BACKGROUND & AIMS: :Changes in the incidence of venous thromboembolism (VTE) during the last two decades have not been extensively studied. Therefore, we studied time trends in the incidence rates (IRs) of deep vein thrombosis (DVT) and pulmonary embolism (PE) in a cohort of 26,855 subjects, aged 25-97 years, enrolled in the Tromsø study in 1994/1995. The subject were followed-up throughout 2012, and all symptomatic, objectively confirmed, incident VTEs were identified using multiple sources (hospital discharge-, radiology procedure- and autopsy registry) and validated by review of medical records. Age-adjusted biennial IR per 100,000 person years (PY) with 95% confidence intervals (CI) were calculated using Poisson regression. Between January 1996 and December 2012, 693 VTEs occurred during 368,150 PY of follow up. The IR of VTE increased from 158 (95% CI 116-199) in 1996/1997 to 201 (95% CI 160-243) in 2010/2011. There was a marked increase in the rates of PE (with/without concurrent DVT) ranging from 45 (95% CI 23-67) in 1996/1997 to 113 (95% CI 82-144) in 2010/2011, whereas the rates of isolated DVT decreased (112, 95% CI 77-146 in 1996/1997 and 88, 95% CI 61-115 in 2010/2011). Despite advances in prophylaxis, the IR of VTE has increased slightly during the last 15 years, mainly due to an increase in PE. Although the introduction of better diagnostic tools to some extent may explain the increase in PE rates, our findings suggest that there is still a need for improvement in risk factor management and prevention strategies of first time VTE.

背景与目标： : 在过去的二十年中，静脉血栓栓塞 (VTE) 的发生率变化尚未得到广泛研究。因此，我们在1994/1995年参加troms ø 研究的26,855名年龄在25-97岁的受试者队列中研究了深静脉血栓形成 (DVT) 和肺栓塞 (PE) 的发生率 (IRs) 的时间趋势。对受试者进行了整个2012的随访，并使用多种来源 (医院出院，放射学程序和尸检注册表) 识别了所有有症状的，客观证实的事件vte，并通过检查病历进行了验证。使用泊松回归计算年龄调整后的每100,000人年IR (PY) 和95% 置信区间 (CI)。在1996年1月和2012年12月之间，在368,150 PY的随访期间发生了693例vte。VTE的IR从1996/1997的158 (95% CI 116-199) 增加到2010/2011的201 (95% CI 160-243)。PE (有/没有并发DVT) 的发生率显着增加，范围从1996/1997的45 (95% CI 23-67) 到2010/2011的113 (95% CI 82-144)，而孤立DVT的发生率降低 (112，95% CI 77-146在1996/1997和88，95% CI 61-115在2010/2011)。尽管在预防方面取得了进展，但在过去15年中，VTE的IR略有增加，这主要是由于PE的增加。尽管引入更好的诊断工具在一定程度上可以解释PE率的增加，但我们的发现表明，仍然需要改善首次VTE的风险因素管理和预防策略。

BACKGROUND & AIMS: :The risk of recurrent thromboembolic disorders in the 10-year period following an episode of unprovoked venous thromboembolism (VTE) ranges between 30 and 50%, the rate being higher in patients with primary deep venous thrombosis (DVT) than in those with primary pulmonary embolism (PE). The clinical presentation with primary PE increases by more than three times the risk of a new PE episode over that with isolated DVT. Baseline parameters that increase this risk are the proximal location of DVT, obesity, old age and male sex, whereas the role of thrombophilia is controversial. An increasing role is played by post-baseline parameters such as the ultrasound assessment of residual vein thrombosis and the determination of D-dimer. While the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, new scenarios are being offered by the identification of risk stratification models and by strategies that have the potential to help identify patients in whom anticoagulation can be safely discontinued, such as those that incorporate the assessment of D-dimer and residual vein thrombosis. New opportunities are being offered by low-dose aspirin, which has recently been reported to decrease by more than 30% the risk of recurrent events without increasing the bleeding risk; and especially by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving at least the same effectiveness, do not require laboratory monitoring, and can be used immediately after the thrombotic episode.

背景与目标： : 在无端静脉血栓栓塞 (VTE) 发作后的10年内，复发性血栓栓塞性疾病的风险在30至50% 之间，原发性深静脉血栓形成 (DVT) 患者的发生率高于原发性肺栓塞 (PE)。与孤立的DVT相比，原发性PE的临床表现增加了新PE发作的风险的三倍以上。增加这种风险的基线参数是DVT的近端位置，肥胖，老年和男性，而血栓形成倾向的作用是有争议的。基线后参数 (例如残余静脉血栓形成的超声评估和D-二聚体的测定) 起着越来越大的作用。虽然最新的国际指南建议对大多数无诱因VTE首发患者进行无限期抗凝治疗，但风险分层模型的识别以及有可能帮助确定可以安全停止抗凝治疗的患者的策略提供了新的方案，例如那些结合了D-二聚体和残余静脉血栓形成的评估。小剂量阿司匹林提供了新的机会，最近据报道，它可以在不增加出血风险的情况下将复发事件的风险降低30% 以上; 尤其是一些新兴的抗Xa和抗IIa口服化合物，与维生素k拮抗剂相比，它们可能引起更少的出血并发症，同时至少保持相同的有效性，不需要实验室监测，并且可以在血栓形成发作后立即使用。

BACKGROUND & AIMS: :Over 50 unselected women with maternal venous thromboembolism were screened for the prothrombin 20210 G-->A and MTHFR C677T mutations, in addition to screening for other thrombophilias. The prevalence of thrombophilia in these women was compared with its prevalence in the general population in our area. The prothrombin (OR 4.4; 95% CI 1.2-16) and factor V Leiden (OR 4.5; 95% CI 2.1-14.5) mutations were more common in our patients, compared with the general population, whereas women homozygous for the C677T mutation in the methylene tetrahydrofolate reductase gene (OR 0.45; 95% CI 0.13-1.58) were not. It is recommended that women with a personal or strong family history of venous thromboembolism should be screened for the prothrombin mutation either before or early in pregnancy, in addition to screening for other thrombophilias. Screening for the MTHFR mutation does not appear to identify women at increased risk of maternal venous thrombosis.

背景与目标： : 除了筛选其他血栓形成倾向外，还筛选了50多名未经选择的孕妇静脉血栓栓塞的凝血酶原20210G->A和MTHFR C677T突变。将这些妇女的血栓形成倾向患病率与我们地区普通人群的患病率进行了比较。与普通人群相比，凝血酶原 (或4.4; 95% CI 1.2-16) 和因子V Leiden (或4.5; 95% CI 2.1-14.5) 突变在我们的患者中更常见，而亚甲基四氢叶酸还原酶基因 (或0.45; 95% CI 0.13-1.58) 没有。建议有静脉血栓栓塞的个人或家族病史的女性在怀孕前或怀孕早期进行凝血酶原突变筛查，此外还应筛查其他血栓形成倾向。MTHFR突变的筛查似乎不能识别出母亲静脉血栓形成风险增加的女性。

BACKGROUND & AIMS: :Patients with a first venous thromboembolic event and a deficiency of the coagulation inhibitors antithrombin, protein C or protein S have an increased risk of recurrent venous thromboembolism compared to patients without such a deficiency. A decision analysis was performed to assess the effect of continuing treatment with vitamin K antagonists on mortality by a reduction in fatal recurrent pulmonary embolism and an induction of fatal haemorrhages associated with their use. The treatment decision involves continuation or discontinuation of vitamin K antagonists in patients with a first spontaneous or secondary venous thromboembolism and an antithrombin, protein C or S deficiency. Although the efficiency of oral anticoagulation is high in all age groups early after the first thromboembolic event, it decreases over time. Our analysis indicates that the optimal treatment duration will vary, depending on the type of the initial event (spontaneous or secondary; deep venous thrombosis or pulmonary embolism), age, and time passed since the initial thromboembolic episode. Moreover, life-long duration of the prophylaxis seems not warranted in all patients.

背景与目标： : 与没有这种缺陷的患者相比，第一次静脉血栓栓塞事件和凝血抑制剂抗凝血酶，蛋白C或蛋白S缺乏的患者复发性静脉血栓栓塞的风险增加。进行了决策分析，以评估继续使用维生素k拮抗剂治疗对死亡率的影响，方法是减少致命性复发性肺栓塞并诱导与使用相关的致命性出血。治疗决定涉及首次自发性或继发性静脉血栓栓塞和抗凝血酶，蛋白C或S缺乏症患者继续或停用维生素k拮抗剂。尽管在第一次血栓栓塞事件发生后的早期，所有年龄组的口服抗凝治疗效率都很高，但随着时间的推移会降低。我们的分析表明，最佳治疗持续时间会有所不同，具体取决于初始事件的类型 (自发性或继发性; 深静脉血栓形成或肺栓塞)，年龄和自初始血栓栓塞发作以来的时间。此外，并非所有患者都必须进行终生的预防。

BACKGROUND & AIMS: :The risk of thromboembolic complications in patients with heart failure and/or chronic left-ventricular systolic dysfunction is increased. Nevertheless, anticoagulant therapy in these patients is still a subject of debate. Atrial fibrillation is the only prospectively evaluated, proven thromboembolic risk factor and patients with atrial fibrillation benefit from long term anticoagulant therapy. The significance of other proposed thromboembolic risk factors in heart failure and/or chronic left-ventricular dysfunction such as gender, cause of myocardial disease, severity of heart failure, left-ventricular ejection fraction, left-ventricular thrombus, left ventricular aneurysm and history of previous thromboembolic event is less clear. This article summarizes key studies, assesses the incidence of thromboembolism, evaluates risk factors and proposes guidelines for anticoagulation of patients with heart failure and/or left ventricular systolic dysfunction.

背景与目标： : 心力衰竭和/或慢性左心室收缩功能障碍患者发生血栓栓塞并发症的风险增加。尽管如此，这些患者的抗凝治疗仍然是争论的主题。心房颤动是唯一经前瞻性评估、证实的血栓栓塞危险因素，心房颤动患者可从长期抗凝治疗中获益。其他拟议的血栓栓塞危险因素在心力衰竭和/或慢性左心室功能障碍中的意义，例如性别，心肌疾病的原因，心力衰竭的严重程度，左心室射血分数，左心室血栓，左心室动脉瘤和既往血栓栓塞事件的历史尚不清楚。本文总结了关键研究，评估了血栓栓塞的发生率，评估了危险因素，并提出了心力衰竭和/或左心室收缩功能障碍患者抗凝的指南。

BACKGROUND & AIMS: PURPOSE:Several factors have been associated with the prescription of direct oral anticoagulants (DOAC) over warfarin such as younger age, fewer concomitant medications, and lower CHADS2 or bleeding scores. The primary objective of this study was to identify predictors of DOAC choice compared with warfarin for patients who are starting a new oral anticoagulant (OAC) for atrial fibrillation (AF). The secondary objective was to describe the proportion of DOAC prescriptions in new users of OAC for AF. METHODS:A retrospective cross-sectional study was conducted in a teaching hospital in Canada. Medical records of adult patients hospitalized in any medical units between October 1st, 2011 and October 1st, 2014, who were newly prescribed an OAC for non valvular AF were systematically reviewed. Baseline characteristics of warfarin and DOAC users were compared and a multivariate logistic regression analysis was completed to identify predictors of DOAC use. Variables included in the multiple regression analysis were: age, hypertension, diabetes, history of stroke or transient ischemic attack, coronary artery disease, peripheral arterial disease, CHADS2 score of 2 or more, creatinine clearance 30mL/min or more, polypharmacy, concomitant use of ASA or clopidogrel, and prescription by a neurologist. RESULTS:Among OAC users (144 patients on DOAC and 295 patients on warfarin), older age (odds ratio [OR] 0.97; 95%CI 0.95-0.98), peripheral arterial disease (OR: O.41;95%CI: 0.21-0.82), polypharmacy (OR: 0.30;95%CI:0.10-0.89), and concomitant use of clopidogrel (OR: 0.19;95%CI:0.07-0.56) decreased the probability of DOAC use. Prescription by a neurologist (OR: 2.77;95%CI:1.34-5.76) and an estimated creatinine clearance of at least 30mL/min (OR: 3.53;95%CI:1.18-10.57) increased the likelihood of DOAC prescription. CONCLUSION:To the best of our knowledge, this is the first observational study finding that concomitant use of clopidogrel reduced the likelihood of DOAC utilization while prescription by a neurologist increased the probability of receiving a DOAC over warfarin in patients with AF.This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

背景与目标：

BACKGROUND & AIMS: INTRODUCTION:Unprovoked venous thromboembolism (VTE) tend to recur. Many factors, patient- or event-related, influence the individual risk of recurrence. After initial and long-term (usually for 3-6 months) anticoagulant therapy, extended anticoagulation has been recommended in patients at high risk of recurrence, provided they do not have a high risk of bleeding. Areas covered: The effect of different risk factors on the risk of recurrence is discussed, as well as risk factors for bleeding. The estimation of individual balance between these two risks is crucial to decide which can be the best treatment duration in single patients. The use of direct oral anticoagulants, with likely less risk of bleeding, may influence the balance. D-dimer assessment during and after anticoagulation is stopped is also commented for its role to help identifying the individual risk of recurrence. Expert commentary: All patients with a first VTE should be reconsidered after the initial 3-6 months of treatment. Anticoagulation can then be stopped or continued in relation to low or very high risk of recurrence, respectively. Serial D-dimer assessment during the first 2 or 3 months after anticoagulation is stopped is useful in patients with uncertain risk evaluation (especially after unprovoked events).

背景与目标： 简介: 无端静脉血栓栓塞 (VTE) 易复发。与患者或事件相关的许多因素都会影响复发的个体风险。在初始和长期 (通常为3-6个月) 抗凝治疗后，建议对复发风险高的患者进行长期抗凝治疗，前提是他们没有出血风险高。涵盖的领域: 讨论了不同危险因素对复发风险的影响，以及出血的危险因素。估计这两种风险之间的个体平衡对于确定哪种可能是单个患者的最佳治疗持续时间至关重要。直接口服抗凝剂的使用可能会降低出血的风险，可能会影响平衡。抗凝期间和停止后的D-二聚体评估也被评论为其有助于识别复发的个体风险的作用。专家评论: 在最初的3-6个月治疗后，应重新考虑所有首次VTE的患者。然后可以分别与低或非常高的复发风险相关地停止或继续抗凝。在抗凝停止后的前2或3个月进行连续D-二聚体评估对于风险评估不确定的患者 (尤其是在无缘无故事件之后) 是有用的。

BACKGROUND & AIMS: :Thrombus formation can be a significant cause for morbidity and mortality after Fontan operation. Intracardiac thrombus formation can lead to chronic pulmonary embolic disease if formed on the right side, or stroke, if on the left side of the heart. Right-sided embolism may result in ventilation/perfusion mismatch or elevation of pulmonary vascular resistance, both of which may seriously hamper cavopulmonary physiology. We report the case of a 22-year-old patient, with past history of classic Fontan procedure performed at the age of six to palliate a single-ventricle tricuspid atresia, who presented with a massive pulmonary embolism and hemodynamic instability. Due to his critical status, mechanical fragmentation of the clot using the angiography catheter was started, followed by a local catheter-directed infusion of urokinase. This case demonstrated that pharmacomechanical thrombolysis therapy with a standard Pig-tail catheter and thrombolytic therapy with urokinase is secure, effective, and appropriated to manage heart chamber and pulmonary arterial thrombosis in patients with congenital heart disease.

背景与目标： : 血栓形成可能是Fontan手术后发病率和死亡率的重要原因。如果在右侧形成心内血栓形成，则可导致慢性肺栓塞疾病，如果在心脏左侧形成，则可导致中风。右侧栓塞可能导致通气/灌注不匹配或肺血管阻力升高，这两种情况都可能严重阻碍腔肺生理。我们报告了一名22岁的患者的病例，该患者过去曾在6岁时进行过经典的Fontan手术，以缓解单心室三尖瓣闭锁，该患者出现大量肺栓塞和血流动力学不稳定。由于他的危急状态，开始使用血管造影导管对血块进行机械碎裂，然后进行局部导管定向的尿激酶输注。该病例表明，使用标准猪尾导管进行药物机械溶栓治疗和使用尿激酶进行溶栓治疗是安全，有效的，并且适合管理先天性心脏病患者的心脏腔和肺动脉血栓形成。

BACKGROUND & AIMS: OBJECTIVES:To assess whether thrombophilia testing following a venous thrombotic event is clinically effective and cost-effective in the management of thrombosis compared with no testing for thrombophilia. DATA SOURCES:Major electronic databases were searched from September to November 2006. REVIEW METHODS:A systematic review of the clinical effectiveness and cost-effectiveness literature was undertaken according to standard methods. A discrete event simulation model was constructed to assess the cost-effectiveness of changing the standard 3-month duration of warfarin treatment to 10 years, 20 years or lifelong. RESULTS:No clinical studies were identified that met the inclusion criteria for the systematic review. Further literature searches and clinical opinion were therefore used to inform the cost-effectiveness analysis. Thrombophilia testing in patients with pulmonary embolism (PE) had an estimated mean cost per quality-adjusted life-year (QALY) of below 20,000 pounds regardless of sex or age. In patients with a previous deep vein thrombosis (DVT), thrombophilia testing had an estimated mean cost per QALY of below 20,000 pounds in men aged 69 years or less and in women aged 49 years or less. The estimated duration of warfarin treatment (lifelong, 20 years, 10 years or no extended treatment) that was most cost-effective is presented for each age, sex, initial venous thromboembolism (VTE) event and type of thrombophilia. CONCLUSIONS:In terms of determining the duration of anticoagulation management, scenarios were found in which the cost per QALY of thrombophilia testing was below 20,000 pounds. However, these results are subject to great uncertainty, largely because of lack of knowledge about the increased risk of recurrence with each type of thrombophilia. Results are influenced by the fact that men have a greater risk of recurrence than women and by the fact that the frequency of adverse events associated with warfarin treatment increases with age. Further research, for example on the likely sensitivity and specificity of the tests for specific types of thrombophilia, is needed to reduce the uncertainty associated with these results. Studies comparing patients with VTE tested for thrombophilia with those whose risk assessment was based on personal and family history of thrombosis would also be beneficial.

背景与目标：

BACKGROUND & AIMS: :Essentials Factor Xa inhibitors cause more abnormal menstrual bleeding (AUB) than vitamin-K antagonists (VKA). We analyzed data of AUB in women, evaluating dabigatran versus VKA. We observed a 41% lower risk of AUB in women on dabigatran compared to those on VKA. Our findings of lower AUB risk on dabigatran should be corroborated in future studies. SUMMARY:Introduction Although direct oral anticoagulants (DOACs) are associated with a better safety profile than warfarin in patients with acute venous thromboembolism (VTE), direct factor Xa inhibitors involve a higher risk of abnormal uterine bleeding (AUB). We aimed to determine the risk of AUB during anticoagulation with dabigatran compared with warfarin. Methods Post-hoc analysis of the pooled RE-COVER studies and the RE-MEDY trial. Incidences of AUB, based on a defined preferred terms search for adverse events, in female patients aged 18-50 years treated with dabigatran, were compared with those in women treated with warfarin. Results Of the 2964 women included in the above-mentioned trials, 1280 women were in the relevant age category (18-50 years) and included in the current analysis. A total of 643 patients were randomized to treatment with dabigatran and 637 to treatment with warfarin. The overall rate of AUB was 8.1%, 5.9% for the women treated with dabigatran and 9.6% in those treated with warfarin, for an odds ratio for dabigatran-treated patients of 0.59 (95% confidence interval [CI], 0.39-0.90; P = 0.015). In the dabigatran-treated patients, three (0.5%) suffered major bleeding (MB) vs. five (0.8%) in the warfarin-treated patients (HR, 0.65; 95% CI, 0.15-2.72). MB or non-major relevant bleeding occurred in 30 (4.7%) patients randomized to receive dabigatran and 57 (8.9%) randomized to receive warfarin (HR, 0.53; 95% CI, 0.34-0.83). None of the bleeding events was fatal. Conclusion Dabigatran treatment was associated with a significantly (41%) lower risk of AUB than warfarin. Future studies in daily practice are needed to corroborate these findings.

背景与目标：

BACKGROUND & AIMS: :Elective total hip arthroplasty and total knee arthroplasty are associated with a high risk of postoperative venous thromboembolism. Traditionally, antithrombotic prophylaxis has been administered during the hospital stay. However, with patients spending less time in the hospital after surgery, there is a need to continue thromboprophylaxis beyond hospital discharge. The current recommendation for prophylaxis in total joint arthroplasty patients is a minimum of 10 days, with extended prophylaxis up to 28 to 35 days following total hip arthroplasty. Prophylaxis with low-molecular-weight heparins for approximately 4 weeks following hip arthroplasty has resulted in clinically significant reductions in the incidence of venographically confirmed deep vein thrombosis. Currently, no data support extended thromboprophylaxis beyond 10 days following total knee arthroplasty. Using weighted risk factors to assess individual risk for venous thromboembolism can help the physician determine the optimal duration of prophylaxis.

背景与目标： 选择性全髋关节置换术和全膝关节置换术与术后静脉血栓栓塞的高风险相关。传统上，在住院期间一直进行抗血栓预防。但是，由于患者手术后在医院花费的时间更少，因此需要在出院后继续进行血栓预防。全关节置换术患者目前的预防建议为最少10天，全髋关节置换术后延长至28 ~ 35天。髋关节置换术后使用低分子量肝素进行预防约4周，可在临床上显着降低静脉造影证实的深静脉血栓形成的发生率。目前，没有数据支持全膝关节置换术后超过10天的延长血栓预防。使用加权危险因素来评估静脉血栓栓塞的个体风险可以帮助医生确定预防的最佳持续时间。

BACKGROUND & AIMS: :Current practice patterns for venous thrombembolism (VTE) prophylaxis in autogenous breast reconstruction are unknown. A web-based survey on VTE prophylaxis was distributed to all American Society of Plastic Surgery members in the United States with a clinical interest in autogenous tissue breast reconstruction (N = 3584). A total of 606 completed surveys were returned for a response rate of 16.9%. Overall compliance with established guidelines was low (25%). High volume surgeons (43% vs. 22%) and surgeons in academic practice (42% vs. 22%) were significantly more likely to report prophylaxis regimens consistent with American College of Chest Physicians guidelines (ACCP) recommendations. Subgroup analysis of 72 surgeons who specifically report conformance to ACCP guidelines demonstrated only 38% actually provided prophylaxis consistent with ACCP recommendations. VTE is a potentially fatal complication of autogenous breast reconstruction. Further research is necessary to create VTE prophylaxis guidelines specific to patients undergoing these procedures. The need for surgeon education on appropriate prophylaxis cannot be overemphasized.

背景与目标： : 目前在自体乳房重建中预防静脉血栓 (VTE) 的实践模式尚不清楚。一项基于网络的VTE预防调查已分发给美国所有对自体组织乳房重建有临床兴趣的美国整形外科协会成员 (N = 3584)。总共返回了606份完成的调查，答复率为16.9%。对既定指南的总体依从性较低 (25%)。高容量外科医生 (43% 对22%) 和学术实践中的外科医生 (42% 对22%) 更可能报告符合美国胸科医师学会指南 (ACCP) 建议的预防方案。对72名专门报告符合ACCP指南的外科医生进行的亚组分析表明，只有38% 名医生实际提供了与ACCP建议一致的预防措施。VTE是自体乳房重建的潜在致命并发症。需要进一步的研究来制定针对接受这些手术的患者的VTE预防指南。对外科医生进行适当预防教育的必要性怎么强调都不为过。

BACKGROUND & AIMS: :Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment. Cancer patients require a composite clinical, social and psychological management that can be effective only if care continuity from hospital to home is guaranteed and if such a care takes place early in the course of the disease, combining standard oncology care and palliative care. In these settings, venous thromboembolism (VTE) represents a difficult medical challenge, for the requirement of acute treatments and for the strong impact on anticancer therapies that might be delayed or, even, totally discontinued. Moreover, cancer patients not only display high rates of VTE occurrence/recurrence but are also more prone to bleeding and this forces clinicians to optimize treatment strategies, balancing between hemorrhages and thrombus formation. VTE prevention is, therefore, regarded as a double-edged sword. Indeed, while on one hand the appropriate use of antithrombotic agents can reduce VTE occurrence, on the other it significantly increases the bleeding risk, especially in the frail patients who present with multiple co-morbidities and poly-therapy that can interact with anticoagulant drugs. For these reasons, thromboprophylaxis should start while active cancer treatment is ongoing, according to a simultaneous care model in a patient-centered perspective.

背景与目标： : 同时护理代表了积极抗肿瘤治疗下癌症患者早期支持和姑息治疗之间的理想整合。癌症患者需要一种综合的临床，社会和心理管理，只有在保证从医院到家庭的护理连续性以及在疾病早期进行这种护理时，将标准的肿瘤学护理和姑息治疗相结合，才能有效。在这些情况下，静脉血栓栓塞 (VTE) 代表了一项艰巨的医学挑战，对于急性治疗的需求以及对可能被延迟甚至完全终止的抗癌疗法的强烈影响。此外，癌症患者不仅显示出高VTE发生/复发率，而且更容易出血，这迫使临床医生优化治疗策略，平衡出血和血栓形成。因此，预防VTE被视为一把双刃剑。事实上，一方面，适当使用抗血栓药物可以减少VTE的发生，另一方面，它显著增加出血风险，特别是在出现多种合并症和多治疗的体弱患者中，这些患者可能与抗凝药物相互作用。由于这些原因，根据以患者为中心的同时护理模型，应在进行积极的癌症治疗时开始进行血栓预防。

BACKGROUND & AIMS: :Although hyperhomocysteinemia is an established risk factor for venous thromboembolism there is no consensus for routine determination of circulating homocysteine in the UK, either at the beginning or end of oral anticoagulation therapy. The purpose of this study was to evaluate the prevalence of hyperhomocysteinemia and its relationship to folate and vitamin B12 status in subjects with venous thromboembolism 4 weeks after discontinuation of warfarin therapy. In 78 consecutively recruited patients, plasma homocysteine was significantly higher (p < 0.001) and red cell folate significantly lower (p = 0.03) than in controls. Plasma vitamin B12 was similar in both groups. Strikingly, 38.5% of patients had hyperhomocysteinemia (> 15 micromol/l). Retrospective analysis revealed a significant positive association between plasma total homocysteine and duration of warfarin therapy (p < 0.001) but a negative, though non-significant (p = 0.06), trend with warfarin dose. The results do not suggest any direct interaction between warfarin and plasma homocysteine but raise the possibility of reduced intake of a common food source of folate and vitamin K. One possibility is the shortage of green-leafy vegetables since patients are often advised to limit their intake of this major source of vitamin K. On the basis of this study we suggest that homocysteine screening should be carried out at the time that patients begin warfarin therapy.

背景与目标： : 尽管高同型半胱氨酸血症是静脉血栓栓塞的既定危险因素，但在口服抗凝治疗开始或结束时，英国对循环同型半胱氨酸的常规测定尚无共识。这项研究的目的是评估停用华法林治疗4周后静脉血栓栓塞症患者高同型半胱氨酸血症的患病率及其与叶酸和维生素B12状态的关系。在78名连续招募的患者中，血浆同型半胱氨酸明显高于对照组 (p <0.001)，红细胞叶酸明显低于对照组 (p = 0.03)。两组血浆维生素B12相似。令人惊讶的是，38.5% 的患者患有高同型半胱氨酸血症 (> 15微摩尔/升)。回顾性分析显示，血浆总同型半胱氨酸与华法林治疗持续时间之间存在显着的正相关 (p <0.001)，但华法林剂量呈阴性 (p = 0.06) 趋势。结果表明华法林与血浆同型半胱氨酸之间没有任何直接相互作用，但增加了减少叶酸和维生素k常见食物来源摄入的可能性。一种可能性是绿叶蔬菜的短缺，因为通常建议患者限制这种主要维生素k来源的摄入。根据这项研究，我们建议在患者开始华法林治疗时应进行同型半胱氨酸筛查。

BACKGROUND & AIMS: :A previous study of fatal pulmonary thromboembolism (PE) during a five-year period (1989-1993) in Singapore found a low post-mortem prevalence of fatal PE (1.05%). The present study investigated cases of fatal PE among 10,097 coroner's post-mortems conducted between 1994 and 1998 at the Centre for Forensic Medicine, Health Sciences Authority, Singapore, and compared the results with the previous study. There were 130 cases of fatal PE, representing a post-mortem prevalence of 1.29%. This is comparable to the previous study but is lower than most other published series from other countries. There was a shift towards younger subjects, with the modal age group being 40 to 49 years, compared with 70 to 79 years previously. A large proportion of subjects had risk factors for PE, with 42.3%, 23.8% and 11.5% having had a history of surgery, trauma or malignancy respectively. After the onset of immobility or trauma, 50% of subjects developed PE in the first seven days and 76.8% in the first two weeks. PE was not suspected as the cause of death in 74.6% of cases under medical care. The incidence of fatal PE in Singapore remains low. However, a large proportion of cases continue to be unsuspected as the cause of death. It would appear that, on the whole, a correct clinical diagnosis of fatal pulmonary thromboembolism remains largely elusive.

背景与目标： : 先前在新加坡进行的五年 (1989-1993年) 致命性肺血栓栓塞 (PE) 的研究发现，致命性PE (1.05%) 的死后患病率较低。本研究调查了在新加坡卫生科学局法医学中心进行的1994年和1998的10,097名验尸官验尸中致命的PE病例，并将结果与先前的研究进行了比较。有130例致命PE，代表1.29% 的死后流行。这与先前的研究相当，但低于其他国家/地区的大多数其他已出版系列。向年轻受试者转变，模式年龄组为40至49岁，而以前为70至79岁。大部分受试者具有PE的危险因素，42.3%，23.8% 和11.5% 分别具有手术，创伤或恶性病史。在不动或创伤发作后，50% 的受试者在前七天发展PE，在前两周发展76.8%。在74.6% 的医疗情况下，PE没有被怀疑是死亡原因。新加坡致命PE的发病率仍然很低。然而，很大一部分病例仍然没有被怀疑是死亡原因。总的来说，致命的肺血栓栓塞的正确临床诊断似乎仍然难以捉摸。