Mechanisms of thrombosis in obesity

Risk factors and impact of portal vein thrombosis in liver transplantation

INTRODUCTION

portal vein thrombosis is a relatively common complication of advanced cirrhosis that increases perioperative risk in liver transplant recipients. This condition was characterized in a cohort of patients, including risk factors and their influence on survival.

MATERIAL AND METHODS

a retrospective study of liver transplant recipients at the Clínica Universidad de Navarra was performed between 2000 and 2015. Differences in clinical and biological characteristics and survival were analyzed in subjects with and without portal vein thrombosis. A predictive index was also developed.

RESULTS

a total of 288 patients were included in the study, portal vein thrombosis was recorded in 46 (16%) cases and seven (15.2%) had stage 3/4 disease according to Yerdel's classification. Factors associated with the presence of esophageal/gastric varices (OR = 3.7; p = 0.03) included variceal ligation or sclerotherapy (OR = 2.3; p = 0.01), being overweight/obesity (OR = 2.1; p = 0.04) and thrombocytopenia (OR = 3.6; p = 0.04). There were no significant differences between the groups with and without portal vein thrombosis in terms of survival according to Kaplan-Meier curve analysis (p = 0.7). However, the mortality rate was higher for Yerdel stages 3-4 (p < 0.01). A predictive index was developed that included varices, body mass index (BMI), thrombocytopenia and activated partial thromboplastin time (APTT). This index had a sensitivity of 76.1% and a specificity of 53.7% for the development of portal thrombosis.

CONCLUSIONS

the presence of esophageal/gastric varices, variceal ligation/sclerotherapy, thrombocytopenia and being overweight/obesity was associated with a higher rate of portal vein thrombosis. Advanced stages had an impact on survival.

Obesity and COVID-19: immune and metabolic derangement as a possible link to adverse clinical outcomes

Recent reports have shown a strong association between obesity and the severity of COVID-19 infection, even in the absence of other comorbidities. After infecting the host cells, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause a hyperinflammatory reaction through the excessive release of cytokines, a condition known as "cytokine storm," while inducing lymphopenia and a disrupted immune response. Obesity is associated with chronic low-grade inflammation and immune dysregulation, but the exact mechanisms through which it exacerbates COVID-19 infection are not fully clarified. The production of increased amounts of cytokines such as TNFα, IL-1, IL-6, and monocyte chemoattractant protein (MCP-1) lead to oxidative stress and defective function of innate and adaptive immunity, whereas the activation of NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome seems to play a crucial role in the pathogenesis of the infection. Endothelial dysfunction and arterial stiffness could favor the recently discovered infection of the endothelium by SARS-CoV-2, whereas alterations in cardiac structure and function and the prothrombotic microenvironment in obesity could provide a link for the increased cardiovascular events in these patients. The successful use of anti-inflammatory agents such as IL-1 and IL-6 blockers in similar hyperinflammatory settings, like that of rheumatoid arthritis, has triggered the discussion of whether such agents could be administrated in selected patients with COVID-19 disease.

Obesity is associated with postinjury hypercoagulability

BACKGROUND

Obesity is linked to hypercoagulability with an increased risk of venous thromboembolic events (VTE) in the uninjured population. Therefore, we hypothesize that obesity (body mass index [BMI] ≥30 kg/m [BMI30]) is associated with a hypercoagulable state postinjury characterized by increased clot strength and resistance to fibrinolysis.

METHODS

Our prospective Trauma Activation Protocol database includes all trauma activations patients for whom a rapid thrombelastography is obtained within 60 minutes postinjury prior to any transfusions. The data set was then stratified by BMI and subjects with BMI30 were compared with those with BMI less than 30 kg/m). The following thrombelastography measurements were obtained: activated clotting time, clot formation rate (angle), maximum clot strength (MA), and % clot lysis 30 minutes after MA (LY30, %). Fibrinolysis shutdown (SD) was defined as LY30 < 0.6% and hyperfibrinolysis (HF) as LY30 greater than 7.6%. Continuous variables are expressed as median (interquartile range).

RESULTS

Overall, 687 patients were included of whom 161 (23%) had BMI30. The BMI30 group was older, had a lower proportion of males and of blunt trauma, and was less severely injured. After adjustment for confounders, BMI30 was independently associated with lower odds of MA less than 55 mm (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60) and of HF (OR, 0.31; 95% CI, 0.10-0.97) and higher odds of SD (OR, 1.82; 95% CI, 1.09-3.05). No independent association was observed with angle less than 65° (OR 0.57 95% CI 0.30-1.05). While VTEs were more frequent among BMI30 patients (5.0 vs. 3.3%), this did not reach significance after confounding adjustment (p = 0.11).

CONCLUSION

Obesity was protective against diminished clot strength and hyperfibrinolysis, and obesity was associated with an increased risk of fibrinolytic SD in severely injured patients. These findings suggest a relative hypercoagulability. Although no difference in VTEs was noted in this study, these findings may explain the higher rate of VTEs reported in other studies.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, level III.

Nutritional Deficiencies, Bariatric Surgery, and Serum Homocysteine Level: Review of Current Literature

Obesity is currently one of the biggest global health problems. In the case of severe obesity, bariatric surgeries are considered to be the most important method of treatment. The 2 most commonly performed bariatric surgery procedures include Roux-en-Y gastric bypass and sleeve gastrectomy. However, these methods are not free from complications, and the most common ones (moderately long or long term) are micronutrient deficiencies. The deficiency of vitamins B6, B12, and folic acid as cofactors of the folate cycle contributes to the development of hyperhomocysteinemia. It seems that apart from nutritional factors, there are other aspects that have a significant influence on the concentration of homocysteine in blood, such as the type of conducted bariatric surgery, the post-surgical concentration of betaine and creatinine, and the clearance of methionine (i.e., the mutations of the gene that encodes the MTHFR reductase as well as other genes associated with the process of methylation, e.g., methionine synthase). Their presence might be one of the causes of the increased concentration of homocysteine after surgery despite the fact that patients take vitamin-mineral supplementation.

Procoagulant activity in children and adolescents on intensive insulin therapy

BACKGROUND

Type 1 diabetes is associated with atherothrombosis, but limited data exist on procoagulant activity in the young. We investigated procoagulant activity in children/adolescents with type 1 diabetes using intensified insulin treatment compared with controls in a 5-year follow-up study, and further any associations with cardiovascular risk factors.

METHODS

The study included 314 diabetes children/adolescents and 120 healthy controls. Prothrombin fragment 1+2 (F1+2), D-dimer, tissue-factor-procoagulant-activity (TF-PCA), and tissue-factor-pathway-inhibitor (TFPI) were analyzed with ELISAs.

RESULTS

F1+2, D-dimer, and TF-PCA did not differ between the groups or correlate to HbA_1c in the diabetes group at either time points. TFPI was significantly higher in the diabetes group compared with controls both at inclusion and follow-up (both P < .001). In the diabetes group, TFPI correlated significantly to HbA_1c at both time points (r = 0.221 and 0.304, both P < .001). At follow-up, females using oral contraceptives had significantly elevated F1+2, D-dimer, and TF-PCA and lower TFPI compared to no-users (all P < .005), and females had lower TFPI (P = .017) and higher F1+2 compared with males (P = .052), also after adjusting for the use of oral contraceptives.

CONCLUSIONS

The current results show similar procoagulant activity in children/adolescents with type 1 diabetes compared with controls over a 5-year period, indicating that these children using modern intensified insulin treatment are not at high thrombotic risk at younger age. The elevated levels of TFPI in the diabetes group, related to hyperglycaemia, are probably reflecting increased endothelial activation. These findings highlight the significance of optimal blood glucose control in children/adolescents with type 1 diabetes, to maintain a healthy endothelium.

Association between obesity and venous thromboembolism

Background and aims

Obesity is associated with numerous pathological conditions, including venous thromboembolism (VTE). VTE is a multifactorial disease; more than half of the hospitalized patients are at risk for VTE.

We aimed to assess the risk of VTE associated with obesity, taking into account the class of obesity (according to the body mass index), gender, age and the intervention of other acquired risk factors.

Methods

A case-control study including 732 patients was designed. Collected data included: age, gender, body mass index, pregnancy/postpartum state, use of hormonal therapy, personal and family history of VTE, smoking, prolonged immobilization and the presence of comorbidities - acquired risk factors for VTE. The risk of VTE was expressed as odds ratio (OR) with 95% confidence interval. Multiple logistic regression analysis was used to detect the independent risk factors. P value <0.05 was considered significant statistic.

Results

Obesity was associated with a 6.2-fold increased risk for VTE. The risk of VTE associated with obesity was highest in patients aged >50 years and in cases included in classes II and III of obesity. The interaction between obesity and another acquired risk factor has almost doubled the risk of VTE. Multivariate logistic regression analysis showed obesity as an independent risk factor for VTE for both female and male patients.

Conclusions

Obesity is an independent and moderate risk factor for VTE. The risk increases with body mass index, age and the presence of other acquired risk factors.

Rheumatoid Arthritis Is Associated With Thromboembolic Complications Following Primary Total Knee Arthroplasty

BACKGROUND

Recent studies have demonstrated patients with rheumatoid arthritis (RA) have deranged coagulation parameters predisposing them to venous thromboembolisms (VTEs). Therefore, the purpose of this study was to investigate whether patients who have RA undergoing primary TKA have higher rates of (1) VTEs; (2) readmission rates; and (3) costs of care.

METHODS

Patients who have RA undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and comorbidities. Exclusions included patients with a history of VTEs and hypercoagulable states. Primary outcomes analyzed included rates of 90-day VTEs, along with lower extremity deep vein thromboses and pulmonary embolisms, 90-day readmission rates, in addition to day of surgery, and 90-day costs of care. A P-value less than .05 was considered statistically significant.

RESULTS

Patients who have RA were found to have significantly higher incidence and odds (OR) of VTEs (1.9 vs 1.3%; OR: 1.51, P < .0001), deep vein thromboses (1.6 vs 1.1%; OR: 1.55, P < .0001), and pulmonary embolisms (0.4 vs 0.3%; OR: 1.26, P= .0001). Study group patients also had significantly higher incidence and odds of readmissions (21.6 vs 14.1%; OR: 1.67, P < .0001) compared to controls. In addition, RA patients incurred significantly higher day of surgery ($12,475.17 vs $11,428.96; P < .0001) and 90-day costs of care ($15,937.34 vs $13,678.85; P < .0001).

CONCLUSION

After adjusting for age, sex, and comorbidities, the study found patients who have RA undergoing primary TKA had significantly higher rates of VTEs, readmissions, and costs.

Circulating and tissue microRNAs as a potential diagnostic biomarker in patients with thrombotic events

Venous and arterial thrombosis are conditions that have a considerable burden if left untreated. The hypoxia-induced by the occluded vessel can disrupt the circulation of any organ, the cornerstone of treating thrombosis is rapid diagnosis and appropriate treatment. Diagnosis of thrombosis may be made by using laboratory tests or imaging techniques in individuals who have clinical manifestations of a thrombotic event. The use of serum micro ribonucleic acids (RNAs) has recently been applied to the diagnosis of thrombosis. These small RNA molecules are emerging as new diagnostic markers but have had very limited applications in vascular disease. Most of the articles provided various microRNAs with different levels of accuracy. However, there remains a lack of an appropriate panel of the most specific microRNA in the literature. The purpose of the present review was to summarize the existing data on the use of microRNAs as a diagnostic biomarker for venous thrombosis.

Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction

PURPOSE

The purpose was to characterize the independent effect of procedure length on the rates of 30-day perioperative complications, hospital readmissions, and overnight hospital stay in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). We hypothesized that longer procedure length in primary ACLR increases the risk for post-operative complications.

METHODS

Primary ACLR cases from 2005 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Patients were categorized into two cohorts based on procedure length, either less than or greater than 90 min. Two equal-sized propensity-matched cohorts were generated to account for differences in baseline and operative characteristics. Thirty-day clinical outcomes were compared using bivariate analyses between propensity-matched groups that controlled for patient-specific factors and concurrent meniscal repair. Multivariate logistic regression models were used to identify independent predictors of hospital readmission and overnight hospital stay.

RESULTS

In total, 12,077 ACLR cases were identified. The rate of any 30-day complication was increased in longer procedures relative to shorter procedures (1.6% vs 0.9%, p = 0.006), as were the rates of returning to the operating room (0.6% vs 0.3%, p = 0.03), hospital readmission (1.0% vs 0.3%, p = 0.001), and overnight hospital stay (16.2% vs 6.0%, p < 0.001). Obesity was a risk factor for both hospital readmission and overnight hospital stay, while hypertension, diabetes, chronic obstructive pulmonary disease, and a smoking history were associated with increased rates of overnight hospital stay. The most common reasons for hospital readmission were deep vein thrombosis or pulmonary embolism (25.0% of all readmitted patients), surgical site infection (25.0%), and post-operative pain (14.1%).

CONCLUSIONS

In this propensity-matched analysis adjusting for baseline patient characteristics and operative factors, procedure length of greater than or equal to 90 min in ACLR was independently associated with an increased risk of hospital readmission and overnight hospital stay. As a surrogate measure of surgical complexity, operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling.

LEVEL OF EVIDENCE

III.

Relationship of Body Adiposity with Platelet Function in Obese and Non-obese Individuals

Background

Adiposity is firmly linked to a higher incidence of various cardiovascular and metabolic morbidities, including diabetes, hypertension, and thromboembolism. This research study was aimed to verify the association of increased adiposity and hyperreactivity of platelets in obese and non-obese individuals.

Methods

This cross-sectional study was conducted on 42 subjects aged 18 years and above. Subjects were divided into obese and non-obese groups based on their body mass index (BMI). The data was collected through self-administered questionnaires. All participants underwent body composition analysis. Blood samples were collected from all subjects and taken to the Pharmacology Department for the preparation of platelet-rich plasma (PRP) and poor platelet plasma (PPP). Platelet aggregation was induced by arachidonic acid and was monitored with a Bio/Data multichannel aggregation profiler (Bio/Data Corp., Horsham, PA, USA).

Results

Significant differences were observed in most parameters, such as fat mass, body fat percentage, free fat mass (FFM), the percentage of trunk fat, total body water, waist-hip ratio (WHR), and basal metabolic rate (BMR) of obese and non-obese subjects. The average percent of platelet aggregation in obese and non-obese subjects was 56.33 ± 15.62 and 59.38 ± 12.62, respectively. The average area under the curve (AUC) for platelet aggregation for both groups was 339.33 ± 191.55 and 342 ± 146.68, respectively. Platelet function was not significantly different and didn’t positively correlate with most parameters of the body composition, except WHR, which positively correlated with AUC for platelet function. 

Conclusion

There was no significant direct correlation between adiposity and platelet activation in obese subjects. However, a significant positive correlation of AUC for platelet aggregation with WHR was observed (resistance (r)-value: 0.307, p < 0.05). These findings suggest that WHR could be an effective determinant to assess the risk of thromboembolism in obese individuals.

How to optimise anticoagulation for patients who are obese

Management of anticoagulation has become a hot topic in the last decade. Health-care professionals are encountering increasing number of patients diagnosed with a thromboembolic episode, probably as a result of heightened awareness. In addition, the recognition that hospital-acquired thrombosis causes substantial mortality has led to an emphasis on appropriate thromboprophylaxis in all patients deemed at risk of thrombosis. However, the use of anticoagulants for both treatment and prophylaxis of thrombosis can pose a challenge in individuals who are obese. There are no detailed studies in this area and as such the dosing and monitoring of anticoagulants in these individuals can be problematic.

Selenium and RNA Virus Interactions: Potential Implications for SARS-CoV-2 Infection (COVID-19)

SARS-CoV-2 is an RNA virus responsible for the COVID-19 pandemic that already claimed more than 340,000 lives worldwide as of May 23, 2020, the majority of which are elderly. Selenium (Se), a natural trace element, has a key and complex role in the immune system. It is well-documented that Se deficiency is associated with higher susceptibility to RNA viral infections and more severe disease outcome. In this article, we firstly present evidence on how Se deficiency promotes mutations, replication and virulence of RNA viruses. Next, we review how Se might be beneficial via restoration of host antioxidant capacity, reduction of apoptosis and endothelial cell damages as well as platelet aggregation. It also appears that low Se status is a common finding in conditions considered at risk of severe COVID-19, especially in the elderly. Finally, we present a rationale for Se use at different stages of COVID-19. Se has been overlooked but may have a significant place in COVID-19 spectrum management, particularly in vulnerable elderly, and might represent a game changer in the global response to COVID-19.

Selenium and RNA Virus Interactions: Potential Implications for SARS-CoV-2 Infection (COVID-19)

SARS-CoV-2 is an RNA virus responsible for the COVID-19 pandemic that already claimed more than 340,000 lives worldwide as of May 23, 2020, the majority of which are elderly. Selenium (Se), a natural trace element, has a key and complex role in the immune system. It is well-documented that Se deficiency is associated with higher susceptibility to RNA viral infections and more severe disease outcome. In this article, we firstly present evidence on how Se deficiency promotes mutations, replication and virulence of RNA viruses. Next, we review how Se might be beneficial via restoration of host antioxidant capacity, reduction of apoptosis and endothelial cell damages as well as platelet aggregation. It also appears that low Se status is a common finding in conditions considered at risk of severe COVID-19, especially in the elderly. Finally, we present a rationale for Se use at different stages of COVID-19. Se has been overlooked but may have a significant place in COVID-19 spectrum management, particularly in vulnerable elderly, and might represent a game changer in the global response to COVID-19.

Body Mass Index and Prognosis of COVID-19 Infection. A Systematic Review

A better understanding of the SARS-CoV-2 virus behavior and possible risk factors implicated in poor outcome has become an urgent need. We performed a systematic review in order to investigate a possible association between body weight and prognosis among patients diagnosed with COVID-19. We searched in Cochrane Library, EMBASE, MEDLINE, WHO-Global Literature on Coronavirus Disease, OpenGrey, and Medrxiv. We used the ROBINS-I tool or Cross-Sectional/Prevalence Study Quality tool from AHRQ, to evaluate the methodological quality of included studies. Nine studies (two prospective cohorts, four retrospective cohorts and three cross-sectional) were included and assessed the relationship between obesity and COVID-19 prognosis. Risk of bias of the included studies ranged from moderate to critical. Clinical and methodological heterogeneity among them precluded meta-analyses. Most of the included studies showed some degree of association to: (a) higher BMI and worse clinical presentation and (b) obesity and need of hospitalization. The results were inconsistent about the impact of obesity on mortality. Based on limited methodological quality studies, obesity seems to predict poor clinical evolution in patients with COVID-19. Further studies with appropriate prospective design are needed to reduce the uncertainty on this evidence.

Effects of different diets used in diet-induced obesity models on insulin resistance and vascular dysfunction in C57BL/6 mice

The aim of the present study was to compare different diets used to induce obesity in a head-to-head manner with a focus on insulin resistance and vascular dysfunction. Male C57BL/6J mice were put on standard chow diet (SCD), normal-fat diet (NFD), cafeteria diet (CAF) or high-fat diet (HFD) for 12 weeks starting at the age of 6 weeks. Both CAF and HFD led to obesity (weight gain of 179% and 194%, respectively), glucose intolerance and insulin resistance to a comparable extent. In aortas containing perivascular adipose tissue (PVAT), acetylcholine-induced vasodilation was best in the NFD group and worst in the CAF group. Reduced phosphorylation of endothelial nitric oxide synthase at serine 1177 was observed in both CAF and HFD groups. Plasma coagulation activity was highest in the HFD group and lowest in the SCD group. Even the NFD group had significantly higher coagulation activity than the SCD group. In conclusions, CAF and HFD are both reliable mouse diets in inducing visceral obesity, glucose intolerance and insulin resistance. CAF is more effective than HFD in causing PVAT dysfunction and vascular dysfunction, whereas hypercoagulability was mostly evident in the HFD group. Coagulation activity was higher in NFD than NCD group.

Impact of Obesity on Ventricular Assist Device Outcomes

BACKGROUND

Obesity remains a relative contraindication for heart transplantation, and hence, obese patients with advanced heart failure receive ventricular assist devices (VADs) either as a destination or "bridge to weight loss" strategy. However, impact of obesity on clinical outcomes after VAD implantation is largely unknown. We sought to determine the clinical outcomes of obese patients with body mass index (BMI) ≥ 35 kg/m²) following contemporary VAD implantation.

METHODS

The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry was queried for patients who underwent VAD implantation. Patients were categorized into BMI groups based on World Health Organization classification.

RESULTS

Of 17,095 patients, 2620 (15%) had a BMI ≥ 35 kg/m². Obese patients were likely to be young, non-white, females with dilated cardiomyopathy and undergo device implantation as destination. Survival was similar amongst BMI groups (P = .058). Obese patients had significantly higher risk for infection (hazard ratio [HR]: 1.215; P = .001), device malfunction or thrombosis (HR: 1.323; P ≤ .001), cardiac arrhythmia (HR: 1.188; P = .001) and hospital readmissions (HR: 1.073; P = .022), but lower risk of bleeding (HR: 0.906; P = .018). Significant weight loss (≥10%) during VAD support was achieved only by a small proportion (18.6%) of patients with BMI ≥ 35 kg/m². Significant weight loss rates observed in obese patients with VAD implantation as destination and bridge to transplant strategy were comparable. Obese patients with significant weight loss were more likely to undergo cardiac transplantation. Weight loss worsened bleeding risk without altering risk for infection, cardiac arrhythmia, and device complications.

CONCLUSIONS

Obesity alone should not be considered a contraindication for VAD therapy in contemporary era. Given durability of heart transplantation, strategies should be developed to promote weight loss, which occurs infrequently in obese patients. Impact of weight loss on clinical outcome of obese patients warrants further investigation.

The Complication Rates of Oral Anticoagulation Therapy in Deep Venous Thrombosis

The objective of the current study is to evaluate the complication rates (embolic and hemorrhagic events) in deep venous thrombosis (DVT) patients on different types of oral anticoagulation therapy (OAC): direct oral anticoagulant therapy and vitamin K antagonist therapy.

Methods: A number of 62 DVT patients were included and divided in two groups, depending on the type of oral anticoagulation therapy administered. The first group was composed of patients treated with direct oral anticoagulant treatment (Dabigatran, Rivaroxaban) and the second group was composed of patients treated with vitamin K antagonist (Acenocumarol). General data, including BMI and comorbidities were noted. Embolic and hemorrhagic events were noticed.

Results: in the first group of patients (DOAC therapy), a number of 34 patients were included (14 of them with BMI higher than 25 kg/m2 and 14 with concomitant atrial fibrillation), while the second group comprised of 28 patients treated with VKA (21 of them with a high BMI and only 3 of them with atrial fibrillation). After a mean period of 36 months of anticoagulant therapy, complications were present in 17 patients, hematuria (8 episodes) and pulmonary embolism (4 cases) were the most frequent, with no difference regarding the treatment applied.

Conclusion: No statistically significant difference was encountered regarding embolic and hemorrhagic event rates in our deep vein thrombosis patients.

[Preoperative risk and perioperative management of obese patients]

The obese patient is at an increased risk of perioperative complications. Most importantly, these include difficult access to the airways (intubation, difficult or impossible ventilation), and post-extubation respiratory distress secondary to the development of atelectasis or obstruction of the airways, sometimes associated with the use of morphine derivatives. The association of obstructive sleep apnea syndrome (OSA) with obesity is very common, and induces a high risk of peri- and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre, per and postoperative pressure. For any obese patient, the implementation of protocols for mask ventilation and/or difficult intubation and the use of protective ventilation, morphine-sparing strategies and a semi-seated positioning throughout the care, is recommended, combined with close monitoring postoperatively. The dosage of anesthetic drugs should be based on the theoretical ideal weight and then titrated, rather than dosed to the total weight. Monitoring of neuromuscular blocking should be used where appropriate, as well as monitoring of the depth of anesthesia. The occurrence of intraoperative recall is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolic disease and early mobilization are recommended, as thromboembolic disease is increased in the obese patient. The use of non-invasive ventilation to prevent the occurrence of acute post-operative respiratory failure and for its treatment is particularly effective in obese patients. In case of admission to ICU, an individualized ventilatory management based on pathophysiology and careful monitoring should be initiated.

Metformin: Mechanisms in Human Obesity and Weight Loss

PURPOSE OF REVIEW

Metformin has multiple benefits for health beyond its anti-hyperglycemic properties. The purpose of this manuscript is to review the mechanisms that underlie metformin's effects on obesity.

RECENT FINDINGS

Metformin is a first-line therapy for type 2 diabetes. Large cohort studies have shown weight loss benefits associated with metformin therapy. Metabolic consequences were traditionally thought to underlie this effect, including reduction in hepatic gluconeogenesis and reduction in insulin production. Emerging evidence suggests that metformin-associated weight loss is due to modulation of hypothalamic appetite regulatory centers, alteration in the gut microbiome, and reversal of consequences of aging. Metformin is also being explored in the management of obesity's sequelae such as hepatic steatosis, obstructive sleep apnea, and osteoarthritis. Multiple mechanisms underlie the weight loss-inducing and health-promoting effects of metformin. Further exploration of these pathways may be important in identifying new pharmacologic targets for obesity and other aging-associated metabolic diseases.

Venous Thromboembolism in Neurocritical Care Patients

BACKGROUND

Venous thromboembolism (VTE) is a potentially life-threatening complication among critically ill patients. Neurocritical care patients are presumed to be at high risk for VTE; however, data regarding risk factors in this population are limited. We designed this study to evaluate the frequency, risk factors, and clinical impact of VTE in neurocritical care patients.

METHODS

We obtained data from the electronic medical record of all adult patients admitted to neurological intensive care unit (NICU) at Henry Ford Hospital between January 2015 and March 2018. Venous thromboembolism was defined as deep vein thrombosis, pulmonary embolism, or both diagnosed by Doppler, chest computed tomography (CT) angiography or ventilation-perfusion scan >24 hours after admission. Patients with ICU length of stay <24 hours or who received therapeutic anticoagulants or were diagnosed with VTE within 24 hours of admission were excluded.

RESULTS

Among 2188 consecutive NICU patients, 63 (2.9%) developed VTE. Prophylactic anticoagulant use was similar in patients with and without VTE (95% vs 92%; P = .482). Venous thromboembolism was associated with higher mortality (24% vs 13%, P = .019), and longer ICU (12 [interquartile range, IQR 5-23] vs 3 [IQR 2-8] days, P < .001) and hospital (22 [IQR 15-36] vs 8 [IQR 5-15] days, P < .001) length of stay. In a multivariable analysis, potentially modifiable predictors of VTE included central venous catheterization (odds ratio [OR] 3.01; 95% confidence interval [CI], 1.69-5.38; P < .001) and longer duration of immobilization (Braden activity score <3, OR 1.07 per day; 95% CI, 1.05-1.09; P < .001). Nonmodifiable predictors included higher International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) scores (which accounts for age >60, prior VTE, cancer and thrombophilia; OR 1.66; 95% CI, 1.40-1.97; P < .001) and body mass index (OR 1.05; 95% CI, 1.01-1.08; P = .007).

CONCLUSIONS

Despite chemoprophylaxis, VTE still occurred in 2.9% of neurocritical care patients. Longer duration of immobilization and central venous catheterization are potentially modifiable risk factors for VTE in critically ill neurological patients.

A novel resveratrol analog PA19 attenuates obesity‑induced cardiac and renal injury by inhibiting inflammation and inflammatory cell infiltration

Obesity is a major global health concern and induces numerous complications, such as heart and kidney injury. Inflammation is an important pathogenic mechanism underlying obesity‑associated tissue injury. (1E,4E)‑1‑{2,4‑Dimethoxy‑6‑[(E)‑4‑methoxystyryl]phenyl}‑5‑​(2,4‑dimethoxyphenyl)penta‑1,4‑dien‑3‑one (PA19) is a novel anti‑inflammatory compound synthesized by our research group. In the present study, the efficacy of PA19 in attenuating high‑fat diet (HFD)‑induced heart and kidney injury was investigated. Heart and kidney pathological injury and fibrosis were detected by hematoxylin and eosin and Sirius red staining, respectively. The expression levels of inflammatory genes and fibrosis‑associated protein were determined by reverse transcription‑quantitative polymerase chain reaction and western blotting. ELISA was used to detect the level of inflammatory cytokines. Following 20 weeks of HFD treatment, mice exhibited increased lipid accumulation in the serum, heart and kidney injury and fibrosis, and inflammation and inflammatory cell infiltration compared with mice fed a control diet. Conversely, treatment with PA19 during the final 12 weeks of the study significantly reduced the degree of heart and kidney fibrosis and inflammation induced by HFD. The results suggested that PA19 attenuates heart and kidney inflammation and injury induced by HFD, and indicated that PA19 may be a novel therapeutic agent in the treatment of obesity, and obesity‑induced cardiac and renal injury.

Swim exercise inhibits hemostatic abnormalities in a rat model of obesity and insulin resistance

BACKGROUND

We sought to determine whether swim exercise can inhibit high carbohydrate and fat diet (HCFD)-induced biomarkers of coagulation and thrombosis.

MATERIAL AND METHODS

Rats were either fed with HCFD (model group) or a standard laboratory chow (control group) for 15 weeks. Swim exercise-'treated' rats started swim exercise training from the 11th week until being sacrificed, on Week 15.

RESULTS

HCFD caused a significant increase in blood glucose, insulin resistance (HOMA-IR), lipidemia, and inflammatory biomarkers. In addition, HCFD significantly modulated coagulation and thrombosis biomarkers; fibrinogen, plasminogen activator inhibitor-1, von Willebrand factor, prothrombin time, activated partial thromboplastin time, blood clotting and bleeding time, and ADP-induced platelet aggregation that was effectively inhibited by swimming exercises.

CONCLUSIONS

We demonstrate that in an animal model of obesity and insulin resistance, there is a significant change in hemostasis, which is ameliorated by swim exercise.

Obstructive sleep apnoea and venous thromboembolism: pathophysiological links and clinical implications

Obstructive sleep apnoea (OSA) and pulmonary embolism (PE) remain major health issues worldwide. Data from pathophysiological studies suggest that both intermittent hypoxia and sleep fragmentation are associated with increased blood coagulability, endothelial dysfunction and venous stasis. There is growing evidence that OSA is potentially prevalent in and a risk factor for PE. Conversely, patients with acute PE have two to four times greater risk of moderate-to-severe OSA. The role of continuous positive airway pressure (CPAP) treatment in improving clinically meaningful outcomes in PE patients remains unclear, although some authors have suggested that CPAP could improve the hypercoagulability state and normalise circadian alterations in some of the coagulation molecules, as observed in patients with OSA. Emerging research highlights the complex interdependent relationships between OSA and PE, emphasising the need for rigorous, well-powered trials that address the impact of OSA and its treatment on the prevention and management of PE. Undoubtedly, these will require closer collaboration between the sleep medicine and clinical/venous thromboembolism communities.

Impact of Nonmalignant Portal Vein Thrombosis in Transplant Recipients With Nonalcoholic Steatohepatitis

Nonalcoholic fatty liver disease is an increasingly prevalent condition, and its more severe progressive state, nonalcoholic steatohepatitis (NASH), is currently the second most common indication for wait-listed adults in the United States. The association of portal vein thrombosis (PVT) prior to or at transplant and poor graft and patient outcomes is not well established, particularly among NASH patients who inherently have an increased hypercoagulable profile. Using the United Network for Organ Sharing data set, we analyzed graft and patient outcomes of patients transplanted for the indication of NASH with and without PVT. Of 3689 NASH transplant recipients, the prevalence of PVT was 12% (450 with PVT and 3239 without PVT). NASH transplant recipients with PVT had inferior graft and patient survival compared with NASH transplant recipients without PVT, even after adjusting for recipient and donor demographic characteristics, body mass index, synthetic dysfunction, and presence of diabetes. In a multivariate Cox regression model, NASH transplant recipients with PVT had a 37% increased risk of graft failure (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.15-1.63; P < 0.001) and 31% increased risk of overall death (HR, 1.31; 95% CI, 1.09-1.58; P < 0.001) compared with NASH transplant recipients without PVT at transplant. This difference in graft and patient survival was most pronounced in the early posttransplant period. These results demonstrate that NASH patients with PVT have decreased graft and patient survival independent of recipient and donor factors.

Prepregnancy maternal body mass index and venous thromboembolism: a population-based cohort study

OBJECTIVE

To assess the relation between maternal body mass index (BMI) and pregnancy-related venous thromboembolism (VTE).

DESIGN

Cohort study.

SETTING AND POPULATION

A total of 2 449 133 women with singleton pregnancies who underwent delivery hospitalisation in California between 2008 and 2012.

METHODS

Association of pre-pregnancy BMI and the risk of an antepartum and postpartum VTE was examined using logistic regression, with normal BMI as reference.

MAIN OUTCOME MEASURES

Antepartum and postpartum VTE-related hospitalisation.

RESULTS

The prevalence of antepartum and postpartum VTE increased with increasing BMI (antepartum: 2.3, 3.0, 3.8, 4.2, 4.7, and 10.6 per 10 000 women for underweight, normal BMI, overweight, obesity class I, II, and III, respectively, P < 0.001; postpartum: 2.0, 3.1, 3.9, 5.6, 9.0, and 13.2 per 10 000 women, P < 0.01). The adjusted odds of antepartum and postpartum VTE increased progressively with increasing BMI, with obesity class III women having the highest risk of pregnancy-related VTE compared with normal BMI women: adjusted odds ratio for antepartum VTE: 2.9; 95% CI 2.2-3.8 and adjusted odds ratio for postpartum VTE: 3.6; 95% CI 2.9-4.6.

CONCLUSIONS

Our findings clearly demonstrate an increasing risk of pregnancy-related VTE with increasing BMI.

TWEETABLE ABSTRACT

Obesity was associated with increased odds of antepartum and postpartum venous thromboembolism.

Metabolites Associated With the Risk of Incident Venous Thromboembolism: A Metabolomic Analysis

Background Venous thromboembolism ( VTE ) is a complex thrombotic disorder that constitutes a major source of mortality and morbidity. To improve understanding of the cause of VTE , we conducted a metabolomic analysis in a case-control study including 240 incident VTE cases and 6963 controls nested within 3 large prospective population-based cohorts, the Nurses' Health Study, the Nurses' Health Study II , and the Health Professionals Follow-Up Study. Methods and Results For each individual, we measured 211 metabolites and collected detailed information on lifestyle factors. We performed logistic regression and enrichment analysis to identify metabolites and biological categories associated with incident VTE risk, accounting for key confounders, such as age, sex, smoking, alcohol consumption, body mass index, and comorbid diseases (eg, cancers). We performed analyses of all VTEs and separate analyses of pulmonary embolism. Using the basic model controlling for age, sex, and primary disease, we identified 60 nominally significant VTE - or pulmonary embolism-associated metabolites ( P<0.05). These metabolites were enriched for diacylglycerols ( P_permutation<0.05). However, after controlling for multiple testing, only 1 metabolite (C5 carnitine; odds ratio, 1.25; 95% confidence interval, 1.10-1.41; P_corrected=0.03) remained significantly associated with VTE . After further adjustment for body mass index, no metabolites were significantly associated with disease after accounting for multiple testing, and no metabolite classes were enriched for nominally significant associations. Conclusions Although our findings suggest that circulating metabolites may influence the risk of incident VTE , the associations we observed were confounded by body mass index. Larger studies involving additional individuals and with broader metabolomics coverage are needed to confirm our findings.

Antiplatelets and profibrinolytic activity of Citrullus colocynthis in control and high-fat diet-induced obese rats: mechanisms of action

The current study aimed to investigate the effect of Citrullus colocynthis (C. colocynthis) hydro-alcoholic extract on blood haemostasis in control and high-fat diet (HFD) induced obese rats. In control rats, the extract significantly enhanced bleeding time and plasma levels of tPA and significantly decreased plasma levels PAI-1 and serum levels of thromboxane B2 leading to inhibition of platelets aggregation. In HFD induced obese rats, similar effects were seen and the extract was also able to reverse HFD induced increases in fibrinogen and VWF. Searching for the mechanism, C. colocynthis acts by (1) inhibiting of food intake, (2) inhibiting the activity of pancreatic lipase, (3) decreasing levels of TNF-α and IL-6 and (4) decreasing circulatory levels of the prothrombotic adipokine, leptin and enhanced circulatory levels of the antithrombic adipokines and adiopnectin. In conclusion, C. colocynthis has antiplatelets and profibrinolytic activity in both control and HFD induced obese rats.

The pharmacological management of metabolic syndrome

INTRODUCTION

The metabolic syndrome includes a constellation of several well-established risk factors, which need to be aggressively treated in order to prevent overt type 2 diabetes and cardiovascular disease. While recent guidelines for the treatment of individual components of the metabolic syndrome focus on cardiovascular benefits as resulted from clinical trials, specific recent recommendations on the pharmacological management of metabolic syndrome are lacking. The objective of present paper was to review the therapeutic options for metabolic syndrome and its components, the available evidence related to their cardiovascular benefits, and to evaluate the extent to which they should influence the guidelines for clinical practice. Areas covered: A Medline literature search was performed to identify clinical trials and meta-analyses related to the therapy of dyslipidemia, arterial hypertension, glucose metabolism and obesity published in the past decade. Expert commentary: Our recommendation for first-line pharmacological are statins for dyslipidemia, renin-angiotensin-aldosteron system inhibitors for arterial hypertension, metformin or sodium/glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists (GLP-1RAs) for glucose intolerance, and the GLP-1RA liraglutide for achieving body weight and waist circumference reduction.

The Role of Inflammation in Venous Thromboembolism

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT), and pulmonary embolism (PE), is becoming increasingly recognized as a cause of morbidity and mortality in pediatrics, particularly among hospitalized children. Furthermore, evidence is accumulating that suggests the inflammatory response may be a cause, as well as consequence, of VTE, but current anticoagulation treatment regimens are not designed to inhibit inflammation. In fact, many established clinical VTE risk factors such as surgery, obesity, cystic fibrosis, sepsis, systemic infection, cancer, inflammatory bowel disease, and lupus likely modulate thrombosis through inflammatory mediators. Unlike other traumatic mechanisms of thrombosis involving vascular transection and subsequent exposure of subendothelial collagen and other procoagulant extracellular matrix materials, inflammation of the vessel wall may initiate thrombosis on an intact vein. Activation of endothelial cells, platelets, and leukocytes with subsequent formation of microparticles can trigger the coagulation system through the induction of tissue factor (TF). Identification of biomarkers to evaluate VTE risk could be of great use to the clinician caring for a patient with inflammatory disease to guide decisions regarding the risk:benefit ratio of various types of potential thromboprophylaxis strategies, or suggest a role for anti-inflammatory therapy. Unfortunately, no such validated inflammatory scoring system yet exists, though research in this area is ongoing. Elevation of C-reactive protein, IL-6, IL-8, and TNF-alpha during a response to systemic inflammation have been associated with increased VTE risk. Consequent platelet activation enhances the prothrombotic state, leading to VTE development, particularly in patients with other risk factors, most notably central venous catheters.

Bleeding Complications After Percutaneous Mitral Valve Repair With the MitraClip

Bleeding after cardiac surgery or cardiovascular interventions is associated with worse patient outcome. Only very limited data are available on the subject of bleeding after percutaneous edge-to-edge mitral valve repair (PMVR). We performed a single center analysis including 347 consecutive patients who underwent PMVR. Bleeding was defined according to the Mitral Valve Academic Research Consortium (MVARC) end point definition. The incidence of MVARC bleeding was 21.6% (n = 75), whereas major MVARC bleeding (hemoglobin decrease ≥3 g/dl) occurred in 7.4% (n = 26). Only 33.3% of all bleeding cases were access site-related. In multivariate regression analyses, independent predictors of MVARC bleeding were the presence of coronary artery disease (2.809, 95% CI 1.123 to 7.022, p = 0.027) and intervention duration (1.010, 95% CI 1.002 to 1.018, p = 0.010). Patients experiencing MVARC bleeding had longer hospital stays (p = 0.026); however, neither major nor extensive MVARC bleeding was associated with increased 30-day or 1-year mortality. A decrease in hemoglobin levels ≥3 g/dl without clinically visible bleeding sign-not considered in the MVARC bleeding definition-occurred in 9.5% of patients. A hemoglobin decrease of ≥4 g/dl had a strong association with worse survival in those patients with obscure bleeding. In conclusion, these data show a relevant incidence of bleeding after PMVR. In contrast to other cardiovascular interventions, the majority of bleedings were not access site-related. Particularly, patients with obscure bleeding, which are not included in the MVARC end point definitions, had worse outcomes and should therefore be considered for a more intensive workup.

Obesity: Risk factors, complications, and strategies for sustainable long-term weight management

Background and Purpose

The aims of this article are to review the effects of obesity on health and well‐being and the evidence indicating they can be ameliorated by weight loss, and consider weight‐management strategies that may help patients achieve and maintain weight loss.

Methods

Narrative review based on literature searches of PubMed up to May 2016 with no date limits imposed. Search included terms such as “obesity,” “overweight,” “weight loss,” “comorbidity,” “diabetes,” cardiovascular,” “cancer,” “depression,” “management,” and “intervention.”

Conclusions

Over one third of U.S. adults have obesity. Obesity is associated with a range of comorbidities, including diabetes, cardiovascular disease, obstructive sleep apnea, and cancer; however, modest weight loss in the 5%–10% range, and above, can significantly improve health‐related outcomes. Many individuals struggle to maintain weight loss, although strategies such as realistic goal‐setting and increased consultation frequency can greatly improve the success of weight‐management programs. Nurse practitioners have key roles in establishing weight‐loss targets, providing motivation and support, and implementing weight‐loss programs.

Implications for Practice

With their in‐depth understanding of the research in the field of obesity and weight management, nurse practitioners are well placed to effect meaningful changes in weight‐management strategies deployed in clinical practice.

Influences of Obesity and Bariatric Surgery on the Clinical and Pharmacologic Profile of Rivaroxaban

The health implications of obesity are myriad and multifaceted. Physiologic changes associated with obesity can affect the absorption, distribution, metabolism, and excretion of administered drugs, thereby altering their pharmacologic profiles. In 2016, the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis published recommendations about the use of direct oral anticoagulants (DOACs) in obese patients. This guidance provides uniform recommendations for all DOACs, yet data suggest that individual agents may be affected to different degrees by obesity. Moreover, there are no recommendations currently available to guide DOAC use in bariatric surgery patients, in whom anatomic and physiologic changes to the digestive system can influence drug pharmacokinetics. Our review of the available literature indicates that the clinical profile of the DOAC rivaroxaban is not affected by high weight or bariatric surgery; hence, it does not appear that rivaroxaban dosing needs to be altered in these patient populations.

Transcriptional analysis of abdominal fat in chickens divergently selected on bodyweight at two ages reveals novel mechanisms controlling adiposity: validating visceral adipose tissue as a dynamic endocrine and metabolic organ

Background

Decades of intensive genetic selection in the domestic chicken (Gallus gallus domesticus) have enabled the remarkable rapid growth of today’s broiler (meat-type) chickens. However, this enhanced growth rate was accompanied by several unfavorable traits (i.e., increased visceral fatness, leg weakness, and disorders of metabolism and reproduction). The present descriptive analysis of the abdominal fat transcriptome aimed to identify functional genes and biological pathways that likely contribute to an extreme difference in visceral fatness of divergently selected broiler chickens.

Methods

We used the Del-Mar 14 K Chicken Integrated Systems microarray to take time-course snapshots of global gene transcription in abdominal fat of juvenile [1-11 weeks of age (wk)] chickens divergently selected on bodyweight at two ages (8 and 36 wk). Further, a RNA sequencing analysis was completed on the same abdominal fat samples taken from high-growth (HG) and low-growth (LG) cockerels at 7 wk, the age with the greatest divergence in body weight (3.2-fold) and visceral fatness (19.6-fold).

Results

Time-course microarray analysis revealed 312 differentially expressed genes (FDR ≤ 0.05) as the main effect of genotype (HG versus LG), 718 genes in the interaction of age and genotype, and 2918 genes as the main effect of age. The RNA sequencing analysis identified 2410 differentially expressed genes in abdominal fat of HG versus LG chickens at 7 wk. The HG chickens are fatter and over-express numerous genes that support higher rates of visceral adipogenesis and lipogenesis. In abdominal fat of LG chickens, we found higher expression of many genes involved in hemostasis, energy catabolism and endocrine signaling, which likely contribute to their leaner phenotype and slower growth. Many transcription factors and their direct target genes identified in HG and LG chickens could be involved in their divergence in adiposity and growth rate.

Conclusions

The present analyses of the visceral fat transcriptome in chickens divergently selected for a large difference in growth rate and abdominal fatness clearly demonstrate that abdominal fat is a very dynamic metabolic and endocrine organ in the chicken. The HG chickens overexpress many transcription factors and their direct target genes, which should enhance in situ lipogenesis and ultimately adiposity. Our observation of enhanced expression of hemostasis and endocrine-signaling genes in diminished abdominal fat of LG cockerels provides insight into genetic mechanisms involved in divergence of abdominal fatness and somatic growth in avian and perhaps mammalian species, including humans.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-4035-5) contains supplementary material, which is available to authorized users.

Assessing the causal relationship between obesity and venous thromboembolism through a Mendelian Randomization study

Observational studies have shown an association between obesity and venous thromboembolism (VTE) but it is not known if observed associations are causal, due to reverse causation or confounding bias. We conducted a Mendelian Randomization study of body mass index (BMI) and VTE. We identified 95 single nucleotide polymorphisms (SNPs) that have been previously associated with BMI and assessed the association between genetically predicted high BMI and VTE leveraging data from a previously conducted GWAS within the INVENT consortium comprising a total of 7507 VTE cases and 52,632 controls of European ancestry. Five BMI SNPs were associated with VTE at P < 0.05, with the strongest association seen for the FTO SNP rs1558902 (OR 1.07, 95% CI 1.02-1.12, P = 0.005). In addition, we observed a significant association between genetically predicted BMI and VTE (OR = 1.59, 95% CI 1.30-1.93 per standard deviation increase in BMI, P = 5.8 × 10-6). Our study provides evidence for a causal relationship between high BMI and risk of VTE. Reducing obesity levels will likely result in lower incidence in VTE.

Eryptosis in health and disease: A paradigm shift towards understanding the (patho)physiological implications of programmed cell death of erythrocytes

During the course of their natural ageing and upon injury, anucleate erythrocytes can undergo an unconventional apoptosis-like cell death, termed eryptosis. Eryptotic erythrocytes display a plethora of morphological alterations including volume reduction, membrane blebbing and breakdown of the membrane phospholipid asymmetry resulting in phosphatidylserine externalization which, in turn, mediates their phagocytic recognition and clearance from the circulation. Overall, the eryptosis machinery is tightly orchestrated by a wide array of endogenous mediators, ion channels, membrane receptors, and a host of intracellular signaling proteins. Enhanced eryptosis shortens the lifespan of circulating erythrocytes and confers a procoagulant phenotype; this phenomenon has been tangibly implicated in the pathogenesis of anemia, deranged microcirculation, and increased prothrombotic risk associated with a multitude of clinical conditions. Herein, we reviewed the molecular mechanisms dictating eryptosis and erythrophagocytosis and critically analyzed the current evidence leading to the pathophysiological ramifications of eryptotic cell death in the context of human disease.

Increased Coagulation and Decreased Fibrinolysis as Measured with Overall Hemostatic Potential Are Dependent on BMI and Not Associated with PCOS

BACKGROUND

Overall hemostatic potential (OHP) captures all factors that affect coagulation and fibrinolysis cascade. It has not yet been assessed in polycystic ovary syndrome (PCOS). The aim of the study was to identify the relationship of OHP with a syndrome per se and body mass index (BMI).

METHODS

In 90 women with PCOS aged 30.9 ± 8.1 years (50 obese, 13 overweight, and 27 lean) and 21 healthy age-matched controls (11 obese and 10 lean), OHP with overall coagulation potential (OCP) and overall fibrinolytic potential (OFP) was determined spectrophotometrically. OFP was calculated.

RESULTS

OHP increased with BMI in PCOS (9.6 ± 2.3 in lean, 12.5 ± 5.1 in overweight, and 15.5 ± 3.8 Abs-sum in obese) and in controls (9.1 ± 1.0 in lean and 17.3 ± 4.6 Abs-sum in obese). There was significant difference between lean and obese PCOS (P < 0.001) and between lean and obese controls (P < 0.001). OCP also increased with BMI in PCOS (P < 0.001 for lean vs. obese) and in controls (P < 0.001 for lean vs. obese). OFP decreased with BMI in PCOS (P < 0.001 for obese vs. overweight vs. lean) and in controls (P < 0.001 for obese vs. lean). OHP in healthy obese and obese PCOS did not differ significantly, while OHP for healthy obese was increased in comparison to overweight and lean PCOS (P < 0.001).

CONCLUSION

PCOS was not associated with increased OHP compared with BMI and age-matched controls. However, increase in OHP was positively associated with BMI in PCOS and healthy women.

Thrombosis in the setting of obesity or inflammatory bowel disease

Obesity and inflammatory bowel disease (IBD) are systemic inflammatory disorders that predispose to arterial and venous thrombosis through similar prothrombotic mechanisms. Obesity and IBD are chronic risk factors that lead to a persistently elevated risk of thrombosis, although the thrombotic risk with IBD appears to wax and wane with disease severity. Because of the lack of high-quality evidence to guide management decisions, approaches to the prevention and treatment of thrombosis in patients with obesity or IBD are based on extrapolation from general guidelines for antithrombotic therapy. Obesity alters the pharmacokinetics of some anticoagulant drugs, and IBD patients present the added management challenge of having a high risk of gastrointestinal bleeding while taking anticoagulants. An extended duration of anticoagulant therapy is often recommended for obese or IBD patients with unprovoked venous thromboembolism unless there is a high risk of bleeding, although more data and better biomarkers are needed to determine whether anticoagulation can be safely stopped in a subset of IBD patients during remission of active disease. Most patients with obesity or IBD require thromboprophylaxis in conjunction with hospitalization or surgery, with adjustment of anticoagulant dosing in patients with severe obesity.

Thrombosis in the setting of obesity or inflammatory bowel disease

Obesity and inflammatory bowel disease (IBD) are systemic inflammatory disorders that predispose to arterial and venous thrombosis through similar prothrombotic mechanisms. Obesity and IBD are chronic risk factors that lead to a persistently elevated risk of thrombosis, although the thrombotic risk with IBD appears to wax and wane with disease severity. Because of the lack of high-quality evidence to guide management decisions, approaches to the prevention and treatment of thrombosis in patients with obesity or IBD are based on extrapolation from general guidelines for antithrombotic therapy. Obesity alters the pharmacokinetics of some anticoagulant drugs, and IBD patients present the added management challenge of having a high risk of gastrointestinal bleeding while taking anticoagulants. An extended duration of anticoagulant therapy is often recommended for obese or IBD patients with unprovoked venous thromboembolism unless there is a high risk of bleeding, although more data and better biomarkers are needed to determine whether anticoagulation can be safely stopped in a subset of IBD patients during remission of active disease. Most patients with obesity or IBD require thromboprophylaxis in conjunction with hospitalization or surgery, with adjustment of anticoagulant dosing in patients with severe obesity.