Lower Limb Deep Venous Thrombosis After Posterior Spinal Fusion as an Initial Manifestation of Factor V Leiden Mutation in a Pediatric Patient: A Case Report.

Deep venous thrombosis (DVT) is a serious condition in which a blood clot forms in a deep vein, usually of the lower extremity. In pediatric orthopedic surgery, the incidence of thrombotic events is rare. This is a case presentation of a 12-year-old female patient without previous events or a family history of thrombotic events who underwent a posterior spinal fusion due to severe adolescent idiopathic scoliosis. The patient developed a DVT due to an underlying Factor V Leiden mutation. The purpose of this case report is to create awareness, facilitate the diagnosis and management, and aid in future interventions and clinical outcomes.

Adult Varicella Complicated by Deep Venous Thrombosis and Pulmonary Embolism: A Case Report and a Literature Review.

Varicella-zoster virus (VZV) infection can rarely present with severe vascular pathologies, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). These events are seldom documented in the literature as complications of primary VZV infection in adults. We present the case of a 52-year-old Caucasian male patient with chickenpox complicated by DVT and PE, which developed despite thrombectomy and anticoagulation. Laboratory analysis revealed elevated antiphospholipid antibodies. Although the patient was discharged home after clinical improvement, antiphospholipid antibodies remained elevated on repeat bloodwork eight weeks later. Our case report is followed by a literature review of 16 prior cases documenting primary VZV infection followed by DVT, PE, or both. The sex distribution of these cases, including ours, had a male-to-female ratio of 15:2. Mostly, DVT and PE occurred in the first and second weeks, underscoring the critical importance of screening for subtle thrombotic symptoms and risk factors for thrombosis during active VZV infection. Additionally, an argument can be made for ensuring the constant availability of the chickenpox vaccine for individuals with an increased baseline thrombotic risk, even if countries decide not to include varicella vaccination in their national immunization programs.

Clinical Management of Mantle Cell Lymphoma With Concurrent Vascular Complications: A Case Report.

This is a case of a 70-year-old patient with no past medical history but a significant family history of cancer, who was admitted with acute pulmonary embolism and left lower extremity deep vein thrombosis concerning malignancy. Further investigations revealed mantle cell lymphoma. This case highlights the complex clinical management of patients presenting with concurrent hematological malignancy and vascular complications.

A prediction nomogram for deep venous thrombosis risk in patients undergoing primary total hip and knee arthroplasty: a retrospective study.

INTRODUCTION: Deep venous thrombosis (DVT) prediction after total hip and knee arthroplasty remains challenging. Early diagnosis and treatment of DVT are crucial. This research aimed to develop a nomogram for early DVT prediction. METHODS: A total of 317 patients undergoing primary total hip and knee arthroplasty in Sun Yat-sen Memorial Hospital were enrolled between May 2020 and September 2022. Data from May 2020 to February 2022 were used as the development datasets to build the nomogram model (n = 238). Using multivariate logistic regression, independent variables and a nomogram for predicting the occurrence of DVT were identified. Datasets used to validate the model for internal validation ranged from March 2022 to September 2022 (n = 79). The nomogram's capacity for prediction was also compared with the Caprini score. RESULTS: For both the development and validation datasets, DVT was found in a total of 38 (15.97%) and 9 patients (11.39%) on post-operative day 7 (pod7), respectively. 59.6% patients were symptomatic DVT (leg swelling). The multivariate analysis revealed that surgical site (Knee vs. Hip), leg swelling and thrombin-antithrombin complex (TAT) were associated with DVT. The previously indicated variables were used to build the nomogram, and for the development and validation datasets, respectively. In development and validation datasets, the area under the receiver operating characteristic curve was 0.836 and 0.957, respectively. In both datasets, the predictive value of the Nomogram is greater than the Caprini score. CONCLUSIONS: A proposed nomogram incorporating surgical site (Knee vs. Hip), leg swelling, and thrombin antithrombin complex (TAT) may facilitate the identification of patients who are more prone to develop DVT on pod7.

A nomogram model based on the combination of the systemic immune-inflammation index, body mass index, and neutrophil/lymphocyte ratio to predict the risk of preoperative deep venous thrombosis in elderly patients with intertrochanteric femoral fracture: a retrospective cohort study.

OBJECTIVES: Deep vein thrombosis (DVT) has been considered as a frequent and serious consequence of intertrochanteric femoral fractures in the elderly. Several negative repercussions of DVT can be considerably mitigated by its timely recognition and treatment. The current work was aimed at exploring the factors independently predicting DVT among cases suffering from intertrochanteric femoral fractures and validate their predictive usefulness in diagnosing DVT. METHODS: Between April 2017 and July 2022, clinical information from 209 cases showing preoperative DVT for femoral intertrochanteric fractures were retrospectively evaluated. In patients with femoral intertrochanteric fractures, logistic regression analysis with a backward stepwise method was adopted for detecting independent predictors for the diagnosis of preoperative DVT. Using multivariate logistic regression, a nomogram prediction model was developed and verified with the testing group. RESULTS: According to multivariate logistic regression model, body mass index (BMI) (OR 0.79, 95% CI 0.63-0.99, P = 0.042), neutrophil/lymphocyte ratio (NLR) (OR 7.29, 95% CI 1.53, 34.64, P = 0.0012), and systemic immune-inflammation index (SII) (OR 6.61, 95% CI 2.35, 18.59, P = 0.001) were independent predictors for DVT before surgery among cases developing intertrochanteric femoral fracture. AUC values were 0.862 and 0.767 for training and testing groups, separately, while their mean errors in the calibration curve were 0.027 and 0.038 separately. Decision curve analysis (DCA) curve revealed a high value of clinical application for both groups. CONCLUSION: Upon admission, BMI, NLR, and SII are independent predictors of DVT before surgery among cases developing intertrochanteric femoral fractures. Additionally, the nomogram based on the BMI, NLR, and SII can assist clinicians in determining if preventive and symptomatic therapies are required to improve DVT prognosis and reduce its associated mortality.

To Study the Correlation of Clinical Severity and Cytokine Storm in COVID-19 Pulmonary Embolism Patients by Using Computed Tomography Pulmonary Angiography (CTPA) Qanadli Clot Burden Scoring System.

BACKGROUND: Pulmonary embolism (PE) is a fatal form of venous thromboembolism (VTE), with an overall untreated mortality of up to 30%. Greater than 50% of patients with lower extremity proximal DVT have concurrent PE at presentation. VTE has been seen in up to one-third of patients with COVID-19 infections requiring intensive care unit (ICU) admission. The objective of this study is to determine the correlation between CT pulmonary angiography, pulmonary embolism clot burden, and the Qanadli scoring system with clinically severe COVID-19 pneumonia and cytokine storm. MATERIAL AND METHOD: 153 COVID-19 hospitalized patients who underwent CT pulmonary angiography (CTPA) for likely PE on pretest probability modified Wells criteria were enrolled. COVID-19 pneumonia was classified as URTI (upper respiratory tract infection), mild, severe, and critical COVID pneumonia. For data analysis, we categorized into two groups: (1) the non-severe group included URTI and mild pneumonia, and (2) the severe group included severe and critical pneumonia. We used the Qanadli scoring system to assess the PE percentages of pulmonary vascular obstruction using CTPA.  Results: 41.8% (64) of COVID-19 patients were diagnosed with pulmonary embolism (PE) on CTPA. The majority of 51.6% of pulmonary vascular occlusions using the Qanadli scoring system for pulmonary embolism were at segmental arterial levels. Out of 104 COVID-19 cytokine storm patients, 45 (43%) were associated with pulmonary embolism. Overall, a 25% (16) mortality rate was observed in COVID-19 patients with pulmonary embolism. DISCUSSION: The pathogenesis of hypercoagulability in COVID-19 may include direct endothelial cell invasion by the virus, microvascular inflammation, endothelial exocytosis, and endotheliitis. A meta-analysis of 71 studies to investigate the occurrence of PE on CTPA in COVID-19 patients found 48.6% in ICU settings and 65.3% of patients have clots in the peripheral pulmonary vasculature. CONCLUSIONS: There is a significant correlation between pulmonary embolism and high clot burden Qanadli CTPA scores, as well as between the severity of COVID-19 pneumonia and mortality. The association between critically ill COVID-19 pneumonia and pulmonary embolism may result in higher mortality and a poor prognostic marker.

An Unusual Case of May-Thurner Syndrome in a Middle-Aged IV Drug Abuser.

May-Thurner syndrome (MTS) is an extrinsic venous compression of the iliocaval venous territory by the arterial system. MTS is common in middle-aged women. Despite its importance, it is uncommonly considered in the differential diagnosis of deep vein thrombosis (DVT), especially in males with other risk factors. Due to the perianal abscess, a 35-year-old male health care worker was abusing IV opioids through his left leg veins. His symptoms included signs and symptoms of cellulitis around the catheter site, followed by recurrent DVTs due to poor response to anticoagulation therapy alone. A comprehensive workup revealed the diagnosis of MTS. The patient eventually required endovenous treatment with stent placement, after which his condition improved dramatically.

Ecografía multiórgano en infección por SARS-COV-2 / Multi-organ ultrasound for SARS-COV-2 disease

Aim: There is growing evidence regarding the imaging ultrasound findings of coronavirus disease 2019 COVID-19. Multi-organ ultrasoundhas played a significant role in the diagnosis and follow-up of thesepatients. The aim of this study was to describe the ultrasound findingsat pulmonary, cardiac and deep venous system of the lower extremities in patients with SARS-COV-2 infection.Material and method: Prospective, cross-sectional, observationalstudy was conducted in patients with confirmed COVID-19 who underwent a multi-organ point-of-care ultrasound (POCUS) examinationduring hospitalization.Results: A total of 107 patients were enrolled. Lung involvement waspresent in 100% of the patients, 93.4% bilaterally involvement. Themost affected lung area was the posteroinferior (94.39%) followed bythe lateral (89.72%). Subpleural consolidations were present in 71%of patients and consolidations larger than 1 cm in 25%. More echographic lung involvement is relational with the degree of respiratoryinsufficiency. Only two patients had proximal deep vein thrombosisin the lower extremities, 27 angiography tomography scan were performed and pulmonary thromboembolism was confirmed in 14 patients. The most frequent echocardiographic findings were impairedleft ventricular relaxation and left ventricular hypertrophy. All patientswith thromboembolic disease had severe or critical echocardiographicpulmonary involvement.Conclusions: Multi-organ POCUS ultrasound may be useful for themanifestations of COVID-19. The degree of lung ultrasound involvement was related to the degree of respiratory failure and to the presence of VTED. The relationship between DVT and PTE was lower thanexpected. Cardiac involvement has little relevance in our series. (AU)

Objetivo: Existe una creciente evidencia con respecto a los hallazgosecográficos y la COVID-19, destacando la ecografía multiórgano parael diagnóstico y el seguimiento de estos pacientes. El objetivo fuedescribir los hallazgos ecográficos a nivel pulmonar, cardiaco y delsistema venoso profundo de extremidades inferiores en pacientes coninfección por SARS-COV-2.Material y Métodos: Estudio prospectivo, transversal y observacionalrealizado en pacientes con COVID-19 confirmado a los que se lesrealizó una ecografía multiórgano en el punto de atención durante lahospitalización.Resultados: Un total de 107 pacientes se inscribieron. El 100% delos pacientes tenían afectación pulmonar (93,4% bilateral). Las zonaspulmonares más afectadas fueron la posteroinferior (94,39%) y la lateral (89,72%). Se observó consolidaciones subpleurales en el 71%de los pacientes y consolidaciones mayores de 1 cm en el 25%. Amayor afectación pulmonar ecográfica, mayor grado de insuficienciarespiratoria. 2 pacientes presentaron TVP proximal en extremidadesinferiores. Se realizaron 27 Angiotomografía computarizada confirmándose tromboembolismo pulmonar en 14 pacientes. Los hallazgosecocardiográficos más frecuentes fueron: alteración de la relajacióndel ventrículo izquierdo e hipertrofia ventricular izquierda. Todos lospacientes con enfermedad tromboembólica tenían una afectación pulmonar ecográfica grave o crítica.Conclusión: la ecografia multiórgano puede ser útil para lasmanifestaciones de la COVID-19. El grado de afectación ecográficapulmonar se relacionó con el grado de insuficiencia respiratoria y conla presencia de ETEV. La relación entre TVP y TEP fue más baja de loesperado. La afectación cardiaca fue poco relevante en nuestra serie. (AU)

High level of neutrophil to lymphocyte ratio increases the risk of deep venous thrombosis in intensive care unit patients after oral cancer surgery: a retrospective study.

Background: The incidence of deep venous thrombosis (DVT) is higher in surgical patients, but there have been few studies on the risk factors of DVT in intensive care unit (ICU) patients after oral cancer surgery, particularly in relation to the inflammatory and nutritional scores, and intervene with these risk factors early may decrease the occurrence of DVT. Methods: We performed a retrospective study of adult patients who were admitted to ICU after undergoing radical resection of oral cancer and performed ultrasound detection for DVT within 1 week after surgery from April 2019 to July 2021. DVT was diagnosed by venous ultrasonography of the lower extremities. Preoperative inflammatory and nutritional scores, including neutrophil to lymphocyte ratio (NLR), plate to lymphocyte ratio (PLR), prognostic nutritional index (PNI) were retrospectively calculated according to test results before surgery. Clinical characteristics, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Caprini Risk Score (CRS), Charlson comorbidity index, anticoagulation therapy, and mechanical ventilation time (MVT) after admitted to ICU were obtained. The risk factors affecting DVT occurrence were analyzed by logistic regression, and the receiver operating characteristic (ROC) curve was used to analyze the value of the relevant indicators in evaluating DVT. Results: Among the 128 patients, 43 patients (33.6%) developed DVT. Compared with the non-DVT group, the preoperative glucose (GLU), postoperative D-dimer (P<0.05), and postoperative NLR (P<0.001) were higher in the DVT group than in the non-DVT group. In multivariate logistic analysis, NLR (P=0.001), postoperative D-dimer >5.57 µg/mL (P=0.002), GLU >5.15 mmol/L (P=0.025) was associated with DVT, and the areas under the curve (AUCs) of NLR in predicting DVT was 0.729. We also found that the DVT group had longer MVT and length of stay (LOS) than the non-DVT group, and correlation analysis indicated that NLR level was positively related with MVT (r=0.36; P<0.0001) and LOS (r=0.452; P<0.0001). Conclusions: A high level of NLR, indicative of a poor immunity and nutrition status, increases the risk of DVT in patients after oral cancer surgery, and improvement of immunity and nutrition status may help decrease the occurrence of postoperative DVT.

Venous thromboembolism risk screening, training and provider awareness in Australian residential aged care facilities.

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in the geriatric post-surgical population, and its prevention is a public health priority. The aim of this study was to assess the use of VTE risk screening and training protocols, and VTE awareness in the Australian residential aged care sector. A cross-sectional survey was conducted that was directed at facility and policy managers of community aged care facilities with ≥10 residents in two Australian states and territories. Forty-nine of 301 (16.3%) providers responded, representing 249/871 (28.6%) aged care facilities and 20,958/66,121 (31.7%) residents. VTE risk screening protocols were used by 1.2% of facilities (3/249), and 79.5% (198/249) were unaware that VTE is an issue in this population. Only 0.8% (2/249) were aware that risk screening and prophylaxis is required to prevent VTE; none were acting upon this. No facility had specific VTE risk assessment or prevention processes in place. Most residential aged care facilities surveyed do not have VTE risk screening protocols and were unaware of the risk that may be associated with this omission. These results have implications for development and implementation of national and international VTE risk screening guidelines in community care.

Encephalomalacia/gliosis, deep venous thrombosis, and cancer in Arg393His antithrombin Hanoi and the potential impact of the ß-amyloid precursor protein (APP) on thrombosis and cancer.

A heterozygous Arg393His point mutation at the reactive site of antithrombin (AT) gene causing thrombosis in a Vietnamese patient is reported and named as Arg393His in AT-Hanoi. The present variant is characterized by a severe reduction of functionally active AT plasma concentration to 42% of normal resulting in multiple severe thrombotic events such as cerebral venous thrombosis (CVT) (encephalomalacia/gliosis), recurrent deep venous thrombosis (DVT) and the development of kidney cancer. Today the complexity of thrombophilia has grown with appreciation that multiple inherited and acquired risk factors may interact to result in a clinically thrombotic phenotype. This article focuses on the following issues: (1) pathophysiology and clinical conditions of Arg393His in AT-Hanoi; (2) "two way association" between cancer and thrombosis in which venous thromboembolism (VTE) can be both a presenting sign and a complication of cancer; (3) efficacy of anticoagulants used for the prevention of cancer-related thrombosis; (4) conditions of acquired risk factors such as cancer or genetic disorders via epigenetic modifications in gene-gene (epistasis) and/or gene-environment interactions such as in Lesch-Nyhan disease (LND), in which the ß-amyloid precursor protein (APP) that may interact to predispose a patient to thrombosis and cancer. It is also necessary to study the hypoxanthine-guanine phosphoribosyltransferase (HGprt) enzyme, AT, and APP using expression vectors for exploring their impact on LND, thrombosis as well as other human diseases, especially the ones related to APP such as Alzheimer's disease (AD) and cancer. For such a purpose, the construction of expression vectors for HGprt and APP, with or without the glycosyl-phosphatidylinositol (GPI) anchor, was performed as described in Ref. #148 (Nguyen, K. V., Naviaux, R. K., Nyhan, W. L. Lesch-Nyhan disease: I. Construction of expression vectors for hypoxanthine-guanine phosphoribosyltransferase (HGprt) enzyme and amyloid precursor protein (APP). Nucleosides Nucleotides Nucleic Acids 2020, 39: 905-922). In the same manner, the construction of expression vectors for AT and APP can be performed as shown in Figure 6. These expressions vectors, with or without GPI anchor, could be used as tools for (a) studying the effects of Arg393His mutation in AT; (b) studying the emerging role of Arg393His mutation in AT and cancer; (c) studying intermolecular interactions between APP and AT. Furthermore, the construction of expression vectors as described in Ref. #148, especially the one with GPI, can be used as a model for the construction of expression vectors for any protein targeting to the cell plasma membrane for studying intermolecular interactions and could be therefore useful in the vaccines as well as antiviral drugs development (studying intermolecular interactions between the spike glycoprotein of the severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, as well as its variants and the angiotensin-converting enzyme 2, ACE2, in coronavirus disease 2019 (COVID-19) [155],[156], for example).

Analysis of influencing factors of community-acquired pneumonia with deep venous thrombosis in elderly communities.

BACKGROUND: Community-acquired pneumonia (CAP) is one of the common infectious diseases that threaten human health, venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), is a global health care problem. Acute infection and age ≥70 years are important risk factors for VTE in internal medicine inpatients. There is increasing evidence that acute infectious diseases caused by bacterial and viral infections can induce coagulation, platelet (PLT) activation and inhibit the activity of anticoagulant factors. However, there is no consensus on whether patients with CAP suffer from DVT. Finding out the clinical characteristics and risk factors of DVT in elderly patients with CAP is helpful for early identification of high-risk patients with VTE and timely prevention, which can significantly reduce the occurrence of VTE in hospitals. METHODS: Data was collected from 505 patients with CAP aged ≥70 years old hospitalized in the Department of Respiratory and Critical Care Medicine. 133 patients with DVT were selected as the DVT group. DVT score and risk grading were performed for all patients using Padua. Fifty-seven cases were diagnosed as having severe pneumonia, including 50 cases diagnosed as having septic shock. Padua, D-dimer, between the DVT group and the control group, the severe pneumonia group and the non-severe pneumonia group, and the severe pneumonia DVT group and the control group were compared. RESULTS: (I) The incidence of DVT with severe pneumonia was much higher than with non-severe pneumonia (P<0.001). The incidence of DVT in patients with septic shock and non-septic shock was 74.0% (37/50) and 28.6% (2/7) respectively (P=0.0154). (II) There were significant differences in Padua scores between the DVT group and the control group and between the severe pneumonia group and non-severe pneumonia group (P<0.001). (III) There were significant differences in D-dimer level between the DVT group and the control group and between the severe pneumonia group and the non-severe pneumonia group (P<0.001). (IV) Regression analysis indicated the central venous catheter (CVC), D-dimer value, and Padua score were significantly correlated with thrombosis (P=0.042, <0.001, 0.043). CONCLUSIONS: Severe pneumonia in elderly patients and septic shock may be complicated by DVT, and central venous catheterization and D-dimer are closely related to thrombosis.

Exploring the genetic relationship between deep vein thrombosis and plasma protein: a new research idea.

BACKGROUND: The aim of this article is to scan and analyze the genetic correlation between plasma proteome and deep venous thrombosis (DVT), and to explore the correlation between plasma protein and DVT. RESEARCH DESIGN AND METHODS: GWAS data of DVT and plasma proteins were analyzed with linkage disequilibrium scores, and plasma proteins that were genetically associated with DVT were screened out. To ascertain the causal link between potential plasma proteins and DVT, a Mendelian randomized (MR) study was used. This study used STRING to examine the pathogenesis of DVT in connection with the gene encoding plasma protein. RESULTS: Several suggestive plasma proteins were detected for DVT, such as Complement factor B (P value=0.0177), Chromogranin-A (P value=0.0158). Through MR analysis, we found that there was a significant positive causal relationship between Chromogranin-A (exposure) and DVT(outcome) (ß=-0.0117, P<0.0001). Our STRING analysis revealed that hsa04610 was associated with coagulation cascade in the KEGG pathway of Complement factor B(P<0.0001), which was based on GO and KEGG analysis of 8 selected plasma proteins. CONCLUSIONS: A genetic link between plasma protein and DVT was thoroughly investigated. Our findings provide a fresh perspective on the genetics and pathogenesis of DVT.

Solitary Retroperitoneal Neurofibroma Associated With Deep Vein Thrombosis in a 40-Year-Old Male.

A neurofibroma is a benign, non-encapsulated neoplasm of the peripheral nerve sheath. These tumors are a notorious manifestation of the autosomal dominant condition known as neurofibromatosis type 1, where they present as multiple, cutaneous masses with high malignant potential. On the contrary, benign solitary retroperitoneal neurofibromas (SRN) occur without any associated conditions and have rarely been documented. Our case is of a 40-year-old male who presented with a three-month history of painful calf swelling, refractory to over-the-counter painkillers which was later diagnosed as deep vein thrombosis (DVT). A computed tomography (CT) angiogram was done which revealed a mass in the retroperitoneum impinging on the inferior vena cava (IVC). Approximately one month later, the whole mass was surgically excised and histopathology confirmed the diagnosis of a neurofibroma. This case presentation proved to be novel as it highlights the evaluation and management of a rare SRN which resulted in extensive DVT.

Increasing Rate of Pulmonary Embolism in Trauma Patients at a Level One Trauma Center: An Opportunity for Quality Improvement?

Introduction Pulmonary embolism (PE) is the most common cause of preventable hospital death in trauma patients, with 100,000 patients dying from PE annually. A steadily increasing PE rate was observed over seven years in the trauma population at a single level one trauma center. Our study seeks to analyze this trend by examining risk factors and searching for targets for improvement. We hypothesized that a change in one or more modifiable risk factors was associated with the increased PE rate.  Methods This retrospective cohort study considered trauma patients admitted to our trauma center between 2012 and 2018. The change in PE rate over time and correlation with various risk factors were examined using logistic regression. The study population was divided into two cohorts: early (2012-2015), and late (2016-2018). Data were collected from a prospectively maintained trauma database. More detailed information was obtained from individual patient charts for 533 patients worked up for PE. Risk factors were evaluated using both univariate and multivariate analysis. Results A total of 14,986 trauma patients were included in the study, of which 132 were diagnosed with PE. The PE rate was 1.11% in the late group compared to 0.67% in the early group (p=.004). We detected no association between the PE rate and preventive measures such as screening for and treating deep venous thrombosis (DVT), placing inferior vena cava (IVC) filters, and patterns of chemical DVT prophylaxis. We did not observe a distal migration of the anatomic distribution of PEs on CT pulmonary angiogram (CTPA). There were nonsignificant trends between PE rate and changes in population demographics and injury patterns, increased frequency of major surgery, and increased tranexamic acid (TXA) use. Of known risk factors for PE, units of packed red blood cells (PRBC) (p=0.041), units of fresh frozen plasma (FFP) (p=.037), and the number of patients receiving transfusion (p=0.043) were all significantly greater in the later period. Conclusion Change in hemostatic resuscitation practices (use of balanced ratios of blood products) is most likely to have contributed to the increased PE rate at our institution. However, PE in trauma is multifactorial, and the increased rate cannot be attributed to any single factor. We did not observe a lapse in preventive measures commonly considered indices of quality of care. Caution is advised against overreliance on PE rate as a measure of quality.

Bleeding complications in patients on new oral anticoagulants for venous thromboembolism in Kenya.

BACKGROUND: The incidence of bleeding complications in patients with venous thromboembolism (VTE) on new oral anticoagulants (NOACs) has not been widely studied in contemporary clinical practice in Africa. The purpose of this study was to determine the rates of major bleeding, clinically relevant non-major bleeding (CRNM) and minor bleeding associated with NOAC use. METHODS: A retrospective review was carried out of patients diagnosed with venous thromboembolism and treated with NOACs at the Aga Khan University Hospital, Nairobi, from January 2014 to December 2019. Clinical and outcome data were collected from medical records and the hospital mortality database. All patients with VTE aged > 18 years and initiated on NOACS were recruited. Patients with missing information were excluded. They were followed up from the time of commencement of oral anticoagulation to completion of therapy, or to the time of the first major bleed, CRNM or minor bleeding. Data on bleeding were obtained from the hospital database and through telephone interviews. Unadjusted rates of the first major bleeding event or CRNM were calculated as the number of bleeding events per 100 person-years. RESULTS: Two hundred and forty-three patients with VTE were recruited and 222 (91.4%) were initiated on rivaroxaban, 12 (4.9%) on dabigatran and nine (3.7%) on apixaban, with a median follow up of 213 [interquartile range (IQR): 119-477] days. The median age of the patients was 57 (IQR: 45-71) years. A total of 64 bleeding events were identified in 50 (20.6%) patients. Overall, the incidence rate for bleeding events was 17.24 per 100 patient-years. The incidence rate of major bleeding was 3.79 per 100 person-years. Gastrointestinal bleeding was the most common major bleeding site. There were more females with bleeding events (70.7%) compared to males. Anaemia and the use of aspirin and other antiplatelets were associated with a higher incidence of major and CRNM bleeding [relative risk (RR) = 3.77, confidence interval (CI) = 1.37-10.39, p = 0.005 and RR = 8.89, CI = 2.06-38.33, p = 0.0003, respectively]. CONCLUSIONS: Most of these bleeds were minor, with the gastrointestinal tract being the most common source of major bleeding and menorrhagia being the commonest cause of bleeding. Anaemia and the use of aspirin were associated with a higher incidence of major bleeding.

Hemodynamic Study on the Relationship Between Collateral Circulation Caused by Iliac Vein Compression and Deep Venous Thrombosis / 医用生物力学

Objective To explore the relationship between the establishment of collateral circulation caused by iliac vein compression syndrom(IVCS) and the deep venous thrombosis (DVT). Methods Different types of ideal collateral circulation models and IVCS patient-specific models were numerically simulated using computational fluid dynamics (CFD) in combination with the blood stasis model. The relationship between blood retention and collateral types and cross-sectional area was studied, and the relationship with thrombosis was explored. Results Wall shear stress (WSS) at the distal end part of each ideal model was 0.3 Pa. After four cardiac cycles, the residual blood stayed at the stenosis and the distal end part for the lumbar ascending and pelvic type models, the old blood volume fraction (OBVF) varied with collateral cross-sectional areas, ranging from 5%-90% and 70%-80%, respectively. The OBVF of the coexistence model was above 80%. The WSS at the distal end part of the patient-specific model was 0.9 Pa, and the OBVF at the distal end part was 51.5%. Conclusions The stenosis and the distal end part are most prone to blood stasis, and closely related with DVT. The larger the collateral cross-sectional area, the more serious the blood stagnation. Blood stagnation of the coexistence model is higher compared with the model with lumbar ascending type and pelvic type.

Venous thromboembolism in musculoskeletal oncology surgery.

Venous thromboembolism (VTE), including both deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major complication of musculoskeletal surgery in general, and the risk is heightened in musculoskeletal oncology surgery. Despite the well-known association between cancer and VTE, the mechanism promoting this pathology is not entirely well understood. It is estimated that nearly all cancer patients will experience from some form of VTE, whether or not clinically relevant, during the course of their disease. Nonetheless, numerous studies have analyzed the occurrence and prevention of VTE in patients with cardiovascular disease or suffering trauma, but very few have specifically examined the safety or efficacy of preventing VTE in cancer patients with metastatic skeletal disease. This review will examine the various types of prophylactic treatment, timing of administration, risk stratification for determining the appropriate course of anticoagulation (AC), and discuss current views on chemical prophylaxes relativity to wound complications and excessive bleeding in orthopedic oncology patients. Overall, careful choice of anticoagulant and timing of administration must be made in order to avoid bleeding complications. A risk stratification system to determine which chemical prophylaxis to administered could be beneficial in both reducing the occurrence of VTE and decreasing associated wound complications or mortality. Further study should be conducted to tailor chemical prophylaxes recommendations to this largely affected population and effectively reduce the occurrence of VTE.

A systematic review and meta-analysis of elastic stockings for prevention of thrombosis after orthopedic surgery.

BACKGROUND: To investigate the preventive effect of elastic stockings on deep vein thrombosis (DVT) after orthopedic surgery by literature search and meta-analysis. METHODS: PubMed, Embase and Cochrane were selected as the search database platforms to search the literature of randomized controlled trials related to elastic stockings and DVT published from 2008 to date. Revman 5.3.5 software was used for statistical analysis of the data to obtain forest and funnel plots. RESULTS: In this study, 90 studies were initially screened and 7 were finally included, covering a total of 3,116 patients. Meta-analysis showed that the 7 studies had statistical heterogeneity (I2=32%, P=0.18), so a random effect model was used. The obtained statistic was [odds ratio (OR) =0.59, 95% confidence interval (CI): (0.34, 1.03)], the statistical effect size was Z=1.84, P=0.07, and the difference was not statistically significant, so a stepwise sensitivity analysis was performed by the exclusion method. One study was excluded, and the remaining 6 showed homogeneity (I2=0%, P=0.46). They were analyzed by subgroup according to the type of operation: ankle surgery or hip and knee arthroplasty. The internal literatures of each subgroup were homogeneous: ankle surgery subgroup (I2=0%, P=0.43), hip and knee arthroplasty subgroup (I2=0%, P=0.88). Therefore, fixed effect mode analysis was used, and the effect size of elastic stockings after ankle surgery was Z=3.65, P=0.0003, while the effect size of elastic stockings in the hip and knee arthroplasty subgroup was Z=1.23, P=0.22. DISCUSSION: Elastic stockings had an obvious preventive effect on DVT in patients undergoing ankle surgery, but not in patients undergoing lumbar, knee or spinal surgery. It is necessary to combine anticoagulant drugs and other physical therapies to prevent DVT.

Observational Study of Thrombotic Events in a Random Cohort of Hospitalized COVID-19 Patients at a Community-Based Hospital of New York City During the Beginning of the 2020 Pandemic.

Coronavirus disease 2019 (COVID-19) continues to pose an unprecedented challenge for the entire world and the healthcare system. Different theories have been proposed elucidating the pathophysiological mechanisms attributing to high mortality and morbidity in COVID-19 infection. Out of them, thrombosis and procoagulant state have managed to earn the maximum limelight. We conducted an observational study based on data from randomly selected 349 hospitalized patients with COVID-19 infection in a community-based hospital in New York City during the first wave of the COVID-19 viral surge in March 2020. The main objective of our study was to assess the risk and occurrence of thrombotic events (both venous and arterial) among the hospitalized patients including the intensive care unit (ICU) and non-ICU admissions with confirmed COVID-19 infection. The primary outcome in our study was defined as the thrombotic events that included myocardial infarction (MI), deep venous thrombosis (DVT), cerebrovascular accidents (CVA), and pulmonary embolism (PE). The study correlated the association of thrombotic events with the level of biomarkers of interest: D-dimer >1000 ng/ml, troponin-I >1 ng/ml, or both. The association of D-dimers and troponin-I with thrombotic events was measured using both univariate and multivariate Cox proportional hazard (PH) regression analysis. Out of a total of 349 patients, 78 patients (22.35%) were found to have elevated biomarkers (D-dimer >1000 ng/ml and/or troponin-I >1 ng/ml) and were categorized as a high-risk group. Eighty-nine patients developed thrombotic complications (evidence of more than one thrombotic event was found in several patients). Two-hundred seventy-one (77.65%) patients had no documentation of thrombosis. The incidence of thrombotic events included myocardial infarction (MI; N=45; 12.8%), cerebrovascular accidents (CVA; N=16; 4.5%), deep venous thrombosis (DVT; N=16; 4.5%), and pulmonary embolism (PE; N=9; 2.57%).