-
BMJ Open Apr 2024A subset of patients with superficial venous thrombosis (SVT) experiences clot propagation towards deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The aim... (Meta-Analysis)
Meta-Analysis
Predictive factors of clot propagation in patients with superficial venous thrombosis towards deep venous thrombosis and pulmonary embolism: a systematic review and meta-analysis.
OBJECTIVE
A subset of patients with superficial venous thrombosis (SVT) experiences clot propagation towards deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The aim of this systematic review is to identify all clinically relevant cross-sectional and prognostic factors for predicting thrombotic complications in patients with SVT.
DESIGN
Systematic review.
DATA SOURCES
PubMed/MEDLINE and Embase were systematically searched until 3 March 2023.
ELIGIBILITY CRITERIA
Original research studies with patients with SVT, DVT and/or PE as the outcome and presenting cross-sectional or prognostic predictive factors.
DATA EXTRACTION AND SYNTHESIS OF RESULTS
The CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling (CHARMS) checklist for prognostic factor studies was used for systematic extraction of study characteristics. Per identified predictive factor, relevant estimates of univariable and multivariable predictor-outcome associations were extracted, such as ORs and HRs. Estimates of association for the most frequently reported predictors were summarised in forest plots, and meta-analyses with heterogeneity were presented. The Quality in Prognosis Studies (QUIPS) tool was used for risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for assessing the certainty of evidence.
RESULTS
Twenty-two studies were included (n=10 111 patients). The most reported predictive factors were high age, male sex, history of venous thromboembolism (VTE), absence of varicose veins and cancer. Pooled effect estimates were heterogenous and ranged from OR 3.12 (95% CI 1.75 to 5.59) for the cross-sectional predictor cancer to OR 0.92 (95% CI 0.56 to 1.53) for the prognostic predictor high age. The level of evidence was rated very low to low. Most studies were scored high or moderate risk of bias.
CONCLUSIONS
Although the pooled estimates of the predictors high age, male sex, history of VTE, cancer and absence of varicose veins showed predictive potential in isolation, variability in study designs, lack of multivariable adjustment and high risk of bias prevent firm conclusions. High-quality, multivariable studies are necessary to be able to identify individual SVT risk profiles.
PROSPERO REGISTRATION NUMBER
CRD42021262819.
Topics: Humans; Male; Venous Thromboembolism; Cross-Sectional Studies; Risk Factors; Venous Thrombosis; Pulmonary Embolism; Neoplasms; Varicose Veins; Anticoagulants
PubMed: 38626964
DOI: 10.1136/bmjopen-2023-074818 -
BMC Anesthesiology Apr 2024An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids have been shown anti-inflammatory and antiemetic effects, but can also elevate blood glucose levels and increase the risk of wound infection. Thus, it is essential to investigate the efficacy and safety of glucocorticoid usage in TKA.
METHOD
A comprehensive systematic search of PubMed, Medline, EMBASE, Cochrane databases, to identify relevant randomized controlled trials (RCTs) of glucocorticoid application in TKA. The primary outcomes assessed were the postoperative pain assessment. Secondary outcomes included the range of motion in knee joint, levels of inflammatory cytokines, adverse complications, and the length of hospital stay.
RESULTS
Thirty-six randomized controlled trials were included in the final analysis. The glucocorticoid group exhibited significant reduction in the resting VAS scores on postoperative days 1, 2 (POD1, 2)and postoperative 3 months (POM3), as well as decreased morphine consumption on POD1 and increased range of motion (ROM) in knee joint on POD1, 3. Additionally, the glucocorticoid group exhibited decreased levels of postoperative inflammatory cytokines and the incidence of PONV along with a shorter length of hospital stay. The blood glucose concentration was significantly increased in the glucocorticoid group on POD1 compared with the control group. While the blood glucose on POD2 and occurrence of postoperative adverse complications were similar between two groups including wound infection and venous thrombosis. The periarticular injection analgesia (PIA) group demonstrated lower VAS scores on POD2 comparing to the systemic administration (SA) group according to two studies. However, there was no significant difference of the resting VAS on POD1 and POD2 between PIA and SA group across all studies.
CONCLUSION
Perioperative glucocorticoids treatment in TKA significantly reduced short-term pain score and opioid-use which was probably not patient relevant. The application of glucocorticoids in TKA implied a beneficial trend in analgesic, anti-inflammatory, and antiemetic effects, as well as improved range of motion and shortened hospital stay. While it will not increase the risk of continued high glucose, postoperative wound infection and venous thrombosis.
Topics: Humans; Glucocorticoids; Arthroplasty, Replacement, Knee; Antiemetics; Blood Glucose; Anti-Inflammatory Agents; Pain, Postoperative; Wound Infection; Cytokines; Venous Thrombosis
PubMed: 38622510
DOI: 10.1186/s12871-024-02530-9 -
Seminars in Thrombosis and Hemostasis Apr 2024Khorana score (KS) is an established risk assessment model for predicting cancer-associated thrombosis. However, it ignores several risk factors and has poor...
Khorana score (KS) is an established risk assessment model for predicting cancer-associated thrombosis. However, it ignores several risk factors and has poor predictability in some cancer types. Machine learning (ML) is a novel technique used for the diagnosis and prognosis of several diseases, including cancer-associated thrombosis, when trained on specific diagnostic modalities. Consolidating the literature on the use of ML for the prediction of cancer-associated thrombosis is necessary to understand its diagnostic and prognostic abilities relative to KS. This systematic review aims to evaluate the current use and performance of ML algorithms to predict thrombosis in cancer patients. This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases Medline, EMBASE, Cochrane, and ClinicalTrials.gov, were searched from inception to September 15, 2023, for studies evaluating the use of ML models for the prediction of thrombosis in cancer patients. Search terms "machine learning," "artificial intelligence," "thrombosis," and "cancer" were used. Studies that examined adult cancer patients using any ML model were included. Two independent reviewers conducted study selection and data extraction. Three hundred citations were screened, of which 29 studies underwent a full-text review, and ultimately, 8 studies with 22,893 patients were included. Sample sizes ranged from 348 to 16,407 patients. Thrombosis was characterized as venous thromboembolism ( = 6) or peripherally inserted central catheter thrombosis ( = 2). The types of cancer included breast, gastric, colorectal, bladder, lung, esophageal, pancreatic, biliary, prostate, ovarian, genitourinary, head-neck, and sarcoma. All studies reported outcomes on the ML's predictive capacity. The extreme gradient boosting appears to be the best-performing model, and several models outperform KS in their respective datasets.
PubMed: 38604227
DOI: 10.1055/s-0044-1785482 -
The Western Journal of Emergency... Mar 2024Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Point-of-care ultrasound (POCUS) performed by emergency physicians (EP) has emerged as an effective alternative to radiology department ultrasounds for the diagnosis of lower extremity deep vein thrombosis (DVT). Systematic reviews suggested good sensitivity and specificity overall for EP-performed POCUS for DVT diagnosis, yet high levels of heterogeneity were reported.
METHODS
In this systematic review and meta-analysis, we aimed to provide the most up-to-date estimates of the accuracy of EP-performed POCUS for diagnosis of DVT and to explore potential correlations with test performance. We performed systematic searches in MEDLINE and Embase for original, primary data articles from January 2012-June 2021 comparing the efficacy of POCUS performed by EPs to the local standard. Quality Assessment of Diagnostic Accuracy Studies-2 for individual articles are reported. We obtained summary measures of sensitivity, specificity, and their corresponding 95% confidence intervals (CI) using bivariate mixed-effects regression models. We performed meta-regression, subgroup, and sensitivity analyses as planned in the protocol CRD42021268799 submitted to PROSPERO.
RESULTS
Fifteen publications fit the inclusion criteria, totaling 2,511 examinations. Pooled sensitivity and specificity were 90% (95% CI 82%-95%) and 95% (CI 91%-97%), respectively. Subgroup analyses by EP experience found significantly better accuracy for exams performed by EP specialists (93%, CI 88%-97%) vs trainees (77%, CI 60%-94%). Specificity for EP specialists (97%, CI 94%-99%) was higher than for trainees (87%, CI 76%-99%, = 0.01). Three-point compression ultrasound (CUS) was more sensitive than two-point CUS but was only statistically significant when limited to EP specialists (92% vs 88%, = 0.07, and 95% vs 88%, = 0.02, respectively).
CONCLUSION
Point-of-care ultrasound performed by emergency physicians is sensitive and specific for the diagnosis of suspected DVT when performed by trained attending EPs. Three-point compression ultrasound examination may be more sensitive than two-point CUS.
Topics: Humans; Point-of-Care Systems; Emergency Service, Hospital; Ultrasonography; Sensitivity and Specificity; Venous Thrombosis; Physicians
PubMed: 38596931
DOI: 10.5811/westjem.18125 -
International Journal of Stroke :... Apr 2024Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage... (Review)
Review
BACKGROUND
Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage (ICH). Various prophylactic strategies have been employed to mitigate this risk, such as heparin, intermittent pneumatic compression (IPC), and graduated compression stockings (GCS). The optimal thromboembolic prophylaxis approach remains uncertain due to the lack of randomized controlled trials (RCTs) comparing all interventions.
AIMS
We conducted a network meta-analysis and meta-analysis to systematically review and synthesize evidence from RCTs and non-randomized studies on the efficacy and safety of thromboembolic prophylaxis strategies in hospitalized ICH patients.
SUMMARY OF FINDINGS
Our study followed a registered protocol (PROSPERO CRD42023489217) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines incorporating the extension for network meta-analyses. Search for eligible studies was performed up to December 2023. We considered the occurrence of DVT, PE, hematoma expansion (HE), and all-cause mortality as outcome measures. A total of 16 studies, including 7 RCTs and 9 non-randomized studies, were included in the analysis. Network meta-analysis revealed that IPC demonstrated the highest efficacy in reducing DVT incidence (odds ratios (OR) 0.30, 95% confidence interval (CI) 0.08-1.16), particularly considering only RCTs (OR 0.33, 95% CI 0.16-0.67). GCS showed the highest safety profile for HE (OR 0.67, 95% CI 0.14-3.13), but without efficacy. Chemoprophylaxis did not reduce the risk of PE events (OR 1.10, 95% CI 0.17-7.19) with a higher occurrence of HE (OR 1.33, 95% CI 0.60-2.96), but the differences were not significant.
CONCLUSION
Our study supports the use of IPC as the primary thromboembolic prophylaxis measure in ICH patients. Further research, including head-to-head RCTs, is needed to strengthen the evidence base and optimize clinical decision-making for thromboembolic prophylaxis in this vulnerable patient population.
PubMed: 38591740
DOI: 10.1177/17474930241248542 -
Injury Jun 2024Optimal thromboprophylaxis in orthopaedic procedures is crucial in an attempt to lower the risk of venous thromboembolism, including deep vein thrombosis and pulmonary... (Review)
Review
OBJECTIVE
Optimal thromboprophylaxis in orthopaedic procedures is crucial in an attempt to lower the risk of venous thromboembolism, including deep vein thrombosis and pulmonary embolism. We aim to: 1) identify clinical practice guidelines (CPGs) and recommendations (CPRs) on thromboprophylaxis in adult patients undergoing orthopaedic procedures, and 2) assess the methodological quality and reporting clarity of these guidelines.
METHODS
The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered on the international prospective register of systematic reviews (PROSPERO) under the registration number (CRD42023406988). An electronic search was conducted using Medline, Embase, Cochrane, Web of Science, Google Scholar and medRxiv. The search terms used were ""adults", "orthopedic surgery", "orthopedic surgeries", "orthopedic surgical procedure", "orthopedic surgical procedures" "english language", "venous thromboembolism", in all possible combinations (January 2013 to March 2023). The eligible studies were evaluated by four blind raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.
RESULTS
The literature research resulted in 931 studies. Finally, a total of 16 sets of guidelines were included in the current analysis. There were 8 national and 8 international CPGs. Eight CPGs made specific recommendations for orthopaedic surgery and referred mostly to joints; one guideline focused on pelvi-acetabular trauma, while the rest were more inclusive and non-specific. Four guidelines, one from the American Society of Hematology (ASH), two from the United Kingdom (UK) and one from India were found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. Inter-rater agreement was very good with a mean Cohens Kappa 0.962 (95 % CI, 0.895-0.986) in the current analysis. So, the reliability of the measurements can be interpreted as good to excellent.
CONCLUSION
Optimal thromboprophylaxis in orthopaedic procedures is crucial. The available guidelines were found to be mostly of high methodological quality and inter-rater agreement was very good, according to our study.
Topics: Humans; Practice Guidelines as Topic; Venous Thromboembolism; Orthopedic Procedures; Anticoagulants; Pulmonary Embolism; Postoperative Complications; Venous Thrombosis
PubMed: 38582056
DOI: 10.1016/j.injury.2024.111517 -
Annals of Medicine and Surgery (2012) Apr 2024Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even... (Review)
Review
BACKGROUND
Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear.
METHODS
MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs.
RESULTS
The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); =0.49, I=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); =0.49, I=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); =0.97, I=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); =0.30].
CONCLUSION
Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.
PubMed: 38576935
DOI: 10.1097/MS9.0000000000001689 -
Journal of Thrombosis and Haemostasis :... Jul 2024Chimeric antigen receptor T-cell (CAR T-cell) therapy is increasingly utilized for treatment of hematologic malignancies. Hematologic toxicities including thrombosis and... (Meta-Analysis)
Meta-Analysis
A meta-analysis to assess the risk of bleeding and thrombosis following chimeric antigen receptor T-cell therapy: Communication from the ISTH SSC Subcommittee on Hemostasis and Malignancy.
BACKGROUND
Chimeric antigen receptor T-cell (CAR T-cell) therapy is increasingly utilized for treatment of hematologic malignancies. Hematologic toxicities including thrombosis and bleeding complications have been reported. Accurate estimates for thrombotic and bleeding outcomes are lacking.
OBJECTIVES
We performed a systematic review and meta-analysis in patients who received CAR T-cell therapy for an underlying hematologic malignancy with the objective to: a) assess the thrombosis and bleeding risk associated with CAR T-cell therapy, b) assess the impact of CRS and ICANS on the risks of thrombosis and bleeding, and c) assess the safety of anticoagulant or antiplatelet use in the period following treatment with CAR T-cell therapy.
METHODS
We searched MEDLINE, EMBASE, and Cochrane CENTRAL up to February 2022 for studies reporting thrombotic or bleeding outcomes in patients receiving CAR T-cell therapy. Pooled event rates were calculated using a random-effects model. We performed subgroup analyses stratified by follow-up duration, CAR T-cell target antigen, and underlying hematologic malignancy.
RESULTS
We included 47 studies with a total of 7040 patients. High heterogeneity between studies precluded reporting of overall pooled rates of thrombotic and bleeding events. In studies with follow-up duration of ≤6 months, the pooled incidence of venous thrombotic events was 2.4% (95% CI, 1.4%-3.4%; I = 0%) per patient-month, whereas the rate was 0.1% (95% CI, 0%-0.1%; I = 0%) per patient-month for studies with longer follow-up periods (>6 months). The pooled incidences of any bleeding events per patient-month in studies with follow-up duration of ≤6 months and >6 months were 1.9% (95% CI, 0.6%-3.1%; I = 78%) and 0.3% (95% CI: 0%-0.8%, I = 40%), respectively. Secondary analyses by CAR T-cell target antigen, underlying malignancy, and primary outcome of the studies did not reveal significant differences in the rates of thromboembolism, any bleeding events, or major bleeding events.
CONCLUSION
The risk of both thrombosis and bleeding following CAR T-cell therapy appears to be highest in the initial months following infusion.
Topics: Humans; Hemorrhage; Immunotherapy, Adoptive; Thrombosis; Hematologic Neoplasms; Risk Assessment; Risk Factors; Treatment Outcome; Hemostasis; Receptors, Chimeric Antigen; Anticoagulants; Male; Female; Middle Aged; Platelet Aggregation Inhibitors; Adult; Aged
PubMed: 38574863
DOI: 10.1016/j.jtha.2024.03.021 -
Vascular Medicine (London, England) Jun 2024Inferior vena cava (IVC) anomalies are uncommon congenital causes of deep vein thrombosis (DVT). KILT syndrome (kidney and IVC abnormalities with leg thrombosis) has... (Review)
Review
Inferior vena cava (IVC) anomalies are uncommon congenital causes of deep vein thrombosis (DVT). KILT syndrome (kidney and IVC abnormalities with leg thrombosis) has only been described as case reports in the literature. Therefore, the characteristics, evaluation, and management of patients with KILT syndrome have not yet been standardized. This study aimed to systematically review and analyze the clinical and radiographic data and treatment of previously reported cases of KILT syndrome. In this systematic review, we performed a literature search of the PubMed, Scopus, and Web of Science databases in December 2023, with no restrictions on the publication date. After duplicate extractions, 4195 articles were screened. Case reports and case series reporting on KILT syndrome were included. In addition to previously published cases, we included a new case of a previously healthy 25-year-old man with KILT syndrome in the analysis. A total of 34 cases were therefore included in this study. The majority (76.5%) were male patients with a median age of 24 years. In most patients, unprovoked bilateral iliofemoral thrombosis was diagnosed, and 64.7% had left kidney abnormalities. Our study suggests that anomalies of the IVC should be suspected in all young patients, especially male patients, with proximal, recurrent, or idiopathic DVT. If an IVC anomaly is confirmed, the kidneys should be examined to monitor and preserve healthy kidneys in cases of KILT syndrome. The data collected from all patients emphasize the requirement of long-term anticoagulation and risk factor control. Surgical measures may be effective for treating symptomatic refractory cases.
Topics: Humans; Vena Cava, Inferior; Venous Thrombosis; Kidney; Male; Adult; Female; Young Adult; Risk Factors; Adolescent; Child; Treatment Outcome; Vascular Malformations; Anticoagulants; Child, Preschool; Middle Aged
PubMed: 38573108
DOI: 10.1177/1358863X241240427 -
Clinical and Applied... 2024Cerebral venous sinus thrombosis (CVST) is a rare neurovascular condition that has been observed in individuals with coronavirus disease 2019 (COVID-19). This systematic...
Cerebral venous sinus thrombosis (CVST) is a rare neurovascular condition that has been observed in individuals with coronavirus disease 2019 (COVID-19). This systematic review aimed to explore the sex differences and characteristics of concurrent COVID-19 and CVST cases. A total of 212 CVST patients were included in the study. Women with CVST had a slightly higher mean age compared to men (47.359 years vs 46.08 years). Women were more likely to report symptoms such as fever (56.1%) and decreased sense of smell or taste (71.4%), while men more frequently experienced nausea or vomiting (55.6%), headache (62.9%), and seizures (72%). Notably, current smokers, who were predominantly men, had a higher occurrence of CVST. On the other hand, women had a higher likelihood of CVST risk factors such as oral contraceptive pill (OCP) use and autoimmune diseases. Treatment approaches also showed sex-based differences. Unfractionated heparin was administered more often to women with CVST (63.2%). The in-hospital mortality rate for CVST patients was 21.3%, with men having a significantly higher mortality rate than women (65.2% vs 34.8%, = .027). Survival analysis revealed that factors such as smoking history, diabetes mellitus, hypertension, OCP use, COVID-19 symptoms, CVST symptoms, and the need for intubation significantly influenced survival outcomes. Understanding these sex differences in COVID-19-related CVST is crucial for accurate diagnosis and effective management, ultimately leading to improved patient outcomes. Our findings highlight the importance of considering sex as a factor in the evaluation and treatment of individuals with COVID-19 and concurrent CVST.
Topics: Humans; Male; Female; Middle Aged; Heparin; Sex Characteristics; Sinus Thrombosis, Intracranial; COVID-19; Risk Factors
PubMed: 38551022
DOI: 10.1177/10760296241240748