Search

Inpatient management of low-risk patients with venous thromboembolism (VTE) places a large resource burden on the healthcare system. Adult patients diagnosed with deep vein thrombosis (DVT) or pulmonary embolism (PE) in the emergency department (ED) have historically been hospitalized and treated with therapeutic anticoagulation. However, over the last two decades, outpatient treatment of patients with acute DVT and low risk PE has become increasingly accepted as an effective and safe option for patients given the low risk of short-term clinical deterioration. The purpose of this project was to establish a transition of care (TCM) program for patients with acute VTE presenting to the ED. The primary goals for the project included better quality patient follow-up in the Vascular Medicine Nurse Practitioner (NP) within one week and medication adherence. The second goal was increasing appropriate ED discharges for patients with low-risk VTE. Outcome metrics include the rate of early discharge of low-risk patients with VTE, follow-up in the Vascular Medicine NP clinic, and anticoagulant adherence. [ABSTRACT FROM AUTHOR]

Inflammation-induced dysregulation of the coagulation cascade and vascular stasis in hospitalized patients with acute necrotizing pancreatitis (ANP) serve as a milieu for venous thromboembolism (VTE). Deep vein thrombosis (DVT) and pulmonary embolism (PE) are often underrecognized. We evaluated the incidence and risk factors for VTE in a cohort of patients with ANP. All adult patients with ANP at our center between 2009 and 2022 were followed for three months after index hospitalization and categorized into cases and controls based on development of VTE. Demographic, clinical, and radiologic characteristics during admission were compared. A multivariable analysis was done to identify independent predictors for VTE. A p value of <0.05 was taken as significant. Among 643 ANP patients, 512 [males-350, median age-52 years] were eligible for inclusion. VTE developed in 64 (12.5 %) patients – 28 DVT (5 %), 22 PE (4 %) and both in 14 (3 %) after a median 16 days from the diagnosis of ANP. Significant independent predictors for VTE on multivariable analysis were age ≥60 years (OR 1.91; 95 % CI 1.04–3.53), peri-pancreatic extent of necrosis (OR 7.61; 95 % CI 3.94–14.70), infected necrosis (OR 2.26; 95 % CI 1.13–4.50) and total length of stay ≥14 days (OR 4.08; 95 % CI 1.75–9.50). The overall incidence of VTE in our cohort of patients with ANP was 12.5 %, which was usually diagnosed within one month of hospitalization. High-risk patients can be stratified based on clinical and imaging characteristics and may benefit from intensive DVT screening and prophylaxis during hospitalization and following discharge. [ABSTRACT FROM AUTHOR]

Perioperative venous thromboembolism (VTE) has a significant impact on morbidity and mortality. Prevention of perioperative VTE begins with risk assessment and formulating a thromboprophylaxis strategy that balances bleeding and thrombosis risks. A standardized approach to assess these risks using relevant guidelines can help direct appropriate use of mechanical and pharmacological prophylaxis. Nevertheless, acute pulmonary embolism (PE) can present in the perioperative period. This brief review summarizes current diagnostic algorithms including the use of transthoracic echocardiography to guide immediate management of acute PE, particularly in an intraoperative setting. [ABSTRACT FROM AUTHOR]

Autoimmune blistering disorders (ABDs) might elevate cardiovascular risk, but studies are lacking. The objective of this study was to examine if ABDs elevate the risk of atherosclerotic cardiovascular disease, heart failure, arrhythmia, venous thromboembolism, and cardiovascular death. A population-based cohort of Danish patients with ABD (≥18 years of age) diagnosed during 1996–2021 (n = 3322) was compared with an age- and sex-matched comparison cohort from the general population (n = 33,195). Compared with the general population, patients with ABDs had higher 1-year risks of atherosclerotic cardiovascular disease (3.4% vs 1.6%), heart failure (1.9% vs 0.7%), arrhythmia (3.8% vs 1.3%), venous thromboembolism (1.9% vs 0.3%), and cardiovascular death (3.3% vs 0.9%). The elevated risk persisted after 10 years for all outcomes but arrhythmia. The hazard ratios associating ABDs with the outcomes during the entire follow-up were 1.24 (1.09-1.40) for atherosclerotic cardiovascular disease, 1.48 (1.24-1.77) for heart failure, 1.16 (1.02-1.32) for arrhythmia, 1.87 (1.50-2.34) for venous thromboembolism, and 2.01 (1.76-2.29) for cardiovascular death. The elevated cardiovascular risk was observed for both pemphigus and pemphigoid. Our findings might only generalize to patients with ABDs without prevalent cardiovascular diseases. Patients with ABDs had an elevated cardiovascular risk compared with age- and sex-matched controls. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals. This study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed. Thirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE. The incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction. [ABSTRACT FROM AUTHOR]

Catheter-based interventions and surgical embolectomy represent alternatives to systemic fibrinolysis for patients with high-risk pulmonary embolism (PE) or those with intermediate-high-risk PE who deteriorate hemodynamically. They are indicated when systemic fibrinolysis is contraindicated or ineffective, or if obstructive shock is imminent. Extracorporeal membrane oxygenation can be added to reperfusion therapies or used alone for severe right ventricular dysfunction and cardiogenic shock. These advanced therapies complement but do not replace anticoagulation, which remains the cornerstone in PE management. This review summarizes the evidence and shares practical recommendations for the use of anticoagulant therapy before, during, and after acute PE interventions. [ABSTRACT FROM AUTHOR]

The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) – a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed. • Multidetector CTPA is widely used in patients with suspected pulmonary embolism (PE). • Over the years, alternative imaging techniques for PE diagnosis have become available. • This review describes current and emerging imaging techniques for acute PE. • Artificial intelligence is expected to enable further innovation in imaging of PE. [ABSTRACT FROM AUTHOR]

Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs. [ABSTRACT FROM AUTHOR]

• The 30-day all-cause mortality of patients with acute pulmonary embolism (PE) was 3.5 %. • This study externally validated the simplified Pulmonary Embolism Severity Index (sPESI), RIETE score, Geneva score, modified FAST and Bova score for 30-day mortality of acute PE, based on the large Chinese nationwide prospective cohort. • Area under the curve for predicting 30-day mortality of sPESI was 0.712 (95 % CI, 0.680, 0.743), with the odds ratio of 4.743 for sPESI ⩾1 point (95 % CI, 3.427, 6.563, p < 0.001). • The sPESI also showed a high sensitivity of 0.809. • The implementation of sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge. The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated. Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores. A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance. The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge. [ABSTRACT FROM AUTHOR]

The advent of advanced computed tomography (CT) technology and the field of radiomics has opened up new avenues in diagnostic assessments. Increasingly, there is substantial evidence advocating for the incorporation of quantitative imaging biomarkers in the clinical decision-making process. This study aimed to examine the correlation between D-dimer levels and thrombus size in acute pulmonary embolism (PE) combining dual-energy CT (DECT) and radiomics and to investigate the diagnostic utility of a machine learning classifier based on dual-energy computed tomography (DECT) radiomics for identifying patients with a complicated course, defined as at least hospitalization at IMC. The study was conducted including 136 participants who underwent pulmonary artery CT angiography from January 2015 to March 2022. Based on DECT imaging, 107 radiomic features were extracted for each patient using standardized image processing. After dividing the dataset into training and test sets, stepwise feature reduction based on reproducibility, variable importance and correlation analyses were performed to select the most relevant features; these were used to train and validate the gradient-boosted tree models.Receiver operating characteristics (ROC) analysis was utilized to evaluate the association between volumetric, laboratory data and adverse outcomes. In the central PE group, we observed a significant correlation between thrombus volumetrics and D-dimer levels (p = 0.0037), as well as between thrombus volumetrics and hospitalization at the Intermediate Care Unit (IMC) (p = 0.0001). In contrast, no statistically significant differences were identified in thrombus sizes between patients who experienced complications and those who had a favorable course (p = 0.3162). The trained machine learning classifier achieved an accuracy of 61% and 55% in identifying patients with a complicated course, as indicated by an area under the ROC curve of 0.63 and 0.58. In conclusion, our findings indicate a positive correlation between D-dimer levels and central PE's pulmonary embolic burden. Thrombus volumetrics may serve as an indicator for complications and outcomes in acute PE patients. Thus, thrombus volumetrics, as opposed to D-dimers, could be an additional marker for evaluating embolic disease severity. Moreover, DECT-derived radiomic feature models show promise in identifying patients with a complicated course, such as hospitalization at IMC. [ABSTRACT FROM AUTHOR]

Reverse total shoulder arthroplasty (rTSA) remains a viable treatment option in elderly patients with proximal humerus fractures (PHF). However, the risk profile of this procedure in this patient population has not been well established by prior studies. The aim of this study is to examine whether there are differences in sociodemographic variables, underlying medical comorbidities, and 90-day outcomes between patients undergoing rTSA for osteoarthritis (OA) vs. PHF. We hypothesized that patients with PHF would be older and have higher comorbidity burden compared to glenohumeral OA controls. Furthermore, we hypothesized that rTSA would yield inferior outcomes and higher costs of care in patients with PHF compared to glenohumeral OA. Patients who underwent primary rTSA from 2016 to 2020 were identified in the Premier Healthcare Database. PHF patients were identified using the International Classification of Diseases, Tenth Revision diagnosis codes and compared to OA controls. All patients < 18 years old and those who underwent rTSA for other indications were excluded. Patients were matched in a 2:1 fashion based on age (± 3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, comorbidities and 90-day surgical (wound complications, dislocation, periprosthetic fracture, periprosthetic joint infection, stiffness, loosening, mechanical complications, and revision) and medical (deep vein thrombosis/pulmonary embolism, pneumonia, respiratory failure, renal failure, stroke, myocardial infarction, and sepsis) complications and readmission were compared between the two cohorts. Descriptive statistics and regression analysis were employed with significance set at P <.05. Odds ratio (OR) and 95% confidence interval were calculated. Before matching 51,150 OA controls and 11,394 PHF cases were identified. After matching, 8661 PHF cases were matched to 17,332 controls. Regarding surgical complications, PHF patients were at significantly increased risk of periprosthetic fracture (OR 2.35), dislocation (OR 2.87), superficial wound infection (OR 5.51), periprosthetic joint infection (OR 1.91) and 90-day revision (OR 4.76). PHF patients were at increased risk of all medical complications examined including hemorrhage (OR 2.20), anemia (OR 2.78) deep vein thrombosis (OR 3.10), pulmonary embolism (OR 2.83), pneumonia (OR 2.93), respiratory failure (OR 3.37), pneumonia (OR 2.93), stroke (OR 2.61), myocardial infarction (OR 2.79), acute renal failure (OR 4.06), urinary tract infection (OR 5.50) and sepsis (OR 3.71) as well as 90-day readmission (OR 2.13). Patients undergoing rTSA for PHF are at significantly increased risk of complications compared to OA controls. Furthermore, these patients are at increased risk of 90-day readmission. These findings should prompt diligent preoperative risk stratification by surgeons and healthcare providers to prevent patient morbidity. [ABSTRACT FROM AUTHOR]

Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised. [ABSTRACT FROM AUTHOR]

There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction. [ABSTRACT FROM AUTHOR]

Acute pulmonary embolism (PE) is a life-threatening situation in cancer patients. In this situation, anticoagulant therapy is complex to administer due to the risk of bleeding. Only few studies have been conducted when these patients are admitted to the intensive care unit (ICU). The aim of this study was to assess the association between anticoagulation strategies as well as other factors with 90-day mortality in patients with cancer and PE admitted to ICU. Major bleeding was also evaluated according to the type of anticoagulation. Retrospective study carried out in 4 ICUs in France over a 12-year period (2009–2021). All patients with cancer and PE were included. An overlap propensity score weighting analysis was performed in the subgroup of patients treated with either unfractionated heparins (UFH) alone or low-molecular-weight heparins (LMWH) alone on 90-day mortality and major bleeding. A total of 218 consecutive cancer patients admitted to ICU and presenting PE were included. The 90-day mortality rate was 42 % for the global cohort. After propensity score analysis in the subgroup of patients treated with either "UFH alone" (n = 80) or "LMWH alone" (n = 71), the 90-day mortality was similar in patients treated with UFH alone (42.6 %) vs LMWH alone (39.9 %): OR = 1.124, CI 95 % [0.571–2.214], p = 0.750. There was a significant increased toward major bleeding rates in the "UFH alone" group (25.5 %) as compared to "LMWH alone" group (11.5 %), p = 0.04. In 218 patients admitted to ICU and presenting PE, the 90-day mortality rate was 42 %. Treatment with UFH alone was associated with a mortality comparable to treatment with LMWH alone but it appeared to be more prone to major bleeding. • UFH alone is associated with a mortality comparable to treatment with LMWH alone. • UFH alone seems to be more prone to major bleeding. • Metastatic cancer and thrombocytopenia are independently associated with mortality. • Pulmonary embolism diagnosed in the early postoperative period is associated with a good outcome. [ABSTRACT FROM AUTHOR]

• There have been still limited data on the transition of management strategies and clinical outcomes after introduction of direct oral anticoagulant (DOAC) for cancer-associated venous thromboembolism (VTE) in the real-world clinical practice. • In the current historical comparison of cancer-associated VTE between the 2 large real-world registries, there was a striking change in the treatment strategies with decreased risks of recurrent VTE and major bleeding in the DOAC era (COMAAND VTE Registry-2) compared with those in the warfarin era (COMAAND VTE Registry-1). • The risks of recurrent VTE has decreased significantly with the transition to the DOAC era, while there seemed to be unmet needs of clinically relevant nonmajor bleeding, DOAC-related gastrointestinal bleeding, and home treatment for pulmonary embolism patients with cancer. There have been still limited data on the transition of management strategies and clinical outcomes after introduction of direct oral anticoagulant (DOAC) for cancer-associated venous thromboembolism (VTE) in the real-world clinical practice. Using the 2 series of multicenter COMMAND VTE registries in Japan enrolling consecutive patients with acute symptomatic VTE, we compared 695 patients with cancer-associated VTE in the Registry-1 of the warfarin era and 1507 patients in the Registry-2 of the DOAC era. Regarding oral anticoagulation therapy, 576 patients (82.9 %) in the Registry-1 received warfarin, whereas 1119 patients (79.6 %) in the Registry-2 received DOACs. The cumulative 3-year incidence of discontinuation of anticoagulation was not significantly different between the 2 registries (56.7 % vs. 62.7 %, P = 0.11). The cumulative 5-year incidence of recurrent VTE was significantly lower in the Registry-2 than in the Registry-1 (17.7 % vs. 10.1 %, P < 0.001). The cumulative 5-year incidence of major bleeding was significantly lower in the Registry-2 than in the Registry-1 (26.6 % vs. 20.4 %, P = 0.045). The proportion of gastrointestinal bleeding numerically increased from the Registry-1 to the Registry-2 (46.7 % and 49.5 %), whereas that of intracranial bleeding numerically decreased from the Registry-1 to the Registry-2 (17.1 % and 14.1 %). In the current historical comparison of cancer-associated VTE between the 2 large real-world registries, there was a striking change in the treatment strategies with decreased risks of recurrent VTE and major bleeding in the DOAC era compared with those in the warfarin era, while there seemed to be unmet needs of DOAC-related gastrointestinal bleeding. URL: http://www.umin.ac.jp/ctr/index.htm UMIN000044816. We compared the management strategies and clinical outcomes of patients with cancer-associated VTE between the COMMAND VTE Registry-1 (Warfarin era) and Registry-2 (DOAC era). The lower adjusted risk of the Registry-2 relative to the Registry-1 was significant for recurrent VTE, but not for major bleeding. CRNMB, clinically relevant nonmajor bleeding; DOAC, direct oral anticoagulant; VTE, venous thromboembolism; CI, confidence interval; HR, hazard ratio [Display omitted] [ABSTRACT FROM AUTHOR]

Acute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. We comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. In this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e−42; 95 % CI, 5.68e−97, 1.37e−07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e−11; 95 % CI, 4.97e−25, 0.386). Our meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay. [Display omitted] • We compared different types of thrombolysis for acute submassive pulmonary embolism (PE). • This is a network meta-analysis of 23 randomized controlled trials with 2521 PE patients. • Standard catheter-directed thrombolysis (SCDT) was associated with the lowest mortality and bleeding risks. • Thrombolytic therapy reduces PE recurrence and hospital stay duration. [ABSTRACT FROM AUTHOR]

This study examined the effect of prior pulmonary embolism (PE) on total joint arthroplasty (TJA) outcomes. We reviewed patients who had a prior PE undergoing TJA at a single tertiary medical center between January 1, 2012 and January 1, 2021. There were 177 TJA patients who had a prior PE who underwent 1:3 propensity-matching to patients without a history of prior PE. Bivariable and multivariable analyses were performed. Changes over time were evaluated. Patients undergoing total knee arthroplasty who had a prior PE had more complications (25.3% versus 2.0%, P <.001), and postoperative PE (17.3% versus 0.0%, P <.001).and longer hospitalizations (3.15 versus 2.32 days, P =.006). Patients undergoing total hip arthroplasty who had a prior PE demonstrated more complications (14.7% versus 1.77%, P <.001) more postoperative PE (17.3% versus 0.0%, P <.001), and longer hospitalizations (3.30 versus 2.11 days, P <.001). Over the study, complication rates and hospitalizations lengths remained elevated in patients who had a prior PE. On multivariate analyses, prior PE was associated with longer hospitalizations (β: 0.67, P =.015) and increased complications (odds ratio [OR]: 9.44, P <.001) among total hip arthroplasty patients. Total knee arthroplasty patients had increased readmission (OR: 4.89, P =.003) and complication rates (OR: 21.4, P <.001). Patients undergoing TJA who had a prior PE are at higher risk of requiring postoperative care. Therefore, thorough preoperative evaluation must be implemented, especially in clinical environments lacking resources for acute care escalation. [ABSTRACT FROM AUTHOR]

High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies. [ABSTRACT FROM AUTHOR]

The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE. • Uniformity in the management of pulmonary embolism (PE) in children is needed. • Pulmonary embolism response teams (PERTs) lead to coordination of care in adult PE. • Pediatric centers should strongly consider developing PERTs to manage PE. • Resource-challenged centers should consider collaborating with a PE-expert center. • Hospitals should follow children with PE for long-term complications. [ABSTRACT FROM AUTHOR]

While accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients. A retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some. Overall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence. SRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups. • Less than half of the IVCF placed have a strongly recommended indication. • In cancer patients, IVCF are more frequently used without a clear indication. • In cancer patients, anticoagulation resumption and filter removal rates are lower. [ABSTRACT FROM AUTHOR]

The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals. We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals. A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes. A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %–27.6 % and 0–50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %–18.6 %). There were limited retrospective data evaluating the clinical decision rules. There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice. • How best to evaluate suspected VTE in postpartum individuals is unknown. • This scoping review evaluates diagnosis of suspected VTE in postpartum individuals. • Postpartum, CT pulmonary angiography was the most common test for suspected PE. • There is heterogeneity globally in the diagnosis of suspected postpartum VTE. [ABSTRACT FROM AUTHOR]

Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings. We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge. In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed. 530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79–0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality. The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital. [ABSTRACT FROM AUTHOR]

• Antithrombotic ability. • 11 South African plants. • H. natalensis - best candidate. Venous thromboembolism (VTE) is a collective term for the cardiovascular diseases namely, deep vein thrombosis and pulmonary embolism. Thrombosis causes the progression of VTE. Many of those who live in developing countries rely on herbal medicinal products as a primary source of healthcare. The study investigated the antithrombotic properties of the selected South African plant extracts. Eleven (11) plant species traditionally used for pain management and wound healing including plants reported in literature with anti-inflammatory and antioxidant activity were selected for this study. Extracts were prepared for each plant using ethanol, dichloromethane, and water. The extracts were tested for their antiproliferative effects on human liver carcinoma (HepG2) cells as well as antioxidant, activated coagulation factor X (anti-FXa) and cyclooxygenase-1 (COX-1) inhibitory activity. The results were interpreted using published information on the phytochemistry of the relevant active extracts. The most effective antioxidant activity was observed for the aqueous extract of Heteropyxis natalensis (H. natalensis) (IC 50 = 2.71 µg/mL), which also displayed potent anti-FXa activity with an IC 50 value of 2.64 µg/mL. The same extract inhibited COX-1 at an IC 50 value of 25.32 µg/mL. Due to the potent antiproliferative, antioxidant, and anti-FXa activity, as well as favourable COX-1 inhibition, the aqueous extract of H. natalensis was identified as the best candidate for future antithrombotic studies. [ABSTRACT FROM AUTHOR]

• Round-the-clock referrals for workup of suspected DVT can contribute to ED overcrowding. • Deferring workup of suspected DVT with a single dose anticoagulant resulted in a very low incidence of bleeding complications and PE events. • No bleeding events were recorded in patients in whom DVT was ruled out. • Deferring workup may offer a more streamlined approach for patient with suspected DVT. Patients with suspected deep venous thrombosis (DVT) are typically referred to the emergency department (ED) for immediate evaluation. However, this often contributes to ED overcrowding and necessitates round-the-clock sonographic examinations. Therefore, we implemented a regionwide care pathway for deferring diagnostic workup of suspected DVT until the following day. Patients receive a single anticoagulant dose from their general practitioner (GP) to prevent progression of DVT in the interval between referral and diagnostic evaluation. The next day, patients undergo comprehensive evaluation at our outpatient DVT clinic, including venous ultrasound. This retrospective study aims to provide real-world data on the safety of this care pathway regarding the occurrence of bleeding complications and pulmonary embolism (PE). We included all GP-referred patients with suspected DVT in 2018 and 2019. Patients with absolute contraindications to deferred evaluation or anticoagulation were excluded. The primary endpoint was the occurrence of bleeding complications. Secondary endpoints included PE events and all-cause mortality within seven days following DVT evaluation. Among 1,024 included patients, DVT was confirmed in 238 patients (23.2%) and superficial thrombophlebitis in 98 patients (9.6%). No bleeding events were recorded in patients in whom DVT was ruled out. PE was confirmed in eight patients on the same day as DVT evaluation (0.8%, 95%CI 0.4–1.6) and in six patients within seven days following DVT evaluation (0.6%, 0.2–1.3%). No deaths occurred during this timeframe. This real-world study observed a very low incidence of bleeding complications and PE events, indicating that this care pathway of deferred DVT workup is safe and may offer a more streamlined diagnostic approach for patients with suspected DVT. [ABSTRACT FROM AUTHOR]

Hereditary thrombophilia (HT) testing is frequently conducted during the evaluation of patients with pulmonary embolism (PE). However, the utility of routine HT testing in this setting is unclear. We sought to assess the association of HT with risk of recurrent venous thromboembolism (VTE) following first-time PE. We conducted a multi-hospital retrospective study. Two hundred and ninety (290) patients with a first-time PE, who had been tested for HT, completed at least 3 months of therapeutic anticoagulation (AC), subsequently discontinued AC, and were followed for at least 36 months thereafter, were included. HT was present in 48 of the 290 included patients (17%). Median follow-up after discontinuing AC was 61 months (interquartile range, 43–79 months). The overall recurrence rate of VTE during follow-up was 58 per 290 (20%). A total of 47 of 242 patients (19%) in the HT-absent group had a recurrent VTE, compared with 11 of 48 (22%) in the HT-present group. There was no significant difference in VTE-free survival between groups on Kaplan–Meier analysis; the hazard ratio (HR) for VTE recurrence for those with HT compared to those without (HR HT-present: HT-absent) was 1.240 (95% confidence interval [CI] 0.614–2.502; p = 0.548). On multivariable analysis, HT was not associated with risk of recurrent VTE (HR 1.262; 95% CI 0.640–2.488), and the only variable associated with VTE recurrence was unprovoked PE (HR 2.954; 95% CI 1.64–5.314). These findings demonstrate that the presence of HT is not associated with the risk of recurrent VTE following first PE, and support limiting the use of HT testing among patients with first PE. [ABSTRACT FROM AUTHOR]

Les patients hospitalisés pour une maladie thromboembolique veineuse aiguë (MTEV), et notamment les patients souffrant d'une embolie pulmonaire, restent souvent à l'hôpital pendant de longues périodes en raison du risque perçu de complications. Cependant, plusieurs études ont montré que le traitement à domicile de patients sélectionnés est faisable et sûr, avec une faible incidence d'événements indésirables. Cela peut présenter des avantages évidents pour la qualité de vie des patients, la planification hospitalière et le coût pour les services de santé. Néanmoins, il est nécessaire de disposer d'un outil de stratification du risque de MTEV qui prenne en compte le pronostic des patients atteints de cancer. Cet outil pourrait aider à sélectionner les patients à faible risque atteints d'un cancer et d'une MTEV qui peuvent bénéficier d'un traitement ambulatoire. Bien que plusieurs scores pronostiques aient été proposés, nous suggérons d'utiliser un outil pragmatique de prise de décision clinique tel que les critères Hestia, afin de sélectionner les patients devant recevoir des soins à domicile dans la pratique clinique quotidienne. Une fois les patients sortis de l'hôpital, il est indispensable de les surveiller régulièrement (nous suggérons après 3 jours, 10 jours, 1 mois et 3 mois, ou plus fréquemment si nécessaire) avec l'implication d'une équipe multidisciplinaire, afin que des mesures correctives appropriées puissent être prises en temps voulu, en cas de signes avant-coureurs de complications. Si les patients sont sélectionnés avec soin et suivis efficacement, de nombreux cas de MTEV aiguë peuvent être soignés en toute sécurité à domicile. Patients hospitalised with acute venous thromboembolism (VTE), and notably patients with pulmonary embolism, often remain in hospital for extended periods due to the perceived risk of complications. However, several studies have shown that home treatment of selected patients is feasible and safe, with a low incidence of adverse events. This may offer clear benefits for patients' quality of life, hospital planning and cost to the health service. Nonetheless, there is a need for a VTE risk-stratification tool specifically addressing prognosis in patients with cancer. This may aid in the selection of low-risk patients with cancer and VTE who are suitable for outpatient treatment. Although several prognostic scores have been proposed, we suggest using a pragmatic clinical decision-making tool such as the Hestia criteria for selecting patients for home care in everyday clinical practice. Once patients have been discharged, it is mandatory to monitor patients regularly (we suggest after 3 days, 10 days, 1 month and 3 months, or more frequently if needed) with the involvement of a multidisciplinary team, so that appropriate and timely remedial action can be taken in case of warning signs of complications. If patients are selected carefully and monitored effectively, many patients who experience acute VTE can be cared for safely at home. [ABSTRACT FROM AUTHOR]

Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P <.05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P <.001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P <.001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P <.001). Finally, there was a decrease of 0.004 (P =.009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations. [Display omitted] [ABSTRACT FROM AUTHOR]

Q fever is a zoonosis caused by Coxiella burnetii. Acute infection is mainly asymptomatic. In other cases it mainly causes a flu-like illness, a pneumonia, or an hepatitis. We present an atypical case of an acute Q fever revealed by a massive pleural effusion. We report the case of a 43-year-old man referred to our hospital for an acute respiratory distress. Further analyses showed an exudative eosinophilic pleural effusion, associated with a pulmonary embolism and a deep femoral vein thrombosis. Aetiologic explorations revealed an acute Q fever (IgM and IgG against C. burnetii phase II antigens) associated with anti-phospholipids. The outcome was favorable with vitamin K antagonists, doxycycline, and hydroxychloroquine, till the negativation of the anti-phospholipid antibodies. During acute C. burnetii infections, anti-phospholipid antibodies are highly prevalent but thrombotic complications are rare. The 2023 ACR/EULAR APS criteria restricts the diagnosis of APS, as in our case of acute severe infection. In front of an atypical pneumonia and/or thrombotic events, screening of C. burnetii and anti-phospholipid antibodies could be useful. Given its low level of evidence, prolongated treatment by doxycycline, hydroxychloroquine ± anticoagulant for C. burnetii's associated anti-phospholipid syndrome is discussed, but succeeded in our case. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is still reported as the leading cause of direct maternal death in pregnancy in serial international reports in developed countries. VTE risk is higher during pregnancy but is further increased by additional well-characterized risk factors. International guidelines recommend that formal VTE risk assessment should be conducted at least in early pregnancy, at delivery and when risk factors change. High quality data supporting optimal VTE prevention strategies are lacking, outside the setting of prevention of VTE recurrence. Moreover, recent high-quality studies have provided much-needed data on diagnostic strategies for pulmonary embolism (PE) in pregnancy. In this review, we summarize knowledge gaps and recently published data in the prevention and diagnosis of VTE in pregnancy. Moreover, we describe ongoing high-quality randomised trials and prospective clinical management studies in this area. High quality clinical studies and trials in pregnancy can be done and must be prioritised, through international network efforts and national funding advocacy. Ultimately, translation of study results to impact upon guidelines and policy will deliver better care to and will protect the lives and health of pregnant people and those contemplating pregnancy throughout the world. • VTE is a leading cause of direct maternal deaths in developed countries. • The interplay of VTE risk factors may influence VTE risk severity and duration. • Studies are needed to guide VTE thromboprophylaxis in pregnancy and puerperium. • Decision aids may better triage cases for VTE diagnostic imaging. • Research on thrombosis in pregnancy and the puerperium should be prioritised. [ABSTRACT FROM AUTHOR]

Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5–10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field. • Up to 50 % of patients surviving PE experience reduced physical capacity. • 243 studies were identified measuring physical capacity. • Of ten identified physical performance measures, the 6-minute walk test was most common. • No physical performance measure has been validated for use in a PE population. [ABSTRACT FROM AUTHOR]

Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15–21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15–9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48–42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15–9.74). Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes. • Among patients with cancer-associated pulmonary embolism treated at home, the rate of adverse events was low. • Cancer patients treated at home and those qualified for hospitalization because of their cancer had similar rate of complications. • Patients treated at home had a higher rate of complications if they had an active cancer. • Home treatment of cancer-associated pulmonary embolism was not associated with adverse evolution. [ABSTRACT FROM AUTHOR]

The PE-SARD score (syncope, anemia, renal dysfunction) was developed to predict the risk of major bleeding in the acute phase of pulmonary embolism (PE). We analyzed data from 50,686 patients with acute PE included in the RIETE registry to externally validate the PE-SARD score. We calculated the overall reliability of the PE-SARD score, as well as discrimination and calibration for predicting the risk of major bleeding at 30 days. The performance of PE-SARD was compared to the BACS and PE-CH models. During the first 30 days, 640 patients (1.3 %) had a major bleeding event. The incidence of major bleeding within 30 days was 0.6 % in the PE-SARD-defined low-risk group, 1.5 % in the intermediate-risk group, and 2.5 % in the high-risk group, for an OR of 2.22 (95 % CI, 2.02–2.43) for the intermediate-risk group (vs low-risk group), and 3.94 for the high-risk group (vs low-risk group). The corresponding sensitivity was 81.1 % (intermediate/high vs low risk), and specificity was 85.9 % (95 % CI, 85.8–86.1) (low/intermediate vs high risk). The applicability of PE-SARD was consistent across clinically relevant patient subgroups and over shorter time periods of follow-up (i.e., 3 and 7 days). The C-index was 0.654 and calibration was excellent. The PE-SARD bleeding score improved the major bleeding risk prediction compared with the BACS and PE-CH scores. The PE-SARD score identifies PE patients with a higher risk of bleeding, which could assist providers for potentially adjusting PE management, in a framework of shared decision-making with individual patients. • Pulmonary embolism management is associated with an estimated risk of major bleeding of 3.0 %. • In this external validation analysis, the PE-SARD score identified 14.9 % of patients at a four-fold risk of developing major bleeding within the first 30 days of PE with moderate discrimination capacity and excellent calibration capacity. • PE-SARD could potentially assist providers in tailoring management of acute PE in high-bleeding risk patients, in the framework of individualized decision-making. [ABSTRACT FROM AUTHOR]

• Pulmonary embolism (PE) is a potentially serious cause of syncope. • It is not known which syncope patients should be screened for PE. • The extensive use of algorithms to exclude PE might lead to over-diagnosis and over-treatment. • Using a simple clinical decision rule based on anamnestic and clinical parameters could significantly reduce unnecessary exams. Syncope can be the presenting symptom of Pulmonary Embolism (PE). It is not known wether using a standardized algorithm to rule-out PE in all patients with syncope admitted to the Emergency Departments (ED) is of value or can lead to overdiagnosis and overtreatment. We tested if simple anamnestic and clinical parameters could be used as a rule to identify patients with syncope and PE in a multicenter observational study. The rule's sensitivity was tested on a cohort of patients that presented to the ED for syncopal episodes caused by PE. The clinical impact of the rule was assessed on a population of consecutive patients admitted for syncope in the ED. Patients were considered rule-positive in the presence of any of the following: hypotension, tachycardia, peripheral oxygen saturation ≤ 93 % (SpO2), chest pain, dyspnea, recent history of prolonged bed rest, clinical signs of deep vein thrombosis, history of previous venous thrombo-embolism and active neoplastic disease. The sensitivity of the rule was 90.3 % (95 % CI: 74.3 % to 98.0 %). The application of the rule to a population of 217 patients with syncope would have led to a 70 % reduction in the number of subjects needing additional diagnostic tests to exclude PE. Most patients with syncope due to PE present with anamnestic and clinical features indicative of PE diagnosis. A clinical decision rule can be used to identify patients who would benefit from further diagnostic tests to exclude PE, while reducing unnecessary exams that could lead to over-testing and over-diagnosis. [ABSTRACT FROM AUTHOR]

Controversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE. We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement. Eight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43–0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01). In patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings. • Controversy surrounds the optimal therapy for submassive and massive PE. • CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy. • CDT was associated with lower in-hospital mortality compared to surgical thrombectomy. • CDT and thrombectomy had similar complications, LOS, 30-day readmissions, and RV/LV ratio improvement. • This study expands the evidence supporting CDT as a feasible option for submassive and massive PE. [ABSTRACT FROM AUTHOR]

Impending paradoxical embolism (IPDE) is a right heart thrombus (RHT), in times of elevated pulmonary arterial pressure, that is trapped in a patent foramen ovale (PFO) Myers et al. (2010) (3). We present a case that highlights our multidisciplinary approach in a patient with IPDE with cardiogenic shock from pulmonary embolism (PE). • Diagnosis of paradoxical embolism (PDE) before advancements in imaging was made presumptively as it was impossible to visualize a clot as it traverses a cardiac defect. With the advent of echocardiography, it is now possible to visualize right heart thrombus (RHT) in vivo and see as it traverses a cardiac defect. This phenomenon is known as an impending paradoxical embolism (IPDE) • IPDE, must be acted promptly as it can embolize systemically. Literature regarding IPDE is scant but shows that surgical intervention is superior to systemic thrombolysis. However, percutaneous interventions have not been studied. • The patient was unable to undergo systemic thrombolysis or surgical intervention because of patient's history of Moyamoya, which proved too great a risk. Thus, a percutaneous approach involving interventional radiology (IR) and structural cardiology was employed. • Patient was initiated on venoarterial extracorporeal membrane oxygenation, a cardioembolic protection device was placed, and the IPDE was aspirated via an Angiovac. Once aspirated, the cardiac defect was occluded percutaneously. Aspiration thrombectomy of the massive pulmonary embolisms was then completed by IR. • As it stands now, the literature regarding which approach is superior is lacking. With advancements in echocardiography, more and more IPDE will be discovered. It is imperative to delineate whether a surgical, percutaneous, or systemic thrombolysis approach should be utilized. Further research should be undertaken. [ABSTRACT FROM AUTHOR]

Smoking has been suggested to be correlated with increased rates of several postoperative complications following total joint arthroplasty. As the utilization of total elbow arthroplasty (TEA) continues to rise, identifying modifiable factors to best optimize the patient is crucial. The goal of this study is to identify if a correlation exists between smoking status and 30-day postoperative complications following TEA. Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2021 using Current Procedural Terminology code 24363 (Arthroplasty, elbow, with distal humeral and proximal ulnar prosthetic replacement; total elbow). Patients were placed into 1 of 2 cohorts based on smoking status. A multivariate logistic regression was used to compare rates of postoperative complications between cohorts and odds ratios (ORs) were calculated to evaluate risk of postoperative complications. Smoking was not found to be significantly correlated with any recorded complication, including surgical site infection (OR = 1.98, P =.219), sepsis (OR = 0.84, P =.879), hospital readmission (OR = 1.9, P =.136), return to operating room (OR = 1.06, P =.913), pulmonary embolism (OR = 0.91, P =.933), and blood loss requiring transfusion (OR = 0.36, P =.211). This study suggests no significant correlation between smoking and increased rates of complications following TEA in the 30-day postoperative window, such as postoperative surgical site infection, hospital readmission, or sepsis. This study found no significant correlation between smoking and complications within the 30-day postoperative window, supporting the safety of TEA procedures for smokers. However, perioperative smoking cessation is still recommended as part of medical optimization before surgery. The results provide a valuable tool for risk stratification in TEA patients, especially smokers, during the acute postoperative phase. Decisions regarding TEA surgery should involve shared decision-making between the surgeon and patient, considering multiple factors. [ABSTRACT FROM AUTHOR]

The diagnosis of pediatric pulmonary embolism (PE) is often delayed due to non-specific symptoms, and clinical prediction tools designed for adults are unsuitable for children. This study aimed to create a PE predictive model and to evaluate the reported tools in the Thai pediatric population. A multi-center retrospective study from 4 university hospitals included children ≤18 years of age undergoing computed tomography pulmonary angiogram from 2000 to 2020 with the suspicion of PE. Patients' clinical presentations and risk factors of venous thromboembolism (VTE) were compared between the PE-positive and PE-negative groups. Significant risk factors from univariate and multivariate logistic regression were included to create a clinical prediction tool. The performance of the model was demonstrated by sensitivity, specificity, area under the curve (AUC), Hosmer Lemeshow test, ratio of observed and expected outcomes and bootstrapping. Of the 104 patients included, 43 (41.3 %) were grouped as PE-positive and 61 (58.7 %) as PE-negative. Five parameters, including congenital heart disease/pulmonary surgery, known thrombophilia, previous VTE, nephrotic syndrome and chest pain showed significant differences between the two groups. Score ≥ 2 yielded a 74.4 % sensitivity and a 75.4 % specificity with an AUC of the model of 0.809. The model performance and validation results were within satisfactory ranges. The study created a clinical prediction tool indicating the likelihood of PE among Thai children. A score ≥2 was suggestive of PE. • Pediatric pulmonary embolism (PE) is associated with certain specific risk factors. • Clinical prediction tools for PE among adults are ineffective among children. • A predictive score included congenital heart disease, known thrombophilia, nephrotic syndrome, previous VTE and chest pain. • Score ≥ 2 from the model yielded a 74.4 % sensitivity and 75.4 % specificity. [ABSTRACT FROM AUTHOR]

Splanchnic vein thrombosis (SVT), a thrombosis which involves the portal, mesenteric, and splenic veins, and the Budd-Chiari syndrome, represents an uncommon type of venous thromboembolism (VTE). Like with deep vein thrombosis of the lower extremities and pulmonary embolism, ample evidence suggests a significant association between SVT and cancer, particularly intra-abdominal solid malignancies (e.g. hepatobiliary and pancreatic cancers) and myeloproliferative neoplasms (MPN). Clinical symptoms of SVT in cancer patients can be ambiguous, and frequently attributed to the primary cancer itself. Alternatively, SVT may be asymptomatic and detected incidentally during cancer staging or follow-up evaluations. SVT can also precede the diagnosis of cancer and has been associated with poorer outcomes in patients with liver or pancreatic cancers. Therefore, an unprovoked SVT warrants a thorough evaluation for an underlying malignancy or MPN. Cancer-associated SVT carries a high risk of VTE extension, recurrence and bleeding. Extended anticoagulant treatment is often required in the absence of a high bleeding risk. Guidelines suggest treatment with either low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), although available data on the safety and effectiveness of DOACs in these patients is limited. This comprehensive review outlines the epidemiology, pathogenesis, risk factors, and diagnosis of cancer-associated SVT and underscores the importance of comprehensive patient evaluation and evidence-based management. • SVT is often linked with abdominal malignancies and myeloproliferative neoplasms. • An apparently unprovoked SVT in cancer may indicate a hidden malignancy. • Cancer-associated SVT increases risks of VTE recurrence, progression and bleeding. • Extended anticoagulant treatment with LMWH or DOACs is recommended. [ABSTRACT FROM AUTHOR]

Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. FXIII activity, mixing studies, FXIII-A 2 B 2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. FXIII-A 2 B 2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2–19.4) vs. 21.8 (17.1–26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A 2 B 2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition. • Causes of acquired FXIII deficiency: immune-mediated inhibition, non-immune-mediated consumption, or decreased synthesis. • Low FXIII levels, as a result of FXIII consumption, were found in newly diagnosed MM patients. • Hypercoagulability and disturbed fibrinolytic balance were detected in MM and in MGUS. • In MM and MGUS, hemostasis alterations are already evident at presentation, calling for awareness during monitoring. [ABSTRACT FROM AUTHOR]

• The characteristics and prognostic value of all ECG parameters were investigated. • Quantitative ECG parameters correlated with disease severity in non-high-risk PE. • A lesser S-V5 (≤ 0.15mv) was predictive for early discharge in non-high-risk PE. Electrocardiogram (ECG) abnormalities indicating right ventricular strain have been reported to have prognostic value in severe cases of acute pulmonary embolism (PE). We aimed to analyze the prognostic significance of other quantitative ECG parameters in non-high-risk acute PE. Consecutive patients with non-high-risk acute PE were prospectively enrolled. The following baseline ECG parameters were collected: rhythm, heart rate, QRS axis, right bundle branch block (RBBB) pattern, S1Q3T3 pattern, T-wave inversion, ST-segment elevation, Qr in lead V1, PR Interval, QRS complex duration, QT interval, P-wave amplitude and duration, R- and S-wave amplitudes. The primary endpoint was early discharge within three days. Associations between ECG parameters and early discharge were analyzed. Overall, 383 patients were enrolled (median age: 67 years, 57% female): 277 (72.3%) with low-risk and 106 (27.7%) with intermediate-risk. The two groups of patients differed in several ECG signs of right ventricular strain and many other quantitative parameters like R- and S-wave amplitudes. In the multivariate logistic regression analysis, the S-wave depth in lead V5 (S-V5) was the only independent prognostic factor for early discharge (odds ratio = 0.137, 95% confidence interval = 0.031-0.613, p = 0.009). The optimum cutoff value of S-V5 for predicting early discharge derived from the receiver operative characteristic curve was 0.15 mv (c-statistic = 0.66, p =0.003). Several ECG signs of right ventricular strain and many other quantitative parameters were associated with disease severity in non-high-risk acute PE. An S-V5 lesser than 0.15 mv was predictive for early discharge in these patients. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the trauma setting, and both prediction and prevention of VTE have long been a concern for healthcare providers in orthopedic surgery. The purpose of this study was to evaluate the use of novel statistical analysis and machine-learning in predicting the risk of VTE and the usefulness of prophylaxis following ankle fractures. The medical profiles of 16,421 patients with ankle fractures were screened retrospectively for symptomatic VTE. In total, 238 patients sustaining either surgical or nonsurgical treatment for ankle fracture with subsequently confirmed VTE within 180 days following the injury were placed in the case group. Alternatively, 937 patients who sustained ankle fractures managed similarly but had no documented evidence of VTE were randomly chosen as the control group. Individuals from both the case and control populations were also divided into those who had received VTE prophylaxis and those who had not. Over 110 variables were included. Conventional statistics and machine learning methods were used for data analysis. Patients who had a motor vehicle accident, surgical treatment, increased hospital stay, and were on warfarin were shown to have a higher incidence of VTE, whereas patients who were on statins had a lower incidence of VTE. The highest Area Under the Receiver Operating Characteristic Curves (AUROC) showing the performance of our machine learning approach was 0.88 with 0.94 sensitivity and 0.36 specificity. The most balanced performance was seen in a model that was trained using selected variables with 0.86 AUROC, 0.75 sensitivity, and 0.85 specificity. By using machine learning, this study successfully pinpointed several predictive factors linked to the occurrence or absence of VTE in patients who experienced an ankle fracture. Training these algorithms using larger, more granular, and multicentric data will further increase their validity and reliability and should be considered the standard for the development of such algorithms. Case-Control study – 3 [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the diagnostic accuracies of ventilation/perfusion-single photon emission computed tomography (V/Q-SPECT) imaging modalities for acute pulmonary embolism (PE). These included, in addition to V/Q-SPECT, V/Q-SPECT with low-dose computed tomography (CT; V/Q-SPECT-CT), Q-SPECT with low-dose CT (Q-SPECT-CT), and Q-SPECT. PubMed, Embase, CINAHL, and Web of Science databases were searched, and studies included if they studied ≥10 adult participants with acute PE and reported data on the imaging tests' diagnostic performance. Data were meta-analyzed using bivariate random effects regression model. Data from participants totaling 4146 from 11 V/Q-SPECT studies, 785 from 7 V/Q-SPECT-CT studies, 1196 from 7 Q-SPECT-CT studies, and 728 from five Q-SPECT studies were separately meta-analyzed. The bivariate weighted mean sensitivity and specificity were 0.94 (95% confidence interval [CI]: 0.88–0.97) and 0.95 (95% CI: 0.87–0.98) for V/Q-SPECT, 0.95 (95% CI: 0.88–0.98) and 0.99 (95% CI: 0.92–1.00) for V/Q-SPECT-CT, 0.92 (95% CI: 0.79–0.97) and 0.92 (95% CI: 0.83–0.96) for Q-SPECT-CT, and 0.89 (95% CI: 0.76–0.95) and 0.86 (95% CI: 0.67–0.95) for Q-SPECT studies. The positive and negative likelihood ratios (+LRs and –LRs) were 17.4 (6.9–44.0) and 0.06 (0.03–0.13), 76.7 (11.8–498.0) and 0.06 (0.02–0.13), 11.0 (5.3–22.9) and 0.09 (0.04–0.23), and 6.4 (2.6–15.8) and 0.13 (0.07–0.27) for V/Q-SPECT, V/Q-SPECT-CT, Q-SPECT-CT, and Q-SPECTs, respectively. In the diagnosis of acute PE, this meta-analysis showed that V/Q-SPECT-CT had the highest specificity and +LR. Conversely, Q-SPECT showed the lowest specificity and an unfavorably high −LR. [ABSTRACT FROM AUTHOR]

To evaluate the potential to reduce the amount of iodinated contrast media (CM) for computer tomographic pulmonary angiography (CTPA) with a novel photon-counting-detector CT (PCCT). Overall, 105 patients referred for CTPA were retrospectively included in this study. CTPA was performed using bolus tracking and high-pitch dual-source scanning (FLASH mode) on a novel PCCT (Naeotom Alpha, Siemens Healthineers). CM (Accupaque 300, GE Healthcare) dose was lowered stepwise following the introduction of the new CT scanner. Thus, patients could be divided into 3 groups as follows: group 1, n = 29, 35 ml of CM; group 2, n = 62, 45 ml of CM and group 3, n = 14, 60 ml of CM. Four readers independently assessed the image quality (Likert-scale 1–5) and adequate assessment of the segmental pulmonary arteries. Additionally, the pulmonary arterial contrast opacification was measured. The subjective image quality was rated highest in group 1 with 4.6 compared to 4.5 (group 2) and 4.1 (group 3) with a significant difference between groups 1 and 3 (p < 0.001) and between groups 2 and 3 (p = 0.003). In all groups, almost all segmental pulmonary arteries could be assessed adequately without significant differences (18.5 vs. 18.7 vs. 18.4). Mean attenuation in the pulmonary trunk did not differ significantly between groups 321 ± 92 HU versus 345 ± 93 HU versus 347 ± 88 HU (p = 0.69). Significant CM dose reduction is possible without a reduction in image quality. PCCT enables diagnostic CTPA with 35 ml of CM. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Pulmonary Embolism (PE) is a blood clot in the pulmonary arteries of the lungs. Currently, Computerized Tomography Pulmonary Angiography (CTPA) scans are used to diagnose this condition. However, to manually locate the presence of a PE in the scan is laborious. In this paper, the detection of PE and prediction of its features like location, Right Ventricle to Left Ventricle (RV/LV) ratio, and chronicity are automated. First, for the detection of the embolisms, image features from the RSNA Pulmonary Embolism CT (RSPECT) dataset - containing over 12,000 CTPA studies, are extracted by several pre-trained Convolutional Neural Networks (CNN) - AlexNet, Inception V3, ResNet-18, and ResNet-50. Then, various Machine Learning (ML) classifiers are trained on these features and their performances are compared. Second, for the prediction of labels, multi-label classification is performed by training these networks with Binary Cross Entropy Logits (BCE Logits) loss. The results showed that for the detection task, k-NN classifier trained on ResNet-50 features achieved the highest sensitivity of 0.98 with 1.7 false positives per scan and an AUROC score of 97.4%. This system also improved on the state-of-the-art sensitivity score by 0.0975 and AUROC score by 3.4%. For multi-label classification, ResNet-18 performed comparatively better with the best validation loss of 0.07 and weighted macro-average ROC AUC score of 0.61. [ABSTRACT FROM AUTHOR]