Venous Thromboembolism Risk Assessment and Prophylaxis in Obstetrics Patients in a Tertiary Health Center in Jeddah, Saudi Arabia.

Aim The study aimed to estimate the proportion of patients who were evaluated for thrombosis risk and received appropriate thromboprophylaxis, if indicated, in King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Method This was a retrospective cross-sectional study conducted among inpatients from May 1 to August 31, 2020, in KAUH. Results Out of 298 pregnant women, the mean age was 32.09 ± 5.29 years. A total of 136 (45.6%) were obese and 97 (32.6%) were overweight. There was a significant relationship between Caprini score categories and the following variables: age, body mass index (BMI), medical disease, history of deep vein thrombosis (DVT), mode of delivery, prophylaxis, and its duration (p < 0.05). Conclusion Awareness about thromboprophylaxis in reducing the risk of developing venous thrombosis has increased compared to before, with more than half of the cases receiving it regardless of the risk level. The highest risk of venous thromboembolism (VTE) was found in older women, obese women, and those with a previous history of DVT. Low-molecular-weight heparin (LMWH) was the main prophylaxis in the hospital with an average duration of three days.

Timing Matters: Ultra-Early and Early versus Late Thromboprophyaxis Following Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis.

Spontaneous intracerebral hemorrhage (ICH) represents a critical and potentially devastating medical event resulting from the rupture of intracerebral vessels. Patients afflicted with ICH face an increased risk of venous thromboembolism (VTE) due to factors such as immobility. However, determining the ideal timing for initiating venous thromboembolism thromboprophylaxis (TP) remains uncertain, as it may carry the potential risk of exacerbating hematoma expansion. Thus, our objective was to ascertain the optimal timing for initiating TP following ICH through a comprehensive systematic review and meta-analysis.This systematic review and meta-analysis were performed following the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines, considering outcomes based on the time of intervention: Ultra early (UEPT) < 24 h, Early (EPT) < 48 h, Late (LPT) > 48 h to perform an analysis on hematoma expansion and mortality.Of 2.777 Hematoma expansion was not more frequent in the 440 patients receiving UEPT/EPT (n = 440) versus 565 receiving LPT (Odds ratio (OR) 0.94 (95% CI; 0.62 to 1.43; I2 = 0%)). Similarly, mortality was not lower in the 293 received UEPT or EPT versus 477 receiving LPT (OR 0.63 (95% CI; 0.39 to 1.0; I2 = 0%).This study, through a systematic review and meta-analysis, conclusively found no difference in intracranial hematoma expansion and/or increased mortality between the use of heparin in the early thromboprophylaxis (< 48 h) group compared to the late thromboprophylaxis (> 48 h) group. Implementing this approach in the management of spontaneous cerebral hemorrhage could facilitate progress towards more optimal care protocols.

Impact of COVID-19 in the incidence of venous thromboembolism (VTE) and clinical outcomes in cancer patients: a cohort study.

PURPOSE: To determine the incidence of VTE and clinical outcomes in a cohort of cancer patients and COVID-19 infection, and to establish possible predictive factors of VTE. METHODS/PATIENTS: A single-center retrospective cohort study was performed to determine the incidence of VTE and mortality in 118 cancer patients with SARS-CoV-2 infection from March to August 2020. We calculated individual Khorana Risk and CATS-MICA scores in order to evaluate their utility to identify risk of VTE or death. Continuous variables were compared using Wilcoxon or Student's T test, and categorical variables were compared using the Chi-Square or Fisher's exact text among patients with and without VTE. A Log-Rank test was performed to detect mortality differences between the groups. RESULTS: A total of 118 patients were included. VTE global incidence was 4.2% (n = 5), and mortality 25.4% (n = 30). Obesity (p = 0.05), recent chemotherapy (p = 0.049) and use of steroids (p = 0.006) were related to higher risk of VTE in the univariate analysis, although they were not confirmed in the multivariate analysis as independent risk factors. Statistically significant differences in all-cause, COVID-19-related and cancer-related mortality according to the Khorana risk score (KRS) were observed. CATS-MICA score (CMS) also showed statistically significant differences in mortality between low- and high-risk patients. Prediction of risk of VTE development with these scores showed a tendency towards significance. CONCLUSIONS: In this cohort, VTE incidence was similar to previously reported in the general population with SARS-CoV-2 infection. KRS was associated with overall and specific-cause mortality, and might be a useful prognostic tool in this setting.

Universal Clinical Decision Support Tool for Thromboprophylaxis in Hospitalized COVID-19 Patients: Post-Hoc Analysis of the IMPROVE-DD Cluster Randomized Trial.

BACKGROUND: Inpatient and extended post-discharge thromboprophylaxis of COVID-19 patients remain suboptimal despite antithrombotic guidelines. OBJECTIVES: To determine whether a novel electronic health record (EHR)-agnostic clinical decision support (CDS) tool incorporating IMPROVE-DD VTE scores increases appropriate inpatient and extended post-discharge thromboprophylaxis and improves outcomes in COVID-19 inpatients. METHODS: This post-hoc analysis of the IMPROVE-DD cluster randomized trial evaluated thromboprophylaxis CDS among COVID-19 inpatients at four New York hospitals between December 21, 2020, and January 21, 2022. Hospitals were randomized 1:1 to CDS (intervention, N=2), versus no CDS (usual care, N=2). The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included rates of major thromboembolism, all-cause and VTE-related readmissions and death, major bleeding (MB), and all-cause mortality 30 days post-discharge. RESULTS: 2,452 COVID-19 inpatients were analyzed (1,355 CDS; 1,097 no CDS). Mean age was 73.7 ± 9.37 years; 50.1% of participants were male. CDS adoption was 96.8% (intervention group). CDS was associated with increased appropriate at-discharge extended thromboprophylaxis (42.6% versus 28.8%, odds ratio [OR] 1.83, 95% Confidence Interval [CI] 1.39 - 2.41, p<0.001). CDS was associated with reduced VTE (OR 0.54, 95% CI 0.39-0.75, p<0.001), arterial thromboembolism (OR 0.10, 95% CI 0.01-0.81, p=0.01), total TE (OR 0.50, 95% CI 0.36-0.69, p<0.001), and 30-day all-cause readmission/death (OR 0.78, 95% CI 0.62-0.99, p=0.04). There were no differences in MB, VTE-related readmissions/death, or all-cause mortality. CONCLUSION: EHR-agnostic CDS incorporating IMPROVE-DD VTE scores had high adoption, was associated with increased appropriate at-discharge extended thromboprophylaxis, and reduced TE and all-cause readmission/death without increasing MB in COVID-19 inpatients.

Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care.

Objectives: This study evaluated the incidence and risk factors for deep venous thrombosis (DVT) while on thromboprophylaxis, in patients admitted to the medical intensive care unit (MICU), and to assess its impact on outcomes. Methods: Consecutive patients admitted to the MICU underwent compression ultrasound of the jugular, axillary, femoral, and popliteal veins at admission, day 3 and 7 to screen for DVT. All patients were on pharmacological and/or mechanical thromboprophylaxis as per protocol. The primary outcome was the incidence of DVT (defined as occurrence on day 3 or 7). Secondary outcomes were death and duration of hospitalization. Risk factors for DVT were explored using bivariate and multivariable logistic regression analysis and expressed as risk ratio (RR) with 95% confidence intervals (CIs). Results: The incidence of DVT was 17.2% (95% CI 12.0, 22.3) (n = 35/203); two-thirds were catheter associated (23/35). There was no difference in mortality between those with and without incident DVT (9/35 vs 40/168, p = 0.81). The mean (SD) duration of hospitalization was longer in the DVT group (20.1 (17) vs 12.9 (8.5) days, p = 0.007). Although day 3 INR (RR 2.1, 95% CI 0.9-5.3), age >40 years (2.1, 0.8-5.3), vasopressor use (1.0, 0.4-2.9) and SOFA score (0.9, 0.85-1.1) were associated with the development of DVT on bivariate analysis, only central venous catheters (15.97, 1.9-135.8) was independently associated with DVT on multivariable analysis. Conclusions: Despite thromboprophylaxis, 17% of ICU patients develop DVT. The central venous catheter is the main risk factor. DVT is not associated with increased mortality in the setting of prophylaxis. How to cite this article: Krishnamoorthy A, Hansdak SG, Peter JV, Pichamuthu K, Rajan SJ, Sudarsan TI, et al. Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care. Indian J Crit Care Med 2024;28(6):607-613.

Risk Factors for Anemia Exacerbation Requiring Red Blood Cell Transfusion During Edoxaban Thromboprophylaxis After Orthopedic Surgery.

Background An increased risk of anemia during edoxaban thromboprophylaxis in orthopedic surgery has been reported. However, the risk factors for the exacerbation of anemia requiring transfusion with irradiated red blood cell concentrates during postoperative edoxaban thromboprophylaxis remain unknown. Therefore, this study investigated the factors that increase the possibility of transfusion during edoxaban thromboprophylaxis after orthopedic surgery by reanalyzing clinical data from a previous collection. Methods A total of 221 patients who underwent total hip or knee arthroplasty at a single center between July 2011 and June 2012 were included in this study. Among these, 167 patients who received 30 mg of postoperative edoxaban thromboprophylaxis were retrospectively analyzed to identify critical factors for transfusion during edoxaban thromboprophylaxis after orthopedic surgery. Results Lower preoperative hemoglobin levels and higher intraoperative blood loss per body weight were significantly associated with an increase in the frequency of transfusion during postoperative edoxaban thromboprophylaxis. These factors were also potentially related to increased coagulation parameters during edoxaban thromboprophylaxis. Conclusion Our study shows that lower preoperative hemoglobin levels and higher intraoperative blood loss are associated with increased coagulation parameters with edoxaban thromboprophylaxis after orthopedic surgery and may lead to worsening of anemia, thereby requiring blood transfusion.

Extended thromboprophylaxis in heart failure patients; the unmet need.

Heart failure (HF) is considered one of a leading cause of cardiovascular morbidity and mortality worldwide. The association between HF and venous thromboembolism (VTE) has been reported in several studies owing to many physiological and thromboembolic risk factors. Thus, the need for extended thromboprophylaxis during the post-discharge period in HF patients has been evaluated. Most guidelines do not recommend extended thromboprophylaxis because of its uncertain benefits and increased risk of bleeding. However, recent evidence in HF patients revealed no increased risk of bleeding with extended thromboprophylaxis, which highlights the importance of identifying ideal candidates who might benefit from extended thromboprophylaxis. Several risk assessment models (RAMs) have been developed to identify patients at a high risk of VTE who would benefit from in-hospital and post-discharge prophylactic anticoagulation therapy based on the risk-benefit principle. However, their accuracy in predicting VTE is questionable, and none have a standardized approach for evaluating the risk of VTE in HF patients. In this review, we provided an overview of the incidence and pathophysiology of VTE in HF patients, a summary of guideline recommendations for VTE prevention, and a summary of studies evaluating the use of extended thromboprophylaxis, with a focus on subgroup or post-hoc analyses of HF patients. We also discussed the need to design an ideal RAM that can identify candidate patients for extended thromboprophylaxis by stratifying the risk of VTE and identifying the key risk factors for bleeding in medically ill patients, including those with HF.

Comparative effectiveness among thromboprophylaxis strategies after the Fontan operation: A systematic review and network meta-analysis.

INTRODUCTION: A variety of thromboprophylaxis regimens have been administered in patients following the Fontan procedure. However, consensus guidelines regarding the optimal thromboprophylaxis strategy have not yet been developed. METHOD: A network meta-analysis was conducted to evaluate the comparative effectiveness among available thromboprophylaxis regimens and major bleeding events associated with these regimens. RESULTS: A total of 28 comparative studies with 4430 Fontan patients were included. The incidence of thromboembolic events (TE) was significantly lower in individuals who underwent thromboprophylaxis compared to those who did not. Compared to a no-treatment strategy, nonvitamin K oral anticoagulants (NOACs) showed the largest treatment effect for preventing TE (OR = 0.08, 95 % CI 0.03 to 0.21), followed by warfarin (OR = 0.16, 95 % CI 0.10 to 0.27), and aspirin (OR = 0.23, 95 % CI 0.14 to 0.38). Indeed, NOACs were significantly more effective than aspirin in preventing TE (OR = 0.35, 95 % CI 0.14 to 0.84). Aspirin was associated with the lowest occurrence of major bleeding events, followed by NOACs, no medication, and warfarin. NOACs were shown to possess a highly favorable overall profile. CONCLUSION: Prescribing thromboprophylaxis drugs, either antiplatelets or anticoagulants, may be more effective in preventing TE after the Fontan operation than not doing so. Among the included regimens, NOACs demonstrated significantly greater efficacy than aspirin; however, they did not show statistically significant superiority over warfarin. Aspirin exhibited lower rates of major bleeding compared to both NOACs and warfarin. Overall, NOACs tended to offer the most advantageous balance of efficacy and safety. However, the findings should be interpreted considering the certainty and limitations of the evidence, including potential residual confounding in observational studies.

Efficacy of therapeutic-dose heparin for severe COVID-19 patients at COVID-19 Emergency Hospital Jakarta.

INTRODUCTION: Arterial and venous thrombotic events in COVID-19 cause significant morbidity and mortality. For optimal thromboprophylaxis treatment for hospitalized patients, especially those with severe COVID-19 symptoms, it is still unclear whether to use full- or therapeutic-dose versus prophylactic-dose anticoagulation therapy. The study aim was to evaluate the efficacy and safety of unfractionated heparin (UFH) for thromboprophylaxis in severe degree of COVID-19. METHODOLOGY: In this cross-sectional study, the medical records of 160 COVID-19 patients at the COVID-19 Emergency Hospital Wisma Atlet, Jakarta, from March to August 2021, were collected. The predetermined inclusion criteria for patients were severe COVID-19 infection; age > 18 years; positive D-dimer level > 400 ng/mL; high-flow nasal cannula (HFNC) oxygenation; IMPROVE bleeding risk score < 7; and willingness to participate in the study. The primary outcome was activated partial thromboplastin time (APTT) target achievement, oxygenation changed to nasal cannula or ended with room air, mortality rate, and the principal safety criterion was presence of bleeding. RESULTS: Of 160 subjects, 63.8% were male and 45.6% were aged 45-59 years old. Obesity was the most common comorbidity at 45.6% Among all subjects, 9.4% experienced bleeding, with hematuria being the most frequent type at 66.7%. All subjects released HFNC, and no deaths were reported. CONCLUSIONS: It can be concluded that administration of therapeutic doses of heparin in patients with severe COVID-19 had a low risk of bleeding and no patients were reported to have died. However, further investigation is needed to determine the long-term effects of therapeutic doses of anticoagulants.

Avoiding the needle: A quality improvement program introducing apixaban for extended thromboprophylaxis after major gynecologic cancer surgery.

OBJECTIVE: Patients undergoing gynecologic cancer surgery at our centre are recommended up to 28 days of enoxaparin for extended post-operative thromboprophylaxis (EP). Baseline survey revealed 92% patient adherence, but highlighted negative effects on patient experience due to the injectable route of administration. We aimed to improve patient experience by reducing pain and bruising by 50%, increasing adherence by 5%, and reducing out-of-pocket cost after introducing apixaban as an oral alternative for EP. METHODS: In this interrupted time series quality improvement study, gynecologic cancer patients were offered a choice between apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously once daily) at time of discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included standardized orders, patient and care team education programs. Telephone survey at 1 and 6 weeks and chart audit informed outcome, process, and balancing measures. RESULTS: From August to October 2022, 127 consecutive patients were included. Apixaban was chosen by 84%. Survey response rate was 74%. Patients who chose apixaban reported significantly reduced pain, bruising, increased confidence with administration, and less negative impact of the medication (p < 0.0001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 (apixaban cost threshold) increased from 45% to 91%. There was no difference in bleeding and no VTE events. CONCLUSIONS: Introduction of apixaban for EP was associated with significant improvement in patient-reported quality measures and reduced financial toxicity with no effect on adherence or balancing measures. Apixaban is the preferred anticoagulant for EP at our centre.

Venous thromboembolism in patients with pancreatic adenocarcinoma: Disease burden and initiation of ambulatory thromboprophylaxis.

BACKGROUND/OBJECTIVES: Ambulatory thromboprophylaxis (AT) in patients with pancreatic adenocarcinoma (PAC) reduces venous thromboembolism (VTE) risk and is recommended for patients receiving systemic chemotherapy. We evaluated VTE rates, severity, timing, and risk factors in PAC patients as well as AT rates and initiation times. METHODS: Patients diagnosed with PAC were included. Data collected included patient demographics, medical history, PAC diagnosis, development of VTE, AT, and bleeding episodes. VTE was defined as a DVT or a PE. Patients were classified as receiving AT for VTE prevention if they received a prescription for outpatient anticoagulation. RESULTS: The cohort included 243 PAC patients. VTE occurred in 24 %. Overall, 52 % developing VTE were hospitalized and 5 % died as a result of the VTE. Of those who developed VTE 50 % were diagnosed within the first 2 months of PAC diagnosis. Univariate predictors of elevated VTE risk included an elevated Onkotev score, metastasis at diagnosis, male gender and not receiving AT. Multivariate predictors of elevated VTE risk included male gender (P = 0.014) and not receiving AT (P = 0.001). Overall, 30 % of patients received AT. The median time from diagnosis to initiation of AT was 43 days. Major bleeding occurred in 5.8 %. Patients receiving AT were not at a significantly increased risk of major bleeding (p = 0.5). Patients with intestinal tumor invasion were at significantly increased risk of major bleeding (P = 0.021). CONCLUSION: VTE risk is significant and morbid in PAC patients. AT rates are low, and initiation is often delayed. Therapeutic endoscopists diagnosing PAC may be helpful in AT initiation.

A Multi-center Cross-Sectional Assessment of Healthcare Professionals' Knowledge, Attitudes, and Practices Toward Thromboprophylaxis.

Background Venous thromboembolism (VTE) is a potentially avoidable condition that affects hospitalized patients. Risk stratification and preventative strategies have substantial evidence supporting their use, but reasons hinder widespread adoption, compliance, and success, explaining the continuation of VTE. Thromboprophylaxis consists of several measures that are frequently adopted to avoid the complications of VTE. The study evaluated knowledge, attitude, and practice toward using thromboprophylaxis by health professionals. Methods This multi-center cross-sectional study was carried out on health professionals involved in patient care working in various secondary and tertiary hospitals in the study region between October 2023 and February 2024. A previously published questionnaire was sent in the form of an online survey to the study participants. Fifteen, ten, and nine questions evaluated the participants' knowledge, attitude, and practice of thromboprophylaxis, respectively. The study followed the checklist for reporting results of the Internet E-survey (CHERRIES) guidelines. Frequency and percentages were calculated. Bi-variable and multi-variable logistic regression were carried out and presented as crude and adjusted odds ratios with corresponding 95% confidence intervals. A P-value of <0.05 was considered significant. Results Of the 219 participants, 115 (52.5%) and 104 (47.5%) were males and females. More than 50.7% were in the age group of >30 years, and the majority of the participants possessed a bachelor's (104 (47.5%)) degree. One hundred seventy-six (80.4%) of the study participants were working in government hospitals, and the majority (112 (51.1%)) were nurses. One hundred sixty-two (74% (67.63-79.65)), 175 (79.9% (73.98-85.01)) and 211 (96.3% (92.93)) had satisfactory knowledge, a positive attitude, and good practice regarding thromboprophylaxis, respectively. Regarding the facility characteristics, 196 (89.5%), 150 (68.5%), and 164 (74.9%) respondents agreed with the availability of a VTE prevention policy, VTE prevention consultants, and the availability of anticoagulants. Eighty (36.5%) participants responded with a 'not availability' of pneumatic compression devices. Of the 15 knowledge questions, the majority (124 (56.6%)) participants faulted the false statements regarding 'patients of DVT being symptomatic' and 119 (54.3%) on the statement that helping patients 'out of bed activity does not prevent VTE'. On multi-variable analysis, participants who were aware of having a VTE prevention policy and availability of anticoagulants were more knowledgeable with adjusted odds ratios of 5.39 (1.88-15.39) and 2.52 (1.12-5.63) respectively. Every practice domain received >90% approval ratings. Conclusions The study concludes that an overall satisfactory knowledge and positive attitude regarding thromboprophylaxis exists among the participants. The study proposes more training sessions on VTE prevention and orientation of health professionals on the availability of VTE policy guidelines and facility availability of resources for thromboprophylaxis.

The Influence of Diabetes on Thrombotic Profiles and Outcomes on Patients with Peripheral Artery Disease.

BACKGROUND: Elevated glycated hemoglobin (HbA1c) is associated with vascular complications, including arterial thrombosis post-revascularization. However, the objective relationship between levels of HbA1c and coagulation profiles has not been established. This study aims to determine the association between specific coagulation parameters and variations in HbA1c in patients undergoing lower extremity revascularization. METHODS: Patients with Peripheral Artery Disease (PAD) undergoing revascularization were prospectively evaluated between December 2020 and July 2023. Patients were categorized based on their HbA1c levels, and their thromboelastography with platelet mapping (TEG-PM) results were compared at baseline, post-operatively day 1, 1 month, 3 months and 6 months. The parameters included Maximum Amplitude (MA) with both adenosine diphosphate (ADP) and arachidonic acid (AA), as well as ADP and AA percent aggregation indicating clot strength. The study further assessed the differences in these parameters between groups with varying HbA1c levels through the use of unpaired Student t test for pairwise analysis and Mann-Whitney U tests. RESULTS: Among 830 samples, those with HbA1c above 6.5 demonstrated a significant increase in ADP MA (52.6 vs. 43.5, p<0.01), AA MA (36.6 vs. 29.65, p<0.05), clot strength without platelets ActF MA (activator F: 13.10 vs. 10.80, p<0.01), and heparin neutralized uninhibited clot strength from thrombin activation HKH MA (heparinized kaolin with heparinase: 61.10 vs. 57.70, p<0.01) values at baseline. Post-operatively, patients with HbA1c levels greater than 6.5 had higher median functional fibrinogen CFF FLEV levels (citrated functional fibrinogen: 40.95 vs. 371.35, p<0.05) and higher formation of fibrin in response to stimulation of thrombin by tissue factor CFF MA values (22.90 vs. 20.40, p<0.05) when measured within 36 hours of intervention, with these trends staying consistent during the 1-month follow-up visit. The trend analysis revealed a progressive increase in ADP MA values with rising HbA1c values, indicating a unit increase in the thrombotic risk relationship. Regression analysis showed a positive relationship between HbA1c and both ADP MA (a 2.261 unit increase for each unit increase in HbA1c) and AA MA. The R-square values indicate that HbA1c only explains a small percentage of the variance in these parameters, suggesting the confounding influence of other factors contributing to thrombosis. CONCLUSION: Elevated HbA1c levels appear to be associated with pro-thrombotic tendencies in clot dynamics as measured by TEG-PM, particularly in parameters related to platelet function. HbA1c explains a limited proportion of the variability in these measures, emphasizing the need for a comprehensive approach to evaluating clotting profiles in patients. This study lays the groundwork for further investigation into personalized antithrombotic strategies for patients with varying HbA1c levels.

Hospital acquired venous thromboembolism in children with sickle cell disease.

Sickle cell disease (SCD) is well recognized as a hypercoagulablestate, however, it remains unclear whether a subgroup of children with SCD at higher risk of venous thromboembolic event (VTE) during hospitalization may benefit from thromboprophylaxis. Our objectives were to describe the clinical characteristics, outcomes and recurrence of hospital acquired VTE in patients with SCD younger than 21 years. This was a single center retrospective study. Data regarding demographics, reason for admission, location of VTE, risk factors like central venous catheter (CVC), intensive care unit (ICU) admission among others were extracted from electronic medical records over a 10-year study period (2011-2021). Recurrence of VTE at 1 and 5 years was assessed. Descriptive statistics were used as indicated. We identified a total of 20 VTE events over the 10-year study period. Six of these events occurred in those younger than 12 years of age. Fourteen (70%) VTE events occurred in the HbSS or HbSßThal0 genotypes compared to 6 (30%) in HbSC. Most common VTE was isolated pulmonary embolism (PE) (n = 10, 50%). VTE were most often associated with acute chest syndrome (ACS) (n = 14, 70%), ICU admissions (n = 10, 50%) and CVC (n = 5/9, 55%). One patient died from the VTE event. One patient with additional underlying risk factors had a recurrent VTE at 13 months. Our study suggests that ICU admission, ACS and presence of CVC increases the risk of VTE in children and young adults with SCD, but larger studies are indicated to validate our findings.

Feline Aortic Thromboembolism: Recent advances and future prospects.

PRACTICAL RELEVANCE: Feline aortic thromboembolism (FATE) is commonly encountered in clinical medicine, especially in emergency situations. This often devastating syndrome usually develops secondarily to severe heart disease, and has short- and long-term consequences. CLINICAL FEATURES: The clinical presentation of FATE is consistent with peripheral ischemic neuropathy, usually in both pelvic limbs. Diagnosis is relatively straightforward, but can be assisted with Doppler ultrasound, point-of-care ultrasound or infrared thermal imaging. RECENT ADVANCES AND FUTURE PROSPECTS: Interpretation of survival rates in cats with FATE has been hampered by historically high admission euthanasia, but recent studies suggest a survival rate with supportive care of 30-40%. Moreover, with advances in post-FATE thromboprophylaxis, median survival times of over 1 year are being achieved. Future directions include use of thrombolytic agents and treatment of common FATE sequelae such as acute kidney injury and reperfusion injury. OUTLINE: This article, aimed at small animal veterinarians, including emergency practitioners, reviews key aspects of the clinical presentation, diagnosis and treatment options for FATE, with a view to guiding client and veterinarian decision-making. Three case studies are included to illustrate the practical application of information presented in the review. EVIDENCE BASE: There are limited prospective studies on FATE, although the recent literature reflects a resurgence in clinical research interest in the past few years. Advances in FATE treatment will benefit many cats and it is important that research efforts continue to identify appropriate treatment modalities.

Evaluating Thromboprophylaxis Strategies for High-Risk Pregnancy: A Current Perspective.

Venous thromboembolism (VTE) represents one of the leading causes of death during pregnancy. The greatest risk for it is the presence of medical or family history of VTE, stillbirth, cesarean section and selected thrombophilia. Appropriate thromboprophylaxis has the potential to decrease the risk of VTE in at-risk pregnant patients by 60-70%. Based on this, the authors reviewed the PubMed, Web of Science and Scopus databases to identify the possibilities of thromboprophylaxis in pregnant patients with a high risk of VTE. Moreover, they summarized its management in specific situations, such as cesarean delivery or neuraxial blockade. Currently, low-molecular-weight heparins (LMWH) are the preferred drugs for anticoagulant thromboprophylaxis in the course of pregnancy and postpartum due to easy administration and a lower rate of adverse events.

HYPERTENSION AND DIABETES MELLITUS ARE ASSOCIATED WITH DEEP VENOUS THROMBOEMBOLISM: A CASE CONTROL STUDY.

Introduction: Identifying risk factors for venous thromboembolism (VTE) is useful in deciding thromboprophylaxis for VTE. A retrospective study had shown an association between hypertension and diabetes mellitus with VTE in our population. The objective of this study was to confirm these findings and to determine if the complete blood count and coagulation tests can also be useful parameters in stratifying VTE patients for prophylaxis. Methods: This is a gender and age matched prospective case-control study of 45 Doppler's confirmed DVT and 43 apparently healthy controls. Results: Identified risk factors included history of hypertension, diabetes mellitus, previous DVT, recent surgery, recent trauma, malignancy, sepsis, and immobility. The cases had a significantly lower mean haematocrit (33±7.4% vs 38±4.6%, p<0.001). Though no differences were observed in leucocyte and platelet counts between cases and controls but stratification as leucocytosis vs leucopaenia (P=0.003) and thrombocytosis vs thrombocytopaenia (P=0.045) differed between both groups. Also, the International normalized ratio (INR) was higher in cases (1.1±0.2 vs 1.0±0.1;P=0.001), hypercoagulable state (INR<0.9) and hypocoagulable state (INR>1.2) were observed in 4.4% and 28.9% of cases respectively but not in controls (P <0.001). Also, aPTT>40 seconds was seen in 4.4% vs 4.7% of cases and controls respectively and aPTT< 30 seconds in 22% of cases but not in controls (P =0.004). Conclusion: Hypertension and diabetes mellitus are identified risk factors not traditionally associated with DVT. These in addition to a complete blood count and coagulation tests can be useful in stratifying patients for prophylaxis in our population and other similar communities.

Characteristics of Patients Not Receiving Chemical Thromboprophylaxis Following Foot and Ankle Surgery: Data From the Multicenter, Prospective UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE).

BACKGROUND: Although the rate of venous thromboembolism (VTE) after foot and ankle surgery is low, multiple factors influence risk for individual patients. Furthermore, there are no clear guidelines on which patients may benefit from chemical thromboprophylaxis. Our aim was to assess patients not treated with chemical thromboprophylaxis after foot and ankle surgery, and to report on their specific patient and surgical risk factors for VTE. METHODS: This was a multicenter, prospective, national audit of patients undergoing foot and ankle surgery (including Achilles tendon ruptures) from 68 participating UK centers. The study was conducted between June 1, 2022, and November 30, 2022, with a further 3-month follow-up. Following data cleansing, 3309 patients were included who did not receive postoperative thromboprophylaxis. RESULTS: Most patients were elective cases (2589 patients, 78.24%) with ASA grade I or II (2679 patients, 80.96%), fully weightbearing postoperatively (2752 patients, 83.17%), and either without ankle splintage, or splinted in a plantigrade boot (2797 patients, 84.53%). The VTE rate was 0.30% overall (11 cases), with no VTE-related mortality. No single demographic, surgical, or postoperative factor was associated with reduced risk of VTE. However, patients who had elective or trauma surgery not involving the ankle, who were ASA grade I or II and who were weightbearing immediately postoperatively (without splinting or in a plantigrade boot) had a VTE rate of 0.05% (1 of 1819 patients), compared with 0.67% (10 of 1490 patients, P = .002). CONCLUSION: Patients not receiving chemical thromboprophylaxis had a low incidence of symptomatic VTE, although they do represent a curated group considered lower risk. Within this group we describe characteristics associated with a substantially lower risk of VTE. All patients should be assessed on an individual basis, and further work is required to substantiate our findings.

Platelet-targeted thromboprophylaxis with a human serum albumin fusion drug: Preventing thrombosis and reducing cardiac ischemia/reperfusion injurywithout bleeding complications.

Background: Myocardial infarction (MI) as a consequence of atherosclerosis-associated acute thrombosis is a leading cause of death and disability globally. Antiplatelet and anticoagulant drugs are standard therapies in preventing and treating MI. However, all clinically used drugs are associated with bleeding complications, which ultimately limits their use in patients with a high risk of bleeding. We have developed a new recombinant drug, targ-HSA-TAP, that combines targeting and specific inhibition of activated platelets as well as anticoagulation. This drug is designed and tested for a prolonged circulating half-life, enabling unique thromboprophylaxis without bleeding complications. Methods: Targ-HSA-TAP combines a single-chain antibody (scFv) that targets activated glycoprotein IIb/IIIa on activated platelets, human serum albumin (HSA) for prolonged circulation, and tick anticoagulant peptide (TAP) for coagulation FX inhibition. A non-binding scFv is employed as a non-targeting control (non-targ-HSA-TAP). Its efficacy was investigated in vivo using murine models of acute thrombosis and cardiac ischemia-reperfusion (I/R) injury. Results: Our experiments confirmed the targeting specificity of targ-HSA-TAP to activated platelets and demonstrated effective prevention of platelet aggregation and thrombus formation, as well as FXa inhibition in vitro. Thromboprophylactic administration of targ-HSA-TAP subcutaneously in mice prevented occlusion of the carotid artery after ferric chloride injury as compared to non-targ-HSA-TAP and PBS-control treated mice. By comparing the therapeutic outcomes between targ-TAP and targ-HSA-TAP, we demonstrate the significant improvements brought by the HSA fusion in extending the drug's half-life and enhancing its therapeutic window for up to 16 h post-administration. Importantly, tail bleeding time was not prolonged with targ-HSA-TAP in contrast to the clinically used anticoagulant enoxaparin. Furthermore, in a murine model of cardiac I/R injury, mice administered targ-HSA-TAP 10 h before injury demonstrated preserved cardiac function, with significantly higher ejection fraction and fractional shortening, as compared to the non-targ-HSA-TAP and PBS control groups. Advanced strain analysis revealed reduced myocardial deformation and histology confirmed a reduced infarct size in targ-HSA-TAP treated mice compared to control groups. Conclusion: The inclusion of HSA represents a significant advancement in the design of targeted therapeutic agents for thromboprophylaxis. Our activated platelet-targeted targ-HSA-TAP is a highly effective antithrombotic drug with both anticoagulant and antiplatelet effects while retaining normal hemostasis. The long half-life of targ-HSA-TAP provides the unique opportunity to use this antithrombotic drug for more effective, long-lasting and safer anti-thrombotic prophylaxis. In cases where MI occurs, this prophylactic strategy reduces thrombus burden and effectively reduces cardiac I/R injury.