Rate Of Venous Thrombosis Research Articles

Anticoagulation for Splanchnic Vein Thrombosis in Patients with Myeloproliferative Neoplasms: A Systematic Review and Meta-Analysis

Introduction: Splanchnic vein thrombosis (SVT) is a common manifestation of myeloproliferative neoplasms (MPN). The optimal anticoagulation strategies in MPN-SVT remain unclear due to the challenge of balancing the concurrent prothrombotic state of MPN with the risk for SVT complications, such as gastrointestinal bleeding. Methods: We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of anticoagulation in patients with MPN following SVT incidence. This study protocol was registered on PROSPERO (#CRD42023414120). On April 07, 2023, we comprehensively searched multiple databases from Cochrane Library, EMBASE, and PubMed/MEDLINE. Retrospective or prospective studies in English with at least ten adult patients with MPN-SVT were included. Study screening by title/abstract, full text, and data extraction were performed in duplicate. Primary outcomes included recurrence of venous thrombosis (SVT and non-SVT), arterial thrombosis, and major bleeding. The risk of bias was assessed with MINORS scale. Pooled risk ratio (RR) of recurrent thrombosis and major bleeding events with respective 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method with random-effects model. Pooled rates of recurrent thrombosis and major bleeding events with respective 95% CI were calculated by DerSimonian and Laird method using random-effects model. Inter study heterogeneity was evaluated using the Cochran Q test and I 2 statistic. Results: Of a total of 4624 studies that were identified on the initial abstract screen, full texts were obtained and reviewed for 192 records. We included five retrospective and one prospective study that provided outcome rates for 387 patients with MPN treated with anticoagulation following SVT. All patients receiving anticoagulation in the six studies included in this analysis were treated with vitamin K antagonists (VKA). Of note, one additional study evaluating MPN-SVT with rivaroxaban was not included in the analysis because of short follow-up compared to the other six studies. Most studies were conducted in Europe (n=4), one was international, and one was done in the United Kingdom. The median follow-up was 3.2 years (follow-up was not reported in one study) and median age of patients at SVT diagnosis was 47.5 years old. JAK2V617F positivity was reported in 311/387 (80.3%). Regarding quality assessment and bias risk, four of the studies had moderate and two high risk of bias by the MINORS scale. Pooled incidence rates showed that subsequent venous thrombosis was the most common complication while on anticoagulation (Pooled rate 9.6%; 95% CI 5.6 - 15.8; I 2=27%), followed by major bleeding (Pooled rate, 9%; 95% CI, 3.7 - 20.3; I 2=72%). Four of the six studies provided data comparing management with anticoagulation vs. no anticoagulation in 288 patients. The rates of venous (SVT and non-SVT) and arterial thrombosis following SVT were similar between the anticoagulation vs. no anticoagulation group (venous: RR 0.90; 95% CI, 0.412 - 1.966; I 2 = 0%, Figure 1 and arterial: RR, 1.01; 95% CI, 0.36 - 2.80; I 2=0%). Similarly, there was no significant difference in the risk of major bleeding between the two groups (RR, 0.52; 95% CI, 0.23- 1.14; I 2=0%). (Figure 2) Conclusion: Risk of recurrent thrombosis and bleeding in patients with MPN-SVT are considerable. Anticoagulation with VKA in MPN patients following SVT was not associated with a reduction in the risk of subsequent venous or arterial thrombosis or increased risk of major bleeding. Further studies with larger populations are warranted to elucidate the optimal medical management for MPN-SVT.

Effect of intermittent pneumatic compression on preventing deep vein thrombosis using microfluidic vein chip.

Background: Deep Vein Thrombosis (DVT) is a common disease, frequently afflicting the lower limb veins of bedridden patients. Intermittent Pneumatic Compression (IPC) is often employed as an effective solution for this problem. In our study, a random selection of 264 patients underwent IPC treatment for either one or 8hours daily. The rate of severe venous thrombosis was substantially reduced in the IPC-treated group compared to the control group. However, real-time monitoring of blood flow during IPC operation periods remains a challenge, leading to rare awareness of IPC working mechanism on thrombosis prevention. Methods: Here, microfluidic chip methodology is used to create an in vitro vein-mimicking platform integrating venous valves in a deformable channel. Whole blood of patients after knee surgery was perfused into the venous channel at a controlled flow rate obtained from patients with IPC treatment clinically. Results: According to the numerical simulations results, both of an increase in compressive pressure and a decrease in time interval of IPC device can accelarete blood flow rate and the shear stress within the vein. The vein chip experiments also reveal that the fibrin accumulation can be greatly lowered in IPC treated group, indicating less thrombosis formation in future. A time interval of 24 seconds and a maximum contraction pressure of 40mmHg were proved to be the most effective parameters for the IPC device adopted in our clinical trail. Conclusion: This vein chip presents a novel method for observing the functional mechanisms of IPC device for DVT prevention. It provides crucial data for further standardization and optimization of IPC devices in clinical usage.

Factor XI/XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism: A narrative review.

During the past decade, direct oral anticoagulants (DOACs) have advanced and simplified the prevention and treatment of venous thromboembolism (VTE). However, there remains a high incidence of bleeds, which calls for agents that have a reduced risk of bleeding. Factor XI (FXI) deficiency is associated with lower rates of venous thrombosis and stroke compared to the general population with a lower risk of bleeding. In conjunction with this, phase 2 studies have demonstrated safety and the potential for reduced thrombotic events with FXI inhibitors as compared to currently available medications. The aim of this review is to summarize key data on the clinical pharmacology of FXI, the latest developments in clinical trials of FXI inhibitors, and to describe the efficacy and safety profiles of FXI inhibitors for the prevention of venous and arterial thromboembolism.

The Influence of the Superficial Venous System on DIEP Flap Drainage in Breast Reconstruction.

Autologous tissue has become the gold standard in breast reconstruction. The use of a deep inferior epigastric perforator (DIEP) flap has the advantages of giving a natural appearance to the reconstructed breast and being associated with lower morbidity at the donor site when compared with the transverse rectus abdominis myocutaneous flap. Venous complications such as venous thrombosis and insufficiency remain the main causes of flap loss and surgical revisions. The aim of this study was to evaluate the influence of superficial venous drainage of the DIEP flap and the addition of a second venous anastomosis have on flap survival. This was a retrospective cohort study collected from a prospective database maintained by our institution. Data was obtained from the medical records of female patients who underwent mastectomy and breast reconstruction with a DIEP flap between March 2010 and March 2017. We evaluated 137 DIEP patients with unilateral breast reconstructions. In 64 (46.7%) the deep venous system was chosen and 73 (53.3%) had an additional superficial vein anastomosed. Out of the 137 patients evaluated, there were 16 (11.67%) cases of revision, 14 (10.21%) were due to venous thrombosis. Twelve cases (8.75%) of flap loss were reported. Reoperation rate was lower in the dual venous drainage group when compared with the single venous drainage group (p = 0.005), as was the rate of flap loss (p = 0.006) and reoperation due to venous thrombosis (p = 0.002). Out of the 125 DIEP flaps, fat necrosis was clinically identified in 7 (5.1%) cases, and the rate was lower in the dual venous drainage system group (p = 0.01). Dual venous drainage of a DIEP flap appears to reduce the rates of venous thrombosis, reoperation, total flap loss, and fat necrosis.

Increased Neonatal Mortality and Increasing Rate of Cerebral Venous Sinus Thrombosis in Hospitalized Children: A Pediatric Health Information System Database Study

Introduction: Pediatric Cerebral Venous Sinus Thrombosis (CVST) poses risks of neurological sequelae and mortality, necessitating timely diagnosis and appropriate antithrombotic therapy. Limited sample sizes in previous studies have led to inconsistent treatment recommendations. To better understand pediatric CVST, we used the Pediatric Health Information System (PHIS) database to compare clinical features, treatment practices, and outcomes in neonates versus older children, and in different time periods, to analyze the influence of various parameters on healthcare outcomes. Methods: Deidentified, retrospective data of pediatric CVST was extracted from the large multi-center PHIS administrative database from January 1, 2011, to October 1, 2022. Diagnostic, imaging, procedure, and pharmaceutical billing codes were used to identify demographic information, clinical characteristics, management, and outcome. Multivariance analysis was performed on study parameters in neonates vs. older children (Table 1) and early (2011-2015) vs. late (2016-2022) study era (Table 2). Results: 6080 hospitalizations with CVST diagnosis (0.1% of all hospitalizations) were identified (61% male; median age 5 years; range 0-17 years). Median hospital stay was 8 days (IQR 4, 22), with 52% (N=3147) admitted to the intensive care unit (ICU). Overall mortality of all children was 4.2%. Neonates constituted 17.3% of the hospitalizations (N=1,054). Clinical features in neonates were less-often reported vs. older children more often had headache, hypertension, vomiting, papilledema and hemiparesis (p<0.001). Congenital heart disease/sepsis were common associated diagnoses in neonates vs. sinusitis/mastoiditis in older children (p<0.001). Neonates had a longer hospital stay (median 24 (IQR 11, 55), vs. 8 days (IQR 4, 17); p <0.001), but lower ICU admission (33.4% vs. 55.6%; p<0.001) and readmission rate (0% vs. 1.0%; p=0.002) when compared to older children. CT without contrast was used less often (33.4% vs. 55.1%; p < 0.001), and head ultrasound more often (76.3% vs. 8.0%; p < 0.001) for neonates vs. older children. Enoxaparin and unfractionated heparin (UFH) remained the primary treatments for CVST, with UFH utilized more often in neonates (71.6% vs. 59.2%; p<0.001). Direct oral anticoagulants (DOACs) were predominantly used in older children in limited numbers. Coma and hydrocephalus as complications were lower (0.7% vs. 5.6%, p<0.001 and 6.2% vs. 9.4%, p=0.001), and intracranial bleeding was (19.1% vs.7.0%, p<0.001) in neonates vs. older children. Neonates had increased mortality rate compared to older children (9.7% vs. 3.1%; p<0.001). The number of CVST admissions increased in the late (2016-2022) compared to the early study era (2011-2015) (0.11% vs. 0.08% of all admissions, p<0.001). Patient demographics, duration of hospital stay, ICU admission rates, clinical features, and imaging modalities remained similar in both groups. The use of bivalirudin, and DOACs was present in the late vs. none in the early era (p<0.001 except Dabigatran). Coma in the late (p<0.001) and brain infarct in the early study era (p<0.001) were more common complications. Both readmission rate (p=0.006) and hospital stay (p=0.006) were slightly higher in the late era. No statistically significant differences were found in mortality rate between the two eras (p= 0.226). Conclusion: Pediatric CVST is a serious disorder, with an overall mortality rate of 4.2% in our study. Neonates had distinct clinical features, associated diagnoses, and complications compared to older children. Predominantly UFH and rarely DOACs were administered in neonates. Neonates experienced longer hospital stay, and statistically significant higher mortality rate when compared to older children, consistent with prior studies. Newer anticoagulants were utilized increasingly in the late vs. early study era. Though readmission rate and hospital stay increased in the late era (not statistically significant), this did not translate into increased mortality. Increasing rate of hospitalizations in late compared to early study era is likely due to increasing medical complexity/technological advances in diagnosis/management of pediatric CVST. Future multi-center, prospective studies are needed to better address the increased neonatal mortality and improve overall care of pediatric CVST which is increasingly prevalent as seen in our study.

Increased 90-Day Mortality and Morbidity Among Patients Recovering From Elective Primary Arthroplasty During the COVID-19 Pandemic in New York City.

All elective procedures were stopped in March 2020 because of the coronavirus disease 2019 (COVID-19) pandemic. We report the 90-day mortality and complications of patients who underwent primary arthroplasty before the stopping of elective procedures at a single academic medical center. A retrospective cohort study was conducted including patients who underwent elective primary arthroplasty between December 2019 and mid-March 2020. Their 90-day postoperative mortality and medical complications were statistically compared with those of a historical cohort from the same operative period in 2019. The 2020 and 2019 cohorts included 372 and 410 patients, respectively. Except for the prevalence of diabetes, there was no significant difference between the two cohorts regarding baseline characteristics or preoperative health. The 2020 cohort had statistically significant higher rates of pneumonia (2.7% vs 0.7%; P=.03), readmission (9.1% vs 5.4%; P=.04), pulmonary embolism (1.6% vs 0.2%; P=.04), and 90-day mortality (1.1% vs 0%; P=.04). The 2020 cohort also had a trend for increased rates of deep venous thrombosis (1.1% vs 0.7%; P=.7) and cardiac complications (1.9% vs 0.5%; P=.07) and no change in emergency department visits (14.0% vs 11.7%; P=.3). There were 7 confirmed cases of COVID-19 in the 2020 cohort and 1 death. This study demonstrates that patients who underwent primary arthroplasty procedures at our institution close to the time of the first wave of the COVID-19 pandemic experienced a statistically significant increase in mortality, pneumonia, pulmonary embolism, and readmission compared with a historical cohort. As elective procedures have resumed during the ongoing pandemic, providers and patients should be aware of these increased risks. [Orthopedics. 2024;47(3):135-140.].

Reevaluating Thrombocytosis as a Risk Factor in Free Flap Surgery

Introduction Thrombocytosis, defined as a platelet count >400,000, has been implicated as a risk factor in free flap failure. Despite proposed mechanisms of pedicle thrombosis, recent studies have suggested that thrombocytosis has no effect on free tissue transfer viability. Risk factors that may compromise successful free tissue transfer should be understood and elucidated, with particular attention to thrombocytosis and its conflicting evidence in the literature. We hypothesize that thrombocytosis has no bearing on free flap success or the rates of pedicle thrombosis. Methods Our institution performed a retrospective chart review on all patients who underwent free flap reconstruction over the past 6 years. Patient demographics, medical history, type and location of free tissue transfer, preoperative platelets, postoperative platelets, and flap outcomes and complications (wound dehiscence, infection, hematoma, seroma, and need for blood transfusion) were recorded. Independent t test, Mann-Whitney U tests, χ 2 test, and Fisher exact tests were used to determine P values to compare flap outcomes in patients with thrombocytosis (platelet count >400,000) and those with platelet counts less than 400,000. Results In our 502-patient cohort, 71 were found to have a platelet count >400,000 (35 preoperatively and 36 postoperatively) and 431 patients had platelet counts <400,000. There were 42 reconstructive failures (flap success rate of 91.6%) and 111 returns to the operating room (OR). For patients with postoperative thrombocytosis, 24 flaps returned to the OR (44.4%), whereas in patients without thrombocytosis, 87 flaps returned to the OR (19.4%; P < 0.001). In patients with postoperative thrombocytosis, 10 OR returns were due to pedicle venous thrombosis (18.5%), in comparison to 10 returns for venous thrombosis in those with normal platelets (2.2%; P < 0.001). There was a small difference in free flap success rates between those with postoperative thrombocytosis and normal platelets, 88.7% versus 92.11%; however, this was not statistically significant (P = 0.71). The thrombocytosis group had a higher incidence of overall postoperative complications (P = 0.002). Conclusions Thrombocytosis has historically been cited as a risk factor for free flap reconstruction failure with recent conflicting evidence in the literature. In patients with postoperative thrombocytosis, we found an increased risk of venous thrombosis; however, this did not result in increased flap failure. There was an increase in postoperative complications, which corresponds with National Surgical Quality Improvement Program data reported in the literature. We suspect that thrombocytosis is not a harbinger of free flap failure but rather a marker for overall inflammation, which may confer a higher rate of venous thrombosis requiring reoperation and postoperative complications.

Effects of humanized nursing care on negative emotions and complications in patients undergoing hysteromyoma surgery.

Uterine fibroids, are prevalent benign tumors affecting women of reproductive age. However, surgical treatment is often necessary for symptomatic hysteromyoma cases. This study examines the impact of humanized nursing care on reducing negative emotions and postoperative complications in patients receiving hysteromyoma surgery. To investigate the impact of humanized nursing care on patients undergoing hysteromyoma surgery. Among patients who underwent hysteromyoma surgery at the Fudan University Affiliated Obstetrics and Gynecology Hospital, 200 were randomly assigned to either the control group (n = 100) or the humanized nursing care group (n = 100). The control group received traditional nursing care, while the humanized nursing care group received a comprehensive care plan encompassing psychological support, pain management, and tailored rehabilitation programs. In addition, anxiety and depression levels were assessed using the hospital anxiety and depression scale preoperatively and postoperatively. Postoperative complications were evaluated during follow-up assessments and compared between both groups. The humanized nursing care group demonstrated a significant decrease in anxiety and depression levels compared to the control group (P < 0.05). The rate of postoperative complications, including infection, bleeding, and deep venous thrombosis, was also markedly lower in the humanized nursing care group (P < 0.05). Humanized nursing care can effectively alleviate negative emotions and reduce the incidence of postoperative complications in patients undergoing hysteromyoma surgery. This approach should be considered a crucial component of perioperative care for these patients. Further research may be needed to explore additional benefits and long-term outcomes of implementing humanized nursing care in this population.

Tissue-type plasminogen activator (tPA) homozygous Tyr471His mutation associates with thromboembolic disease.

Tissue-type plasminogen activator (tPA) encoded by PLAT is a major mediator that promotes fibrinolysis and prevents thrombosis. Pathogenetic mutations in PLAT associated with venous thromboembolism have rarely been reported. Here, we report the first case of a homozygous point mutation c.1411T>C (p.Y471H) in PLAT leading to thromboembolic events and conduct related functional studies. The corresponding tPA mutant protein (tPA-Y471H) and wild-type tPA (tPA-WT) were synthesized in vitro, and mutant mice (PLATH/H mice) were constructed. The molecular docking and surface plasmon resonance results indicated that the mutation impeded the hydrogen-bonding interactions between the protease domain of tPA and the kringle 4 domain of plasminogen, and the binding affinity of tPA and plasminogen was significantly reduced with a difference of one order of magnitude. mRNA half-life assay showed that the half-life of tPA-Y471H was shortened. The inferior vena cava thrombosis model showed that the rate of venous thrombosis in PLATH/H mice was 80% compared with 53% in wild-type mice. Our data suggested a novel role for the protease domain of tPA in efficient plasminogen activation, and demonstrated that this tPA mutation could reduce the fibrinolysis function of the body and lead to an increased propensity for thrombosis.

Free Flap Failure and Complications in Acute Burns: A Systematic Review and Meta-analysis.

Severe acute burn injuries represent a challenge to the reconstructive surgeon. Free flap reconstruction might be required in cases of significant critical structure exposure and soft tissue deficits, when local options are unavailable. This study aimed to determine the free flap complication rate in acute burn patients. A systematic review and meta-analysis were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and registered on the International Prospective Register of Systematic Reviews database (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was the free flap failure rate. The study identified 31 articles for inclusion. A total of 427 patients (83.3% men, 16.7% women) accounting for 454 free flaps were included. The mean patient age was 36.21 [95% confidence interval (CI), 31.25-41.16]. Total free flap loss rate was 9.91% [95% CI, 7.48%-13.02%], and partial flap loss was 4.76% [95% CI, 2.66%-8.39%]. The rate of venous thrombosis was 6.41% [95% CI, 3.90%-10.36%] and arterial thrombosis was 5.08% [95% CI, 3.09%-8.26%]. Acute return to the operating room occurred in 20.63% [16.33%-25.71%] of cases. Stratified by body region, free flaps in the lower extremity had a failure rate of 8.33% [95% CI, 4.39%-15.24%], whereas in the upper extremity, the failure rate was 6.74% [95% CI, 3.95%-11.25%]. This study highlights the high risk of free flap complications and failure in acute burn patients.

Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial

BackgroundThe prevalence of pulmonary embolism (PE) is approximately 11–17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined. AimsTo evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD. MethodPost-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy. Results740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %–1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (−10.1 % to −32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %–3.4 %). ConclusionRevised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.

An Updated Systematic Review and Meta-analysis of the Impact of Graduated Compression Stockings in Addition to Pharmacological Thromboprophylaxis for Prevention of Venous Thromboembolism in Surgical Inpatients.

To compare the rate of venous thromboembolism (VTE) in surgical inpatients with pharmacological thromboprophylaxis and additional graduated compression stockings (GCSs) versus pharmacological thromboprophylaxis alone. Surgical inpatients have elevated VTE risk; recent studies cast doubt on whether GCS confers additional protection against VTE, compared with pharmacological thromboprophylaxis alone. The review followed "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines using a registered protocol (CRD42017062655). The MEDLINE and Embase databases were searched up to November 2022. Randomized trials reporting VTE rate after surgical procedures, utilizing pharmacological thromboprophylaxis, with or without GCS, were included. The rates of deep venous thrombosis (DVT), pulmonary embolism, and VTE-related mortality were pooled through fixed and random effects. In a head-to-head meta-analysis, the risk of DVT for GCS and pharmacological thromboprophylaxis was 0.85 (95% CI: 0.54-1.36) versus for pharmacological thromboprophylaxis alone (2 studies, 70 events, 2653 participants). The risk of DVT in pooled trial arms for GCS and pharmacological thromboprophylaxis was 0.54 (95% CI: 0.23-1.25) versus pharmacological thromboprophylaxis alone (33 trial arms, 1228 events, 14,108 participants). The risk of pulmonary embolism for GCS and pharmacological prophylaxis versus pharmacological prophylaxis alone was 0.71 (95% CI: 0.0-30.0) (27 trial arms, 32 events, 11,472 participants). There were no between-group differences in VTE-related mortality (27 trial arms, 3 events, 12,982 participants). Evidence from head-to-head meta-analysis and pooled trial arms demonstrates no additional benefit for GCS in preventing VTE and VTE-related mortality. GCS confer a risk of skin complications and an economic burden; current evidence does not support their use for surgical inpatients.

Thromboembolic complications after COVID-19 in kidney transplant recipients.

Increased venous thrombosis and arterial embolism rates are observed in the general population during or after COVID-19. Data regarding the kidney transplant population are scarce. In this study, we aim to investigate the thrombotic complications and risk factors associated with thrombotic complications in kidney transplant patients. This retrospective observational study included adult kidney transplant recipients diagnosed with COVID-19 between March 2020 and June 2022. The endpoint was the occurrence of thromboembolic events. Four hundred and sixty-nine patients were followed for a median of 10.8 months after COVID-19. Forty patients (8.5%) died. Thromboembolic complications developed in 51 (11.9%) of the surviving patients. Twenty-four patients with thromboembolic events were receiving prophylactic anticoagulation before the event. The patients with mild, moderate, and severe COVID-19 were 292, 129, and 48, respectively. Patients with moderate COVID-19 had a significantly higher percentage of thromboembolic complications than patients with mild COVID-19. Older age, prior heart disease, and moderate COVID-19 were significantly associated with thromboembolic events. The incidence of thromboembolic events after COVID-19 is 10.9 per 100 patient-year. Thromboembolic complications were observed at increased rates in kidney transplant recipients after COVID-19. Therefore, prospective and cohort studies for post-COVID-19 complications regarding the treatment modalities are urgently needed.

The Anterior Versus Posterior Approach for Interbody Fusion in Patients Who Are Classified as Obese: A Retrospective Cohort Study of 9,021 Patients From a National Database.

Introduction Lumbar spine interbody fusions have been performed to relieve back pain and improve stability due to various underlying pathologies.Anterior interbody fusion and posterior interbody fusion approaches are two main approaches that are classically compared.In an attempt to compare these two approaches to the spine, large retrospective national database reviews have been performed to compare and predict 30-day postoperative outcomes; however, they have conflicting findings.Obesity, defined as having a body mass index (BMI) over 30kg/m2, may also contribute to the extent of spine pathology and isassociated withincreased rates of postoperative complications. Complication rates in patients who are obese have yet to be thoroughly investigated using a large national database.Our present investigation aims to make this comparison using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.The goal of the present study is to utilize a nationwide prospective database to determine short-term differences in postoperative outcomes between posterior and anterior lumbar fusion in patients with obesity and relate these findings to previous studies in the general population. Methods A retrospective cohort analysis was conducted on 9,021 patientdata from the ACS-NSQIP database from 2015 to 2019 who underwent an elective, single-level fusion via anterior or posterior surgical approach. This database captures over 150 clinical variables on individual patient cases, including demographic data, preoperative risk factors and laboratory values, intraoperative data, and significant events up to postoperative day 30. All outcome measures were included in this analysis with special attentionto rates of deep venous thrombosis (DVT) and pulmonary embolism (PE), prolonged length of stay (LOS), reoperation, and operation time. Results Multivariable analysis controlling for age, BMI, sex, race, functional status, American Society of Anesthesiologists (ASA) class, and selected comorbidities with P < 0.05 demonstrated that the anterior approach was an independent predictor for all significant outcomes except prolonged length of stay. Compared to the posterior approach, the anterior approach had a shorter total operation time (B = -13.257, 95% confidence interval (CI) [-17.522, -8.992], P< 0.001), higher odds of deep vein thrombosis (odds ratio (OR) = 2.210, 95% CI [1.211, 4.033], P= 0.010), and higher odds of pulmonary embolism (OR = 2.679, 95% CI [1.311, 5.477], P= 0.007) and was protective against unplanned reoperation (OR = 0.702, 95% CI [0.548, 0.898],P= 0.005). Conclusions The obese population makes up a large and growing demographic of those undergoing spine surgery, and as such, it is pertinent to investigate the differences, advantages, and disadvantages of lumbar fusion approaches in this group. While anterior approachesmaybe protective of longer operation time and unplanned reoperation, this benefit may not be clinically significant when considering an increased risk of DVT and PE. Given the short-term nature of this dataset and the limitations inherent in large de-identified retrospective database studies, these findings are interpreted with caution. Longer-term follow-up studies accounting for confounding variables with spine-centered outcomes will be necessary to further elucidate these nuances.

Efficacy of erythropoietin combined with tranexamic acid in reducing perioperative blood loss and blood transfusion rate in elderly patients with femoral intertrochanteric fractures

Purpose: To investigate the efficacy of exogenous recombined human erythropoietin (rhEPO), combined with tranexamic acid (TXA) and administered by different routes, in the treatment of elderly patients with femoral intertrochanteric fractures.Methods: 252 elderly patients in Suzhou Xiangcheng People's Hospital were randomly divided into groups (A, B and C), with 84 patients in each group. All the patients were given rhEPO and iron sucrose, followed by TXA which was administered via topical injection at the fracture site in Group A, via intravenous infusion in Group B, and via topical injection combined with intravenous infusion in Group C. The perioperative actual total blood loss, occult blood loss, hematocrit (HCT), platelet count (PLT), hemoglobin (Hb), and activated partial thromboplastin time (APTT) were assessed. Also evaluated were prothrombin time (PT), fibrinogen (FIB), blood transfusion rate and incidence of deep venous thrombosis (DVT) of the lower limbs. The results were then compared among the three groups.Results: Perioperative total blood loss and occult blood loss as well as the blood transfusion rate were lowest in Group C, followed by Group B and then Group A. The differences were statistically significant (p &lt; 0.05). The HCT and Hb levels were highest in Group C, followed by Group B and then Group A (p &lt; 0.05).Conclusion: Multi-modal administration of drugs (rhEPO combined with topical injection and intravenous infusion of TXA) is effective in treating elderly patients with femoral intertrochanteric fractures. The strategy efficiently reduces perioperative blood loss and blood transfusion rate, and also improves relevant blood biochemical indicators.

The role of aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis after total knee arthroplasty: a meta-analysis of randomized controlled trials.

There is a debate over the use of aspirin after total knee arthroplasty (TKA) for venous thromboembolism (VTE) prophylaxis. To evaluate the clinical effectiveness and safety of aspirin after TKA, the authors performed a meta-analysis of randomized controlled trials that compared aspirin with low-molecular-weight heparin (LMWH). PubMed, Cochrane Library, Embase, and Web of Science were last searched on 31 January 2023 for studies comparing the effect of VTE prophylaxis between aspirin and LMWH. The results of eligible studies were analyzed in terms of VTE, deep venous thrombosis, pulmonary embolism, and bleeding complications rates. Six randomized controlled trials including 6772 patients met the inclusion criteria. LMWH showed a statistically significant reduction in the overall VTE rate (RR 1.46, 95% CI: 1.16-1.84). No significant differences in deep venous thrombosis, pulmonary embolism, and bleeding complications rates were found between aspirin and LMWH. Compared with LMWH, aspirin presents a higher risk of VTE after TKA. In terms of safety, aspirin and LMWH show comparable outcomes. The results do not support the role of aspirin role as an anticoagulant for preventing VTE after TKA.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis.

Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA. A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants. Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61). Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Midterm Outcomes of Operatively and Nonoperatively Managed Achilles Tendon Ruptures in Young Adults.

There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated. At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores. Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59). This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts. Level III, retrospective cohort study.

Abatacept for immune checkpoint inhibitor associated myocarditis (ATRIUM): Phase 3, investigator-initiated, randomized, placebo-controlled study to evaluate the efficacy and safety of abatacept compared to placebo in hospitalized patients with immune checkpoint inhibitor associated myocarditis.

TPS2680 Background: Patients with myocarditis secondary to treatment with an immune checkpoint inhibitor (ICI) represent a poor prognosis population with a critical unmet clinical need. Data have shown that the rate of major adverse cardiac events (MACE) with ICI myocarditis despite administration of corticosteroids ranges from 25-50%. Abatacept is a selective co-stimulation modulator that inhibits T cell activation by binding to CD80 and CD86, thereby blocking its interaction with CD28. In preclinical animal models of ICI myocarditis, the administration of abatacept led to a reduction in cardiac immune activation and an increase in survival. Methods: The abatacept for immune checkpoint inhibitor associated myocarditis (ATRIUM) trial is designed as a phase 3, investigator-initiated, randomized, placebo-controlled study to evaluate the efficacy and safety of abatacept compared to placebo in hospitalized participants with ICI associated myocarditis. Hospitalized participants diagnosed with ICI-related myocarditis, as defined by the International Cardio-Oncology Society, ≥ 18, with serum evidence of ongoing myocardial injury (troponin ≥5 times the upper limit normal), and treated, or with intent to treat, with 1000 mg of solumedrol/day are eligible. In the randomized protocol, participants receive either abatacept (10 mg/kg) or placebo given IV followed by study drug infusion/placebo again at 24 hours and on day 14. Of note, there is an optional 4th dose on day 28. The primary aim is to test whether abatacept, as compared to placebo, is associated with a reduction in MACE among participants hospitalized with myocarditis secondary to an ICI. The primary outcome, MACE, is a composite of first occurrence of cardiovascular death, non-fatal sudden cardiac arrest, cardiogenic shock, significant ventricular arrhythmias, significant bradyarrhythmias, or incident heart failure. Each component of the primary composite end point will be evaluated individually as a secondary endpoint, as are troponin levels, rates of deep venous thrombosis and pulmonary embolism, and incidence rates of treatment-related adverse events. Exploratory outcomes focus on cancer outcomes, healthcare utilization, quality of life, and correlative studies. Recently, the trial has been amended to allow eligible participants who have achieved an ATRIUM primary end-point prior to randomization to be eligible for inclusion in the RESCUE arm of the protocol where they will be given open-label Abatacept on day 1, 2, 14, with optional dose at 28. The study is open at 20 sites across the US with a plan for a total of 50 locations across US and Canada. This study is recruiting at time of submission. Target enrollment is 390 patients. Clinical trial information: NCT05335928 .

Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury.

Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI. This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups. Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028). Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.