Is diabetes mellitus a risk factor for venous thromboembolism? A systematic review and meta-analysis of case-control and cohort studies

Hospital admissions for anxiety disorder, depression, and bipolar disorder and venous thromboembolism: A UK biobank prospective cohort study

BACKGROUND

Few studies have investigated whether and which anxiety and affective disorders are associated with the risk of venous thromboembolism. We aimed to examine whether anxiety disorder, depression, and bipolar disorder increase the risk of venous thromboembolism, independent of socioeconomic confounders and each other, in a UK general population.

METHODS

This is a prospective cohort study using UK Biobank. Participants were excluded if they were diagnosed with venous thromboembolism before the baseline assessment, if they were first diagnosed with anxiety disorder, depression, or bipolar disorder thereafter, or if they had missing sociodemographic data. Diagnosed anxiety disorder, depression, and bipolar disorder were ascertained through hospital admission data and incident venous thromboembolism, pulmonary embolism, and deep vein embolism were ascertained through both hospital admission and death certificate data. Hazard ratios were calculated, adjusted for sociodemographic confounders and comorbid anxiety and affective disorders.

RESULTS

Our main analysis included 455,705 participants, of whom 53.6 % were female, with a mean age (standard deviation) of 56.6 (8.1) years. Anxiety disorder, depression, and bipolar disorder were associated with venous thromboembolism both before and after adjusting for sociodemographic confounders. After adjustment for comorbid anxiety and affective disorders, depression (HR: 2.00; 95 % CI: 1.68-2.38) and bipolar disorder (HR: 2.08; 95 % CI: 1.28-3.37) remained associated with venous thromboembolism, but anxiety did not (HR: 1.17; 95 % CI: 0.88-1.57). Similar results were found for pulmonary embolism and deep vein embolism.

CONCLUSIONS

Depression and bipolar disorder were associated with the risk of venous thromboembolism. Further research is required to understand the mechanism underlying their increased risk.

Hyperglycemia and Venous Thromboembolism

Patients with diabetes mellitus (DM) have chronically increased blood glucose and multiple physiologic alterations that place them at elevated risk for vascular disease. Traditionally, this vascular risk has mainly referred to chronic atherosclerosis and embolic arterial disease. Retrospective studies have suggested an increased risk of a pulmonary embolism (PE) and deep vein thrombosis (DVT), collectively termed venous thromboembolism (VTE), in patients with DM, but this association has been difficult to demonstrate with comorbidities such as obesity in meta-analysis. Clinical studies have demonstrated worse outcomes for patients with DM who suffer from VTE. In vitro studies show multiple physiologic abnormalities with chronic inflammation, endothelial dysfunction, dysfunction in the coagulation cascade, as well as other changes that drive a vicious cycle of hypercoagulability. Aggressive medical management of DM can improve vascular outcomes, and some anti-hyperglycemic therapies may modify VTE risk as well. Anticoagulation strategies are similar for patients with DM, but with some added considerations, such as high rates of comorbid renal dysfunction. More research is needed to definitively categorize DM as a risk factor for VTE and elucidate specific therapeutic strategies.

Multimorbidity disease clusters are associated with venous thromboembolism: an extended cross-sectional national study

Multimorbidity, i.e., two or more non-communicable diseases (NCDs), is an escalating challenge for society. Venous thromboembolism (VTE) is a common cardiovascular disease and it is unknown which multimorbidity clusters associates with VTE. Our aim was to examine the association between different common disease clusters of multimorbidity and VTE. The study is an extended (1997-2015) cross-sectional Swedish study using the National Patient Register and the Multigeneration Register. A total of 2,694,442 Swedish-born individuals were included in the study. Multimorbidity was defined by 45 NCDs. A principal component analysis (PCA) identified multimorbidity disease clusters. Odds ratios (OR) for VTE were calculated for the different multimorbidity disease clusters. There were 16% (n = 440,742) of multimorbid individuals in the study population. Forty-four of the individual 45 NCDs were associated with VTE. The PCA analysis identified nine multimorbidity disease clusters, F1-F9. Seven of these multimorbidity clusters were associated with VTE. The adjusted OR for VTE in the multimorbid patients was for the first three clusters: F1 (cardiometabolic diseases) 3.44 (95%CI 3.24-3.65), F2 (mental disorders) 2.25 (95%CI 2.14-2.37) and F3 (digestive system diseases) 4.35 (95%CI 3.63-5.22). There was an association between multimorbidity severity and OR for VTE. For instance, the occurrence of at least five diseases was in F1 and F2 associated with ORs for VTE: 8.17 (95%CI 6.32-10.55) and 6.31 (95%CI 4.34-9.17), respectively. In this nationwide study we have shown a strong association between VTE and different multimorbidity disease clusters that might be useful for VTE prediction.

A pharmacoepidemiological nested case-control study of risk factors for venous thromboembolism with the focus on diabetes, cancer, socioeconomic group, medications, and comorbidities

OBJECTIVES

A pharmacoepidemiological study to assess VTE risk factors in a diabetes-rich population.

METHODS

The study comprised 299,590 individuals. We observed 3450 VTEs and matched them with 15,875 controls using a nested case-control approach and collected data on comorbidities and prescriptions. By multivariable conditional logistic regression, we calculated ORs with 95%CIs for comorbidities and medications to evaluate their associations with VTE.

RESULTS

Diabetes (aOR 2.16; 95%CI 1.99-2.34), inflammatory bowel disease (1.84; 1.27-2.66), and severe psychiatric disorders (1.72; 1.43-2.05) had the strongest associations among the non-cancer comorbidities. Pancreatic (12.32; 7.11-21.36), stomach (8.57; 4.07-18.03), lung and bronchus (6.26; 4.16-9.43), and ovarian (6.72; 2.95-15.10) cancers were ranked as high-risk for VTE. Corticosteroids, gabapentinoids, psychotropic drugs, risedronic acid, and pramipexole were most strongly associated (aOR exceeding 1.5) with VTE. Insulin (3.86; 3.33-4.47) and sulphonylureas (2.62; 2.18-3.16) had stronger associations than metformin (1.65; 1.49-1.83). Statins and lercanidipine (0.78; 0.62-0.98) were associated with a lowered risk of VTE.

CONCLUSIONS

In this cohort, with 50% diabetes prevalence, pancreatic, stomach, lung and bronchus, and ovarian cancers were strongly associated with VTE. Corticosteroids, gabapentinoids, and psychotropic medications had the strongest associations with VTE among medications. This may be valuable for generating hypotheses for the further research. Lercanidipine may be a novel protective medication against VTE.

The risk for venous thromboembolism and cardiometabolic disorders in offspring from thrombosis-prone pedigrees

BACKGROUND

Most family studies on venous thromboembolism (VTE) have focused on first-degree relatives.

OBJECTIVES

We took a pedigree-based approach and examined the risk of VTE and cardiometabolic disorders in offspring from extended pedigrees according to the densities of VTE in pedigrees.

METHODS

From the Swedish population, we identified a total of 482 185 pedigrees containing a mean of 14.2 parents, aunts/uncles, grandparents, and cousins of a core full sibship that we termed the pedigree offspring (n = 751 060). We then derived 8 empirical classes of these pedigrees based on the density of cases of VTE. The risk was determined in offspring for VTE and cardiometabolic disorders as a function of VTE density in their pedigrees. Bonferroni correction for multiple comparisons was performed.

RESULTS

VTE was unevenly distributed in the population; the Gini coefficient was 0.59. Higher VTE density in pedigrees was associated in the offspring with a higher risk of different VTE manifestations (deep venous thrombosis, pulmonary embolism, pregnancy-related VTE, unusual thrombosis, and superficial thrombophlebitis), thrombophilia, and lower age of first VTE event. Moreover, VTE density in pedigrees was significantly associated in the offspring with obesity, diabetes, gout, varicose veins, and arterial embolism and thrombosis (excluding brain and heart). No significant associations were observed for retinal vein occlusion, hypercholesterolemia, hypertension, coronary heart disease, myocardial infarction, ischemic stroke, atrial fibrillation, heart failure, primary pulmonary hypertension, cerebral hemorrhage, aortic aneurysm, peripheral artery disease, and overall mortality.

CONCLUSION

Offspring of pedigrees with a high density of VTE are disadvantaged regarding VTE manifestations and certain cardiometabolic disorders.

Portal Vein or Superior Mesenteric Vein Thrombosis with Dose-Escalated Radiation for Borderline or Locally Advanced Pancreatic Cancer

PURPOSE

Portal vein and superior mesenteric vein thrombosis (PVT/SMVT) are potentially morbid complications of radiation dose-escalated local therapy for pancreatic cancer. We retrospectively reviewed records for patients treated with and without intraoperative radiation (IORT) to identify risk factors for PVT/SMVT.

METHODS

Ninety-six patients with locally advanced or borderline resectable pancreatic adenocarcinoma received neoadjuvant therapy followed by surgical exploration from 2009 to 2014. Patients at risk for close or positive surgical margins received IORT boost to a biologically effective dose (BED10) > 100. Prognostic factors for PVT/SMVT were evaluated using competing risks regression.

RESULTS

Median follow-up was 79 months for surviving patients. Fifty-six patients (58%) received IORT. Twenty-nine patients (30%) developed PVT/SMVT at a median time of 18 months. On univariate competing risks regression, operative blood loss and venous repair with a vascular interposition graft, but not IORT dose escalation or diabetes history, were significantly associated with PVT/SMVT. The development of thrombosis in the absence of recurrence was significantly associated with a longstanding diabetes history, post-neoadjuvant treatment CA19-9, and operative blood loss. All 4 patients who underwent both IORT and vascular repair with a graft developed PVT/SMVT. PVT/SMVT in the absence of recurrence is not associated with significantly worsened overall survival but led to frequent medical interventions.

CONCLUSIONS

Approximately 30% of patients who underwent neoadjuvant chemoradiation for PDAC developed PVT/SMVT a median of 18 months following surgery. This was significantly associated with venous reconstruction with vascular grafts, but not with escalating radiation dose. PVT/SMVT in the absence of recurrence was associated with significant morbidity.

Association between diabetes and venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) plays a vital role in the development of cardiovascular disease. However, its association with venous thromboembolism (VTE) remains unclear, for the published study results are conflicting. We performed a meta-analysis of published cohort studies and case-control studies to assess the role of DM in the formation and prognosis of VTE.

METHODS

PubMed and EMBASE databases were searched for articles from the database's establishment until September 15, 2022. Of the 15,754 publications retrieved, 50 studies were identified that met the selection criteria. The New castle-Ottawa Scale was used to evaluate the quality of the literature. Pooled odds ratios (ORs) and 95% confidence intervals were calculated using fixed- or random-effect models.

RESULTS

We combined OR using a random-effects or fixed-effects model: patients with DM had an increased risk of VTE (OR 1.27, 95% confidence interval [CI]: 1.15-1.41), which still showed a partial association in studies adjusted by confounding factors (OR 1.20, 95% CI: 1.07-1.35). DM was not significantly associated with VTE when analyzed in studies adjusted by body mass index (OR 1.04, 95% CI: 0.94-1.15). VTE patients with DM had a higher risk of short-term and long-term mortality than those without DM (OR 1.58 [95% CI: 1.26-1.99] for long-term mortality and OR 1.20 [95% CI: 1.19-1.21] for short-term mortality).

CONCLUSION

There was no significant association between DM and VTE risk, and body mass index may be a significant confounding factor between DM and VTE risk. However, DM can still lead to an increased risk of long-term and short-term mortality in patients with VTE.

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Importance

Systematic data on the association between anticancer therapies and thromboembolic events (TEEs) in patients with COVID-19 are lacking.

Objective

To assess the association between anticancer therapy exposure within 3 months prior to COVID-19 and TEEs following COVID-19 diagnosis in patients with cancer.

Design, Setting, and Participants

This registry-based retrospective cohort study included patients who were hospitalized and had active cancer and laboratory-confirmed SARS-CoV-2 infection. Data were accrued from March 2020 to December 2021 and analyzed from December 2021 to October 2022.

Exposure

Treatments of interest (TOIs) (endocrine therapy, vascular endothelial growth factor inhibitors/tyrosine kinase inhibitors [VEGFis/TKIs], immunomodulators [IMiDs], immune checkpoint inhibitors [ICIs], chemotherapy) vs reference (no systemic therapy) in 3 months prior to COVID-19.

Main Outcomes and Measures

Main outcomes were (1) venous thromboembolism (VTE) and (2) arterial thromboembolism (ATE). Secondary outcome was severity of COVID-19 (rates of intensive care unit admission, mechanical ventilation, 30-day all-cause mortality following TEEs in TOI vs reference group) at 30-day follow-up.

Results

Of 4988 hospitalized patients with cancer (median [IQR] age, 69 [59-78] years; 2608 [52%] male), 1869 had received 1 or more TOIs. Incidence of VTE was higher in all TOI groups: endocrine therapy, 7%; VEGFis/TKIs, 10%; IMiDs, 8%; ICIs, 12%; and chemotherapy, 10%, compared with patients not receiving systemic therapies (6%). In multivariable log-binomial regression analyses, relative risk of VTE (adjusted risk ratio [aRR], 1.33; 95% CI, 1.04-1.69) but not ATE (aRR, 0.81; 95% CI, 0.56-1.16) was significantly higher in those exposed to all TOIs pooled together vs those with no exposure. Among individual drugs, ICIs were significantly associated with VTE (aRR, 1.45; 95% CI, 1.01-2.07). Also noted were significant associations between VTE and active and progressing cancer (aRR, 1.43; 95% CI, 1.01-2.03), history of VTE (aRR, 3.10; 95% CI, 2.38-4.04), and high-risk site of cancer (aRR, 1.42; 95% CI, 1.14-1.75). Black patients had a higher risk of TEEs (aRR, 1.24; 95% CI, 1.03-1.50) than White patients. Patients with TEEs had high intensive care unit admission (46%) and mechanical ventilation (31%) rates. Relative risk of death in patients with TEEs was higher in those exposed to TOIs vs not (aRR, 1.12; 95% CI, 0.91-1.38) and was significantly associated with poor performance status (aRR, 1.77; 95% CI, 1.30-2.40) and active/progressing cancer (aRR, 1.55; 95% CI, 1.13-2.13).

Conclusions and Relevance

In this cohort study, relative risk of developing VTE was high among patients receiving TOIs and varied by the type of therapy, underlying risk factors, and demographics, such as race and ethnicity. These findings highlight the need for close monitoring and perhaps personalized thromboprophylaxis to prevent morbidity and mortality associated with COVID-19-related thromboembolism in patients with cancer.

Implication of diabetic status on platelet reactivity and clinical outcomes after drug-eluting stent implantation: results from the PTRG-DES consortium

BACKGROUND

Diabetes mellitus (DM) is associated with thrombogenicity, clinically manifested with atherothrombotic events after percutaneous cutaneous intervention (PCI). This study aimed to investigate association between DM status and platelet reactivity, and their prognostic implication in PCI-treated patients.

METHODS

The Platelet function and genoType-Related long-term Prognosis-Platelet Function Test (PTRG-PFT) cohort was established to determine the linkage of platelet function test (PFT) with long-term prognosis during dual antiplatelet therapy including clopidogrel in patients treated with drug-eluting stent (DES). We assessed platelet reactivity using VerifyNow and 'high platelet reactivity (HPR)' was defined as ≥ 252 P2Y12 reaction unit (PRU). Major adverse cardiac and cerebrovascular event (MACCE) was a composite of all-cause death, myocardial infarction, stent thrombosis or stroke.

RESULTS

Between July 2003 and Aug 2018, DES-treated patients with available PFT were enrolled (n = 11,714). Diabetic patients demonstrated significant higher levels of platelet reactivity (DM vs. non-DM: 225.7 ± 77.5 vs. 213.6 ± 79.1 PRU, P < 0.001) and greater prevalence of HPR compared to non-diabetic patients (38.1% vs. 32.0%, P < 0.001). PRU level and prevalence of HPR were significantly associated with insulin requirement and HbA1c level, as well as diabetic status. DM status and HPR phenotype had a similar prognostic implication, which showed the synergistic clinical impact on MACCE. Association between PRU level and MACCE occurrence seemed higher in diabetic vs. non-diabetic patients. In non-DM patients, HPR phenotype did not significantly increase the risk of MACCE (adjusted hazard ratio [HRadj]: 1.073; 95% confidence interval [CI]: 0.869-1.325; P = 0.511), whereas HPR was an independent determinant for MACCE occurrence among diabetic patients (HRadj: 1.507; 95% CI: 1.193-1.902; P < 0.001).

CONCLUSION

The levels of on-clopidogrel platelet reactivity are determined by diabetic status and the severity of DM. In addition, HPR phenotype significantly increases the risk of MACCE only in diabetic patients.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov . Unique identifier: NCT04734028.

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.

A hypothesis - generating Swedish extended national cross-sectional family study of multimorbidity severity and venous thromboembolism

OBJECTIVES

Venous thromboembolism (VTE) is a common worldwide disease. The burden of multimorbidity, that is, two or more chronic diseases, has increased. Whether multimorbidity is associated with VTE risk remains to be studied. Our aim was to determine any association between multimorbidity and VTE and any possible shared familial susceptibility.

DESIGN

A nationwide extended cross-sectional hypothesis - generating family study between 1997 and 2015.

SETTING

The Swedish Multigeneration Register, the National Patient Register, the Total Population Register and the Swedish cause of death register were linked.

PARTICIPANTS

2 694 442 unique individuals were analysed for VTE and multimorbidity.

MAIN OUTCOMES AND MEASURES

Multimorbidity was determined by a counting method using 45 non-communicable diseases. Multimorbidity was defined by the occurrence of ≥2 diseases. A multimorbidity score was constructed defined by 0, 1, 2, 3, 4 or 5 or more diseases.

RESULTS

Sixteen percent (n=440 742) of the study population was multimorbid. Of the multimorbid patients, 58% were females. There was an association between multimorbidity and VTE. The adjusted odds ratio (OR) for VTE in individuals with multimorbidity (2 ≥ diagnoses) was 3.16 (95% CI: 3.06 to 3.27) compared with individuals without multimorbidity. There was an association between number of diseases and VTE. The adjusted OR was 1.94 (95% CI: 1.86 to 2.02) for one disease, 2.93 (95% CI: 2.80 to 3.08) for two diseases, 4.07 (95% CI: 3.85 to 4.31) for three diseases, 5.46 (95% CI: 5.10 to 5.85) for four diseases and 9.08 (95% CI: 8.56 to 9.64) for 5 ≥ diseases. The association between multimorbidity and VTE was stronger in males OR 3.45 (3.29 to 3.62) than in females OR 2.91 (2.77 to 3.04). There were significant but mostly weak familial associations between multimorbidity in relatives and VTE.

CONCLUSIONS

Increasing multimorbidity exhibits a strong and increasing association with VTE. Familial associations suggest a weak shared familial susceptibility. The association between multimorbidity and VTE suggests that future cohort studies where multimorbidity is used to predict VTE might be worthwhile.

Risk factors for venous thromboembolism in patients with spinal cord injury: A systematic review and meta-analysis

CONTEXT

Patients with spinal cord injury (SCI) are at high risk for venous thromboembolism (VTE). The risk factors for VTE in patients with SCI are complex.

OBJECTIVE

This meta-analysis was conducted to clarify the risk factors for VTE in patients with SCI.

METHODS

The Cochrane Library, PubMed, EBSCO, Web of Science, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), Wanfang Med Data Database, and VIP Database were searched to identify studies reporting on risk factors for VTE in patients with SCI.

RESULTS

The meta-analysis included 25 studies. Findings showed that risk of VTE in patients with SCI was significantly associated with middle- and old-age (OR = 2.08, 95%CI, 1.47, 2.95), male sex (OR = 1.41, 95%CI, 1.26, 1.59), complete paralysis (OR = 3.69, 95%CI, 2.60, 5.24), personal/family history of venous thrombosis (OR = 1.95, 95%CI, 1.35, 2.81), history of smoking (OR = 2.67, 95%CI, 1.79, 3.98), lack of compression therapy (OR = 2.44, 95%CI, 1.59, 3.73), presence of lower limb/pelvic fracture (OR = 3.47, 95%CI, 1.79, 6.75), paraplegia (OR = 1.81, 95%CI, 1.49, 2.19), and diabetes (OR = 4.24, 95%CI, 2.75, 6.52).

CONCLUSION

The meta-analysis identified 9 risk factors for VTE in patients with SCI. Healthcare providers should be aware of the risk factors for VTE when rehabilitating patients with SCI.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Venous thromboembolism in patients with idiopathic pulmonary fibrosis, based on nationwide claim data

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a known risk factor for venous thromboembolism (VTE). However, it is currently unknown which factors are associated with an increase of VTE in patients with IPF.

OBJECTIVES

We estimated the incidence of VTE in patients with IPF and identified clinical characteristics related to VTE in patients with IPF.

DESIGN AND METHODS

De-identified nationwide health claim data from 2011 to 2019 was collected from the Korean Health Insurance Review and Assessment database. Patients with IPF were selected if they had made at least one claim per year under the J84.1 [International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10)] and V236 codes of rare intractable diseases. We defined the presence of VTE as at least one claim of pulmonary embolism and deep vein thrombosis ICD-10 codes.

RESULTS

The incidence rate per 1000 person-years of VTE was 7.08 (6.44-7.77). Peak incidence rates were noted in the 50-59 years old male and 70-79 years old female groups. Ischemic heart disease, ischemic stroke, and malignancy were associated with VTE in patients with IPF, with an adjusted hazard ratio (aHR) of 1.25 (1.01-1.55), 1.36 (1.04-1.79), and 1.53 (1.17-2.01). The risk for VTE was increased in patients diagnosed with malignancy after IPF diagnosis (aHR = 3.18, 2.47-4.11), especially lung cancer [hazard ratio (HR) = 3.78, 2.90-4.96]. Accompanied VTE was related to more utilization of medical resources.

CONCLUSION

Ischemic heart disease, ischemic stroke, and malignancy, especially lung cancer, were related to higher HR for VTE in IPF.

A practical nomogram based on systemic inflammatory markers for predicting portal vein thrombosis in patients with liver cirrhosis

INTRODUCTION

Immunothrombosis has recently been used to describe the responses/mechanisms in thrombosis. Systemic inflammatory markers are prognostic markers for a variety of thrombotic conditions; however, their potential value in predicting portal vein thrombosis (PVT) is unknown. This study aimed to establish an easy-to-use nomogram based on systemic inflammatory markers to predict portal vein thrombosis (PVT) in patients with liver cirrhosis.

PATIENTS AND METHODS

This retrospective study included 478 patients with cirrhosis between January 2013 and January 2021. Reputed systemic inflammatory markers (systemic immune-inflammation index [SII], neutrophil-to-lymphocyte ratio [NLR], monocyte-to-lymphocyte ratio [MLR], and platelet-to-lymphocyte ratio (PLR)) were measured, and the clinical data were recorded. The independent risk factors for PVT were determined using univariate analyses and multivariate logistic regression analyses, and a nomogram to predict the occurrence of PVT was established. The concordance index, receiver operating characteristic curves, and calibration plots were used to evaluate the performance of the model.

RESULTS

A total of 239 patients with PVT and 239 patients without PVT were selected. In the univariate analysis, high SII, NLR, PLR, and MLR were significantly associated with PVT. NLR and PLR were independent risk factors for PVT (P < 0.05) by multivariate analysis. The nomogram had good predictive efficiency for PVT in patients with cirrhosis, with an area under the receiver operating characteristic (AUROC) curves of 0.891 (95% CI 0.862-0.919) and the calibration curves fit as well, indicating that the nomogram had good clinical application value.

CONCLUSIONS

PVT in patients with cirrhosis is associated with increased levels of systemic inflammatory markers. We successfully developed a practical nomogram based on NLR and PLR to accurately predict PVT, which is a practical method helping clinicians rapidly and conveniently diagnose and guide the treatment of PVT in patients with cirrhosis.Key MessagesThe present study is the first report on a nomogram based on systemic inflammatory markers in patients with portal vein thrombosis (PVT).The nomogram had good predictive efficiency and a good clinical application value for predicting PVT in patients with cirrhosis.

[Contraception in adolescents with obesity and diabetes mellitus]

Today most adolescents have their first sexual experience at the age of 15-19. However, only 44% of girls and young women (15-24 years old) report about contraception at that moment. A decision on pregnancy in adolescence is a difficult choice and any scenario may cause serious medical and social problems. Complications after an artificial abortion have a negative impact on a woman's fertility. Diabetes mellitus type 1 and arterial hypertension accompanied with obesity within the metabolic syndrome are defined by the World Health Organization (WHO) as diseases, which increase risk of an unplanned pregnancy. The article consoders problems of interaction of a doctor and a teenage girl with endocrinopathy, when discussing her sexual health, the analysis of the literature reflecting the influence of contraception on the course of the underlying pathology is presented. The authors formed a list of drugs acceptable for use in diabetes and obesity based on assessment of risks and preferences from the use of different methods of fertility control. The work contains information about the procedure of starting contraception, the rules of future dynamic monitoring of the patient.

Current use of D-dimer for the exclusion of venous thrombosis in hospitalized patients

D-dimer assay’s utility for excluding venous thromboembolism (VTE) in hospitalized patients is debatable. We aimed to assess the current use of D-dimer as a diagnostic tool for excluding VTE in hospitalized patients and examine a mandatory age-adjusted D-dimer (AADD) threshold for diagnostic imaging. Retrospective cohort study between 2014 to 2019 that included patients from medical and surgical wards with a positive AADD result drawn during their hospitalization. The outcomes were determining a D-dimer threshold requiring further evaluation and assessing the prognostic value of D-dimer in predicting clinically relevant VTE in hospitalized patients. The cohort included 354 patients, 56% of them underwent definitive diagnostic imaging, and 7.6% were diagnosed with VTE after a positive AADD within 90 days of follow-up. Mortality rates were higher in patients diagnosed with VTE (33.3% vs. 15.9%, p = 0.03). Patients with pneumonia and other infectious etiologies were less likely to be further evaluated by definitive imaging (p = 0.001). Patients with a respiratory complaint (p = 0.02), chest pain (p < 0.001), or leg swelling (p = 0.01) were more likely to undergo diagnostic imaging. Patients with D-dimer levels > X2 the AADD were at increased risk of VTE [OR 3.87 (1.45–10.27)]. At 90 days of follow-up, no excess mortality was observed for patients without diagnostic evaluation following elevated AADD. D-dimer may be used in hospitalized patients to exclude VTE using the traditional AADD thresholds, with a high negative predictive value. D-dimer levels > X2 the AADD usually mandates further diagnostic imaging, while lower levels, probably do not require additional workup, with a sensitivity of almost 80% and no excess mortality.

Association between cardiovascular risk factors and venous thromboembolism in the elderly

BACKGROUND

The preponderance of the evidence supports no association between traditional cardiovascular risk factors and venous thromboembolism (VTE), other than obesity. There are limited data in older people.

OBJECTIVES

To investigate whether cardiovascular risk factors (body mass index, smoking, alcohol intake, hypertension, and diabetes) are associated with the risk of VTE in elderly and to assess the combined effect between cardiovascular risk factors and genetic risk factors for VTE (factor V Leiden/prothrombin 20210A, positive family history of VTE, and non-O blood group).

METHODS

The Age and Thrombosis, Acquired and Genetic risk factors in the Elderly study is a multicenter case-control study performed in Vermont, USA and Leiden, the Netherlands, comprising 401 cases with first VTE and 431 control subjects, all aged ≥70 years. To assess the risk of VTE, odds ratios (OR) with 95% confidence intervals (CIs) were calculated, adjusting for potential confounders.

RESULTS

Both height and weight were positively associated with VTE risk: the ORs were 2.2 (95% CI, 1.2-3.9) and 1.5 (95% CI, 1.0-2.4) in the top quartile for height and weight separately. This risk was more pronounced for unprovoked VTE. Smoking, alcohol intake, and diabetes were not associated with VTE. Higher systolic and diastolic blood pressure and hypertension were associated with a decreased risk of VTE. In the presence of a genetic predisposition, height and weight further increased the risk of VTE.

CONCLUSIONS

In the elderly, height and weight are positively associated with the risk of VTE. With genetic predisposition, higher levels of height and weight further increase the risk of VTE.

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.

Admission Prevalence and Risk Factors of Deep Vein Thrombosis in Patients with Spinal Cord Injury Complicated with Cervical Fractures

The purpose of this study was to investigate the prevalence of deep vein thrombosis (DVT) and to clarify the risk factors of DVT in patients with acute spinal cord injury (SCI) complicated with cervical fractures at admission. From January 2018 to December 2021, a total of 175 patients with acute SCI complicated with cervical fractures in our hospital were retrospectively analyzed. Duplex ultrasound was used to diagnose the DVT. All patients' medical record data, including demographic variables, medical history, and laboratory results, were collected. The patients were divided into DVT group and non-DVT group according to ultrasound results. The prevalence of DVT was determined and risk factors of DVT were identified. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of different factors. The prevalence of DVT at admission was 21.71%(38/175), including one (2.63%) with central DVT, thirty-two (84.21%) with peripheral DVT and five (13.16%) with mixed DVT. The multivariate analysis revealed that decreased lower extremity muscle strength, time from injury to admission, and D-dimer were risk factors for DVT at admission. The diagnostic value of D-dimer was the highest among these risk factors. In conclusion, in patients with acute SCI complicated with cervical fractures, the risk of DVT at admission is very high. Decreased lower extremity muscle strength, time from injury to admission, and D-dimer are risk factors for DVT. Moreover, D-dimer has the highest diagnostic value among these risk factors.

The Higher Prevalence of Venous Thromboembolism in the Hungarian Roma Population Could Be Due to Elevated Genetic Risk and Stronger Gene-Environmental Interactions

Background: Interactions between genetic and environmental risk factors (GxE) contribute to an increased risk of venous thromboembolism (VTE). Understanding how these factors interact provides insight for the early identification of at-risk groups within a population and creates an opportunity to apply appropriate preventive and curative measures.

Objective: To estimate and compare GxE for VTE risk in the general Hungarian and Roma populations.

Methods: The study was based on data extracted from a database consisting of results previously obtained from a complex health survey with three pillars (questionnaire-based, physical, and laboratory examinations) involving 406 general Hungarian and 395 Roma subjects. DNA was genotyped for rs121909567 (SERPINC1), rs1799963 (F2), rs2036914 (F11), rs2066865 (FGG), rs6025 (F5), and rs8176719 (ABO) polymorphisms. After allele frequency comparisons, the odds ratio (OR) was calculated for individual SNPs. Furthermore, genetic risk scores (weighted GRS, unweighted GRS) were computed to estimate the joint effect of the genetic factors. Multivariable linear regression analysis was applied to test the impact of GxE on VTE risk after interaction terms were created between genetic and VTE risk factors [diabetes mellitus (DM), cancer, chronic kidney diseases (CKD), coronary artery diseases (CAD), migraine, depression, obesity, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high density lipoprotein (HDL-C), triglyceride (TG), and smoking].

Results: Interestingly, the rs121909567 (SERPINC1, ATBp3 mutation) SNP was not present in the general population at all. However, the risk allele frequency was 1% among the Roma population, which might suggest a founder effect in this minority. This polymorphism multiplicatively interacted with CAD, CKD, cancer, DM, depression, migraine, and obesity. Even though interactions were not statistically significant, the trend of interaction showed the probability of an incremental VTE risk among the Roma population. The risk of VTE was 4.7 times higher (p > 0.05) for Roma subjects who had ≥3 wGRS (median value) compared with individuals having lower wGRS values but lower for the general subjects (OR = 3.1 × 10⁻⁸). Additionally, the risk of VTE was 6.6 times higher in the Roma population that had ≥3 risk alleles (median value) than in individuals with the 0–1 risk allele, and the overall risk was much higher for the Roma population (OR = 6.6; p > 0.05) than for the general Hungarian population (OR = 1.5; p > 0.05). Five positive and significant GxE interactions were identified in the Roma population. The risk of VTE was higher among depressive Roma subjects who carried the risk variant rs2036914 (β = 0.819, p = 0.02); however, this interaction was not significant for the general subjects. The joint presence of high levels of LDL-C and rs2066865 (FGG) increased the VTE risk only among Roma individuals (β = 0.389, p = 0.002). The possibility of VTE risk increment, as a result of a multiplicative interaction between rs8176719 (ABO) and cancer, was identified, which was higher for the Roma population (β = 0.370, p < 0.001) than for the general population (β = −0.042, p = 0.6). The VTE risk increased in the Roma population (β = 0.280, p = 0.001), but was higher in the general population (β = 0.423, p = 0.001) as a result of the multiplicative interaction between CAD and rs2036914 (F11). The presence of a multiplicative interaction between rs2066865 (FGG) and CAD increased the VTE risk for the Roma population (β = 0.143, p = 0.046) but not for the general population (β = −0.329, p < 0.001).

Conclusions: rs121909567 (SERPINC1, ATBp3) was confirmed as a founder mutation in the Roma population. Our study revealed some evidence on the burden of the joint presence of genetic and environmental risk factors on VTE, although the finding is highly subjected to the selection and observational biases due to the very small number of VTE cases and the observational nature of the study design, respectively. As a result of higher genetic load and GxE interactions, this minority Roma population is at higher risk of VTE than the general Hungarian population. Thus, our results suggest the need for an intensive search for the rs121909567 (SERPINC1; ATBp3) founder mutation, which might be an important factor for the assessment of thrombotic disease susceptibility among the Roma population. In addition, we strongly recommend further studies among a large number of VTE cases to explore the more precise impact of genetic and environmental risk factors on VTE in the study populations.

Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study

BACKGROUND

The incidence of deep vein thrombosis (DVT) in hepatocellular carcinoma (HCC) patients after laparoscopic hepatectomy (LH) is unclear, and there is no effective method for DVT risk assessment in these patients.

METHODS

The data from the total of 355 consecutive HCC patients who underwent LH were included. A DVT risk algorithm was developed using a training set (TS) of 243 patients, and its predictive performance was evaluated in both the TS and a validation set (VS) of 112 patients. The model was then used to develop a DVT risk nomogram (TRN).

RESULTS

The incidence of DVT in the present study was 18.6%. Age, sex, body mass index (BMI), comorbidities and operative position were independent risk factors for DVT in the TS. The model based on these factors had a good predictive ability. In the TS, it had an area under the receiver operating characteristic (AUC) curve of 0.861, Hosmer-Lemeshow (H-L) goodness of fit p value of 0.626, sensitivity of 44.4%, specificity of 96.5%, positive predictive value (PPV) of 74.1%, negative predictive value (NPV) of 88.4%, and accuracy of 86.8%. In the VS, it had an AUC of 0.818, H-L p value of 0.259, sensitivity of 38.1%, specificity of 98.9%, PPV of 88.9%, NPV of 87.4%, and accuracy of 87.5%. The TRN performed well in both the internal and the external validation, indicating a good clinical application value. The TRN had a better predictive value of DVT than the Caprini score (p < 0.001).

CONCLUSION

The incidence of DVT after LH was high, and should not be neglected in HCC patients. The TRN provides an efficacious method for DVT risk evaluation and individualized pharmacological thromboprophylaxis.

Multidisciplinary Practice Variations of Anti-Thrombotic Strategies for Free Tissue Transfers

Background: Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. Methods: National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. Results: There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. Conclusions: There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.

Type 2 Diabetes Is a Risk Factor for Suffering and for in-Hospital Mortality with Pulmonary Embolism. A Population-Based Study in Spain (2016-2018)

(1) Background: The relationship between type 2 diabetes (T2DM) and pulmonary embolism (PE) has not been well stablished so far. We aim to analyze incidence, clinical conditions and in-hospital mortality (IHM) according to the presence of T2DM among patients hospitalized for suffering from PE. The factors associated with IHM were identified. (2) Methods: Patients aged ≥40 years hospitalized for PE from 2016 to 2018 included in the Spanish National Health System Hospital Discharge Database were analyzed. Dependent variables included incidence, IHM and length of hospital stay. Independent variables were age, sex, diagnosed comorbidities, thrombolytic therapy and inferior vena cava filter placement. Poisson and logistic regression models were constructed for multivariable analysis. (3) Results: Of the 47,190 hospitalizations for PE recorded, 16.52% had T2DM. Adjusted incidence of PE was higher among T2DM women (IRR 1.83; 95% CI: 1.58-1.96) and men (IRR 1.22; 95% CI: 1.18-1.27) than among non-diabetic subjects. Crude IHM in T2DM patients with PE was similar in both sexes but higher than in non-diabetic patients. Among T2DM patients with PE, risk factors for IHM included older age, comorbidity, atrial fibrillation and massive PE. Obesity was associated with lower IHM. Suffering T2DM was a risk of IHM (OR 1.15; 95% CI 1.05-1.26) after PE. (4) Conclusions: The incidence of PE is higher in T2DM men and women than in non-diabetic patients. T2DM was a risk factor for IHM after PE.

Long-acting contraception in adolescents and young women with type 1 and type 2 diabetes

Adolescent pregnancy is a major public health problem worldwide. Adolescents living with diabetes are not aware of the risks of unplanned pregnancy and the high rate of fetal and maternal complications when gestation occurs in women with significant hyperglycemia. These data highlight the significance of pregnancy prevention in young women with diabetes. Long-acting reversible contraceptives (LARCs), which include subdermal progestin implants and hormonal and nonhormonal intrauterine devices (IUDs), have been recommended by the American College of Obstetricians Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents and young women. This article reviews LARC options for adolescents and young women with type 1 (T1D) and type 2 (T2D) diabetes as well as the possible complications and side effects.

Elevated HbA1c is not associated with recurrent venous thromboembolism in the elderly, but with all-cause mortality- the SWEETCO 65+ study

The association of glycated hemoglobin (HbA1c) with venous thromboembolism (VTE) and death in the elderly is unknown. In the SWEETCO 65+ study we analyzed prospectively a Swiss Cohort of Elderly Patients with Venous Thromboembolism (SWITCO 65+). 888 patients were enrolled for the SWEETCO 65+ analysis. HbA1c was determined at baseline and divided into three categories (HbA1c < 5.7%, normal range; 5.7–6.49%, pre-diabetic range; and >6.5%, diabetic range). Median follow-up was 2.5 years. The primary endpoint was recurrent VTE. Secondary endpoints included all-cause mortality and major bleeds. The total prevalence of diabetes was 22.1%. The risk of recurrent VTE was similar in patients with HbA1c with pre-diabetes (adjusted subhazard ratio (aSHR) 1.07 [0.70 to 1.63]) and diabetes (aSHR 0.73 [0.39 to 1.37]) as compared to those with a HbA1c in the normal range. However, a HbA1c ≥ 6.5% (median IQ range 7.0 [6.70;7.60]) was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio [aHR] 1.83 [1.21 to 2.75]). In summary we found no association between HbA1c and major bleeding. Elevated HbA1c levels are not associated with recurrent VTE but with increased all-cause mortality in an elderly population with acute VTE.

Glucose metabolism affects coagulation factors: The NEO study

BACKGROUND

It is insufficiently understood if there is an association between diabetes and VT, and what the underlying mechanism would be.

OBJECTIVES

We aimed to study the association between glucose concentrations with several coagulation factors in the general population.

METHODS

This is a cross-sectional analysis of baseline measurements within 5778 participants of the Netherlands Epidemiology of Obesity (NEO) study, a population-based cohort study of individuals 45 to 65 years. Associations between fasting glucose and HbA1c concentrations, and postprandial glucose response and factor (F) VIII, FIX, FXI, and fibrinogen levels were examined using linear regression analyses and by calculating mean levels per category of glucose concentrations while adjusting for confounding factors.

RESULTS

Per each mmol/L higher fasting glucose concentration we observed higher levels of fasting FVIII (5.33%, 95% CI: 4.00-6.65), FIX (6.19%, 95% CI: 5.15-7.23), and FXI (2.11%, 95% CI: 1.20-3.02). Results for fasting HbA1c and postprandial glucose response were similar. Participants with an impaired fasting glucose, high fasting glucose, and diabetes mellitus had higher mean levels of FVIII, FIX, and FXI than those with a normal glucose metabolism, with the highest differences in the levels of FVIII, FIX, and FXI between a high fasting glucose and a normal glucose metabolism. All associations attenuated after adjustment for total body fat, yet all of the above associations remained after adjustment for the confounding factors, except for fibrinogen when contrasted to glucose.

CONCLUSION

Concentrations of fasting glucose and HbA1c and postprandial glucose response were positively associated with FVIII, FIX, and FXI, and to some extent also with fibrinogen.

EndoBarrier®: a Safe and Effective Novel Treatment for Obesity and Type 2 Diabetes?

Background and Aims

Obesity associated with diabetes mellitus is a significant worldwide problem associated with considerable health care costs. Whilst surgical intervention is effective, it is invasive, costly and associated with complications. This study aims to evaluate the safety and efficacy of the EndoBarrier®, a duodenal-jejunal sleeve bypass as an alternative treatment of diabetes mellitus in obese patients.

Materials and Methods

This was a multi-centre, non-randomised trial recruiting obese patients with type 2 diabetes from three sites in the UK. Eligible participants had a BMI of 30–50 kg/m² and HbA1c levels of 7.5–10%. The study comprised a 12-month period with the EndoBarrier® inserted and a 6-month follow-up period after it had been explanted. The primary study outcomes were weight, BMI, HbA1c levels and fasting insulin and glucose levels.

Results

Forty-five patients were recruited and 31 patients (69%) completed the 12-month study period. Significant reductions in weight (95%CI 0.62–29.38; p < 0.05) and BMI (95%CI 1.1–8.7; p < 0.005) were documented 12 months after device insertion. The mean HbA1c was significantly reduced (95%CI 0.1–1.6; p < 0.05) after the device insertion period and reductions in metabolic parameters (fasting insulin and glucose levels) were also documented during the study. Adverse events were also assessed in all patients, the vast majority of which were reported as mild.

Conclusions

The EndoBarrier® appears to be a safe and effective treatment strategy in overweight patients with poor glycaemic control despite medical therapy, or in those who are eligible but decline bariatric surgery.

Effects of glycemic control and hypoglycemia on Thrombus formation assessed using automated microchip flow chamber system: an exploratory observational study

Background

Thrombus formation is an important factor affecting cardiovascular events and venous thromboembolism in type 2 diabetes. However, it is unclear whether glycemic control reduces thrombogenicity. We investigated the effect of short-term glycemic control (STUDY 1) and hypoglycemia (STUDY 2) on thrombus formation using an automated microchip flow chamber system.

Methods

For STUDY 1, we recruited 10 patients with type 2 diabetes. Before and after 2 weeks of treatment, blood glucose was analyzed with a continuous glucose monitoring system, and thrombogenicity was analyzed with an automated microchip flow chamber system. For STUDY 2, we recruited 10 subjects without diabetes who underwent an insulin tolerance test. We evaluated the change in thrombogenic potential with hypoglycemia.

Results

STUDY1: The mean blood glucose level reduced from 10.1 ± 2.6 to 6.9 ± 0.97 mM (P < 0.01). T10, an indicator of thrombogenicity, significantly attenuated after glycemic control (338 ± 65 vs. 425 ± 117 s, P < 0.05). The attenuation in T10 was significantly correlated with changes in mean blood glucose level after treatment (r = - 0.718, P < 0.05). STUDY 2: Platelet function was enhanced with decreasing blood glucose; increased platelet function was strongly correlated with an increase in epinephrine.

Conclusions

We demonstrated attenuation in thrombogenicity with short-term comprehensive diabetes care and enhancement in thrombogenicity with hypoglycemia, using a new flow chamber system.

Trial registration

UMIN-CTR UMIN 000019899, registered 26-Jan-2015 (STUDY 2).

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.

Cardiovascular Risk Factors Associated With Venous Thromboembolism

Importance

It is uncertain to what extent established cardiovascular risk factors are associated with venous thromboembolism (VTE).

Objective

To estimate the associations of major cardiovascular risk factors with VTE, ie, deep vein thrombosis and pulmonary embolism.

Design, Setting, and Participants

This study included individual participant data mostly from essentially population-based cohort studies from the Emerging Risk Factors Collaboration (ERFC; 731 728 participants; 75 cohorts; years of baseline surveys, February 1960 to June 2008; latest date of follow-up, December 2015) and the UK Biobank (421 537 participants; years of baseline surveys, March 2006 to September 2010; latest date of follow-up, February 2016). Participants without cardiovascular disease at baseline were included. Data were analyzed from June 2017 to September 2018.

Exposures

A panel of several established cardiovascular risk factors.

Main Outcomes and Measures

Hazard ratios (HRs) per 1-SD higher usual risk factor levels (or presence/absence). Incident fatal outcomes in ERFC (VTE, 1041; coronary heart disease [CHD], 25 131) and incident fatal/nonfatal outcomes in UK Biobank (VTE, 2321; CHD, 3385). Hazard ratios were adjusted for age, sex, smoking status, diabetes, and body mass index (BMI).

Results

Of the 731 728 participants from the ERFC, 403 396 (55.1%) were female, and the mean (SD) age at the time of the survey was 51.9 (9.0) years; of the 421 537 participants from the UK Biobank, 233 699 (55.4%) were female, and the mean (SD) age at the time of the survey was 56.4 (8.1) years. Risk factors for VTE included older age (ERFC: HR per decade, 2.67; 95% CI, 2.45-2.91; UK Biobank: HR, 1.81; 95% CI, 1.71-1.92), current smoking (ERFC: HR, 1.38; 95% CI, 1.20-1.58; UK Biobank: HR, 1.23; 95% CI, 1.08-1.40), and BMI (ERFC: HR per 1-SD higher BMI, 1.43; 95% CI, 1.35-1.50; UK Biobank: HR, 1.37; 95% CI, 1.32-1.41). For these factors, there were similar HRs for pulmonary embolism and deep vein thrombosis in UK Biobank (except adiposity was more strongly associated with pulmonary embolism) and similar HRs for unprovoked vs provoked VTE. Apart from adiposity, these risk factors were less strongly associated with VTE than CHD. There were inconsistent associations of VTEs with diabetes and blood pressure across ERFC and UK Biobank, and there was limited ability to study lipid and inflammation markers.

Conclusions and Relevance

Older age, smoking, and adiposity were consistently associated with higher VTE risk.

Mortality after pulmonary embolism in patients with diabetes. Findings from the RIETE registry

BACKGROUND

Among patients presenting with pulmonary embolism (PE), those with diabetes are at increased risk to die than those without diabetes. The reasons have not been identified. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to compare the mortality rate and the causes of death during anticoagulation in patients with PE according to the presence or absence of diabetes.

METHODS

A matched retrospective cohort study from consecutively enrolled patients in RIETE, from 179 hospitals in 24 countries. For each patient with diabetes we selected two patients with no diabetes matched by age, sex and year of diagnosis of the PE.

RESULTS

As of September 2017, there were 2010 PE patients with diabetes and two age-and-gender matched controls. Mean age was 74 ± 11 years, 46% were men. Patients with diabetes were more likely to have co-morbidities, to be using antiplatelets and to have more severe PE. During anticoagulation (median, 219 days), patients with diabetes had a higher mortality (hazard ratio [HR]: 1.45; 95% confidence intervals [CI]: 1.25-1.67) and a higher rate of arterial ischemic events (HR: 2.89; 95%CI: 1.71-4.94) than those without diabetes. On multivariable analysis, diabetes was not associated with an increased risk for death (HR: 1.26; 95%CI: 0.97-1.63). We also failed to find differences according to the use of antiplatelet drugs concomitantly.

CONCLUSIONS

In our cohort of patients with PE, diabetes was not an independent predictor for death. The influence of arterial events or antiplatelet drugs (if any) was low.

Venous Thromboembolism in Upper Extremity Fractures

BACKGROUND

Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes.

METHODS

Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality.

RESULTS

Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021).

CONCLUSIONS

VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Does Hyperglycemia Affect Risk of Peripherally Inserted Central Catheter-Related Upper Extremity Venous Thrombosis?

It is not clear whether blood glucose (BG) affects the risk of peripherally inserted central catheter (PICC)-related upper extremity venous thrombosis (PRUEVT). A case-control study was conducted comparing patients with PRUEVT versus patients with PICCs who did not develop PRUEVT. BG on admission was significantly higher among cases with PRUEVT than controls. No significant differences were found between the groups in hemoglobin A1c or BG on the third day of hospitalization. PRUEVT cases were more likely to be diabetic, but this did not reach statistical significance. The time that a PICC was in place before PRUEVT was diagnosed was longer for diabetic patients, but the authors believe this result must be viewed with caution.

Epidemiology of venous thromboembolism in Africa: a systematic review and meta-analysis protocol

INTRODUCTION

Venous thromboembolism (VTE) is among the three major causes of cardiovascular diseases worldwide after ischaemic heart disease and stroke. Knowledge on the global epidemiology of this condition is deficient in Africa. Accurate data are needed to evaluate the burden of VTE in Africa to design effective preventive and treatment strategies. This systematic review and meta-analysis aims to summarise epidemiological data on VTE in Africa and to evaluate the use of prophylaxis in African patients at risk of VTE.

METHODS AND ANALYSIS

Medline, Embase, Scopus and African Journal Online will be searched for relevant abstracts of studies published between 1 January 1986 and 5 December 2016, without language restriction. After a screening of abstracts, study selection, data extraction and assessment of the risk of bias, we shall assess studies individually for clinical and statistical heterogeneity. Appropriate meta-analytic technics will then be used to pool studies judged to be clinically homogeneous. Funnel-plots analysis and Egger's test will be used to detect publication bias. Results will be presented by geographical region (Central, Eastern, Northern, Southern and Western Africa). This systematic review will be reported according to the Meta-analysis of Observational Studies in Epidemiology Guidelines.

ETHICS AND DISSEMINATION

The current study will be based on published data, and thus ethics consideration is not required. This review is expected to provide relevant data to help in quantifying the magnitude of this disease in Africa. The final report of this study will be published in a peer-reviewed journal and the findings will be submitted to relevant health authorities.

TRIAL REGISTRATION NUMBER

The protocol for this review has been published in the International Prospective Register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO), registration number: PROSPERO CRD42017056253.

Clinical significance of glycemic parameters on venous thromboembolism risk prediction in gastrointestinal cancer

AIM

To investigate the possible predictive role of routinely used glycemic parameters for a first venous thromboembolism (VTE) episode in gastrointestinal (GI) cancer ambulatory patients - with or without clinically diagnosed type 2 diabetes (T2D) or obesity - treated with chemotherapy.

METHODS

Pre-treatment fasting blood glucose, insulin, glycated hemoglobin (HbA_1c) and homeostasis model of risk assessment (HOMA) were retrospectively evaluated in a cohort study of 342 GI cancer patients. Surgery was performed in 142 (42%) patients with primary cancer, 30 (21%) and 112 (79%) of whom received neoadjuvant and adjuvant therapies, respectively. First-line chemotherapy was administered in 200 (58%) patients with metastatic disease. The study outcome was defined as the occurrence of a first symptomatic or asymptomatic VTE episode during active treatment.

RESULTS

Impaired glucose tolerance (IGT) or T2D were diagnosed in 30% of GI cancer patients, while overweight/obesity had an incidence of 41%. VTE occurred in 9.4% of patients (7% of non-diabetic non-obese), especially in those with a high ECOG score (P = 0.025). No significant association was found between VTE incidence and T2D, obesity, different tumor types, metastatic disease, Khorana class of risk, or different anti-cancer drugs, although VTE rates were substantially higher in patients receiving bevacizumab (17% vs 8%, P = 0.044). Conversely, all glucose metabolic indexes were associated with increased VTE risk at ROC analysis. Multivariate Cox proportional analyses confirmed that HOMA index (HR = 4.13, 95%CI: 1.63-10.5) or fasting blood glucose (HR = 3.56, 95%CI: 1.51-8.39) were independent predictors of VTE occurrence during chemotherapy.

CONCLUSION

The results here reported demonstrate that evaluating glucose metabolic asset may allow for VTE risk stratification in GI cancer, helping to identify chemotherapy-treated patients who might benefit from thromboprophylaxis. Further multicenter prospective studies involving a larger number of patients are presently needed.

Association of Traditional Cardiovascular Risk Factors With Venous Thromboembolism: An Individual Participant Data Meta-Analysis of Prospective Studies

BACKGROUND

Much controversy surrounds the association of traditional cardiovascular disease risk factors with venous thromboembolism (VTE).

METHODS

We performed an individual level random-effect meta-analysis including 9 prospective studies with measured baseline cardiovascular disease risk factors and validated VTE events. Definitions were harmonized across studies. Traditional cardiovascular disease risk factors were modeled categorically and continuously using restricted cubic splines. Estimates were obtained for overall VTE, provoked VTE (ie, VTE occurring in the presence of 1 or more established VTE risk factors), and unprovoked VTE, pulmonary embolism, and deep-vein thrombosis.

RESULTS

The studies included 244 865 participants with 4910 VTE events occurring during a mean follow-up of 4.7 to 19.7 years per study. Age, sex, and body mass index-adjusted hazard ratios for overall VTE were 0.98 (95% confidence interval [CI]: 0.89-1.07) for hypertension, 0.97 (95% CI: 0.88-1.08) for hyperlipidemia, 1.01 (95% CI: 0.89-1.15) for diabetes mellitus, and 1.19 (95% CI: 1.08-1.32) for current smoking. After full adjustment, these estimates were numerically similar. When modeled continuously, an inverse association was observed for systolic blood pressure (hazard ratio=0.79 [95% CI: 0.68-0.92] at systolic blood pressure 160 vs 110 mm Hg) but not for diastolic blood pressure or lipid measures with VTE. An important finding from VTE subtype analyses was that cigarette smoking was associated with provoked but not unprovoked VTE. Fully adjusted hazard ratios for the associations of current smoking with provoked and unprovoked VTE were 1.36 (95% CI: 1.22-1.52) and 1.08 (95% CI: 0.90-1.29), respectively.

CONCLUSIONS

Except for the association between cigarette smoking and provoked VTE, which is potentially mediated through comorbid conditions such as cancer, the modifiable traditional cardiovascular disease risk factors are not associated with increased VTE risk. Higher systolic blood pressure showed an inverse association with VTE.

Epidemiology of venous thromboembolism in the Framingham Heart Study

BACKGROUND

Reports of the crude incidence of venous thromboembolism (VTE) in Western countries vary widely. Data regarding risk factors, incidence and recurrence of VTE from deeply-phenotyped community-based cohort studies are needed.

OBJECTIVES

To study the incidence, associated mortality, and predisposing factors of VTE in the prospective, longitudinal community-based Framingham Heart Study.

PATIENTS/METHODS

The study sample consisted of the Framingham Heart Study Original, Offspring, Third Generation, and Omni cohorts (N=9754). Incidence rates (IR) were standardized to the 2000 US population. Cox proportional hazards regression models were used to study risk factor associations.

RESULTS

During 1995-2014 (total follow-up time 104,091 person-years [median 9.8 (range 0-20) years]), 297 incident VTE events were observed. Age-adjusted IR of VTE was 20.3/10,000 (95% CI 17.9-22.6). Of the events 120 (40%) were pulmonary embolism (PE) and 177 (60%) were deep venous thrombosis (DVT); 29% were unprovoked, 40% provoked, and 31% cancer-related. Cancer-related VTE was associated with high mortality at 30days (24.2%), 1year (66.3%), and 5years (75.6%). In multivariable models, age and obesity, but no other traditional cardiovascular risk factors, were significantly associated with VTE (hazard ratio [HR] per 10-year increase in age 1.69, 95% CI 1.48-1.92; HR for obesity (BMI≥30kg/m(2)) 1.88, 95% CI 1.44-2.45).

CONCLUSIONS

We provide data on the epidemiology of VTE. VTE is associated with significant mortality, and prognosis after cancer-related VTE is particularly poor. Traditional cardiovascular risk factors beyond age and obesity are not associated with VTE.

Fatal Pulmonary Thromboembolism in Patients with Diabetic Ketoacidosis: A Seven-Case Series and Review of the Literature

Diabetes mellitus is a well-recognized risk factor for arterial thrombosis, however its relationship to venous thromboembolism (VTE) in adults is still debated. We report here seven cases of fatal pulmonary thromboembolism in adults with diabetic ketoacidosis as the underlying cause. In four of seven cases, there was no prior diagnosis of diabetes mellitus and patients were newly diagnosed either upon presenting to the hospital in diabetic ketoacidosis (DKA) or at the time of autopsy by the vitreous glucose concentration. None of the patients had family history, recent surgery, recent trauma, long distance travel, or other strong risk factors for VTE. Only two patients had a body mass index greater than 35 kg/m² and the same two cases had hospital stays that ranged from three to five days. We believe that DKA is a frequently unrecognized and sometimes overlooked risk factor for VTE, particularly in the forensic setting where routine toxicology and vitreous glucose analysis may not be standard practices. We encourage forensic pathologists, medical examiners, and coroners to consider the possibility of diabetic ketoacidosis as a risk factor, and in some cases, the underlying etiology for pulmonary thromboembolism. Additionally, we recommend vitreous glucose testing be performed if there are any signs of DKA or diabetes present, such as acetone in the blood.