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Martens ESL, Huisman MV, van Mens TE, Klok FA. The History of Diagnosing Venous Thromboembolism. Semin Thromb Hemost 2024. [PMID: 38373722 DOI: 10.1055/s-0044-1779484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
An accurate and prompt diagnosis of deep vein thrombosis and/or pulmonary embolism is important to prevent serious complications and mortality. Because the clinical presentation of venous thromboembolism (VTE) is often nonspecific, objective testing by means of radiological imaging is required to confirm the diagnosis. Historically, a diagnosis of VTE involved invasive imaging techniques like contrast venography or conventional pulmonary angiography. Technological developments toward more accurate and less invasive diagnostics have driven the implementation of a variety of newer technologies over the past decades, as well as the derivation and validation of clinical decision rules (CDRs) that can be used to rule out VTE in combination with D-dimer blood tests. In this narrative review, we provide a historical overview of the most notable developments in the imaging techniques and CDRs for VTE diagnosis.
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Affiliation(s)
- Emily S L Martens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Thijs E van Mens
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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2
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de Jong CMM, van den Hout WB, van Dijk CE, Heim N, van Dam LF, Dronkers CEA, Gautam G, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, van Mens TE, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis. Thromb Haemost 2023. [PMID: 37984402 DOI: 10.1055/a-2213-9230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison. OBJECTIVES To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients. METHODS Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared. RESULTS All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. CONCLUSION One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences - Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Noor Heim
- National Health Care Institute, The Netherlands
| | - Lisette F van Dam
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Charlotte E A Dronkers
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gargi Gautam
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Gralum, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Anders von Heijne
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marcel M C Hovens
- Department of Vascular Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stan Kolman
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel A van de Ree
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | | | | | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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3
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van Mens TE, Klok FA, Levi M. [Pitfalls of searching online: all symptoms, diseases and adverse events appear correlated]. Ned Tijdschr Geneeskd 2023; 167:D7753. [PMID: 38175564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
When confronted with an unexpected clinical observation, such as a remarkable symptom in a patient with an unrelated rare disease, clinicians increasingly apply online literature search to support the observed correlation. Against a background of an exponential rise in medical publications and the well-documented problem of publication bias, the easy access to literature carries the risk of suggesting spurious correlations. The current paper expounds on this phenomenon. Queries in medical search engines often provide a number of hits, regardless of the plausibility of the correlation searched for. To quantify this, we recently performed a study involving 30.000 automated queries in PubMed using completely random search terms drawn from lists of diseases, symptoms and medications. This provided a background rate of PubMed hits. The data support that several hits by no means automatically indicate a relevant correlation, and underline need for judicious critical appraisal when searching for a correlation observed in daily practice.
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Affiliation(s)
- Thijs E van Mens
- LUMC, afd. Interne geneeskunde, Leiden
- Contact: Thijs E. van Mens
| | - F A Klok
- LUMC, afd. Interne geneeskunde, Leiden
| | - Marcel Levi
- Amsterdam UMC, afd. Interne geneeskunde, Amsterdam
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Luijten D, Talerico R, Barco S, Cannegieter SC, Delcroix M, Ende-Verhaar YM, Huisman MV, Konstantinidis S, Mairuhu ATA, van Mens TE, Ninaber M, Pruszczyk P, Vonk Noordegraaf A, Klok FA. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: an updated systematic review and meta-analysis. Eur Respir J 2023; 62:2300449. [PMID: 37321620 DOI: 10.1183/13993003.00449-2023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Talerico
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Suzanne C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marion Delcroix
- Department of Respiratory Diseases, University Hospital of Leuven, Leuven, Belgium
| | - Yvonne M Ende-Verhaar
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Albert T A Mairuhu
- Department of Vascular Medicine, Haga Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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van Mens TE, Middeldorp S, Coppens M. [Venous thromboembolism and antiphospholipid syndrome - considerations on diagnosis and treatment]. Ned Tijdschr Geneeskd 2023; 167. [PMID: 36928879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Antiphospholipid syndrome (APS) is an auto-immune syndrome defined by thrombosis and/or pregnancy morbidity in the persistent presence of antiphospholipid antibodies. Antiphospholipid antibodies are a group of antibodies predominantly directed at phospholipid-bound plasma proteins. The more antibodies a patient has the higher the risk of thrombosis. The origin of the antibodies and the precise prothrombotic mechanism are incompletely understood. A diagnosis of APS can in certain clinical scenarios implicate a longer treatment with anticoagulants after a venous thromboembolism. High level evidence is absent. In addition, APS patients with a high risk antibody profile had a higher risk of arterial thrombosis in randomized trials when treated with direct oral anticoagulants compared to vitamin K antagonists. The number needed to screen in light of these possible consequences of an APS diagnosis for treatment, appears to high to justify routine screening. In this review we suggest indications for APS testing in the context of venous thromboembolism.
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Affiliation(s)
- Thijs E van Mens
- Amsterdam UMC, locatie AMC, afd. Vasculaire Geneeskunde, Amsterdam
- Contact: Thijs E. van Mens
| | | | - Michiel Coppens
- Amsterdam UMC, locatie AMC, afd. Vasculaire Geneeskunde, Amsterdam
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Luijten D, Klok FA, van Mens TE, Huisman MV. Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research. Expert Rev Respir Med 2023; 17:181-189. [PMID: 36912598 DOI: 10.1080/17476348.2023.2190888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. AREAS COVERED (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. EXPERT OPINION Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
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Luijten D, Klok FA, van Mens TE, Huisman MV. Response to letter to the editor: "Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research". Expert Rev Respir Med 2023; 17:427-428. [PMID: 37191014 DOI: 10.1080/17476348.2023.2215015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Thijs E van Mens
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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van Mourik DJM, Salet DM, Middeldorp S, Nieuwdorp M, van Mens TE. The role of the intestinal microbiome in antiphospholipid syndrome. Front Immunol 2022; 13:954764. [PMID: 36505427 PMCID: PMC9732728 DOI: 10.3389/fimmu.2022.954764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022] Open
Abstract
The antiphospholipid syndrome (APS) is a thrombotic autoimmune disease in which the origin of the disease-characterizing autoantibodies is unknown. Increased research effort into the role of the intestinal microbiome in autoimmunity has produced new insights in this field. This scoping review focusses on the gut microbiome in its relation to APS. EMBASE and MEDLINE were searched for original studies with relevance to the relation between the gut microbiome and APS. Thirty studies were included. Work on systemic lupus erythematosus, which strongly overlaps with APS, has shown that patients often display an altered gut microbiome composition, that the disease is transferable with the microbiome, and that microbiome manipulation affects disease activity in murine lupus models. The latter has also been shown for APS, although data on microbiome composition is less consistent. APS patients do display an altered intestinal IgA response. Evidence has accrued for molecular mimicry as an explanatory mechanism for these observations in APS and other autoimmune diseases. Specific gut microbes express proteins with homology to immunodominant APS autoantigens. The disease phenotype appears to be dependent on these mimicking proteins in an APS mouse model, and human APS B- and T-cells indeed cross-react with these mimics. Pre-clinical evidence furthermore suggests that diet may influence autoimmunity through the microbiome, as may microbial short chain fatty acid production, though this has not been studied in APS. Lastly, the microbiome has been shown to affect key drivers of thrombosis, and may thus affect APS severity through non-immunological mechanisms. Overall, these observations demonstrate the impact of the intestinal microbiome on autoimmunity and the importance of understanding its role in APS.
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Affiliation(s)
- Dagmar J. M. van Mourik
- Amsterdam UMC location University of Amsterdam, Department of (Experimental) Vascular Medicine, Amsterdam, Netherlands,Amsterdam Cardiovascular Sciences, Pulmonary hypertension & thrombosis, Amsterdam, Netherlands,*Correspondence: Dagmar J. M. van Mourik, ; Thijs E. van Mens,
| | - Dorien M. Salet
- Amsterdam UMC location University of Amsterdam, Department of (Experimental) Vascular Medicine, Amsterdam, Netherlands,Amsterdam Cardiovascular Sciences, Pulmonary hypertension & thrombosis, Amsterdam, Netherlands,Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Max Nieuwdorp
- Amsterdam UMC location University of Amsterdam, Department of (Experimental) Vascular Medicine, Amsterdam, Netherlands
| | - Thijs E. van Mens
- Amsterdam UMC location University of Amsterdam, Department of (Experimental) Vascular Medicine, Amsterdam, Netherlands,Amsterdam Cardiovascular Sciences, Pulmonary hypertension & thrombosis, Amsterdam, Netherlands,Amsterdam Reproduction & Development, Pregnancy & Birth, Amsterdam, Netherlands,*Correspondence: Dagmar J. M. van Mourik, ; Thijs E. van Mens,
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9
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Haghikia A, van Mens TE, Pontarollo G, Reinhardt C. Editorial: Impact of the gut microbiota on cardiovascular medicine. Front Med (Lausanne) 2022; 9:939890. [PMID: 35911413 PMCID: PMC9327641 DOI: 10.3389/fmed.2022.939890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arash Haghikia
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thijs E. van Mens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Giulia Pontarollo
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christoph Reinhardt
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), University Medical Center of the Johannes Gutenberg University Mainz, Partner Site Rhine Main, Mainz, Germany
- *Correspondence: Christoph Reinhardt
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Killian M, van Mens TE. Risk of Thrombosis, Pregnancy Morbidity or Death in Antiphospholipid Syndrome. Front Cardiovasc Med 2022; 9:852777. [PMID: 35299976 PMCID: PMC8921454 DOI: 10.3389/fcvm.2022.852777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
The antiphospholipid syndrome is an autoimmune disease characterized by thrombosis and pregnancy morbidity. The manifestations are caused by antibodies targeting cell membrane phospholipids and/or associated proteins. The triggers leading to these antibodies' production are unknown but recent work suggests cross-reactivity between the autoantigens and peptides produced by the intestinal microbiome. Work on how the autoantibodies could cause clinical manifestations implicates different mechanisms. Binding to surface proteins of different cell types can induce intracellular signaling leading to cell activation and tissue factor expression. Complement activation and neutrophil extracellular-traps are also involved, and recent evidence implicates endothelial protein C receptor-lysobisphosphatidic acid complex. Pregnancy is a high-risk situation for antiphospholipid syndrome patients due to the increased risk of thrombosis and obstetric complications. Epidemiological and clinical research on APS is hampered by heterogeneity in populations, testing and treatment strategies. About one in 10 to one in fifty APS pregnancies is complicated by thrombosis, despite treatment. Pregnant patients with prior thrombosis are prescribed therapeutic dose heparins and low dose aspirin. Without prior thrombosis a prophylactic dose is used. The most frequent obstetrical manifestation is recurrent early pregnancy loss. The association of APS antibodies with late pregnancy loss is stronger, however. Prevention of recurrence is achieved with aspirin and prophylactic dose heparin, although the evidence is of low certainty. The third obstetrical classifying manifestation comprises preterm delivery due to placenta-mediated complications and is treated in subsequent pregnancies with aspirin with or without prophylactic dose heparin, again based on low quality evidence. New therapies are under investigation.
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Affiliation(s)
- Martin Killian
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, Saint-Étienne, France.,Internal Medicine Department, Saint-Etienne University Hospital, Saint-Étienne, France
| | - Thijs E van Mens
- Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
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Abstract
The gut microbiome affects the development and progress of various types of disease such as obesity, diabetes, atherosclerosis and arterial thrombosis. Gut microbiome derived metabolites have been established to be predictive of arterial thrombosis in epidemiological studies. In these studies atherosclerosis and prothrombotic effect cannot be distinguished but preclinical studies show gut derived metabolites can induce platelet hyperreactivity and increase thrombotic potential. Gut commensals can also influence platelets through serotonin synthesis and may enhance Von Willebrand factor production. The effects on secondary haemostasis are less studied. In antiphospholipid syndrome, a thrombotic auto-immune disorder, autoreactive T cells and antibodies cross-react with auto-antigen mimicking peptides from gut commensals which appears to contribute to the pathophysiology. This review focusses on the prothrombotic effect of the gut microbiome and aims to provide insight into its influence on thromboembolic disease and the haemostatic system.
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Affiliation(s)
- Valérie Lbi Jansen
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, Netherlands.
| | - Victor Ea Gerdes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands.
| | - Saskia Middeldorp
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, Netherlands; Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Thijs E van Mens
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, Netherlands.
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Bistervels IM, Scheres LJJ, Spijker R, Middeldorp S, van Mens TE. Diagnostic tests for pregnancy-related deep vein thrombosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ingrid M Bistervels
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
| | - Luuk JJ Scheres
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
- Department of Internal Medicine; Radboud UMC; Nijmegen Netherlands
| | - René Spijker
- Cochrane Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University; Utrecht Netherlands
- Amsterdam UMC, University of Amsterdam, Medical Library, Amsterdam Public Health; Amsterdam Netherlands
| | - Saskia Middeldorp
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
| | - Thijs E van Mens
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
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Mohammed Y, Kootte RS, Kopatz WF, Borchers CH, Büller HR, Versteeg HH, Nieuwdorp M, van Mens TE. The intestinal microbiome potentially affects thrombin generation in human subjects. J Thromb Haemost 2020; 18:642-650. [PMID: 31808596 PMCID: PMC7065057 DOI: 10.1111/jth.14699] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/06/2019] [Accepted: 11/27/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The intestinal microbiome plays a versatile role in the etiology of arterial thrombosis. In venous thrombosis, driven chiefly by plasma coagulation, no such role has yet been established. We hypothesized that the intestinal microbiome composition affects coagulation in humans. METHODS We used healthy donor fecal microbiota transplant (FMT) to experimentally change the microbiome composition in metabolic syndrome patients. Thirty-five subjects were randomized in a blinded fashion to healthy donor FMT or autologous FMT as a control in a 2:1 ratio. We measured thrombin generation at baseline and after 6 weeks using automated calibrated thrombinography, and we determined plasma abundance of 32 coagulation related proteins using a targeted mass spectrometry-based quantitative proteomics assay with heavy labeled internal standards. RESULTS Healthy donor FMT prolonged the thrombinography lag time (median delta 0.0 versus 0.25 minutes, P = .039). The other thrombinography parameters showed no significant difference. Unsupervised cluster analysis suggested overall downregulation of coagulation related plasma proteins in subject clusters containing predominantly subjects that had a metabolic response to healthy donor FMT. FMT treatment status itself showed no clear clustering pattern with up- or downregulation, however, and proteins did not cluster according to an apparent biological grouping. DISCUSSION A single healthy donor FMT tends to modestly suppress the onset thrombin generation in metabolic syndrome patients, representing initial proof-of-principle that the intestinal microbiota composition might affect the coagulation system in humans. The findings merit external validation as a role for intestinal microbiota in coagulation can have clinically important implications.
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Affiliation(s)
- Yassene Mohammed
- Center for Proteomics and MetabolomicsLeiden University Medical CenterLeidenthe Netherlands
- University of Victoria‐Genome BC Proteomics CentreUniversity of VictoriaVictoriaBCCanada
- Division of Medical SciencesUniversity of VictoriaVictoriaBCCanada
| | - Ruud S. Kootte
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Wil F. Kopatz
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Christoph H. Borchers
- University of Victoria‐Genome BC Proteomics CentreUniversity of VictoriaVictoriaBCCanada
- Department of Biochemistry and MicrobiologyUniversity of VictoriaVictoriaBCCanada
- Proteomics CentreSegal Cancer CentreLady Davis InstituteJewish General HospitalMcGill UniversityMontrealQCCanada
| | - Harry R. Büller
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Henri H. Versteeg
- Department of Internal MedicineEinthoven Laboratory for Experimental Vascular MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Max Nieuwdorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
| | - Thijs E. van Mens
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Department of Vascular MedicineAmsterdam Reproduction and DevelopmentAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
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14
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van der Pol LM, Bistervels IM, van Mens TE, van der Hulle T, Beenen LFM, den Exter PL, Kroft LJM, Mairuhu ATA, Middeldorp S, van Werkhoven JM, Ten Wolde M, Huisman MV, Klok FA. Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm. Br J Haematol 2018; 183:629-635. [PMID: 30198551 PMCID: PMC6282699 DOI: 10.1111/bjh.15556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
The rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.
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Affiliation(s)
- Liselotte M van der Pol
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Thijs E van Mens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Paul L den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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15
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Groom KM, McCowan LM, Mackay LK, Lee AC, Said JM, Kane SC, Walker SP, van Mens TE, Hannan NJ, Tong S, Chamley LW, Stone PR, McLintock C. Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a history: a randomized trial. Am J Obstet Gynecol 2017; 216:296.e1-296.e14. [PMID: 28153659 DOI: 10.1016/j.ajog.2017.01.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/05/2017] [Accepted: 01/13/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Preeclampsia and small-for-gestational-age pregnancy are major causes of maternal and perinatal morbidity and mortality. Women with a previous pregnancy affected by these conditions are at an increased risk of recurrence in a future pregnancy. Past trials evaluating the effect of low-molecular-weight heparin for the prevention of recurrence of preeclampsia and small-for-gestational-age pregnancy have shown conflicting results with high levels of heterogeneity displayed when trials were compared. OBJECTIVE We sought to assess the effectiveness of enoxaparin in addition to high-risk care for the prevention of preeclampsia and small-for-gestational-age pregnancy in women with a history of these conditions. STUDY DESIGN This was an open-label randomized controlled trial in 5 tertiary care centers in 3 countries. Women with a viable singleton pregnancy were invited to participate between >6+0 and <16+0 weeks if deemed to be at high risk of preeclampsia and/or small for gestational age based on their obstetric history. Eligible participants were randomly assigned in a 1-to-1 ratio to standard high-risk care or standard high-risk care plus enoxaparin 40 mg (4000 IU) by subcutaneous injection daily from recruitment until 36+0 weeks or delivery, whichever occurred sooner. Standard high-risk care was defined as care coordinated by a high-risk antenatal clinic service, aspirin 100 mg daily until 36+0 weeks, and-for women with prior preeclampsia-calcium 1000-1500 mg daily until 36+0 weeks. In a subgroup of participants serum samples were taken at recruitment and at 20 and 30 weeks' gestation and later analyzed for soluble fms-like tyrosine kinase-1, soluble endoglin, endothelin-1, placental growth factor, and soluble vascular cell adhesion molecule 1. The primary outcome was a composite of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile. All data were analyzed on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12609000699268). RESULTS Between July 26, 2010, and Oct. 28, 2015, a total of 156 participants were enrolled and included in the analysis. In all, 149 participants were included in the outcome analysis (72 receiving standard high-risk care plus enoxaparin and 77 receiving standard high-risk care only). Seven women who miscarried <16 weeks' gestation were excluded. The majority of participants (151/156, 97%) received aspirin. The addition of enoxaparin had no effect on the rate of preeclampsia and/or small-for-gestational-age <5th customized birthweight percentile: enoxaparin 18/72 (25%) vs no enoxaparin 17/77 (22.1%) (odds ratio, 1.19; 95% confidence interval, 0.53-2.64). There was also no difference in any of the secondary outcome measures. Levels of soluble fms-like tyrosine kinase-1 and soluble endoglin increased among those who developed preeclampsia, but there was no difference in levels of these antiangiogenic factors (nor any of the other serum analytes measured) among those treated with enoxaparin compared to those receiving standard high-risk care only. CONCLUSION The use of enoxaparin in addition to standard high-risk care does not reduce the risk of recurrence of preeclampsia and small-for-gestational-age infants in a subsequent pregnancy.
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Affiliation(s)
- Katie M Groom
- Department of Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand; National Women's Health, Auckland City Hospital, Auckland, New Zealand.
| | - Lesley M McCowan
- Department of Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand; National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Laura K Mackay
- Department of Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand
| | - Arier C Lee
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Joanne M Said
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia; Department of Maternal-Fetal Medicine, Sunshine Hospital, Melbourne, Australia
| | - Stefan C Kane
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia; Pregnancy Research Center, Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia; Mercy Hospital for Women, Melbourne, Australia
| | - Thijs E van Mens
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Natalie J Hannan
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Melbourne, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Melbourne, Australia
| | - Larry W Chamley
- Department of Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand
| | - Peter R Stone
- Department of Obstetrics and Gynecology, University of Auckland, Auckland, New Zealand
| | - Claire McLintock
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
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16
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Abstract
BACKGROUND Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.
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Affiliation(s)
- Thijs E van Mens
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Luuk JJ Scheres
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mariska MG Leeflang
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
| | - Mathilde Nijkeuter
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University Medical Centre UtrechtDepartment of Internal MedicineHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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17
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ten Cate-Hoek AJ, Weitz JI, Gailani D, Meijer K, Philippou H, Bouman AC, Whitney Cheung Y, van Mens TE, Govers-Riemslag JW, Vries M, Bleker S, Biedermann JS, Stoof SCM, Buller HR. Theme 3: Non-invasive management of (recurrent) venous thromboembolism (VTE) and post thrombotic syndrome (PTS). Thromb Res 2016; 136 Suppl 1:S13-8. [PMID: 26387731 DOI: 10.1016/j.thromres.2015.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Arina J ten Cate-Hoek
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA.
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Canada
| | - David Gailani
- Vanderbilt University, Department of Pathology, Microbiology and Immunology, Nashville, USA
| | - Karina Meijer
- University of Groningen, University Medical Center Groningen, Department of Hematology, Netherlands
| | - Helen Philippou
- University of Leeds, Division of Cardiovascular and Diabetes Research, The LIGHT Labs, Leeds, UK
| | - Annemieke C Bouman
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA
| | - Y Whitney Cheung
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Thijs E van Mens
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jose W Govers-Riemslag
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Minka Vries
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Suzanne Bleker
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jossi S Biedermann
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - S Carina M Stoof
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - Harry R Buller
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
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18
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Spronk HM, Cannegieter S, Morange P, Hackeng T, Huisman M, Nagler M, Posthuma J, Ninivaggi M, Zwaveling S, van der Hulle T, Scheres LJ, van Mens TE, Mackman N. Theme 2: Epidemiology, Biomarkers, and Imaging of Venous Thromboembolism (and postthrombotic syndrome). Thromb Res 2015; 136 Suppl 1:S8-S12. [DOI: 10.1016/j.thromres.2015.07.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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