Risk Factor For Thromboembolic Disease Research Articles

Acquired SERPINC1/antithrombin deficiency during oral contraceptive consumption: a case report

BackgroundSERPINC1 is a glycoprotein that regulates blood coagulation. SERPINC1 congenital or acquired deficiencies represent a significant risk factor for thromboembolic disease. SERPINC1 acquired defects are observed in very few cases and can occur in many clinical conditions such as treatment with l-asparaginase or oral contraceptive (particularly estrogen derivatives), but these conditions are not routinely investigated.Case presentationA 50-year-old Caucasian woman who took gestodene 75 µg/ethinylestradiol 20 µg as oral contraceptive, was sent to our thrombophilia clinic because, on thrombophilia testing, a reduction of SERPINC1 (74%) and a slight increase in circulating D-dimer and homocysteine were found. We investigated triggers of such SERPINC1 reduction, and identified gestodene 75 µg/ethinylestradiol 20 µg use as the most likely candidate. Two months after the discontinuation of the oral contraceptive, SERPINC1 value returned to normal (92%) and D-dimer and homocysteine were normalized.ConclusionEach patient has a different sensitivity to contraceptive use. Genetic (or epigenetic) regulation of anticoagulant proteins might account for a different rate of consumption of anticoagulant proteins as oral contraceptives and probably determine the susceptibility to thrombotic events.

Is periodontal infection a risk factor for thromboembolic disease? A systematic review.

Venous thromboembolism (VTE) is a rising major health problem comprising pulmonary embolism (PE) and deep vein thrombosis. It is of concern due to premature mortality, increased morbidity, and associated healthcare costs and hospitalization. Periodontitis can increase the risk of VTE by way of systemic inflammation induced by infection that can contribute to hypercoagulability and platelet aggregation. This systematic review aims to synthesize all the evidence concerning periodontal infection as a risk factor for thromboembolic disease. A search for articles published from 1967 till December 2020 was conducted in the PubMed (MEDLINE), Scopus, and EMBASE data bases. Five hundred and five articles were retrieved after running search strategies in PubMed, Scopus, and EMBASE search databases. Based on the inclusion criteria, three clinical studies, two case series, and ten case reports were included for qualitative analysis. The presence of periodontal disease was reported to influence the occurrence of venous thromboembolic disease with a statistical significance of <0.010. Case series and case reports of septic PE due to periodontal disease showed complete resolution of lung lesions and subsiding of symptoms after dental treatment and antimicrobial therapy. The results of this systematic review suggested for an association between periodontal disease and the incidence of thromboembolic disease. As most of the included/available studies are case series and case reports, the strength of evidence is weak. Evidence generated from well-designed longitudinal controlled clinical trials may be helpful to further assess the strength of the association.

Doubly bi-allelic variants of MTHFR and MTHFD1 in a Chinese patient with hyperhomocysteinemia and failure of folic acid therapy.

Background: Hyperhomocysteinemia (HHcy) is a risk factor for thromboembolic disease. Defects in one-carbon metabolism (1-CM)-related genes, such as methylenetetrahydrofolate reductase (MTHFR), methylenetetrahydrofolate dehydrogenase, cyclohydrolase, and formyltetrahydrofolate synthetase 1 (MTHFD1), can cause HHcy and may also affect the efficacy of folic acid therapy. The details of mechanisms are yet to be further investigated. Method: We described a Chinese family with hereditary HHcy. The proband suffered from severe thromboembolic disease and experienced failure of folic acid therapy. Two sons of the proband were also diagnosed with HHcy but were sensitive to folic acid therapy. Whole-exome sequencing (WES) was conducted to evaluate the genetic lesion of this family. Results: Compound heterozygous variants (a common polymorphism, p. A222V, and a novel variant, p. C631*fs*1) of the MTHFR gene and a homozygous missense variant (p. K134R) of the MTHFD1 gene were identified in the proband. The two sons, with successful intervention, only harbored the homozygous p. A222V variant of the MTHFR gene. Conclusion: The clinical manifestations and genetic research synergistically confirmed the diagnosis of HHcy and clarified the failure of folic acid therapy in the proband caused by doubly bi-allelic variants of the MTHFR and MTHFD1 genes. Our study increased our understanding of the molecular basis of 1-CM-related gene defects on folic acid therapy in HHcy.

A Prospective Study Evaluating Cumulative Incidence and a Specific Prediction Rule in Pulmonary Embolism in COVID-19.

RationaleAbnormal values of hypercoagulability biomarkers, such as D-dimer, have been described in Coronavirus Disease 2019 (COVID-19), which has also been associated with disease severity and in-hospital mortality. COVID-19 patients with pneumonia are at greater risk of pulmonary embolism (PE). However, the real incidence of PE is not yet clear, since studies have been limited in size, mostly retrospective, and PE diagnostic procedures were only performed when PE was clinically suspected.Objectives(1) To determine the incidence, clinical, radiological, and biological characteristics, and clinical outcomes of PE among patients hospitalized for COVID-19 pneumonia with D-dimer > 1,000 ng/mL. (2) To develop a prognostic model to predict PE in these patients.MethodsSingle-center prospective cohort study. Consecutive confirmed cases of COVID-19 pneumonia with D-dimer > 1,000 ng/mL underwent computed tomography pulmonary angiography (CTPA). Demographic and laboratory data, comorbidities, CTPA scores, treatments administered, and clinical outcomes were analyzed and compared between patients with and without PE. A risk score was constructed from all these variables.ResultsBetween 6 April 2020 and 2 February 2021, 179 consecutive patients were included. The overall incidence of PE was 39.7% (71 patients) (CI 95%, 32–47%). In patients with PE, emboli were located mainly in segmental/subsegmental arteries (67%). Patients with PE did not differ from the non-PE group in sex, age, or risk factors for thromboembolic disease. Higher urea, D-Dimer, D-dimer-to-ferritin and D-dimer-to-lactate dehydrogenase (LDH) ratios, platelet distribution width (PDW), and neutrophil-to-lymphocyte ratio (NLR) values were found in patients with PE when compared to patients with non-PE. Besides, lymphocyte counts turned out to be lower in patients with PE. A score for PE prediction was constructed with excellent overall performance [area under the ROC curve-receiver operating characteristic (AUC-ROC) 0.81 (95% CI: 0.73–0.89)]. The PATCOM score stands for Pulmonary Artery Thrombosis in COVID-19 Mallorca and includes platelet count, PDW, urea concentration, and D-dimer-to-ferritin ratio.ConclusionCOVID-19 patients with pneumonia and D-dimer values > 1,000 ng/mL were presented with a very high incidence of PE, regardless of clinical suspicion. Significant differences in urea, D-dimer, PDW, NLR, and lymphocyte count were found between patients with PE and non-PE. The PATCOM score is presented in this study as a promising PE prediction rule, although validation in further studies is required.

PREVENTION OF DEEP VENOUS THROMBOSIS IN POST-OPERATIVE ARTHROPLASTY PATIENTS WITHOUT USE OF ANTICOAGULANT THERAPY

Background: Deep vein thrombosis (DVT) is one of the most common complications of total hip (THA) and total knee arthroplasty (TKA), mostly due to immobilisation and to some extent due to pre-existing co-morbidities along with genetic predisposition. Though the reported incidence of DVT is very high in multiple studies, fatal thromboembolism is very rarely seen in clinical setup. Hence the issue of prophylaxis for DVT remains highly debated1. The incidence of DVT is largely based on various studies in European and American populations. Asian population is genetically and socially quite different from American and European populations, so the incidence of DVT can be quite different2. We conducted a retrospective study at our centre to determine incidence of DVT after THA and TKA in Indian patients. Methods: A retrospective study was conducted on in 45 patients and who underwent THA and TKA respectively, without any known risk factors for thromboembolic disease. No prophylaxis was given to the patients. The patients were monitored in the post op period for any signs and symptoms of DVT along with starting of adequate physiotherapy Results: DVT was found in one patient who had undergone THA, which was confirmed on colour Doppler ultrasonography of the affected limb. No case of DVT was detected in any patient who had undergone TKA. Conclusion: These results suggest that the incidence of DVT in patients is very low and is not comparable when adequate postoperative mobilisation and physiotherapy was done.We conclude that advising prophylactic anticoagulant therapy to these patients in the post op period could be successfully substituted by a simple and cost effective but adequate physiotherapy prevent DVT, in the process also bypassing the side effects of the anticoagulant therapy.

Asthma is a risk factor for thromboembolic disease in pregnancy

IntroductionFinding the risk factors for thromboembolic (TE) disease and preventing its development in pregnant women is important. Asthma is a common chronic disease in pregnant women. The aim of the study is to find the risk factors.Material and methodsFrom 2004 to 2011, 55,057 pregnant women were recruited from a Taiwan database. They were grouped into AS and non-AS groups. AS subjects were divided into three groups. Group 1: with AS before pregnancy or during pregnancy; without AS after childbirth. Group 2: without AS before pregnancy, with AS during pregnancy or after childbirth. Group 3: with AS before, during pregnancy and after childbirth. The rate of TE (during pregnancy and 60 days after childbirth) was compared between different groups.ResultsIn pregnant women, TE rate was 2.47‰ in AS and 0.71‰ in non-AS subjects. The rate was higher in AS subjects (OR 3.47, adjust p 0.005). In group 2, the rate was 3.97‰, higher than that in non-AS subjects (OR 5.44, p 0.013). The TE rate in groups 1 and 3 was similar to non-AS subjects.ConclusionsThe rate of TE increases if pregnant women have AS. Physicians need to be alert to the occurrence of TE as early as possible in pregnant women with AS. If AS was re-appeared or worsened during pregnancy (group 2), the rate of TE increased. Pregnant women and physicians should prevent the re-appear of AS or control AS properly during pregnancy to prevent the occurrence of TE.

An Anomalous Cause of Deep Venous Thrombosis: A Case Report.

IntroductionLower extremity deep venous thrombosis (DVT) is a common diagnosis in the emergency department (ED). Deep venous thromboses can be the result of anatomical variation in the vasculature that predisposes the patient to thrombosis. May-Thurner syndrome (MTS) is one such anatomic variant defined by extrinsic compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae.Case ReportWe report such a case of a 39-year-old woman with no risk factors for thromboembolic disease who presented to the ED with extensive unilateral leg swelling and was ultimately diagnosed with MTS.ConclusionThis diagnosis is an important consideration particularly in patients who are young, female, have scoliosis or spinal abnormalities, or are at low risk for DVT yet who present with extensive lower extremity swelling and are found to have proximal thrombus burden. Often further imaging, anticoagulation, angioplasty, or thrombectomy are indicated to prevent morbidity and post-thrombotic syndrome in these patients.

A Case Report of Cerebral Venous Thrombosis as a Complication of Coronavirus Disease 2019 in a Well-appearing Patient.

IntroductionWhile thrombotic complications of severe coronavirus disease 2019 (COVID-19) have been documented, the overall risk in non-critically ill cases of COVID-19 remains unknown.Case ReportWe report a case of a previously healthy male patient who presented to the emergency department with headache and extremity paresthesia. The patient was diagnosed with cerebral venous thrombosis (CVT) and found to have a positive COVID-19 test. Inpatient anticoagulation was initiated, and symptoms had largely resolved at discharge.ConclusionThis case demonstrates the importance of considering thrombotic complications, such as CVT, even in well-appearing COVID-19 patients with no other risk factors for thromboembolic disease.

Procoagulant State of Sleep Apnea Depends on Systemic Inflammation and Endothelial Damage

IntroductionGrowing evidence shows a hypercoagulable state in obstructive sleep apnea (OSA) that could be a risk factor for thromboembolic disease. ObjectivesWe aimed to elucidate mechanisms involved in the procoagulant profile observed in patients with OSA and to investigate the potential utility of global tests in its characterization. MethodsThirty-eight patients with severe OSA without previous history of thrombosis and nineteen healthy age- and sex-matched controls were included.Kinetic of clot formation was determined using rotational thromboelastometry.Haemostatic capacity of plasma and microparticles was determined by Calibrated Automated Thrombinography.Platelet surface receptors, activation markers and formation of platelet/leukocytes aggregates were analyzed by flow cytometry. ResultsThromboelastometry showed a procoagulant state in patients with OSA that did not seem to be related to a basal activation of platelets but by the increased existence of platelet/leukocyte aggregates.Patients with OSA presented many signs of endothelial damage such as increased plasma levels of E-selectin and cfDNA and enhanced thrombin generation due to the presence of microparticles rich in tissue-factor, which is related to OSA severity. ConclusionsOSA induces an enhancement in the dynamics of clot formation which appears to be caused by at least two pathological mechanisms. First, a greater formation of platelet-leukocyte aggregates; secondly, endothelial damage which provokes a greater procoagulant potential due to the increase in tissue factor-rich microparticles. Moreover, this study has identified thromboelastometry and thrombin generation assay as useful tools to evaluate the prothrombotic state in these patients.

Case Report: A Near Miss of Pulmonary Embolism in a Division 1 Collegiate Basketball Player.

IntroductionThe clinical presentation of pulmonary embolism (PE) is often associated with classic vital instability such as tachycardia, hypoxia, and tachypnea. This critical diagnosis is often less likely if a patient is negative by Pulmonary Embolism Rule-Out Criteria (PERC) standards with a low pre-test probability of disease. Caution must be used when evaluating elite athletes with the PERC rule due to low resting heart rate and certain risk factors, which are inherent to athletics.Case ReportWe report the case of a 20-year-old male Division 1 collegiate athlete with pleuritic chest pain diagnosed with PE despite being PERC negative. His presenting heart rate (HR) of 79 beats per minute was correctly determined to be tachycardic relative to his resting HR of 47–60 beats per minute. Despite his PERC negative status, PE was found after an elevated D-dimer and subsequent computed tomography angiography.ConclusionSpecial consideration should be used when evaluating elite athletes for PE, as their resting physiology may differ from the general population. Additionally, certain risk factors for thromboembolic disease are inherent in competitive athletics and should be considered during an initial risk assessment. The presented patient was successfully treated with oral anticoagulation for three months and was able to return to play.

Prevalence of pulmonary embolism in patients with COVID-19 pneumonia and high D-dimer values: A prospective study.

IntroductionCoronavirus disease 2019 (COVID-19) pneumonia is associated to systemic hyper-inflammation and abnormal coagulation profile. D-dimer elevation is particularly frequent, and values higher than 1μg/mL have been associated with disease severity and in-hospital mortality. Previous retrospective studies found a high pulmonary embolism (PE) prevalence, however, it should be highlighted that diagnoses were only completed when PE was clinically suspected.Material and methodsSingle-center prospective cohort study. Between April 6th and April 17th 2020, consecutive confirmed cases of COVID-19 pneumonia with D-dimer >1 μg/mL underwent computed tomography pulmonary angiography (CTPA) to investigate the presence and magnitude of PE. Demographic and laboratory data, comorbidities, CTPA scores, administered treatments, and, clinical outcomes were analysed and compared between patients with and without PE.ResultsThirty consecutive patients (11 women) were included. PE was diagnosed in 15 patients (50%). In patients with PE, emboli were located mainly in segmental arteries (86%) and bilaterally (60%). Patients with PE were significantly older (median age 67.0 (IQR 63.0–73.0) vs. 57.0 (IQR 48.0–69.0) years, p = .048) and did not differ in sex or risk factors for thromboembolic disease from the non-PE group. D-dimer, platelet count, and, C reactive protein values were significantly higher among PE patients. D-dimer values correlated with the radiologic magnitude of PE (p<0.001).ConclusionsPatients with COVID-19 pneumonia and D-dimer values higher than 1 μg/mL presented a high prevalence of PE, regardless of clinical suspicion. We consider that these findings could contribute to improve the prognosis of patients with COVID-19 pneumonia, by initiating anticoagulant therapy when a PE is found.

P-64 P-selectin and factor VIII as risk factors of thromboembolic disease in patients with hepatocellular carcinoma

Venous thromboembolism (VTE) is a common complication in patients with hepatocellular carcinoma (HCC). Its pathomechanism is associated with non-malignant origin in chronic liver disease as well as malignant disease. However, this high incidence is likely to correlate with other factors. Patients with HCC and VTE have a shorter survival time than patients without VTE. Factor VIII is an important procoagulant protein that binds with high affinity to von Willebrand factor. Factor VIII increased to more than 150% may cause an approximately 6-fold higher risk of venous thrombosis compared to patients with normal factor VIII.

MANAGEMENT OF INTERMEDIATE RISK PULMONARY EMBOLI WITH THE PRESENCE OF A RIGHT VENTRICULAR THROMBUS

TYPE: Abstract Publication TOPIC: Pulmonary Vascular Disease PURPOSE: Discuss management of bilateral pulmonary emboli (PE) with the presence of a right ventricular (RV) thrombus. METHODS: A 37 year old female with morbid obesity presented for evaluation of acute onset chest pain and shortness of breath. She lacked traditional risk factors for thromboembolic disease. She was hemodynamically stable with the exception of tachycardia and tachypnea. RESULTS: EKG demonstrated sinus tachycardia. Labs showed troponin-I of 0.19 ng/mL and D-dimer of 1.22 mcg/mL FEU. CTA chest revealed PE in the bilateral main pulmonary arteries and lobar branches with thrombus in the RV. Contrast-enhanced echocardiogram confirmed RV thrombus, evidence of right heart strain, moderately reduced RV function and estimated at least moderate to severe pulmonary hypertension. CONCLUSIONS: Patient was started on intravenous heparin and underwent right heart catheterization confirming CTA findings showing pulmonary artery systolic pressure (PASP) of 79 mmHg, followed by pulmonary angiography with bilateral mechanical thrombectomy albeit with an unsuccessful attempt of RV thrombectomy. Catheter directed alteplase was initiated with two transfusion catheters. Repeat right heart catheterization revealed PASP of 64 mmHg, only moderate residual clot in the right pulmonary artery with good lung perfusion and minimal residual clot in the left pulmonary artery. She was bridged to warfarin and discharged home with marked symptom resolution. She has not yet had followup. CLINICAL IMPLICATIONS: Idiopathic RV thrombus is an uncommon finding that portends higher risk. Our patient’s acute symptoms resolved with an approach involving thrombectomy followed by catheter-directed lysis. Optimal treatment strategies for these intermediate to high risk PE with RV thrombus are still uncertain. DISCLOSURE: No significant relationships. KEYWORDS: Pulmonary Embolism, Right ventricular thrombus, Mechanical thrombectomy

Diagnostic strategy of pulmonary embolism in the cardiology department of Ibn Rochd University hospital, Casablanca, Morocco

Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis (DVT). PE is third most common cause of cardiovascular death worldwide after stroke and heart attack. Management of PE has evolved recently with availability of local thrombolysis; mechanical extraction devices; hemodynamic support devices like extracorporeal membrane oxygenation; and surgical embolectomy. The aim of our work is to study the clinical features and the management of pulmonary embolism in a cardiology department. We performed a prospective study of 120 patients hospitalized between 2016 and 2018 for acute pulmonary embolism in the cardiology department of CHU Casablanca. A total of 120 patients (mean age 54.3 ± 16.7 years, 77.5% women) with a confirmed PE were included in this study. For risk factors for thromboembolic disease, historic of cancer was present in 23.3%, immobility in 25%, oral contraception in 14%, obesity in 10.8%. Right ventricular dysfunction was assessed by echocardiography in 41.6%, with 48.3% with pulmonary hypertension. The most common clinical signs were dyspnea and chest pain. The most common physical signs were tachypnea and tachycardia. Electrocardiographic abnormalities were found in 35.8%. Chest X-ray was abnormal in 40%. D-dimer was high in 60 patients (50%). US doppler of deep leg veins was positive in 58.3% of patients. Pulmonary helical CT was positive in majority of cases. Unfractionated heparin was administered to about 45.8% of patients and low-molecular-weight-heparin was prescribed at only 22.5% of patients. Management of pulmonary embolism in our cardiology department is characterized by the frequent use of non-invasive techniques on the diagnostic view and appeal to heparin on the therapeutic view.

Acute Systolic Heart Failure as the only Risk Factor for Cardioembolic Cerebrovascular Accident in the Setting of Nonischemic Cardiomyopathy and Normal Sinus Rhythm: A Case Report with Literature Review

The association between atrial fibrillation and stroke is well-known by use of the CHA2DS2VASc risk assessment. However, little is known about the thromboembolic risk in patients who have isolated systolic heart failure (HF) with sinus rhythm. Despite growing literature which shows how HF in the setting of normal sinus rhythm is a risk factor for thromboembolic disease, the recommendation for use of anticoagulation, whether warfarin or direct oral anticoagulation (DOAC) in this setting, is not yet reflected in cardiology guidelines. To reduce the risk of thromboembolism, anticoagulation trials have been done but have not conclusively shown benefit over risk. We present a case of left middle cerebral artery (MCA) stroke after de novo HF in a patient with sinus rhythm, who was previously not on anticoagulation. Case: A 57-year-old male presented to our hospital with worsening shortness of breath for 3 days. He had signs of hypervolemia consistent with an acute heart failure exacerbation. Pertinent physical exam findings included lower extremity edema, rales, and jugular venous distension. He also had fatigue and exertional dyspnea. During his hospital course, he underwent imaging studies that revealed cardiomegaly, absence of pulmonary embolism, and a severely reduced ejection fraction. During his acute heart failure admission, he developed a left MCA stroke suspected to be of cardioembolic etiology and was successfully treated with tissue plasminogen activator (tPA). Conclusion: According to the most recent AHA/ACC cardiovascular disease guidelines, anticoagulation is not indicated in systolic heart failure patients with sinus rhythm. However, our case is rare because the patient had no underlying risk factors for thromboembolism and significant past medical history. He developed new-onset nonischemic cardiomyopathy complicated by a stroke. Therefore, we suggest the need for prophylactic anticoagulation should be assessed on an individual basis, with the assistance of shared decision making, especially when the ejection fraction is acutely and severely reduced.

An atypical case of pulmonary embolism from a jugular vein

SummaryNeck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

Risk Factors of Thromboembolic Disease in Men with Prostate Cancer: Report from a Hispanic Population

IntroductionProstate cancer is the most frequent malignant neoplasm diagnosed in men worldwide. Patients with prostate cancer have higher rates of thrombotic events when compared with other groups of cancer patients; that can be explained because of the presence of multiple risk factors such as age, histopathology, type of therapy, and associated comorbidities. The aim of this study was to determine the risk factors related to development of thrombosis in patients with prostate cancer in a tertiary care center.MethodsRetrospective cohort study that included patients ≥18yo diagnosed with prostate cancer at our institution between 2014 and 2017. Univariate and multivariate analysis were performed including all previously described thrombosis risk factors in cancer patients.ResultsA total of 101 patients were included. Median age was 72 years (52-92). A total of 23 patients (22.8%) presented with a thrombotic event. Regarding baseline characteristics, patients with thrombosis were older (77 vs. 71 years; p=.015), had lower levels of HDL (40.4 vs. 48 mg/dL; p=.033), and a higher prevalence of primary hypertension (65.2% vs.34.6%; p=.009).In patients with thrombosis, 52.2% (n=12) were venous thrombosis and 47.8% (n=11) were arterial. The most common events were pulmonary thromboembolism (n=7; 58.3%) for venous thrombosis and acute coronary syndromes (n=6; 54.5%) for arterial events.In univariate analysis risk factors related to the development of thrombosis were: prostration > 3 days (p=.039), immobility (p=.023), central venous catheter (p=.004), congestive heart failure (p=.021), history of TE (p=.021), major surgery (p=.031) and hip fracture (p=.021). Table 1. On multivariate analysis factors that remained statistically significant were: central venous catheter OR 8.8 (CI 95% 2.2-35.7, p=.002), previous thrombosis OR 10.3 (CI 95% 1.5-72.8, p=.020), and hip fracture OR 8.5 (CI 95% 1.2-63.5,p=.037).ConclusionsIn conclusion, our study confirms findings from previous studies regarding factors that significantly predispose cancer patients to thrombosis development. Considering our population age, it is not surprising that risk factors in patients with prostate cancer were mainly related to the presence of other comorbiditiesparticularly cardiovascular and atherothrombotic disease. The main risk factor was history of previous thrombosis, suggesting that closer and prolonged anticoagulation therapy should be consider. Multicenter prospective studies most be urged in our population to asses and validate risk factors, and design prognostic scores that can help on determining which patients could be candidates to early intervention modifying preexisting factors and/or receiving prophylactic dose of anticoagulants. DisclosuresNo relevant conflicts of interest to declare.

ACUTE PULMONARY EMBOLISM FOLLOWING TWO DOSES OF INTRAVENOUS CONJUGATED ESTROGEN

SESSION TITLE: Medical Student/Resident Pharmacotherapeutics SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Estrogens can increase the synthesis of several clotting factors and increase platelet aggregation.Intravenous estrogen therapy is used to manage uterine bleeding in hospitalized patients.The intravenous route is preferred for a more rapid response.Venous thromboembolism (VTE) is a potentially life-threatening consequence of estrogen therapy.This report describes a case of acute pulmonary embolism following two doses of intravenous conjugated estrogen in a female with no identifiable risk factors for VTE CASE PRESENTATION: 41 year old G3 P3 003 female presented with recurrent heavy vaginal bleed associated with clots and fatigue.Three weeks prior to this, she was admitted with weakness, fatigue, vaginal bleed was found to have a hemoglobin of 3.5g/dl, received 4 units of packed red blood cells.Transvaginal ultrasound at the time revealed a fibroid in the lower uterine segment and she was discharged with oral iron supplementation with her hemoglobin at discharge being 8.7g/dl. She was then referred for surgical management of the bleed. During the current admission for recurrent vaginal bleeding, hemoglobin was 9.8/dl. Physical examination revealed a prolapsed fibroid encompassing the cervical os. She received a one dose of 25mg of intravenous Premarin (conjugated estradiol).The same afternoon while receiving the second dose, she experienced severe chest pain and shortness of breath with desaturation, with an oxygen saturation of 79%. A Computed tomography angiography showed filling defects in the right lateral and posterior lower lobe segmental pulmonary artery embolus. She was started on a heparin drip and eventually underwent uterine artery embolization, which helped control her presenting symptoms. The intravenous Premarin was discontinued and she was transferred to the Intensive care unit.She was discharged on Rivaroxaban for 6 months. Given the fact that she was ambulatory and had no other risk factors for thromboembolic disease, Premarin was the presumed cause of her pulmonary embolus. DISCUSSION: Given that our patient is a young female with no comorbidities who was ambulatory, non-obese and a non-smoker with no family history of thrombophilia developed a pulmonary embolus during her inpatient stay, we would attribute the most likely cause of the event to be the dose of premarin that she received. Use of the Naranjo probability scale indicated a possible relationship between IV estrogen and development of pulmonary embolism in this patient.(1) CONCLUSIONS: The causal effect of dose of estrogen and the risk of thromboembolism has been previously established in those using oral contraceptives.(2) It has been determined that there is a direct correlation with dose and incidence of VTE and has been found to be the highest within the first three months of use. It would be of interest to analyze the risk of thromboembolic events with minimal estrogen exposure such as in our patient. Reference #1: Naranjo CA et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239245. Reference #2: van Hylckama Vlieg A et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type. BMJ 2009 Aug 13 DISCLOSURES: No relevant relationships by Nikhil Jagan, source=Web Response No relevant relationships by Mridula Krishnan, source=Web Response No relevant relationships by Mark Malesker, source=Web Response No relevant relationships by Michael Sanley, source=Web Response

Risk Factors and Management of Venous Thromboembolic Diseases in Donor of Living Donor Liver Transplant

Background: liver transplantation surgically replaces a failing or diseased liver with one that is normal and healthy. At this time, transplantation is the only cure for liver insufficiency or liver failure because no device or machine reliably performs all of the functions of the liver. Aim of the Work: this study aimed to highlight risk factors of the venous thromboembolism in donors of living donor liver transplant and its management. Patients and Methods: this study included 40 patients who underwent hepatectomy for living donor liver transplant. All patients were evaluated extensively, including history and physical examination and specialty consultations when indicated. All patients did haematological studies to detect the risk factors of thromboembolic disease. Results: in patients with manifestations of venous thromboembolism 2 donors have single risk factor for venous thromboembolism and 4 donors have double risk factors. Conclusion: presence of multiple risk factors for venous thromboembolism led to increase in its incidence, so during preoperative assessment of the donors, if they have multiple risk factors for thrombosis some precautions should be taken to avoid venous thrombosis. Recommendations: preoperative precautions include heamatological consultations for the donors and prophylaxis dose of anticoagulant. Intra operative precautions included pneumatic calf pressure, elastic stocking. Finally postoperative precautions should be continued , these donors should take therapeutic doses of anticoagulants and follow up by lower limb venous duplex.

Prostate Cancer Radiation Therapy and Risk of Thromboembolic Events

Toinvestigate the risk of thromboembolic disease (TED) after radiation therapy (RT) with curative intent for prostate cancer (PCa). We identified all men who received RT as curative treatment (n=9410) and grouped according to external beam RT (EBRT) or brachytherapy (BT). By comparing with an age- and county-matched comparison cohort of PCa-free men (n=46,826), we investigated risk of TED after RT using Cox proportional hazard regression models. The model was adjusted for tumor characteristics, demographics, comorbidities, PCa treatments, and known risk factors of TED, such as recent surgery and disease progression. Between 2006 and 2013, 6232 men with PCa received EBRT, and 3178 underwent BT. A statistically significant association was found between EBRT and BT and risk of pulmonary embolism in the crude analysis. However, upon adjusting for known TED risk factors these associations disappeared. No significant associations were found between BT or EBRT and deep venous thrombosis. Curative RT for prostate cancer using contemporary methodologies was not associated with an increased risk of TED.