Review of D-dimer testing: Good, Bad, and Ugly

Diagnostic accuracy of adropin as a preliminary test to exclude acute pulmonary embolism: a prospective study

Background

This study aims to investigate the diagnostic accuracy of adropin as a biomarker to exclude the diagnosis of acute pulmonary embolism (PE).

Methods

Patients admitted to the emergency department of a tertiary health centre between August 2019 and August 2020 and diagnosed with PE were included in this prospective cohort study. The amount of serum adropin was determined in patients with (PE) and compared with that of healthy volunteers. Receiver operating characteristic analysis was performed with the obtained data, and the area under the curve (AUC) with a 95% confidence interval was determined. The parameters of diagnostic accuracy for PE were determined.

Results

A total of 57 participants were included in the study (28 controls and 29 PE patients). The mean adropin level in the PE group was 187.33 ± 62.40 pg/ml, which was significantly lower than that in the control group (524.06 ± 421.68 pg/ml) (p < 0.001). When the optimal adropin cut-off value was 213.78 pg/ml, the likelihood ratio of the adropin test was 3.4, and the sensitivity of the adropin test at this value was 82% with specificity of 75% (95% CI; AUC: 0.821).

Conclusion

Our results suggest that adropin may be considered for further study as a candidate marker for the exclusion of the diagnosis of PE. However, more research is required to verify and support the generalizability of our study results.

A Tale of Two D-Dimers: Comparison of Two Assay Methods to Evaluate Deep Vein Thrombosis or Pulmonary Embolism

BACKGROUND

D-dimer testing rules out deep vein thrombosis (DVT) and pulmonary embolism (PE) in low-risk emergency department (ED) patients. Most research has measured fibrin-equivalent units (FEUs), however, many laboratories measure D-dimer units (DDUs).

OBJECTIVE

Our aim was to determine whether either DDU measurements or FEU measurements can rule out DVT/PE using traditional or age-related cutoff values.

METHODS

We performed a de-identified multicenter retrospective evaluation of D-dimer in nonpregnant adult ED patients to evaluate for DVT/PE. DDUs were multiplied by 2 to determine equivalent FEUs prior to analysis. Sensitivity measurements for D-dimer were calculated for FEUs, DDUs, combined FEU/DDUs, and multiple age-adjusted values.

RESULTS

We identified 47,088 ED patients with a D-dimer laboratory value (27,307 FEUs/19,781 DDUs) and 1623 DVT/PEs. The median combined FEU/DDU D-dimer was 400 ng/mL FEUs (interquartile range [IQR] 300-900 ng/mL FEUs) for patients without a DVT/PE vs 2530 ng/mL FEU (IQR 1094-6000 ng/mL FEUs) with a DVT/PE (p < 0.001), overall sensitivity of 87.3% (95% confidence interval [CI] 87.0-87.6%) and negative predictive value of 99.3% (95% CI 99.2-99.4%). Individually, FEUs performed better than DDUs, with sensitivities of 88.0% (95% CI 85.8-89.9%) and 86.1% (95% CI 83.1-88.7%), respectively; however, this difference was not statistically significant. Combined age-adjusted performance had a sensitivity of 90.3% (95% CI 88.3-92.0%); however, a new DDU-only age-adjusted criteria had the highest sensitivity of 91.1% (95% CI 87.9-93.6%).

CONCLUSIONS

Our undifferentiated D-dimer measurements had a slightly lower sensitivity to rule out DVT/PE than reported previously. Our data support using either DDU or FEU measurements for all ages or when using various age-adjusted criteria to rule out DVT/PE.

Targeted biomarkers of progression in chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is an increasingly significant health issue worldwide. Early stages of CKD can be asymptomatic and disease trajectory difficult to predict. Not everyone with CKD progresses to kidney failure, where kidney replacement therapy is the only life-sustaining therapy. Predicting which patients will progress to kidney failure would allow better use of targeted treatments and more effective allocation of health resources. Current diagnostic tests to identify patients with progressive disease perform poorly but there is a suite of new and emerging predictive biomarkers with great clinical promise.

METHODS

This narrative review describes new and emerging biomarkers of pathophysiologic processes of CKD development and progression, accessible in blood or urine liquid biopsies. Biomarkers were selected based on their reported pathobiological functions in kidney injury, inflammation, oxidative stress, repair and fibrosis. Biomarker function and evidence of involvement in CKD development and progression are reported.

CONCLUSION

Many biomarkers reviewed here have received little attention to date, perhaps because of conflicting conclusions of their utility in CKD. The functional roles of the selected biomarkers in the underlying pathobiology of progression of CKD are a powerful rationale for advancing and validating these molecules as prognosticators and predictors of CKD trajectory.

Diagnostic Accuracy of Multiple D-Dimer Cutoff Thresholds and Other Clinically Applicable Biomarkers for the Detection and Radiographic Evaluation of Pulmonary Embolism

Background: Diagnostic work-up of pulmonary embolism (PE) remains a challenge. Methods: We retrospectively studied all patients referred for computed tomography pulmonary angiography (CTPA) with suspicion of PE during a 12-month period (2018). The diagnostic accuracy of different D-dimer (Dd) cutoff thresholds for ruling out PE was evaluated. Furthermore, the association of Dd and red cell distribution width (RDW) with embolus location, CTPA findings, and patient outcome was recorded. Results: One thousand seventeen (n = 1017) patients were finally analyzed (mean age: 64.6 years (SD = 11.8), males: 549 (54%)). PE incidence was 18.7%. Central and bilateral embolism was present in 44.7% and 59.5%, respectively. Sensitivity and specificity for conventional and age-adjusted Dd cutoff was 98.2%, 7.9%, and 98.2%, 13.1%, respectively. A cutoff threshold (2.1 mg/L) with the best (64.4%) specificity was identified based on Receiver Operating Characteristics analysis. Moreover, a novel proposed Dd cutoff (0.74 mg/L) emerged with increased specificity (20.5%) and equal sensitivity (97%) compared to 0.5 mg/L, characterized by concurrent reduction (17.2%) in the number of performed CTPAs. Consolidation/atelectasis and unilateral pleural effusion were significantly associated with PE (p < 0.05, respectively). Patients with consolidation/atelectasis or intrapulmonary nodule(s)/mass on CTPA exhibited significantly greater median Dd values compared to patients without the aforementioned findings (2.34, (IQR 1.29−4.22) vs. 1.59, (IQR 0.81−2.96), and 2.39, (IQR 1.45−4.45) vs. 1.66, (IQR 0.84−3.12), p < 0.001, respectively). RDW was significantly greater in patients who died during hospitalization (p = 0.012). Conclusions: Age-adjusted Dd increased diagnostic accuracy of Dd testing without significantly decreasing the need for imaging. The proposed Dd value (0.74 mg/L) showed promise towards reducing considerably the need of CTPA. Multiple radiographic findings have been associated with increased Dd values in our study.

A review of pathophysiological mechanism, diagnosis, and treatment of thrombosis risk associated with COVID-19 infection

Severe coronavirus (COVID-19) infection has been reportedly associated with a high risk of thromboembolism. Developing macrovascular thrombotic complications, including myocardial injury/infarction, venous thromboembolism, and stroke have been observed in one-third of severe COVID-19 hospitalized patients, leading to an increase in mortality and morbidity. The diagnosis of COVID-19 associated coagulopathy may be challenging because there are close similarities between pulmonary embolism and severe COVID-19 disease. Therefore, a critical step in improving the clinical outcome of patients with hospitalized COVID-19 is the recognition of coagulation abnormalities and the identification of patients with poor prognoses, prophylactic guidance, or antithrombotic therapy. Prescribing anticoagulants in all patients hospitalized with COVID-19 and 2-6 weeks post-hospital discharge in the absence of contraindications is recommended by most consensus documents published on behalf of professional societies. However, a decision on some variable factors such as intensity and duration of anticoagulation may be made based on an individual case and needs future randomized trial studies. Regarding little information on this subject, this study aims to review how inflammation and thrombosis are related to COVID-19 patients, discuss the types of thrombosis in these patients, and summarize the diagnosis and treatment of thrombosis in COVID19 patients.

Triglyceride to HDL-C ratio is associated with plasma D-dimer levels in different types of pancreatitis

This study aims to evaluate levels of D-dimer and serum lipid in different types of pancreatitis, and the relationship between D-dimer and dyslipidemia, especially triglyceride to HDL-C ratio (TG/HDL-C) in different types of pancreatitis. We analyzed the D-dimer and dyslipidemia levels in acute pancreatitis (AP), recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP). A single-centered retrospective study was conducted on 1013 patients diagnosed with AP, RAP or CP. Only patients hospitalized within 24 h of onset were included, and 204 patients were enrolled in pancreatitis groups. 68 normal persons without pancreatitis, malignant diseases, pregnancy, or organ failure, who had health check-ups, were enrolled in the control group. Blood samples were taken within 24 h of admission. The relevant information on epidemiology and etiology was collected. D-dimer and serum lipid levels in different types of pancreatitis were analyzed. Furthermore, the area under the receiver-operating characteristic curve (AUC) was used to estimate the validity of the predictor and to define optimal cut-off points for prediction. We found that D-dimer and TG/HDL-C ratio could distinguish mild AP (MAP) and non-MAP in AP and RAP patients. The D-dimer level was related to TG/HDL-C ratio and severity of pancreatitis, with the coefficient correlation of 0.379 and 0.427(p < 0.05), respectively. TG/HDL-C was related to D-dimer in different types of pancreatitis. Logistic regression analysis was conducted in the parameters at admission like alcohol abuse, dyslipidemia and coagulation disturbance in distinguishing AP and RAP groups from the control group, and the parameter like diabetes in RAP and CP groups significantly increased compared with that of the control group. The value of D-dimer level and TG/HDL-C ratio in predicting the severity of AP and RAP was confirmed but there was no significant difference between CP group and the control group. The D-dimer level was related to dyslipidemia and TG/HDL-C ratio.

Procalcitonin as a Predictive Tool for Death and ICU Admission among Febrile Neutropenic Patients Visiting the Emergency Department

Background and Objectives: Risk stratification tools for febrile neutropenia exist but are infrequently utilized by emergency physicians. Procalcitonin may provide emergency physicians with a more objective tool to identify patients at risk of decompensation. Materials and Methods: We conducted a retrospective cohort study evaluating the use of procalcitonin in cases of febrile neutropenia among adult patients presenting to the Emergency Department compared to a non-neutropenic, febrile control group. Our primary outcome measure was in-hospital mortality with a secondary outcome of ICU admission. Results: Among febrile neutropenic patients, a positive initial procalcitonin value was associated with significantly increased odds of inpatient mortality after adjusting for age, sex, race, and ethnicity (AOR 9.912, p < 0.001), which was similar, though greater than, our non-neutropenic cohort (AOR 2.18, p < 0.001). All febrile neutropenic patients with a positive procalcitonin were admitted to the ICU. Procalcitonin had a higher sensitivity and negative predictive value (NPV) in regard to mortality and ICU admission for our neutropenic group versus our non-neutropenic control. Conclusions: Procalcitonin appears to be a valuable tool when attempting to risk stratify patients with febrile neutropenia presenting to the emergency department. Procalcitonin performed better in the prediction of death and ICU admission among patients with febrile neutropenia than a similar febrile, non-neutropenic control group.

The usefulness of D-dimer as a predictive marker for mortality in patients with COVID-19 hospitalized during the first wave in Italy

Background

The coronavirus disease 2019 (COVID-19) presents an urgent threat to global health. Identification of predictors of poor outcomes will assist medical staff in treatment and allocating limited healthcare resources.

Aims

The primary aim was to study the value of D-dimer as a predictive marker for in-hospital mortality.

Methods

This was a cohort study. The study population consisted of hospitalized patients (age >18 years), who were diagnosed with COVID-19 based on real-time PCR at 9 hospitals during the first COVID-19 wave in Lombardy, Italy (Feb-May 2020). The primary endpoint was in-hospital mortality. Information was obtained from patient records. Statistical analyses were performed using a Fine-Gray competing risk survival model. Model discrimination was assessed using Harrell’s C-index and model calibration was assessed using a calibration plot.

Results

Out of 1049 patients, 507 patients (46%) had evaluable data. Of these 507 patients, 96 died within 30 days. The cumulative incidence of in-hospital mortality within 30 days was 19% (95CI: 16%-23%), and the majority of deaths occurred within the first 10 days. A prediction model containing D-dimer as the only predictor had a C-index of 0.66 (95%CI: 0.61–0.71). Overall calibration of the model was very poor. The addition of D-dimer to a model containing age, sex and co-morbidities as predictors did not lead to any meaningful improvement in either the C-index or the calibration plot.

Conclusion

The predictive value of D-dimer alone was moderate, and the addition of D-dimer to a simple model containing basic clinical characteristics did not lead to any improvement in model performance.

Analysis of the Risk Factors for Elevated D-Dimer Level After Breast Cancer Surgery: A Multicenter Study Based on Nursing Follow-Up Data

D-dimer level is often used to assess the severity of trauma as well as the risk of thrombosis. This study investigated the risk factors for high postoperative D-dimer level. This study included a total of 2706 patients undergoing breast cancer surgery to examine the associations between various clinicopathological factors and variation in D-dimer levels. After adjusting for other factors, T stage, neoadjuvant chemotherapy, blood loss, surgery type, diabetes, and elevated leukocyte and neutrophil counts were found to be significant risk factors for D-dimer variation. This study identified several factors associated with elevated D-dimer levels and consequent thrombosis after breast cancer surgery, which may aid in the development of more precise preventive measures and interventions as well as serve as a reference for future research.

Blood biomarkers for predicting coagulopathy occurrence in patients with traumatic brain injury: a systematic review

Purpose: The occurrence of coagulopathy in patients with traumatic brain injury (TBI) is related to severe complications. The authors performed the first systematic review to investigate whether biomarkers can predict the occurrence of hypocoagulopathy or progressive hemorrhagic injury in patients with TBI. Methods: The authors included studies that performed a receiver operating characteristics analysis for the biomarker and provided a clear value along with the respective sensitivity and specificity. Additionally, they attempted to classify each biomarker, taking into account its physiological role. Results: Twelve studies were included. All biomarkers were protein molecules, except in one study that examined the prognostic role of glucose. Copeptin had the highest sensitivity, and S100A12 had the highest specificity in predicting coagulopathy, while IL-33 had the highest sensitivity and GALECTIN-3 had the highest specificity in predicting progressive hemorrhagic injury. Conclusion: The study of the role of biomarkers in predicting the occurrence of coagulopathy in patients with TBI remains in its infancy.

Association between D-dimer levels and post-acute sequelae of SARS-CoV-2 in patients from a tertiary care center

Background: Post-acute sequelae of SARS-CoV-2 (PASC) is becoming an important concern in SARS-CoV-infected people. The pathophysiology behind PASC is unknown, and much study should be carried out to check the D-dimer levels in the PASC population. Methodology: In COVID-19 patients, the D-dimer level was checked during admission and discharge, and a follow-up study was carried out after 3 and 6 months of discharge. The results were compared with the appropriate statistical tests. Results: Patients had a high D-dimer value than the normal range, and the elevated D-dimer value continued to increase up to 6 months. Conclusion: Persistence of PASC has a direct correlation with increased D-dimer values. D-dimer can be used as biomarker in PASC patients.

Screening Protocol and Prevalence of Venous Thromboembolic Disease in Hospitalized Patients With COVID-19

BACKGROUND

SARS-CoV-2 disease (COVID-19) induces endothelial damage and sustained hypoxia and facilitates immobilization as factors of hypercoagulability.

OBJECTIVES

The objective of our study was to assess the prevalence of venous thromboembolic disease (VTD) in COVID-19 patients and the usefulness of VTD screening based on age-adjusted D-dimer and point-of-care ultrasound (POCUS).

PATIENTS/METHODS

We conducted a single cohort, prospective observational study in 102 consecutive hospitalized patients.

RESULTS

A total of 102 POCUS and 39 pulmonary computed tomography angiography (PCTA) were performed diagnosing 27 VTD (26.5%): 17 deep vein thrombosis (DVT) (16.6% positive POCUS) and 18 pulmonary embolism (PE) (46.2% positive PCTA). COVID-19 patients with VTD were older (P < .030), had higher D-dimer (P < .001), higher International Society on Thrombosis and Hemostasis score (P < .001), and higher mortality (P = .025). However, there were no differences in inflammatory laboratory parameters neither in the cytokine storm syndrome (CSS) development. The ROC curve for D-dimer showed an AUC of 0.91. We have evidenced that patients with D-dimer between 2000 and 6000 ng/mL could benefit from a screening strategy with POCUS given the high sensitivity and specificity of the test. Furthermore, patients with D-dimer ≥6000 ng/mL should undergo POCUS and PCTA to rule out DVT and PE, respectively.

CONCLUSIONS

In our cohort, 26.5% of the patients presented VTD. Screening strategy based on age-adjusted D-dimer and POCUS proved high sensitivity and specificity. Future trials focused on screening strategies are necessary to early detect the presence of DVT and PE and determine thromboprophylaxis strategies in patients with COVID-19.

Biomarkers of Venous Thromboembolism Recurrence after Discontinuation of Low Molecular Weight Heparin Treatment for Cancer-Associated Thrombosis (HISPALIS-Study)

The most appropriate duration of anticoagulant treatment for cancer-associated venous thromboembolism (CAT) remains unclear. We have conducted a prospective multicenter study in CAT patients with more than 6 months of anticoagulant treatment to predict the risk of venous thromboembolism (VTE) recurrence after anticoagulation discontinuation. Blood samples were obtained when patients stopped the anticoagulation, at 21 days and at 90 days. In each sample we assessed different coagulation-related biomarkers: D-dimer (DD), high-sensitivity C-reactive protein (hs-CRP), P-selectin (PS), phospholipids, soluble tissue factor, factor VIII and the thrombin generation test. It was evaluated 325 CAT patients and 166 patients were included in the study, mean age 64 ± 17 years. VTE recurrence until 6 months after stopping anticoagulation treatment was 9.87% [95% confidence interval (CI): 6−15]. The biomarkers sub-distribution hazard ratios were 6.32 for ratio DD basal/DD 21 days > 2 (95% CI: 1.82−21.90), 6.36 for hs-CRP > 4.5 (95% CI: 1.73−23.40) and 5.58 for PS > 40 (95% CI: 1.46−21.30) after 21 days of stopping anticoagulation. This is the first study that has identified the DD ratio, hs-CRP and PS as potential biomarkers of VTE recurrence in cancer patients after the discontinuation of anticoagulation treatment. A risk-adapted strategy may allow the identification of the optimal time to withdraw the anticoagulation in each CAT patient.

Blood biochemical parameters for assessment of COVID-19 in diabetic and non-diabetic subjects: a cross-sectional study

This study aims to identify blood biomarkers for rapidly predicting progression and severity assessment of COVID-19 in type 2 diabetic (DM) and non-DM (NDM) patients. Among 211 hospitalized patients suspected of COVID-19, 98 were confirmed COVID-19 by rRT-PCR. The COVID-19 positive group contained 58 DM and 40 NDM patients with total death 9 of which 7 were males and 6 were DM, indicating males and DM individuals as more susceptible to COVID-19. Blood biomarkers notably serum ferritin, CRP, D-dimer, ALT, troponin I, and Hb1Ac were significantly (p < 0.05) higher in COVID-19 patients. Ferritin and HbA1c levels were significantly (p < 0.05) higher in DM than NDM COVID-19 patients. The present study suggests that ferritin and HbA1c levels for DM patients, and ferritin, D-dimer, ALT for NDM patients could be routinely used as biomarkers for progression and severity assessment of COVID-19. CRP and Troponin-I could be the predictor only for poor prognosis of COVID-19.

Thrombosis Risk History and D-dimer Levels in Asymptomatic Individuals with Prader-Willi Syndrome

Individuals with Prader–Willi syndrome (PWS) may be at higher risk of developing blood clots as compared to the typical population, but this risk is poorly understood. It is also unclear if laboratory testing of D-dimer concentration might be useful to screen for thrombosis in PWS. Here, we surveyed the thrombosis history of 883 individuals with PWS and evaluated the D-dimer concentration in a subset of 214 asymptomatic individuals, ages 5–55. A history of at least one blood clot was reported by 3.6% of respondents. Thrombosis increased with age, but no significant difference was found on the basis of sex or family history. Genetic subtype was a significant factor when considering only those with a known subtype, and individuals with a history of edema had significantly more blood clots. In the D-dimer sub-study, ≈15% of participants had high D-dimer concentrations, and 3.7% had D-dimer values more than twice the normal upper limit. One participant with a high D-dimer result was found to have a blood clot. No significant differences in D-dimer results were found on the basis of age, sex, genetic subtype, family history of blood clots, edema history, or BMI. The D-dimer test does not appear to be a sensitive and specific screening tool for blood clots in asymptomatic individuals with PWS.

Prevalence and risk factor of post-operative lower extremities deep vein thrombosis in patients undergoing gynecologic surgery: a single-institute cross-sectional study

Background and aim

The study of prevalence and risk factors of postoperative lower limb deep vein thrombosis (DVT) in Thai gynecologic patients was limited. The present study was conducted to evaluate this issue.

Methods

The patients were age > 15 years old without a history of DVT or pulmonary emboli (PE) scheduled for laparotomy or vaginal gynecologic surgery between May and November 2020 were invited to participate. All of these patients were scheduled for a complete duplex ultrasound to detect lower limb DVT 72 h before and within 14 days after the operation. The patients without DVT were scheduled for an interview by telephone about DVT symptoms 30 days after the operation. The clinical variables were compared using univariate and multivariate analysis to identify the independent factors related to the development of DVT.

Results

One hundred and twelve patients met the inclusion criteria. Of these patients, 44 cases (39.3%) were diagnosed as malignancy and 102 patients underwent a hysterectomy. Post-operative DVTs were detected in six patients (5.4%) and all except one had a malignancy. Thus, the prevalence of DVT in malignancy cases was five in 44 patients (11.4%). The independent risk factors for postoperative DVT were age > 60-year-old and receiving a perioperative blood transfusion. Five of six DVT patients received low molecular-weight heparin for treatment of DVT and none developed PE. The rest of the participants reported no symptom-related DVTs from the interview 30 days after the operation.

Conclusion

The prevalence of postoperative DVT in gynecologic patients was 5%, and the independent risk factors were elderly patients and receiving a perioperative blood transfusion.

A new method of monitoring catheter-directed thrombolysis for deep venous thrombosis-application of D-dimer and fibrinogen testing

BACKGROUND

Catheter-directed thrombolysis (CDT) is one of the main treatment methods for acute deep venous thrombosis (DVT), which has the characteristics of long treatment time and large dosage of thrombolytic drugs. In the absence of good monitoring methods, problems such as low thrombolytic efficiency and high risk of bleeding are easy to occur.

OBJECTIVE

To evaluate the value of D-dimer (D-D) and fibrinogen (FIB) testing as a thrombolysis-monitoring method during CDT for acute DVT.

METHODS

Twenty patients with acute DVT were divided into group A and group B. During CDT, the D-D and FIB testing every 8 h were used in group A, and the venography and FIB testing every 24 h in group B. The thrombolysis rate, thrombolysis time, urokinase dosage, and X-ray radiation dose were compared.

RESULTS

The thrombolysis rate in group A was significantly higher than that in group B (p < 0.05), but the number of venography and radiation dose were significantly lower than those in group B (p < 0.05).

CONCLUSION

D-D and FIB testing can improve the thrombolysis rate, reduce the risk of bleeding, and decrease the number of angiograms and X-ray radiation dose during CDT.

Analytical performance of a new immunoturbidimetric D‐dimer assay and comparison with available assays

Background

The routine D‐dimer quantification to exclude venous thromboembolism has led to the development of many assays, the usefulness of which depends on their reliability and performance.

Objective

We evaluated the analytical performances of the immunoturbidimetric Yumizen G DDi 2 assay (HORIBA Medical, Montpellier, France) performed on the Yumizen G800 analyzer and compared it with other available D‐dimer assays.

Methods

Within‐run and between‐run imprecision were evaluated using low‐ and high‐level quality‐control plasma samples. Interference due to hemolysis, icterus, lipemia, rheumatoid factor (RF), or heterophilic antibodies (human antimouse antibodies [HAMAs]) was evaluated by spiking plasma samples with hemolysate, bilirubin, Intralipid, RF, or HAMAs. The measurements obtained with the different D‐dimer assays were compared using Passing‐Bablok regression analysis and Bland‐Altman plot method, using fresh citrated plasma samples collected from 66 consecutive routine patients with a wide range of D‐dimer concentrations.

Results

Within‐ and between‐run variation coefficients for the Yumizen G DDi 2 assay ranged from 1.7% to 5.8% and from 2.8% to 5.5%, respectively. Hemolysis and icterus did not have any effect up to 10 g/L hemoglobin and 300 mg/L bilirubin. Lipemia seemed to generate an underestimation of D‐dimer concentration when the Intralipid concentration was >5 g/L. RF and HAMAs did not have any effect. The Passing‐Bablok and Bland‐Altman analyses showed small differences with other available D‐dimer assays, which were more pronounced with increasing values.

Conclusions

Its analytical performances and main technical features indicate that the new Yumizen G DDi 2 assay is suitable for the rapid quantification of D‐dimer in clinical hemostasis laboratories.

Is it possible to make a common reference standard for D-dimer measurements? Communication from the ISTH SSC Subcommittee on Fibrinolysis

BACKGROUND

D-dimer antigen is a heterogeneous mixture of fibrin degradation products that when present at high levels in plasma indicate ongoing coagulation and fibrinolysis. The heterogeneous nature of the target D-dimer antigen and the variety of assay systems means that it is difficult to compare results from different methods.

OBJECTIVES

To identify a universally agreed D-dimer standard that could help harmonize results from different methods.

METHODS

A pool of patient plasma with high D-dimer levels was freeze-dried and investigated as a long-term World Health Organization international standard for D-dimer. Fibrin degradation products from clot lysis reactions were also freeze-dried in various formulations and investigated in commutability studies with patient plasma.

RESULTS

Problems of instability of D-dimer plasma emerged suggesting loss of reactivity after freeze-drying and storage at -20°C of 10%-18% per year. Freeze-dried fibrin degradation products added to plasma were also unstable, but the sugar trehalose was found to improve stability. However, this preparation was not suitable as a standard in widely used assay platforms. Previous studies suggest fibrin degradation products are prone to structural rearrangements and amyloid formation, which may explain the instability of candidate D-dimer standards.

CONCLUSIONS

The known difficulties of D-dimer standardization are compounded by instability of D-dimer antigen after freeze-drying, described in this report. Fibrin degradation products added to plasma and stabilized by trehalose are not suitable as a standard for D-dimer measurement harmonization. Trehalose stabilization of pooled patient plasma containing high D-dimer levels may produce a useful standard, but this requires confirmation.

ASSOCIATION OF SCREENING MARKERS OF COAGULATION WITH THE SHORT-TERM OUTCOME IN THE SMALL BOWEL OBSTRUCTION IN ADULTS: A RETROSPECTIVE STUDY

OBJECTIVE

The aim: To evaluate the possibility of using screening markers of coagulation to the assessment of severity and predict short-term outcomes in patients with small bowel obstruction.

PATIENTS AND METHODS

Materials and methods: The study was based on the results of treatment of 71 patients 18-60 years old in 2019-2021. Patients were divided into two groups: in the 1st included those with a positive outcome (90.1%), and in the 2nd those with adverse outcomes (9.9%).

RESULTS

Results: Only the laparoscopy approach has been in 12.5%, the laparotomy in 78.9%, and the hybrid in 9.9% of patients. There were no significant differences in screening tests of coagulation function indicators, including D-dimer, fibrinogen, Activated Partial Thromboplastin, International Normalised Ratio levels, and the International Society on Thrombosis and Hemostasis Criteria (ISTHC) score in two groups of patients before surgery. The predictive value of preoperative Sequential Organ Failure Assessment (SOFA) data (AUC = 0.844), serum lactate (AUC = 0.805), and systolic blood pressure (SPB) data (AUC = 0.808) before surgery were significant. The SOFA (AUC = 0.844) and APACHE II scores (AUC = 0.802), serum lactate (AUC = 0.884), D-dimer (AUC = 0.812), Antithrombin (AUC = 0.815), and CRP (AUC = 0.856) levels, SPB (0.856) within the first 72 hours after surgery were also good predictors of short-term outcomes (P = 0.000).

CONCLUSION

Conclusions: It was confirmed that three parameters were predictors of early mortality before surgery, none of them included parameters of coagulation and seven parameters via 72 hours after surgery, which had included some parameters of coagulation.

Mild abusive head injury: diagnosis and pitfalls

Clinicians often miss making the diagnosis of abusive head injury in infants and toddlers who present with mild, non-specific symptoms such as vomiting, fussiness, irritability, trouble sleeping and eating, and seizure. If abusive head injury is missed, the child is likely to go on to experience more severe injury. An extensive review of the medical literature was done to summarize what is known about missed abusive head injury and about how these injuries can be recognized and appropriately evaluated. The following issues will be addressed: the definition of mild head injury, problems encountered when clinicians evaluated mildly ill young children with non-specific symptoms, the risk of missing the diagnosis of mild abusive head trauma, the risks involved in subjecting infants and young children to radiation and/or sedation required for neuroimaging studies, imaging options for suspected neurotrauma in children, clinical prediction rules for evaluating mild head injury in children, laboratory tests than can be helpful in diagnosing mild abusive head injury, history and physical examination when diagnosing or ruling out mild abusive head injury, social and family factors that could be associated with abusive injuries, and interventions that could improve our recognition of mild abusive head injuries. Relevant literature is described and evaluated. The conclusion is that abusive head trauma remains a difficult diagnosis to identify in mildly symptomatic young children.

Colchicine, COVID-19 and hematological parameters: A meta-analysis

INTRODUCTION

Colchicine has the potential in reducing patient morbidity and mortality in COVID-19 infection owing to its anti-inflammatory properties. This study aims to determine the efficacy of colchicine in optimizing inflammatory hematological biomarker levels among COVID-19 patients.

METHODS

In accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement guidelines, a systematic search was conducted using the following keywords: Colchicine, covid*, SARS-CoV-2, anti-inflammatory, trials, clinical, hematological, laboratory. Databases were searched from December 2019 until August 26, 2021: MEDLINE/PubMed, Web of Science, Cochrane, Scopus, and EMBASE. Other sources were located through ClinicalTrials.Gov, manually searching SAGE, Science Direct, Elsevier, and Google Scholar. The meta-analysis was conducted using Review Manager 5.4.

RESULTS

In total, six studies were included, of which four reported c-reactive protein (CRP) standardized mean reductions in the colchicine group (N = 165) as opposed to the control (N = 252; SMD = -0.49, p < 0.001). On noting lactate dehydrogenase (LDH) values post treatment, the colchicine group (N = 204) showed significant reductions at the end of treatment compared to control (N = 290; SMD = -0.85, p < 0.001). Finally, the D-dimer values in colchicine groups (N = 129) compared to control (N = 216) also documented a negative effect size (SMD = -0.9, p < 0.001).

CONCLUSION

Colchicine has efficacy in reducing inflammatory biomarkers observed in moderate-to-severe COVID-19 patients. It may be worthwhile to consider monitoring the clinical and laboratory parameters of patients in further trials to consider colchicine as a strong candidate for an adjunct to COVID-19 treatment.

D-Dimer Tests in the Emergency Department: Current Insights

In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.

Nuts and bolts of COVID-19 associated coagulopathy: the essentials for management and treatment

INTRODUCTION

COVID-19-associated coagulopathy (CAC) is a well-recognized hematologic complication among patients with severe COVID-19 disease, where macro- and micro-thrombosis can lead to multiorgan injury and failure. Major societal guidelines that have published on the management of CAC are based on consensus of expert opinion, with the current evidence available. As a result of limited studies, there are many clinical scenarios that are yet to be addressed, with expert opinion varying on a number of important clinical issues regarding CAC management.

METHODS

In this review, we utilize current societal guidelines to provide a framework for practitioners in managing their patients with CAC. We have also provided three clinical scenarios that implement important principles of anticoagulation in patients with COVID-19.

CONCLUSION

Overall, decisions should be made on acase by cases basis and based on the providers understanding of each patient's medical history, clinical course and perceived risk.

Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study

AIM

To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE).

METHODS AND RESULTS

We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives.

CONCLUSION

A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

Exploring the pathways of inflammation and coagulopathy in COVID-19: A narrative tour into a viral rabbit hole

Worldwide COVID-19 pandemic has taken a huge toll of morbidity and mortality. In selected patients, classified as severe, the overwhelming inflammatory state imposed by this infection is accompanied by a hypercoagulable state, hallmarked by a unique pattern; a marked increase in D-dimer, out of proportion to other markers of coagulopathy. In this review, we turn a spotlight to this phenomenon, offering a unified conceptual model depicting the leading hypotheses of coagulopathy in COVID-19. The key players of the coagulation cascades accompanying the COVID-19 inflammation malfunction on virtually every level; tissue factor expression is amplified, physiological anti-coagulant pathways (anti-thrombin, protein C and S, and the inhibitor of the tissue factor pathway) are impaired and fibrinolysis is inhibited. Components of autoimmunity, the complement system amongst others, further contribute to the pathology. As data continue to gather, our model offers a pathophysiological overview of COVID-19 coagulopathy, defined by the resultant histopathology: either intra-vascular or extra-vascular. We hope this review will facilitate understanding and serve as a lead point to future therapeutic directives.

The pathophysiology of sepsis - 2021 update: Part 2, organ dysfunction and assessment

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This is the second article in a 2-part series discussing the pathophysiology of sepsis. Part 1 of the series reviewed the immunologic response and overlapping pathways of inflammation and coagulation that contribute to the widespread organ dysfunction. In this article (part 2), major organ systems and their dysfunction in sepsis are reviewed, with discussion of scoring systems used to identify patterns and abnormal vital signs and laboratory values associated with sepsis.

SUMMARY

Sepsis is a dysregulated host response to infection that produces significant morbidity, and patients with shock due to sepsis have circulatory and cellular and metabolic abnormalities that lead to a higher mortality. Cardiovascular dysfunction produces vasodilation, reduced cardiac output and hypotension/shock requiring fluids, vasopressors, and advanced hemodynamic monitoring. Respiratory dysfunction may require mechanical ventilation and attention to volume status. Renal dysfunction is a frequent manifestation of sepsis. Hematologic dysfunction produces low platelets and either elevation or reduction of leucocytes, so consideration of the neutrophil:lymphocyte ratio may be useful. Procoagulant and antifibrinolytic activity leads to coagulation that is stimulated by inflammation. Hepatic dysfunction manifest as elevated bilirubin is often a late finding in sepsis and may cause reductions in production of essential proteins. Neurologic dysfunction may result from local endothelial injury and systemic inflammation through activity of the vagus nerve.

CONCLUSION

Timely recognition and team response with efficient use of therapies can improve patient outcome, and pharmacists with a complete understanding of the pathophysiologic mechanisms and treatments are valuable members of that team.

A Case Report of a Patient on Therapeutic Warfarin Who Died of COVID-19 Infection with a Sudden Rise in D-Dimer

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has disrupted social and economic life globally. The global pandemic COVID-19 caused by this novel SARS-CoV-2 shows variable clinical manifestations, complicated further by cytokine storm, co-infections, and coagulopathy, leading to severe cases and death. Thrombotic complications arise due to complex and unique interplay between coronaviruses and host cells, inflammatory response, and the coagulation system. Heparin and derivatives are World Health Organization (WHO) recommended anticoagulants for moderate and severe Corona Virus Disease 19 (COVID-19), that can also inhibit viral adhesion to the cell membrane by interfering with heparan sulfate-dependent binding to angiotensin-converting enzyme 2 (ACE2) receptor. Heparin also possesses anti-inflammatory, immunomodulatory, antiviral, and anti-complement activity, which offers a benefit in limiting viral and microbial infectivity and anticoagulation from the immune-thrombosis system. Here we present a case study of the pathophysiology of unexpected COVID-19 coagulopathy of an obese African American patient. While being on therapeutic warfarin since admission, he had a dismal outcome due to cardio-pulmonary arrest after the sudden rise in D-dimer value from 1.1 to >20. This indicates that for such patients on chronic warfarin anticoagulation with "moderate COVID 19 syndromes", warfarin anticoagulation may not be suitable compared to heparin and its derivatives. Further research should be done to understand the beneficial role of heparin and its derivatives compared to warfarin for COVID-19 inflicted patients.

Pulmonary Thrombosis and Thromboembolism in COVID-19

COVID-19, the disease responsible for the devastating pandemic that began at the end of 2019, has been associated with a significantly increased risk of pulmonary thrombosis, even in patients receiving prophylactic anticoagulation. The predilection for thrombosis in COVID-19 may be driven by at least two distinct, but interrelated, processes: a hypercoagulable state responsible for large-vessel thrombosis and thromboembolism and direct vascular and endothelial injury responsible for in situ microvascular thrombosis. The presence of pulmonary thrombosis may explain why hypoxemia is out of proportion to impairment in lung compliance in some patients with COVID-19 pneumonia. Because pulmonary embolism (PE) and COVID-19 pneumonia share many signs and symptoms, diagnosing PE in patients with COVID-19 can be challenging. Given the high mortality and morbidity associated with severe COVID-19 and the concern that aspects of the disease may be driven by thrombosis, many hospital systems have instituted aggressive anticoagulation protocols above standard VTE prophylaxis. In this review, the epidemiologic and pathophysiologic features, diagnosis, and treatment of COVID-19 pulmonary thrombosis and thromboembolism are discussed.

Performance of C-Reactive Protein, Procalcitonin, TAT Complex, and Factor VIII in Addition to D-Dimer in the Exclusion of Venous Thromboembolism in Primary Care Patients

BACKGROUND

In primary care, D-dimer-combined with a clinical assessment-is recommended for ruling-out venous thromboembolism (VTE). However, D-dimer testing frequently yields false-positive results, notably in the elderly, and the search for novel biomarkers thus continues. We assessed the added diagnostic value of 4 promising laboratory tests.

METHODS

Plasma samples from 256 primary care patients suspected of VTE were collected. We explored added value (beyond D-dimer) of C-reactive protein (CRP), procalcitonin (PCT), thrombin-antithrombin III complex (TAT-c), and factor VIII (FVIII). Diagnostic performance of these biomarkers was assessed univariably and by estimating their area under the receiver operating curve (AUC). Added diagnostic potential beyond D-dimer testing was assessed using multivariable logistic regression.

RESULTS

Plasma samples of 237 VTE-suspected patients were available for analysis-36 patients (25%) confirmed deep vein thrombosis, 11 patients (12%) pulmonary embolism. Apart from D-dimer, only CRP, and FVIII levels appeared to be higher in patients with VTE compared to patients without VTE. The AUCs for these 3 markers were 0.76 (95% CI: 0.69-0.84) and 0.75 (95% CI: 0.68-0.83), respectively, whereas the AUC for D-dimer was 0.90 (95% CI: 0.86-0.94). Combining these biomarkers in a multivariable logistic model with D-dimer did not improve these AUCs meaningfully.

CONCLUSIONS

In our dataset, we were unable to demonstrate any added diagnostic performance beyond D-dimer testing of novel biomarkers in patients suspected of VTE in primary care. As such, D-dimer testing appears to remain the best choice in the exclusion of clinically suspected VTE in this setting.

TRIAL REGISTRATION

Netherlands Trial Register NL5974. (METC protocol number: 16-356/M; NL56475.041.16.).

Hematological and biochemical parameters as diagnostic and prognostic markers in SARS-COV-2 infected patients of Pakistan: a retrospective comparative analysis

Objectives: This study was conducted to investigate alteration in blood parameters and their association with the presence, severity, and mortality of COVID-19 patients as the data on hematological abnormalities associated with the Pakistani COVID-19 patients is limited.Methodology: A double-centered, hospital-based comparative retrospective case study was conducted, to include all the admitted patients (n = 317) having COVID-19 Polymerase chain reaction (PCR) positive. The control group (n = 157) tested negative for COVID-19.Results: Of 317 admitted cases, the majority were males n = 198 (62.5%). Associated comorbidities, lower lymphocytes, platelets, and higher White blood cells, neutrophil, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were found in COVID-19 cases as compared to healthy controls (p < 0.001 for all). The biochemical parameters of cases including Ferritin, D-Dimer, CRP, IL-6, LDH, ALT, AST, and APTT also showed a statistically significant difference compared with standard values (p < 0.001 for all). However, their comparison with a severity level of the severe and non-severe groups showed significance for WBCs, neutrophils, NLR (p < 0.001 for all), and PLR (p = 0.06) only. Receiver operating characteristic curve analysis showed that NLR had the highest area under curve (0.84) followed by 1/lymphocyte (0.82), neutrophils (0.74), PLR (0.67),1/platelets (0.68) and WBC's (0.65). Comparison of cases and controls with recommended cut-off values derived from sensitivity and 1-specificity was also done (p < 0.001).Conclusion: Monitoring all the hematological and biochemical parameters including novel hemograms NLR, PLR can aid clinicians to identify potentially severe cases at early stages and initiate effective management in time which may reduce the overall mortality of COVID-19 patients.

D-Dimer Levels Are Not Elevated in SARS-CoV-2 IgG Positive Patients Undergoing Elective Orthopedic Surgery

INTRODUCTION

In acute COVID-19, D-Dimer levels can be elevated and those patients are at risk for thromboembolic events. This study aims to investigate differences in preoperative D-Dimer levels in SARS-CoV-2 IgG positive and negative patients undergoing primary total knee and total hip replacement (TJA) or spine surgery.

METHODS

D-Dimer levels of 48 SARS-CoV-2 IgG positive and 718 SARS-CoV-2 IgG negative spine surgery patients were compared to those of 249 SARS-CoV-2 IgG positive and 2102 SARS-CoV-2 IgG negative TJA patients. Patients were assigned into groups based on D-Dimer levels as follows: <200 ng/mL, 200-400 ng/mL, and >400 ng/mL D-Dimer Units (DDU).

RESULTS

D-Dimer levels did neither differ significantly between SARS-CoV-2 IgG positive spine surgery patients and TJA patients (p = 0.1), nor between SARS-CoV-2 IgG negative spine surgery and TJA patients (p = 0.7). In addition, there was no difference between SARS-CoV-2 IgG positive and negative spine surgery patients and SARS-CoV-2 IgG positive and negative TJA patients (p = 0.3).

CONCLUSIONS

There is no difference in D-Dimer levels between SARS-CoV-2 IgG positive and negative patients and there does not seem to be any difference for different orthopedic specialty patients. Routine testing of D-Dimer levels is not recommended for patients undergoing elective orthopedic surgery.

Metabolomic Profile in Venous Thromboembolism (VTE)

Venous thromboembolism (VTE) is a condition comprising deep venous thrombosis (DVT) and pulmonary embolism (PE). The prevalence of this disease is constantly increasing and it is also a chief reason for morbidity. Therefore, the primary prevention of VTE remains a highly important public health issue. At present, its diagnosis generally relies on subjective clinical examination and ultrasound imaging. D-dimer is also used as a biomarker, but it is considered to be poorly specific and only moderately sensitive. There are also no reliable methods that could accurately guide the type of treatment and potentially identify patients who may benefit from more aggressive therapies without the risk of bleeding. The application of metabolomics profiling in the area of vascular diseases may become a turning point in early diagnosis and patient management. Among the most described metabolites possibly related to VTE are carnitine species, glucose, phenylalanine, 3-hydroxybutarate, lactic acid, tryptophan and some monounsaturated and polyunsaturated fatty acids. The cell response to acute PE was suggested to involve the uncoupling between glycolysis and oxidative phosphorylation. Despite technological advancement in the identification of metabolites and their alteration in thrombosis, we still do not understand the mechanisms and pathways responsible for the occurrence of observed alterations.

Tranexamic acid evidence and controversies: An illustrated review

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.

Clinical Characteristics and Early Prognostic Factors of Severe Acute Pancreatitis

Objectives: To analyze the clinical characteristics of severe acute pancreatitis (SAP) patients retrospectively and explore the effective factors in death from severe acute pancreatitis (SAP). Methods: The required data were collected from 234 SAP patients admitted to our department from January 2013 to December 2020 and then analyzed retrospectively. According to the prognosis, all patients were admitted within 72 hours of onset and were assigned to the death and survival groups. The participants’ clinical and demographic information, laboratory indices when patients were brought to the intensive care unit (ICU), and organ failure were analyzed using univariate and logistic multivariate regression. The logistic regression (LR) model was developed and evaluated by the receiver operating characteristic (ROC) curve. Results: In this study, the total mortality rate was 11.96% (95% CI, 8.1 - 16.8%). The univariate analysis revealed a significant relationship between SAP-related death with age, ICU admission within 24 hours of onset, APACHE II score, serum amylase, serum albumin, PaO2, acute respiratory distress syndrome (ARDS), renal insufficiency, and other diseases (P < 0.05). The multivariate logistic regression analysis further demonstrated that ICU admission within 24 hours of onset, serum albumin, ARDS, and renal insufficiency were independent early prognostic factors of SAP (P < 0.05). LR model: Y = -0.108 - 1.852 × ICU admission within 24 hours of onset -0.102 × serum albumin + 1.790 × ARDS + 1.150 × renal insufficiency. The area under the curve (AUC) and 95% CI of the LR model were 0.864 (0.811 - 0.917) with the optimal threshold of 2.246. The sensitivity and specificity were 0.709 and 0.929, respectively. Conclusions: The SAP patients or acute pancreatitis (AP) patients at risk of developing SAP should be transferred to ICU at the earliest convenience. Moreover, hypoalbuminemia, ARDS, and renal insufficiency indicate poor prognosis.

The clinical significance of ultra-high D-dimer levels

Objective

Plasma D-dimer levels >5000 ng/mL are encountered in a number of conditions other than venous thromboembolism (VTE). Recent studies have used plasma D-dimer levels as a prognostic indicator for coronavirus disease 2019 (COVID-19) infection. The implications of abnormal levels are less clear for patients diagnosed with COVID-19 with a baseline elevation in plasma D-dimer levels. In the present study, we reviewed the occurrence of plasma D-dimer levels >5000 ng/mL and investigated the clinical significance of this finding before the onset of the COVID-19 pandemic.

Methods

Inpatient records for a 4-year period were screened for laboratory results of plasma D-dimer levels >5000 ng/mL. The patient data were reviewed for the clinical identifiers commonly associated with elevated plasma D-dimer levels, including VTE, cancer, sepsis, pneumonia, other infection, bleeding, and trauma. The patients were then categorized into groups stratified by the plasma D-dimer level to allow for comparisons between the various clinical diagnoses.

Results

A total of 671 patients were included in the present study. VTE was the most common diagnosis for patients with a plasma D-dimer level >5000 ng/mL, followed by cancer and pneumonia. Multiple clinical diagnoses were present in 61% of the patients. No clear cause for the ultra-high plasma D-dimer level could be identified in 11.3% of the patients. Among the patients lacking a clinical diagnosis at discharge, mortality was 24% in the 5000- to 10,000-ng/mL group, 28.6% in the 10,000- to 15,000-ng/mL group, and 75% in the >15,000-ng/mL group.

Conclusions

VTE, cancer, and pneumonia were frequently present when ultra-high plasma D-dimer levels were encountered, and mortality was high when the levels were >15,000 ng/mL. The results from our study from a pre–COVID-19 patient population suggest that ultra-high plasma D-dimer levels indicate the presence of severe underlying disease. This should be considered when using the plasma D-dimer level as a screening tool or prognostic indicator for COVID-19 infection.

Nomogram for Predicting Deep Venous Thrombosis in Lower Extremity Fractures

Deep venous thrombosis (DVT) is a common complication in patients with lower extremity fractures, causing delays in recovery short-term and possible impacts on quality of life long-term. Early prediction and prevention of thrombosis can effectively reduce patient pain while improving outcomes. Although research on the risk factors for thrombosis is prevalent, there is a stark lack of clinical predictive models for DVT occurrence specifically in patients with lower limb fractures. In this study, we aim to propose a new thrombus prediction model for lower extremity fracture patients. Data from 3300 patients with lower limb fractures were collected from Wuhan Union Hospital and Hebei Third Hospital, China. Patients who met our inclusion criteria were divided into a thrombosis and a nonthrombosis group. A multivariate logistic regression analysis was carried out to identify predictors with obvious effects, and the corresponding formulas were used to establish the model. Model performance was evaluated using a discrimination and correction curve. 2662 patients were included in the regression analysis, with 1666 in the thrombosis group and 996 in the nonthrombosis group. Predictive factors included age, Body Mass Index (BMI), fracture-fixation types, energy of impact at the time of injury, blood transfusion during hospitalization, and use of anticoagulant drugs. The discriminative ability of the model was verified using the C-statistic (0.676). For the convenience of clinical use, a score table and nomogram were compiled. Data from two centers were used to establish a novel thrombus prediction model specific for patients with lower limb fractures, with verified predictive ability.

Association of age-adjusted D-dimer with deep vein thrombosis risk in patients with spinal cord injury: a cross-sectional study

STUDY DESIGN

Article.

OBJECTIVE

To elucidate the association of age-adjusted D-dimer (AAD) with deep vein thrombosis (DVT) risk to lower limbs in patients with spinal cord injury (SCI).

SETTING

Rehabilitation Medicine Department of the First Affiliated Hospital of China University of Science and Technology.

METHODS

Retrospective analysis of 250 patients with SCI in the rehabilitation department from August 2018 to December 2021. Quartiles divided the D-dimer level into four groups to analyze the association between AAD level and DVT risk.

RESULTS

Age was identified as a covariate of D-dimer and DVT risk. For non-adjusted model, when D-dimer increased by 1 mg/L, DVT risk increased 0.23-fold (P < 0.05); for minimally-adjusted model (adjusted for age), the risk increased 0.22-fold (P < 0.05); and for fully-adjusted model (adjusted for age, sex, pulmonary infection, degree, grades, and career), it increased 0.19-fold (P < 0.05). AAD had a curvilinear association with DVT risk, and the fold point was 1.9 mg/L (P < 0.05). When serum AAD level was <1.9 mg/L (K < 1.9), the estimated change in DVT risk was 3.34 (P < 0.05), and when serum AAD level was >1.9 mg/L (K > 1.9), the estimated change was 1.14 (P < 0.05). Urinary tract infection (UTI) and fibrinogen(tertile) had a interaction association with D-dimer level and DVT risk (P interaction < 0.05).

CONCLUSION

Patients with SCI who receive rehabilitation treatment with AAD level >1.9 mg/L need to be paid close attention to, especially those with UTI and high levels of fibrinogen.

Vitamin D Levels in COVID-19 Outpatients from Western Mexico: Clinical Correlation and Effect of Its Supplementation

BACKGROUND

The immunomodulatory effects of vitamin D are known to be beneficial in viral infections; it is also known that its deficiency is associated with a prognosis more critical of Coronavirus Disease 2019. This study aimed to determine baseline vitamin D serum concentrations and the effects of its supplementation in asymptomatic or mildly symptomatic Coronavirus Disease 2019 outpatients.

METHODS

42 outpatients were included, 22 of which received a supplement of 10,000 IU of vitamin D3 for 14 days; the remaining 20 outpatients were designated as a control group. Serum levels of transferrin, ferritin, vitamin D, and D-dimer were measured at baseline in both groups. After 14 days, serum levels of total vitamin D were determined in the supplemented group.

RESULTS

At baseline, only 19% of infected outpatients had vitamin D levels corresponding to sufficiency. All outpatients with vitamin D insufficiency had at least one symptom associated with the disease, while only 75% of patients with symptoms presented sufficiency. On the seventh and fourteenth day of follow-up, the supplemented group presented fewer symptoms with respect to those non-supplemented. A vitamin D3 dose of 10,000 IU/daily for 14 days was sufficient to raise vitamin D serum concentrations.

CONCLUSIONS

Immunomodulatory effects of vitamin D appear to be linked to the development of symptoms in positive outpatients. Vitamin D supplementation could have significant benefits in the Western Mexican population.

Diagnostic Value of Neutrophil Lymphocyte Ratio and D-Dimer as Biological Markers of Deep Vein Thrombosis in Patients Presenting with Unilateral Limb Edema

Introduction

Patients with deep vein thrombosis (DVT) pose high morbidity and mortality risk thus needing fast and accurate diagnosis. Wells clinical prediction scores with D-dimer testing are traditionally used to rule out patients with low probability of DVT. However, D-dimer testing has a few limitations regarding its relatively low specificity. Neutrophil-lymphocyte ratio (NLR), a marker of inflammation, was found to increase in DVT. Hence, we aimed to evaluate the role of NLR for DVT diagnosis.

Methods

Data were collected from medical records of patients with suspected DVT at Cipto Mangunkusumo National General Hospital during January–December 2014. Diagnosis of DVT was conducted using lower limb ultrasonography. Diagnostic values for NLR, D-dimer, and NLR + D-dimer were determined by receiver operating characteristic (ROC) analysis to obtain area under the curve (AUC), sensitivity, specificity, negative predictive value, and positive predictive values. Sensitivity and specificity analyses of NLR and D-dimer were also conducted based on Wells score and divided into groups of low and high probability of DVT.

Results

The AUC values for NLR, D-dimer, and NLR + D-dimer were 72.6%, 70.4%, and 76.1%, respectively. The optimal cut-off value determined for NLR was 5.12 with sensitivity of 67.7%, specificity of 67.9%, PPV of 68.85%, and NPV of 64.91% in differentiating subjects with and without DVT. This study also found that D-dimer had sensitivity of 69.4%, specificity of 71.4%, PPV of 72.88%, and NPV of 67.8%. Meanwhile, the NLR + D-dimer combination had sensitivity of 66.1% and specificity of 72.6%. Multivariate analysis showed that NLR (OR: 2.636; 95% CI: 1.144–6.076; p: 0.023) and D-dimer (OR: 4.175; 95% CI: 1.810–9.633; p: 0.001) were associated with DVT.

Conclusion

NLR value has wider AUC than D-Dimer and is relatively easier to obtain and does not require specific assay, thus enabling rapid evaluation of symptomatic patients suspected of having DVT. Adding NLR to D-dimer increased AUC to detect DVT. Therefore, NLR could serve as a complementary diagnostic tool for D-dimer to exclude DVT, especially in low clinical probability patients.

Peripherally inserted central venous catheter in upper extremities leads to an increase in D-dimer and deep vein thrombosis in lower extremities

Background

The purpose of this study is to elucidate the association between peripherally inserted central venous catheter (PICC) in upper extremities and lower extremity deep venous thrombosis (LEDVT) by observing the changes in D-dimer.

Methods

This was a retrospective cohort study with 3452 patients (104 inserted with PICCs and 3348 without PICC) enrolled at the neurology department from April 1, 2017 to April 1, 2020. The patients underwent color Doppler ultrasound (CDU) and D-dimer examinations. LEDVT-related factors and D-dimer value were analyzed before and after PICC insertion. The predictive value of D-dimer for LEDVT was also evaluated.

Results

Univariate logistic regression analysis showed that PICC insertion increased the risk of LEDVT by 9 times and promoted the increase of D-dimer by 5 times. After risk adjustment, multivariate logistic regression analysis showed that PICC insertion increased the risk of LEDVT by 4 times and tripled the risk of D-dimer increase. The concentration of D-dimer was significantly increased after PICC insertion. D-dimer was unsuitable for excluding venous thrombosis in patients inserted with PICCs.

Conclusions

PICC insertion increases the level of D-dimer and the risk of LEDVT. The risks of venous thrombosis need to be assessed in patients inserted with PICCs to ensure the expected clinical outcomes.

Study on the Risk Factors of Preoperative Deep Vein Thrombosis (DVT) in Patients With Lower Extremity Fracture

Objective:

The objective of this work is to discuss and analyze the related factors of lower extremity fracture complicated by preoperative deep vein thrombosis (DVT).

Methods:

A total of 11,891 patients with closed fractures of lower extremities were selected. By analyzing each patient’s gender, age, presence or absence of diabetes and hypertension, preoperative plasma D-dimer level, and color Doppler ultrasound of the lower extremity vein, the pertinent factors of the patients with lower extremity fractures complicated by preoperative DVT were analyzed.

Results:

A total of 578 with preoperative DVT were detected, displaying a total incidence of 4.86%. All patients were categorized into either the DVT group or non-DVT group. The results demonstrate that there were statistically significant differences between the 2 groups in age, the presence of diabetes and hypertension, the fracture site, and the preoperative plasma D-dimer level (P < 0.05). Logistic multivariate analysis revealed that age, the presence of diabetes, and the preoperative plasma D-dimer level of patients were independent risk factors for lower extremity fracture complicated by DVT.

Conclusion:

Age, the presence of diabetes, the fracture site, and increased D-dimer levels were found to be potential risk factors and indicators for preoperative DVT in patients with lower extremity fractures. In addition, the preoperative plasma D-dimer level has certain guiding significance for the prediction of venous thrombosis after lower extremity fracture, which is conducive to the early prediction and diagnosis of DVT, but it often must be followed with good clinic acumen and examinations.

Analysis of HLA haplotype and clinical factors during hematopoietic stem cell transplantation

BACKGROUND

The human leukocyte antigen (HLA) haplotype of the recipient in hematopoietic stem cell transplantation (HSCT) is a key factor in its success or failure. We analyzed the relationship between HLA haplotype frequency and associated clinical factors in HSCT patients.

METHODS

Patients who underwent allogeneic HSCT between 2000 and 2019 at our institution were enrolled in this study. The HSCT composition was 77 bone marrow transplantations (BMT), 38 peripheral blood stem cell transplantations (PBSCT), and 36 cord blood transplantations (CBT). Patients were classified into three groups according to their donor HLA haplotype frequency in the Japan Population: group A, top 1-10 haplotypes; group B, top 11-100 haplotypes; and group C, haplotype 101-. We then compared various items including clinical biomarkers with the HLA haplotype frequency.

RESULTS

A significant negative correlation was identified between older persons and length of survival. There are also significant correlations between survival and levels of immunoglobulin G, D-dimer, and C-reactive protein, as well as the platelet-large cell ratio before transplantation. A total of 96, 30, and 25 patients were classified into groups A, B, and C, respectively. The HSCT match rate was significantly higher in group A patients than in those of groups B and C. In contrast, the death rate, D-dimer level, and length of time for engraftment were significantly higher in group B and C patients than in those of group A.

CONCLUSION

An assessment of transplant-related complications is important in improving the performance of HSCT. The present data suggest that a special therapeutic strategy is necessary for HSCT using low-frequency HLA haplotypes.

D-Dimer as Predictor of Large Vessel Occlusion in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Improving prehospital triage of large vessel occlusion (LVO) would reduce time to reperfusion therapies. We aimed to study early predictors of LVO in acute ischemic stroke to identify candidates for endovascular treatment.

METHODS

The Stroke-Chip was a prospective observational study conducted at 6 Stroke Centers in Catalonia. Blood samples were obtained in the first 6 hours from symptom onset of consecutive patients. Stroke severity was evaluated with National Institutes of Health Stroke Scale (NIHSS) and LVO was assessed. Independent association of multiple blood biomarkers with LVO was evaluated using logistic regression models adjusted by covariates. Sensitivity, specificity, and predictive values were assessed for NIHSS and the combination of NIHSS and selected serum biomarkers levels.

RESULTS

One thousand three hundred eight suspected strokes were enrolled for a 17-month period. LVO was not assessed in 131 patients. One thousand one hundred seventy-seven patients were selected for analysis (mean age 69.3 years, 56% men, median baseline NIHSS of 6, and median time to blood collection 2.5 hours). LVO was detected in 262 patients. LVO patients were older, had higher baseline NIHSS, history of atrial fibrillation, and lower time from stroke onset to admission. After logistic regression analysis, D-dimer remained an independent predictor of LVO (odds ratio, 1.59 [1.31-1.92]). Specificity and positive predictive value to exclude or detect LVO were higher when using combined D-dimer levels and NIHSS score assessment rather than NIHSS alone.

CONCLUSIONS

Early D-dimer levels are an independent predictor of LVO and may be useful to better optimize prehospital patient transport to the appropriate stroke center.

Incidence and risk factors predicting deep venous thrombosis of lower extremity following spinal fractures

The aim of this study was to investigate the presence of preoperative DVT following spinal fracture and the association between the presence of DVT and risk factors. Ultrasonography and blood analyses were performed preoperatively in patients diagnosed with spinal fracture between October 2014 and December 2018. Univariate analyses were performed on the data of demographics, comorbidities, location of injury, spinal cord injury (SCI) grading and laboratory biomarkers. The receiver operating characteristic (ROC) curve analysis was employed to obtain the optimal D-dimer cut-off value for diagnosis. In total, 2432 patients with spinal fractures were included, among whom 108 (4.4%) patients had preoperative DVTs. The average interval between fracture and initial diagnosis of DVT was 4.7 days (median, 2 days), ranging from 0 to 20 days; 78 (72.2%) were diagnosed within 7 days after injury and 67 (62.0%) within 3 days; 19 (17.5%) patients had proximal vein involved and 89 (82.4%) presented in distal veins. Multivariate logistic regression suggested six risk factors independently correlated to DVT, including delay to DUS (in each day) (odds ratio [OR] = 1.11), ASA class III-IV (OR = 2.36), ASIA grade (A/B) (OR = 2.36), ALB < 3.5 g/dL (OR = 2.08), HDL-C < 1.1 mmol/L (OR = 1.68) and D-Dimer > 1.08 µg/ml (OR = 2.49).