Sildenafil improves hemodynamic changes caused by acute pulmonary embolism by inhibiting Rho kinase activity

OBJECTIVE

This study examined the effects of sildenafil on acute pulmonary embolism (APE) using a rat model.

METHODS

Sprague-Dawley rats were randomly divided into the sham, pulmonary thromboembolism (PTE), and sildenafil groups. The sham and PTE groups received normal saline once daily via gavage for 14 consecutive days, whereas the sildenafil group received sildenafil (0.5 mg/kg/day) once daily via gavage for 14 consecutive days. Autologous emboli were prepared from blood samples collected from the left femoral artery of rats in each group on day 13, and autologous emboli were injected into the jugular vein cannula of rats in the PTE and sildenafil groups on day 14. Sham-treated rats received the same volume of saline. Right systolic ventricular pressure (RVSP) and mean pulmonary arterial pressure (MPAP) were used to assess pulmonary embolism, and western blotting and enzyme-linked immunosorbent assay were used to detect relevant markers.

RESULTS

The Rho kinase signaling pathway was significantly activated in rats with APE, and sildenafil significantly inhibited this activation.

CONCLUSIONS

Sildenafil protected against APE through inhibiting Rho kinase activity, thereby reducing pulmonary vasoconstriction and decreasing elevated pulmonary arterial pressure. These findings might provide new ideas for the clinical treatment of acute pulmonary thromboembolism.

Prevention of Natural Disaster-Induced Cardiovascular Diseases

Natural disasters, such as floods and landslides caused by heavy rainfall, earthquakes, and tsunamis, can induce stress, which may contribute to the onset and aggravation of various cardiovascular diseases. The circulatory system is most susceptible to the effects of stress, and stress-related cardiovascular diseases, such as Takotsubo cardiomyopathy, pulmonary thromboembolism, hypertension, stroke triggered by increased blood pressure, and acute myocardial infarction, can occur during natural disasters. The risk of developing angina pectoris, arrhythmia, sudden cardiac death, and heart failure increases rapidly and can persist for several months. Moreover, treating cardiovascular diseases is essential during the acute phase, and continuous disease management is necessary during the chronic phase. However, disaster medical care for the victims must be given priority during natural disasters, which may cause a delay in diagnosis or access to necessary treatment for pre-existing medical conditions that could worsen or may cause death in patients with cardiovascular diseases. In this review, we summarize the predisposing factors for cardiovascular diseases that have been obtained through disasters such as major earthquakes and provide potential insights to help medical staff prevent the onset and aggravation of cardiovascular diseases during disasters.

Clonal Hematopoiesis of Indeterminate Potential in Chronic Thromboembolic Pulmonary Hypertension: A Multicenter Study

BACKGROUND

The pathogenesis of chronic thromboembolic pulmonary hypertension (CTEPH) is multifactorial and growing evidence has indicated that hematological disorders are involved. Clonal hematopoiesis of indeterminate potential (CHIP) has recently been associated with an increased risk of both hematological malignancies and cardiovascular diseases. However, the prevalence and clinical relevance of CHIP in patients with CTEPH remains unclear.

METHODS

Using stepwise calling on next-generation sequencing data from 499 patients with CTEPH referred to 3 centers between October 2006 and December 2021, CHIP mutations were identified. We associated CHIP with all-cause mortality in patients with CTEPH. To provide insights into potential mechanisms, the associations between CHIP and inflammatory markers were also determined.

RESULTS

In total, 47 (9.4%) patients with CTEPH carried at least 1 CHIP mutation at a variant allele frequency of ≥2%. The most common mutations were in DNMT3A, TET2, RUNX1, and ASXL1. During follow-up (mean, 55 months), deaths occurred in 22 (46.8%) and 104 (23.0%) patients in the CHIP and non-CHIP groups, respectively (P<0.001, log-rank test). The association of CHIP with mortality remained robust in the fully adjusted model (hazard ratio, 2.190 [95% CI, 1.257-3.816]; P=0.006). Moreover, patients with CHIP mutations showed higher circulating interleukin-1β and interleukin-6 and lower interleukin-4 and IgG galactosylation levels.

CONCLUSIONS

This is the first study to show that CHIP mutations occurred in 9.4% of patients with CTEPH are associated with a severe inflammatory state and confer a poorer prognosis in long-term follow-up.

A Case Report of Urinary Tract Infection and Fungemia Due to Pichia ohmeri Complicated with Pulmonary Thromboembolism

Pichia ohmeri (P. ohmeri) is a rare human pathogen known to cause severe conditions such as sepsis, fungemia, endocarditis, and peritonitis, often resulting in high mortality rates. This report presents a case of a febrile 66-year-old male with a urinary tract infection and fungemia caused by P. ohmeri. The patient had additional complications of pulmonary thromboembolism (PTE) and deep venous thrombosis (DVT) in the left lower extremity. Notably, the pathogen was isolated in both urine and blood cultures, an uncommon finding in immunocompetent patients. Treatment with fluconazole was initiated based on the antifungal susceptibility testing (AFST) results. Following treatment, the patient experienced a gradual resolution of fever and urinary tract infection symptoms. Concurrently, anticoagulant therapy was administered for the management of PTE and DVT. The patient was eventually discharged in a stable condition.

Factors associated with thrombotic disease in dogs with renal proteinuria: A retrospective of 150 cases

BACKGROUND

Knowledge of additional risk factors for thrombotic disease (TD) among dogs with renal proteinuria is limited; these might differ for TD affecting the systemic arterial (AT), systemic venous (VT), and pulmonary circulation (PT).

HYPOTHESIS/OBJECTIVES

To compare signalment and clinicopathological data between dogs with renal proteinuria with or without TD, and between dogs with AT, VT, and PT.

ANIMALS

One hundred fifty client-owned dogs with renal proteinuria, 50 of which had TD.

METHODS

Retrospective case-controlled study. A database search (2004-2021) identified proteinuric dogs (UPC > 2) with and without TD. Clinicopathological data were obtained from the records. TD and non-TD (NTD) groups were compared by binary logistic regression, and AT, VT, and PT groups by multinomial regression. Normal data presented as mean ± SD, non-normal data presented as median [25th, 75th percentiles].

RESULTS

Cavalier King Charles Spaniels were overrepresented in the TD group (OR = 98.8, 95% CI 2.09-4671, P = .02). Compared to NTD cases, TD cases had higher concentration of neutrophils (11.06 [8.92, 16.58] × 109 /L vs 7.31 [5.63, 11.06] × 109 /L, P = .02), and lower concentration of eosinophils (0 [0, 0.21] × 109 /L vs 0.17 [0.04, 0.41] × 109 /L, P = .002) in blood, and lower serum albumin (2.45 ± 0.73 g/dL vs 2.83 ± 0.73 g/dL, P = .04). AT cases had higher serum albumin concentrations than VT cases (2.73 ± 0.48 g/dL vs 2.17 ± 0.49 g/dL, P = .03) and were older than PT cases (10.6 ± 2.6 years vs 7.0 ± 4.3 years, P = .008). VT cases were older (9.1 ± 4.2 years vs 7.0 ± 4.3 years, P = .008) and had higher serum cholesterol concentration (398 [309-692 mg/dL] vs 255 [155-402 mg/dL], P = .03) than PT cases.

CONCLUSIONS AND CLINICAL IMPORTANCE

Differences between thrombus locations could reflect differences in pathogenesis.

The relationship between echocardiographic parameters and albumin bilirubin score in patients with acute pulmonary thromboembolism

PURPOSE

The Albumin-Bilirubin (ALBI) score is useful and easy-to-use for objectively assessing liver function. We investigated whether the ALBI score, a parameter indicating liver stiffness, congestion and fibrosis, has any relationship with echocardiographic parameters in patients with acute pulmonary thromboembolism (PTE).

MATERIAL AND METHODS

A total of 140 patients diagnosed with acute PTE were retrospectively analyzed. These patients were divided into three groups according to the hemodynamic severity of acute PTE: Group I [Low risk]; Group II [Submassive or intermediate-risk]; and Group III [Massive or high-risk]. Biochemical data obtained from venous blood samples taken at admission were analyzed. In addition, data were also analyzed from transthoracic echocardiography and pulmonary computed tomographic angiography performed at admission. ALBI, Bova, and PESI scores were calculated.

RESULTS

ALBI scores (-3.32 ± 0.21 vs -2.86 ± 0.15 vs -2.46 ± 0.2, p < .001) were statistically significantly higher in Group III than Groups I and II. There was a significant difference between the three groups in terms of echocardiographic parameters, and LVEF and TAPSE values tended to decrease from group I to group III. In multivariate linear regression analysis, sPAP, RV/RA diameter, and NT-pro-BNP were found to be significantly associated with the ALBI score. An ALBI score higher than -2.87 was associated with Bova stage II-III in patients with Group I and Group II PTE, with a sensitivity of 87% and a specificity of 62% (AUC = 0.804; 95% CI 0.713-0.895; p < .001).

CONCLUSION

The ALBI score, which is a common, easy-to-use, and inexpensive method, may be beneficial to select intermediate and high-risk patients in patients with acute PTE. Additionally, it may have prognostic value in distinguishing low and intermediate-risk acute PTE patients.

Incidence and Distribution of Deep Vein Thrombosis Following Total Hip Arthroplasty Using an Anterolateral Supine Approach

Purpose

Venous thromboembolism (VTE) is a potential major complication in patients undergoing total hip arthroplasty (THA). However, the incidence of VTE following THA using anterolateral supine approach (ALS) has not been reported. The purpose of this study was to investigate the incidence of perioperative VTE and the distribution and characteristics of deep vein thrombosis (DVT) following ALS THA.

Patients and Methods

This retrospective single-arm study analyzed the 182 consecutive hips of 164 patients who underwent primary ALS THA. Pharmacological prophylaxis consisted of enoxaparin 20 mg twice daily for approximately 6 days starting 24 h postoperatively until duplex ultrasonography was performed to determine whether postoperative DVT was present. DVT was assessed by whole-leg Doppler ultrasound, and the location and characteristics of any thrombus were recorded. If pulmonary thromboembolism was suspected, contrast-enhanced computed tomography was performed.

Results

The overall incidence of VTE was 9.9% for DVT (18/182 hips) and 0.5% for pulmonary thromboembolism (1/182 hips). Most DVTs were in the soleal vein on the affected side and showed isoechoic or hypoechoic echogenicity. All thrombi were non-floating.

Conclusion

Following ALS THA with standard pharmacological prophylaxis and an early weight-bearing protocol, the incidence of perioperative DVT was approximately 10%, mostly occurring in the lower leg.

Pulmonary thromboembolism as a rare complication of Plasmodium vivax malaria: A case report

Key Clinical Message

Low threshold is required to suspect complications of Plasmodium vivax malaria. Pulmonary thromboembolism, though rare, should be considered as its complication in the presence of unexplained and sudden onset shortness of breath.

Abstract

The hypercoagulable complications of malaria typically manifest in the microvasculature. However, there are several cases of intracranial venous thrombosis caused by Plasmodium falciparum and Plasmodium vivax malaria, and there was one case report of pulmonary thromboembolism (PTE) due to P. falciparum. A 30-year-old Ethiopian male patient presented with sudden onset of shortness of breath for 3 days. He had also high-grade fever, chills, and rigors associated with loss of appetite and fatigue of similar duration. He was from malaria endemic area. He had a pulse rate of 108 beats per minutes, respiratory rate of 32 breaths per minute, oxygen saturation of 82% with atmospheric air and temperature of 38.9°C. Further examination revealed accentuation of pulmonary component of second heart sound. Complete blood count revealed mild anemia and peripheral blood film showed trophozoites of P. vivax. Pulmonary CT angiography showed filling defects in the right and left pulmonary arteries. The patient was diagnosed to have P. vivax malaria complicated by PTE. He was managed with intranasal oxygen, antimalarial agent, and anticoagulation. Upon serial evaluations on the third week and second month of follow up, he did not have complaints and physical examination was non-remarkable. Malaria is a protozoan disease with high mortality and morbidity. For a long time, severe cases of malaria were thought to be mostly caused by P. falciparum. However, recent evidences have shown a paradigm shift and we should remember that P. vivax can also cause severe malaria and this can be complicated by hypercoagulable conditions including PTE.

[Pulmonary Artery Intimal Sarcoma Involving the Peripheral Pulmonary Artery, Initially Misdiagnosed as Pulmonary Artery Thromboembolism and Vasculitis: A Case Report]

Pulmonary artery sarcomas are rare, high-grade malignancies, primarily affecting the proximal elastic pulmonary artery and usually manifesting as tumoral impaction on imaging. Due to similar clinical and imaging findings, pulmonary artery sarcomas are frequently misdiagnosed as pulmonary thromboembolism or, occasionally, as vasculitis. Herein, we reported a case of pulmonary artery intimal sarcoma initially misdiagnosed as pulmonary thromboembolism and vasculitis due to its relatively atypical location and morphology, along with a literature review.

AI-Driven Decision Support for Early Detection of Cardiac Events: Unveiling Patterns and Predicting Myocardial Ischemia

Cardiovascular diseases (CVDs) account for a significant portion of global mortality, emphasizing the need for effective strategies. This study focuses on myocardial infarction, pulmonary thromboembolism, and aortic stenosis, aiming to empower medical practitioners with tools for informed decision making and timely interventions. Drawing from data at Hospital Santa Maria, our approach combines exploratory data analysis (EDA) and predictive machine learning (ML) models, guided by the Cross-Industry Standard Process for Data Mining (CRISP-DM) methodology. EDA reveals intricate patterns and relationships specific to cardiovascular diseases. ML models achieve accuracies above 80%, providing a 13 min window to predict myocardial ischemia incidents and intervene proactively. This paper presents a Proof of Concept for real-time data and predictive capabilities in enhancing medical strategies.

Predictive value of hematological indices on incidence and severity of pulmonary embolism in COVID-19 patients

BACKGROUND

Pulmonary thromboembolism (PTE) is a common complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which raises the COVID-19 disease's fatality rate from 3% to 45%. Nevertheless, due to fairly indistinguishable clinical symptoms and a lack of validated clinical prediction models, PTE diagnosis in COVID-19 patients is challenging. This study aims to investigate the applicability of hematological indices to predict PTE incidence and its severity in SARS-CoV-2 patients.

METHODS

A retrospective cohort study was conducted on hospitalized patients with a confirmed diagnosis of SARS-CoV-2 infection who underwent CT angiography to assess probable PTE in them. The correlation between complete blood count parameters 1 day before CT angiography and CT angiography outcomes, and simplified pulmonary embolism severity index (s-PESI) was investigated.

RESULTS

We discovered that among individuals with a probable PTE, males and those with higher platelet-to-lymphocyte (PLR) and neutrophil-to-lymphocyte (NLR) ratios had a greater likelihood of PTE incidence (p < .001, .027, and .037, respectively). PLR was a significant and independent predictor of PTE with a p value of .045. Moreover, a higher neutrophil count was associated with a higher s-PESI score in COVID-19 patients developing PTE (p: .038).

CONCLUSIONS

Among hematological indices, NLR and more precisely PLR are cost-effective and simply calculable markers that can assist physicians in determining whether or not COVID-19 patients with clinically probable PTE require CT angiography and the higher neutrophil count can be employed as an indicator of PTE severity in COVID-19 patients. Further large multicenter and prospective studies are warranted to corroborate these observations.

Venous thromboembolism in orthopedic surgery: Global guidelines

Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM.

A pharmacovigilance study of the association between antipsychotic drugs and venous thromboembolism based on Food and Drug Administration Adverse Event Reporting System data

BACKGROUND

This study aimed to measure and present a comprehensive overview of the association of antipsychotic drugs and venous thromboembolism (VTE) in the Food and Drug Administration Adverse Event Reporting System (FAERS). Method: All VTE cases treated with antipsychotic drugs as primary suspected medicines were extracted from the FAERS database from 2004 to 2021. Disproportionality analyses were conducted by estimating the reporting odds ratio (ROR) and the information component (IC).

RESULTS

In the FAERS system, 4,455 VTE cases associated with antipsychotics were identified. The VTE signal was detected with olanzapine, haloperidol, paliperidone, and quetiapine. The RORs and 95% confidence intervals (95% CI) of olanzapine, haloperidol, paliperidone, and quetiapine were (ROR = 2.53 95% Cl 2.38-2.69 IC = 1.31 95% Cl 1.11-1.52), (ROR = 2.17 95% Cl 1.91-2.46 IC = 1.1 95% Cl 0.66-1.52), (ROR = 1.6 95% Cl 1.4-1.83 IC = 0.67 95% Cl 0.22-1.11), and (ROR = 1.37 95% Cl 1.28-1.47 IC = 0.45 95% Cl 0.23-0.67). Pulmonary embolism occurred in more than 50% of VTE events (2760 cases, 52.84%).

CONCLUSION

The data mining of FAERS suggested an association between VTE and antipsychotic drugs, which reminds medical workers to pay attention to the serious adverse drug effects of antipsychotic drugs leading to venous thromboembolism.

Case report: Granzyme-B expression by T- and B- cells during severe AQP4-positive Neuromyelitis Optica spectrum disorder with fatal venous thromboembolism outcome

Background

The expression of serine protease granzyme-B (GzmB) by circulating CD8+ T lymphocytes has been recently suggested as a biomarker for poor immunotherapy response and severe disability in patients with Neuromyelitis Optica spectrum disorders (NMOSD). In parallel, venous thromboembolism (VTE) has been reported mainly in NMOSD patients exhibiting transverse myelitis.

Case presentation

Here, we describe an Aquaporin-4 positive (AQP4-positive) NMOSD patient who showed short myelitis (SM) and experienced a fatal pulmonary thromboembolism/lower extremity deep vein thrombosis during anti-CD20 treatment. Flow cytometry analyses from the peripheral blood revealed an enhanced cytotoxic behavior through circulating CD8+GzmB+ T, CD4+GzmB+ T lymphocytes, and residual CD19+GzmB+ B cells.

Conclusions

Fatal VTE may be a rare outcome, particularly in patients exhibiting SM, and may share poorly understood immunological mechanisms with AQP4-positive NMOSD severity.

Lung iodine mapping images of acute postpartum dyspnea without pulmonary thromboembolism using dual-energy CT

BACKGROUND

Postpartum dyspnea is commonly observed, but its cause is often unknown.

PURPOSE

To investigate postpartum dyspnea, we compared lung iodine mapping (LIM) using dual-energy computed tomography (DECT) between postpartum women and women suspected of having pulmonary thromboembolism (PTE).

MATERIAL AND METHODS

In this retrospective study, 109 women of reproductive age (50 postpartum women, 59 women unrelated to pregnancy) underwent DECT between March 2009 and August 2020. Among the postpartum women, 23 patients were excluded due to late-onset dyspnea (n=20: >48 h after delivery) or the presence of PTE (n=3). A total of 86 patients were divided into three groups (27 postpartum women [postpartum group], 19 women with PTE [PTE group], and 40 women without PTE [non-PTE group]). Quantitation was applied to a decreased LIM value (LIM5; defined as <5 HU) and the relative value of LIM5 to whole LIM volume (%LIM5). LIM defects were classified into five patterns (0 = none, 1 = wedge-shaped, 2 = reticular/liner, 3 = diffuse granular/patchy, 4 = massive defects) based on a consensus between two readers.

RESULTS

There were significant differences in the LIM5 and %LIM5 values among the three groups. The LIM5 and %LIM5 were largest in the PTE group, and postpartum women showed intermediate values between the non-PTE and PTE groups. Wedge-shaped defects were prominent in the PTE group, and diffuse granular/patchy defect was a typical feature in the postpartum group.

CONCLUSION

Postpartum women with dyspnea showed granular/patchy defects on DECT with a median quantitative value between the PTE and non-PTE groups.

Use of direct oral anticoagulants and low molecular weight heparin in venous thromboembolism associated with cancer: real-world evidence in Argentina

BACKGROUND

Venous thromboembolism (VTE) and major bleeding (MB) are common in cancer patients. Reduced-doses of antithrombotics as secondary prophylaxis have limited data. This work aims to describe and to compare treatments and outcomes for cancer-associated VTE.

RESEARCH DESIGN AND METHODS

Retrospective study. Adults with cancer-associated VTE were included. After 3-6 months of full-doses of anticoagulants, three strategies were considered: A) lowering the doses; B) maintaining full-doses; C) stopping treatment. The strategy and medication used were shown in a descriptive analysis and the rate of bleeding and VTE-recurrence between those in a comparative analysis.

RESULTS

A total of 420 patients were included, 56.2% received DOACs, 43.8% enoxaparin. Strategy was defined in 257 patients: A (50.2%), B (46.3%), and C (3.5%). Forty-one (9.8%) had VTE-recurrence and 15 (3.6%) had MB or clinically relevant non-major bleeding (CRNMB).According to strategy, recurrent-VTE was 8.5% (A), 4.2% (B), and 11.1 (C) (p = 0.22), MB or CRNMB was 0.8% (A), 1.7% (B), and 0% (C) (p = 0.64).

CONCLUSIONS

DOACs and strategy A were the most frequently used agent and strategy, respectively. There were no differences between medications or strategies used. The results must be interpreted with caution, and it is a retrospective single-center study, probably with information and selection bias.

Pulmonary Microcirculation in Experimental Model of Pulmonary Thromboembolism after Pretreatment with Chloroquine

Changes of pulmonary microcirculation in response to pulmonary artery embolization after pretreatment with chloroquine were studied on the model of isolated perfused rabbit lungs. The increase in the pulmonary vascular resistance and pre- and postcapillary resistance was less pronounced than after pulmonary thromboembolism after pretreatment with mibefradil (T-type Ca2+ channels blocker) or nifedipine (L-type Ca2+ channels blocker). The shifts of capillary filtration coefficient correlated with changes in the precapillary resistance. When modeling pulmonary thromboembolism after pretreatment with chloroquine combined with glibenclamide (KATP channels blocker), the studied hemodynamics parameters increased to the same extent as after pretreatment with nifedipine. The results indicate that chloroquine exhibits the properties of an L- and T-type Ca2+ channels blocker and an activator of KATP channels.

Case of intraoperative acute pulmonary embolism diagnosed by transesophageal echocardiography under general anesthesia and successfully managed with extracorporeal membrane oxygenation

Acute pulmonary thromboembolism (PTE), which carries a high mortality rate, is difficult to diagnose when it occurs intraoperatively. Therefore, patient prognosis depends on a prompt diagnosis by anesthesiologists. A 49-year-old woman underwent right lower extremity dissection due to a contusion of the right lower extremity caused by trauma. Eleven days after surgery, she underwent debridement for necrosis of the amputation wound. Intraoperatively, a drop in blood pressure and tachycardia were observed, and PTE was suspected based on a rapid deterioration in oxygen saturation and a drop in end-tidal carbon dioxide partial pressure. Transesophageal echocardiography (TEE) showed a thrombus filling the right pulmonary artery, and a diagnosis of PTE was made. The patient was treated using venoarterial extracorporeal membrane oxygenation, and thrombectomy was performed the next day to save her life. In this case, we were able to diagnose and treat the intraoperative acute PTE at an early stage. In addition, the appropriate choice of treatment saved the patient's life without complications.

Covishield vaccination and pulmonary thromboembolism: A coincidence or a causal association?

With the eruption of COVID pandemic, many cases of thromboembolic events in association with the COVID infection were reported suggesting the prothrombotic state associated with the infection. After a few years, eventually some of the COVID vaccines came into implementation. With the discovery and implementation of COVID vaccinations, a very few cases have been reported to have developed thromboembolic events, including pulmonary thromboembolism. Different types of vaccines have been associated with different rates of thromboembolic events. Covishield vaccine is rarely associated with thrombotic complications. In the case report below, we present a case summary of a young married female, who presented with shortness of breath a week after the Covishield vaccination and presented to our tertiary care center with further worsening of symptoms during a course of 6 months. On detailed workup, she was diagnosed to have a large pulmonary thrombus affecting the left main pulmonary artery. Other possible etiologies of the hypercoagulable states were ruled out. Though COVID vaccines are known to induce prothrombotic state in the body, we could not be sure if it was the actual cause for the pulmonary thromboembolism or just a coincidence.

Correlation between Pulmonary Embolism and Sleep Apnea

Introduction

It has been shown that there is a correlation between Obstructive Sleep Apnea Syndrome (OSAS) and pulmonary thromboembolism (PTE); OSAS is a risk factor for PTE. We aimed to evaluate the frequency of OSAS in PTE patients, the correlation of OSAS with the severity of PTE, and its effect on 1-month mortality in PTE patients.

Methods

This single-center, prospective, comparative case control study contains 198 patients diagnosed with non-massive PTE in our hospital between the dates of 01/07/2018-04/01/2020 who were confirmed by imaging methods. Daytime sleepiness was assessed with Epworth questionnaires, and OSAS risk was assessed with Berlin, STOP, STOP-BANG sleep questionnaires. Alongside demographic and clinical data, comorbidities, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), WELLS scores, troponin, D-dimer values, echocardiyography (ECHO) findings were also examined. Epworth, Berlin, STOP, STOP-BANG sleep groups were compared in terms of PTE parameters.

Results

A hundred and thirty-eight patients (69.6%) was assesed as high risk group according to Berlin, meanwhile STOP-BANG defined 174 patients (87.8%), furthermore STOP has considered 152 patients in the high risk group (76.7%) and Epworth questionnaire determined this number as 127 (64.1%). As a result of the logistic regression analysis, statistically significant correlation was found between Berlin score and heart failure, PESI, sPESI and troponin values; between Epworth score and WELLS score; between STOP-BANG score and PESI score (p<0.05). During the 1-month follow-up period, 9 of the patients were exitus and mortality was 4.5%.

Conclusion

OSAS risk is more common in patients with PTE and it may be a risk factor for PTE. It has been shown that the risk of OSAS may aggravate PTE severity and prognosis.

Effect of Anticoagulants in Pulmonary Thromboembolism in Post-COVID-19 Patients

Background and objective COVID-19 may predispose to both venous and arterial thromboembolism (VTE and ATE) due to excessive inflammation, immobilization, and hypoxia. The purpose of this study is to evaluate clinical and laboratory risk factors, as well as related medications such as anticoagulants, to predict the risk of thromboembolic disease and/or death in COVID-19 patients. Methods Over a period of 14 months (from August 2020 to September 2021), a total of 145 consecutive patients with signs and symptoms suspicious of pulmonary embolism (PE) were referred for perfusion single-photon emission computed tomography/computed tomography (Q SPECT/CT). All patients had a history of SARS‑CoV‑2 infection, diagnosed with a positive real-time polymerase chain reaction (RT-PCR) test. Results Among the 145 patients included in the study, the risk of PE was found to be greater in elderly patients (odds ratio [OR] [95% CI]: 1.05 [1.02‑1.07]; p<0.001) and in patients with higher maximum d-dimer levels (OR [95% CI]: 1.14 [1.01‑1.3]; p=0.04). We also analyzed the utility of the maximum d-dimer level for predicting acute PE with receiver operating characteristic (ROC) curve analysis. For d‑dimer = 0.5 mg/dL, cut-off sensitivity is 91%, specificity is 23%, and for d-dimer = 1 mg/dL, cut-off sensitivity is 79%, specificity is 43% Conclusion D-dimer titers were higher in the PE group in our study. Another significant finding was that, possibly due to thromboinflammation, anticoagulants did not prevent the development of PE in COVID-19 patients.

Lung Ventilation-Perfusion Scan in COVID-19: Various Patterns of Perfusion Defects

ABSTRACT

Although COVID-19 infection is associated with the increased risk of pulmonary thromboembolism (PTE), COVID-19 pulmonary lesions cause ventilation-perfusion (V/Q) patterns other than PTE. Although extensive research has been done to address different anatomical patterns of COVID-19, there is a knowledge gap in terms of V/Q lung scintigraphy in these patients. The purpose of this study is to demonstrate these patterns and to show how important it is to use SPECT/CT in addition to planar images to differentiate between these patterns from PTE. In the current collection, we presented various patterns of V/Q SPECT/CT abnormalities in COVID-19 patients.

Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy

INTRODUCTION

Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy.

METHODS

We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain.

RESULTS

Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1).

CONCLUSIONS

Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.

Clinical value of deep vein thrombosis density on lower-extremity CT venography: prediction of pulmonary thromboembolism

AIM

Diagnosis of pulmonary thromboembolism (PTE) can be delayed if the signs and symptoms of patients are nonspecific.

INTRODUCTION

To assess the clinical value of deep vein thrombosis (DVT) density on computed tomography (CT) venography for predicting PTE.

METHOD

From 2016 to 2021, patients with DVT diagnosed on lower-extremity CT venography were included. Of these patients, those without PTE were classified into 'DVT-only group' and those with PTE were classified into the 'DVT with PTE group'. The DVT Hounsfield unit (HU) density was measured by drawing free-hand region-of-interests within the thrombus at the most proximal filling defect level. The risk factors associated with PTE were identified by using multivariate logistic regression analysis. A receiver operating characteristic (ROC) analysis was used to evaluate the value of DVT density for predicting the risk of PTE.

RESULTS AND DISCUSSION

This study included 177 patients with a mean age of 41.7 ± 10.3 years (DVT-only group: 105 patients; DVT with PTE group: 72 patients). DVT density was significantly higher in DVT with the PTE group than DVT-only group (66.8HU ± 8.7 vs. 57.9HU ± 11.1, p < 0.001). The ROC analysis revealed that the area under the curve (AUC), sensitivity, and specificity for predicting the risk of PTE were 0.737, 72.2%, and 66.7%, respectively, at a DVT density cutoff of 63.0 HU. On univariate and multivariate analysis, DVT density was the only significant risk factor associated with PTE.

CONCLUSION

Higher DVT density was a significant risk factor for PTE. In addition, DVT density could be a predictive factor for PTE.

Effectiveness of Fondaparinux in the Japanese Population with Acute Venous Thromboembolism -A Study Comparing Patients with and without Cancer

Objective Venous thromboembolism (VTE) is a common cancer complication. Patients with cancer have a high risk of recurrent VTE and bleeding. We analyzed the effectiveness of VTE treatment via subcutaneous fondaparinux injection for patients with and without cancer. Methods This study included 260 inpatients who had received fondaparinux therapy. Fondaparinux's therapeutic effect was quantitatively and qualitatively evaluated by imaging tests. To quantitatively evaluate the deep vein thrombosis (DVT) clot burden of the lower limbs, we calculated the quantitative ultrasound thrombosis (QUT) score, which was devised by our institution. Results There were 80 and 180 patients with and without cancer, respectively. The QUT score significantly reduced after treatment in both groups (cancer: 6.70±4.37 vs. 4.19±4.17, p<0.001; noncancer: 7.08±4.37 vs. 4.17±3.94, p<0.001). The changes in the QUT score showed no significant difference between the 2 groups (cancer: 2.23±3.09; noncancer: 3.04±3.45, p=0.06). In addition, the quantitative evaluation of pulmonary thromboembolism (PTE) after treatment showed that PTE decreased or disappeared in 38/40 patients (95.0%) in the cancer group and 55/63 patients (87.3%) in the noncancer group, indicating no significant difference in the improvement rate between the groups. Conclusion Fondaparinux was effective for VTE both in patients with and without cancer, with no significant differences in the changes in the QUT score. However, the change in the QUT score was smaller in patients with cancer than in those without cancer, suggesting that the efficacy of fondaparinux might be diminished in patients with cancer.

Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism

Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.

Comparison of CT Values between Thrombus and Postmortem Clot Based on Cadaveric Pulmonary Angiography

OBJECTIVES

To explore the difference in CT values between pulmonary thromboembolism and postmortem clot in postmortem CT pulmonary angiography (CTPA) to further improve the application value of virtual autopsy.

METHODS

Postmortem CTPA data with the definite cause of death from 2016 to 2019 were collected and divided into pulmonary thromboembolism group (n=4), postmortem clot group (n=5), and control group (n=5). CT values of pulmonary trunk and left and right pulmonary artery contents in each group were measured and analyzed statistically.

RESULTS

The average CT value in the pulmonary thromboembolism group and postmortem clot group were (168.4±53.8) Hu and (282.7±78.0) Hu, respectively, which were lower than those of the control group (1 193.0±82.9) Hu (P<0.05). The average CT value of the postmortem clot group was higher than that of the pulmonary thromboembolism group (P<0.05).

CONCLUSIONS

CT value is reliable and feasible as a relatively objective quantitative index to distinguish pulmonary thromboembolism and postmortem clot in postmortem CTPA. At the same time, it can provide a scientific basis to a certain extent for ruling out pulmonary thromboembolism deaths.

Cerebellar infarction risk in a mild COVID-19 case

Thrombotic events in SARS-COV-2 disease patients are frequent, especially in patients with comorbidities such as heart failure, hypertension, cancer, diabetes mellitus, kidney failure, vascular disease, and other pulmonary illnesses. In severe cases, in particular those of hospitalized patients with other comorbidities, the development of thrombotic events in spite of anticoagulation therapy has been observed. The main thrombotic events are pulmonary thromboembolism, cerebral ischemic stroke, and peripheral artery thrombosis. Despite the severity of SARS-COV-2 disease, some patients with the aforementioned comorbidities develop thrombotic events regardless of the severity of their SARS-COV-2 infection. In this setting, the cerebellum makes no exception as an uncommon, but still possible target for thrombotic events.

Significance of Clinico-radiological Correlation in a Patient with Pulmonary Intimal Sarcoma Simulating as Pulmonary Thromboembolism

Pulmonary intimal sarcoma (PAS) is a highly aggressive malignant mesenchymal tumor affecting the central pulmonary arteries. Similar clinical presentation and indeterminate laboratory parameters often result in misdiagnosis of this condition as pulmonary thromboembolism, which is a relatively common disease. Certain imaging features can however allow differentiation between these two diagnoses. We present one such case of PAS that was initially treated as pulmonary embolism; and briefly review the relevant imaging characteristics to avoid overlooking PAS especially in patients with an atypical clinical history for thromboembolism.

The association between glycemia and clinical outcomes in patients with diabetes mellitus and pulmonary thromboembolism

Objective

Various studies have shown that diabetes mellitus (DM) increases the risk of thrombosis in the venous system as well as in the arterial system. In this study, it was aimed to evaluate the association between admission blood glucose levels and clinical severity, recurrence, and mortality in pulmonary embolism in patients with DM.

Materials and methods

This study was designed as a retrospective cross-sectional study. Patients with DM who were admitted to a tertiary care hospital due to pulmonary embolism (PE) between 2014 and 2019 were included. Demographic characteristics, radiological findings, clinical class of embolism, and mortality data were retrieved from hospital records. Patients with and without recurrent disease, as well as patients who survived and died, were compared. Also, patients were classified according to quartiles of admission blood glucose levels. The quartiles were compared in terms of mortality, clinical, class, and recurrence.

Results

Two hundred ninety-three patients with DM and PE were included in the study. Patients with adverse outcome had significantly higher admission blood glucose levels (respectively, 197.9 ± 96.30 mg/dL vs. 170.7 ± 74.26 mg/dL; p = 0.03). Patients in the third and fourth quartile of admission blood glucose levels (>152 mg/ dL) had significantly more severe disease with a higher proportion of massive and sub-massive PE and higher pro-BNP levels (respectively, p = 0.01 and 0.02).

Conclusion

Non-survived patients and recurrent disease were associated with higher admission blood glucose levels. Also, patients with admission blood glucose levels higher than 152 mg/dL tend to have clinically more severe diseases.

Profile of Solid Tumor Patients Complicated With Venous Thromboembolism: A 10-Year Retrospective Cross-Sectional Study Based on 1482 Cases

The aim of this single-centre 10-year retrospective observational study was to evaluate the profile of Chinese cancerous patients complicated with venous thromboembolism (VTE) based on demographic features, clinical characteristics, and medication exposure. Consecutive 1482 patients with solid tumor complicated with VTE at a tertiary center between 2012 and 2021 were retrospectively enrolled. Data were collected on demographics, comorbidities, discharge diagnoses, laboratory examination data, treatment details, and imaging description of the lesion. The overall incidence of clinical VTE was 1.35% in hospitalized patients with cancer in our center. Lung cancer was the most frequent tumor subtype for developing VTE events, accounting for 24.83% of all cases. Over half of the patients (66.60%) were observed to have an increased risk of VTE within the first 6 months of cancer diagnosis. Close to half of the patients (46.49%) had received chemotherapy within 6 months prior to the diagnosis of VTE. The frequency of massive ascites group (＞2000 mL) in gynecological patients with VTE was significantly larger than that of nonmassive ascites group (≤2000 mL) (P < .001). Patients with ovarian, vulvar, lung cancers were considered at high risk for VTE. The assessment and monitoring of VTE in patients with cancer within the first 6 months of cancer diagnosis should be strengthened. VTE occurrence was closely related to advanced age and stage, adenocarcinoma, obesity and noval anticancer therapies in patients with cancer. Early detection of VTE-related examination may lead to earlier intervention for patients with gynecological tumors with preoperative massive ascites.

Point-of-care transthoracic echocardiography: An essential management tool for acute massive pulmonary thromboembolism

The pulmonary thromboembolism may be a life-threatening condition. A hip fracture surgery patient aged >90 years old had a sudden post-operative episode of shock, de-saturation, and reverted cardiac arrest. A point-of-care transthoracic echocardiography (TTE) undertaken by an anesthesiologist revealed inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end-systole, indicating a high ejection fraction in the context of obstructive shock. As such, it revealed signs of pulmonary thromboembolism. Despite the absolute contraindication for thrombolysis and therapeutic hypocoagulation, the treatment was started immediately along with vasopressor support, which was life-saving in this patient. A summary TTE played a pivotal role in our patient's case, helping with the differential diagnosis of the cause of shock.

Improved Oral Health Status Is Associated with a Lower Risk of Venous Thromboembolism: A Nationwide Cohort Study

Oral health is reportedly associated with several systemic diseases, particularly cardiovascular diseases, through systemic inflammatory and thrombotic mechanisms. This study aimed to investigate the association between oral health status, oral hygiene behavior, and venous thromboembolism (VTE) in a nationwide, population-based cohort database in a longitudinal setting. Data of participants who underwent oral health screening by dentists between January and December 2003 (n = 2,415,963) were retrieved from the National Health Insurance Database of the Korean National Health Insurance Service. Periodontitis was identified using claims or oral health screening data. Periodontal pockets and the number of missing teeth were examined by dentists during oral health screenings. Data on oral hygiene behaviors (tooth brushing, dental visits, and dental scaling) were collected. VTE was defined as two or more claims of one of the following ICD-10 codes: deep (I80.2−80.3), pulmonary (I26, I26.0, I26.9), intra-abdominal (I81, I82, I82.2, I82.3), and other (I82.8, I82.9) VTE and concurrent medication (anticoagulants and antiplatelets). VTE was analyzed using the Cox proportional hazard model according to periodontitis, number of missing teeth, tooth brushing frequency, dental visits, and dental scaling. VTE occurred in 39,851 (1.8%) participants within a median of 17.0 (interquartile range 16.3−17.7) years. Periodontitis was associated with VTE (adjusted hazard ratio (HR), 1.2; 95% confidence interval (CI), 1.15−1.28; p < 0.001). An increased number of missing teeth was associated with an increased risk of VTE; the adjusted HR (versus participants without missing teeth) was 1.58 (95% CI, 1.46−1.71; p < 0.001, p for trend < 0.001) for participants with ≥15 missing teeth. Furthermore, tooth brushing ≥3 times a day was negatively correlated with VTE (adjusted HR, 0.67; 95% CI, 0.65−0.69; p < 0.001, p for trend < 0.001). Dental scaling within one year was associated with a significantly lower risk of VTE (adjusted HR, 0.95; 95% CI, 0.93−0.98; p < 0.001). Improved oral hygiene, including tooth brushing and dental scaling, may be associated with a decreased risk of VTE. Periodontitis and an increased number of missing teeth may increase the risk of VTE.

A rare presentation of pulmonary thromboembolism as seizure

Acute pulmonary thromboembolism is a critical and sometimes fatal event that is difficult for clinicians to diagnose because of its various initial manifestations. Here, we report a previously healthy 50-year-old man without any history of seizures who presented to the emergency ward with the new-onset seizure. Neurology consult was performed, but found no focal neurological deficits. The diagnosis of massive pulmonary embolism was confirmed by echocardiography and pulmonary CT angiography. Alteplase and heparin with therapeutic dosage were started for the patient. After initiating treatment, patient's dyspnea, arterial O2 saturation, and general condition were significantly improved. Echocardiography was repeated and showed a smaller right ventricle size and lower pulmonary artery pressure than the first echocardiography.

Lower limb arterial thrombosis followed by sub-massive pulmonary thromboembolism after Sinopharm BBIBP-CorV COVID-19 vaccination

The global COVID-19 vaccination had an undeniable influence on the pandemic management, despite of having reported rare but life-threatening side-effects of vaccines. Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare autoimmune complication determined by thrombocytopenia and thrombosis propensity in the circulatory system. The activation of antibodies against platelet factor-4 (PF-4) which mimics the heparin-induced thrombocytopenia (HIT) characteristic is the main known pathogenicity of the disease. Herein, we reported a case of VITT in a middle-aged woman with no previous history of thrombophilia or other medical conditions who presented with thrombosis of the left superficial femoral artery 3-days after receiving the second dose of inactivated BBIBP-CorV (Sinopharm) vaccine. The patient underwent bypass vascular surgery and received none-heparin anticoagulation consistent with high-dose intravenous immunoglobin. Eight days after the discharge, she was subsequently referred to our center with the presentation of sub-massive pulmonary thromboembolism in spite of receiving the prophylactic anticoagulants during follow-up period. Details on side-effects of COVID-19 vaccines, specifically the inactivated ones are yet to be fully ascertained. Clinicians should consider the history of COVID-19 vaccines in thromboembolism patients who do not have well-acknowledged risk factors. Further studies about the necessity of prophylactic anticoagulants and clinical judgment for receiving other vaccines in such patients are required.

Deep Venous Thrombosis and Pulmonary Thromboembolism Associated With Retroperitoneal Hematoma in a Patient With Ehlers-Danlos Syndrome Type VI

Ehlers-Danlos Syndrome (EDS) is a group of genetic diseases of the connective tissue, which is rare and is characterized by joint hypermobility, tissue, and vascular fragility. We present the case of a 38-year-old woman with a known diagnosis of EDS type VI who came to the emergency room, complaining of sudden dyspnea in the context of abdominal pain and pain in the left lower limb with one week of evolution. Computed axial tomography showed the presence of bilateral pulmonary thromboembolism, iliofemoral thrombosis, and a retroperitoneal hematoma. Anticoagulation was started and the patient was admitted to the intermediate care ward. This case highlights the need to know the implications of increased vascular fragility in type VI EDS, with potentially serious consequences. Underlying is the inevitable need for judicious consideration of the decision to undergo anticoagulation, in the context of a retroperitoneal hemorrhagic event and pulmonary thromboembolism.

Analysis of Prior Aspirin Treatment on in-Hospital Outcome of Geriatric COVID-19 Infected Patients

Background and Objectives: Aspirin (ASA) is a commonly used antithrombotic drug that has been demonstrated to reduce venous thromboembolism. The aim was to analyze if geriatric COVID-19 patients undergoing a 100 mg/day Aspirin (ASA) treatment prior to hospitalization differ in hospital outcome compared to patients without previous ASA therapy. Materials and Methods: An observational retrospective study was carried out using an anonymized database including geriatric COVID-19 patients (March to April 2020) admitted to Madrid Hospitals Group. A group of COVID-19 patients were treated with low ASA (100 mg/day) prior to COVID-19 infection. Results: Geriatric ASA-treated patients were older (mean age over 70 years; n = 41), had higher frequency of hypertension and hyperlipidemia, and upon admission had higher D-dimer levels than non-ASA-treated patients (mean age over 73 years; n = 160). However, patients under ASA treatment did not show more frequent pulmonary thromboembolism (PE) than non-ASA-treated patients. ASA-treated geriatric COVID-19-infected patients in-hospital < 30 days all-cause mortality was more frequent than in non-ASA-treated COVID-19 patients. In ASA-treated COVID-19-infected geriatric patients, anticoagulant therapy with low molecular weight heparin (LMWH) significantly reduced need of ICU care, but tended to increase in-hospital < 30 days all-cause mortality. Conclusions: Prior treatment with a low dose of ASA in COVID-19-infected geriatric patients increased frequency of in-hospital < 30 days all-cause mortality, although it seemed to not increase PE frequency despite D-dimer levels upon admission being higher than in non-ASA users. In ASA-treated geriatric COVID-19-infected patients, addition of LMWH therapy reduced frequency of ICU care, but tended to increase in-hospital < 30 days all-cause mortality.

Clinical Differences and Outcomes of COVID-19 Associated Pulmonary Thromboembolism in Comparison with Non-COVID-19 Pulmonary Thromboembolism

(1) Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been reported to increase the risk of pulmonary thromboembolism (PTE). The aim of this study is to elucidate whether Coronavirus disease COVID-19-associated PTE has a different clinical expression than non-COVID-19 PTE due to a different pathophysiology. (2) Methods: retrospective study of PTE episodes conducted at our hospital between January 2019 and December 2020, comparing the group of COVID-19-associated PTE patients with a control group of non-COVID-19 PTE patients. (3) Results: A total of 229 patients with PTE were registered, 79 of whom had COVID-19. Cancer (15.2% vs. 39.3%; p < 0.001), previous surgery (0% vs. 8%; p = 0.01), previous VTE (2.5% vs. 15.3%; p = 0.003), signs and/or symptoms of deep venous thrombosis (DVT) (7.6% vs. 22.7%; p = 0.004) and syncope (1.3% vs. 8.1%; p = 0.035) were less frequent in the COVID-19 group. Central thrombosis was more frequent in the control group (35.3% vs. 13.9%; p = 0.001). No VTE recurrent episodes were observed in the COVID-19 group, whereas four (2.7%) episodes were recorded for the control group. One-month bleeding rate was higher in the COVID-19 group (10.1% vs. 1.3%; p = 0.004). (4) Conclusion: COVID-19-associated PTE has clinical characteristics that differ from those of PTE without COVID-19, including inferior severity and a lower rate of VTE recurrence. Physicians should be aware of the high risk of bleeding in the first month of COVID-19-associated PTE.

Risk Assessment of Death of Tumor-Related PTE by CAR Combined with DD Detection

Objective

To investigate the risk of death in patients with tumor-related PTE (pulmonary thromboembolism) detected by CAR (C-reactive protein/albumin ratio) combined with DD (D-dimer).

Methods

The peripheral hematology and coagulation-related indexes of 109 patients with tumor-related PTE diagnosed by PTCA were retrospectively analyzed, and the differences in relationship indexes between tumor-related PTE patients with good prognosis and poor prognosis were compared and analyzed. The receiver operating characteristic curve (ROC) was used to analyze the risk of death in patients with tumor-related PTE by CAR and DD.

Results

① The values of CAR and DD in the poor prognosis group were 3.90 ± 2.69 and 21.25 ± 21.20, respectively, which were significantly higher than those in the good prognosis group (1.66 ± 1.77, 9.53 ± 3.57) (P all <0.01). ② WBC, NE and SII in tumor-related PTE patients with poor prognosis were significantly higher than those in patients with good prognosis, while Hb in patients with poor prognosis was significantly lower than that in patients with good prognosis. ③ There was a significant positive correlation between CAR and DD (P=0.018). ④ The values of CAR and DD in the death group were 4.07 ± 2.42 and 19.65 ± 20.48, respectively, which were significantly higher than those in the survival group (1.94 ± 2.12, 11.52 ± 15.84) (P all<0.05). ⑤ The results of logistic regression analysis showed that both CAR (P=0.000) and DD (P=0.031) were independent prognostic factors in patients with tumor-related PTE. ⑥ CAR combined with DD had high sensitivity (77.8%) and specificity (83.5%), and the Youden index was 0.613. ⑦ The area under the receiver operating characteristic curve of CAR combined with DD was the largest (up to 0.806).

Conclusion

CAR and DD were highly expressed in patients with poor prognosis of tumor-related PTE. CAR combined with DD detection is helpful to improve the correct assessment of the risk of death in patients with tumor-related PTE.

Difficulty in Distinguishing Pulmonary Arterial Intimal Sarcoma from Pulmonary Thromboembolism Using FDG PET/CT

BACKGROUND/AIM

Pulmonary arterial intimal sarcoma (PAIS) is a rare malignant soft tissue tumor that is difficult to differentiate from pulmonary thromboembolism (PTE). Therefore, pre-operative diagnosis is often difficult. However, recent advances in fluorodeoxyglucose positron emission tomography (FDG-PET) have enabled the use of standardized uptake values (SUVs) for the differential diagnosis of PAIS from PTE, and the frequency of diagnosis of PAIS has increased. Here, we report a case of PAIS that was difficult to differentiate from PTE despite using FDG-PET.

CASE REPORT

A 40-year-old woman presented with gradually worsening exertional dyspnea. Contrast-enhanced computed tomography (CT) revealed lesions with poor enhancement in the right lateral basal pulmonary artery. FDG-PET/CT did not reveal any tumor or thrombosis in other areas. Cytological evaluation using a right ventricular catheter did not lead to a definitive diagnosis. Because the patient did not respond to anticoagulation, we performed pulmonary artery endarterectomy. Pathological examination of the pulmonary artery tumor revealed a mucinous tumor with an edematous stroma and spindle-shaped tumor-cell proliferation, which confirmed the diagnosis of PAIS. However, FDG/PET demonstrated a low SUV of 3.4.

CONCLUSION

Some PAISs with low cellular densities and high mucous tissue proportions have SUVs similar to those in PTE. In patients with low FDG uptake, if PAIS is suspected based on other objective findings, additional exploration using highly invasive tests or surgical procedures specific to PAIS is warranted.

Role of low-dose tissue plasminogen activator in patients with refractory hypoxia due to presumed microthrombi in pulmonary vasculature in coronavirus disease 2019: A case series and review of the literature

Severe hypoxia due to coronavirus disease 2019 (COVID-19) is challenging in the intensive care unit (ICU). It is often unresponsive to mechanical ventilation at high positive end-expiratory pressure and the fraction of inspired oxygen combination. The cause of such worsening hypoxia may be microvascular thrombosis in the pulmonary vascular system because of the procoagulant nature of COVID-19 infection. Confirming the diagnosis with computed tomographic pulmonary angiography is not always possible, as the patients are too sick to be shifted. Tissue plasminogen activator (tPA) is recommended for pulmonary thromboembolism with hypotension and worsening hypoxia, as confirmed by computed tomography pulmonary angiography. However, its role in worsening hypoxia because of presumed microthrombi in the pulmonary vasculature in COVID-19 is unclear. We present six cases from our ICU where we used low-dose tPA in COVID-19 refractory hypoxia with presumed microthrombi in the pulmonary vasculature (oligemic lung field, refractory hypoxia, increased D dimer, electrocardiographic features of pulmonary embolism, and right ventricular strain on echocardiography). Oxygenation improved within 6 h and was maintained for up to 48 h in all patients. Therefore, there is a possible role of microthrombi in the mechanism of hypoxia in this setting. An early decision to start low-dose tPA may improve the outcome. However, all patients finally succumbed to sepsis and multiorgan failure later in their course. A systematic review of the literature has also been performed on the mechanism of thrombosis and the use of tPA in hypoxia due to COVID-19.

Blockade of interleukin seventeen (IL-17A) with secukinumab in hospitalized COVID-19 patients - the BISHOP study

BACKGROUND

Patients with severe COVID-19 seem to evolve with a compromised antiviral response and hyperinflammation. Neutrophils are critical players in COVID-19. IL-17A plays a major role in protection against extracellular pathogens and neutrophil attraction/activation. We hypothesized that secukinumab, an anti-IL17A monoclonal antibody, could prevent the deleterious hyperinflammation in COVID-19.

METHODS

BISHOP was a randomized, open-label, single-centre, phase-II controlled trial. Fifty adult patients hospitalized with PCR-positive Covid-19, were randomized 1:1 to receive 300 mg of secukinumab subcutaneously at day-0 plus standard of care (group A) or standard of care alone (group B). A second dose of 300 mg of secukinumab could be administered on day-7, according to staff judgement. The primary endpoint was ventilator-free days at day-28 (VFD-28). Secondary efficacy and safety outcomes were also explored.

RESULTS

An intention-to-treat analysis showed no difference in VFD-28: 23.7 (95%CI 19.6-27.8) in group A vs. 23.8 (19.9-27.6) in group B, p = .62; There was also no difference in hospitalization time, intensive care unit demand and the incidence of circulatory shock, acute kidney injury, fungal or bacterial co-infections. There was no difference in the incidence of severe adverse events. Pulmonary thromboembolism occurred only in males and was less frequent in secukinumab-treated patients (4.2% vs. 26.2% p = .04). There was one death in each group. Upper airway viral clearance was also similar in both groups.

CONCLUSION

The efficacy of secukinumab in the treatment of Covid19 was not demonstrated. Secukinumab decreased pulmonary embolism in male patients. There was no difference between groups in adverse events and no unexpected events were observed.

Case Report: Successful Reperfusion of Pulmonary Thromboembolism Using tPA in a Cat

Pulmonary thromboembolism is a potentially life threatening condition that is uncommonly recognized in cats. Thrombolytic agents have been described as a treatment for this condition in human and canine patients, particularly in cases where hemodynamic instability is persistent despite supportive care. This report describes the clinical course, echocardiographic diagnosis, and successful thrombolysis of a cat with pulmonary thromboembolism. Despite confirmed reperfusion, the cat succumbed to thromboembolic disease highlighting the dearth of knowledge about optimal treatment of this disease process in small animals, particularly in cats.

Incidence, clinical characteristics and long-term prognosis of postoperative symptomatic venous thromboembolism: a retrospective cohort study

OBJECTIVES

The purpose of this study was to evaluate the incidence, clinical characteristics and prognosis of postoperative symptomatic venous thromboembolism (VTE) in Japan.

DESIGN

Retrospective observational study. Two data sets, Contemporary ManageMent AND outcomes in patients with Venous ThromboEmbolism (COMMAND VTE) Registry and Japanese Society of Anesthesiologists (JSA) annual report, were used for current analyses.

SETTING

Eighteen of 29 centres participated in the COMMAND VTE Registry.

PARTICIPANTS

Acute symptomatic patients with VTE who had undergone surgery 2 months prior to the diagnosis at 18 centres from January 2010 to December 2013 were identified in the COMMAND VTE Registry. From each centre's JSA annual report, the overall population that had received anaesthetic management during this period was retrieved.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the incidences and clinical characteristics of postoperative symptomatic VTE. The secondary outcomes were recurrent VTE, major bleeding and all-cause death.

RESULTS

We identified 137 patients with postoperative symptomatic VTE, including 57 patients with pulmonary embolism. The incidences of postoperative symptomatic VTE and pulmonary embolism were 0.067% and 0.028%, respectively, based on data from 2 03 943 patients who underwent surgery, managed by anaesthesiologists, during the study period. The incidences of postoperative symptomatic VTE varied widely, depending on surgical and anaesthetic characteristics. Postoperative symptomatic VTE occurred at a median of 8 days after surgery, with 58 patients (42%) diagnosed within 7 days. The cumulative incidence, 30 days after VTE, of recurrent VTE, major bleeding, and all-cause death was 3.0%, 5.2%, and 3.7%, respectively.

CONCLUSION

This study, combining the large real-world VTE and anaesthesiology databases in Japan revealed the incidence, clinical features and prognosis of postoperative symptomatic VTE, providing useful insights for all healthcare providers involved in various surgeries.

TRIAL REGISTRATION

Not applicable.

Pulmonary thromboembolism and alveolar hemorrhage as initial manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects multiple organs. SLE can affect the lung, the pulmonary vasculature, and the pleura. A 38-year-old female with limb pain and ecchymosis who later developed pulmonary thromboembolism and alveolar hemorrhage is presented here. Clinical, imaging, laboratory, and histopathological evidence is presented. The patient met the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) criteria for SLE. Furthermore, the patient had a Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score of 35; thus, indicating severe disease. This case is an example of concomitant venous and arterial lung complications in an SLE patient.

Thromboembolic complications in children with primary nephrotic syndrome: A Tunisian series

INTRODUCTION

Nephrotic syndrome is a common pathology in children. Despite its good prognosis, it can become complicated and threaten the patient's vital and functional prognosis. Thromboembolic complications are rare but serious.

AIM

To study the main thromboembolic events and their outcome during primary nephrotic syndrome in children.

METHODS

It was a retrospective study of the records of children followed for primary nephrotic syndrome who presented one or more thromboembolic events.

RESULTS

Twenty thromboembolic events in 19 children were identified (15 boys and 4 girls). The average age was 5.13±3.4 years at the time of NS diagnosis. The location of the thrombosis was venous in 14 cases. Cerebral venous thrombosis was noted in seven cases, pulmonary thromboembolism in five cases. We noted deep venous thrombosis of lower limbs in three cases, occlusive mesenteric ischemia in two cases, vein portal thrombosis in one case, renal vein thrombosis in one case, and thrombosis of a peripheral artery in one case.

CONCLUSION

Venous and arterial thrombotic complications can occur in children with nephrotic syndrome. Clinical features may be subtle; therefore, neuroimaging and angiographic techniques are essential for diagnosis.

Nutcracker syndrome as the main cause of left renal vein thrombus and pulmonary thromboembolism

INTRODUCTION

Left renal vein thrombus complicating nutcracker syndrome is relatively rare. To the best of our knowledge, there have been only four previous case reports. Furthermore, there have been no reports of pulmonary thromboembolism caused by nutcracker syndrome. Herein, we report a rare case of pulmonary thromboembolism caused by nutcracker syndrome and its clinical management.

CASE PRESENTATION

A 40-year-old man was admitted to our hospital with acute left flank pain. Computed tomography angiography revealed compression of the left renal vein between the aorta and the superior mesenteric artery with a left renal vein thrombus. Furthermore, computed tomography revealed bilateral pulmonary thromboembolism. Rivaroxaban was administered as an anticoagulant. Twenty days after initiation, computed tomography revealed complete resolution of pulmonary thromboembolism and left renal vein thrombus, and repeated computed tomography showed no recurrence.

CONCLUSION

This case report highlights nutcracker syndrome as a likely cause of pulmonary thromboembolism.

Differences in the prevention and incidence of maternal venous thromboembolism according to the type of institution in Japan in 2018: A sub-analysis of national questionnaire surveillance

AIM

To clarify the relation between institutions capacity to manage venous thromboembolism (VTE) and its incidence in pregnant women throughout Japan.

METHODS

Among the 2299 institutions that received the surveillance questionnaire, 666 (29.0%) responded, after which data from 295 961 women who gave birth at those institutions in 2018 were analyzed. Incidences and characteristics of antepartum and postpartum VTE in perinatal medical centers (PMCs), general hospital with obstetric facilities (GHs), and maternal clinic with beds (MCs) were then determined.

RESULTS

The frequencies at which routine antepartum and postpartum thromboprophylaxis for high-risk women and routine transport to the more advanced medical institutions upon antepartum and postpartum pulmonary thromboembolism (PE) onset were performed differed significantly according to types of institution (PMCs: 92.4%, 96.2%, 23.8%, and 21.2%; GHs: 76.5%, 80.6%, 58.8%, and 54.1%; MCs: 29.2%, 41.7%, 96.5%, and 96.2%, respectively). Among the 295 961 women analyzed, 243 (0.082%) developed VTE. Incidences of antepartum VTE differed significantly according to institution types (PMCs: 106.4, GHs: 51.6, and MCs: 11.6 per 100 000 women). PMCs and GHs had significantly higher incidences of postpartum VTE compared to MCs (43.3 and 26.6 vs. 10.7 per 100 000 women, respectively), although PMCs and GHs had similar incidences. Among the four women (1.4%) who died due to VTE, three and one developed a PE in a PMC and MC, respectively.

CONCLUSIONS

PMCs had higher incidences of VTE despite their more frequent performance of thromboprophylaxis. Several pregnant women with higher risk of VTE transported to PMCs.

Evaluation of Prognosis and Risk of Death by Neutrophil/Lymphocyte Ratio, C-Reactive Protein/Albumin Ratio and Plasma D-Dimer in Patients with Pulmonary Thromboembolism

Objective

To investigate the relationship between neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio, plasma D-dimer and prognosis in patients with pulmonary thromboembolism, and to evaluate the risk of death.

Methods

We retrospectively analyzed peripheral hematology and coagulation-related indicators of 362 pulmonary thromboembolism patients and 32 normal people, and the differences between the patients and control group and between good and poor prognosis groups were compared. And we analyzed and compared separate detection and combined detection of neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio and D-dimer on the efficiency of risk of death in patients.

Results

① Neutrophil/lymphocyte ratio of pulmonary thromboembolism patients was 8.96±1.94, significantly higher than that of control group 1.76±0.53 (t=2.4281, P<0.05). C-reactive protein/albumin ratio was 2.13±2.08, significantly higher than 0.03±0.01 in control group (t=20.7736, P<0.01). D-dimer was 9.69±8.61mg/L, significantly higher than 0.20±0.11mg/L in control group (t=3.0066, P<0.01). ② Hemoglobin, lymphocyte, albumin and lymphocyte/monocyte ratio in patients with good prognosis were significantly lower than those in poor prognosis group, while white blood cell, C-creative protein, neutrophil, C-reactive protein/albumin ratio, neutrophil/lymphocyte ratio and D-dimer were significantly lower than those in poor prognosis group (P all <0.05). ③ Regression analysis showed that neutrophil/lymphocyte ratio (P=0.007), C-reactive protein/albumin ratio (P=0.010) and D-dimer (P=0.003) were independent prognostic factors for pulmonary thromboembolism. ④ In assessing the risk of death of patients, D-dimer alone had the highest sensitivity (93.1%), and C-reactive protein/albumin ratio alone had the highest specificity (68.8%). The combined detection of these three indicators had higher sensitivity (86.2%) and higher specificity (67.6%) at the same time. ⑤ The area under receiver operating characteristic curve for combined detection of neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio and D-dimer was the largest (up to 0.821).

Conclusion

Patients with pulmonary thromboembolism highly expressed in neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio and D-dimer. The combined detection of these three indicators can improve the assessment efficacy of the risk of death in patients with pulmonary thromboembolism.