BackgroundThere is limited information on short- and long-term effects of venous thromboembolism (VTE) on health-related quality of life (HRQoL) in the elderly.ObjectivesTo assess change in generic... Show moreBackgroundThere is limited information on short- and long-term effects of venous thromboembolism (VTE) on health-related quality of life (HRQoL) in the elderly.ObjectivesTo assess change in generic HRQoL and disease-specific HRQoL in patients 1 year after the VTE.MethodsThe Age and Thrombosis, Acquired and Genetic risk factors in the elderly (AT-AGE) study is a 2-center case-control study performed in Leiden, the Netherlands, and Vermont, United States, among individuals aged ≥70 years. We measured generic HRQoL using the 36-item Short Form Health Survey (SF-36) and disease-specific HRQoL using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire (VEINES-QoL/Sym) and the Pulmonary Embolism–Specific Quality of Life Questionnaire (PEmb-QoL). All patients completed these questionnaires shortly after their VTE and 1 year later, while controls completed the 36-item Short Form Health Survey questionnaire once. Linear regression for change in quality of life scores was performed and adjusted for potential confounders.ResultsFor the current analysis, we included patients who were visited twice (n = 316) and controls (n = 427) with HRQoL information. Mean age of patients and controls was similar (78.8 vs 75.5 years). In patients who survived at least 1 year after the VTE, generic HRQoL improved for both summary scores, but it did not reach the level of the age-matched controls: physical and mental summary scores increased by 5.6 and 5.5 points, respectively, but compared with controls, remained 8.2 and 6.4 points lower. For disease-specific HRQoL, the Pulmonary Embolism–Specific Quality of Life Questionnaire overall score decreased from 21.7% to 15.2%, indicating improved HRQoL. Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire scores did not change over time.ConclusionOverall, the quality of life of patients with VTE was worse than that of controls after 1 year, indicating a long-term impact of VTE diagnosis in the elderly. Show less
Author summaryThe growth and maintenance of tissues is a fundamental characteristic of metazoan life, controlled by a highly conserved core of cell signal transduction networks. One such pathway,... Show moreAuthor summaryThe growth and maintenance of tissues is a fundamental characteristic of metazoan life, controlled by a highly conserved core of cell signal transduction networks. One such pathway, the Notch signalling system, plays a unique role in these phenomena by orchestrating the generation of the phenotypic and genetic asymmetries which underlie tissue development and remodeling. At the molecular level, it achieves this via two specific types of receptor/ligand interaction: intercellular binding of receptors and ligands expressed in neighbouring cells, which triggers receptor activation (trans activation); intracellular receptor/ligand binding within the same cell which blocks receptor activation (cis inhibition). Together, these counterposed mechanisms determine the strength, the direction and the specificity of Notch signalling output. Whilst, the basic mechanisms of receptor transactivation have been delineated in some detail, the precise nature of cis inhibition has remained enigmatic. Through a combination of experimental approaches and computational modelling, in this study, we present a new model of Notch signalling in which ligand monomers promote Notch receptor transactivation, whereas cis inhibition is induced via ligand dimers. This is the first model to include a concrete molecular distinction, in terms of ligand configuration, between the main branches of Notch signalling. Our model faithfully recapitulates both our presented experimental results as well as the recently published work of others, and provides a novel perspective for understanding Notch-regulated biological processes such as embryo development and angiogenesis.All tissue development and replenishment relies upon the breaking of symmetries leading to the morphological and operational differentiation of progenitor cells into more specialized cells. One of the main engines driving this process is the Notch signal transduction pathway, a ubiquitous signalling system found in the vast majority of metazoan cell types characterized to date. Broadly speaking, Notch receptor activity is governed by a balance between two processes: 1) intercellular Notch transactivation triggered via interactions between receptors and ligands expressed in neighbouring cells; 2) intracellular cis inhibition caused by ligands binding to receptors within the same cell. Additionally, recent reports have also unveiled evidence of cis activation. Whilst context-dependent Notch receptor clustering has been hypothesized, to date, Notch signalling has been assumed to involve an interplay between receptor and ligand monomers. In this study, we demonstrate biochemically, through a mutational analysis of DLL4, both in vitro and in tissue culture cells, that Notch ligands can efficiently self-associate. We found that the membrane proximal EGF-like repeat of DLL4 was necessary and sufficient to promote oligomerization/dimerization. Mechanistically, our experimental evidence supports the view that DLL4 ligand dimerization is specifically required for cis-inhibition of Notch receptor activity. To further substantiate these findings, we have adapted and extended existing ordinary differential equation-based models of Notch signalling to take account of the ligand dimerization-dependent cis-inhibition reported here. Our new model faithfully recapitulates our experimental data and improves predictions based upon published data. Collectively, our work favours a model in which net output following Notch receptor/ligand binding results from ligand monomer-driven Notch receptor transactivation (and cis activation) counterposed by ligand dimer-mediated cis-inhibition. Show less
Wang, H.J.; Cushman, M.; Rosendaal, F.R.; Vlieg, A.V. 2022
IMPORTANCE Previous venous thrombosis (VT) is associated with risk of future VT, but quantification of risk over the life course is poorly understood. More information is needed for clinicians to... Show moreIMPORTANCE Previous venous thrombosis (VT) is associated with risk of future VT, but quantification of risk over the life course is poorly understood. More information is needed for clinicians to understand the association of remote history of VT with the risk of VT in older patients.OBJECTIVE To assess the association between a remote history of VT and the development of VT in older age.DESIGN, SETTING, AND PARTICIPANTS The Age and Thrombosis, Acquired and Genetic Risk Factors in the Elderly case-control study enrolled patients 70 years and older with VT and control individuals 70 years and older without VT between June 2008 and August 2011. The Age and Thrombosis, Acquired and Genetic Risk Factors in the Elderly study is a 2-center, population-based case-control study that was conducted in Burlington, Vermont, in the US and in Leiden, the Netherlands. Consecutively diagnosed patients with an objectively proven episode of VT (deep vein thrombosis of the leg or pulmonary embolism) were included. Control individualswere identified in the same geographic areas as the patients andwere randomly selected. Datawere analyzed between May 2021 and October 2021.EXPOSURES Self-reported remote VT (occurring >10 years before to enrollment).MAIN OUTCOMES AND MEASURES The main outcome was the risk of VT at older age. The association of self-reported history of remote VT with VT at older age was assessed by calculating odds ratios (ORs) as estimates of relative risk with 95% CIs.RESULTS A total of 460 patients with VT and 456 control participants were included. There were slightly more women than men in both groups (60.2% of patients [n = 277] were women and 52.4% of control participants [n = 239] were women), and the mean (range) age of patients was 78.7 (70.0-100.9) years, which was similar to the control participants. Compared with individuals without remote VT, those with a remote history of VT had an increased risk of VT (OR, 2.54; 95% CI, 1.56-4.13). The crude risk estimate was robust to adjustment and time since remote VT, that is, individuals with a VT 10 to 30 years ago (OR, 2.74; 95% CI, 1.34-5.57) and those with a VT more than 30 years ago (OR, 2.42; 95% CI, 1.21-4.84) had a an increased risk of VT. The populationattributable fraction of a remote history of VT was 7.7%.CONCLUSIONS AND RELEVANCE In this study, a remote history of VT was associated with risk of VT in older individuals. This quantification could assist clinicians in advising patients on VT prevention. Show less
Wang, H.J.; Rosendaal, F.R.; Cushman, M.; Vlieg, A.V. 2022
Background: The preponderance of the evidence supports no association between traditional cardiovascular risk factors and venous thromboembolism (VTE), other than obesity. There are limited data in... Show moreBackground: The preponderance of the evidence supports no association between traditional cardiovascular risk factors and venous thromboembolism (VTE), other than obesity. There are limited data in older people.Objectives: To investigate whether cardiovascular risk factors (body mass index, smoking, alcohol intake, hypertension, and diabetes) are associated with the risk of VTE in elderly and to assess the combined effect between cardiovascular risk factors and genetic risk factors for VTE (factor V Leiden/prothrombin 20210A, positive family history of VTE, and non-O blood group).Methods: The Age and Thrombosis, Acquired and Genetic risk factors in the Elderly study is a multicenter case-control study performed in Vermont, USA and Leiden, the Netherlands, comprising 401 cases with first VTE and 431 control subjects, all aged >= 70 years. To assess the risk of VTE, odds ratios (OR) with 95% confidence intervals (Cis) were calculated, adjusting for potential confounders.Results: Both height and weight were positively associated with VTE risk: the ORs were 2.2 (95% CI, 1.2-3.9) and 1.5 (95% CI, 1.0-2.4) in the top quartile for height and weight separately. This risk was more pronounced for unprovoked VTE. Smoking, alcohol intake, and diabetes were not associated with VTE. Higher systolic and diastolic blood pressure and hypertension were associated with a decreased risk of VTE. In the presence of a genetic predisposition, height and weight further increased the risk of VIE.Conclusions: In the elderly, height and weight are positively associated with the risk of VTE. With genetic predisposition, higher levels of height and weight further increase the risk of VTE. Show less
Wang, H.J.; Rosendaal, F.R.; Cushman, M.; Vlieg, A.H. 2021
Background: A high D-dimer level and parameters of the thrombin generation (TG) potential are associated with the risk of a first venous thrombosis (VT) in young and middle-aged populations... Show moreBackground: A high D-dimer level and parameters of the thrombin generation (TG) potential are associated with the risk of a first venous thrombosis (VT) in young and middle-aged populations.Objectives: To investigate whether D-dimer and TG potential (lag-time, time-to-peak [ttPeak], peak thrombin, endogenous thrombin potential [ETP], and velocity index), are associated with the risk of a first VT in those aged 70 years and older.Methods: We included 215 patients with a first VT and 358 controls, all aged >70 years, from the Age and Thrombosis, Acquired and Genetic Risk Factors in the Elderly (AT-AGE) study. To assess the risk of VT, odds ratios with 95% confidence intervals (CIs) were estimated using logistic regression analysis.Results: D-dimer and all TG parameters except lag time were associated with an increased risk of VT in a dose-response manner. Comparing the fourth with the first quartile (for ttPeak comparing the first with the fourth quartile), risk estimates were: 7.8 (95% CI, 4.0-15.0) for peak, 2.0 (95% CI, 1.2-3.3) for ttPeak, 9.1 (95% CI, 4.4-18.9) for ETP, and 11.5 (95% CI, 5.7-23.3) for velocity index. Comparing the highest quartile of D-dimer with the lowest, the risk was 7.7-fold increased (95% CI, 4.0-14.8). Furthermore, all factors also increased the risk of VT after dichotomizing at more extreme cutoff values. The risk of VT was further increased in the presence of multiple prothrombotic TG parameters and elevated D-dimer level or in combination with prothrombotic mutations.Conclusions: D-dimer and TG parameters (except lag time) are associated with the risk of first VT in elderly population. Show less
Wang, H.J.; Rosendaal, F.R.; Cushman, M.; Vlieg, A.V. 2020
Essentials Venous thrombosis (VT) risk and coagulation factor levels increase with age. We studied the association between levels of procoagulant factors and the risk of a first VT in the elderly.... Show moreEssentials Venous thrombosis (VT) risk and coagulation factor levels increase with age. We studied the association between levels of procoagulant factors and the risk of a first VT in the elderly. Higher levels of factors VIII, IX, and XI, but not prothrombin, were associated with the risk of VT. Similar risk patterns were observed for provoked and unprovoked VT and for deep vein thrombosis and pulmonary embolism separately. ABSTRACT: Background Venous thrombosis (VT) incidence increases markedly with age. Coagulation factors are also positively associated with age. Objective To study whether higher levels of coagulation factors II (prothrombin), VIII, IX, and XI are associated with risk of a first VT in the elderly. Methods Four hundred and one patients and 431 control subjects aged 70 and older were included in the Age and Thrombosis, Acquired and Genetic risk factors in the Elderly (AT-AGE) study. Blood was collected 1 year after the event in patients and in all control subjects for measurement of coagulation factors. To assess the risk of VT, odds ratios (ORs) were calculated after stratification of coagulation factors in quartiles and at the 90th percentile, adjusting for potential confounders (age, sex, body mass index, and study center). Results Mean age was 78 years (range: 70-100 years). The ORs of VT for factors in the top quartile compared with the lowest quartile were 4.5 (95% confidence interval [CI]:2.7-7.3) for factor VIII, 2.4 (95% CI:1.1-5.2) for factor IX, and 1.7 (95% CI:1.0-2.9) for factor XI. High prothrombin was not associated with an increased VT risk. There was no dose-response association between the number of high coagulation factors and VT risk. The population attributable risk (PAR) of VT was 37.6%, 23.3%, and 12.4% for factor VIII, IX, and XI, respectively. Conclusion In this study of the elderly, higher factors VIII, IX, and XI but not prothrombin, were positively associated with the risk of VT. Show less
Wang, H.J.; Rosendaal, F.R.; Cushman, M.; Vlieg, A.V. 2020
Background: Venous thrombosis (VT) incidence increases markedly with age. Coagulation factors are also positively associated with age.Objective: To study whether higher levels of coagulation... Show moreBackground: Venous thrombosis (VT) incidence increases markedly with age. Coagulation factors are also positively associated with age.Objective: To study whether higher levels of coagulation factors II (prothrombin), VIII, IX, and XI are associated with risk of a first VT in the elderly.Methods: Four hundred and one patients and 431 control subjects aged 70 and older were included in the Age and Thrombosis, Acquired and Genetic risk factors in the Elderly (AT-AGE) study. Blood was collected 1 year after the event in patients and in all control subjects for measurement of coagulation factors. To assess the risk of VT, odds ratios (ORs) were calculated after stratification of coagulation factors in quartiles and at the 90th percentile, adjusting for potential confounders (age, sex, body mass index, and study center).Results: Mean age was 78 years (range: 70-100 years). The ORs of VT for factors in the top quartile compared with the lowest quartile were 4.5 (95% confidence interval [CI]:2.7-7.3) for factor VIII, 2.4 (95% CI:1.1-5.2) for factor IX, and 1.7 (95% CI:1.0-2.9) for factor XI. High prothrombin was not associated with an increased VT risk. There was no dose-response association between the number of high coagulation factors and VT risk. The population attributable risk (PAR) of VT was 37.6%, 23.3%, and 12.4% for factor VIII, IX, and XI, respectively.Conclusion: In this study of the elderly, higher factors VIII, IX, and XI but not prothrombin, were positively associated with the risk of VT. Show less
