• After splenectomy, patients with ITP have a higher risk of venous thrombosis and sepsis than patients with ITP who do not undergo splenectomy.Patients with immune thrombocytopenia (ITP) who relapse after an initial trial of corticosteroid treatment present a therapeutic challenge. Current guidelines recommend consideration of splenectomy, despite the known risks associated with surgery and the postsplenectomy state. To better define these risks, we identified a cohort of 9976 patients with ITP, 1762 of whom underwent splenectomy. The cumulative incidence of abdominal venous thromboembolism (AbVTE) was 1.6% compared with 1% in patients who did not undergo splenectomy; venous thromboembolism (VTE) (deep venous thrombosis and pulmonary embolus) after splenectomy was 4.3% compared with 1.7% in patients who did not undergo splenectomy. There was increased risk of AbVTE early (<90 days; hazard ratio [HR] 5.4 [confidence interval (CI), 2.3-12.5]), but not late ( ‡90 days; HR 1.5 [CI, 0.9-2.6]) after splenectomy. There was increased risk of VTE both early (HR 5.2 [CI, 3.2-8.5]) and late (HR 2.7 [CI, 1.9-3.8]) after splenectomy. The cumulative incidence of sepsis was 11.1% among the ITP patients who underwent splenectomy and 10.1% among the patients who did not. Splenectomy was associated with a higher adjusted risk of sepsis, both early (HR 3.3 [CI, 2.4-4.6]) and late (HR 1.6 or 3.1, depending on comorbidities). We conclude that ITP patients post splenectomy are at increased risk for AbVTE, VTE, and sepsis. (Blood. 2013;121(23):4782-4790)

Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients but did not account for frequency of hospitalization. We determined the incidence of VTE in a SCD cohort versus matched controls. For SCD patients, risk factors for incident VTE, recurrence and the impact on mortality were also determined. Among 6237 patients with SCD, 696 patients (11·2%) developed incident-VTE: 358 (51·6%) had PE (±DVT); 179 (25·7%) had lower-extremity DVT only and 158 (22·7%) had upper-extremity DVT. By 40 years of age, the cumulative incidence of VTE was 17·1% for severe SCD patients (hospitalized ≥3 times a year) versus 8·0% for the matched asthma controls. Amongst SCD patients, women (Hazard ratio [HR] = 1·22; 95% confidence interval [CI]: 1·05-1·43) and those with severe disease (HR = 2·86; 95% CI: 2·42-3·37) had an increased risk of VTE. Five-year recurrence was 36·8% in patients with severe SCD. VTE was associated with increased risk of death (HR = 2·88, 95% CI: 2·35-3·52). In this population-based study, the incidence of VTE was higher in SCD patients than matched controls and was associated with increased mortality. The high incidence of recurrent VTE in patients with severe SCD suggests that extended anticoagulation may be indicated.

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The incidence of venous thromboembolism (VTE) is known to be higher in patients with malignancy as compared with the general population. It is important to understand and review the epidemiology of VTE in cancer patients because it has implications regarding treatment and prognosis. Multiple studies have shown that cancer patients who develop VTE are at higher risk for mortality. This article will focus on an update regarding the epidemiology of cancer-associated thrombosis (CT). The authors will describe factors associated with CT risk including cancer type and stage at the time of diagnosis, race and ethnicity, and cancer-directed therapy. In addition, recurrent thrombosis and the effect of thromboembolism on survival in cancer patients will also be addressed.

Background:The extent to which vena cava filter (VCF) use varies between hospitals in the management of acute venous thromboembolism (VTE) is not clear.Methods : We conducted a retrospective observational study that compared the frequency of VCF use among California hospitals from January 1, 2006, through December 31, 2010. Using administrative hospital discharge data, we followed explicit criteria to identify nontrauma patients with acute VTE, and determined the frequency of VCF placement in each of the hospitals that admitted more than 55 VTE patients. Multivariable hierarchical regression models to predict VCF use included important clinical and demographic variables as fixed effects and hospital as a random effect.Results: Among the 263 hospitals included, 130 643 acute VTE hospitalizations occurred with the placement of 19 537 VCFs (14.95%). Variation in the percentage of acute VTE hospitalizations that included VCF placement was very high, from 0% to 38.96% (interquartile range, 6.23%-18.14%), with 18.49% of the observed variation due to differences among the hospitals that provided care. Significant clinical predictors of VCF use included acute bleeding at the time of admission (odds ratio, 3.4 [95% CI, 3.2-3.6]), a major operation after admission for ), presence of metastatic cancer (1.7 [1.6-1.8]), and extreme severity of illness (2.5 [2.3-2.7] vs mild). Insertion of VCFs occurred more frequently than expected in 109 hospitals and less frequently in 59. Hospital characteristics associated with VCF use included a small number of beds (odds ratio, 0.2 [95% CI, 0.2-0.4], Ͻ100 vs Ͼ400 beds), a rural location (0.4 [0.2-0.5]), and other private vs Kaiser hospitals (1.5 [1.1-2.0]). Use of VCFs varied widely even in geographically proximate areas. Conclusions:The frequency of VCF use in patients with acute VTE varied widely and depended on which hospital provided the care, even after adjusting for clinical and socioeconomic factors. Further research is needed to determine whether this variation is associated with local cultural differences between hospitals or with differences in the availability of interventional radiologists or specialists, or whether it reflects the absence of highquality evidence that VCFs are effective.

Cancer associated thrombosis (CAT) is an important cause of morbidity and mortality for patients with malignancy and varies by primary cancer type, stage and therapy. We aimed to characterize the incidence, risk factors, temporal trends and the effect on mortality of CAT. The California Cancer Registry was linked to the statewide hospitalization database to identify individuals with the 13 most common malignancies diagnosed 2005 -2017 and determine the 6 and 12-month cumulative incidence of CAT by venous thromboembolism (VTE) location, tumor type and stage after adjusting for competing risk of death. Cox proportional hazard regression models were used to determine risk factors associated with CAT and the effect of CAT on all-cause mortality. 942,019 patients with cancer were identified; 62,003 (6.6%) had an incident diagnosis of CAT. Patients with pancreatic, brain, ovarian, and lung cancer had the highest and patients with breast and prostate cancer had the lowest 12-month cumulative incidence of CAT. For most malignancies, men, those with metastatic disease and more co-morbidities, and African-Americans (vs. non-Hispanic Whites) were at highest risk for CAT. Patients diagnosed with cancer 2014-2017 had higher risk of CAT compared to those diagnosed 2005-2007. CAT was associated with increased overall mortality for all malignancies (HR ranges 1.89 - 4.79). The incidence of CAT increased over time and was driven by an increase in PE±DVT. CAT incidence varies based on tumor type and stage, and on individual risk factors including gender, race/ethnicity, and co-morbidities. For all tumor types CAT is associated with an increased mortality.

• In sickle cell disease, ONFH incidence accelerates in early adulthood.• Frequent hospitalizations and antecedent acute chest syndrome are independently associated with sickle cell-related ONFH.Osteonecrosis of the femoral head (ONFH) is a prevalent complication of sickle cell disease (SCD) that has not been well described in population-based cohort studies. ongoing studies into prevention and effective nonsurgical interventions for SCD-induced osteonecrosis must remain a high research priority.

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