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SLICE Trial Group., [Importance] Active search for pulmonary embolism (PE) may improve outcomes in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD)., [Objective] To compare usual care plus an active strategy for diagnosing PE with usual care alone in patients hospitalized for COPD exacerbation., [Design, Setting, and Participants] Randomized clinical trial conducted across 18 hospitals in Spain. A total of 746 patients were randomized from September 2014 to July 2020 (final follow-up was November 2020)., [Interventions] Usual care plus an active strategy for diagnosing PE (D-dimer testing and, if positive, computed tomography pulmonary angiogram) (n = 370) vs usual care (n = 367)., [Main Outcomes and Measures] The primary outcome was a composite of nonfatal symptomatic venous thromboembolism (VTE), readmission for COPD, or death within 90 days after randomization. There were 4 secondary outcomes, including nonfatal new or recurrent VTE, readmission for COPD, and death from any cause within 90 days. Adverse events were also collected., [Results] Among the 746 patients who were randomized, 737 (98.8%) completed the trial (mean age, 70 years; 195 [26%] women). The primary outcome occurred in 110 patients (29.7%) in the intervention group and 107 patients (29.2%) in the control group (absolute risk difference, 0.5% [95% CI, −6.2% to 7.3%]; relative risk, 1.02 [95% CI, 0.82-1.28]; P = .86). Nonfatal new or recurrent VTE was not significantly different in the 2 groups (0.5% vs 2.5%; risk difference, −2.0% [95% CI, −4.3% to 0.1%]). By day 90, a total of 94 patients (25.4%) in the intervention group and 84 (22.9%) in the control group had been readmitted for exacerbation of COPD (risk difference, 2.5% [95% CI, −3.9% to 8.9%]). Death from any cause occurred in 23 patients (6.2%) in the intervention group and 29 (7.9%) in the control group (risk difference, −1.7% [95% CI, −5.7% to 2.3%]). Major bleeding occurred in 3 patients (0.8%) in the intervention group and 3 patients (0.8%) in the control group (risk difference, 0% [95% CI, −1.9% to 1.8%]; P = .99)., [Conclusions and Relevance] Among patients hospitalized for an exacerbation of COPD, the addition of an active strategy for the diagnosis of PE to usual care, compared with usual care alone, did not significantly improve a composite health outcome. The study may not have had adequate power to assess individual components of the composite outcome., [Trial Registration] ClinicalTrials.gov Identifier: NCT02238639.

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90‐day and 1‐year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90‐day all‐cause (odds ratio [OR], 2.81; 95% CI, 2.33–3.38) and PE‐related mortality (OR, 2.38; 95% CI, 1.37–4.14) and increased 1‐year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10–9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all‐cause mortality (OR, 1.91; 95% CI, 1.57–2.32) but not PE‐related mortality (OR, 1.50; 95% CI, 0.85–2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90‐day all‐cause (OR, 2.28; 95% CI, 1.75–2.97) and PE‐related (OR, 3.64; 95% CI, 2.01–6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.

Background Ascent to high altitude (> 2500 m) exposes people to hypobaric atmospheric pressure and blood hypoxemia. It provokes a syndrome whose symptoms vary from the mild acute mountain sickness (AMS) to the life-threatening, high-altitude pulmonary edema (HAPE). This study analyzed the risk for developing high-altitude sickness in a group of HAPE patients (n = 59), which was contrasted against a group of AMS patients (n = 240) as the NO HAPE group, after sojourning above 4,000 m height. The objective of this retrospective was to analyse the factors contributing to the HAPE prevalence among travellers and dwellers of the Ecuadorian Andes. Methods AMS and HAPE groups were compared through demographic (ethnicity, sex, and age), environmental (permanent residence altitude and recent stay at sea-level), health status (vital signs), and blood analysis variables. The Cramer´s V, simple logistic regression(SLR), and multiple logistic regression(MLR) analyses revealed patterns of significant associations. Results Analyses revealed that high-altitude indigenous residents were HAPE-prone, while mestizos living at sea level only had AMS. Blood pressure played a role in HAPE risk. Women were more tolerant to HAPE than men. Among indigenes, HAPE prevalence significantly rose after sojourning at sea level, a phenomenon called “reentry HAPE”. Conclusions In Andean indigenes, HAPE could be produced by a poor adaptation to high altitude, a high haemoglobin, and a blunted reactivity of blood pressure to environmentally-induced hypoxia. All the above gives support to the complex gene-environment interactions in the progress of HAPE, which may give some clues about of the etiopathogenesis of non-cardiogenic edema.

Background The L-STIFF tool of the Lokomat evaluates the hip and knee flexors and extensors spasticity in a standing position. It moves the lower limb at a controlled velocity, measuring joint resistance to passive movements. Since its reliability in children with cerebral palsy remains unknown, our goal was to evaluate the relative and absolute reliability of L-STIFF in children with cerebral palsy. Methods Reliability was determined in 16 children with cerebral palsy by two experienced therapists. The changes in resistive torque in hip and knee in both flexion and extension were measured. Relative and absolute reliability were estimated using the intraclass correlation coefficient, standard error of measurement, and minimal detectable change. Reliability was assessed on three levels: (1) intra- and (2) inter-tester within session, and (3) intra-tester between sessions. Results Intraclass correlation coefficients were moderate to excellent for intra-tester reliability (all p ≤ 0.01). The standard error of measurement ranged from 0.005 to 0.021 Nm/° (i.e., 7–16%) and minimal detectable change from 0.014 to 0.059 Nm/°. Inter-tester intraclass correlation coefficients ranged from 0.32 to 0.70 (all p ≤ 0.01), standard error of measurement ranged from 0.012 to 0.029 Nm/° (i.e., 6–39%), and minimal detectable change ranged from 0.033 to 0.082 Nm/°. L-STIFF reliability was better during fast and medium movement speeds compared to slow speeds. Conclusions The assessment tool L-STIFF is a promising tool for quantifying lower limb spasticity in children with cerebral palsy in a standing position. However, the results should be interpreted carefully.

Background The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR) and mean platelet volume-to-platelet ratio (MPR) are combined hematology tests useful for the assessment of COVID-19 severity, but different cut-off values have been reported. Sex can significantly impact immune responses and the course of COVID-19, so these combined hematology tests should be differentiated by gender. Purpose The aim of this study was to evaluate sex differences in the contribution of the NLR, PLR, MLR and MPR to severity and mortality using a sample of COVID-19 patients infected with SARS-CoV-2 from Quito (Ecuador). Methods This single center observational cross-sectional study included 3280 subjects with COVID-19 disease admitted in the IESS Hospital from Quito. Subjects over 18 years old having a positive result in the real time reverse transcriptase polymerase chain reaction (RT-PCR) test for SARS-CoV-2. Confirmed COVID-19 cases were categorized as Severe (PaO2 2 ≥ 60 mmHg). Area under the curve, sensibility and specificity were calculated for these ratios to identify optimal cut-offs according to gender to predict severity and mortality in COVID-19 subjects. Results Covid-19 mortality rate among men was double that in women. Severe and non-surviving patients had a higher NLR and MLR, and a lower MPR. A higher PLR was also associated with severity, but not with mortality. The means of NLR, MLR, and PLR in men were significantly higher, yet MPR levels were lower than in women. In men, these ratios had lower cut-offs than in women (NLR: 2.42 vs. 3.31, MLR: 0.24 vs. 0.35 and PLR: 83.9 vs. 151.9). The sensitivity of NLR, MLR and PLR to predict severity was better in men (69%-77%), while their specificity enhanced in women compared to men (70%-76% vs. 23%-48%). Conclusion High NLR, MLR, PLR and low MPR levels were related to COVID-19 severity with different performance in men and women.

Anemia is a common condition in cancer patients and is associated with a wide variety of symptoms that impair quality of life (QoL). However, exactly how anemia affects QoL in cancer patients is unclear because of the inconsistencies in its definition in previous reports. We aimed to examine the clinical impact of anemia on the QoL of cancer patients using specific questionnaires. We performed a post-hoc analysis of a multicenter, prospective, case-control study. We included patients with cancer with (cases) or without (controls) anemia. Participants completed the European Organization for Research and Treatment of Cancer Quality of Life questionnaire version 3.0 (EORTC QLQ-C30) and Euro QoL 5-dimension 3-level (EQ−5D−3L) questionnaire. Statistically significant and clinically relevant differences in the global health status were examined. From 2015 to 2018, 365 patients were included (90 cases and 275 controls). We found minimally important differences in global health status according to the EORTC QLQ-C30 questionnaire (case vs. controls: 45.6 vs. 58%, respectively, mean difference: −12.4, p &lt, 0.001). Regarding symptoms, cancer patients with anemia had more pronounced symptoms in six out of nine scales in comparison with those without anemia. In conclusion, cancer patients with anemia had a worse QoL both clinically and statistically.

Funding Acknowledgements Type of funding sources: None. Background To stop Coronavirus-19 pandemic, Spanish government ordained home confinement in Basque Country from 13th March to 11th May, although some people had previously confined themselves. In this period, a decrease in cardiovascular admissions, except pulmonary embolism has been reported, speculating about viral activation of coagulation. As patients could not receive the standard care, augmented mortality of non-Covid pathologies could happen. Methods We, selected patients admitted with intermediate-high and high risk from 1st March to 30th June. Other risks or those occurred during a hospitalization were excluded. Several characteristics were reported. Results Among 21 cases (13 women), there were 3 Covid-positive (2 women). All presented an intermediate-high risk, except 2. 16 cases happened in March and April. Mean age was 72,5 years (range 30-94). Mean total stay length was 7,24 days (range 3-12). 14 patients presented original Pulmonary Embolism Severity Index (PESI) class ≥ III and mean simplified PESI (sPESI) was 1.43 points (range 0-4). On average, patients presented 1,95 risk factors for pulmonary embolism (range 0-6), mainly weak ones. Average Troponin T was 130.15 ng/L (range 15-1099, one case unknown). Average NT-proBNP was 6690.42 pg/ml (range 267-35000, 2 cases unknown). Fibrinolytic therapy and vasopressors were only used in intensive care unit (ICU), in 2 and 1 patients respectively. 2 patients were on Unfractionated Heparin, the rest received low-molecular-weight heparin. All patients admitted in ICU were transferred later to ward, except 1 that was transfer to Intermediate respiratory care unit (IRCU). There were no mortality during hospitalization. There were 3 complications that not required intensive therapy. 8 were admitted in ICU (50% women, mean age 61,2 years (range 30-78), average sPESI 1,4 (range 0-4), 6 patients PESI class ≥ III, average troponin 109,25 ng/L (19-259) and NT-proBNP 7219.86 pg/ml (446-15787), 1,88 risk factors on average, stay length 8,25 days (6-11)). The rest were admitted in ward (4 in IRCU) (62% women, mean age 79.46 years (66-94), average sPESI 1,46 (0-4), 8 patients PESI class ≥ III, average troponin 144,08 ng/L (15-1099) and NT-proBNP 6351.58 pg/ml (439-35000), 2 risk factors on average, stay length 6,62 days (3-12)). Conclusions Probably coronavirus-19 is not a risk factor for admission due to severe pulmonary embolism. Home confinement may be a risk factor, and if it happened again, advice against sedentary lifestyle should be given to population. Despite a possible delay in diagnosis or treatment, there were no mortality or severe complications, irrespectively of age or site of admission, although patients in intensive care tend to be younger, presented more frequently PESI class > III and stay more time in hospital. Studies are needed to determine which patients would benefit from admission in intensive care units, especially if resources are limited again. Abstract Figure. Number of cases per month

OBJECTIVE The aim of this study was to evaluate kinematic changes and muscle fatigue in jump gait during a walking exercise and the relationship between kinematic changes and muscle fatigue and strength. DESIGN This preliminary study included 10 children with cerebral palsy who walk with jump gait. Hip and knee maximal isometric muscle strength were measured using a dynamometer. Then, lower-limb kinematics and electromyography were collected while children walked continuously for 6 min at their self-selected speed. Electromyography median frequency and lower-limb joint angles were compared between the first and the sixth minutes of the walking exercise using t test and Wilcoxon rank test. The relationship between kinematic changes and muscle strength and changes in electromyography median frequency were assessed using correlation analyses. RESULTS During stance, maximal knee flexion significantly increased at the sixth minute (P = 0.01) and was associated with knee extensor muscle weakness (ρ = -0.504, P = 0.03). Muscle fatigue was observed only in the gluteus medius muscle (P = 0.01). CONCLUSIONS Children with cerebral palsy who walked with jump gait and who had knee extensor weakness were more prone to an increase in knee flexion during a continuous walk. The fatigue in the gluteus medius muscle suggests that physical intervention should target the endurance of this muscle to improve jump gait.

Background: Recent literature shows a rate of ACL retear after ACLR when returning to sport between 8% and 23%, depending on the population and clinical implications. The risk of a second injury is higher in patients who (1) return to cutting and pivoting sports, (2) do not meet the return to sport criteria before returning to sport, and (3) returning to pivoting sports earlier than 9 months after ACLR. A second ACL injury, either a graft rupture or contralateral ACL injury after ACLR, negatively impacts knee function, quality of life, accelerates degenerative changes in the knee and challenges an athlete’s career. Purpose: This systematic review aimed to investigate whether a knee brace when returning to sport (RTS) could prevent a second injury after anterior cruciate ligament reconstruction (ACLR). Methods: This study was registered with the PROSPERO database and followed PRISMA guidelines. A systematic search of PubMed, Ovid Medline, Ovid All EBM Reviews, Ovid Embase, EBSCO Sportdiscus and ISI Web of Science databases for meta-analysis, randomized controlled trials and prospective cohort studies published before July 2020 was undertaken. The inclusion criteria were: (1) Comparing with and without brace at RTS, (2) follow up of at least 18 months after ACLR, (3) reinjury rates included in the outcomes. Data were extracted independently by two reviewers. Quality appraisal analyses were performed for each study using the Cochrane Collaboration tools for randomized and nonrandomized trials. Results: A total of 1196 patients in 3 studies were included. One study showed a lower rate of reinjury when wearing a knee brace at RTS. One study found the knee brace to have a significant protective effect for younger patient. (p < 0.05). Conclusion: Current data cannot support that using a knee brace when RTS will decrease the rate of reinjury after ACL reconstruction. [Table: see text][Figure: see text][Table: see text][Table: see text][Table: see text][Table: see text]

Background Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at‐risk patients could help to guide the duration of therapy. Methods We used the RIETE database to assess the prognostic value of d‐dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel). Results In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d‐dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19–9.57) events per 100 patient‐years in those with raised d‐dimer levels and 2.68 (95% CI: 1.45–4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71–10.4) and 3.34 (95% CI: 2.39–4.53), respectively. Patients with major risk factors and raised d‐dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96–4.79) than those with normal levels. Patients with minor risk factors and raised d‐dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51–3.63) than those with normal levels. On multivariate analysis, raised d‐dimers (HR: 1.74; 95% CI: 1.09–2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors. Conclusions Patients with raised d‐dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences. Sin financiación 8.989 JCR (2020) Q1, 12/167 Medicine, General & Internal 2.625 SJR (2020) Q1, 9/131 Internal Medicine No data IDR 2020 UEM

The RIETE investigators., In young patients with acute pulmonary embolism (PE), the predictive value of currently available prognostic tools has not been evaluated. Our objective was to compare prognostic value of 7 available tools (GPS, PESI, sPESI, Prognostic Algorithm, PREP, shock index and RIETE) in patients aged, This study received funding: SEPAR (1/2016) grupo GeCIR. We express our gratitude to Sanofi Spain for supporting this Registry with an unrestricted educational grant. We also wish to thank Bayer Pharma AG for supporting this Registry. Bayer Pharma AG’s support was limited to the part of RIETE outside Spain, which accounts for a 25.20% of the total patients included in the RIETE Registry.

Isolated distal deep-vein thrombosis (DVT, infra-popliteal DVT without pulmonary embolism) is a common presentation of venous thromboembolism (VTE), but was an exclusion criterion from the pivotal trials that validated the use of direct oral anticoagulants (DOACs) for VTE management. Using data from the international RIETE registry, we analyzed and compared trends in DOACs prescription between January 2011 and June 2019 in patients with distal vs. proximal DVT. We also assessed DOACs' prescriptions and compared the outcomes (VTE recurrence, bleeding and death) of distal DVT patients treated with DOACs vs. those on vitamin K antagonists (VKAs). 2308 patients with distal DVT and 11,364 patients with proximal DVT were included in the current analysis. DOACs were more frequently prescribed in patients with distal than proximal DVT (25% vs. 16%, p < 0.001). DOACs use increased sharply during the observation period (P < 0.001 for trend). In 2018, 56% of patients with distal DVT received DOACs. Distal DVT patients treated with rivaroxaban or edoxaban received the dose recommended for VTE management in most (> 85%) cases. Patients treated with apixaban were older, more likely to have underlying conditions than patients treated with rivaroxaban and, in most cases (> 75%), did not receive the recommended 1-week loading dose for acute VTE management. Outcomes between distal DVT patients treated with VKAs or DOACs appeared to be similar. In patients with distal DVT, DOACs have become the most common anticoagulant regimen. Specific trials are needed to determine the optimal DOACs dose regimen for treatment of distal DVT.

Index de les obres ressenyades: Thomas Edward LAWRENCE, Guerrilla

The dynamics of granular media within a silo in which the grain velocities are controlled by a conveyor belt has been experimentally investigated. To this end, the building of coarse-grained field maps of different magnitudes has allowed a deep analysis of the flow properties as a function of two parameters: the orifice size and the belt velocity. First, the internal dynamics of the particles within the silo has been fully characterized by the solid fraction, the velocity of the particles and the kinetic stress. Then, the analysis of the vertical profiles of the same magnitude (plus the acceleration) has allowed connection of the internal dynamics with the flow rate. In particular, we show that the gamma parameter – which accounts for the integration of the normalized acceleration along the vertical direction – can successfully discriminate the kind of flow established within the silo (from the quasistatic regime to the free discharge) depending on the outlet size and belt velocity.

Pretendemos mostrar cómo el desarrollo y uso de las TICs, junto con otros procesos y elementos, están ayudando a crear algo que denominaremos estado de guerra global. En este nuevo contexto, dicotomías tales como paz-guerra, local-global, frente-retaguardia, material-inmaterial están quedando borradas o confusas. Para ello, nos fijaremos en cómo algunos aspectos del conflicto palestino-israelí cambian la forma de hacer y entender la guerra. Concretamente, analizaremos aspectos como la seguridad, el control social, y la expansión de la guerra a todos los ámbitos de la vida a través de los asesinatos selectivos, la figura del suicida y el uso de las excavadoras en un contexto bélico, entre otros. Y esto tiene unos efectos que llevan la guerra más allá de sí misma, afectando a otras esferas.

Isolated distal deep-vein thrombosis (DVT, infra-popliteal DVT without pulmonary embolism) is a common presentation of venous thromboembolism (VTE), but was an exclusion criterion from the pivotal trials that validated the use of direct oral anticoagulants (DOACs) for VTE management. Using data from the international RIETE registry, we analyzed and compared trends in DOACs prescription between January 2011 and June 2019 in patients with distal vs. proximal DVT. We also assessed DOACs' prescriptions and compared the outcomes (VTE recurrence, bleeding and death) of distal DVT patients treated with DOACs vs. those on vitamin K antagonists (VKAs). 2308 patients with distal DVT and 11,364 patients with proximal DVT were included in the current analysis. DOACs were more frequently prescribed in patients with distal than proximal DVT (25% vs. 16%, p 0.001). DOACs use increased sharply during the observation period (P 0.001 for trend). In 2018, 56% of patients with distal DVT received DOACs. Distal DVT patients treated with rivaroxaban or edoxaban received the dose recommended for VTE management in most ( 85%) cases. Patients treated with apixaban were older, more likely to have underlying conditions than patients treated with rivaroxaban and, in most cases ( 75%), did not receive the recommended 1-week loading dose for acute VTE management. Outcomes between distal DVT patients treated with VKAs or DOACs appeared to be similar. In patients with distal DVT, DOACs have become the most common anticoagulant regimen. Specific trials are needed to determine the optimal DOACs dose regimen for treatment of distal DVT.

Objective Robotic gait training presents a promising training modality. Nevertheless, evidence supporting the efficacy of such therapy in children with cerebral palsy remains insufficient. This study aimed to assess the effect of robotic gait training in children/adolescents with cerebral palsy. Methods Twenty-four children/adolescents with bilateral cerebral palsy (12 female, 10.1 ± 3.1 years, Gross Motor Function Classification System II to IV) took part in this study. They received two 30−45 min sessions/week of Lokomat training for 12-weeks. Muscle strengths, 6-min walk exercise and gait parameters were evaluated pre- and post-training and at 6-months-follow-up. Training effect according to the level of impairment severity (moderate vs severe) was analyzed using a change from the baseline procedure. Results A significant increase in muscle strength was observed after training (p ≤ 0.01). Hip flexors and knee extensors strength changes were maintained or improved at follow-up (p

Background: The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE. Methods: Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001–January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging. Results: Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6–78.7]); including pregnant patients (58.9% [99% CI, 47.7%–69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9–65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%, P P Conclusions: In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.

Background Venous thromboembolism (VTE) is a major cause of morbidity and mortality postoperatively. The use of pharmacologic prophylaxis is effective in reducing the incidence of VTE. However, the prophylaxis is often discontinued at hospital discharge, especially for those with benign disease. The implications of this practice are not known. We assessed the data from a large, ongoing registry regarding the time course of VTE and outcomes after noncancer surgery. Methods We analyzed the RIETE (Computerized Registry on Venous Thromboembolism) registry, which includes data from consecutive patients with symptomatic confirmed VTE. In the present study, we focused on general surgical patients who had developed symptomatic postoperative VTE in the first 8 weeks after noncancer surgery. The main objective was to assess the interval between surgery and the occurrence of VTE. Additional variables included the clinical presentation associated with the event, the use of thrombosis prophylaxis, and unfavorable outcomes. Results The data from 3296 patients were analyzed. The median time from surgery to the detection of VTE was 16 days (interquartile range, 8-30 days). Of the VTE events, 77% were detected after the first postoperative week and 27% after 4 weeks. Overall, 43.9% of the patients with VTE had received pharmacologic prophylaxis after surgery for a median of 8 days (interquartile range, 5-14 days), and three quarters of the VTE events were detected after pharmacologic prophylaxis had been discontinued. Overall, 54% of the patients with VTE had presented with pulmonary embolism. For 15% of the patients, the clinical outcome was unfavorable, including 4% who had died within 90 days. Conclusions The risk of VTE after noncancer general surgery remains high for ≤2 months. More than one half of the patients had presented with symptomatic PE as the VTE event, and 15% had had unfavorable outcomes. Only 44% of these patients had received pharmacologic prophylaxis for around 1 week.

Introduction Risk stratification of normotensive patients with acute pulmonary embolism (PE) includes the assessment of right ventricular dysfunction (RVD), biomarker levels, and a clinical score as suggested by the 2014 guidelines of the European Society of Cardiology (ESC). We performed an external validation of the prognostic performance of Heart-type Fatty Acid Binding Protein (H-FABP) and incorporated it into the new ESC algorithm. Material and methods H-FABP was measured by fully-automated immunoturbidimetry in 716 patients from the PROTECT study (PROgnosTic valuE of CT scan in haemodynamically stable patients with acute symptomatic PE). Results H-FABP ranged from 0.7 to 123.6 ng/ml (median 4.13; IQR, 2.53–6.61) and was above the cut-off of 6 ng/ml in 209 patients (29.2%). A complicated course within 30 days (death, catecholamine administration, mechanical ventilation, resuscitation) occurred in 1.1% ( n = 3) of the 271 low risk patients with a simplified Pulmonary Embolism Severity Index (sPESI) of 0 and was particular low (0.4%), if H-FABP levels were normal. In the case of elevated H-FABP, 4.3% of patients suffered complications despite sPESI of 0. The risk for an adverse 30-day outcome increased for patients of the intermediate-low and intermediate-high risk group and was highest for the combination of sPESI ≥1 with RVD on MDCT and elevated H-FABP (odds ratio 12.3, 95% confidence interval, 3.49–43.32; P Conclusions H-FABP is suitable for risk stratification of normotensive PE patients if integrated in the new ESC algorithm and may help to identify patients with higher risk for adverse clinical events.