High Prevalence and Mortality Associated with Upper Extremity Deep Venous Thrombosis in Hospitalized Patients at a Tertiary Care Center.

BACKGROUND: Upper extremity deep venous thrombosis (UEDVT) and its associated complications are increasing in incidence, but management strategies are largely derived from experience treating lower extremity deep venous thrombosis (LEDVT). The purpose of this study is to examine our single institution's experience with in-hospital venous thromboembolism (VTE), specifically the characteristics and outcomes of the UEDVT population as it compares to LEDVT. METHODS: This is a single tertiary care center retrospective cohort study of all consecutive inpatients diagnosed with acute VTE from June 2015 to December 2015. During this period, 4,495 patients underwent venous duplex examination (622 UE and 3,873 LE), identifying 83 inpatient DVTs. Chronic DVT and those diagnosed in the outpatient population were excluded. DVTs were classified as either provoked or unprovoked. Provoked DVT were defined as the presence of any of the following factors within 30 days prior to diagnosis: major surgery, immobilization (greater than 3 days of bedrest), trauma, infection requiring antibiotics, central venous access, pregnancy, and/or hormonal medication use. Inpatient pulmonary embolisms (PE) detected on chest computed tomography (CT) were also evaluated during this time frame. Patient data were collected, including age, gender, race, lifestyle factors, comorbidities, VTE risk factors, symptomatology at presentation, management including anticoagulation choice and filter placement if applicable, as well as discharge disposition. Statistical analysis was performed using GraphPad Prism 8.0 (GraphPad Software, San Diego, California), and a threshold P-value of <0.05 set for significance. RESULTS: During the study period, 83 DVTs (48 LEDVT, 35 UEDVT) and 24 PE were identified in 96 inpatients. Of these DVTs, 77.1% of these were defined as provoked. Eleven patients had simultaneous DVT and PE, and thirteen patients had PE with presumed occult pelvic or LEDVT. UEDVT patients had a higher proportion of comorbidities than LEDVT patients: coronary artery disease (25.7% vs. 13.1%, P = 0.16), congestive heart failure (20% vs. 6.6%, P = 0.09), as well as a trend toward higher incidence of malignancy (60% vs. 42.6%, P = 0.13). Of provoked VTE, UEDVT correlated more significantly with central venous catheters (88.4% vs. 12.5%, P=<0.0001), but was less commonly associated with prolonged bed rest (19.2% vs. 39.5%, P = 0.11). PE was diagnosed in 24/96 (25%) of the study population. Patients with LEDVT were found to have a significantly higher incidence of PE compared to those with UEDVT (34.4% vs. 8.6%, P = 0.006). Same-admission mortality for patients with VTE was 13/96 (13.5%). Of these, patients with UEDVT had significantly higher all-cause mortality than patients with LEDVT (28.5% vs. 4.9%, P = 0.004). When catheter-related UEDVT was excluded, there remained a significant difference in mortality between non-catheter-related UEDVT and LEDVT (33.3% vs. 4.9% P = 0.0119). CONCLUSIONS: This study demonstrates a high prevalence of UEDVT in hospitalized patients who experience VTE. Despite a lower incidence of synchronous PE, patients with UEDVT had a higher prevalence of significant medical comorbidities and higher all-cause mortality on the index hospital admission.

Symptoms and Impaired Quality of Life After COVID-19 Hospitalization: Effect of Therapeutic Heparin in Non-ICU Patients in the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 Acute Trial: Effect on 3-Month Symptoms and Quality of Life.

BACKGROUND: Therapeutic-dose heparin decreased days requiring organ support in noncritically ill patients hospitalized for COVID-19, but its impact on persistent symptoms or quality of life (QOL) is unclear. RESEARCH QUESTION: In the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 ACUTE (ACTIV-4a) trial, was randomization of patients hospitalized for COVID-19 illness to therapeutic-dose vs prophylactic heparin associated with fewer symptoms and better QOL at 90 days? STUDY DESIGN AND METHODS: This was an open-label randomized controlled trial at 34 hospitals in the United States and Spain. A total of 727 noncritically ill patients hospitalized for COVID-19 from September 2020 to June 2021 were randomized to therapeutic-dose vs prophylactic heparin. Only patients with 90-day data on symptoms and QOL were analyzed. We ascertained symptoms and QOL by the EQ-5D-5L at 90-day follow-up in a preplanned analysis for the ACTIV-4a trial. Individual domains assessed by the EQ-5D-5L included mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Univariate and multivariate analyses were performed. RESULTS: Among 571 patients, 288 (50.4%) reported at least one symptom. Among 410 patients, 148 (36.1%) reported moderate to severe impairment in one or more domains of the EQ-5D-5L. The presence of 90-day symptoms was associated with moderate-severe impairment in the EQ-5D-5L domains of mobility (adjusted OR [aOR], 2.37; 95% CI, 1.22-4.59), usual activities (aOR, 3.66; 95% CI, 1.75-7.65), pain (aOR, 2.43; 95% CI, 1.43-4.12), and anxiety (aOR, 4.32; 95% CI, 2.06-9.02), compared with patients reporting no symptoms There were no differences in symptoms or in the overall EQ-5D-5L index score between treatment groups. Therapeutic-dose heparin was associated with less moderate-severe impairment in all physical functioning domains (mobility, self-care, usual activities) but was independently significant only in the self-care domain (aOR, 0.32; 95% CI, 0.11-0.96). INTERPRETATION: In a randomized controlled trial of hospitalized noncritically ill patients with COVID-19, therapeutic-dose heparin was associated with less severe impairment in the self-care domain of EQ-5D-5L. However, this type of impairment was uncommon, affecting 23 individuals. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT04505774; URL: www. CLINICALTRIALS: gov.

Long-term dentoskeletal changes with the Bionator, Herbst, Twin Block, and MARA functional appliances.

OBJECTIVE: To determine if the long-term dentoskeletal changes in patients treated with tooth-borne functional appliances were comparable to each other and to matched controls. MATERIALS AND METHODS: The experimental sample consisted of 80 consecutively treated patients who were equally divided into Bionator, Herbst, Twin Block, and mandibular anterior repositioning appliance (MARA) groups. The control group comprised 21 children with untreated skeletal Class II malocclusions. Lateral cephalograms were taken for the treated group at T1 (initial records), T2 (completion of functional therapy), and T3 (completion of fixed appliance therapy). A repeated measure analysis of variance (ANOVA) was used to assess the differences between and within groups. If ANOVA results were significant, Tukey-Kramer tests were used to determine where the significant differences occurred. RESULTS: (1) Temporary restriction of maxillary growth was found in the MARA group (T2-T1). (2) SNB increased more with the Twin Block and Herbst groups when compared with the Bionator and MARA groups. (3) The occlusal plane significantly changed in the Herbst and Twin Block groups. (4) The Twin Block group expressed better control of the vertical dimension. (5) The overbite, overjet, and Wits appraisal decreased significantly with all of the appliances. (6) The Twin Block group had significant flaring of the lower incisors at the end of treatment. (7) Over the long-term, there were no significant soft tissue changes among treated and untreated subjects. CONCLUSIONS: No significant dentoskeletal differences were observed long-term, among the various treatment groups and matched controls.

Isotope ratios of H, C, and O in CO2 and H2O of the martian atmosphere.

Stable isotope ratios of H, C, and O are powerful indicators of a wide variety of planetary geophysical processes, and for Mars they reveal the record of loss of its atmosphere and subsequent interactions with its surface such as carbonate formation. We report in situ measurements of the isotopic ratios of D/H and (18)O/(16)O in water and (13)C/(12)C, (18)O/(16)O, (17)O/(16)O, and (13)C(18)O/(12)C(16)O in carbon dioxide, made in the martian atmosphere at Gale Crater from the Curiosity rover using the Sample Analysis at Mars (SAM)'s tunable laser spectrometer (TLS). Comparison between our measurements in the modern atmosphere and those of martian meteorites such as ALH 84001 implies that the martian reservoirs of CO2 and H2O were largely established ~4 billion years ago, but that atmospheric loss or surface interaction may be still ongoing.

Dentoskeletal effects of functional appliances vs bimaxillary surgery in hyperdivergent Class II patients.

OBJECTIVE: To compare treatment outcomes of growing and nongrowing Class II patients characterized by mandibular retrusion and increased vertical dimension. MATERIALS AND METHODS: Seventeen patients (mean age 9 years 5 months) were treated with a Bionator fabricated with posterior bite block and high-pull headgear, while 15 patients (mean age 23 years 6 months) received Le Fort I osteotomy for maxillary impaction and mandibular advancement. These groups were compared with 17 nontreated control subjects from the Bolton and Michigan growth studies. Lateral cephalograms taken for the functional group at T1 (initial records), T2 (completion of functional appliance treatment), and T3 (completion of comprehensive treatment) were compared with radiographs taken at T1 (initial records), T2 (immediate post surgery), and T3 (1 year post surgery) for the surgical patients. A null hypothesis of no difference in treatment outcomes between the functional and surgical groups was proposed. A mixed-design analysis of variance was used to compare changes within and between groups. Significance was set at P ≤ .002. RESULTS: In the functional appliance group, the mandible showed a more favorable growth direction and rotation. Both groups had stable results over time and finished treatment with similar cephalometric measurements. CONCLUSION: Both the functional appliances and orthognathic surgery resulted in similar dentoskeletal treatment changes. The control groups did not self correct either in the anteroposterior or vertical dimensions.

The reliability of crown-root ratio, linear and angular measurements on panoramic radiographs.

The aim of this study was to evaluate the reliability of crown and root length, crown-root ratio and angular measurements of teeth relative to constructed reference lines and to other teeth in the same region on consecutive (T1 and T2) panoramic radiographs (OPGs). This retrospective study employed 20 cases; ten with five implants in each jaw (age range between 20 and 60 years) and ten with a full permanent dentition (age range between 12 and 16 years). The consecutive pairs of OPGs ranged from 6 months to 3 years apart. Four variables were measured and compared: 1) the crown or coronal segment length and the root or apical segment length; 2) the crown-root ratio; 3) the angulations of teeth and implants relative to specific reference lines in each jaw; 4) the angle between teeth and implants in the same sextant. The results revealed that comparisons of measurements taken of the same structures at T1 and T2, there were no statistically significant differences (p>0.05) between vertical linear measurements. The crown-root ratios and coronal-apical segment ratios too, showed no significant differences (p>0.05). Whereas, angulations of teeth or implants relative to respective reference lines showed significant differences (p=0.001) for some of the teeth. These differences, however, were less than 5 degrees; a clinically acceptable range. Angles measured between teeth or implants in the same sextant showed no significant differences (p>0.05). These results seem to support the hypothesis, therefore, that the linear vertical measurements, ratio calculations and angular measurements can be used to compare crown and root lengths, crown-root ratios and tooth angulations on OPGs taken of the same patient at different times with consistent accuracy.