The risk of venous thromboembolism is markedly elevated in patients with diabetes

Deep Vein Thrombosis as the Presenting Sign in an Adolescent With New-Onset Type 2 Diabetes

Prothrombin G20210A mutation occurs in only 2% to 3% of the population, but usually does not become apparent unless the individual exhibits another risk factor for clotting. A risk factor such as hyperglycemia in the setting of diabetes mellitus may accelerate this clotting process, even at a very young age. In this case report, we discuss a 15-year-old boy presenting with left calf swelling and pain, found to have extensive deep vein thrombosis in the setting of hyperglycemia and a newly discovered prothrombin G20210A mutation. Venous thromboembolism in the setting of type 2 diabetes mellitus has not been described in children.

Charlson and Elixhauser Comorbidity Indices for Prediction of Mortality and Hospital Readmission in Patients With Acute Pulmonary Embolism

Several risk stratification systems aid clinicians in classifying pulmonary embolism (PE) severity and prognosis. We compared 2 clinical PE scoring systems, the PESI and sPESI scores, with 2 comorbidity indices, the Charlson Comorbidity Index (CCI) and the val Walraven Elixhauser Comorbidity Index (ECI), to determine the utility of each in predicting mortality and hospital readmission. Information was collected from 436 patients presenting with PE via retrospective chart review. The PESI, sPESI, CCI, and ECI scores were calculated for each patient. Multivariate analysis was used to determine each system's ability to predict in-hospital mortality, 90-day mortality, overall mortality, and all-cause hospital readmission. The impact of various demographic and clinical characteristics of each patient on these outcomes was also assessed. The PESI score was found to be an independent predictor of in-hospital mortality and 90-day mortality. The PESI score and the CCI were able to independently predict overall mortality. None of the 4 risk scores independently predicted hospital readmission. Other factors including hypoalbuminemia, serum BNP, coagulopathy, anemia, and diabetes were associated with increased mortality and readmission at various endpoints. The PESI score was the best tool for predicting mortality at any endpoint. The CCI may have utility in predicting long-term outcomes. Further work is needed to better determine the roles of the CCI and ECI in predicting patient outcomes in PE. The potential prognostic implications of low serum albumin and anemia at the time of PE also warrant further investigation.

Exploring Risk Factors for Lower Extremity Deep Vein Thrombosis Patients with Co-existing Pulmonary Embolism Based on Multiple Logistic Regression Model

Valuable data on deep vein thrombosis (DVT) patients with coexisting pulmonary embolism (PE) is scarce. This study aimed to identify risk factors associated with these patients and develop logistic regression models to select high-risk DVT patients with coexisting PE. We retrospectively collected data on 150 DVT patients between July 15, 2022, and June 15, 2023, dividing them into groups based on the presence of coexisting PE. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors and construct predictive models. Discrimination and calibration statistics evaluated the validation and accuracy of the developed models. Of the 130 patients analyzed, 40 (30.77%) had coexisting PE. Univariate analysis revealed four significant predictors of DVT patients with coexisting PE: sex (OR 3.83, 95% CI: [1.76; 8.59], P = 0.001), body mass index (BMI) (OR 1.50, 95% CI: [1.28; 1.75], P < 0.001), chronic disease (OR 5.15, 95% CI: [2.32; 11.8], P < 0.001), and high-density lipoprotein (HDL) (OR 0.03, 95% CI: [0.01; 0.20], P < 0.001). Additionally, BMI > 24 kg/m2 (OR 9.70, 95% CI: [2.70; 67.5], P < 0.001) and BMI > 28 kg/m2 (OR 4.80, 95% CI: [2.15; 11.0], P < 0.001) were associated with concurrent PE. Three multiple regression models were constructed, with areas under the receiver-operating characteristic curves of 0.925 (95% CI: [0.882; 0.968]), 0.908 (95% CI: [0.859; 0.957]), and 0.890 (95% CI: [0.836; 0.944]), respectively. Sex, BMI, chronic disease, and HDL levels are significant predictors of DVT patients with coexisting PE.

Splenic Infarction with Myocardial Injury in a Diabetic Patient: A Case Report

Splenic infarction (SI) is an uncommon complication of type 2 diabetes (T2D). Diabetes predisposes individuals to blood vessel abnormalities, such as atherosclerosis or thrombosis, increasing the risk of vessel occlusion and subsequent tissue infarction. If the diabetic patient has other serious diseases, such as a severe pneumonia infection and acute cardiac infarction, SI incidence may go unrecognized, making it challenging for physicians to identify. This case report discussed an 80-year-old hospitalized diabetic woman with a history of chronic bronchitis and 20 years of T2D who suffered an SI. The patient was at elevated risk for thrombosis of atrial fibrillation, manifested as an embolism of the spleen characterized by a high concentration of white blood cells. This patient also demonstrated a rapid increase in cardiac biomarkers troponin I, suggesting acute myocardial infarction (AMI) and increased amylase, which could not preclude the concern about the existence of acute pancreatitis. Abdominal CT displayed the calcification of only the splenic and other arteries, and low-density shadows were observed at the center portion of the spleen. This case demonstrated the significant occurrence of thrombotic complications in various blood vessels of multiple organs in T2D patients. Thus, clinicians should be aware of the possibility of simultaneous acute vascular infarction of several organs in diabetic patients with prior vascular constriction.

The Causality between Diabetes and Venous Thromboembolism: A Bidirectional Two-Sample Mendelian Randomization Study

BACKGROUND

 Diabetes was considered as a risk factor for venous thromboembolism (VTE), but conflicting findings have been reported from observational studies. This study aimed at investigating the causal associations of type 1 and type 2 diabetes with VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

 We designed a bidirectional two-sample Mendelian randomization (MR) analysis by using summary-level data from large genome-wide association studies performed in European individuals. Inverse variance weighting with multiplicative random effect method was used to obtain the primary causal estimates, and weighted median, weighted mode, and MR egger regression were replenished as sensitivity analyses to test the robustness of the results.

RESULTS

 We found no significant causal effects of type 1 diabetes on VTE (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.96-1.00, p = 0.043), DVT (OR: 0.98, 95% CI: 0.95-1.00, p = 0.102), and PE (OR: 0.98, 95% CI: 0.96-1.01, p = 0.160). Similarly, no significant associations of type 2 diabetes with VTE (OR: 0.97, 95% CI: 0.91-1.03, p = 0.291), DVT (OR: 0.96, 95% CI: 0.89-1.03, p = 0.255), and PE (OR: 0.97, 95% CI: 0.90-1.04, p = 0.358) were also observed. Results from multivariable MR analysis were consistent with the findings in univariable analysis. In the other direction, the results showed no significant causal effects of VTE on type 1 and type 2 diabetes.

CONCLUSION

 This MR analysis demonstrated no significant causal associations of type 1 and type 2 diabetes with VTE in both directions, in conflict with previous observational studies reporting positive association, which provided clues for understanding the underlying pathogenesis of diabetes and VTE.

Diabetes status and other factors as correlates of risk for thrombotic and thromboembolic events during SARS-CoV-2 infection: A nationwide retrospective case-control study using Cerner Real-World Data™

OBJECTIVES

We sought to examine in individuals with SARS-CoV-2 infection whether risk for thrombotic and thromboembolic events (TTE) is modified by presence of a diabetes diagnosis. Furthermore, we analysed whether differential risk for TTEs exists in type 1 diabetes mellitus (T1DM) versus type 2 diabetes mellitus (T2DM).

DESIGN

Retrospective case-control study.

SETTING

The December 2020 version of the Cerner Real-World Data COVID-19 database is a deidentified, nationwide database containing electronic medical record (EMR) data from 87 US-based health systems.

PARTICIPANTS

We analysed EMR data for 322 482 patients >17 years old with suspected or confirmed SARS-CoV-2 infection who received care between December 2019 and mid-September 2020. Of these, 2750 had T1DM; 57 811 had T2DM; and 261 921 did not have diabetes.

OUTCOME

TTE, defined as presence of a diagnosis code for myocardial infarction, thrombotic stroke, pulmonary embolism, deep vein thrombosis or other TTE.

RESULTS

Odds of TTE were substantially higher in patients with T1DM (adjusted OR (AOR) 2.23 (1.93-2.59)) and T2DM (AOR 1.52 (1.46-1.58)) versus no diabetes. Among patients with diabetes, odds of TTE were lower in T2DM versus T1DM (AOR 0.84 (0.72-0.98)).

CONCLUSIONS

Risk of TTE during COVID-19 illness is substantially higher in patients with diabetes. Further, risk for TTEs is higher in those with T1DM versus T2DM. Confirmation of increased diabetes-associated clotting risk in future studies may warrant incorporation of diabetes status into SARS-CoV-2 infection treatment algorithms.

Preoperative and Perioperative Management of Diabetics Undergoing Elective Foot and Ankle Surgery

Diabetics are a highly comorbid population with an elevated risk profile when undergoing surgery. Proper preparation and management of modifiable risk factors can optimize outcomes in diabetics. A multidisciplinary approach to preoperative optimization, including surgeons, primary care providers, and anesthesiologists, ensures diabetic patients receive comprehensive evaluation before elective surgery. Orthopedic surgeons must understand preoperative optimization goals as they pertain to nutrition, glycemic control, and cardiovascular disease in diabetic patients.

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Emerging Evidence on Membrane Estrogen Receptors as Novel Therapeutic Targets for Central Nervous System Pathologies

Nuclear- and membrane-initiated estrogen signaling cooperate to orchestrate the pleiotropic effects of estrogens. Classical estrogen receptors (ERs) act transcriptionally and govern the vast majority of hormonal effects, whereas membrane ERs (mERs) enable acute modulation of estrogenic signaling and have recently been shown to exert strong neuroprotective capacity without the negative side effects associated with nuclear ER activity. In recent years, GPER1 was the most extensively characterized mER. Despite triggering neuroprotective effects, cognitive improvements, and vascular protective effects and maintaining metabolic homeostasis, GPER1 has become the subject of controversy, particularly due to its participation in tumorigenesis. This is why interest has recently turned toward non-GPER-dependent mERs, namely, mERα and mERβ. According to available data, non-GPER-dependent mERs elicit protective effects against brain damage, synaptic plasticity impairment, memory and cognitive dysfunctions, metabolic imbalance, and vascular insufficiency. We postulate that these properties are emerging platforms for designing new therapeutics that may be used in the treatment of stroke and neurodegenerative diseases. Since mERs have the ability to interfere with noncoding RNAs and to regulate the translational status of brain tissue by affecting histones, non-GPER-dependent mERs appear to be attractive targets for modern pharmacotherapy for nervous system diseases.

An Overview of Specific Considerations in Chronic Venous Disease and Iliofemoral Venous Stenting

Unlike arterial disease, chronic venous disease (CVD) is rarely life-threatening or limb-threatening. However, it can impose substantial morbidity on patients by influencing their lifestyle and quality of life (QoL). The aim of this nonsystematic narrative review is to provide an overview of the most recent information on the management of CVD and specifically, iliofemoral venous stenting in the context of personalized considerations for specific patient populations. The philosophy of treating CVD and phases of endovenous iliac stenting are also described in this review. Additionally, the use of intravascular ultrasound is described as the preferred operative diagnostic procedural tool for iliofemoral venous stent placement.

Glycemic Control and Plasma Levels of Pro-Inflammatory and Pro-Thrombotic Biomarkers in Diabetic Patients Presenting with Acute Pulmonary Embolism

Type I and type II diabetes are closely associated with a pro-inflammatory state and to a pro-thrombotic state. The role of glycemic control in pulmonary embolism (PE) is poorly understood and requires additional investigation. The aim of this study is to investigate the relationship between glycemic control and thrombo-inflammatory biomarkers in a PE patient cohort compared to normal samples. Demographic and clinical information for 86 diabetic patients and 106 non-diabetic patients presenting with acute PE was collected via retrospective chart review. Plasma levels of pro-inflammatory (C-reactive protein [CRP], tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and pro-thrombotic (d-dimer, plasminogen activator inhibitor-1 [PAI-1], tissue plasminogen activator [tPA], thrombin activatable fibrinolysis inhibitor [TAFI], von-Willebrand factor [vWF], endogenous glycosaminoglycans [GAGs]) biomarkers were drawn within 24 hours of diagnosis of acute PE. Data was also obtained for a population of healthy adult controls. All the pro-inflammatory and pro-thrombotic biomarkers were elevated in diabetic PE patients in comparison to healthy controls. None of the biomarkers were elevated in diabetic PE patients when compared to non-diabetic PE patients. There was no difference in the levels of the pro-inflammatory biomarkers according to glycemic control. The plasma level of TAFI was elevated in diabetic patients with poor glycemic control. Diabetic patients were more likely to have a more severe PE. These studies demonstrate that thrombo-inflammatory biomarkers are elevated in diabetic PE patients with associated comorbidities in comparison to normal individuals. However, there is no difference between the PE cohort alone in comparison to PE with diabetes. The role of TAFI within the continuum of diabetic vascular disease warrants additional investigation.

Diabetes mellitus is associated with a higher relative risk for venous thromboembolism in females than in males

AIMS

The risk for developing venous thromboembolism (VTE) is about equal in both sexes. Research suggests diabetes mellitus (DM) is a risk factor for pulmonary embolism and deep vein thrombosis, both forms of VTE. We aimed at investigating the sex-specific impact of DM on VTE risk.

MATERIALS AND METHODS

Medical claims data were analyzed in a retrospective, population-level cohort study in Austria between 1997 and 2014. 180,034 patients with DM were extracted and compared to 540,102 sex and age-matched controls without DM in terms of VTE risk and whether specific DM medications might modulate VTE risk.

RESULTS

The risk to develop VTE was 1.4 times higher amongst patients with DM than controls (95% CI 1.36-1.43, p < 0.001). The association of DM with newly diagnosed VTE was significantly greater in females (OR = 1.52, 95% CI 1.46-1.58, p < 0.001) resulting in a relative risk increase of 1.17 (95% CI 1.11-1.23) across all age groups with a peak of 1.65 (95% CI 1.43-1.89) between 50 and 59 years. Dipeptidyl peptidase 4 inhibitors were associated with a higher risk for VTE amongst female DM patients (OR = 2.3, 95% CI 1.3-4.3, p = 0.0096).

CONCLUSION

Amongst DM patients, females appear to be associated with a higher relative risk increase in VTE than males, especially during perimenopause.

Platelet-Neutrophil Interaction and Thromboinflammation in Diabetes: Considerations for Novel Therapeutic Approaches

Thromboinflammation has become a topic of key interest in cardiovascular disease and the prevention of diabetes complications because of the interplay between thrombosis and inflammation in diabetes. Specifically, the significant risk of vascular thrombotic disease in diabetes highlights the need for new and better therapeutic targets to help manage and prevent vascular thrombo-occlusive disease in this condition. Similarly, the prominent role of inflammation in diabetes has sparked interest in anti-inflammatory agents to better prevent and control vascular disease. Investigations on the effects of anticoagulation and antiplatelet interventions in patients with diabetes and cardiovascular disease show a potential role for these agents in decreasing morbidity and mortality. Neutrophils and platelets are key players in inflammation and wound-healing response, respectively. The interaction between neutrophils and platelets is thought to be an important driver of thromboinflammation. Therefore, this review describes the mechanisms involved in platelet-neutrophil interactions that contribute to the development or exacerbation of thromboinflammation in the context of diabetes and its associated comorbidities. The effects observed by the antithrombotic/antidiabetic treatments and physical activity/dietary interventions on attenuating thromboinflammation are discussed. These data suggest that mechanisms involved in platelet-neutrophil interaction, platelet activation/aggregation, and the recruitment of neutrophils have a promising potential to become therapeutic targets to decrease thromboinflammation in patients with diabetes.

Organ-specific metabolic pathways distinguish prediabetes, type 2 diabetes, and normal tissues

Environmental and genetic factors cause defects in pancreatic islets driving type 2 diabetes (T2D) together with the progression of multi-tissue insulin resistance. Mass spectrometry proteomics on samples from five key metabolic tissues of a cross-sectional cohort of 43 multi-organ donors provides deep coverage of their proteomes. Enrichment analysis of Gene Ontology terms provides a tissue-specific map of altered biological processes across healthy, prediabetes (PD), and T2D subjects. We find widespread alterations in several relevant biological pathways, including increase in hemostasis in pancreatic islets of PD, increase in the complement cascade in liver and pancreatic islets of PD, and elevation in cholesterol biosynthesis in liver of T2D. Our findings point to inflammatory, immune, and vascular alterations in pancreatic islets in PD that are hypotheses to be tested for potential contributions to hormonal perturbations such as impaired insulin and increased glucagon production. This multi-tissue proteomic map suggests tissue-specific metabolic dysregulations in T2D.

Does diabetes mellitus increase the incidence of early thrombosis in deep vein following unicompartmental knee arthroplasty: a retrospective cohort study

Background

Many patients following unicompartmental knee arthroplasty (UKA) also suffer from diabetes mellitus, which may lead to an increased likelihood of postoperative deep venous thrombosis (DVT). Therefore, we evaluated whether DVT incidence would increase 3 days following UKA in diabetic patients.

Methods

Patients who underwent UKA from August 2018 to September 2021 in our hospital were retrospectively included. Age, gender, body mass index, hypertension, mode of anesthesia, surgery time, intraoperative blood loss, tourniquet pressure and time, and glycosylated hemoglobin concentration were recorded as confounders. We compared the incidence and type of DVT between non-diabetic and diabetic patients and evaluated the effect of glycosylated hemoglobin levels on DVT.

Results

Of all the 224 patients, 96 had diabetes and 128 did not. Within 3 days after surgery, DVT occurred in 25 cases in the diabetic group and 17 cases in the non-diabetic group (p < 0.05), and the difference mainly exists in the lower limbs on the surgical side. Logistic regression analysis demonstrated that the risk of DVT in the diabetic group was 4.50 times higher compared with the non-diabetic group. For every 1 unit increase of glycosylated hemoglobin, the incidence of DVT increased 2.35 times. Differences in age, gender, body mass index, hypertension, mode of anesthesia, surgery time, intraoperative blood loss, tourniquet pressure, and time between the two groups were not significant.

Conclusions

The incidence of DVT in diabetic patients within 3 days after UKA was significantly higher than that in non-diabetic patients and was proportional to the concentration of glycosylated hemoglobin.

Atherosclerosis and Its Impact on the Outcomes of Patients with Deep Venous Thrombosis

Introduction: Atherosclerosis and pulmonary embolism (PE) affect cardiovascular mortality substantially. We aimed to investigate the impact of atherosclerosis on the outcomes of patients with deep venous thrombosis (DVT) and to identify the differences in DVT patients with and without PE. Methods: Patients with DVT with and without symptomatic atherosclerosis (defined as coronary artery disease, myocardial infarction and/or peripheral artery disease) as well as with and without PE under oral anticoagulation were enrolled during January 2011−April 2013 and compared. The impact of symptomatic atherosclerosis on several outcomes was analyzed. Results: Overall, 509 DVT patients (70.0 [56.0−77.0] years, 51.9% females) were included in this study. Among them, 179 (36.3%) had symptomatic atherosclerosis and 204 (40.1%) a concomitant PE. DVT patients with symptomatic atherosclerosis were older (74.0 [IQR 65.0−80.0] vs. 63.0 [48.0−75.0] years, p < 0.0001), more often male (56.4% vs. 43.9%, p = 0.0087) and had a higher prevalence of classical CVRF and a higher Charlson comorbidity index (7.00 [5.00−8.00] vs. 4.00 [2.00−6.00], p < 0.001). Symptomatic atherosclerosis was associated with increased mortality (HR 1.98 [95%CI 1.12−3.49], p = 0.018) and hospitalizations (HR 1.64 [95%CI 1.21−2.21], p = 0.0012) and primary long-term outcome (HR 1.99 [95%CI 1.31−3.04], p = 0.0013) during the 2 years follow-up-period in DVT patients. DVT patients without PE had diabetes mellitus (28.2% vs. 16.3%, p < 0.01) and symptomatic atherosclerosis (42.9% vs. 26.4%, p < 0.001) more often compared to DVT patients with PE, and symptomatic atherosclerosis was associated with isolated DVT (without PE) (OR 2.01 [95%CI 1.28−3.16], p < 0.01). Conclusions: Atherosclerosis was associated with isolated DVT (without PE) and increased mortality in DVT patients under oral anticoagulation. The profile of CVRF and comorbidities differed between DVT patients with and without a concomitant PE. In the case of DVT or PE, patients should be screened for concomitant atherosclerotic disease. Clinical Trial Registration: at clinicaltrials with Unique identifier NCT01809015.

Association of Metformin Use With Risk of Venous Thromboembolism in Adults With Type 2 Diabetes: A General-Population-Based Cohort Study

Metformin is hypothesized to protect against the risk of venous thromboembolism (VTE); however, there is a paucity of data supporting this hypothesis. Among individuals aged 40-90 years with a diagnosis of type 2 diabetes in the Health Improvement Network database (2000-2019), we compared the risks of incident VTE, pulmonary embolism, and deep vein thrombosis among metformin initiators with those among sulfonylurea initiators. Individuals were followed from their first prescription refill to an incident VTE, drug discontinuation, switching or augmenting, plan disenrollment, or the end of the study, whichever occurred first. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using the Cox model, adjusting for confounders using inverse probability of treatment weighting. Among 117,472 initiators of metformin and 13,835 initiators of sulfonylureas, 555 (1.3/1,000 person-years) and 75 (2.1/1,000 person-years) VTE cases occurred in each group, respectively. The multivariable-adjusted HR was 0.65 (95% CI: 0.51, 0.84). The corresponding risks for pulmonary embolism (adjusted HR = 0.71, 95% CI: 0.50, 1.01) and deep vein thrombosis (adjusted HR = 0.64, 95% CI: 0.48, 0.87) were also lower in metformin initiators than in sulfonylurea initiators. Our study provided empirical evidence to support a lower risk of VTE after initiation of metformin as compared with sulfonylureas among patients with type 2 diabetes.

Incidence and risk factors of preoperative deep venous thrombosis in closed tibial shaft fracture: a prospective cohort study

OBJECTIVE

To investigate the preoperative morbidity of deep venous thrombosis (DVT) and predictive risk factors associated with DVT after closed tibial shaft fracture.

METHODS

Ultrasonography and blood analyses were performed preoperatively in patients who sustained tibial shaft fracture between October 2014 and December 2018. Univariate analyses were used in the data of demographics, comorbidities, mechanism of injury, concomitant fractures and laboratory biomarkers. Multivariate logistic regression analyses were conducted to determine the independent risk factors associated with DVT.

RESULTS

In total, 918 patients with an operatively treated tibial shaft fracture were included, among whom 122 patients had preoperative DVTs, indicating a crude morbidity of 13.3%. Ninety-two of 758 (12.1%) patients with isolated tibial shaft fracture developed DVT, while 30 of 160 (18.8%) patients with concurrent fracture presented with DVT. The average interval between fracture and initial diagnosis of DVT was 3.1 days (median, 2 days), ranging from 0 to 33 days. Among DVT-positive patients, 16 (13.1%) patients presented with proximal DVT and 106 (86.9%) patients had distal DVT. Multivariate logistic regression analysis showed four independent risk factors were significantly correlated to the development of DVT, including increased age (OR = 1.17, p = 0.003), diabetes (OR = 1.99, p = 0.009), serum hydroxybutyrate dehydrogenase > 182 U/L (OR = 1.83, p = 0.008), and delay to DUS (in each day) (OR = 1.13, p < 0.001).

CONCLUSION

In the present cohort study, the incidence of DVT was 12.1% in patients with isolated tibial shaft fracture. We suggest individualized risk stratification and early anticoagulation for patients with high risk factors including pre-existing diabetes, HBDH > 182 U/L, delay to DUS and older age.

LEVEL OF EVIDENCE

Level III, a prospective cohort study.

Association between glycemic control and risk of venous thromboembolism in diabetic patients: a nested case-control study

BACKGROUND

Previous studies suggested an elevated risk of venous thromboembolism (VTE) among patients with type 2 diabetes mellitus (T2DM), with a possible sex difference. The impact of glycemic control on the risk of VTE is unclear. Our objective was to analyze the association between glycemic control and the risk of unprovoked (idiopathic) VTE in men and women with T2DM.

METHODS

We conducted a nested case-control analysis (1:4 matching) within a cohort of patients with incident T2DM between 1995 and 2019 using data from the CPRD GOLD. We excluded patients with known risk factors for VTE prior to onset of DM. Cases were T2DM patients with an unprovoked treated VTE. The exposure of interest was glycemic control measured as HbA1c levels. We conducted conditional logistic regression analyses adjusted for several confounders.

RESULTS

We identified 2'653 VTE cases and 10'612 controls (53.1% females). We found no association between the HbA1c level and the risk of VTE in our analyses. However, when the most recent HbA1c value was recorded within 90 days before the index date, women with HbA1c levels > 7.0% had a 36-55% increased relative risk of VTE when compared to women with HbA1c > 6.5-7.0%.

CONCLUSIONS

Our study raises the possibility that female T2DM patients with HbA1c levels > 7% may have a slightly higher risk for unprovoked VTE compared to women with HbA1c levels > 6.5-7.0%. This increase may not be causal and may reflect differences in life style or other characteristics. We observed no effect of glycemic control on the risk of VTE in men.

Perioperative glycemic status is linked to postoperative complications in non-intensive care unit patients with type-2 diabetes: a retrospective study

BACKGROUND

Perioperative hyperglycemia is a risk factor for postoperative complications in the general population. However, it has not been clarified whether perioperative hyperglycemia increases postoperative complications in patients with type-2 diabetes mellitus (T2D). Therefore, we aimed to analyze the relationship between perioperative glycemic status and postoperative complications in non-intensive care unit (non-ICU) hospitalized patients with T2D.

MATERIALS AND METHODS

Medical records of 1217 patients with T2D who were admitted to the non-ICU in our hospital were analyzed retrospectively. Relationships between clinical characteristics including perioperative glycemic status and postoperative complications were assessed using univariate and multivariate analyses. Perioperative glycemic status was evaluated by calculating the mean, standard deviation (SD), and coefficient of variation (CV) of blood glucose (BG) measurements in preoperative and postoperative periods for three contiguous days before and after surgery, respectively. Postoperative complications were defined as infections, delayed wound healing, postoperative bleeding, and/or thrombosis.

RESULTS

Postoperative complications occurred in 139 patients (11.4%). These patients showed a lower BG immediately before surgery (P = 0.04) and a higher mean postoperative BG (P = 0.009) than those without postoperative complications. There were no differences in the other perioperative BG parameters including BG variability and the frequency of hypoglycemia. The multivariate analysis showed that BG immediately before surgery (adjusted odds ratio (95% confidence interval [CI]), 0.91 (0.85-0.98), P = 0.01) and mean postoperative BG (1.11 (1.05-1.18), P < 0.001) were independently associated with postoperative complications.

CONCLUSION

Perioperative glycemic status, that is, a low BG immediately before surgery and a high mean postoperative BG, are associated with the increased incidence of postoperative complications in non-ICU patients with T2D.

Diabetes mellitus and COVID-19: review of a lethal interaction from the cellular and molecular level to the bedside

INTRODUCTION

While the main mode of transmission of coronavirus disease 2019 (COVID-19) is close contact with other individuals, the presence of chronic underlying diseases such as Diabetes Mellitus (DM) increases the chance of hospitalization and mortality rate due to infection.

AREAS COVERED

To investigate the effects of COVID-19 infection in DM patients, we reviewed literature from Google Scholar search engine and PubMed database from '2013 to 2020' using the terms "COVID-19; SARS-CoV-2; Diabetes mellitus; obesity; Angiotensin-converting enzyme 2; ACE2; Insulin and Metformin. Evidence suggests that COVID-19 exacerbates the course of diabetes. Presence of pro-inflammatory conditions, increased expression of receptors, and more difficult control of glucose levels in diabetics COVID-19 patients are some of the problems that diabetic patients may face. Also, psychological problems caused by the COVID-19 epidemic in diabetic patients is one of the most important problems in these patients, which is less covered.

EXPERT OPINION

DM is a strong and independent risk factor with a poor prognosis, which increases the risk of COVID-19 infection, the need for emergency services, the rate of hospitalization in the intensive care unit and also increases the mortality rate of COVID-19 patients.

Simultaneous determination of rivaroxaban and sitagliptin in rat plasma by LC–MS/MS and its application to pharmacokinetic drug-drug interaction study

A sensitive and accurate LC-MS/MS method was developed and validated for the simultaneous quantification of rivaroxaban (RIV) and sitagliptin (SIT) in rat plasma using apixaban as internal standard (IS). An Agilent Eclipse plus C18 column (2.1 × 100 mm, 3.5 µm, Agilent) was used for chromatographic separation with isocratic elution. Multiple reaction monitoring (MRM) using positive-ion ESI mode to monitor ion transitions of m/z 436.8→144.9 for RIV, m/z 407.7→173.8 for SIT, m/z 459.8→442.8 for IS. The procedure of method validation included selectivity, linearity, precision, accuracy, matrix effect, extraction recovery and stability were conducted according to the guidelines of EMA and FDA. The results indicated that no obvious drug-drug interactions occurred might be owing to their differences in metabolic pathways.

Diabetes mellitus and its impact on mortality rate and outcome in pulmonary embolism

Aims/Introduction

In patients with pulmonary embolism (PE), the impact of diabetes mellitus on patient profile and outcome is not well investigated.

Material and Methods

The German nationwide inpatient sample of the years 2005–2018 was analyzed. Hospitalized PE patients were stratified for diabetes, and the impact of diabetes on in‐hospital events was investigated.

Results

Overall, 1,174,196 PE patients (53.8% aged ≥70 years, 53.5% women) and, among these, 219,550 (18.7%) diabetes patients were included. In‐hospital mortality rate amounted to 15.8%, and was higher in diabetes patients than in non‐diabetes patients (19.8% vs 14.8%, P < 0.001). PE patients with diabetes had a higher prevalence of cardiovascular risk factors, comorbidities, right ventricular dysfunction (31.8% vs 27.7%, P < 0.001), prolonged in‐hospital stay (11.0 vs 9.0 days, P < 0.001) and higher rates of adverse in‐hospital events. Remarkably, diabetes was independently associated with increased in‐hospital mortality (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.20–1.23, P < 0.001) when adjusted for age, sex and comorbidities. Within the observation period of 2005–2018, a relevant decrease of in‐hospital mortality in PE patients with diabetes was observed (25.5% to 16.8%). Systemic thrombolysis was more often administered to diabetes patients (OR 1.18, 95% CI 1.01–3.49, P < 0.001), and diabetes was associated with intracerebral (OR 1.19, 95% CI 1.12–1.26, P < 0.001), as well as gastrointestinal bleeding (OR 1.11, 95% CI 1.07–1.15, P < 0.001). Type 1 diabetes mellitus was shown to be a strong risk factor in PE patients for shock, right ventricular dysfunction, cardiopulmonary resuscitation and in‐hospital death (OR 1.75, 95% CI 1.61–1.90, P < 0.001).

Conclusions

Despite the progress in diabetes treatments, diabetes is still associated with an unfavorable clinical patient profile and higher risk for adverse events, including substantially increased in‐hospital mortality in acute PE.

Glycemia and venous thromboembolism in patients with primary brain tumors - A speculative review

Venous thromboembolism (VTE) is a significant public health issue causing severe morbidity and mortality. One of the most vulnerable populations for VTE development are cancer patients. And among them, patients with brain tumors have arguably the highest risk of developing this often fatal complication. Hyperglycemia is a well-known factor which leads to a wide variety of pro-thrombotic changes. In this article, we review the current literature on the topic of VTE in brain tumor patients. We also discuss the known correlation between VTE and glycemia, as well as the importance and frequency of glycemia dysregulation in brain tumor patients. Based on the already well-known importance of glucose metabolism in cancer patients, as well as the previous research of our group, we hypothesize that there is a significant number of brain tumor patients who have chronically elevated glycemia, a fact that so-far hasn't been reported. We argue that these patients carry a significantly higher risk of VTE development and would benefit greatly from strict glycemic control. We present our hypothesis, the ways in which to test it, as well as the possible counter-arguments against it. Our hope is that other investigators will be inspired by our article to continue this type of research, since we consider the topic of VTE in brain tumor patients highly important and urgent, primarily due to its prevalence and severity.

Clinical Trials of COVID-19 Therapies Should Account for Diabetes and Hyperglycemia

Complications of Coronavirus Disease 2019 (COVID-19) occur with increased frequency in people admitted to the hospital with diabetes or hyperglycemia. The increased risk for COVID-19 infections in the presence of these metabolic conditions is in part due to overlapping pathophysiologic features of COVID-19, diabetes, and glucose control. Various antiviral treatments are being tested in COVID-19 patients. We believe that in these trials, it will be useful to evaluate treatment effect differences in patients stratified according to whether they have diabetes or hyperglycemia. In this way, it will be possible to better facilitate development of antiviral treatments that are most specifically beneficial for the large subset of COVID-19 patients who have diabetes or hyperglycemia.

Prophylactic anticoagulants to prevent venous thromboembolism in patients with nephrotic syndrome-A retrospective observational study

Background

Nephrotic syndrome (NS) is associated with increased risk of venous thromboembolism (VTE). Guidelines suggest prophylactic anticoagulants to patients with high risk of thrombosis and low risk of bleeding, but the evidence behind this is poor. This study aims to investigate the effectiveness and risks of prophylactic anticoagulants (PAC) and investigate risk factors for VTE and bleeding in NS.

Methods

A retrospective medical records study including adults with NS, biopsy proven glomerular disease in the county of Västernorrland, Sweden. Outcomes were VTE, bleeding and death. Patients divided into PAC- and no PAC group were compared using Fisher’s exact test. Patient time was divided into serum/plasma(S/P)-albumin intervals (<20g/L and ≥20g/L) and VTE- and bleeding rates were calculated.

Results

In 95 included NS patients (PAC = 40, no PAC = 55), 7 VTE (7.4%) and 17 bleedings (18%) were found. Outcomes didn’t differ significantly between the PAC and no PAC group. Time with S/P-albumin <20g/L conferred higher rates/100 years of VTE (IRR 21.7 (95%CI 4.5–116.5)) and bleeding (IRR 5.0 (1.4–14.7)), compared to time with S/P-albumin>20g/L.

Conclusion

Duration of severe hypoalbuminemia (S/P-albumin <20g/L) in NS is a risk factor for both VTE and bleeding. There is a need for randomized controlled studies regarding the benefit of PAC in NS as well as risk factors of thrombosis and bleeding in NS.

Incidence of deep venous thrombosis in patients with both Pulmonary Embolism and COPD

Introduction.

There are no studies investigating populations of patients with both pulmonary embolism and chronic obstructive pulmonary disease (PE-COPD) with and without deep venous thrombosis (DVT).

Aim of the study.

To define the prevalence of DVT in COPD with PE and to compare the characteristics of COPD patients who develop PE, with and without DVT. Secondly, we aimed to assess differences in the localization of PE among study groups.

Methods.

116 patients with pulmonary embolism (PE) were enrolled in a retrospective study. Clinical data as well as echocardiographic and lower limb ultrasonography records were collected for all subjects. Subjects were divided into two groups according to the presence of COPD: Group 1, 54 patients with diagnosis of PE without COPD and Group 2, 66 patients diagnosed of PE with COPD. Then, individuals of Group 2 were subdivided in two subgroups according to the presence (n=21) or absence (n=45) of DVT.

Results.

33% of patients with COPD and PE showed DVT. These subjects had higher PaCO2 and ejection fraction (p<0.05 for all) and higher percentage of chronic renal failure and diabetes mellitus compared to those without DVT (p<0.05 for all). Moreover, in COPD-PE patients with DVT, the most frequent localization was proximal (54% of total), whereas COPD-PE patients without DVT showed a more frequent segmental localization (60% of total). No difference was found in clinical presentation and blood chemistry tests.

Conclusions.

DVT was non common in PE-COPD patients. Chronic renal failure, and type 2 diabetes mellitus are more frequent in PE-COPD patients with DVT, that showed a higher frequency of proximal localization, thereby indicating a greater risk of more severe clinical implications. Conversely, PE- COPD subjects without DVT showed a more frequent segmental localization and were less hypercapnic. PE should be taken into account in COPD with worsening of respiratory symptoms, also in absence of DVT. (www.actabiomedica.it).

Do We Need Chemoprophylaxis to Prevent Venous Thromboembolism following Medial Open-Wedge High Tibial Osteotomy?

The aim of this study was to investigate the overall incidence of venous thromboembolism (VTE) and to assess the efficacy of chemoprophylaxis to prevent VTE following medial open-wedge high tibial osteotomy (MOWHTO) in Asian patients. A total of 133 patients who consecutively underwent MOWHTO for the treatment of knee osteoarthritis with varus deformity were enrolled. All patients underwent preoperative ultrasonography and computed tomography venography on postoperative day 5 to detect deep vein thrombosis (DVT). Patients were divided into two groups: chemoprophylaxis group included patients (n = 66) who received 2.5 mg fondaparinux for 5 days postoperatively, whereas control group comprised patients (n = 67) who received placebo (67 patients). We evaluated the efficacy and safety outcomes of the treatment. We also assessed the predisposing factors that may affect the occurrence of VTE. The incidence of overall DVT was 14.9% in the control group and 10.6% in the chemoprophylaxis group (p > 0.05). Proximal DVT occurred in one patient in the control group. There was no symptomatic DVT or pulmonary embolism in either group. The patients with DVT had significantly higher mean body mass index (BMI) than the patients without DVT. Multivariate logistic regression showed BMI > 30 kg/m² that was significantly correlated with the development of DVT (odds ratio = 0.8; p = 0.017). There were no cases of major bleeding; however, minor bleeding episodes occurred in four patients in the chemoprophylaxis group. The current study showed that the overall incidence of VTE following MOWHTO was low in Asian patients even without chemoprophylaxis. Therefore, routine chemoprophylaxis following MOWHTO seems to be not necessary in a population with low-VTE incidence. However, selective chemoprophylaxis should be considered in patients with BMI > 30 kg/m².

Sodium-Glucose Co-Transporter 2 Inhibitors and the Risk of Venous Thromboembolism in Patients with Type 2 Diabetes: A Cohort Study

PURPOSE

We assessed whether sodium-glucose co-transporter type 2 (SGLT2) inhibitors are associated with a higher incidence rate of venous thromboembolism in patients with type 2 diabetes.

METHODS

We conducted a population-based cohort study using the InGef database including patients with type 2 diabetes newly treated with noninsulin antidiabetic drugs between 2012 and 2018. Cases of venous thromboembolism identified during follow-up were matched to 40 controls on age, sex, cohort entry date, and duration of follow-up. Using a nested case-control approach, conditional logistic regression estimated incidence rate ratios (RRs) with 95% confidence intervals (CIs) of venous thromboembolism adjusted for sociodemographic and clinical variables, comparing current use of SGLT2 inhibitors with current use of dipeptidyl peptidase-4 (DPP-4) inhibitors.

RESULTS

In a cohort of 219,538 patients, we identified 2152 cases of venous thromboembolism and matched them to 85,104 controls. Compared with DPP-4 inhibitors, current use of SGLT2 inhibitors was associated with a lower rate of venous thromboembolism (RR, 0.75; 95% CI, 0.59-0.94). Effect estimates were similar for dapagliflozin (RR, 0.77; 95% CI, 0.57-1.03) and empagliflozin (RR, 0.71; 95% CI, 0.52-0.98).

CONCLUSIONS

Compared with DPP-4 inhibitors, SGLT2 inhibitors were not associated with a higher rate of venous thromboembolism, providing reassurance regarding their thromboembolic safety.

Mitochondria-DNA copy-number and incident venous thromboembolism among middle-aged women: a population-based cohort study

Venous thromboembolism (VTE) is the third most common cardiovascular disease. Low amount of mitochondrial DNA copy number (mtDNA-CN) has been associated with arterial cardiovascular disease (CVD) and reflects mitochondrial dysfunctions. However, whether mtDNA-CN is associated with VTE has not been determined. To examine the association between mtDNA-CN and incident VTE among middle-aged women. 6917 women aged 50-64 years, followed for 20 years in the Women's Health In the Lund Area (WHILA) study. DNA samples for mtDNA quantification were available from 2521 women. Quantification of mtDNA-CN was performed using a well-optimized droplet digital PCR method. After exclusions of women with anticoagulant treatment, women living in nursing homes, and women who were diagnosed with cancer, stroke, VTE, or coronary heart disease at baseline, a cohort of 2117 women remained for analysis. Cox regression was used to analyze the relationship between mtDNA-CN and time to VTE (hazard ratio = HR). In total, 87 women were diagnosed with VTE during follow-up, corresponding to an incidence rate of 2.8 per 1000 person-years. Neither crude nor adjusted HR for mtDNA-CN were significantly associated with incident VTE. A sensitivity analysis with inclusion of excluded women did not change the results. MtDNA-CN was not significantly associated with VTE. The present study suggests that mtDNA-CN, reflecting mitochondrial dysfunction, should not be considered a biomarker that plays a major role for developing VTE. However, due to limited study size we may not exclude minor associations.

The effect of deep vein thrombosis on major adverse limb events in diabetic patients: a nationwide retrospective cohort study

Little is known about the association between deep vein thrombosis (DVT) and arterial complications in patients with type 2 diabetes (T2DM). The aim of this retrospective cohort study was to assess the influence of prior DVT on major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) in T2DM. A total of 1,628,675 patients with T2DM with or without a history of DVT from 2001 to 2013 were identified in the National Health Insurance Research Database of Taiwan. Before matching, the patients in the DVT group (n = 2020) were older than the control group (66.3 vs. 58.3 years). Patients in the DVT group were more likely to be female than the control group (54.3% vs. 47.5%). Before matching, the DVT group had higher prevalence of most comorbidities, more prescription of antiplatelet, antihypertensive agents and insulins, but less prescription of metformin and sulfonylurea. During a mean follow-up of 5.2 years (standard deviation: 3.9 years), the matched DVT group (n = 2017) have a significantly increased risk of MALE (8.4% vs. 5.2%; subdistribution hazard ratio [SHR] 1.60, 95% CI 1.34–1.90), foot ulcer (5.2% vs. 2.6%, SHR 1.96, 95% CI 1.57–2.45), gangrene (3.4% vs. 2.3%, SHR 1.44, 95% CI 1.10–1.90) and amputation (2.5% vs. 1.7%; SHR 1.42, 95% CI 1.03–1.95) than the 10,085 matched controls without DVT. They also tended to have a greater risk of all-cause mortality (38.1% vs. 33.1%; hazard ratio [HR] 1.18, 95% CI 1.09–1.27) and systemic thromboembolism (4.2% vs. 2.6%; SHR 1.56, 95% CI 1.22–1.99), respectively. We showed the presence of DVT may be associated with an increased risk of MALEs, major amputation, and thromboembolism, contributing to a higher mortality rate in T2DM.

Diabetes: a major risk factor in trauma and orthopaedic surgery

Diabetes mellitus is a growing epidemic and places a great burden on healthcare services in the UK. Trauma and orthopaedic surgeons find themselves dealing with patients with diabetes on an increasingly regular basis. Any level of surgical trauma can lead to a physiological stress response involving the hypothalamic-pituitary-adrenal axis. The resultant hormone releases can have negative effects on glucose homeostasis. General risks of operating on patients with diabetes include endothelial dysfunction, postoperative sepsis, impaired wound healing and cerebral ischaemia. Polytrauma patients with diabetes have a significantly greater risk of mortality than patients who do not have diabetes. Non-union of fractures is more common in patients with diabetes, as are deep-seated postoperative infections. National guidelines from the Joint British Diabetes Societies for Inpatient Care advise how to manage patients with diabetes in the perioperative period. Trauma and orthopaedic surgeons must be aware of these increased risks of operating and ensure that patients are involved in surgical decision making.

The adrenal medulla in cardiovascular medicine: an untold story

Unlike noradrenaline, the sympathetic neurotransmitter which overflows to the circulation, adrenaline (ADR) is a secreted hormone, with a low plasma concentration, and plasma concentration for biological action a log order lower than that of noradrenaline. The venous drainage of the left adrenal medulla into the left renal vein does expose this vein to uniquely high plasma ADR concentrations and possible risk of thrombosis at high rates of ADR secretion. There is typically a different timeframe for adrenal medullary and sympathetic nervous system responses: ADR release is short term in contrast with sympathetic activation persisting for years in heart failure and hypertension. The historic view of Walter Cannon, subject to recent review, that the sympathoadrenal system is a unified biological system, was deconstructed further with demonstration of frequent mismatching of adrenal medullary and sympathetic nervous responses. Under gravity stimulation with standing, there is prompt sympathetic activation without ADR release. In many diseases, notably obesity, hypertension, heart failure and depressive illness, an activated sympathetic nervous system and silent adrenal medulla coexist. The therapeutic corollary of this is that ADR blockade is much less commonly needed clinically than pharmacological antagonism of the sympathetic nervous system.

Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor

Background

The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis.

Methods

A case-control study was performed of patients with PE admitted to our hospital [2010–2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus.

Results

A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95–3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27–2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24–2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02–7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82–34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25–51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06–49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance.

Conclusions

A relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.

Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs

Diabetes mellitus is an important risk factor for a first cardiovascular event and for worse outcomes after a cardiovascular event has occurred. This situation might be caused, at least in part, by the prothrombotic status observed in patients with diabetes. Therefore, contemporary antithrombotic strategies, including more potent agents or drug combinations, might provide greater clinical benefit in patients with diabetes than in those without diabetes. In this Consensus Statement, our Working Group explores the mechanisms of platelet and coagulation activity, the current debate on antiplatelet therapy in primary cardiovascular disease prevention, and the benefit of various antithrombotic approaches in secondary prevention of cardiovascular disease in patients with diabetes. While acknowledging that current data are often derived from underpowered, observational studies or subgroup analyses of larger trials, we propose antithrombotic strategies for patients with diabetes in various cardiovascular settings (primary prevention, stable coronary artery disease, acute coronary syndromes, ischaemic stroke and transient ischaemic attack, peripheral artery disease, atrial fibrillation, and venous thromboembolism). Finally, we summarize the improvements in cardiovascular outcomes observed with the latest glucose-lowering drugs, and on the basis of the available evidence, we expand and integrate current guideline recommendations on antithrombotic strategies in patients with diabetes for both primary and secondary prevention of cardiovascular disease.

Patients with diabetes mellitus have a prothrombotic status that increases the risk of cardiovascular events and worsens prognosis after these events. In this Consensus Statement, the Working Group on Thrombosis of the Italian Society of Cardiology proposes antithrombotic strategies for patients with diabetes in various cardiovascular settings.

Reasons for admission of individual with diabetes to the Tripoli Medical Center in 2015

BACKGROUND

Diabetes mellitus is a complex, chronic, metabolic disease manifested in hyperglycemia and associated with various complications, Consequently, people with diabetes have higher rates of hospital admissions than the general population. There is little information about the burden of hospitalizations of diabetic patients in Libya.

AIM

The aim was to identify the causes of admission of individual with diabetes and to identify the risk factors for hospitalization.

PATIENTS AND METHODS

This is a retrospective case-series study conducted in Tripoli Medical Center, Tripoli. It covers 1037 individual with diabetes admitted between 1 January 2015 and 31 December 2015. All the data were collected from the patient files.

RESULTS

The mean age of the patients was 60.7 years ±15.1 standard deviation. The male-to-female ratio was 1:1. Type 2 diabetes accounted for 90.2% of the patients, 56.5% of whom had diabetes for >10 years, 40.5% had no prior chronic illness, 26.7% had hypertension, and 26.4% had multiple co-morbidities. The mean hospital stay was 6.1 days, and 60.8% of the patients were on insulin therapy. The main causes of admission were infection (23%), mainly in the chest, followed by lower extremity disease (22.4%), cardiovascular disease (19.3%), cerebrovascular disease (14.4%) and renal disease (11.8%).

CONCLUSIONS

The main causes of hospitalization as shown by this study were infections, and chronic complications of diabetes in the lower extremities and cardiovascular system. Most of the patients were >60 years old, had diabetes type 2 for >10 years, were on insulin treatment, and had no other comorbidity.

Glucose levels and diabetes are not associated with the risk of venous thrombosis: results from the MEGA case-control study

It is unclear whether hyperglycaemia or diabetes mellitus are risk factors for a first venous thrombosis (VT). Self‐reported diabetes status and fasting glucose (FG) measures were collected from the Multiple Environmental and Genetic Assessment (MEGA) study to confirm these associations. FG levels were categorized based on the World Health Organization criteria [<6·1 (reference), 6·1–7·0 (2nd), ≥7·0 (3rd) mmol/l]. Logistic regression was performed to quantify the associations. Neither increased FG levels [Odds ratio (95% confidence interval): 0·98 (0·69–1·37) 2nd vs. reference, 0·97 (0·58–1·63) 3rd vs. reference] nor self‐reported diabetes [1·12 (0·80–1·58)] were associated with an increased risk of a first VT.

Treadmill exercise alleviates diabetic cardiomyopathy by suppressing plasminogen activator inhibitor expression and enhancing eNOS in streptozotocin-induced male diabetic rats

OBJECTIVE

To investigate the biological mechanism of the effect of different intensity exercises on diabetic cardiomyopathy.

METHODS

87 raise specific pathogen SPF healthy 6-week-old male Sprague-Dawley rats, fed 6 weeks with high-fat diet for rats were used, and a diabetic model was established by intraperitoneal injection of streptozotocin - randomly selected 43 rats were divided into Diabetic control group (DCG, n = 10), Diabetic exercise group 1 (DEG1, n = 11), Diabetic exercise group 2 (DEG2, n = 11) and Diabetic exercise group 3 (DEG3, n = 11). The rats in DEG1 were forced to run on a motorized treadmill, the exercise load consisted of running at a speed of 10 m/min, the exercise load of the rats in DEG2 were running at a speed of 15 m/min, the exercise load of the rats in DEG3 were running at a speed of 20 m/min, for one hour once a day for 6 weeks. After 6 weeks of exercise intervention, glucose metabolism-related indexes in rats such as blood glucose (FBG), glycosylated serum protein (GSP) and insulin (FINS); cardiac fibrinolytic system parameters such as PAI-1 (plasminogen activator inhibitor 1), Von Willebrand factor (vWF), protein kinase C (PKC) and diacylglycerol (DAG); and serum level of NO, eNOS and T-NOS were measured.

RESULT

Compared with DCG, fasting blood glucose and GSP were decreased, while insulin sensitivity index and insulin level were increased in all rats of the three exercise groups. FBG decrease was statistically significant (P < 0.01), only GSP decrease was statistically significant (P < 0.05) in DEG1 and DEG2, PAI-1 in three exercise groups were significantly reduced (P < 0.05), plasma vWF levels in the three exercise groups were significantly lower than those in the DCG group (P < 0.01); PKC levels decreased dramatically in the three exercise groups and DAG levels decrease slightly (P < 0.05), but with no significant difference. Compared with DCG, the serum level of NO was significantly higher (P < 0.05), and eNOS level was significantly elevated (P < 0.05). T-NOS elevation was statistically significant in DEG1 (P < 0.05).

CONCLUSIONS

Low- and moderate-intensity exercise can better control blood glucose level in diabetic rats; myocardial PAI-1 in DEG1, DEG2 and DEG3 rats decreased significantly (P < 0.05), serum NO increased (P < 0.05) and eNOS increased (P < 0.05) significantly. Therefore, it is inferred that exercise improves the biological mechanism of diabetic cardiomyopathy by affecting the levels of PAI-1 and eNOS, and there is a dependence on intensity.

Atrial fibrillation is related to lower incidence of deep venous thrombosis in patients with pulmonary embolism

Background

Atrial fibrillation (AF) is an established risk factor of left atrial thrombosis and systemic embolism. Traditionally pulmonary embolism (PE) is a recognized complication of deep vein thrombosis (DVT). However, whether AF is responsible for right atrial thrombosis and leads to PE has not been examined.

Methods

We retrospectively analyzed medical records of patients with confirmed diagnosis of PE with AF (study group) from 2002-2015. Patients with PE without AF, matched by age and sex, served as controls (control group). The CHA₂DS₂-VASc and CHADS₂ scores were classified into two categories, low-intermediate (<2 points) and high-risk (≥2 points).

Results

A total of 330 patients (110 in study group and 220 in control group). The study group had significantly lower incidence of newly diagnosed DVT (21% vs. 44%, P<0.001), previous history of DVT (6% vs. 17%, P=0.006) and recent surgery or trauma (10% vs. 23%, P=0.004) compared to the control group. When stratified by the CHADS₂ score, 49 patients (44.5%) were considered low-intermediate risk. This proportion significantly differed when stratified using CHA₂DS₂-VASc, in which 13 patients (13.6%) were considered low-intermediate risk, P<0.001.

Conclusions

The incidence of DVT was much lower in the study group, suggesting the possibility of clots originated from the right heart that may increase the risk of PE. The CHA₂DS₂-VASc scoring system might be more sensitive for prediction and stratification of the PE in AF patients than the CHADS₂ score.

The Effect of a Simulated Commercial Flight Environment with Hypoxia and Low Humidity on Clotting, Platelet, and Endothelial Function in Participants with Type 2 Diabetes - A Cross-over Study

AIMS

To determine if clotting, platelet, and endothelial function were affected by simulated short-haul commercial air flight conditions (SF) in participants with type 2 diabetes (T2DM) compared to controls.

METHODS

10 participants with T2DM (7 females, 3 males) and 10 controls (3 females, 7 males) completed the study. Participants were randomized to either spend 2 h in an environmental chamber at sea level conditions (temperature: 23°C, oxygen concentration 21%, humidity 45%), or subject to a simulated 2-h simulated flight (SF: temperature: 23°C, oxygen concentration 15%, humidity 15%), and crossed over 7 days later. Main outcome measures: clot formation and clot lysis parameters, functional platelet activation markers, and endothelial function measured by reactive hyperemia index (RHI) by EndoPAT and serum microparticles.

RESULTS

Comparing baseline with SF conditions, clot maximal absorption was increased in controls (0.375 ± 0.05 vs. 0.39 ± 0.05, p < 0.05) and participants with T2DM (0.378 ± 0.089 vs. 0.397 ± 0.089, p < 0.01), while increased basal platelet activation for both fibrinogen binding and P-selectin expression (p < 0.05) was seen in participants with T2DM. Parameters of clot formation and clot lysis, stimulated platelet function (stimulated platelet response to ADP and sensitivity to prostacyclin), and endothelial function were unchanged.

CONCLUSION

While SF resulted in the potential of denser clot formation with enhanced basal platelet activation in T2DM, the dynamic clotting, platelet, and endothelial markers were not affected, suggesting that short-haul commercial flying adds no additional hazard for venous thromboembolism for participants with T2DM compared to controls.

Repeated measurements of carotid atherosclerosis and future risk of venous thromboembolism: the Tromsø Study

Essentials The relationship between atherosclerosis and venous thromboembolism (VTE) is controversial. In total, 10 426 participants recruited from the general population were included. Carotid intima media thickness and total plaque area was not associated with VTE. There was no association between plaque initiation or plaque progression and subsequent VTE.

SUMMARY

Background Whether a relationship between atherosclerosis and subsequent venous thromboembolism (VTE) exists is controversial. Objective To investigate the association between carotid atherosclerosis and VTE by using repeated measurements of intima media thickness (IMT) and total plaque area (TPA) in participants recruited from the general population. Methods Participants were recruited from the fourth (1994-1995), fifth (2001-2002) and sixth (2007-2008) surveys of the Tromsø Study. In total, 10 426 participants attended, for whom measurements of carotid IMT and TPA and potential confounders were updated at each available survey. Time-varying Cox regression models were used to calculate hazard ratios (HRs) of VTE across various levels of IMT and TPA adjusted for age, sex, and body mass index. Results There were 368 incident VTE events during a median follow-up of 10.8 years. Participants with increasing IMT were, on average, older and had a less favorable cardiovascular risk profile. There was no association between tertiles of increasing TPA and the risk of VTE in the time-varying model, and increasing IMT was not associated with an increased risk of VTE (HR 0.96, 95% confidence interval [CI] 0.86-1.07). Neither plaque formation nor plaque progression was associated with the risk of VTE (respectively: HR 1.00, 95% CI 0.98-1.02; and HR 0.96, 95% CI 0.84-1.11). Conclusion Carotid IMT and TPA were not associated with an increased risk of VTE in time-varying analyses. Furthermore, there was no association between plaque initiation or plaque progression and subsequent VTE.

Determination of age-specific and sex-specific familial risks for the different manifestations of venous thromboembolism: A nationwide family study in Sweden

This nationwide study aimed to determine whether differences exist in age-specific and sex-specific familial risks for pulmonary embolism (PE), venous thrombosis of the lower limbs (VT) and other forms of venous thromboembolism (OVTE) among offspring, siblings and spouses of affected individuals. The Swedish Multi-Generation Register was linked to the Hospital Discharge Register data for the period 1987–2007. Standardised incidence ratios (SIRs) were calculated for individuals whose relatives were hospitalised for venous thromboembolism (VTE), as determined by the International Classification of Diseases (ICD), and those whose relatives were unaffected by VTE. The total number of hospitalised VTE patients was 45,362. All VTE patients were categorised as PE, VT or OVTE according to ICD at first hospitalisation. For example, the parental SIRs for PE, VT and OVTE in offspring at age 10–19 years were 2.89 (95% CI 1.48–5.06), 4.99 (95% CI 3.22–6.10) and 3.89 (95% CI 2.51–5.75), respectively. The low spousal risks of PE (1.08; 95% CI 1.02–1.13), VT (1.06; 95% CI 1.011.12) and OVTE (1.07; 95% CI 1.00–1.15) suggest the familial risks to be largely genetic. In both men and women, familial relative risks were increased for all the different manifestations of VTE with the exception of those older than 70 years. Familial history is a risk indicator in both sexes, and is potentially useful for clinical risk assessment for the different manifestations of VTE.

Thrombosis: A major contributor to global disease burden

Thrombosis is a common pathology underlying ischaemic heart disease, ischaemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischaemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden due to VTE in low, middle and high income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1,000 individuals in the population. The incidence increased to between 2 and 7 per 1,000 among those 70 years of age or more. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalisation was the leading cause of disability-adjusted-lifeyears (DALYs) lost in low and middle income countries, and second in high income countries, responsible for more DALYs lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events. VTE causes a major burden of disease across low, middle, and high income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate if improved utilisation of preventive measures will reduce the burden.

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