembolism (VTE). Early diagnosis and even prediction of thromboembolic complications using biomarkers could facilitate the treatment and decrease the mortality rate. Objectives: This study evaluated and compared the clinical and laboratory findings of COVID-19 patients with thrombotic events with other COVID-19 patients. Methods: A total of 114 confirmed COVID-19 patients referred to Taleghani Hospital, Tehran, Iran, between February and September 2020 were included in this cross-sectional study. Those with a history of thromboembolic disease were excluded. The laboratory data, including the levels of lactate dehydrogenase (LDH), D-dimer, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and counts of lymphocyte and neutrophil, along with clinical findings (such as oxygen saturation and lung involvement percentage), were retrospectively collected from the patients’ clinical files. The incidence of thrombotic events was evaluated in patients. Results: The prevalence of thrombosis in the right and left main pulmonary arteries, right and left sub-segmental pulmonary arteries, and right and left deep veins was 2.7%, 3.5%, 7%, 7.9%, 4.4%, and 1.8% of all patients, respectively. The results showed that thromboembolic complications were significantly associated with mortality (P &lt; 0.001). Besides, it was found that LDH (P &lt; 0.001) and neutrophil (P = 0.002) levels in thromboembolic COVID-19 patients were respectively higher and lower than those without thromboembolic manifestations. Conclusions: High LDH and neutropenia might serve as biomarkers for thromboembolism in COVID-19 patients.

Selección de pacientes para cierre percutáneo en el ictus isquémico no lacunar criptogénico asociado a foramen oval permeable. Datos del registro cooperativo NORDICTUS

IntroductionThere is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. MethodA prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. ResultsIn the group ≤60 years (n=488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4,11; IC 2,6-6,5, p<0,001), criteria for paradoxical embolism (OR 2,61; IC 1,28-5,28; p=0,008) and previous use of antithrombotics (OR 2,67; IC 1,38-5,18; p=0,009). In the group>60 years old (n=124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria and high-risk PFO. ConclusionsThe detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry

IntroductionThere is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. MethodA prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. ResultsIn the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28−5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38−5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. ConclusionsThe detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.

Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy.

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty.

Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery. The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty. A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort. A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration. This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

Successful treatment of thrombotic thrombocytopenia with cerebral sinus venous thrombosis following Ad26.COV2.S vaccination

Successful treatment of thrombotic thrombocytopenia with cerebral sinus venous thrombosis following Ad26.COV2.S vaccination

Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study.

Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36-62 years; range, 17-95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

Kidney allograft infarction associated with transplant renal artery stenosis in a COVID-19 kidney transplant recipient

Kidney allograft infarction is rare, but an urgent condition that requires prompt intervention to avoid allograft loss. Renal artery thrombosis is the leading cause of infarction. Apart from traditional risk factors for thrombosis, emerging SARS-CoV-2 predisposes patients to thrombotic diseases both in arterial and venous vasculatures. We report a case of kidney transplant recipient with known transplant renal artery stenosis (TRAS) status post angioplasty with severe COVID-19, complicated by oliguric acute kidney injury requiring continuous renal replacement therapy (CRRT). She did not have a history of thromboembolic disease. The hospital course was complicated by new-onset atrial and ventricular fibrillation and cardiac arrest requiring multiple rounds of cardiopulmonary resuscitation. She had no signs of renal recovery, and an abdominal CT scan showed evidence of allograft infarcts. She underwent an allograft nephrectomy. Pathology revealed diffuse thrombotic microangiopathy involving glomeruli, arterioles, and arteries associated with diffuse cortical infarction with negative SARS-CoV-2 immunostain and in situ hybridization. This is the first case of kidney allograft infarct with a history of TRAS in a COVID-19 patient. Underlying TRAS and COVID-19-associated thrombosis in this patient are unique and likely play a key role in allograft infarction from arterial thrombosis. Recognizing risk factors and early therapy for allograft infarction may improve transplant outcomes.

Prevalence and Effect of Genetic Risk of Thromboembolic Disease in Inflammatory Bowel Disease

The largest cause of mortality in patients with inflammatory bowel disease (IBD) remains thromboembolic disease (TED). Recent reports have demonstrated that both monogenic and polygenic factors contribute to TED and 10% of healthy subjects are genetically at high risk for TED. Our aim was to utilize whole-exome sequencing and genome-wide genotyping to determine the proportion of IBD patients genetically at risk for TED and investigate the effect of genetic risk of TED in IBD. The TED polygenic risk score was calculated from genome-wide genotyping. Thrombophilia pathogenic variants were extracted from whole-exome sequencing. In total, 792 IBD patients had both whole-exome sequencing and genotyping data. We defined patients at genetically high risk for TED if they had a high TED polygenic risk score or carried at least 1 thrombophilia pathogenic variant. We identified 122 of 792 IBD patients (15.4%) as genetically high risk for TED. Among 715 of 792 subjects whose documented TED status were available, 63 of the 715 patients (8.8%) had TED events. Genetic TED risk was significantly associated with increased TED event (odds ratio, 2.5; P= .0036). In addition, we confirmed an additive effect of monogenic and polygenic risk on TED (P= .0048). Patients with high TED genetic risk more frequently had thrombosis at multiple sites (78% vs 42%, odds ratio, 3.96; P= .048). Genetic risk (both poly- and monogenic) was significantly associated with TED history. Our results suggest that genetic traits identify approximately 1 in 7 patients with IBD who will experience 2.5-fold or greater risk for TED.

Postoperative Length of Stay May Predict Foot and Ankle Patients at Risk for Readmission

Category:Other; Ankle; Ankle Arthritis; Arthroscopy; Diabetes; Hindfoot; Lesser Toes; Midfoot/Forefoot; TraumaIntroduction/Purpose:Reduction of postoperative readmissions is an important goal for the improvement of patient outcomes and satisfaction, as well as mitigating rising healthcare costs. As a result of changing federal and insurer guidelines and requirements, hospitals monitor and report 90-day all-cause readmissions. This data can be used to drive both local and national improvements in patient care. The purpose of our study is to evaluate patient and perioperative factors associated with 90-day readmissions specifically in a foot and ankle surgery population.Methods:After obtaining Institutional Review Board approval, admissions and readmissions data from October 2012 to September 2016 at a Level 1, private, academic hospital were reviewed for patients treated surgically by four foot and ankle orthopaedic surgeons. Only foot and ankle surgical procedures were included, as identified by diagnosis codes (ICD-9/ICD-10), performed on patients from 10-95 years of age. All-cause readmission rate was recorded. A medical records review was performed to collect patient demographics, admissions, readmissions, and surgical data. Data was analyzed using an analysis of variance model with a Dunn’s post-hoc test as well as Spearman rank order correlation test, with significance set at α=0.05.Results:6,054 patients were identified, and 4,578 met study inclusion criteria; 4,404 cases did not result in readmission and 174 cases resulted in readmission within 90 days of discharge of the index inpatient/outpatient case, leading to an overall, all-cause readmission rate of 3.80%. Between non-readmission and readmission cohorts, there were no significant differences in patient age (p=0.627) or sex (p=0.208; female: male ratio in both cohorts ˜ 60% v. 40%); however, there was a significant difference in BMI (29.8 v. 31.9, respectively; p<0.001). Readmitted patients had significantly greater lengths of stay (LOS) of index procedure (3.79 v. 2.09 average days, respectively; p<0.001). Readmitted patients had a statistically higher likelihood of diabetes (25.3% vs 14.8%, p<0.002) and history of DVT/PE (23.0% vs 9.3%, p<0.0001) compared to non-readmitted patients.Conclusion:This study identified statistically significant relationships between postoperative LOS, diabetes, and thromboembolic disease history with 90-day readmission rate. Diabetes and thromboembolic history are unmodifiable risk factors that have been shown to increase readmission in other work, while initial LOS has variable relationships with readmission depending on the patient population studied. In our foot and ankle specific population, initial length of stay was nearly doubled in the readmission population. As foot and ankle surgery often leads to decreased mobility and independence, increasing LOS may be useful in predicting patients that will require more social or medical support at and after discharge.

1817P - Randomized phase II trial evaluating the safety of peripherally inserted central catheters vs implanted port catheters during adjuvant chemotherapy in early breast cancer patients

BackgroundBoth peripherally inserted central catheters (PICC) and implanted port catheters (PORT) are used for adjuvant chemotherapy (ACT) administration in early breast cancer (EBC) patients. We evaluated the safety of the two devices in ACT setting. MethodsThis monocentric phase II randomized trial (NCT02095743) included patients with an EBC and eligible to an ACT. Patients with curative anticoagulation were excluded. The primary endpoint was to identify the device with the less probability of occurrence of a significant adverse event related to the central venous device (SAERCVD) during the 37 weeks following device implantation. A SAERCVD was defined as: CTCAE grade ≥3, inducing a delay in CT administration >7 days, or requiring a replacement of the implanted device. PICC were removed the day of last CT administration; PORT were removed within 4 weeks after the last CT administration. Based on our previous study (Support Care Cancer. 2016; 24(3):1397-403), 256 patients were needed to meet the primary endpoint. ResultsFrom February 2014 to April 2018, 256 patients were included; 248 (97%) were analyzed (PICC, n=125; PORT, n=123). Overall, 25 patients (10%) had a SAERCVD: thrombosis (n=13), local infection (n=6), systemic infection (n=3) and mechanical complication (n=3). Probability of occurrence of a SAERCVD within 37 weeks was 4.9% (6 SAERCVD) in PORT vs 15.2% (19 SAERCVD) in PICC (HR=3.2 [1.3-8.1], p=0.007). Regarding baseline characteristics, patients experiencing a SAERCVD had a trend toward a higher body mass index (p=0.08) and a history of thrombo-embolic disease (p=0.08) compared to patients without SAERCVD. Among the 223 patients without SAERCVD, probability of occurrence of a non-significant adverse event related to the device was 20.8% (22/106) in PICC vs 17.1% (20/117) in PORT (HR=1.2 [0.7-2.2], p=0.5), mainly grade 1 local pruritus. Grade≥3 adverse events not related to the implanted device were observed for 48 patients in each group (HR=1 [0.7-1.5], p=0.9), mainly CT induced neutropenia. ConclusionsAlthough side effects related to central venous devices are rare during ACT in EBC patients, SAERCVD are more frequently observed with PICC rather than PORT. Clinical trial identification2012-A01440-43 NCT02095743. Legal entity responsible for the studyFlorian Clatot. FundingLa Ligue contre le cancer. DisclosureF. Clatot: Honoraria (self), Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: Lilly; Honoraria (self), Advisory / Consultancy, Travel / Accommodation / Expenses: Merck; Honoraria (self), Advisory / Consultancy, Travel / Accommodation / Expenses: BMS; Research grant / Funding (institution): AstraZeneca; Travel / Accommodation / Expenses: Roche. All other authors have declared no conflicts of interest.

Intravenous versus topical tranexamic acid as a blood conservation intervention in hip joint replacement surgeries

Background: Hip arthroplasty is associated with substantial blood loss intraoperatively as well as postoperatively. The objective of the present experimental study was to compare the effectiveness of topical tranexamic acid with intravenous tranexamic acid in reducing blood loss in hip joint replacement surgeries. Methods: The experimental study comprised of 60 cases undergoing hip joint replacement surgeries who were randomly assigned to the intravenous group (n=30) and topical group (n=30). Tranexamic acid was used in the dose of 15 mg/kg. All Patients undergoing hip joint replacement surgeries and preoperative Hb > 10 g/dl for males and > 9 g/dl for females were included in this study. Patients having a known history of thromboembolic disease, myocardial infarction, cerebrovascular disease, angina, coagulopathy, any liver or renal disease or any other source of active bleeding were excluded from the study. Results: In hemiarthroplasty the blood loss in the topical and intravenous group was 547.8±178.11ml and 617.73±192.51ml with a p value of 0.298. The haemoglobin and PCV was 2.01±1.18 mg/dl, 6.22±4.08% and 2.41±1.74 mg/dl, 6.69±5.03 with a p value of 0.521 and 0.865. Similarly in total hip replacement the blood loss in the topical and intravenous group was 620.80±160.33ml and 745.30±152.67ml with a significant p value of 0.046. The haemoglobin and PCV was 2.75±1.60 mg/dl, 6.15±7.05% and 2.80±1.84 mg/dl, 8.52±5.47 with a p value of 0.534 and 0.214. Conclusion: Tranexamic acid can be given by intravenous or topical route as both the routes are equally effective in reducing the intraoperative blood loss.

Visual Loss Following Spine Surgery

A retrospective review of the Scoliosis Research Society (SRS) morbidity and mortality (M&M) database. The aim of this study was to investigate visual related complications in spinal deformity patients undergoing spine surgery. The SRS compiles surgeon-reported complications into an M&M database, tracking postoperative complications including visual loss, neurological deficits, infections, and death. Limited literature exists on postoperative visual complications, a rare but devastating complication following spine surgery. We utilized the SRS M&M database to determine demographics, perioperative risk factors, and prognosis for visual related complications in spinal deformity patients undergoing corrective spine surgery from 2009 to 2012. A total of 167,972 spinal deformity patients from 2009 to 2012 were identified with a visual acuity complication (VAC) rate of 0.01%, or 12.5 per 100,000 patients. VAC rates for patients with kyphosis were significantly higher than patients with scoliosis (0.049% vs. 0.010%, P = 0.002) and spondylolisthesis (0.049% vs. 0.005%, P = 0.001). Postoperative visual loss rates significantly decreased from 2010 to 2012 (0.022% vs. 0.004%, P = 0.029). Twenty-one patients identified with VACs had a mean age of 34.8 ± 24.3 years. Two (9.5%) patients had preoperative vision changes, two (9.5%) were diabetic, two (9.5%) had vascular disease, one (4.8%) had a history of thromboembolic disease, and five (23.8%) had hypertension. Extent of VAC was bilateral-partial in four (19.0%), bilateral-total in five (23.8%), unilateral-partial in eight (38.1%), and unilateral-total in three (14.3%) patients. Four (19.0%) patients developed anterior ischemic optic neuropathy, four (19.0%) had posterior ischemic optic neuropathy (PION), five (23.8%) had central retinal artery occlusion, and five (23.8%) developed cortical blindness (CB). Greater than 50% of the VACs occurred on, or before, the first postoperative day. Ten (47.6%) patients recovered complete vision and four (19.0%) improved. All patients with CB and 50% with posterior ischemic optic neuropathy experienced complete resolution. VACs occur in approximately 12.5 per 100,000 deformity patients, with a rate five times higher in patients with kyphosis. More than 50% of these complications occur within 24 hours postoperatively. Nearly half of these complications resolve completely, and another 19% improve postoperatively. 4.

Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial

BackgroundWhile it is has been proven that tranexamic acid (TXA) reduces blood loss in primary total hip and knee arthroplasty (THA and TKA), there is little published evidence on the use of TXA beyond 3 h post-operatively. Most blood loss occurs after wound closure and the primary aim of this study is to determine if the use of oral TXA post-operatively for up to 24 h will reduce calculated blood loss at 48 h beyond an intra-operative intravenous bolus alone following primary THA and TKA. To date, most TXA studies have excluded patients with a history of thromboembolic disease.Methods/designThis is a phase IV, single-centred, open-label, parallel-group, randomised controlled trial. Participants are randomised to one of three groups: group 1, an intravenous (IV) bolus of TXA peri-operatively plus oral TXA post-operatively for 24 h; group 2, an IV bolus of TXA peri-operatively or group 3, standard care (no TXA). Eligible participants, including those with a history of thromboembolic disease, are allocated to these groups with a 2:2:1 allocation ratio. The primary outcome is the indirectly calculated blood loss 48 h after surgery. Researchers and patients are not blinded to the treatment; however, staff processing blood samples are. Originally 1166 participants were required to complete this study, 583 THA and 583 TKA. However, following an interim analysis after 100 THA and 100 TKA participants had been recruited to the study, the data monitoring ethics committee recommended stopping group 3 (standard care).DiscussionTRAC-24 will help to determine whether an extended TXA dosing regimen can further reduce blood loss following primary THA and TKA. By including patients with a history of thromboembolic disease, this study will add to our understanding of the safety profile of TXA in this clinical situation.Trial registrationISRCTN registry, ISRCTN58790500. Registered on 3 June 2016, EudraCT: 2015–002661-36.

Right Ventricular Dilation in Patient With Submassive Pulmonary Embolism

Author(s): Diez, Adrian; Bryczkowski, Christopher | Abstract: ABSTRACT: History of present illness: A 73-year-old female with a past medical history of tracheobronchomalacia, obstructive sleep apnea, diabetes, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) presented to the emergency department with four days of moderate to severe dyspnea on exertion. She endorsed right calf pain for the last few weeks and bilateral leg swelling, as well as productive cough, orthopnea, and non-radiating chest tightness but denied any hemoptysis. She had no history of thromboembolic disease, nor did she have any family history of clotting disorders. She was not currently on any anticoagulation. The patient lives a sedentary lifestyle at baseline. Upon arrival, her vital signs were as follows: temperature 97.3 F, pulse 60 per min, respirations 34 per min, blood pressure 113/85 mmHg, and oxygen saturation 97% on 4L nasal cannula. Physical exam was notable for jugular venous distension and bilateral lower extremity pitting edema. Lungs were clear to auscultation.Significant findings: Bedside echocardiography four chamber view revealed enlarged right ventricular (RV) to left ventricular (LV) ratio (greater than 1) on apical four-chamber view (see red and blue outlines respectively). The right atrium is not clearly delineated in this image and therefore is not outlined. One can also rule out a large pericardial effusion as the cause of her dyspnea, since there is no large hypoechoic collection surrounding the heart on either four- chamber view or parasternal long view. Discussion: Point of care ultrasound is a powerful tool that can aid in the diagnosis of undifferentiated dyspnea. Right ventricular size is one parameter that can signify right heart strain possibly due to an increase in resistance in the pulmonary vasculature. The normal RV should be approximately two-thirds the size of the left ventricle. Any RV between two-thirds and equal to the size of the LV is considered moderately dilated, and any RV greater in size than the LV is considered severely dilated.1,2 The RV to LV size ratio is best measured from the apical four-chamber view. Right ventricular shape will also change as afterload increases in the pulmonary circuit. As pulmonary vascular resistance increases, the RV (which has significantly less myocardium and thus greater compliance as compared to the LV) begins to lose its typical triangular shape and takes on a more rounded appearance.3 Likewise, the intraventricular septum becomes flattened during early diastole due to higher RV:LV pressures causing the LV to take on a “D” shaped appearance. These findings, collectively referred to as signs of “right heart strain,” typically improve with resolution of the clot burden.4 Unfortunately, while right ventricular dilatation and consequently an asymmetrical LV appearance are commonly encountered findings, they do not help distinguish acute from chronic right heart strain. Evaluation for McConnell’s sign, or right ventricular mid-free wall akinesia with RV apical sparing is important because it is considered to be the most specific finding (94%) for acute right heart strain.5 The decision to anti-coagulate empirically with heparin was delayed until the diagnosis could be confirmed with a CT angiogram of the chest. This patient had other underlying reasons for having a dilated RV (mainly her history of COPD, which can chronically increase afterload in the pulmonary circuit and require higher RV filling pressures to maintain cardiac output).6 As such, patients with COPD can develop cor pulmonale and exhibit right heart strain.7-9 Furthermore, this patient also had no clinical signs of deep venous thrombosis. In a patient with no underlying disease that might cause a chronic RV dilation and no electrocardiographic evidence of RV ischemia or infarction (usually in association with an inferior myocardial infarction),10 a dilated RV on bedside echocardiogram in the acutely dyspneic patient should make one immediately suspicious for acute pulmonary embolism and may even prompt the clinician to begin empiric anticoagulation.The patient’s lab work was significant for an elevated Troponin T of 0.03 ng/mL (normal ≤ 0.02 ng/mL), suggestive of right heart strain. The diagnosis of pulmonary embolism was confirmed on CT angiogram of the chest, which revealed large filling defects in the right and left pulmonary arteries extending into their respective segmental branches. Upon confirmation of the diagnosis, the patient was taken for emergent endovascular catheter-directed tissue plasminogen activator (tPA) and was subsequently admitted to the medical intensive care unit. She had an inferior vena cava (IVC) filter placed after five days and was discharged from the hospital seven days after admission. Topics: Pulmonary embolism, right heart strain, echocardiography, US, POCUS.

Venous Thromboembolic Complications to Hysterectomy for Benign Disease: A Nationwide Cohort Study

Study ObjectiveTo estimate the risk of venous thromboembolic complications after abdominal, laparoscopic, and vaginal hysterectomy when performed for benign disorders. DesignA nationwide cohort study (Canadian Task Force classification II-2). SettingData from Danish national registers on all women undergoing hysterectomy for benign conditions from 1996 to 2015. PatientsWomen aged 18 years and older who underwent hysterectomy for benign disease were stratified into 3 groups according to the hysterectomy approach: abdominal, laparoscopic, or vaginal. InterventionsHysterectomy. Measurements and Main ResultsEighty-nine thousand nine hundred thirty-one women met the inclusion criteria. Venous thromboembolism (VTE) as a diagnosis or cause of death was identified. The risk of postoperative VTE was examined with Cox proportional hazard models adjusting for age, surgical approach, and relevant comorbidities. The mean age was 49.9, 47.9, and 54.3 years for women with abdominal, laparoscopic, and vaginal hysterectomy, respectively. The crude incidences of VTE within 30 days after hysterectomy were 0.24% (n = 142), 0.13% (n = 12), and 0.10% (n = 21). The most important predictors of VTE were the approach to hysterectomy and a history of thromboembolic disease. In the multivariable analysis, the risk of VTE was significantly reduced with laparoscopic hysterectomy (hazard ratio [HR] = 0.51; 95% confidence interval [CI], 0.28–0.92; p = .03) and vaginal hysterectomy (HR = 0.39; 95% CI, 0.24–0.63; p < .001) when compared with the abdominal procedure. Data on postoperative heparin thromboprophylaxis were available in 53 566 patients, and the adjusted HR was 0.63 (95% CI, 0.42–0.96; p = .03) in patients receiving heparin thromboprophylaxis. ConclusionThe 30-day cumulative incidence of VTE after hysterectomy for benign conditions was low overall (0.19%). Laparoscopic hysterectomy and vaginal hysterectomy carry a lower risk than the abdominal procedure. Postoperative heparin thromboprophylaxis significantly reduces the risk of VTE and should be considered, especially if risk factors are present.

Homocysteine Concentrations in Heterozygote MTHFR (677C-T) and Factor V (1691 G-A) Mutation-carrying Individuals with the History of Thromboembolic Disease

Objective: Factor V (FV) (1691 G-A) and methylenetetrahydrofolate reductase (MTHFR) (677 C-T) mutations have been identified as potential risk factors for cardiovascular disease. In this study, we determined vitamin B 12 , folate, and total homocysteine t(Hcy) concentrations in heterozygote MTHFR (677 C-T) and FV (1691 G-A) mutation-carrying individuals. Materials and Methods: The study included a total of 74 individuals with MTHFR (677 C-T) or FV (1691 G-A) mutations and 70 controls. All subjects had the history of thromboembolic disease. t(Hcy), folate, and vitamin B12 concentrations were compared between the groups. Results: A significant difference was found in vitamin B 12 and folate concentrations between patients and controls in the MTHFR (677 C-T) group (p=0.041, p=0.049, respectively). Further, t(Hcy) concentrations were found to be higher in pa- tients than in controls in the FV (1691 G-A) mutation-carrying group (p=0.002). No significant difference was found between the groups in relation with gender in both mutations. Conclusion: t(Hcy) concentrations should be assessed to decrease the risk of future venous thromboembolism in the pres- ence of heterozygote FV (1691 G-A) mutation.