<p><strong>This analysis demonstrated that elderly population with type 2 diabetes mellitus (T2DM) visiting Primary Health Care (PHC) units had a satisfactory glycemic control with the combined use of oral anti-diabetic drugs and insulin.</strong></p>
<h2>Main takeaway</h2>
<ul>
 <li>
  <p>Oral anti-diabetic drugs plus insulin showed better glycemic control in elderly population with T2DM.</p></li>
 <li>
  <p>In addition,&nbsp;<strong>about 75% of the elderly people</strong>&nbsp;had acceptable glycemic control.</p></li>
 <li>
  <p>Negative associations were noted between glycemic control (poor) and other variables,&nbsp;<strong>such as cardiovascular disease, amputation of lower extremities, and ulcer.</strong></p></li>
</ul>
<h2>Why this matters</h2>
<ul>
 <li>
  <p>PHC units play a vital role in managing T2DM via collective and individual interventions.</p></li>
 <li>
  <p>In aging population, health conditions and variables affecting the care of non-communicable chronic diseases should be assessed.</p></li>
 <li>
  <p>The present study aimed to evaluate the glycemic control of elderly T2DM people attending PHCs.</p></li>
</ul>
<h2>Study design</h2>
<p>This cross-sectional study included elderly people with T2DM registered at the local family healthcare units in Ribeirão Preto, São Paulo, Brazil, and assessed data on adhesion to treatment.</p>
<ul>
 <li>The study was conducted from March to October 2018 via household interviews and by assessing laboratory tests in past 6 months.</li>
</ul>
<h3>Inclusion criteria:&nbsp;</h3>
<p>People aged ≥60 years; clinical diagnosis of T2DM regardless of time; continuous use of medication for T2DM treatment; registered in the family health system selected and non-institutionalized.</p>
<h3>Exclusion criteria:&nbsp;</h3>
<p>Participants without results of laboratory tests conducted in past 6 months.</p>
<h3>Dependent variable:&nbsp;</h3>
<p>Glycemic control (assessed by measuring glycated hemoglobin [HbA1c ≤8.0% (64 mmol/mol)] and fasting glucose test [≤150 mg/dL])</p>
<h3>Independent variables:&nbsp;</h3>
<p>Gender, age group, self-reported skin color, education level, time since T2DM diagnosis</p>
<h2>Key results</h2>
<p>In total, 243 elderly people with T2DM participated in the study (women: 67.1%; mean age: 70.3 ± 7.7 years)</p>
<h3>Dependent variables:</h3>
<ul>
 <li>
  <p>The Kappa concordance for glycemic control between HbA1c and fasting glucose test results was 0.52 (95% confidence interval [CI]: 0.40–0.65).</p></li>
 <li>
  <p>Mean HbA1c was 7.2% (standard deviation [SD] = 1.7).</p></li>
 <li>
  <p>Overall, 74.1% (95% CI: 68.5–79.5) elderly people had HbA1c &lt;8%.</p></li>
</ul>
<h3>Independent variables:</h3>
<ul>
 <li>
  <p>The predominant self-reported skin color was white (58.4%).</p></li>
 <li>
  <p>Most participants (74.9%) had a low education level,i.e., up to 4 years of schooling.</p></li>
 <li>
  <p>Overall, &gt;80% participants did not report alcohol or tobacco abuse; 60.9% reported having good or very good health.</p></li>
 <li>
  <p>On average, 3.1 diseases (SD = 1.8) were associated with T2DM, with the most common diseases being systemic arterial hypertension (82.5%), dyslipidemia (57.7%), and overweight/obesity (24.6%).</p></li>
 <li>
  <p>In total, 4.9% reported the presence of ulcer and 3.7% reported amputation of lower extremities.</p></li>
 <li>
  <p>A majority of participants (87.3%) had T2DM for &gt;5 years.</p></li>
 <li>
  <p>Overall, 72.8%, 5.8%, and 21.4% of elderly people used oral anti-diabetic drugs only, insulin only, and a combination of oral anti-diabetic drug and insulin, respectively.</p></li>
</ul>
<p>Glycemic control was positively associated with the use of oral anti-diabetic drugs plus insulin (adjusted prevalence ratio [PR] = 1.18, 95% CI: 1.07−1.32, P &lt;0.001).</p>
<p><strong>However, glycemic control was negatively associated with the following:</strong></p>
<ul>
 <li>
  <p>Cardiovascular disease: Adjusted PR = 0.79, 95% CI: 0.74−0.85, P &lt;0.001.</p></li>
 <li>
  <p>Ulcer: Adjusted PR = 0.81, 95% CI: 0.75−0.87, P&lt;0.001</p></li>
 <li>
  <p>Amputation of lower extremities: Adjusted PR = 0.80,95% CI: 0.75−0.87, P &lt;0.001</p></li>
</ul>
<h2>Limitations</h2>
<ul>
 <li>
  <p>The model proposed does not allow the establishment of causal correlations between the variations</p></li>
 <li>
  <p>Reference values of HbA1c and fasting glycemia could not be determined owing to uncertainties regarding the ideal glycemic index for older adults with T2DM.</p></li>
</ul>

Reference

A Cross-Sectional Analysis of Glycemic Control in Elderly People with Type 2 Diabetes Attending Primary Health Care Unit

INTEGRATED-DIABETES-CARE

DIABETES

<h2>Objective<sup>1</sup></h2>
<p>This meta-analysis explores the risk for severe hypoglycemia with Gla-300 versus Gla-100 in the pool of studied patients with T1D.</p>

<h2>Study Design</h2>
<p>The following patients with T1D were pooled in the present study:</p>
<ul>
 <li>
  <p data-font="legal">Edition&nbsp;4 (n=549): adult patients (age ≥18 years), worldwide<sup>2</sup></p></li>
 <li>
  <p data-font="legal">Edition JP 1 (n=243): adult patients (age ≥18 years), Japan<sup>3</sup></p></li>
 <li>
  <p data-font="legal">Edition&nbsp;Junior&nbsp;(n=463): children and adolescents (age 6−17 years), worldwide<sup>4</sup></p></li>
</ul>

<h3>Previous Basal Insulin<sup>4</sup></h3>

<h3>Results<sup>1</sup></h3>
<p>Gla-300 provides effective and similar glycemic control versus Gla-100 in patients with T1D&nbsp;<strong>-0.3%&nbsp;</strong>HbA1c reduction&nbsp;<strong>LSM difference at week 26 (95% CI):</strong>&nbsp;0.05% (-0.044 to 0.150)</p>
<p>Significant Lower percentage of patients with ≥1 Severe Hypoglycemic event with Gla-300 vs. Gla-100 from baseline to month 6 in pooled analysis&nbsp;<strong>-35% From baseline to month 6:</strong>&nbsp;OR (95% CI): 0.65 (0.42 to 0.98)</p>
<h3>Conclusion<sup>1</sup></h3>
<ul>
 <li>Gla-300 showed a lower risk for severe hypoglycemia compared with Gla-100 in a broad spectrum of patients with T1D, especially during the titration phase.</li>
 <li>Gla-300 provides effective and similar glycemic control versus Gla-100 in patients with T1D.</li>
</ul>
<p>Gla-300, insulin glargine 300 U/ml; Gla-100, insulin glargine 100U/ml; T1D, type 1 diabetes; IDet, insulin detemir; NPH, Neutral Protamine Hagedorn insulin; IDeg, insulin degludec; CI, confidence interval; LS, least square; SE, standard error</p>

References

Exploring the risk for severe hypoglycemia in the pool of studied patients with T1D

TYPE-1-DIABETES

<h2>Key Takeaway</h2>
<h3>In patients with T2D and poor glycemic control receiving BI without prandial insulin, CGM vs BGM monitoring showed:</h3>
<ul>
 <li>Significantly greater improvement in -8month HbA 1c level</li>
 <li>Increased time in target glucose range of 70–180mg/dL</li>
 <li>Reduction in both time spent at &gt;250 mg/dL and mean glucose level</li>
</ul>
<h2>Why This Matters</h2>
<ul>
 <li>Glucose monitoring is critical for safe and effective management of individuals with T2D using insulin</li>
 <li>As the role of CGM in T2D using less-intensive insulin regimens is not well defined; present study compared CGM vs BGM monitoring in this study population.</li>
</ul>
<h2>Study Design</h2>
<h3>This Multicenter, Randomized (N = 175 [CGM Or BGM Group: 2:1]), Open - Label, Parallel - Group Trial Was Conducted At 15 Centers In The United States*</h3>
<p><strong>Key inclusion criteria</strong></p>
<ul>
 <li>Age ≥30 years</li>
 <li>T2D treated with 1 or 2 daily&nbsp;injections of long- or&nbsp;intermediate-acting basal insulin&nbsp;for ≤6 months</li>
 <li>HbA&nbsp;1c: 7.8%–11.5%</li>
 <li>Self-reported BGM testing: ≥3 times&nbsp;per week</li>
 <li>Smart phone compatible with CGM&nbsp;device<sup>†</sup></li>
</ul>
<p><strong>Study outcomes</strong></p>
<ul>
 <li>Primary outcome: HbA1c level at 8 months (adjusted for BL value)</li>
 <li>Key secondary outcomes: 
  <ul>
   <li>Time in target glucose range of 70-180 mg/dL</li>
   <li>Time at glucose level &gt;250 mg/dL</li>
   <li>Mean glucose level at 8 months (adjusted for BL value)</li>
  </ul></li>
</ul>
<h2>Key Result</h2>
<p>A total of&nbsp;<strong>175</strong>&nbsp;participants were randomized (2:1) into CGM vs BGM group<br>
  (n = 116 vs 59; mean age = 57 years; mean BL HbA1c = 9.1%)</p>
<p><strong>Primary outcome (cgm vs bgm group):</strong></p>
<ul>
 <li>HbA<sub>1c</sub>&nbsp;level at 8 months<sup>‡</sup>&nbsp;<strong>8.0%</strong>&nbsp;vs&nbsp;<strong>8.4%&nbsp;</strong>(adjusted difference in mean change in HbA<sub>1c</sub>&nbsp;level from baseline: 
  <ul>
   <li>-<strong>0.4%</strong>&nbsp;[%95 CI: %0.8− to %0.1−; P = 0.02])</li>
  </ul></li>
</ul>
<p><strong>Key secondary outcomes (cgm vs bgm group):</strong></p>
<ul>
 <li>Time in target glucose range of 70-180 mg/dL (mean%):&nbsp;<strong>59%</strong>&nbsp;vs&nbsp;<strong>43%&nbsp;</strong>(adjusted mean difference:&nbsp;<strong>15%</strong>&nbsp;[%95 CI: %8 to %23; P &lt;0.001§])</li>
 <li>Time at glucose level &gt;250 mg/dL (mean%):<strong>11%</strong>&nbsp;vs&nbsp;<strong>27%&nbsp;</strong>(adjusted mean difference:&nbsp;<strong>−16%</strong>&nbsp;[%95 CI: %21− to %11−; P &lt;0.001<sup>¶]</sup>)</li>
 <li>Mean glucose levels at 8 months:&nbsp;<strong>179</strong>&nbsp;vs&nbsp;<strong>206</strong>&nbsp;mg/dL (adjusted difference:&nbsp;<strong>26− mg/dL</strong>&nbsp;[%95 CI: 41− to 12−; P &lt;0.001])</li>
 <li>ADVERSE EVENTS: Severe hypoglycemic event (one in both, CGM and BGM group) and diabetic ketoacidosis (one in CGM group)</li>
 <li>CGM satisfaction scale: Mean score (CGM group) =&nbsp;<strong>4.1/5</strong></li>
</ul>
<h2>Limitations</h2>
<ul>
 <li>Follow-up duration was only 8 months</li>
 <li>Due to virtual visits -8month HbA 1c or CGM data was not available for some participants</li>
 <li>Limited generalizability of study findings to most routine clinical practice settings</li>
 <li>In one-third of the CGM group HbA1c level still remained &gt;%8 after 8 months highlighting the need for more aggressive pharmacological management</li>
</ul>

Footnotes

Abbreviations

Effectiveness of continuous glucose monitoring in adults with Type 2 diabetes treated with basal insulin

TYPE-2-DIABETES

<p><strong>Novel basal insulins and fixed-ratio combinations of basal insulin and GLP-1RA are safer and more convenient options for uncontrolled type 2 diabetes</strong>.</p>
<ul>
</ul>
<h2>Main Takeaway</h2>
<ul>
 <li>
  <p>This review informs about new and advanced therapeutic options available for patients with type 2 diabetes (T2D) uncontrolled with oral antidiabetic drugs (OADs).</p></li>
 <li>
  <p>Basal insulin (BI), with its advanced new formulations, is an important therapeutic option in patients with advancing T2D.</p></li>
 <li>
  <p>If BI is insufficient in achieving the desired glycaemic goals, treatment intensification with prandial insulin, pre-mixed insulin or glucagon-like peptide-1 receptor agonist (GLP-1RA) should be considered.</p></li>
 <li>
  <p>Recently, ‘fixed-ratio combinations’ (FRCs) of BI and GLP-1RA have been approved for use with safe and effective antihyperglycaemic profiles whilst reducing injection burden, thereby promoting adherence.</p></li>
</ul>
<h2>Key Highlights</h2>
<ul>
 <li>
  <p>As T2D is a progressive disorder, most patients eventually require insulin therapy to obtain optimal glycaemic control.</p></li>
 <li>
  <p>The American Diabetes Association (ADA), European Association for the Study of Diabetes and American Association of Clinical Endocrinologists recommend the early use of BI in the course of T2D treatment.</p></li>
 <li>
  <p>Generally, BI therapy is initiated on non-achievement of glycaemic targets after receiving 2-3 OADs.</p></li>
 <li>
  <p>Advances in BI formulations have led to flatter and longer action profiles, resulting in a significant reduction in hypoglycaemia.</p></li>
 <li>
  <p>Recent BI analogues are easy to initiate as a once-daily injection.</p></li>
 <li>
  <p>However, insulin dosing and subsequent titration are prescribed on the basis of insulin formulations and clinician and patient preferences.</p></li>
 <li>
  <p>Recommended insulin initiation dosages vary with formulations, but are generally conservative to reduce the risk for hypoglycaemia.</p></li>
 <li>
  <p>Post-initiation, BI should be appropriately titrated to achieve optimal fasting plasma glucose targets.</p></li>
 <li>
  <p>If the daily BI dose is approximately &gt;0.5 U/kg and glycated haemoglobin (HbA1c) targets are unmet, initiation of combination injectable therapies should be considered, primarily to address postprandial hyperglycaemia.</p></li>
 <li>
  <p>Three options of therapy intensification recommended by the ADA include the addition of rapid-acting insulin, switching to premixed insulin and addition of GLP-1RA.</p></li>
 <li>
  <p>Insulin intensification increases the risk for hypoglycaemia and weight gain with the increased need for self-monitoring of blood glucose levels.</p></li>
 <li>Addition of GLP-1RA to existing BI therapy results in similar HbA1c reductions compared with basal-bolus insulin therapy, with a decreased risk for hypoglycaemia and weight gain. 
  <ul>
   <li>However, gastrointestinal side effects are common with GLP-1RA and its use should be contraindicated or cautionary in at-risk patient populations.</li>
  </ul></li>
 <li>
  <p>Recently, FRCs of BI and GLP-1RA have been approved for T2D treatment.</p></li>
 <li>Studies indicate that in patients suboptimally controlled on OADs or BI, FRCs (vs individual components) have the following beneficial effects: 
  <ul>
   <li>significant improvement in glycaemic control with 55-75% of patients achieving HbA1c &lt;7.0%;</li>
   <li>mitigation of weight gain and no higher risk for hypoglycaemia vs BI alone; and</li>
   <li>reduced gastrointestinal side effects vs GLP-1RA alone.</li>
  </ul></li>
 <li>
  <p>In patients not achieving glycaemic targets with less than 50-60 U BI, FRCs are a safe and effective option with convenient once-daily subcutaneous injectable dosing.</p></li>
</ul>

Basal Insulin and Beyond: Advanced Therapies for Type 2 Diabetes

CHRONIC-OBSTRUCTIVE-PULMONARY-DISEASE-(COPD)

RESPIRATORY

A deeper look at the inflammation behind exacerbations in COPD

<p>Role of type 2 inflammation in type 2 COPD</p>

<h2>Each Copd Exacerbation May Increase the Risk of Another, Putting Patients’ Lives at Greater Risk</h2>
<h3>Exacerbation risk accelerates after each exacerbation<sup>1</sup></h3>

<p>Based on data from a large population-based cohort of 73,106 Canadian patients who were hospitalized for the first time because of a severe exacerbation of COPD (1990-2005, followed until death or March 31, 2007) with a median follow-up of 3.6 years (range 1 day to 17 years). The mean age of patients in this retrospective study was 75 years old.<sup>1</sup></p>
<p data-font="legal"><sup>a</sup>Adjusted for age, sex, calendar time, and the modified Chronic Disease Score.<sup>1</sup></p>
<h3>Exacerbations have been shown to accelerate lung function decline<sup>2</sup></h3>
<p><strong>Significant lung function decline may occur even after a single COPD exacerbation<sup>2</sup></strong></p>
<ul>
 <li>The annual decline in postbronchodilator FEV<sub>1</sub>&nbsp;nearly doubled after 1 moderate-to-severe exacerbation (pre-exacerbation 39.1 mL/year vs 76.5 mL/year postexacerbation [P=0.003])<sup>2,b</sup></li>
</ul>
<p data-font="legal"><sup>b</sup>Based on data from a retrospective analysis of 586 patients with moderate-to-severe (postbronchodilator FEV<sub>1</sub>&nbsp;70% of the predicted normal and FEV<sub>1</sub>&nbsp;70% of FVC) COPD participating in the 4-year, randomized, double-blind, placebo-controlled, parallel-group UPLIFT trial.</p>
<h2>Exacerbations may increase morbidity risk<sup>3-6</sup></h2>
<p><strong>Patients with exacerbations leading to hospitalization are at an increased risk for hospital readmissions</strong></p>
<ul>
 <li>Up to 35% of patients were readmitted within 90 days following an exacerbation<sup>3-5,c</sup></li>
</ul>
<p><strong>COPD exacerbations are associated with a worsening of symptoms that can seriously impact quality of life</strong></p>
<p><strong>Patients typically experience:</strong></p>

<p>Limited activity levels and exercise capacity<sup>6</sup></p>

<p>Sleep-related disturbances<sup>8,9</sup></p>

<p>Anxiety and depression<sup>8</sup></p>

<p><sup>c</sup>Based on data from an investigation that examined outcomes (in-hospital and 90-day postdischarge mortality and 90-day readmission) in patients with a severe COPD exacerbation (n=15,191) seen within the European COPD Audit.<sup>3</sup></p>
<h3>Exacerbations may increase mortality risk<sup>1</sup></h3>

<h3>~2x<strong>&nbsp;</strong></h3>
<p><strong>higher risk<sup>e</sup></strong></p>

<strong>After second exacerbation<sup>d</sup></strong>

black

<h3>~3x&nbsp;</h3>
<p><strong>higher risk<sup>e</sup></strong></p>

<strong>After fifth exacerbation<sup>d</sup></strong>

<h4>Noteworthy</h4>
<h3><strong>All-cause mortality data show<sup>f</sup>:&nbsp;</strong>&nbsp;50<sup>%</sup>&nbsp;&nbsp;<strong>of patients died less than 4 years after their first COPD-related hospitalization<sup>1,d</sup></strong></h3>
<p><sup>d</sup>Based on data from a large population-based cohort of 73,106 Canadian patients who were hospitalized for the first time because of a severe exacerbation of COPD (1990-2005, followed until death or March 31, 2007) with a median follow-up of 3.6 years (range 1 day to 17 years). The mean age of patients in this retrospective study was 75 years old.<br><sup>e</sup>Relative risk of mortality compared to the first exacerbation (adjusted hazard ratio).<br><sup>f</sup>The median survival was 3.6 years.</p>

<h2>Chronic Underlying Inflammation Drives the Downward Spiral of Copd Progression<sup>10-18</sup></h2>
<p><strong>Different types of chronic inflammation have an important role in COPD pathophysiology</strong></p>
<p><strong>Many cell types and cytokines are involved in these processes, including:</strong></p>

<h4>Noteworthy</h4>
<h3><strong>Up to&nbsp;&nbsp;</strong>37<strong><sup>%</sup></strong>&nbsp;&nbsp;<strong>of COPD patients without an asthma comorbidity had evidence of type 2 inflammation<sup>25-29,g</sup></strong></h3>
<p data-font="legal"><sup>g</sup>Based on findings from 5 studies in COPD patients without asthma. Eosinophil levels used to define type 2 inflammation ranged from ≥300 cells/μL to ≥340 cells/μL (blood), ≥2% (blood and sputum), or &gt;3% nonsquamous cells (sputum). Percentages of patients with type 2 inflammation ranged from 12.3% to 37%.<sup>25-29</sup></p>
<h2>Type 2 inflammation may drive poor outcomes in COPD<sup>9,30,31</sup></h2>
<p data-font="legal"><strong>Type 2 inflammation encompasses both type 2 effector cells (eg, Th2, ILC2, eosinophils, and mast cells) and key cytokines (eg, IL-4, IL-13, and IL-5)<sup>16,19,20,32-41</sup></strong></p>

<p><strong>Persistent symptoms (dyspnea, chronic cough, sputum)<sup>9</sup></strong></p>

<strong>Progressive lung function decline<sup>9</sup></strong>

<strong>Exacerbations<sup>9</sup></strong>

<p><strong>Select cytokines play important roles in type 2 inflammation</strong></p>

<p>IL-4 and IL-13 promote the activation and trafficking of type 2 inflammatory cells, including eosinophils, to the lungs, which may contribute to airway remodeling and parenchymal destruction in COPD<sup>32,34,42-48</sup></p>

<strong>IL-4 and IL-13 drive inflammatory cell activity</strong>

<p>IL-13 plays a role in emphysema, fibrosis, and goblet cell hyperplasia and increases expression of MUC5AC, a major constituent of airway mucus<sup>17,33,34,48-51</sup></p>

<strong>The critical role of IL-13 in airflow limitation</strong>

<p>IL-33 initiates and amplifies the broad inflammatory cascades in COPD, inclusive of type 2 inflammation and beyond<sup>22,23</sup></p>

<strong>The role of IL-33</strong>

<p>IL-5 is required for the growth and differentiation, recruitment, activation, and survival of eosinophils, which may be biomarkers of a broader type 2 inflammatory response<sup>32</sup></p>

<strong>The role of IL-5</strong>

<h2>Look for Elevated Blood Eosinophils (≥300 Cells/μl)—a Biomarker of Type 2 Inflammation in Copd<sup>9,31</sup></h2>
<h3>Identifying COPD patients with type 2 inflammation may help determine those at increased risk of exacerbations</h3>

<p><strong>Blood eosinophils</strong></p>
<h3>≥300</h3>
<p><strong>cells/μL</strong></p>

<h3>32<sup>%</sup></h3>
<p><strong>increased risk of<br>
   COPD exacerbations<sup>30,h,i</sup></strong></p>

<p><sup>h</sup>Results from an observational analysis of 1553 patients with GOLD spirometry grade 2-4 COPD evaluating the relationship between blood eosinophil counts and COPD exacerbation risk.<sup>30</sup></p>
<p><sup>i</sup>Stratified analysis confirmed that increased exacerbation risk was driven by subjects with a history of frequent exacerbations, defined as ≥2 exacerbations per year.</p>
<h3>Elevated eosinophils and a history of frequent exacerbations help identify patients and guide treatment options<sup>9,52</sup></h3>
<p><strong>According to GOLD 2023 recommendations, patients with frequent exacerbations (GOLD Group E) and blood eosinophils ≥300 cells/μL may receive an ICS in combination with LABA + LAMA<sup>9</sup></strong></p>
<h4>Noteworthy</h4>
<p><strong>Even when treatment is optimized with inhaled triple therapy, many patients with COPD may continue to experience exacerbations<sup>52</sup></strong></p>

<p><strong>Understanding type 2 inflammation in COPD may help shed light on why some patients continue to experience exacerbations</strong></p>

A deeper look at the inflammation behind exacerbations can IGNITE NEW THINKING IN COPD

THROMBOSIS

CARDIOLOGY

What is the Thrombotic Risk vs Hemorrhagic Risk in Surgical Patients?

<p>Watch Prof. Juan I. Arcelus, MD. PHD Department of Surgery, University of Granada, Spain: Discussing VTE management in general surgical patients.</p>

<h2>More invasive surgery is associated with a higher rate of VTE.</h2>
<p>In the GAPS non-inferiority randomized controlled trial (RCT) in elective surgical inpatients at moderate or high risk of venous thromboembolism (VTE), administration of pharmacological thromboprophylaxis alone was non-inferior to a combination of pharmacological thromboprophylaxis plus graduated compression stockings (GCS).</p>

<h2>Main Takeaway</h2>
<ul>
 <li>The risk for venous thromboembolism (VTE) is significantly higher with emergency general surgery than elective surgery.</li>
 <li>Emergency surgery and procedures with increased invasiveness are associated with significant risk for VTE.</li>
</ul>

<h2>Why This Matters&nbsp;</h2>
<ul>
 <li>This is the first study to compare the rate of VTE in the emergency surgery compared with the same operations performed electively.</li>
 <li>Surgeons and hospitals should promote research and quality improvement processes aimed at patients undergoing elective surgery to prevent and mitigate VTE.</li>
 <li>A more aggressive VTE chemoprophylaxis regimen may be considered for emergency and more invasive surgery.&nbsp;</li>
</ul>

<h2>Study Design</h2>
<ul>
 <li>A retrospective cohort study of 604,537 patients from the American College of Surgeons National Surgical Quality Improvement Program database.</li>
 <li>Patients underwent cholecystectomies (n=285,847), ventral hernia repairs (VHRs; n=158,500) and partial colectomies (PCs; 160,190) during 2005-2016.</li>
 <li>Primary outcome was VTE at 30 days</li>
 <li>Funding: None disclosed.</li>
</ul>

<h2>Key Results</h2>
<ul>
 <li>Mean age was 55.3 years.</li>
 <li>Of the procedures, 57.3% were performed laparoscopically.</li>
 <li>Overall rate of VTE within 30 days was 1.1% (deep vein thrombosis [DVT], 0.8% and pulmonary embolism [PE], 0.4%).</li>
 <li>The rate of VTE within 30 days was 1.9% for emergency surgery and 0.8% for elective surgery (P&lt;0.001).</li>
 <li>At 30 days, emergency vs. elective showed significantly higher rate of: 
  <ul>
   <li>DVT: 1.4% vs. 0.5% (P&lt;0.001)</li>
   <li>PE: 0.6% vs. 0.3% (P&lt;0.001).</li>
  </ul></li>
 <li>The rate of VTE was 0.4% for laparoscopic surgery and 2.0% for open surgery.</li>
 <li>The rate of VTE increased with increasing invasiveness of surgery (0.5% for cholecystectomy, 0.8% for VHR and 2.4% for PC; P&lt;0.001).</li>
 <li>The 30-day mortality rate was 9 times higher in patients undergoing emergency vs. elective surgery (3.6% vs. 0.4%; P&lt;0.001).</li>
 <li>On multivariable analysis, independent risk factors for VTE were: 
  <ul>
   <li>Emergency general surgery (OR, 1.70; 95% CI, 1.61-1.79; P&lt;0.001);</li>
   <li>Open surgery (OR, 3.38; 95% CI, 3.15-3.63; P&lt;0.001); and</li>
   <li>PC (OR, 1.86; 95% CI, 1.73-1.99; P&lt;0.001).</li>
  </ul></li>
</ul>

<h2>Limitations</h2>
<ul>
 <li>Retrospective design.</li>
 <li>The database represents only a sample of procedures performed and therefore, the findings may not be generalisable.</li>
 <li>VTE chemoprophylaxis adherence, dosing or the type of anticoagulants used were not known.</li>
 <li>Information on specific practice locations or facility types was not available</li>
</ul>

Risk for VTE is higher in emergency surgery than elective procedures

<p>The authors concluded that among patients who had undergone gynecological laparoscopic surgery, the incidence of postoperative deep vein thrombosis (DVT) was high, and that this incidence can be reduced by targeting high-risk factors.</p>

<h2>Key Takeaway</h2>
<ul>
 <li>After gynecological laparoscopic surgery: 
  <ul>
   <li>Incidence of DVT among patients was 11.55%.</li>
   <li>Independent risk factors of DVT: Age &gt;50 years, hypertension, D-dimer &gt;0.5 mg/L, duration of surgery≥60 min, intraoperative pneumoperitoneum pressure≥15 mm Hg, and duration of days in bed &gt;3 days.</li>
  </ul></li>
 <li>Clinical management of these high-risk factors should be strengthened to reduce DVT incidence.</li>
</ul>

<h2>Why This Matters</h2>
<ul>
 <li>DVT of the lower extremities continues to be one of the common complications of gynecological surgery.</li>
 <li>Therefore, it is essential to understand the risk factors of DVT after gynecological laparoscopic surgery, to guide early prevention and treatment of DVT in clinical settings, and to reduce DVT occurrence after surgery.</li>
 <li>This study analyzed relevant clinical data of patients who had undergone gynecological laparoscopic surgery and explored the related factors of postoperative DVT.</li>
</ul>

<h2>Study Design</h2>
<ul>
 <li>The study enrolled patients who underwent gynecological laparoscopic surgery from January 1, 2018, to May 31, 2020.</li>
 <li>Inclusion criteria: Patients who (1) underwent gynecological laparoscopic surgery for the first time; (2) underwent venous color ultrasound to detect DVT pre- and post-operatively; (3) were not using contraceptives or other hormonal drugs, or drugs possibly affecting blood clotting function before surgery; and (4) were well informed and agreed to participate in the study</li>
 <li>Exclusion criteria: Patients who (1) underwent traditional gynecological open surgery; (2) were receiving drugs for anticoagulation before surgery; (3) had diseases involving abnormal blood coagulation function, such as hemophilia and leukemia; and (4) were not willing to participate in the study</li>
 <li>The criteria for diagnosing DVT were as follows: 
  <ul>
   <li>Clinical characteristics: Postoperative pain, numbness, swelling, and limited mobility of the affected side of the lower limb</li>
   <li>Signs: Larger circumference of the lower limb of the affected side than that of the healthy side, as well as a positive Homans sign</li>
   <li>Auxiliary examination: Substantial echo in the venous cavity as observed using color Doppler ultrasound venous examination of the lower extremities</li>
  </ul></li>
</ul>

<h2>Key Results</h2>
<ul>
 <li>In total, 355 patients who underwent gynecological laparoscopic surgery were included. Of these, 41 patients developed DVT (DVT group, incidence: 11.55%); 314 patients were included in the non-DVT group.</li>
 <li>Patient characteristics: 
  <ul>
   <li>The DVT and non-DVT groups demonstrated significant differences with regard to age, hypertension, D-dimer, duration of surgery, intraoperative pneumoperitoneum pressure, duration of days in bed (all P &lt;0.05).</li>
   <li>In contrast, the two groups did not differ significantly with regard to body mass index, diabetes, hyperlipidemia, American Association of Anesthesiologists classification, and intraoperative blood transfusion (all P &gt;0.05).</li>
  </ul></li>
 <li>Independent risk factors of DVT in patients who had undergone gynecological laparoscopic surgery: 
  <ul>
   <li>Age &gt;50 years: Odds ratio [OR] = 4.246, 95% confidence interval [CI]: 1.234–7.114; P = 0.012</li>
   <li>Hypertension: OR = 2.219, 95% CI: 1.153–4.591; P = 0.028</li>
   <li>D-dimer &gt;0.5 mg/L: OR = 3.914, 95% CI: 1.083–5.229; P = 0.008</li>
   <li>Duration of surgery 60 min: OR = 2.542, 95% CI: 1.101–4.723; P = 0.031</li>
   <li>Intraoperative pneumoperitoneum pressure 15 mmHg: OR = 3.845, 95% CI: 1.119–5.218; P = 0.022</li>
   <li>Duration of days in bed &gt;3 days: OR = 1.566, 95% CI: 1.182–1.994; P = 0.037</li>
  </ul></li>
</ul>

<h2>Limitations</h2>
<ul>
 <li>The sample size of cases selected in this study was small.</li>
 <li>This was a single-center study.</li>
</ul>

Risk factors of lower extremity DVT in patients undergone gynecological laparoscopic surgery

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