Transient Risk Factors Research Articles

Selection of Home Treatment and Identification of Low-Risk Patients With Pulmonary Embolism Based on Simplified Pulmonary Embolism Severity Index Score in the Era of Direct Oral Anticoagulants.

The simplified Pulmonary Embolism Severity Index (sPESI) score could help identify low-risk patients with pulmonary embolism for home treatment. However, the application of the sPESI score and selection for home treatment have not been fully evaluated in the direct oral anticoagulants era. The COMMAND VTE (Contemporary Management and Outcomes in Patients With Venous Thromboembolism) Registry-2 is a multicenter registry enrolling consecutive patients with acute symptomatic venous thromboembolism. The current study population consists of 2496 patients with hemodynamically stable pulmonary embolism (2100 patients [84%] treated with direct oral anticoagulants), who were divided into 2 groups: sPESI scores of 0 and ≥1. We investigated the 30-day mortality, home treatment prevalence, and factors predisposing to home treatment using the Kaplan-Meier method and logistic regression model. Patients with an sPESI score of 0 accounted for 612 (25%) patients, and only 17% among 532 patients with out-of-hospital pulmonary embolism were treated at home. The cumulative 30-day mortality was lower in patients with an sPESI score of 0 than the score of ≥1 (0% and 4.8%, log-rank P<0.001). There was no patient with 30-day mortality with an sPESI score of 0. Independent factors for home treatment among out-of-hospital pulmonary embolism patients with an sPESI score of 0 were no transient risk factors for venous thromboembolism, no cardiac biomarker elevation, and direct oral anticoagulants use in the acute phase. The 30-day mortality rate was notably low in an sPESI score of 0. Nevertheless, only a minority of patients with an sPESI score of 0 were treated at home between 2015 and 2020 after the introduction of direct oral anticoagulants for venous thromboembolismin Japan.

Effect of anteroposterior vibration frequency on the risk of lumbar injury in seated individuals

Few studies investigate the impact of anterior-posterior excitation frequency on the time-domain vibrational response and injury risk of the lumbar spine in seated individuals. Firstly, this study utilised a previously developed finite element model of an upright seated human body on a rigid chair without a backrest to investigate the modes that affect the anterior-posterior vibrations of the seated body. Subsequently, transient dynamic analysis was employed to calculate the lumbar spine’s time-domain responses (displacement, stress, and pressure) and risk factors under anteroposterior sinusoidal excitation at varying frequencies (1–8 Hz). Modal analysis suggested the frequencies significantly affecting the lumbar spine’s vibration were notably at 4.7 Hz and 5.5 Hz. The transient analysis results and risk factor assessment indicated that the lumbar responses were most pronounced at 5 Hz. In addition, risk factor assessment showed that long-term exposure to 8 Hz vibration was associated with a greater risk of lumbar injury.

Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate.

To investigate the clinical trajectories and identify risk factors linked to post-enucleation urinary incontinence (UI). In this prospective study (April 2020 to March 2022) at a single institution, 316 consecutive patients receiving endoscopic enucleation due to benign prostatic enlargement were included. Patient information and perioperative details were collected. Follow-ups, from 1 to 6 months, assessed postoperative UI using International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and a four-item pad questionnaire, classified per International Continence Society definitions. Logistic regression analysed predictors at 1 week, while generalised estimating equation assessed risk factors from 1 to 3 months postoperatively. Patients with a median prostate volume of 57 mL underwent enucleation, with 22.5% experiencing postoperative UI at 1 week, 5.6% at 3 months, decreasing to 1.9% at 6 months. Multivariable analysis identified age (>80 years), specimen weight (>70 g), en bloc with anteroposterior dissection, and anal tone (Digital Rectal Examination Scoring System score <3) as potential factors influencing UI. Subgroup analysis revealed that specimen weight was associated with both continuous and stress UI. Anal tone was related to both other types and stress UI, while overactive bladder symptoms were associated with urge UI. In summary, our study elucidates transient risk factors contributing to temporary post-enucleation UI after prostatectomy. Informed decisions and personalised interventions can effectively alleviate concerns regarding postoperative UI.

Risk of recurrent venous thromboembolism and major bleeding according to risk factor profiles in Asian patients: a subgroup analysis EINSTEIN-Extension and EINSTEIN-CHOICE

BackgroundRisks of recurrence and major bleeding with extended anticoagulation in Asian patients with venous thromboembolism (VTE) are similar to those in non-Asian patients but risks according to baseline risk factor profiles is not well documented.MethodsSubgroup analysis of two randomized trials, which compared once-daily rivaroxaban (20 mg or 10 mg) with placebo or aspirin (100 mg) for extended treatment in Asian patients with VTE who had completed 6–12 months of anticoagulation. Index events were classified as unprovoked, provoked by major persistent risk factors, minor persistent risk factors, minor transient risk factors, or major transient risk factors. One-year cumulative risks of recurrent VTE were calculated for these risk factor profiles.Results367 patients received rivaroxaban, 159 aspirin, and 48 placebo. For patients with unprovoked VTE, one-year cumulative incidences of recurrence in the 202 patients given rivaroxaban, the 89 given aspirin and the 28 given placebo were 1.6%, 5.8%, and 14.8%, respectively. For patients with VTE provoked by minor persistent risk factors, these incidences were 0% in the 74 patients given rivaroxaban, 9.3% in the 36 given aspirin, and 0% in the 12 given placebo. No recurrent VTE occurred in patients with VTE provoked by major persistent or transient risk factors or minor transient risk factors. Rivaroxaban was not associated with a significant increase in major bleeding.ConclusionsRivaroxaban seems to be an effective and safe option for extended treatment in Asian patients, especially those presenting with unprovoked VTE. Subgroups of patients with provoked risk factors were too small to draw meaningful conclusions.Trial registrationNCT00439725 and NCT02064439.

Optimizing Venous Stenting: Consensus Recommendations for Enhanced Management of Lower Extremity Deep Vein Thrombosis.

Deep vein thrombosis (DVT) poses a complex challenge and often leads to postthrombotic syndrome (PTS), a debilitating complication. The emergence of venous stents offers a potential preventive avenue against this complication. This study aimed to provide consensus recommendations on the use of venous stent for DVT. From June to July 2023, 20 internal medicine, angiology and vascular surgery, and vascular and interventional radiology experts were involved in the Delphi process. Thirty-one recommendations, categorized into three thematic areas, were rigorously evaluated: indications for stent use, stent selection and placement, and monitoring and prevention of complications. Agreement was evaluated using a Likert scale, with consensus defined as agreement by two-thirds of the participants. Consensus was reached for 23 (74.2%) of 31 recommendations. The agreement was centered on considerations, such as stent placement in specific acute DVT scenarios, emphasizing pivotal stent characteristics. However, there were divergences in the recommended stent length to prevent migration and stent characteristics based on iliocaval bifurcation morphology. Notably, there was no consensus on whether patients with DVT caused by a major transient risk factor need more than 3 months of anticoagulation therapy or whether aspirin should be added to anticoagulant treatment after venous stenting. These consensus recommendations offer practical insights into optimizing venous stent use to prevent PTS in DVT patients. Addressing the critical aspects of stent selection, placement, and postprocedural care, these recommendations contribute to clinical decision-making. The identified divergences underscore the importance of consensus and thus indicate the need for further investigation.

403 Malignant Cerebral Venous Infarction: Decompressive Craniectomy Versus Medical Treatment

INTRODUCTION: Cerebral venous thrombosis (CVT) is a common stroke in young adults and is associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are these patients' most common causes of death. METHODS: In this retrospective study, Patients with the following inclusion criteria have entered the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive mid-position pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered the study. 23 patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils’ reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P &lt; 0.001). A favorable outcome (modified Rankin scale score 0e2) was achieved in 52% of the DC group and 0% of the MG group (P &lt; 0.001). CONCLUSIONS: Our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcomes in most patients.

Behavioural ecology meets oncology: quantifying the recovery of animal behaviour to a transient exposure to a cancer risk factor.

Wildlife is increasingly exposed to sublethal transient cancer risk factors, including mutagenic substances, which activates their anti-cancer defences, promotes tumourigenesis, and may negatively impact populations. Little is known about how exposure to cancer risk factors impacts the behaviour of wildlife. Here, we investigated the effects of a sublethal, short-term exposure to a carcinogen at environmentally relevant concentrations on the activity patterns of wild Girardia tigrina planaria during a two-phase experiment, consisting of a 7-day exposure to cadmium period followed by a 7-day recovery period. To comprehensively explore the effects of the exposure on activity patterns, we employed the double hierarchical generalized linear model framework which explicitly models residual intraindividual variability in addition to the mean and variance of the population. We found that exposed planaria were less active compared to unexposed individuals and were able to recover to pre-exposure activity levels albeit with a reduced variance in activity at the start of the recovery phase. Planaria showing high activity levels were less predictable with larger daily activity variations and higher residual variance. Thus, the shift in behavioural variability induced by an exposure to a cancer risk factor can be quantified using advanced tools from the field of behavioural ecology. This is required to understand how tumourous processes affect the ecology of species.

Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry.

Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.

Cerebral Venous Thrombosis in Pediatric Age: Risk Factors and Prognosis.

Cerebral venous thrombosis (CVT) is a rare but potentially fatal disease in pediatric age with an important morbimortality. In adults several factors have been associated with worse outcomes, however there are still few studies in children. This study aims to identify risk factors associated with clinical manifestations and long-term sequelae in pediatric CVT. Retrospective analysis of pediatric inpatients admitted to a tertiary-care hospital due to CVT between 2008 and 2020. Fifty-four children were included, 56% male, median age of 6.5 years (9 months-17.3 years). Permanent risk factors were identified in 13 patients (malignancy, 8; hematologic condition, 5) and transient risk factors in 47, including head and neck infections (57%) and head trauma (15%). Multiple venous sinuses involvement was present in 65% and the deep venous system was affected in four patients. Seventeen percent had intracranial hemorrhage and 9% cerebral infarction. Sixty-four percent of patients with multiple venous sinuses involvement presented with severe clinical manifestations: impaired consciousness, intracranial hypertension, acute symptomatic seizures or focal deficits. Regarding long-term prognosis, six patients had major sequelae: epilepsy (n = 3), sensory motor deficits (n = 2), and cognitive impairment (n = 3). Permanent risk factors were associated with severe clinical manifestations (p = 0.043). Cerebral infarction and intracranial hemorrhage were associated with major sequelae (p = 0.006 and p = 0.03, respectively, adjusted for age and sex). Permanent risk factors, involvement of multiple venous sinuses, intracranial hemorrhage, and cerebral infarction, were related to worse prognosis. Detection and early management of risk factors may limit CVT extension and reduce its morbimortality.

Multiple risk factors are associated with an incremental increase in acute venous thromboembolism risk after total joint arthroplasty: A pearldiver cohort study.

Several risk factors are associated with acute venous thromboembolism (VTE) after total joint arthroplasty (TJA). However, there is a lack of literature regarding the cumulative impact of multiple risk factors. To address this gap, we utilized the PearlDiver database, an insurance billing claims database containing de-identified data from 91 million orthopedic patients. The PearlDiver database was queried for records of patients who underwent total hip and knee arthroplasty from 2010 to 2019 using ICD-10 and CPT codes. Twelve persistent and two transient risk factors were analyzed for their association with the occurrence of acute VTE within three months after surgery. Univariate and logistic regression analyses with odds ratios (ORs) and confidence intervals (CIs) were conducted to determine the odds associated with each risk factor and the impact of multiple concurrent risk factors. A total of 988,675 patients who underwent hip and knee arthroplasty met the inclusion criteria, of whom 1.5% developed acute VTE after three months. The prevalence of VTE risk factors ranged from 0.2 to 38.6%. Individual, persistent risk factors demonstrated 14-84% increased odds of VTE compared to a 1.2% increase for a transient risk factor (acute myocardial infarction). Three or more persistent risk factors were associated with a higher risk of VTE. Persistent risk factors were associated with a higher incidence of postoperative VTE than transient risk factors. An incremental increase in risk was noted if three or more persistent risk factors were present.

Quantitative patient graph analysis for transient ischemic attack risk factor distribution based on electronic medical records

A transient ischemic attack (TIA) affects millions of people worldwide. Although TIA risk factors have been identified individually, a systemic quantitative analysis of all health factors relevant to TIA using electronic medical records (EMR) remains lacking. This study employed a data-driven approach, leveraging hospital EMR data to create a TIA patient health factor graph. This graph consisted of 737 TIA and 737 control patient nodes, 740 health factor nodes, and over 33,000 relations between patients and factors. For all health factors in the graph, the connection delta ratios (CDRs) were determined and ranked, generating a quantitative distribution of TIA health factors. A literature review confirmed 56 risk factors in the distribution and unveiled a potential new risk factor “rhinosinusitis” for future validation. Moreover, the patient graph was visualized together with the TIA knowledge graph in the Unified Medical Language System. This integration enables clinicians to access and visualize patient data and international standard knowledge within a unified graph. In conclusion, graph CDR analysis can effectively quantify the distribution of TIA risk factors. The resulting TIA risk factor distribution might be instrumental in developing new risk prediction machine learning models for screening and early detection of TIA.

Clinical features and long-term outcomes of venous thromboembolism in the warfarin era versus in the direct oral anticoagulant era

Abstract Background/Introduction After the introduction of direct oral anticoagulant (DOAC) for venous thromboembolism (VTE), DOAC for VTE have prevailed all over the world, which could change the daily clinical practice and clinical outcomes. However, there have been still limited data on the issue in the real world. Purpose We aimed to investigate demographics, practice patterns and long-term clinical outcomes in patients with VTE comparing a large observational study in the warfarin era and that in the DOAC era. Methods The COMMAND VTE Registry-1 (enrolled 3,027 VTE patients among 29 center between January 2010 and August 2014 in the warfarin era) and Registry-2 (enrolled 5,197 VTE patients among 31 centers between January 2015 and August 2020 in the DOAC era) are the series of a multicenter observational study in Japan enrolling consecutive patients with acute symptomatic VTE. Results Patients characteristics were comparable in most of aspects between the groups, whereas prevalence of active cancer was higher in the Registry-2 (Registry-1: 23% vs. Registry-2: 29%, P&amp;lt;0.001). As for oral anticoagulation therapy, 88% (2,676/3,027) of patients were treated with warfarin in the Registry-1 and 79% (4,128/5,197) of patients were treated with DOAC in the Registry-2. The proportion of patients admitted to the hospital was lower in the Registry-2 (80% vs. 69%, P&amp;lt;0.001). The discontinuation rate of anticoagulation therapy was significantly higher in the Registry-2 (42.8% vs. 52.5% at 3-year, Log rank P&amp;lt;0.001). The cumulative 5-year incidence of recurrent VTE was lower in the Registry-2 (10.5% vs. 9.5%, Log rank P=0.02), which remained significant even after adjusting the confounders (adjusted hazard ratio [HR]: 0.78 (0.65-0.93), P=0.006). There was no significant difference in the cumulative incidence of major bleeding between the groups (12.1% vs. 13.7%, Log-rank P=0.26), which remained insignificant even after adjusting the confounders (adjusted HR: 1.03 (0.89-1.20), P=0.67). After stratifying a total cohort into sub-groups according to the risk classification of recurrent VTE in the current guidelines (major transient risk factors, minor transient risk factors, unprovoked, non-malignant persistent risk factors, and active cancer), the risks of recurrent VTE and major bleeding were significantly lower in the Registry-2 among active cancer group (recurrent VTE: 17.7% vs 10.1% at 5-year, Log rank P&amp;lt;0.001, major bleeding: 26.6% vs 20.4% at 5-year, Log rank P=0.04), while those were not significantly different between the groups among other sub-groups. Conclusion In the current series of large real-world VTE registries, there seemed to be a significant risk reduction of recurrent VTE in the DOAC era compared with in the warfarin era, while there was no sign of increased risk of major bleeding in the DOAC era.

Clinical long-term outcomes in fragile patients with venous thromboembolism receiving direct oral anticoagulant: From the COMMAND VTE Registry-2

Abstract Background In patient with venous thromboembolism (VTE), assessment of risk of the opposing complications, major bleeding and recurrent VTE, is clinically imperative to determine the duration of anticoagulation therapy. Patients with VTE and fragility (age ≥75 years, creatinine clearance level ≤50 ml/min, and/or body weight ≤50 kg) are reportedly at increased risk of bleeding complications associated with anticoagulant. However, there is lack of real-world data with respect to bleeding risk in fragile patients with VTE receiving direct oral anticoagulant (DOAC). Purpose The current study aimed to assess the relationship between fragility and long-term outcomes in such patients. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. The current study population consisted of 3,928 patients with treatment with DOAC and available data of body weight and serum creatine level, who were divided into a fragile group (N=2,136, 45.6%) and a non-fragile group (N=1,792, 54.4%). The primary outcomes were major bleeding and recurrent VTE. Results In the entire study population, the mean age was 68±15 years, 59% was women, and mean body weight, body mass index, creatinine clearance level were 59.2±14.1 kg, 23.4±4.4 kg/m², and 67.8 (49.1-94.2) ml/min, respectively. The fragile group showed a higher proportion of female and higher prevalence of several comorbidities including hypertension and history of stroke than the non-fragile group, while there was not statistically difference in diabetes mellitus, liver cirrhosis, autoimmune disorder, active cancer, history of VTE, history of major bleeding, and transient VTE risk factor between the two groups. As for laboratory test, the fragile group showed higher prevalence of anemia. The fragile group more often received off-label doses of DOAC, while discontinuation of anticoagulation therapy was not statistically different between the two groups. There was a significantly difference in the cumulative 5-year incidence of major bleeding between the two groups but not in the cumulative 5-year incidence of recurrent VTE (the fragile group, 15.0% vs the non-fragile group, 11.1%, P = 0.049; and 9.6% vs 8.9%, P = 0.38, respectively). However, after adjusting for potential confounders, the excess risk of the fragile group relative to the non-fragile group was not statistically significant for major bleeding or recurrent VTE (adjusted HR 1.09, 95%CI 0.87-1.37, P = 0.47 and adjusted HR 1.06, 95%CI 0.80-1.41, P = 0.67, respectively). Conclusions In the multivariate analysis with data from the current large-scale observational study, there was not statistically significant association between the fragility and major bleeding or recurrent VTE in patient receiving DOAC.

Incidence and predictors of post-thrombotic syndrome in patients with proximal DVT in a real-world setting: findings from the GARFIELD-VTE registry.

Although substantial progress has been made in the pathophysiology and management of the post-thrombotic syndrome (PTS), several aspects still need clarification. Among them, the incidence and severity of PTS in the real world, the risk factors for its development, the value of patient's self-evaluation, and the ability to identify patients at risk for severe PTS. Eligible participants (n = 1107) with proximal deep-vein thrombosis (DVT) from the global GARFIELD-VTE registry underwent conventional physician's evaluation for PTS 36months after diagnosis of their DVT using the Villalta score. In addition, 856 patients completed a Villalta questionnaire at 24months. Variable selection was performed using stepwise algorithm, and predictors of severe PTS were incorporated into a multivariable risk model. The optimistic adjusted c-index was calculated using bootstrapping techniques. Over 36-months, 27.8% of patients developed incident PTS (mild in 18.7%, moderate in 5.7%, severe in 3.4%). Patients with incident PTS were older, had a lower prevalence of transient risk factors of DVT and a higher prevalence of persistent risk factors of DVT. Self-assessment of overall PTS at 24months showed an agreement of 63.4% with respect to physician's evaluations at 36months. The severe PTS multivariable model provided an optimistic adjusted c-index of 0.68 (95% CI 0.59-0.77). Approximately a quarter of DVT patients experienced PTS over 36months after VTE diagnosis. Patient's self-assessment after 24months provided added value for estimating incident PTS over 36months. Multivariable risk analysis allowed good discrimination for severe PTS.

Anticoagulation strategies and long-term recurrence in patients with venous thromboembolism in the era of direct oral anticoagulants

BackgroundThere has been limited data on anticoagulation strategies and long-term recurrence in patients with venous thromboembolism (VTE) in the era of direct oral anticoagulant (DOAC). MethodsThe COMMAND VTE Registry-2 is a multicenter retrospective cohort study enrolling 5197 consecutive patients with acute symptomatic VTE between January 2015 and August 2020 among 31 centers in Japan. In this primary report, the entire cohort was divided into 5 groups; major transient risk factors (N = 475, 9.1%), minor transient risk factors (N = 788, 15%), unprovoked (N = 1913, 37%), non-malignant persistent risk factors (N = 514, 9.9%), and active cancer (N = 1507, 29%) groups. ResultsDOACs were administered in 79% of patients who received oral anticoagulants. Discontinuation of anticoagulant at 1 year was most frequent in the major transient risk factors group (57.2%, 46.3%, 29.1%, 32.0%, and 45.6%). The cumulative 5-year incidence of recurrent VTE was lowest in the major transient risk factors group (2.6%, 6.4%, 11.0%, 12.1%, and 10.1%, P < 0.001). The cumulative 5-year incidence of major bleeding was highest in the active cancer group (9.8%, 11.4%, 11.0%, 15.5%, and 20.4%, P < 0.001). After discontinuation of anticoagulation therapy, the cumulative 5-year incidence of recurrent VTE was highest in the unprovoked group (3.3%, 11.0%, 24.9%, 17.5%, and 11.8%, P < 0.001). ConclusionsIn this large real-world VTE registry, anticoagulation strategies and long-term recurrence widely differed depending on the baseline characteristics. Detailed risk stratifications of recurrent VTE could be useful for decision-making of anticoagulation strategies, whereas the bleeding-risk assessment might be especially important in the era of DOAC. Clinical Trial RegistrationURL: http://www.umin.ac.jp/ctr/index.htm Unique identifier: UMIN000044816.

Surgery As a Trigger for Incident Venous Thromboembolism: Results from a Population-Based Case-Crossover Study.

Background Surgery is a major transient risk factor for venous thromboembolism (VTE). However, the impact of major surgery as a VTE trigger has been scarcely investigated using a case-crossover design. Aim To investigate the role of major surgery as a trigger for incident VTE in a population-based case-crossover study while adjusting for other concomitant VTE triggers. Methods We conducted a case-crossover study with 531 cancer-free VTE cases derived from the Tromsø Study cohort. Triggers were registered during the 90 days before a VTE event (hazard period) and in four preceding 90-day control periods. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to major surgery and after adjustment for other VTE triggers. Results Surgery was registered in 85 of the 531 (16.0%) hazard periods and in 38 of the 2,124 (1.8%) control periods, yielding an OR for VTE of 11.40 (95% CI: 7.42-17.51). The OR decreased to 4.10 (95% CI: 2.40-6.94) after adjustment for immobilization and infection and was further attenuated to 3.31 (95% CI: 1.83-5.96) when additionally adjusted for trauma, blood transfusion, and central venous catheter. In a mediation analysis, 51.4% (95% CI: 35.5-79.7%) of the effect of surgery on VTE risk could be mediated through immobilization and infection. Conclusions Major surgery was a trigger for VTE, but the association between surgery and VTE risk was in part explained by other VTE triggers often coexisting with surgery, particularly immobilization and infection.

Occupational hand trauma – Mechanism of injury and transient risk factors in Jerusalem

IntroductionAlthough prevalent, and variable geographically, there is little information on the incidence and risk factors for occupation hand trauma in our health care system. This pilot study was designed to determine the optimal data collection methods for transient risk factors locally MethodsAll adult patients with occupational hand trauma treated at an emergency department (ED) during a three-month period were interviewed, either in person or by phone, using a case crossover designed questionnaire, regarding occupation and exposure to potential transient risk factor. ResultsOf 206 patients treated with occupational trauma during the study period, 94 had trauma distal to the elbow (46%). Patient compliance was high - 89% of the patients consented to phone interviews and 83% completed in-person ED interviews. In the 75 patients which participated in the study, several risk factors were found to be significant, including machine maintenance and being distracted, including by a cellular phone. We found lack of job experience, limited training on the job site and reports of previous injuries in these workplaces to be prevelent. DiscussionThe risk factors implicated in this study are similar to those reported in previous studies at other locations and are modifiable although this is the first report linking cellular phone use and occupation trauma. This finding should be further examined in a larger group and according to occupational categories. Compliance with the study was high, in person or with phone interviews, making these options viable for further studies. Several minor changes to the questionnaire were suggested although it did conform with the case-crossover study design. According to this study, standard preventive measures may be lacking in Jerusalem and should be implemented more uniformly, including specific workplace safety plans and education and taking into consideration the risk factors documented here.

Transient global amnesia recurrence: prevalence and risk factor meta‐analysis

AbstractBackgroundTGA is an acute amnestic disorder with unclear pathophysiology. Although considered a benign phenomenon, the possibility of a recurrence is a major concern for the patient and their relatives. Our aim is: to identify the prevalence of transient global amnesia (TGA) recurrence and risk factors for it, to help clinicians counsel patients about it.MethodAccording to PRISMA guidance, we screened 1658 studies from MEDLINE, Lilacs and Embase databases, published from 1985 to April 2021, in English or Spanish. We included 36 observational case‐control and cohort studies that included patients with TGA according to Caplan’s or Hodges and Warlow’s diagnostic criteria. We performed a meta‐analysis with a random effect model for proportions and calculation of odds ratio for identified risk factors. Methodological quality was assessed according to the Newcastle‐Ottawa Scale.ResultWe identified 4514 TGA and 544 recurrence events (12.73%). Follow‐up had no impact on its variance. We identified a significant association between recurrence and sexual activity as a trigger, personal history of migraine and depression (OR 1,481 95%CI [1,0341; 2,1222] p = 0,04; OR = 2,0795 IC95% [1,3892; 3,1128] p = 0,003; and OR = 4,487195%CI[1,890; 10,651] p = 0,0288, respectively).ConclusionsThe analysis showed that about 1 out of 8 subjects may have recurrence, with an increased risk in case of history of migraine, depression or sexual intercourse prior to the event. Personal history of migraine and depression are associated with two and four times risk, with cortical spreading depression as a possible pathophysiological mechanism.

Bone health in childhood and adolescence: an overview on dual-energy X-ray absorptiometry scanning, fracture surveillance and bisphosphonate therapy for low-middle-income countries.

Bone accrual in childhood determines bone health in later life. Loss of bone strength in early life can lead to increased morbidity and reduced quality of life in childhood and adolescence. Increased availability of assessment tools and bisphosphonate therapy, together with increased awareness on the significance of fracture history and risk factors, have led to greater opportunities, to improve detection and optimize management of children and adolescents with bone fragility globally, including those in lower resource settings. Bone mineral density z-scores and bone mineral content are surrogate measures of bone strength, which can be measured by dual-energy X-ray absorptiometry (DXA), in growing individuals. DXA can aid in the diagnosis and management of primary and secondary bone fragility disorders in childhood. DXA helps evaluate children with clinically significant fractures, and monitor those with bone fragility disorders, or at high risk for compromised bone strength. Obtaining DXA images can however be challenging, especially in younger children, due to difficulty in positioning and movement artefacts, while paediatric DXA interpretation can be confounded by effects of growth and puberty. Furthermore, access to DXA facilities as well as appropriate paediatric reference norms and expertise for interpretation, may not be easily available especially in lower resource settings. Pediatric bone experts are now placing increasing emphasis on the fracture phenotype and clinical context to diagnose osteoporosis over bone mineral density (BMD) by DXA. Low trauma vertebral fractures are now recognized as a hallmark of bone fragility, and spinal fracture surveillance by either conventional lateral thoracolumbar radiographs or vertebral fracture assessment by DXA is gaining increasing importance in diagnosing childhood osteoporosis, and initiating bone protective therapy. Furthermore, it is now understood that even a single, low-trauma long bone fracture can signal osteoporosis in those with risk factors for bone fragility. Intravenous bisphosphonate therapy is the mainstay of treatment for childhood bone fragility disorders. Other supportive measures to improve bone strength include optimizing nutrition, encouraging weight bearing physical activity within the limits of the underlying condition, and treating any associated endocrinopathies. With this paradigm shift in childhood osteoporosis evaluation and management, lack of DXA facilities to assess BMD at baseline and/or provide serial monitoring is not a major barrier for initiating IV bisphosphonate therapy in children in whom it is clinically indicated and would benefit from its use. DXA is useful, however, to monitor treatment response and optimal timing for treatment discontinuation in children with transient risk factors for osteoporosis. Overall, there is lack of awareness and paucity of guidelines on utilizing and adopting available resources to manage paediatric bone disorders optimally in lower-resource settings. We provide an evidence-based approach to the assessment and management of bone fragility disorders in children and adolescents, with appropriate considerations for lower resource settings including LMIC countries.

Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía

IntroductionRecent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. MethodsA prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. ResultsA total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 – 2.05). ConclusionsIn patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.