Clinical presentation and outcome of venous thromboembolism in COPD

The impact of deep venous thrombosis on 90 day mortality in chronic obstructive pulmonary disease patients presenting with pulmonary embolism

BACKGROUND

There are a limited number of studies investigating the effect of deep venous thrombosis (DVT) in patients presenting with both pulmonary embolism and chronic obstructive pulmonary disease. The aim of this study is to investigate the prevalence and prognostic significance of DVT in patients with PE-COPD.

METHODS

COPD patients admitted with a diagnosis of PE to our tertiary hospital between January 2016 and January 2021 were retrospectively evaluated with an electronic hospital database. Univariate and multivariate Cox regression analyses were performed to reveal independent prognostic factors.

RESULTS

Two hundred thirty-three patients (mean age 65.1 ± 12.2, 158 men (67.5 %)) were included. DVT was present at the time of diagnosis in 45 (19.31 %) of the patients. Patients with DVT tend to have more comorbidities, central pulmonary embolism, higher CRP and d-dimer levels, and SPESI score (p<0.05). After performing multivariate analyses, the presence of DVT (HR=3.48, CI: 1.02- 11.88, p = 0.046), ischemic heart disease (HR=3.82, CI: 1.38- 10.80, p = 0.01), and malignancy (HR=4.85, CI: 1.53- 15.41, p = 0.007) were found to be independent factors in predicting 90-day mortality.

CONCLUSIONS

In PE-COPD patients, co-existing DVT may predict a worse outcome.

Pulmonary embolism diagnostic strategies in patients with COPD exacerbation: Post-hoc analysis of the PEP trial

BACKGROUND

The prevalence of pulmonary embolism (PE) is approximately 11-17 % in patients with an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The optimal diagnostic strategy for PE in these patients remains undetermined.

AIMS

To evaluate the safety and efficacy of standard (revised Geneva and Wells PE scores combined with fixed D-dimer cut-off) and computed tomography pulmonary angiogram (CTPA)-sparing diagnostic strategies (ADJUST-PE, YEARS, PEGeD, 4PEPS) in patients with AE-COPD.

METHOD

Post-hoc analyses of data from the multicenter prospective PEP study were performed. The primary outcome was the diagnostic failure rate of venous thromboembolism (VTE) during the entire study period. Secondary outcomes included diagnostic failure rate of PE and deep venous thrombosis (DVT), respectively, during the entire study period and the number of CTPA needed per diagnostic strategy.

RESULTS

740 patients were included. The revised Geneva and Wells PE scores combined with fixed D-dimer cut-off had a diagnostic failure rate of VTE of 0.7 % (95%CI 0.3 %-1.7 %), but >70.0 % of the patients needed imaging. All CTPA-sparing diagnostic algorithms reduced the need for CTPAs (-10.1 % to -32.4 %, depending on the algorithm), at the cost of an increased VTE diagnosis failure rate of up to 2.1 % (95%CI 1.2 %-3.4 %).

CONCLUSION

Revised Geneva and Wells PE scores combined with fixed D-dimer cut-off were safe, but a high number of CTPA remained needed. CTPA-sparing algorithms would reduce imaging, at the cost of an increased VTE diagnosis failure rate that exceeds the safety threshold. Further studies are needed to improve diagnostic management in this population.

Pulmonary Embolism and Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a frequent and devastating chronic respiratory disease. COPD is ranked among the top five causes of death worldwide. Patients with COPD suffer from persistent dyspnea, with periods of acute worsening, called exacerbations. Such exacerbations may be severe. In fact, one-third of COPD patients will be hospitalized because of an exacerbation. Hospitalization due to respiratory failure has been identified as a powerful predisposing risk factor for venous thromboembolism (VTE) for many years. Therefore, COPD is recognized as a moderate risk factor for VTE, with an odds ratio between 2 and 9, similar to other risk factors such as estrogen-containing contraceptives or (any) cancer. However, unlike other risk factors such as contraception, the presence of COPD can modify the initial presentation of VTE and worsen the short-term prognosis of patients who have acute pulmonary embolism (PE), particularly during a COPD exacerbation. It is not only that both stable COPD and acute exacerbations of COPD might increase the risk of VTE, but PE itself may mimic the symptoms of a COPD exacerbation. Hence, some authors have evaluated the prevalence of PE among COPD patients with acute worsening. This clinical review (1) gives an update on epidemiological data, clinical presentation, and prognosis of PE associated with COPD; (2) presents the results of the Prevalence de l'Embolie Pulmonaire chez les patients admis pour exacerbation de BPCO study, which aimed at determining the frequency of PE in COPD patients hospitalized for an acute exacerbation; (3) discusses the results of the Significance of Pulmonary Embolism in COPD Exacerbations study, the first randomized trial having compared the efficacy of a systematic search for PE versus routine care on admission for a COPD exacerbation; and (4) provides a selection of remaining unmet needs on the association between COPD and PE.

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region

BACKGROUND

Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events.

METHODS

A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE.

RESULTS

Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001).

CONCLUSIONS

Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.

In-hospital venous thromboembolism: are glucocorticoids a prime suspect?

The objective of the study was to determine whether glucocorticoid use is associated with an increased incidence of in-hospital VTE. We conducted a case-control study of patients with an in-hospital VTE from October 2015 to December 2019. Adult patient cases were identified by ICD-10 codes for acute venous thromboembolism. Controls were selected from all patients without a VTE diagnosis and matched by hospital length of stay and admission type (medical/surgical). Patients were excluded if they had a history of VTE, received therapeutic anticoagulation, or were pregnant. All patients were evaluated to determine the presence or absence of glucocorticoid exposure. Glucocorticoid dose, duration, and route of administration were assessed for patients with steroid exposure. Overall, 78 patients with VTE and 234 controls were included. Receipt of glucocorticoids within the preceding 90 days was similar between the VTE cases and controls (39.7 vs. 38.9%, P  = 0.89). No differences were noted with regard to oral (21.8 vs. 19.2%, P = 0.62), intravenous (30.8 vs. 29.1%. P = 0.774), or inhaled (6.4 vs. 10.3%, P = 0.31) routes of administration between VTE case and control patients. Cumulative prednisone equivalent doses were similar between cases and controls (877 ± 1366 vs. 697 ± 1963 mg, P = 0.435). The risk of in-hospital venous thromboembolism was not influenced by glucocorticoid exposure within the past 90 days. These results were consistent across all routes of administration, exposure time, and steroid dose. Blood Coagul Fibrinolysis 33:000-000 Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Venous thromboembolism risk assessment of surgical patients in Southwest China using real-world data: establishment and evaluation of an improved venous thromboembolism risk model

Background

Venous thromboembolism (VTE) risk assessment in surgical patients is important for the appropriate diagnosis and treatment of patients. The commonly used Caprini model is limited by its inadequate ability to discriminate between risk stratums on the surgical population in southwest China and lengthy risk factors. The purpose of this study was to establish an improved VTE risk assessment model that is accurate and simple.

Methods

This study is based on the clinical data from 81,505 surgical patients hospitalized in the Southwest Hospital of China between January 1, 2019 and June 18, 2021. Among the population, 559 patients developed VTE. An improved VTE risk assessment model, SW-model, was established through Logistic Regression, with comparisons to both Caprini and Random Forest.

Results

The SW-model incorporated eight risk factors. The area under the curve (AUC) of SW-model (0.807 [0.758, 0.853], 0.804 [0.765, 0.840]), are significantly superior (p = 0.001 and p = 0.044) to those of the Caprini (0.705 [0.652, 0.757], 0.758 [0.719, 0795]) on two test sets, but inferior (p < 0.001 and p = 0.002) to Random Forest (0.854 [0.814, 0.890], 0.839 [0.806, 0.868]). In decision curve analysis, within threshold range from 0.015 to 0.04, the DCA curves of the SW-model are superior to Caprini and two default strategies.

Conclusions

The SW-model demonstrated a higher discriminative capability to distinguish VTE positive in surgical patients compared with the Caprini model. Compared to Random Forest, Logistic Regression based SW-model provided interpretability which is essential in guarantee the procedure of risk assessment transparent to clinicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01795-9.

Effect of a Pulmonary Embolism Diagnostic Strategy on Clinical Outcomes in Patients Hospitalized for COPD Exacerbation: A Randomized Clinical Trial

IMPORTANCE

Active search for pulmonary embolism (PE) may improve outcomes in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To compare usual care plus an active strategy for diagnosing PE with usual care alone in patients hospitalized for COPD exacerbation.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted across 18 hospitals in Spain. A total of 746 patients were randomized from September 2014 to July 2020 (final follow-up was November 2020).

INTERVENTIONS

Usual care plus an active strategy for diagnosing PE (D-dimer testing and, if positive, computed tomography pulmonary angiogram) (n = 370) vs usual care (n = 367).

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of nonfatal symptomatic venous thromboembolism (VTE), readmission for COPD, or death within 90 days after randomization. There were 4 secondary outcomes, including nonfatal new or recurrent VTE, readmission for COPD, and death from any cause within 90 days. Adverse events were also collected.

RESULTS

Among the 746 patients who were randomized, 737 (98.8%) completed the trial (mean age, 70 years; 195 [26%] women). The primary outcome occurred in 110 patients (29.7%) in the intervention group and 107 patients (29.2%) in the control group (absolute risk difference, 0.5% [95% CI, -6.2% to 7.3%]; relative risk, 1.02 [95% CI, 0.82-1.28]; P = .86). Nonfatal new or recurrent VTE was not significantly different in the 2 groups (0.5% vs 2.5%; risk difference, -2.0% [95% CI, -4.3% to 0.1%]). By day 90, a total of 94 patients (25.4%) in the intervention group and 84 (22.9%) in the control group had been readmitted for exacerbation of COPD (risk difference, 2.5% [95% CI, -3.9% to 8.9%]). Death from any cause occurred in 23 patients (6.2%) in the intervention group and 29 (7.9%) in the control group (risk difference, -1.7% [95% CI, -5.7% to 2.3%]). Major bleeding occurred in 3 patients (0.8%) in the intervention group and 3 patients (0.8%) in the control group (risk difference, 0% [95% CI, -1.9% to 1.8%]; P = .99).

CONCLUSIONS AND RELEVANCE

Among patients hospitalized for an exacerbation of COPD, the addition of an active strategy for the diagnosis of PE to usual care, compared with usual care alone, did not significantly improve a composite health outcome. The study may not have had adequate power to assess individual components of the composite outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02238639.

Pulmonary embolism with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease. The incidence of COPD is growing annually in China, and it is a significant and growing public health burden. Multivariate analysis showed that COPD was one of the independent risk factors for the occurrence of pulmonary embolism (PE), and the incidence of PE was significantly higher in COPD patients than in normal subjects. However, PE is often overlooked in patients with acute exacerbation of COPD (AECOPD) because there are many similarities in clinical symptoms between PE and AECOPD, which are difficult to distinguish, resulting in the failure of timely treatment and poor prognosis. Therefore, it is of great significance to understand the clinical manifestations, diagnosis, and treatment of COPD combined with PE for making a more accurate diagnosis, providing timely and effective treatment, and improving the prognosis of such patients.

The prevalence and clinical features of pulmonary embolism in patients with AE-COPD: A meta-analysis and systematic review

BACKGROUND

The prevalence of pulmonary embolism (PE) in the acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) is highly controversial. We conducted a systematic review and meta-analysis to summarize the epidemiology and characteristics of PE with AE-COPD for current studies.

METHODS

We searched the PubMed, EMBASE, Cochrane Library and Web of Science databases for studies published prior to October 21, 2020. Pooled proportions with 95% confidence intervals (95% CIs) were calculated using a random effects model. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals were used as effect measures for dichotomous and continuous variables, respectively.

RESULTS

A total of 17 studies involving 3170 patients were included. The prevalence of PE and deep vein thrombosis (DVT) in AE-COPD patients was 17.2% (95% CI: 13.4%-21.3%) and 7.1% (95% CI: 3.7%-11.4%%), respectively. Dyspnea (OR = 6.77, 95% CI: 1.97-23.22), pleuritic chest pain (OR = 3.25, 95% CI: 2.06-5.12), lower limb asymmetry or edema (OR = 2.46, 95% CI:1.51-4.00), higher heart rates (MD = 20.51, 95% CI: 4.95-36.08), longer hospital stays (MD = 3.66, 95% CI: 3.01-4.31) were associated with the PE in the AE-COPD patients. Levels of D-dimer (MD = 1.51, 95% CI: 0.80-2.23), WBC counts (MD = 1.42, 95% CI: 0.14-2.70) were significantly higher and levels of PaO2 was lower (MD = -17.20, 95% CI: -33.94- -0.45, P<0.05) in the AE-COPD with PE group. The AE-COPD with PE group had increased risk of fatal outcome than the AE-COPD group (OR = 2.23, 95% CI: 1.43-3.50).

CONCLUSIONS

The prevalence of PE during AE-COPD varies considerably among the studies. AE-COPD patients with PE experienced an increased risk of death, especially among the ICU patients. Understanding the potential risk factors for PE may help clinicians identify AE-COPD patients at increased risk of PE.

PROSPERO REGISTRATION NUMBER

CRD42021226568.

Systemic Corticosteroids and the Risk of Venous Thromboembolism in Patients with Severe COPD: A Nationwide Study of 30,473 Outpatients

Due to frequent exacerbations, many patients with chronic obstructive pulmonary disease (COPD) are exposed to oral corticosteroids (OCS), which may be thrombogenic. We evaluated the risk of hospitalisation with venous thromboembolism (VTE) and death in patients with acute exacerbation of COPD (AECOPD) treated with long and short OCS regimens. In this nationwide cohort study of 30,473 COPD outpatients treated for AECOPD, we compared the risk of VTE hospitalisation and all-cause mortality within 6 months in OCS dose of >250 mg vs. ≤250 mg. A multivariable Cox proportional hazard regression was used to estimate the risk. The incidence of VTE hospitalisations was 0.23%. A long OCS treatment course was associated with an increased risk of VTE compared to a short course (hazard ratio (HR) 1.69, [95% confidence interval (CI) 1.05 to 2.72], p < 0.031). A higher risk of all-cause mortality was seen in the group of COPD patients treated with a long OCS course (HR 1.71, [95% CI 1.63 to 1.79], p < 0.0001). The risk of reported VTE hospitalisation was higher among AECOPD patients treated with long courses of OCS, but the absolute risk was low, suggesting under-reporting of the condition.

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).

Glucocorticoid use and risk of first and recurrent venous thromboembolism: self-controlled case-series and cohort study

Glucocorticoid treatment increases venous thromboembolism (VTE) risk. Whether this is due to the medication or the underlying disease, or affects the risk of VTE recurrence, has been difficult to determine. The aim of our present study was to quantify the risk for first and recurrent VTE associated with oral glucocorticoids use, considering the underlying disease. A total of 2547 patients with VTE from the Multiple Environmental and Genetic Assessment of Risk Factors for Venous Thrombosis (MEGA) study were linked to the Dutch Pharmaceutical Statistics register. The risk of first VTE during periods of exposure with oral glucocorticoids was estimated by the self‐controlled case series method and that of recurrent VTE was examined in a cohort design. The incidence rate ratio (IRR) of first VTE in the period of glucocorticoid treatment was 3·51 [95% confidence interval (CI) 2·55–4·80]. This IRR was 2·53 (95% CI 1·10–5·72) in the week before treatment started, 5·28 (95% CI 2·89–9·53) in the first 7 days of treatment, remained elevated afterwards and decreased to 1·55 (95% CI 0·85–3·12) after 6 months, as compared to unexposed periods. The hazard ratio for recurrence was 2·72 (95% CI 1·64–4·78) in treatment periods as compared with no treatment. The increased risk of VTE associated with oral glucocorticoid treatment is due to a combined effect of the treatment and the underlying disease, remaining high during the first months of prescription.

The effect of COPD on the incidence and mortality of hospitalized patients with pulmonary embolism: A nationwide population-based study (2016-2018)

BACKGROUND

To examine the incidence, clinical characteristics, and in-hospital outcomes of pulmonary embolism (PE) among hospitalized patients with or without chronic obstructive pulmonary disease (COPD) in Spain, and to identify predictors of in-hospital-mortality (IHM) after PE among patients with and without COPD.

METHODS

We included all patients aged ≥ 40 years who were hospitalised for PE between 2016 and 2018. Data were collected from the Spanish National Hospital Discharge Database.

RESULTS

We identified 47,190 hospitalizations for PE during the study period, 7.49% with COPD. Adjusted incidence of PE was higher in COPD patients than in those without COPD (IRR 1.16; 95%CI 1.13-1.19). Crude IHM was significantly higher in PE hospitalized patients with COPD than in those without COPD (9.86% vs 3.59%; p<0.001). Predictor factors of IHM in COPD patients with PE included older age, higher Charlson comorbidity index, atrial fibrillation, massive PE and dependence on oxygen prior to hospital admission. However, obesity was associated with lower IHM. For PE hospitalized patients, suffering COPD increased the probability of dying in the hospital (adjusted OR 2.84; 95%CI 2.27-3.55).

CONCLUSIONS

Our results revealed that incidence of PE was higher in COPD patients than in those without COPD. Furthermore, COPD was a risk factor for IHM after PE.

Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms

IMPORTANCE

The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain.

OBJECTIVE

To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017.

EXPOSURES

Acutely worsening respiratory symptoms in patients with COPD.

MAIN OUTCOMES AND MEASURES

The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not.

RESULTS

Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441).

CONCLUSIONS AND RELEVANCE

Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.

The Predictive Value of microRNA-134 and microRNA-1233 for the Early Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Acute Pulmonary Embolism

Background

The differential diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute pulmonary embolism (APE) complications are difficult because of the variability of clinical presentations and the shortage of an unfailing screening biomarkers or instruments.

Objective

Aimed to detect and compare the expression of serum microRNAs (miR-1233, miR-134) in AECOPD patients complicated with APE.

Patients/Methods

Blood samples were collected from 52 AECOPD patients (13 patients with APE complications, 39 patients without APE) and 10 patients with stable COPD. Serum miRNAs expression was detected with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). The levels of plasma D-dimers were determined by detection with an enzyme-linked immunosorbent assay (ELISA). The receiver-operator characteristic (ROC) curve was used for evaluating the diagnostic accuracy of the studied miRNAs.

Results

According to the Wells score, 42 of the 52 AECOPD patients were unlikely to have APE (≤4 points), whereas the remaining 10 (>4 points) were likely to have APE. There were 4 cases (4/13 30.8%) in the AECOPD combined with APE group with a Wells score of >4 points. The expression levels of miR-1233 and miR-134 in the serum were considerably upregulated in the AECOPD+APE group compared with the AECOPD group and the stable COPD group (P<0.05). The areas under the curve (AUCs) for miR-134 and miR-1233 were, respectively, 0.931 (95% CI 0.863–0.999) (P<0.05) and 0.884 (95% CI 0.79–0.978) (P<0.05) and were higher compared with the AUC for D-dimer of 0.628 (95% CI 0.447–0.809), the AUC for age-adjusted D-dimer of 0.705 (95% CI 0.525–0.885) and the AUC for Wells score of 0.577 (95% CI 0.389–0.765).

Conclusion

Our study indicated that serum miR-1233 and miR-134 have high clinical value in the early diagnosis of AECOPD patients combined with APE, or could be used as potential biomarkers for clinical identification of AECOPD with or without APE complication.

Chronic Obstructive Pulmonary Disease Is Associated With Higher Rates of Venous Thromboemboli Following Primary Total Knee Arthroplasty

BACKGROUND

There is discordance in the literature regarding the presence of chronic obstructive pulmonary disease (COPD) and the development of venous thromboemboli (VTEs). Therefore, the purpose of this study is to determine whether COPD patients undergoing primary total knee arthroplasty (TKA) have higher rates of (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) VTEs; and (4) costs of care.

METHODS

COPD patients undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, gender, and medical comorbidities. Patients with a history of VTEs or hypercoagulable states were excluded. The query yielded 211,378 patients in the study (n = 35,230) and control (n = 176,148) cohorts. Outcomes analyzed included in-hospital LOS, readmission rates, VTEs, and costs of care. A P-value less than .01 was considered statistically significant.

RESULTS

COPD patients were found to have significantly longer in-hospital LOS (4 vs 3 days, P < .0001). Study group patients were also found to have significantly higher incidence and odds ratio (OR) of readmission rates (20.9% vs 16.3%; OR 1.36, P < .0001) and VTEs (1.75 vs .93; OR 1.18, P < .0001). Additionally, the study demonstrated that COPD patients incurred higher 90-day episode-of-care costs ($15,626.85 vs $14,471.29, P < .0001).

CONCLUSION

After adjusting for confounding variables, our study found an association between COPD and higher rates of developing VTEs following primary TKA. The study can be used by orthopedic surgeons to adequately counsel and educate these patients of the potential complications which may arise following their TKA.

Pulmonary Artery Thrombosis: A Diagnosis That Strives for Its Independence

According to a widespread theory, thrombotic masses are not formed in the pulmonary artery (PA) but result from migration of blood clots from the venous system. This concept has prevailed in clinical practice for more than a century. However, a new technologic era has brought forth more diagnostic possibilities, and it has been shown that thrombotic masses in the PA could, in many cases, be found without any obvious source of emboli. Chronic obstructive pulmonary disease, asthma, sickle cell anemia, emergency and elective surgery, viral pneumonia, and other conditions could be complicated by PA thrombosis development without concomitant deep vein thrombosis (DVT). Different pathologies have different causes for local PA thrombotic process. As evidenced by experimental results and clinical observations, endothelial and platelet activation are the crucial mechanisms of this process. Endothelial dysfunction can impair antithrombotic function of the arterial wall through downregulation of endothelial nitric oxide synthase (eNOS) or via stimulation of adhesion receptor expression. Hypoxia, proinflammatory cytokines, or genetic mutations may underlie the procoagulant phenotype of the PA endothelium. Both endotheliocytes and platelets could be activated by protease mediated receptor (PAR)- and receptors for advanced glycation end (RAGE)-dependent mechanisms. Hypoxia, in particular induced by high altitudes, could play a role in thrombotic complications as a trigger of platelet activity. In this review, we discuss potential mechanisms of PA thrombosis in situ.

Aspects extrapulmonaires des exacerbations de bronchopneumopathie chronique obstructive

La bronchopneumopathie chronique obstructive (BPCO) est une maladie systémique aux multiples atteintes, émaillée d’exacerbations. L’inflammation, l’hypoxémie, les troubles de la coagulation et les perturbations des interactions coeur–poumon expliquent en partie les atteintes non pulmonaires observées notamment lors d’exacerbations aiguës. Les événements cardiovasculaires sont la première cause de mortalité des patients BPCO, et leur recrudescence est observée pendant plusieurs semaines après une exacerbation. Aux urgences, la prise en charge des patients en exacerbation de BPCO repose donc en plus du support ventilatoire sur une bonne évaluation des potentielles pathologies associées telles que l’insuffisance cardiaque, l’ischémie myocardique, l’insuffisance rénale ou encore la maladie thromboembolique. Cette évaluation globale permet d’adapter les thérapeutiques parfois délétères sur la fonction cardiaque ou l’équilibre acide−base et de prendre en compte le risque extrapulmonaire dans le choix du parcours de soins du patient. Dans cette mise au point, nous abordons quelques explications physiologiques des multiples perturbations observées au cours de l’exacerbation de BPCO, et proposons une vision globale de l’évaluation de ces patients admis pour une dyspnée ou un autre motif pouvant être en rapport avec la BPCO.

Advances in the diagnosis of acute pulmonary embolism

Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.

Clinical relevance of chronic respiratory disease in Korean patients with pulmonary thromboembolism

Background

Data regarding clinical and radiological features of patients with pulmonary thromboembolism (PTE) and concomitant chronic respiratory disease (CRD) are limited. Accordingly, the aim of the present study was to investigate clinico-radiological features of this patient population.

Methods

Patients with PTE were retrospectively classified into one of two groups: those with and without CRD. Clinical characteristics, blood biomarkers, and computed tomographic (CT) findings were compared between the groups.

Results

Of 1,207 PTE patients included, CRD was detected in 128 (11%). The most common CRD was chronic obstructive pulmonary disease [41 (32%)], followed by bronchial anthracofibrosis [32 (25%)]. In multivariate analysis, unprovoked PTE [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.29-3.05, P=0.002], dyspnea (OR 1.54, 95% CI: 1.11-2.34, P=0.041), lower respiratory tract infection (LRTI) (OR 3.90, 95% CI: 2.13-7.14, P<0.001), Pulmonary Embolism Severity Index (PESI) class IV-V (OR 5.24, 95% CI: 3.43-8.00, P<0.001), in-situ pulmonary artery thrombosis (OR 10.62, 95% CI: 3.71-30.45, P<0.001), and pulmonary artery enlargement (OR 1.65, 95% CI: 3.71-30.45, P<0.001) were found to be independent clinical factors related to CRD in patients with PTE. CRD was an independent predictor of PTE-related in-hospital mortality (OR 3.96, 95% CI: 1.32-11.88, P=0.014).

Conclusions

Patients with PTE and concomitant CRD were characterized by higher incidences of dyspnea, LRTI, PESI class IV-V, and in-situ pulmonary artery thrombosis, compared with non-CRD patients. In these patients, CRD was a predictor of PTE-related in-hospital mortality.

Association between features of COPD and risk of venous thromboembolism

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is associated with risk of venous thromboembolism (VTE) events. A detailed understanding of which clinical features of COPD increase risk of VTE events is needed.

OBJECTIVES

To investigate the association between features of COPD and risk of venous thromboembolism.

METHODS

A retrospective observational clinical study was conducted on 551 consecutive COPD patients visiting the Department of Respiratory and Critical Care Medicine of Tianjin Chest Hospital between February 2014 and April 2018. Finally, 151 patients were eligible for inclusion. Of these, 29 patients had COPD with VTE and 121 patients had COPD without VTE. Patient informations regarding age, gender, BMI, smoking history, smoking status (package/year), COPD-related symptoms, lung function, number of acute exacerbations and imaging visual emphysema were gathered.

RESULTS

Among the 29 VTE patients, 18 patients had PE and five had DVT, while 6 patients had simultaneous PE and DVT. There were statistically significant differences in GOLD grade, Imaging visual emphysema, and frequent acute exacerbations between the two groups. Multivariate logistic regression analysis showed that after adjustment for gender, age, BMI and smoking history, there were statistically significant for visible emphysema (OR = 3.54, 95% CI: 1.13-11.08; P = 0.03) and GOLD grade (OR = 1.77, 95% CI: 1.04-3.01; P = 0.035), but not for frequent acute exacerbations (OR = 1.65, 95% CI: 0.62-4.38; P = 0.31).

CONCLUSIONS

Visual emphysema is an independent risk factor for VTE events and the risk of VTE in COPD patients increases with the degree of airway obstruction. However, there is no evidence of an association between exacerbation frequency and VTE events.

Venous Thromboembolism in Special Populations: Preexisting Cardiopulmonary Disease, Cirrhosis, End-Stage Renal Disease, and Asplenia

Venous thromboembolism (VTE) is a common cause of morbidity and mortality. Presence of preexisting conditions, such as cardiopulmonary diseases, cirrhosis, renal dysfunction, and asplenia, commonly occurs in VTE patients. Moreover, these conditions often are risk factors for developing VTE. These preexisting conditions make VTE diagnosis and treatment challenging and worsen outcomes. Current guidelines do not include detailed features in the diagnosis and management of patients with preexisting conditions. This review discusses presence of VTE in patients with preexisting cardiopulmonary diseases, cirrhosis, renal dysfunction, and asplenia.

The problem of under-diagnosis and over-diagnosis of pulmonary embolism

Pulmonary embolism (PE) is an increasingly recognised condition which is associated with significant morbidity and mortality. Despite the better awareness of this serious condition, the diagnosis is still overlooked in many cases with sometimes fatal consequences. Under-diagnosis may be due to several reasons including reliance on non-specific 'classic' symptoms, belief that bedside measurements will likely be abnormal in the setting of acute PE, and confounding factors like co-existent cardiorespiratory diseases or being in an intensive care unit, where the diagnosis may not be considered. At the same time, incidental diagnosis of PE is occurring more often due to frequent use of imaging investigations alongside advancements in CT technology, and dilemma exists as to whether the chance finding of PE requires anticoagulation, especially when identified only at the subsegmental level. This article reviews these two issues of under-diagnosis and over-diagnosis of PE in the current era.

Deep venous thrombosis in the clinical course of pulmonary embolism

Objectives

The aim of the study is to find how concomitant deep venous thrombosis (DVT) changes the clinical course of pulmonary embolism.

Methods

Three hundred and five patients with pulmonary embolism were examined and grouped into DVT and non-DVT groups. Both groups were compared with regard to demography, predisposing factors, clinical signs, thrombotic burden, and one-month mortality rate.

Results

The patients with DVT had a more severe clinical presentation: higher heart rate (94.80 ± 18.66 beats per minute versus 87.9 ± 13.90 in the non-DVT group, p = 0.00033), more hemodynamic instability (11.35% versus 3.05% in the non-DVT group, p = 0.005), and less pCO2 in arterial blood gases (30.81 ± 7.94 mmHg versus 32.59 ± 7.35 mmHg in the non-DVT group, p = 0.049). The DVT group had heavier thrombotic burden in pulmonary artery, measured by Mastora score. The one-month mortality rate did not differ statistically between groups.

Conclusions

Patients with symptomatic pulmonary embolism and concomitant DVT have heavier thrombotic burden in the pulmonary artery and more severe clinical presentation compared to those without DVT, but a similar one-month mortality rate.

Pulmonary Embolism in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective

In most countries, nearly 6% of the adults are suffering from chronic obstructive pulmonary disease (COPD), which puts a huge economic burden on the society. Moreover, COPD has been considered as an independent risk factor for pulmonary embolism (PE). In this review, we summarized the existing evidence that demonstrates the associations between COPD exacerbation and PE from various aspects, including epidemiology, pathophysiological changes, risk factors, clinical features, management, and prognosis.

Data Sources

We searched the terms "chronic obstructive pulmonary disease," "pulmonary embolism," "exacerbations," and "thromboembolic" in PubMed database and collected the results up to April 2018. The language was limited to English.

Study Selection

We thoroughly examined the titles and abstracts of all studies that met our search strategy. The data from prospective studies, meta-analyses, retrospective studies, and recent reviews were selected for preparing this review.

Results

The prevalence of PE in patients with COPD exacerbation varied a lot among different studies, mainly due to the variations in race, sample size, study design, research setting, and enrollment criteria. Overall, whites and African Americans showed significantly higher prevalence of PE than Asian people, and the hospitalized patients showed higher prevalence of PE compared to those who were evaluated in emergency department. PE is easily overlooked in patients with COPD exacerbation due to the similar clinical symptoms. However, several factors have been identified to contribute to the increased risk of PE during COPD exacerbation. Obesity and lower limb asymmetry were described as independent predictors for PE. Moreover, due to the high risk of PE, thromboprophylaxis has been used as an important treatment for hospitalized patients with COPD exacerbation.

Conclusions

According to the previous studies, COPD patients with PE experienced an increased risk of death and prolonged length of hospital stay. Therefore, the thromboembolic risk in patients with acute exacerbation of COPD, especially in the hospitalized patients, should carefully be evaluated.

The prevalence and risk factors of venous thromboembolism in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease

INTRODUCTION

Venous thromboembolism (VTE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is not rare, which would affect the patient's prognosis.

OBJECTIVES

To examine the prevalence, risk factors and clinical characteristics of AECOPD patients with VTE.

METHODS

We performed this multi-center, prospective, observational study that involved 16 hospitals in China. Patients admitted to hospital due to AECOPD were consecutively enrolled. Baseline characteristics, VTE risk factors, symptoms, signs and auxiliary examination results were collected. Lower limb venous ultrasound and computed tomography pulmonary angiography were examined.

RESULTS

Between June 2009 and October 2010, a total of 1144 AECOPD patients (the average age 72.0 ± 9.1 years, 761 males) were enrolled in this study. Seventy-eight (6.8%) were diagnosed with VTE, including 24 PE, 64 DVT, 10 combined PE and DVT. VTE patients were older than non-VTE patients. History of venous thromboembolism and lower extremity varicose vein, and presence of longer immobility (≥3 days), lower limbs problems of swelling, pain and walking difficulties, diuretics use, fever, syncope, higher d-dimer and lower hemoglobin were more common in VTE patients than in non-VTE patients. After adjusting the covariates, venous thrombosis history, prolonged immobility (≥3 days), lower limb pain before hospitalization, higher d-dimer independently associated with VTE development. Regular glucocorticoid use was not associated with increased risk of VTE in this set of patients.

CONCLUSION

VTE is relatively common among hospitalized AECOPD patients. Conventional prophylactic anticoagulant therapy may be considered for those hospitalized AECOPD patients with risk factors.

Lack of association between airflow limitation and recurrence of venous thromboembolism among cancer patients with pulmonary embolism

Background

COPD is a well-known risk factor for venous thromboembolism (VTE) development. However, recent data showed that it was not associated with VTE recurrence risk, which excluded cancer patients. This study investigated the association of airflow limitation and VTE recurrence in cancer patients with pulmonary embolism (PE).

Methods

This is a retrospective cohort study of cancer patients with newly diagnosed PE at a university hospital. PE was confirmed using contrast-enhanced computed tomography scan. Airflow limitation was defined as pre-bronchodilator forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) <0.7 within 2 years of PE diagnosis. VTE recurrence was defined as a composite of recurrence as PE or deep vein thrombosis or both.

Results

Among 401 cancer patients with newly diagnosed PE, spirometry-based airflow limitation was observed in 126 (31.4%) patients. Half of the patients had lung cancer, which was more common in the group with airflow limitation (65.1% vs 42.9%, p < 0.001). Symptomatic PE was present in less than half (45.4%) of the cases, and 62.6% of patients were treated for PE. During the median follow-up period of 9.7 months, VTE recurred in 49 (12.2%) patients. Compared with patients without airflow limitation, those with airflow limitation did not have an increased risk of VTE recurrence in univariate or multivariate analyses (adjusted hazard ratio, 1.29 [95% CI 0.68, 2.45]).

Conclusion

The presence of airflow limitation did not increase the risk of VTE recurrence in cancer patients with PE. Prospective studies are needed to validate this finding.

Efficacy and safety of low-dose urokinase for the treatment of hemodynamically stable AECOPD patients with acute pulmonary thromboembolism

PURPOSE

The aim of this study was to assess the incidence of pulmonary thromboembolism (PTE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD),and to evaluate the efficacy and safety of low-dose urokinase (UK) thrombolysis therapy when treating hemodynamically stable AECOPD patients with acute PTE (AECOPD-PTE).

METHODS

A total of 419 AECOPD patients, including 96 AECOPD-PTE, were enrolled. A total of 30 AECOPD-PTE patients were collected retrospectively, and 66 AECOPD-PTE patients were prospectively divided into anticoagulation-only, low-dose UK and standard-dose UK groups. Follow-up 1 year, we evaluated the efficacy and safety of low-dose UK therapy for hemodynamically stable AECOPD-PTE patients.

RESULTS

The incidence of PTE in AECOPD patients was 22.9% (96/419), which increased with COPD severity degree ranging from 3.5% (2/57) in mild, 13.6% (19/140) in moderate and 33.8% (75/222) in severe subgroups (P < .05). In the prospective study, the total effective rate of low-dose UK group 97.2% (35/36) was higher than that in anticoagulation 75.0% (12/16) and standard-dose UK group 78.6% (11/14) respectively (P < .05). In the follow-up, the adverse events rate in low-dose UK group 8.3% (3/36) was significantly lower than that in anticoagulation group 25.0% (4/16) and standard-dose UK group 71.4% (10/14) respectively (P < .05). In addition, the mean PTE recurrence time of low-dose UK group (9.0 ± 0) months was longer than anticoagulation group (2.0 ± 1.41) months (P < .05). AECOPD relapse time in anticoagulation, low-dose UK and standard-dose UK groups corresponding to (8.5 ± 2.12), (9.0 ± 0) and (8.8 ± 3.40) months were compared with no significant difference (P > .05).

CONCLUSIONS

The incidence of PTE in AECOPD patients was 22.9%, especially with higher occurrence rate in severe COPD. Compared with anticoagulation-only therapy, low-dose UK treatment (500 000 IU/day for 5-7 days) could obtain a better efficacy and safety in hemodynamically stable AECOPD patients with acute PTE, corresponding with a higher effective rate (97.2%) and lower adverse events rate (8.3%) respectively.

Imbalance between Subpopulations of Regulatory T Cells in Patients with Acute Exacerbation of COPD

Human regulatory T cells (Tregs) have been reported to be not significantly different in the peripheral blood of patients with chronic obstructive pulmonary disease (COPD) and healthy controls. Recent research has identified some new markers for Tregs and indicated that Tregs are composed of distinct subpopulations. The aim of the study was to describe the changing patterns of circulating Treg subpopulations in patients with acute exacerbation of COPD (AECOPD) and healthy controls, and to explore their potential roles in AECOPD pathogenesis. Blood samples were obtained from 30 never-smokers with normal lung function and 30 patients with COPD before and after they had an exacerbation. The proportions of Treg subpopulations were evaluated using flow cytometry. In the peripheral blood, decreased proportions of CD4⁺CD25⁺CD127^low Tregs, CD4⁺CD25⁺CD45RA⁺ Tregs, and CD4⁺CD25⁺CD62L⁺ Tregs and an increased proportion of CD4⁺CD25⁺CD45RO⁺ Tregs were found in patients with stable COPD compared with non-smokers with normal lung function. The patients showed further changes in Treg subpopulations when they had an AECOPD, with an overall decrease in a suppressive subset, indicating that the immune negative regulatory population of Tregs did not play an effective role. Immune homeostasis favored inflammation, and a negative correlation between the circulating tumor necrosis factor-alpha and the proportions of CD4⁺CD25⁺CD62L⁺ cells (r = -0.698, p < 0.05) in patients with AECOPD was found. The imbalance between the suppressive subsets and the proinflammatory subset of Tregs and the decline of Treg subpopulations with immunosuppressive activity may play important roles in AECOPD progression.

Risk of recurrent venous thromboembolism in COPD patients: results from a prospective cohort study

We aimed to assess the risk of recurrent venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) following cessation of anticoagulation therapy.In a prospective cohort of 1468 patients with a documented episode of VTE, followed for up to 5 years after cessation of anticoagulation therapy, the diagnosis of COPD was confirmed in 136. The main outcome was recurrent VTE. The secondary outcome was overall mortality. Univariate and multivariate analyses were performed to identify the risk factors of recurrence.Of the 1468 patients included, recurrent VTE was observed in 306 (34 with COPD and 272 without) during a median follow-up period of 36.5 months. The incidence rate of recurrent VTE was 9.1% (95% CI 6.5-12.8) for COPD patients and 7.0% (95% CI 6.2-7.9) for non-COPD patients. COPD was not associated with an increased risk of VTE recurrence on univariate or multivariate analyses (hazard ratio: 1.0 (95% CI 0.7-1.4)). The risk of death, adjusted for demographic and clinical characteristics, showed no increase in COPD patients, as compared to non-COPD patients.In patients with COPD who had an acute episode of VTE, the risk of recurrent VTE was not any higher than that in non-COPD patients.

Recent Progress in Research on the Pathogenesis of Pulmonary Thromboembolism: An Old Story with New Perspectives

Pulmonary thromboembolism (PTE) is part of a larger clinicopathological entity, venous thromboembolism. It is also a complex, multifactorial disorder divided into four major disease processes including venous thrombosis, thrombus in transit, acute pulmonary embolism, and pulmonary circulation reconstruction. Even when treated, some patients develop chronic thromboembolic pulmonary hypertension. PTE is also a common fatal type of pulmonary vascular disease worldwide, but earlier studies primarily focused on the pathological changes in the blood component of the disease. With contemporary advances in molecular and cellular biology, people are becoming increasingly aware of coagulation pathways, the function of vascular smooth muscle cells, microparticles, and the inflammatory pathways that play key roles in PTE. Combined hypoxia and immune research has revealed that PTE should be regarded as a class of complex diseases caused by multiple factors involving the vascular microenvironment and vascular cell dysfunction.

Infection as cause of immobility and occurrence of venous thromboembolism: analysis of 1635 medical cases from the RIETE registry

Several risk assessment models include infection and immobility among the items to be considered for venous thromboembolism (VTE) prevention. However, information on patients with infection leading to immobility and developing VTE are limited, as well as on the role of specific types of infection. Data were collected from the worldwide RIETE registry, including patients with symptomatic objectively confirmed VTE, and followed-up for at least 3 months. The overall population of RIETE at June 2013 (n = 47,390) was considered. Acute infection leading to immobility was reported in 3.9 % of non-surgical patients. Compared with patients immobilized due to dementia, patients with infection had a shorter duration of immobilization prior to VTE (less than 4 weeks in 94.2 vs. 25.9 % of cases; p < 0.001). During the 3-month follow-up, VTE patients with infection versus those with dementia had a lower rate of fatal bleeding (0.5 vs. 1.1 %; p < 0.05) or fatal PE (1.7 vs. 3.5 %; p < 0.01). Patients with respiratory tract infections had more likely PE as initial VTE presentation than other types of infection (62.3 vs. 37.7 %; p < 0.001). Significantly more patients with pneumonia than those with other respiratory infections had received VTE prophylaxis (50.2 vs. 30.6 %; p < 0.001). Following VTE, patients with sepsis showed a significantly higher risk of fatal bleeding. Based on our real-world data, infection seems to contribute to the pathogenesis of VTE by accelerating the effects of immobility. Its role as VTE risk factor probably deserves further attention and specific assessment in order to optimize VTE prophylaxis and treatment.

Lung function, respiratory symptoms and venous thromboembolism risk: the Atherosclerosis Risk in Communities Study

Essentials The association of lung function with venous thromboembolism (VTE) is unclear. Chronic obstructive pulmonary disease (COPD) patterns were associated with a higher risk of VTE. Symptoms were also associated with a higher risk of VTE, but a restrictive pattern was not. COPD may increase the risk of VTE and respiratory symptoms may be a novel risk marker for VTE.

SUMMARY

Background The evidence for the association between chronic obstructive pulmonary disease (COPD) and venous thromboembolism (VTE) is limited. There is no study investigating the association between restrictive lung disease (RLD) and respiratory symptoms with VTE. Objectives To investigate prospectively the association of lung function and respiratory symptoms with VTE. Patients/Methods In 1987-1989, we assessed lung function by using spirometry, and obtained information on respiratory symptoms (cough, phlegm, and dyspnea) in 14 654 participants aged 45-64 years, without a history of VTE or anticoagulant use, and followed them through 2011. Participants were classified into four mutually exclusive groups: 'COPD' (forced expiratory volume in 1 s [FEV1 ]/forced vital capacity [FVC] below the lower limit of normal [LLN]), 'RLD' (FEV1 /FVC ≥ LLN and FVC < LLN), 'respiratory symptoms with normal spirometic results' (without RLD or COPD), and 'normal' (without respiratory symptoms, RLD, or COPD). Results We documented 639 VTEs (238 unprovoked and 401 provoked VTEs). After adjustment for VTE risk factors, VTE risk was increased for individuals with either respiratory symptoms with normal spirometric results (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.12-1.73) or COPD (HR 1.33, 95% CI 1.07-1.67) but not for those with RLD (HR 1.15, 95% CI 0.82-1.60). These elevated risks of VTE were derived from both unprovoked and provoked VTE. Moreover, FEV1 and FEV1 /FVC showed dose-response relationships with VTE. COPD was more strongly associated with pulmonary embolism than with deep vein thrombosis. Conclusions Obstructive spirometric patterns were associated with an increased risk of VTE, suggesting that COPD may increase the risk of VTE. Respiratory symptoms may represent a novel risk marker for VTE.

Relative Citation Ratio of Top Twenty Macedonian Biomedical Scientists in PubMed: A New Metric that Uses Citation Rates to Measure Influence at the Article Level

AIM

The aim of this study was to analyze relative citation ratio (RCR) of top twenty Macedonian biomedical scientists with a new metric that uses citation rates to measure influence at the article level.

MATERIAL AND METHODS

Top twenty Macedonian biomedical scientists were identified by GoPubMed on the base of the number of deposited abstracts in PubMed, corrected with the data from previously published paper, and completed with the Macedonian biomedical scientists working in countries outside the Republic of Macedonia, but born or previously worked in the country. iCite was used as a tool to access a dashboard of bibliometrics for papers associated with a portfolio.

RESULTS

The biggest number of top twenty Macedonian biomedical scientists has RCR lower than one. Only four Macedonian biomedical scientists have bigger RCR in comparison with those in PubMed. The most prominent RCR of 2.29 has Rosoklija G. RCR of the most influenced individual papers deposited in PubMed has shown the biggest value for the paper of Efremov D (35.19). This paper has the biggest number of authors (860).

CONCLUSION

It is necessary to accept top twenty Macedonian biomedical scientists as an example of new metric that uses citation rates to measure influence at the article level, rather than qualification of the best Macedonian biomedical scientists.

COPD disease severity and the risk of venous thromboembolic events: a matched case-control study

Background

It is generally accepted that people with chronic obstructive pulmonary disease (COPD) are at increased risk of vascular disease, including venous thromboembolism (VTE). While it is plausible that the risk of arterial and venous thrombotic events is greater still in certain subgroups of patients with COPD, such as those with more severe airflow limitation or more frequent exacerbations, these associations, in particular those between venous events and COPD severity or exacerbation frequency, remain largely untested in large population cohorts.

Methods

A total of 3,594 patients with COPD with a first VTE event recorded during January 1, 2004 to December 31, 2013, were identified from the Clinical Practice Research Datalink dataset and matched on age, sex, and general practitioner practice (1:3) to patients with COPD with no history of VTE (n=10,782). COPD severity was staged by degree of airflow limitation (ie, GOLD stage) and by COPD medication history. Frequent exacerbators were defined as patients with COPD with ≥ 2 exacerbations in the 12-month period prior to their VTE event (for cases) or their selection as a control (for controls). Conditional logistic regression was used to estimate the association between disease severity or exacerbation frequency and VTE.

Results

After additional adjustment for nonmatching confounders, including body mass index, smoking, and heart-related comorbidities, there was evidence for an association between increased disease severity and VTE when severity was measured either in terms of lung function impairment (odds ratio [OR]_{moderate:mild} =1.16; 95% confidence intervals [CIs] =1.03, 1.32) or medication usage (OR_{severe:mild/moderate} =1.17; 95% CIs =1.06, 1.26). However, there was no evidence to suggest that frequent exacerbators were at greater risk of VTE compared with infrequent exacerbators (OR =1.06; 95% CIs =0.97, 1.15).

Conclusion

COPD severity defined by airflow limitation or medication usage, but not exacerbation frequency, appears to be associated with VTE events in people with COPD. This finding highlights the disconnect between disease activity and severity in COPD.

30-Day Mortality in Acute Pulmonary Embolism: Prognostic Value of Clinical Scores and Anamnestic Features

Purpose

Identification of high-risk patients with pulmonary embolism is vital. The aim of the present study was to examine clinical scores, their single items, and anamnestic features in their ability to predict 30-day mortality.

Materials and Methods

A retrospective, single-center study from 06/2005 to 01/2010 was performed. Inclusion criteria were presence of pulmonary embolism, availability of patient records and 30-day follow-up. The following clinical scores were calculated: Acute Physiology and Chronic Health Evaluation II, original and simplified pulmonary embolism severity index, Glasgow Coma Scale, and euroSCORE II.

Results

In the study group of 365 patients 39 patients (10.7%) died within 30 days due to pulmonary embolism. From all examined scores and parameters the best predictor of 30-day mortality were the Glasgow Coma scale (≤ 10) and parameters of the circulatory system including presence of mechanical ventilation, arterial pH (< 7.335), and systolic blood pressure (< 99 mm Hg).

Conclusions

Easy to ascertain circulatory parameters have the same or higher prognostic value than the clinical scores that were applied in this study. From all clinical scores studied the Glasgow Coma Scale was the most time- and cost-efficient one.

COPD and risk of venous thromboembolism and mortality in a general population

The relationship between chronic obstructive pulmonary disease (COPD) and risk of venous thromboembolism (VTE) has been scarcely studied in the general population. We aimed to investigate the association between COPD and risk of VTE and mortality in a population-based cohort.Spirometry was conducted in 8646 males and females, participating in the fifth (2001-02) and sixth (2007-08) surveys of the Tromsø Study. Incident VTE events during follow-up were registered from the date of inclusion to December 31, 2011. Cox-regression models with COPD stages and confounders as time varying covariates were used to calculate hazard ratios with 95% confidence intervals for VTE and all-cause mortality.During a median follow-up of 6.2 years, 215 subjects developed VTE. Subjects with COPD stage III/IV had a two-fold higher risk of secondary VTE compared to subjects with normal airflow (HR 2.05, 95% CI 1.02-4.10). COPD patients, particularly those with stage III/IV disease, with VTE had a higher mortality rate than COPD patients without VTE (50.2% versus 5.6% per year).Our findings suggest that patients with severe COPD may have increased risk of secondary VTE, and that COPD patients with VTE have a higher mortality rate than COPD patients without VTE.

Risk Factors for Venous Thromboembolism Among Reproductive Age Women

BACKGROUND

Venous thromboembolism (VTE) is rare among young women and is often presumed to occur in the setting of a genetic predisposition or during the use of estrogen-containing combined hormonal contraceptive or to have an unknown cause. This study aims to describe the distribution of VTE risk factors among women with a confirmed VTE.

METHODS

We identified all women aged 15-46 years with a VTE diagnosis at Columbia University Medical Center from 2005 to 2012 using medical center databases. We then reviewed all electronic medical records to validate the diagnoses and identify risk factors associated with each confirmed case.

RESULTS

We identified 315 cases and confirmed 186 (59%). The proportion of unconfirmed cases increased over time. Forty percent of confirmed cases were associated with hormonal contraceptives or pregnancy. Ninety-five percent of confirmed cases had identifiable major risk factors including a personal history, family history, malignancy or other predisposing illness, recent long-haul travel, trauma, hospitalization, and obesity; many had multiple simultaneous risk factors. None of the confirmed cases was associated with a previously known genetic predisposition, but in 10 confirmed cases a genetic predisposition was identified during evaluation. In only 10 of the 186 confirmed cases could we not identify any acquired risk factor, and only 2 of those 10 women had a genetic predisposition.

CONCLUSIONS

Many reproductive age women experiencing a VTE have risk factors unique to this group, and most have multiple risk factors, confirming that this is a multifactorial disease. The large proportion of unconfirmed cases suggests the need for great caution in using administrative databases for research due to poor diagnostic specificity and due to lack of information about additional risk factors.

Chronic Venous Disease and Comorbidities

We report the relations between comorbidities and chronic venous disease. In this cross-sectional study, information was gathered from 1679 Serbian patients. The majority (65.0%) of patients were women. Mild forms of chronic venous disease (clinical, etiologic, anatomic and pathophysiologic [CEAP] classification; C0s-C1) were more frequent in women (11.6%), while severe forms (CEAP C4-C6) were more commonly encountered in men (42.1%). The most frequent comorbidity was emphysema/chronic obstructive pulmonary disease in both groups (74.3% in males and 70.6% in females). For females, diabetes mellitus ( P < .005), arterial hypertension ( P < .000), and skeletal/joint diseases ( P < .042) were more commonly found in the C4 to C6 category. Both males and females, with severe form of chronic venous disease, may benefit from additional screening for comorbidities. Further studies are needed to clarify the nature of association among comorbidities and chronic venous disease.