In Introduction, the author of this dissertation deals with postoperative venous thromboembolism (VTE), hereditary and acquired risk factors, prophylaxis regimens and recent recommendation of VTE prevention in surgery. In Practical part of this work the author assesses the risk of VTE in surgical patients according to risk assessment model. Genetic testing is carried out in all patients to determine the incidence of hereditary thrombophilia and coagulation markers are measured in 28-days postoperative period. Prevalence of VTE in 1-year postoperative period is observed. The results are analysed in group of patients with benign disease (hernia and gallstone disease) and group of patients with malignancy (colorectal cancer and pancreatic cancer) separately. The objective of this work is to determine the incidence of the most frequent thrombophilic mutations (factor V Leiden mutation and protrombin G20210A mutation) and assess the impact of hereditary thrombophilia on incidence of postoperative venous thromboembolism in general surgery. Validation of venous thrombosis risk assessment model recommended by Czech Society for Thrombosis and Hemostasis is further objective.

Postthrombotic syndrome (PTS) is a frequent complication of venous thromboembolism (VTE). Using MarketScan claims data from January 2012 to June 2015, we identified adults with a primary diagnosis code for VTE during a hospitalization/emergency department visit, ≥6 months of insurance coverage prior to the index event and newly started on rivaroxaban or warfarin within 30 days of the index VTE. Patients with <4-month follow-up postindex event or a claim for any anticoagulant during 6-month baseline period were excluded. Differences in baseline characteristics between rivaroxaban and warfarin users were adjusted for using inverse probability of treatment weights based on propensity scores. Patients were followed for the development of PTS starting 3 months after the index VTE. Cox regression was performed and reported as hazard ratios with 95% confidence intervals (CIs). In total, 10 463 rivaroxaban and 26 494 warfarin users were followed for a mean of 16 ± 9 (range, 4-39) months. Duration of anticoagulation was similar between cohorts (median = 6 months). Rivaroxaban was associated with a 23% (95% CI: 16-30) reduced hazard of PTS versus warfarin. Rivaroxaban was associated with a significant risk reduction in symptoms of PTS compared to warfarin in patients with VTE treated in routine practice.

Venous thromboembolism (VTE) is one of the most common cardiovascular diseases. KTH and its academic and industrial partners intend to develop a system to combat VTE by forcing movements of inactive muscles. An important part of this system is a unit that can sense muscular activity over time. Electromyography (EMG) is used to measure the activation potential of muscles. The goal of this thesis is to develop an EMG device that can measure bioelectric signals and convey this data to other devices. This thesis is mainly an exploration to identify the potential solution and more work is needed to develop the required system. The EMG device must be small, modular, battery powered and be able to communicate wirelessly with other devices. A functioning EMG system requires an appropriate amplification for the result to be legible and requires extensive filtering as well as detailed circuit board design to eliminate noise or interference that can affect the result.This project utilized a top down approach. An architecture of the EMG system was made and broken down into functional blocks. Each block was implemented separately and the whole solution was tested experimentally to ensure that all the specifications were fulfilled. To validate the EMG device, a series of reference images were used together with directly observing the correlation between muscle activation and its signal with an oscilloscope.The result was a fully functional EMG device that consisted of two PCB: a PCB with EMG circuitry (analog circuit) and a PCB with digital processing for communication (digital circuit). The EMG results were consistent between test subjects and could easily be correlated to muscle movement and force. The reference images indicated that it was functioning as intended. There was still 50 Hz common mode noise present in the EMG device which could have been due to its wide bandwidth and poor low frequency properties.The goals and requirements were fulfilled: a fully functional wireless, modular, small and battery driven EMG device was developed. The noise level of the EMG could have been lower and would need some further improvements. An integrated battery could be implemented to eliminate the need for users to provide a battery. An app could be developed in tandem with the EMG device, with friendly user interface, for healthcare personnel.The thesis workers strived to minimize the number of used components and power consumption. All components were RoHS certified and discarded components were collected for proper waste management. Energy consumption could have been further minimized in the digital PCB by implementing sleep mode and a watchdog timer. This thesis strived to implement as much of the 17 global sustainability goals set by the United Nations (UN). In conclusion, the main sustainability goal of this thesis was “3 – Good Health and well-being”. Other sustainability goals were “12 – Responsible consumption and production”, “13 – Climate action”, “15 – Life on land” were deemed to have been considered in this thesis. / Venös tromboemboli (VTE) är en av de vanligaste kardiovaskulära sjukdomarna. KTH och dess akademiska och industriella partner avser att utveckla ett system med uppdrag att bekämpa VTE genom att stimulera inaktiva muskler. Elektromyografi (EMG) används för att mäta musklernas aktiveringspotential. Syftet med denna avhandling är att utveckla en EMG-enhet som kan mäta bioelektriska signaler och överföra denna data till andra enheter. Ett fungerande EMG system kräver en lämplig förstärkning för att resultatet ska vara läsbart och kräver filtrering samt utförlig kretskortdesign för att eliminera brus/störningar som kan påverka resultatet negativt.Projektet använde en Top-Down strategi. En arkitektur av EMG-systemet genomfördes och sedan delades upp i funktionella block. Varje block implementerades separat och hela lösningen testades experimentellt för att säkerställa att alla specifikationer uppfylldes. För att validera EMG- enheten användes referensbilder tillsammans med att direkt observera sambandet mellan muskelaktivering och dess signal via ett oscilloskop.Resultatet var en helt funktionell EMG-enhet som bestod av två PCB: en PCB med EMG funktionalitet (analog krets) och en PCB med digital processering för kommunikation (digital krets). EMG mätningarna var konsistenta mellan testpersoner och kunde lätt korreleras med muskelrörelse och spänningskraft. Referensbilderna indikerade att den fungerade som avsedd. Det fanns fortfarande 50 Hz common mode brus i EMG-enheten, vilket kan ha orsakas av dess breda bandbredd och dåliga lågfrekvensegenskaper.Målen och kraven uppfylldes: en fullt funktionell trådlös, modulär, liten och batteridriven EMG- enhet. Brusnivån för EMG kunde ha varit lägre och skulle behöva ytterligare förbättringar. Ett integrerat batteri kunde implementeras för att eliminera användarnas behov av att tillhandahålla ett batteri. En applikation kunde ha utvecklats för EMG-enheten, med ett användarvänligt användargränssnitt, för vårdpersonal.Examensarbetarna strävade efter att minimera användning av komponenter och strömförbrukning under arbetsprocessen. Alla komponenter var RoHS-certifierade och kasserade komponenter insamlades för korrekt avfallshantering. Energiförbrukning kunde ha minimerats ytterligare i det digitala kretskortet genom att implementera sleep mode och en watchdog timer. I detta examensarbete var det önskvärt att implemnetera de 17 globala hållbarhetsmålen uppsatta av FN (Förenta Nationerna). Sammanfattningsvis uppfylldes huvudsakligen “3 – Good Health and well-being”. Hållbarhetsmålen ”12 - Ansvarig konsumtion och produktion”, ”13 – Klimatåtgärder”, ”15 - Liv på land” anses även att ha beaktas i denna avhandling.

Venous thromboembolism (VTE), defined as deep vein thrombosis and/or pulmonary embolism is the second leading cause of mortality in cancer patients, second only to cancer itself. A number of reports suggest that circulating extracellular vesicles (EVs) may be increased in cancer patients with VTE. The aim of this study was to examine circulating EVs in high-risk ambulatory cancer patients, determine if levels are associated with hematological outcomes (VTE, major bleeding event), and to assess the impact of prophylactic antithrombotic therapy (Apixaban). We hypothesized that elevated levels of circulating large EVs will be predictive of cancer associated VTE and/or bleeding events and that treatment with Apixaban will reduce EV levels and incidence of cancer VTE. Plasma samples from patients at baseline, and 90-days follow-up from the Apixaban for the Prevention of Venous Thromboembolism in High-Risk Ambulatory Cancer patients (AVERT) trial were investigated. Total EVs were quantified by their pro-coagulant activity using the Zymuphen MP-Activity kit. Platelet, endothelial and tissue-factor EV levels were quantified by flow cytometry. We observed that circulating EVs exhibited significant associations with sex, age, and cancer type, however we did not observe any relationships with clinical outcomes. Thus, it appears that circulating EVs may not have a role in risk stratification for VTE in in high-risk ambulatory cancer patients.

Venous thromboembolism that cause blood clotting in blood vessels, prevent blood circulation, depending on changes in one or more of the coagulation factors II, VII, IX and X. Patients who have had a blood clot or cardiovascular diseases are treated with oral anti-vitamin K (Warfarin®) to reducing and prevent relapse. Warfarin is also used as a preventive treatment before the disease. An overdose of Warfarin® may cause bleeding-complications and low dose cause blood clotting. The dosage of the drug is controlled by measuring prothrombin in plasma. The aim of this study was to investigate if prothrombin-complex value changes due to re-spinning and re-analysis after six hours. Fitty whole blood samples from warfarin-treated patients were divided into three subgroups, those with protrombinkomplex-values of 2-4 (n=20), &gt;4 (n=15) and &lt;2 (n=15). The samples were centrifugated and measured (Method A), re-centrifugated and measured (Method B) or re-analysed after six hours (Method C). All results were compared in a Bland-Altman plot as follows: Method B vs. Method A and Method C vs. Method A. The scatter graph yielded a strong correlation between Method A and Method B (R2=0.9984) and Method A and Methods C (R2=0.9977). The results from t-test showed a significance level (p&lt;0.001) for both analyses (statistical significance=p&lt;0.05). In this study we showed that prothrombin complex value ware stable after re-centrifugation and re-measurement after six hours. Statistical calculations yielded a strong correlation between the methods (A, B, C), and there was no significance difference between the methods.

Background: Venous thromboembolism (VTE), comprising the conditions of deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common acute cardiovascular event associated with increased long-term morbidity, functional disability, all-cause mortality, and high rates of recurrence. Major advances in identification, prophylaxis, and treatment over the past 3-decades have likely changed its clinical epidemiology. However, there are little published data describing contemporary, population-based, trends in VTE prevention and management. Objectives: To examine recent trends in the epidemiology of clinically recognized VTE and assess the risk of recurrence after a first acute episode of VTE. Methods: We used population-based surveillance to monitor trends in acute VTE among residents of the Worcester, Massachusetts, metropolitan statistical area (WMSA) from 1985 through 2009, including in-hospital and ambulatory settings. Results: Among 5,025 WMSA residents diagnosed with acute PE and/or lower-extremity DVT between 1985 and 2009 (mean age = 65 years), 46% were men and 95% were white. Age- and sex-adjusted annual event rates (per 100, 000) of clinically recognized acute first-time and recurrent VTE was 142 overall, increasing from 112 in 1985/86 to 168 in 2009, due primarily to increases in PE occurrence. During this period, non-invasive diagnostic VTE testing increased, vi while treatment shifted from the in-hospital (chiefly with warfarin and unfractionated heparin) to out-patient setting (chiefly with low-molecular-weight heparins and newer anticoagulants). Among those with community-presenting first-time VTE, subsequent 3-year cumulative event rates of key outcomes decreased from 1999 to 2009, including all-cause mortality (41% to 26%), major bleeding episodes (12% to 6%), and recurrent VTE (17% to 9%). Active-cancer (with or without chemotherapy), a hypercoagulable state, varicose vein stripping, and Inferior vena cava filter placement were independent predictors of recurrence during short- (3-month) and long-term (3-year) follow-up after a first acute episode of VTE. We developed risk score calculators for VTE recurrence based on a 3-month prognostic model for all patients and separately for patients without active cancer. Conclusions: Despite advances in identification, prophylaxis, and treatment between 1985 and 2009, the disease burden from VTE in residents of central Massachusetts remains high, with increasing annual events. Declines in the frequency of major adverse outcomes between 1999 and 2009 were reassuring. Still, mortality, major bleeding, and recurrence rates remained high, suggesting opportunities for improved prevention and treatment. Clinicians may be able to use the identified predictors of recurrence and risk score calculators to estimate the risk of VTE recurrence and tailor outpatient treatments to individual patients.

O objetivo do presente estudo foi avaliar a diferença de resultados maternos e neonatais em gestações complicadas por trombofilias hereditárias em pacientes com e sem tromboembolismo venoso. Apesar do aumento de evidências, na literatura, sobre a associação de trombofilias congênitas e resultados obstétricos adversos, há ainda dúvida se pacientes trombofílicas com tromboembolismo venoso apresentam resultados maternos e neonatais piores que as pacientes trombofílicas sem tromboembolismo venoso. O estudo analisou 66 gestantes com trombofilias hereditárias, de forma retrospectiva observacional e comparativa, das quais 33 apresentavam tromboembolismo venoso e 36 o não apresentavam. Os principais desfechos relacionados a resultados maternos e neonatais adversos foram: pré-eclâmpsia grave, descolamento prematuro de placenta, restrição de crescimento fetal, natimortalidade, prematuridade e complicações hemorrágicas maternas. As trombofilias congênitas incluídas no estudo foram o fator V de Leiden (FVL), mutação da protrombina G20210A, mutação C677T do gene da 5,10-metilenotetrahidrofolato redutase (MTHFR), deficiência de proteína S, deficiência de proteína C e deficiência de antitrombina. Ambos os grupos apresentaram características populacionais similares. A ocorrência de complicações maternas e fetais/neonatais foi similar nos dois grupos: pré-eclâmpsia grave (P=0,097), descolamento prematuro de placenta (P=0,478), restrição de crescimento fetal (P=0,868), natimortalidade (P=0,359), prematuridade (P=0,441) e complicações hemorrágicas maternas (P=0,478). Este estudo concluiu que a presença de tromboembolismo venoso em gestantes com trombofilia hereditária apresenta resultados maternos e neonatais semelhantes àquelas com trombofilias hereditárias sem tromboembolismo venoso. / The aim of this study was to evaluate differences in maternal and neonatal outcomes in pregnancies complicated by inherited thrombophilias between patients with and without venous thromboembolism. Despite increasing evidence in the literature indicating an association between inherited thrombophilias and adverse obstetric outcomes, doubts remain whether thrombophilic patients with venous thromboembolism present poorer maternal and neonatal outcomes than thrombophilic patients without venous thromboembolism. In this retrospective, observational and comparative study, 66 pregnant women with inherited thrombophilias, including 33 with venous thromboembolism and 36 without thromboembolism, were investigated. The main end-points analyzed were severe pre-eclampsia, placental abruption, fetal growth restriction, stillbirth, preterm delivery, and maternal hemorrhagic complications. The congenital thrombophilias included in this study were factor V Leiden (FVL), prothrombin G20210A mutation, C677T mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, protein S deficiency, protein C deficiency, and antithrombin deficiency. The two groups were similar in terms of population characteristics. The frequency of maternal and fetal/neonatal complications was similar in the two groups: severe pre-eclampsia (P=0.097), placental abruption (P=0.478), fetal growth restriction (P=0.868), stillbirth (P=0.359), preterm delivery (P=0.441), and maternal hemorrhagic complications (P=0.478). This study concluded that venous thromboembolism in thrombophilic patients does not worsen maternal or neonatal outcomes when compared to thrombophilic patients without venous thromboembolism.

O objetivo do presente estudo foi avaliar a diferença de resultados maternos e neonatais em gestações complicadas por trombofilias hereditárias em pacientes com e sem tromboembolismo venoso. Apesar do aumento de evidências, na literatura, sobre a associação de trombofilias congênitas e resultados obstétricos adversos, há ainda dúvida se pacientes trombofílicas com tromboembolismo venoso apresentam resultados maternos e neonatais piores que as pacientes trombofílicas sem tromboembolismo venoso. O estudo analisou 66 gestantes com trombofilias hereditárias, de forma retrospectiva observacional e comparativa, das quais 33 apresentavam tromboembolismo venoso e 36 o não apresentavam. Os principais desfechos relacionados a resultados maternos e neonatais adversos foram: pré-eclâmpsia grave, descolamento prematuro de placenta, restrição de crescimento fetal, natimortalidade, prematuridade e complicações hemorrágicas maternas. As trombofilias congênitas incluídas no estudo foram o fator V de Leiden (FVL), mutação da protrombina G20210A, mutação C677T do gene da 5,10-metilenotetrahidrofolato redutase (MTHFR), deficiência de proteína S, deficiência de proteína C e deficiência de antitrombina. Ambos os grupos apresentaram características populacionais similares. A ocorrência de complicações maternas e fetais/neonatais foi similar nos dois grupos: pré-eclâmpsia grave (P=0,097), descolamento prematuro de placenta (P=0,478), restrição de crescimento fetal (P=0,868), natimortalidade (P=0,359), prematuridade (P=0,441) e complicações hemorrágicas maternas (P=0,478). Este estudo concluiu que a presença de tromboembolismo venoso em gestantes com trombofilia hereditária apresenta resultados maternos e neonatais semelhantes àquelas com trombofilias hereditárias sem tromboembolismo venoso. / The aim of this study was to evaluate differences in maternal and neonatal outcomes in pregnancies complicated by inherited thrombophilias between patients with and without venous thromboembolism. Despite increasing evidence in the literature indicating an association between inherited thrombophilias and adverse obstetric outcomes, doubts remain whether thrombophilic patients with venous thromboembolism present poorer maternal and neonatal outcomes than thrombophilic patients without venous thromboembolism. In this retrospective, observational and comparative study, 66 pregnant women with inherited thrombophilias, including 33 with venous thromboembolism and 36 without thromboembolism, were investigated. The main end-points analyzed were severe pre-eclampsia, placental abruption, fetal growth restriction, stillbirth, preterm delivery, and maternal hemorrhagic complications. The congenital thrombophilias included in this study were factor V Leiden (FVL), prothrombin G20210A mutation, C677T mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, protein S deficiency, protein C deficiency, and antithrombin deficiency. The two groups were similar in terms of population characteristics. The frequency of maternal and fetal/neonatal complications was similar in the two groups: severe pre-eclampsia (P=0.097), placental abruption (P=0.478), fetal growth restriction (P=0.868), stillbirth (P=0.359), preterm delivery (P=0.441), and maternal hemorrhagic complications (P=0.478). This study concluded that venous thromboembolism in thrombophilic patients does not worsen maternal or neonatal outcomes when compared to thrombophilic patients without venous thromboembolism.

Venös tromboembolism (VTE) inkluderar både djup ventrombos (DVT) och lungemboli (PE) och är en vanlig och komplex kardiovaskulär sjukdom med allvarliga kortsiktiga och långsiktiga komplikationer. I dagens kliniska praxis skulle diagnoseringen av VTE gynnas av en plasmaproteinpanel som antingen kan utesluta fall av akut VTE på egen hand eller komplettera den nuvarande biomarkören D-dimer, som i sig är begränsad av låg specificitet. På grund av den höga återfallsfrekvensen och de allvarliga post-syndromen skulle en plasmaproteinpanel som kan bedöma risken för återkommande VTE underlätta för kliniker i efterbehandlingsbeslut. Mot denna bakgrund syftade denna studie till att föreslå två separata plasmaproteinpaneler, en för att utesluta akuta VTE-patienter och en annan för att bedöma risken för återkommande VTE. Med 1463 unika plasmaproteiner screenades plasmaproteomet hos 194 individer från två undergrupper av venös tromboembolism-biomarkörstudien (VEBIOS), närmare bestämt VEBIOS ER och VEBIOS Coag, med hjälp av proximity extension assay (PEA). Både genuttryck (DE) -analys och maskininlärning (ML) -algoritmer användes för att identifiera signifikanta respektive viktiga proteiner. För akut VTE identifierades 10 signifikanta proteiner genom DE, samt en panel bestående av fem proteiner tillsammans med D-dimer hade tillsammans en area under kurvan (AUC) på 0,97 genom ML. För återkommande VTE identifierades inga signifikanta proteiner och den bästa proteinpanelen hade en AUC på 0,62. Vissa av dessa proteiner har tidigare rapporterats vara associerade med VTE och vissa inte, vilket resulterar i ortogonal validering eller påvisande av en potentiell ny biomarkör. Sammanfattningsvis hittades flera intressanta plasmaproteiner som potentiellt skulle kunna användas för att utesluta fall av akut VTE. GP1BA och S100A12 var särskilt intressanta då de var återkommande som högt ansenliga enligt DE och ML. Resultaten från denna studie kommer förhoppningsvis bidra till forskningen gällande förbättrad diagnos av VTE-patienter genom användning av plasmaproteinmarkörer och argumentationen för ytterligare undersökningar för dessa identifierade plasmaproteiner. / Venous thromboembolism (VTE) is a common and complex cardiovascular disorder with serious short- and long-term complications, comprising both deep vein thrombosis (DVT) and pulmonary embolism (PE). In current clinical practice, diagnosis of acute VTE would greatly benefit from a plasma protein panel that can exclude cases of VTE on its own or complement the current biomarker, D-dimer, which is limited by low specificity. Because of the high recurrence rate and serious post-syndromes, a protein panel that can assess the risk of VTE recurrence would help clinicians in post-treatment decision-making. Hence, this study sought out to propose two separate plasma biomarker panels, one to exclude acute VTE patients and another to risk-assess VTE recurrence.  To accomplish this, 1463 unique plasma proteins were used to investigate the plasma proteome of 194 individuals from two subgroups of the venous thromboembolism biomarker study (VEBIOS), specifically VEBIOS ER and VEBIOS Coag, using proximity extension assay (PEA). Both differential expression (DE) analysis and machine learning (ML) algorithms were used to find significant and important proteins respectively. For acute VTE, 10 significant proteins were identified through DE, and a panel of five proteins together with D-dimer had together an area under the curve (AUC) of 0.97 through ML. For VTE recurrency, no significant proteins were identified, and the best protein panel had an AUC of 0.62. Some of these proteins have previously been reported as associated to VTE and some not, resulting in some orthogonal validation or novelty. In summary, several interesting plasma proteins were found that could potentially be used to exclude cases of VTE in an acute setting. GP1BA and S100A12 were particularly interesting as they performed well in both DE and ML. The results in this study will hopefully aid the research of improving diagnosis of VTE patients using plasma biomarkers, strengthening the claim and further investigations for these identified plasma proteins.