Minor Risk Factors Research Articles

Association between exposure to ambient fine particulate matter and prevalence of type 2 diabetes in Iran: an ecological study.

Epidemiological evidence for the link between long-term exposure to air particulate matter (PM2.5) and occurrence of type 2 diabetes (T2D) is limited such that little is known about the effect of PM2.5 exposure and adult T2D prevalence. Thus, the aim of this ecological study is to evaluate the contribution of ambient PM2.5 exposure to the adult T2D prevalence in the large population of Iran. The study was conducted based on Iran's large-scale cross-sectional surveilling non-communicable diseases (NCDs) risk factors (Timpka et al. 2015b). A total of 31,050 participants were enrolled in three sequential processes of study using cluster random sampling. PM2.5 data in the urban area of 31 provinces of Iran were acquired from Tehran Air Quality Control Company (AQCC) and the Department of Environment (DoE) of Iran during 2012-2016. Moreover, major and minor diabetes risk factors were considered; the Pearson correlation and a stepwise regression model were performed to estimate associations between risk factors and diabetes and prediabetes prevalence. The results showed T2D prevalence was more frequent among women (10.61%) than men (9.35%). A weak positive correlation was observed between PM2.5 level and diabetes prevalence with a correlation coefficient of 0.275, although there was no significant association between PM2.5 value and prediabetes prevalence. Moreover, none of the variables included in the regression model could predict the prevalence of diabetes and prediabetes. According to our study results, it can be suggested that investigating the association between PM2.5 exposure and T2D prevalence at individual level may provide a better understanding of PM2.5 exposure and the risk of T2D prevalence.

Atrial fibrillation and CHA2DS2VASc score of 1 - is there a problem in clinical practice?

Aim. To study the incidence of nonvalvular atrial fibrillation (AF) in patients with a CHA2DS2VASc score of 1 in actual clinical practice, to determine the major and minor risk factors of thromboembolism and the frequency of oral anticoagulant therapy in these patients.Material and methods. We performed a retrospective analysis of 6575 medical records of patients hospitalized for five years in a therapeutic inpatient unit. To determine the stroke risk, major and minor modifying factors were assessed.Results. Of 1160 patients with nonvalvular AF, 93 (8,0%) patients had a CHA2DS2VASc score of 1: hypertension (87,1%), heart failure (4,3%), vascular diseases (4,3%), diabetes (2,15%) and age 65-74 years (2,2%); minor modifying factors were as follows: left atrial (LA) dilatation (81,7%), obesity (40,9%), persistent/permanent AF (37,6%), proteinuria (26,9%), chronic kidney disease (3,2%). A combination of minor risk factors was observed in 61,3%, the most common of which were obesity, LA dilatation, persistent/permanent AF. Anticoagulants were prescribed to 72% of patients with a CHA2DS2VASc score of 1.Conclusion. In actual clinical practice, patients with nonvalvular AF with a CHA2DS2VASc score of 1 are often found. The most common risk factors for stroke in these patients are hypertension, persistent or permanent AF, LA dilatation, and obesity. The use of anticoagulant therapy in these patients does not contradict current guidelines. However, further prospective follow-up is necessary to determine the effectiveness and safety of this therapy.

The characteristics of neonatal sepsis in Low Birth Weight (LBW) infants at Sanglah General Hospital, Bali, Indonesia

Backgrounds: Neonatal sepsis is a significant cause of mortality and long-term morbidity. The preterm infant has high-risk sepsis and its sequelae. Low birth weight infants were more susceptible to sepsis. Initial infections in neonates may not be identified due to non-specific symptoms and sign with the limited laboratory criteria. This study aims to describe the characteristics of neonatal sepsis in low birth weight infants in the neonatology intensive care unit of Sanglah Hospital.Methods: A retrospective cross-sectional study was conducted among 168 infants aged zero to 28 days with birth weights <2,500 grams from May 2017 – April 2018 at Sanglah General Hospital, Bali, Indonesia using a purposive sampling technique. The inclusion criteria were sepsis infants who were hospitalized in neonatology care rooms during the study period at Sanglah General Hospital. Variables assessed in this study were sex, location and mode of delivery, birth weight, gestational age, number of parity, length of stay, the onset of sepsis, as well as the outcome. Data were analysed using SPSS version 17 for Windows.Results: The mortality rate of sepsis in low birth weight infants was 29.8%. Most of the subjects were male (53%), location of delivery at Sanglah Hospital (60.7%), born spontaneously (51.2%), birth weight were 1500-2499 grams (58,3%) and the most gestational ages were 32-36 weeks (44,6%). Early-onset neonatal sepsis (EONS) dominates patients with neonatal sepsis, with a mean length of stay was 23.27±20.32 days. The major infection risk factor was premature rupture membrane (PRM) >24 hours (14.9%), and minor infection risk factor was gestational age <37 weeks (78%), very low birth weight (44.6%) and asphyxia (41.1%). The total blood culture positivity was 38 (22.6%) cases, and Enterococcus faecalis was the most common organism in this study.Conclusion: The incidence and mortality of neonatal sepsis in LBW infants were still high. The importance of knowledge and awareness of pregnant women about danger signs and the risk of infection can reduce the incidence of early-onset neonatal sepsis. Prevention of healthcare-associated infections can reduce the incidence of late-onset neonatal sepsis.

Risk Factors for Puncture Site Complications Using the Angio-Seal Closure Device in Endovascular Therapy: A Single-center Analysis.

To retrospectively analyze the complication rates and risk factors associated with the use of the Angio-Seal vascular closure device during neuroendovascular therapy. In this study, we enrolled 283 patients who underwent Angio-Seal hemostasis between December 2005 and June 2019 at our institute. We retrospectively analyzed the major and minor complication rates and risk factors between the complication and no-complication groups using the medical charts of patients for whom the device was used. Of the 283 patients, 5 had major complications (1.8%) and 18 had minor complications (6.3%). There were no significant differences between the complication (n = 23) and no-complication (n = 260) groups regarding the baseline characteristics or operation procedures. Among the major complications, superficial femoral artery puncture, 8Fr device, Angio-Seal Evolution, post-carotid artery stenting, dual antiplatelet therapy, and delirium were considered risk factors. The Angio-Seal is a safe and useful hemostatic device. However, puncture site complications need to be considered when the device is used for contraindicated patients or for those with delirium who cannot rest following the procedure.

Risk factors for adverse events within one year after atrial septal closure in children: a retrospective follow-up study

Secundum atrial septal defect is one of the most common congenital heart defects. Previous paediatric studies have mainly addressed echocardiographic and few clinical factors among children associated with adverse events. The aim of this study was to identify neonatal and other clinical risk factors associated with adverse events up to one year after closure of atrial septal defect. This retrospective case-control study includes children born in Sweden between 2000 and 2014 that were treated surgically or percutaneously for an atrial septal defect. Conditional logistic regression was used to evaluate the association between major and minor adverse events and potential risk factors, adjusting for confounding factors including prematurity, neonatal sepsis, neonatal general ventilatory support, symptomatic atrial septal defects, and pulmonary hypertension. Overall, 396 children with 400 atrial septal defect closures were included. The median body weight at closure was 14.5 (3.5-110) kg, and the median age was 3.0 (0.1-17.8) years. Overall, 110 minor adverse events and 68 major events were recorded in 87 and 49 children, respectively. Only symptomatic atrial septal defects were associated with both minor (odds ratio (OR) = 2.18, confidence interval (CI) 95% 1.05-8.06) and major (OR = 2.80 CI 95% 1.23-6.37) adverse events. There was no association between the investigated neonatal comorbidities and major or minor events after atrial septal defect closure. Patients with symptomatic atrial septal defects had a two to four times increased risk of having a major event, suggesting careful management and follow-up of these children prior to and after closure.

Broadening the Categories of Patients Eligible for Extended Venous Thromboembolism Treatment.

Traditionally, venous thromboembolism (VTE) resulting from major transient risk factors (e.g., surgery or trauma) or a major persistent risk factor such as cancer, has been defined as being provoked, whereas unprovoked VTE encompasses events without an identifiable cause. These categorizations influence anticoagulant treatment duration; unlike VTE provoked by major transient risk factors, extended anticoagulation beyond 3 months is advised for patients with cancer or unprovoked VTE due to risk persistence after treatment cessation. However, some patients with VTE provoked by minor transient or minor persistent risk factors may also be candidates for extended anticoagulation therapy due to the continuing risk of recurrence. In patients who require extended therapy, vitamin K antagonists (VKAs) are effective but are associated with an increased risk of bleeding and various treatment burdens (e.g., anticoagulation monitoring and dose adjustment). Evaluations of extended VTE treatment with the less-burdensome direct oral anticoagulants such as apixaban, dabigatran, edoxaban, and rivaroxaban show that they are at least as safe and effective as VKAs in a broad range of patients. In addition, apixaban and rivaroxaban offer more than one dosing option, allowing tailoring of treatment to the patient's specific risk factor profile. Analysis of more granular definitions for risk factor groupings has also yielded vital information on the most appropriate strategies for the treatment of patients with specific risk factors, highlighting that extended anticoagulation treatment may benefit those with minor transient and persistent environmental and nonenvironmental risk factors who commonly receive shorter-duration therapy.

Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care

Prehospital care of severe trauma patients often involves endotracheal intubation (ETI), which has complications. The frequency and predictors of post-ETI hypotension and cardiac arrest are not well defined in this population. We sought to derive and validate a scoring system that predicts post-ETI hypotension in prehospital patients and to describe the impact of hypotension on outcome. We performed an observational cohort study including normotensive adult trauma patients requiring ETI, treated from 2001 to 2018 by critical care transport providers in a regional air medical transport system. We divided eligible patients into a derivation cohort (2001–2010) and validation cohort (2011–2018) for analysis. We identified predictors of new systolic hypotension (<90 mmHg) or cardiac arrest within 15 minutes of ETI then developed and validated a scoring system that stratified patients into low, moderate and high risk. We included 4,866 subjects, 3,127 in the derivation and 1,739 in the validation cohort. Post-ETI hypotension occurred in 11% and 21%, respectively; 5% of each cohort experienced post-ETI cardiac arrest. Major independent predictors of post-ETI hypotension were age, pre-ETI systolic blood pressure and pre-ETI oxygen saturation. We developed a well-calibrated scoring system based on these major and several minor risk factors. Applying our system, 890 (33%) derivation patients and 550 (37%) validation patients were higher risk for post-ETI adverse outcomes. Of these, 21% and 33% respectively experienced post-ETI hypotension and 6% and 4%, respectively suffered post-ETI cardiac arrest. Patients at high risk for post-ETI hypotension or arrest are common and identifiable in prehospital trauma care.

Circumstances of provoked recurrent venous thromboembolism: the Austrian study on recurrent venous thromboembolism

Patients with unprovoked deep-vein thrombosis (DVT) of the leg or pulmonary embolism (PE) have a high recurrence risk. How often these recurrences are provoked by a temporary risk condition is unknown. In a cohort of patients with unprovoked venous thromboembolism (VTE), we evaluated the clinical circumstances of recurrence. We studied patients with DVT of the leg and/or PE. End point was recurrence of objectively verified symptomatic VTE. Provoked recurrence was defined according to guidance criteria. 1188 patients were followed for a median of 8.9 years after withdrawal of oral anticoagulants. 312 patients had recurrent VTE, which was provoked in 42 (13%). Recurrence was related to a major risk factor in 19, to a minor risk factor in 22, and to a persistent risk factor in one patient(s). 14 recurrences occurred after major surgery and 5 during hospitalization. Ten recurrences occurred after minor surgery, eight after trauma and three during female hormone intake. Four recurrences occurred during heparin prophylaxis. The incidence of provoked VTE recurrence appears to be low. VTE can recur when prevention is stopped or even during thromboprophylaxis. Surgery and trauma are frequent risk factors.

P6141Associations between atmospheric parameters and haemostatic factors: a case control study

Abstract Background One of the biggest health challenges in the 21st century is global climate change. The health effect of climate change is partly mediated through atmospheric parameters. There is a growing concern that atmospheric parameters might increase cardiovascular (CV) morbidity. Increased levels of haemostatic factors are predictors of CV events. The associations between CV diseases and atmospheric parameters have been widely reported, however there are few studies of atmospheric parameters' effects on markers of haemostasis. Purpose We examined the possible association between atmospheric parameters and several haemostatic markers. Methods The study consisted of 3800 hospitalized patients with acute CV diseases (ACVDs) and 260 healthy blood donors. We examined the relationship of haemoglobin (Hgb), white blood cells (WBC), thrombocytes (THR) and local atmospheric parameter conditions (temperature, atmospheric pressure, humidity, wind speed, atmospheric front) on a day-to-day basis in a 5-year period (2009–2013) using a General Additive Model with cubic splines of covariates, regularized by a ridge penalty, and employing generalized cross validation. Atmospheric parameters were allowed to have a lagged effect by up to 21 days. Results Among blood donors, the average of daily temperature lagged by 8–14 days had a significant effect on Hgb, exhibiting a U-shaped relationship, where higher Hgb values were associated with extremities of the observed temperature interval. For ACVD patients, all examined blood test variables has a significant association with at least some of the atmospheric parameters. Hgb was shown to have a negative linear relationship with mean daily humidity, and the average of daily temperature lagged by 15–21 days, while the average of daily temperature variation lagged by 2–7 days had highly non-linear effect. The relative strength of the association with Hgb was largest for daily temperature variation. WBC values had a slightly non-linear positive relationship with atmospheric pressure lagged by 1 day, with WBC being significantly increased above 1030 hPa. THR values decreased linearly with an increase in mean daily temperature averaged for days lagged 15–21. Atmospheric pressure lagged by 1 day also had a significant effect on THR, with a positive linear effect under 1010 and over 1020 hPa but no effect between. The relative effect of atmospheric pressure on THR was twice as large compared to temperature. Conclusions Our study showed that exposure to certain atmospheric parameters is associated with significant changes in haemostatic marker levels. In the context of global climate change, the importance of focusing on atmospheric parameters as minor CV risk factor is substantially growing. A better understanding of the fluctuation of the examined markers, in light of atmospheric parameters, appears to be of particular importance for future studies and could help establish new CV prevention strategies.

P3850Impact of sex and risk factors for venous thromboembolism on the clinical course of first acute venous thromboembolism. Insights from the PREFER in VTE

Abstract Introduction The interaction between sex and specific provoking risk factors for venous thromboembolism (VTE) may influence initial presentation and prognosis. Purpose We investigated the impact of sex on the risk of recurrence across subgroups of patients with first VTE classified according to baseline risk factors. Methods PREFER in VTE was an international, non-interventional registry (2013–2015) including patients with a first episode of acute symptomatic objectively diagnosed VTE. We studied the risk of recurrence in patients classified according to baseline provoking risk factors for VTE consisted of i) major transient (major surgery/trauma, &gt;5 days in bed), ii) minor transient (pregnancy or puerperium, estroprogestinic therapy, prolonged immobilization, current infection or bone fracture/soft tissue trauma); iii) unprovoked events, iv) active cancer-associated VTE. Results A total of 3,455 patients diagnosed with first acute VTE were identified, of whom 1,623 (47%) were women. The percentage of patients with a major transient risk factor was 22.2% among women and 19.7% among men. Minor transient risk factors were present in 21.3% and 12.4%, unprovoked VTE in 51.6% and 61.6%, cancer-associated VTE in 4.9% of women and 6.3% of men, respectively. The proportions of cases treated with Vitamin-K antagonists (VKAs) and direct oral anticoagulants (DOACs) were similar between sexes. Median length of treatment of VKAs was 181.5 and 182.0 days and of DOACs was 113.0 and 155.0 days in women and men, respectively. At 12-months of follow-up, VTE recurrence was reported in 74 (4.8%) women and 80 (4.5%) men. Table 1 shows the sex-specific proportion of recurrences by VTE risk factor categories. Table 1 Major Transient (n=722) Minor transient (n=573) Cancer-associated (n=195) Unprovoked (1965) Women (361) Men (361) OR (95% CI) Women (346) Men (227) OR (95% CI) Women (79) Men (116) OR (95% CI) Women (837) Men (1128) OR (95% CI) One-year follow-up, n (N%) Recurrent VTE, 21 (6.2) 10 (2.9) 0.46 (0.2; 0.9) 9 (2.7) 12 (5.4) 2.09 (0.9; 5.0) 6 (8.0) 5 (4.5) 0.54 (0.2; 1.9) 38 (4.7) 53 (4.7) 1.03 (0.7; 1.6) Major bleeding, 6 (1.8) 5 (1.5) 0.83 (0.3; 2.7) 5 (1.5) 1 (0.5) 0.30 (0.1; 2.6) 1 (1.3) 3 (2.7) 2.07 (0.2; 20) 10 (1.2) 15 (1.4) 1.11 (0.6; 2.4) All-cause death, 37 (10.2) 31 (8.5) 0.82 (0.5; 1.4) 10 (2.9) 14 (6.2) 2.21 (0.9; 5.1) 26 (32.9) 49 (42.2) 1.49 (0.8; 2.7) 33 (3.9) 30 (2.7) 0.66 (0.4; 1.1) Conclusions The proportion of patients with recurrent VTE events after first acute symptomatic VTE provoked by transient risk factors was not negligible during the first year of follow-up during in both women and men. These results may have implications on the decision whether to consider extended anticoagulant therapy in selected patients with provoked events. Acknowledgement/Funding This study was funded by Daiichi Sankyo.

D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry.

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy. We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel). In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n=171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n=382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors. Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

Atmospheric fronts as minor cardiovascular risk factors, a new approach to preventive cardiology

BackgroundCardiovascular diseases are the number one cause of death globally and represent 31% of all global deaths. The aim of our study was to determine the influence of front effects on acute cardiovascular diseases (ACVDs). MethodsWe obtained all ACVD admissions in a Central-European region, Hungary, Budapest. A time-series analysis was applied to 6499 morbidity cases during a five-year period (2009–2013). Poisson-regression model was used and adjusted for air temperature, pressure, humidity, wind velocity, their interactions and seasonality to assess the association of fronts and ACVDs. ResultsThere is a positive significant association between ACVDs and a cold front effect lagged by one day (p=0.018) with a relative risk (RR) of 1.095 [95% CI (1.021,1.181)]. Our findings show that among patient subgroups with major cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, history of CVDs) the patterns are similar, but occluded fronts also have a significant effect. ConclusionAtmospheric fronts could play an important role in the pathogenesis of ACVDs. Our findings might help to provide a better understanding about fronts as minor cardiovascular risk factors and to organize medical prevention more effectively. Our research project may become a basis of a new field of preventive cardiovascular medicine in the future.

The potential role of scavengers in spreading African swine fever among wild boar

Understanding the transmission patterns of African swine fever (ASF) among wild boar (Sus scrofa) is an issue of major interest, especially in the wake of the current ASF epidemic. Given the high stability of ASF-virus, there is concern about scavengers spreading infectious carcass material in the environment. Here, we describe scavenging activities on 32 wild boar carcasses in their natural habitat in Germany. Using digital cameras, we detected 22 vertebrates at the study sites, thereof two mammal and three bird species scavenging. The most frequently detected species was the raccoon dog Nyctereutes procyonoides (44% of all visits). Raccoon dogs, red foxes (Vulpes vulpes), and buzzards (Buteo buteo) scavenged in the warm and the cold season, while ravens (Corvus corax) and white-tailed eagles (Haliaeetus albicilla) scavenged only in the cold season. In summer, however, insects removed most of the carcass biomass. Although most of the material was consumed on the spot, foxes, raccoon dogs and ravens left the study sites in rare cases with a small piece of meat in their mouths or beaks. We conclude that scavengers represent a minor risk factor for spreading ASF, but may contribute to reducing local virus persistence by metabolizing infected carcasses.

Associations between depression, anxiety, stress, hopelessness, subjective well-being, coping styles and suicide in Chinese university students.

Suicide is a major public health concern worldwide. This study aimed to predict the suicidal behavior of Chinese university students by studying psychological measures such as hopelessness, orientation to happiness, meaning in life, depression, anxiety, stress, and coping styles. In November 2016, a stratified-clustered-random sampling approach was utilized to select subjects from two large public medical-related universities in Shandong province, China. This sample consisted of 2,074 undergraduate students (706 males, 1,368 females; mean age = 19.79±1.39 years). The students’ major risk factors for suicide were depression, anxiety, stress, and hopelessness, and the students’ minor risk factors included orientation to happiness and coping styles (including self-distraction, self-blame and substance use). Notably, the presence of meaning in life had a positive effect on preventing suicide and acted as a protective factor, which suggests that it is important to identify risk factors as well as protective factors relevant to the target population group in order to increase the effectiveness of counseling and suicide prevention programs.

Is periodontitis a prognostic factor in order to indicate antibodies against citrullinated peptides in patients with rheumatoid arthritis?

In this cross-sectional study we investigated antibody titres against cyclic citrullinated peptides derived from filaggrin (anti-CCP) and citrullinated α-enolase (anti-CEP-1) among patients with RA as a function of periodontal findings. 107 patients with RA (median age 56 years, 75% females) were included. For periodontal diagnoses missing teeth, periodontal epithelial surface area, periodontal inflamed surface area and periodontal diagnosis according to the working group's guidelines of the Center for Disease Control and Prevention were determined. Subgingival bacterial DNA of five periodontopathic bacteria was assessed by PCR with sequence-specific oligonucleotides. Anti-CCP and anti-CEP-1 antibodies in plasma samples were investigated using enzyme-linked immunosorbent assays. Low resolution human leukocyte antigen (HLA) typing was carried out using PCR with sequence-specific primers. PESA was found associated with a low adjusted odds ratio for anti-CCP positivity (OR=1.002, p=0.040). All patients who were infected with Aggregatibacter actinomycetemcomitans were simultaneously anti-CCP positive (p=0.043). HLA-DRB1*13 lowered the adjusted odds ratio for anti-CCP (OR=0.073, p=0.002) and anti-CEP-1 (OR=0.068, p=0.018) positivity whereas HLA-DRB1*07 indicated a lower risk only for demonstrable anti-CCP antibodies (OR=0.079, p=0.004). HLA-DRB1*04 was associated with increased adjusted odds ratio for anti-CEP-1 positivity (OR=4.154, p=0.005) and the simultaneous proof of both investigated autoantibodies (OR=3.725, p=0.011). Among patients with RA periodontitis may be a minor risk factor for anti-CCP positivity. Our data first provide evidence that an infection with A. actinomycetemcomitans is associated with an increased formation of anti-CCP. HLA phenotype proved to be a significant risk indicator for both investigated antibodies.

PB2444 INHERITED THROMBOPHILIA IN EGYPTIAN CHILDREN: A 13 YEAR SINGLE CENTER STUDY

Background:Thrombophilia is most commonly due to genetic mutation affecting the amount or function of a protein in the coagulation system. Thrombosis can be arterial or venous with the latter being commoner and increasingly reported in children. There are few big studies describing inherited thrombophilia in the paediatric age group nonetheless in countries with high prevalence of consanguinity.Aims:So we assessed all our cohort diagnosed with inherited thrombophilia and correlated clinical data with genetic mutations.Methods:Retrospective study collecting data from the medical records of 52 children diagnosed with inherited thrombophilia and following up in Haematology Outpatient clinic, Cairo University Paediatric Hospital. Collected data was analysed and statistically correlatedResults:Our cohort included 52(30 males,22 females; 23% neonates, 19% &lt; 6 months and 13% &gt;6 months) children diagnosed with inherited thrombophilia. 30.7 % are of a consanguineous marriage and 12 % have a have a positive family history of thrombosis. 55.7% of patients presented in the first year of life(23% neonates, 19%&lt; 6 months, 13% &gt;6 months);28.8% presented at age 1 to 5years whereas 13.4% at the age of 5 to 10 years and only one child was &gt; 10 years old. Thrombosis was venous in 39/52 (75%) patients, arterial in 12/52 (23.1%) and intra‐cardiac in only one(1.9%) patient. 36.5% of our cohort had recurrent thrombosis. Thrombotic events involved the cerebral vessels in 44.2% children, lower limb vessels in 32.7%, upper limbs in 7.7%, head and neck in 11.5% and the heart in 3.8%. 10 patients presented with both bleeding symptoms and thrombotic events. Thrombosis occurred spontaneously in 34.6% while 65.4% of children had risk factors; dehydration(65.4, fever and infection in nine patients (17.3%), surgery and blood sampling each in 7.7%, trauma and CVP insertion each in 3.8%.44 (84.6%) patients had more than one mutation and only 8 (15.4%). patients had a single mutation. 14(26.9%) had Factor V G1691A(13 heterozygous, 1 homozygous) whereas 10 had heterozygous Factor V 1299R (R2). 3(5.8%)patients had heterozygous Prothrombin 20210A, 9(17.3%) had Factor XIII V34L(7 heterozygous, 2 homozygous). 18 (34.6%), children had B‐Fibrinogen ‐455 G &gt; A (heterozygous in 16, homozygous in 2). Uncommonly reported mutations in the literature but showing a higher prevalence in our cohort included PAI‐1 mutation in 24(46.2%, heterozygous in 19 and homozygous in 5); HPA‐1 in 15(28.8%, heterozygous in 7, homozygous in 8); ACE in 28(53.8%, heterozygous in (n = 16), homozygous in (n = 12); APO E mutations in 20(38.5%, heterozygous in 6,homozygous in 14). Twenty (38.5%) patients had MTHFR C6777T,heterozygous in 17 and homozygous in 3 whereas and another 20 patients had heterozygous MTHFR 1298C mutation. 3 patients had protein C(PC) deficiency which together with MTHFR C6777T mutation usually present at a very early age.26 (50%) had complications; amputation (15.4%) blindness and developmental delay each in 7.7%, renal atrophy, hydrocephalus, and death each in 3.8%, and ischemic insult (1.9%).Summary/Conclusion:Egyptian children having more than one heterozygous mutation even if weakly thrombophiliac are prone to develop significant thrombotic events when exposed to minor risk factors or spontaneously

Direct oral anticoagulants for extended treatment of venous thromboembolism: insights from the EINSTEIN CHOICE study.

The risk of recurrence of venous thromboembolism (VTE) persists after interruption of the initial anticoagulation therapy. New evidence shows that direct oral anticoagulants are effective for extended treatment of VTE and may reduce the risk of all-cause mortality. The optimal duration of anticoagulation after VTE is, however, controversial and complicated by the need for individualised assessment and balance between thrombosis and bleeding risks. Three direct oral anticoagulants (rivaroxaban, apixaban and dabigatran) have been studied for extended treatment of VTE. Dabigatran was shown to be safer than vitamin K antagonists and similarly effective for the prevention of recurrent VTE. Dabigatran, apixaban and rivaroxaban resulted in significant decreases in the rate of recurrent symptomatic VTE when compared to placebo, without a statistically significant difference in the risk of major bleeding. The latest guidelines of the American College of Chest Physicians suggest the use of low-dose aspirin to prevent VTE recurrence in patients who want to stop anticoagulation. In the randomised, double-blind, phase 3 EINSTEIN CHOICE trial, once-daily rivaroxaban at doses of 20 mg or 10 mg and 100 mg of aspirin were compared in VTE patients for whom there was clinical equipoise for extended anticoagulation. Either a treatment dose (20 mg) or a prophylactic dose (10 mg) of rivaroxaban significantly reduced the risk of VTE recurrence without a significant increase in bleeding risk compared with aspirin. The EINSTEIN CHOICE trial included patients with provoked or unprovoked VTE. Patients with VTE provoked by minor persistent or minor transient risk factors enrolled in this trial had not-negligible VTE recurrence rates. These new findings on extended therapy suggest the possibility of anticoagulation regimens at intensities tailored to the patients' risk profiles and VTE characteristics, with a shift of the risk-benefit balance in favour of extended treatment.

Analysis of the Risk Factors Associated with Minor Bleeding in Patients with Venous Thromboembolism during Treatment with Direct Oral Anticoagulants

Direct oral anticoagulants (DOACs) are safe and efficacious when compared to warfarin for patients with venous thromboembolism (VTE). However, bleeding is a major side effect of anticoagulant therapy in VTE patients. Discontinuation of the DOACs associated to adverse events such as bleeding. The HAS-BLED score predicts warfarin-associated hemorrhage. However, little is known about risk factors for DOAC-associated minor bleeding in VTE patients. We aimed to identify risk factors for minor bleeding in VTE patients that were treated with edoxaban, rivaroxaban, or apixaban. We retrospectively evaluated the data of 212 VTE patients who received treatment with a DOAC. The study endpoint was defined as the occurrence of minor bleeding. Logistic regression analysis was used to determine risk factors that were significantly associated with minor bleeding. A total of 36 (17.0%) patients experienced minor bleeding, with rates of 15.7%, 0%, and 21.3% for edoxaban, rivaroxaban, and apixaban, respectively. In the multivariate analysis, bleeding history or predisposition [odds ratio (OR) 6.083, 95% confidence interval (CI) 2.131-17.364, p=0.001] and cancer (OR 6.397, 95% CI 2.858-14.317, p<0.001) were significantly associated with minor bleeding. Bleeding history or predisposition and cancer were the most important risk factors for DOAC-induced minor bleeding in VTE patients in this study. To continue anticoagulant therapy of the DOACs, further management systems by minor bleeding risk factors for patients with VTE will be required.

Characteristics and Cardiovascular Disease Event Rates among African Americans and Whites Who Meet the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) Trial Inclusion Criteria.

Determine the risk for cardiovascular disease (CVD) events among adults with clinically evident CVD who meet the inclusion criteria for the FOURIER clinical trial on PCSK9 inhibition in a real-world database. We analyzed data from 2072 African American and 2972 white REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 45-85years of age with clinically evident CVD. Study participants meeting the FOURIER inclusion criteria (one major or two minor cardiovascular risk factors, fasting LDL cholesterol ≥ 70mg/dL or non-HDL cholesterol ≥ 100mg/dL, triglycerides ≤ 400mg/dL, and taking statin) were followed for CVD events (myocardial infarction, stroke, coronary revascularization, and CVD death) from baseline in 2003-2007 through 2014. Overall, 771 (37.2%) African Americans and 1200 (40.4%) whites met the FOURIER inclusion criteria. The CVD event rate per 1000 person years was 60.6 (95% CI 53.6-67.6) among African Americans and 63.5 (95% CI 57.7-69.3) among whites. The risk for CVD events among adults meeting the FOURIER inclusion criteria was higher for those with a history of multiple cardiovascular events (hazard ratios among African Americans and whites 1.34 [95% CI 1.05-1.71] and 1.34 [1.10-1.63], respectively), a prior coronary revascularization (1.44 [1.13-1.84] and 1.23 [1.00-1.52], respectively), diabetes (1.38 [1.08-1.76] and 1.41 [1.15-1.72], respectively), reduced glomerular filtration rate (1.63 [1.26-2.11] and 1.29 [1.03-1.62], respectively), and albuminuria (1.77 [1.37-2.27] and 1.33 [1.07-1.65], respectively). The CVD event rate is high among African Americans and whites meeting the FOURIER inclusion criteria. Characteristics associated with a higher CVD risk may inform the decision to initiate PCSK9 inhibition.

P073 RISK STRATIFICATION TO INCREASE VENOUS THROMBOEMBOLISM PROPHYLAXIS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE

Pediatric patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE), but are often overlooked for pharmacologic prophylaxis. We instituted a risk-stratification algorithm to identify high-risk patients and offer enoxaparin prophylaxis (EP) aimed at preventing VTE in hospitalized children with IBD flares. We performed a prospective observational quality improvement and patient safety initiative at a large pediatric tertiary care hospital from September 2012 to June 2017. Major risk factor was admission for IBD flare with colonic involvement. Minor risk factors were personal history of thrombosis, first-degree family history of VTE, known thrombophilia, persistent anti-phospholipid antibody >12 weeks, oral contraceptive use, smoking, obesity, thalidomide use, or central venous catheter. The algorithm was incorporated into the electronic medical record (EMR). 458 patients aged 1-27 years (mean 14.6 years, 58.4% male) were admitted 787 times. The electronic risk-stratification algorithm was applied to 234 (29.7%) admissions. Of those, 29 (12.4%) met high-risk criteria and received prophylactic enoxaparin. Forty-three admissions were not screened in the EMR but received VTE prophylaxis, indicating likely use of the posted paper algorithm. Patients assessed with the electronic tool were more likely to receive prophylactic enoxaparin than those who were not screened (p < 0.05). There were 8 total VTE events (7 venous, 1 arterial), 3 of whom were receiving EP. There were no bleeding complications in patients receiving EP. A standardized approach to risk-stratification and EP is important in preventing thrombotic events in pediatric patients with IBD. Risk assessment using our EMR algorithm increased the number of patients who receive thromboprophylaxis. EP is safe for children with active IBD flares.