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Muhammad R, Ogunti R, Ahmad B, Munawar M, Donaldson S, Sumon M, Kibreab A, Thomas AN, Mehari A. Clinical Characteristics and Predictors of Mortality in Minority Patients Hospitalized with COVID-19 Infection. J Racial Ethn Health Disparities 2022; 9:335-345. [PMID: 33538998 PMCID: PMC7861003 DOI: 10.1007/s40615-020-00961-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To identify the early mortality predictors in minority patients hospitalized with coronavirus disease 2019 (COVID-19). DESIGN Demographics, presenting characteristics, admission laboratory data, ICU admission, and mortality data were collected from 200 consecutively hospitalized patients with COVID-19. RESULTS The mean (SD) age was 58.9 (15.1) years, 121(60.5%) were men, 143 (71.5%) were African Americans, and 33 (16.5%) were Latino. Common presenting symptoms were cough 130 (65.0%), shortness of breath 129 (64.5%), and fever 121 (60.5%). One or more comorbid illness occurred in 171 (85.5%) and common comorbidities were hypertension (130 (65.2%)), diabetes (100 (50.0%)) and chronic kidney disease (60 (30.0%)). Of the 200 patients, 71 (35.5%) were treated in the ICU, 47 (24.2%) received mechanical ventilation, 45 (22.5%) died, and 155(77.5%) patients discharged home alive. The non-survivors were significantly older and had elevated markers of inflammation, coagulation, and acute organ damage on presentation. Age ≥ 65 years (odds ratio (OR), 3.78; 95% CI, 1.74-8.22; P = .001), lactate dehydrogenase level > 400 IU/L (OR, 9.1; 95% CI, 2.97-28.1; p < 0.001), C-reactive protein > 20 mg/dl (OR, 5.56; 95%CI, 1.84-16.8; p < 0.001), ferritin > 2000 ng/ml (OR, 5.42; 95%CI, 1.63-17.9; p = 0.006), creatinine kinase > 1000 iu/l (OR, 3.57; 95% CI, 1.23 10.3; p = 0.019), procalcitonin > 2.5 ng/ml (OR, 4.21; 95% CI, 1.47-12.0; p = 0.007), D-dimer level > 3.0 μg/ml (OR,10.9; 95% CI, 3.33-36.2; p = < 0.001), creatinine > 2 mg/dl (OR, 4.5; 95% CI, 1.29-15.8; P = 0.018) at admission were associated independently with increases risk of in-hospital mortality. CONCLUSION Patients of advanced age that present with elevated biomarkers of inflammation, coagulation, and end-organ damage were at higher risk of mortality.
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Affiliation(s)
- Rizwan Muhammad
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Richard Ogunti
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Basharat Ahmad
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Muhammad Munawar
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Sahai Donaldson
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
- Division of Pulmonary and Critical Care, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Mahbubur Sumon
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
- Division of Pulmonary and Critical Care, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Angesom Kibreab
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
- Division of Gastroenterology and Hepatology, Washington, DC, USA
| | - Alicia N Thomas
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
- Division of Pulmonary and Critical Care, 2041 Georgia Ave, NW, Washington, DC, 20060, USA
| | - Alem Mehari
- Howard University College of Medicine, 2041 Georgia Ave, NW, Washington, DC, 20060, USA.
- Division of Pulmonary and Critical Care, 2041 Georgia Ave, NW, Washington, DC, 20060, USA.
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Stamm B, Huang D, Royan R, Lee J, Marquez J, Desai M. Pathomechanisms and Treatment Implications for Stroke in COVID-19: A Review of the Literature. Life (Basel) 2022; 12:207. [PMID: 35207494 PMCID: PMC8877423 DOI: 10.3390/life12020207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 11/25/2022] Open
Abstract
Stroke in patients with COVID-19 has received increasing attention throughout the global COVID-19 pandemic, perhaps due to the substantial disability and mortality that can result when the two conditions co-occur. We reviewed the existing literature and found that the proposed pathomechanism underlying COVID-19-associated ischemic stroke is broadly divided into the following three categories: vasculitis, endothelialitis, and endothelial dysfunction; hypercoagulable state; and cardioembolism secondary to cardiac dysfunction. There has been substantial debate as to whether there is a causal link between stroke and COVID-19. However, the distinct phenotype of COVID-19-associated strokes, with multivessel territory infarcts, higher proportion of large vessel occlusions, and cryptogenic stroke mechanism, that emerged in pooled analytic comparisons with non-COVID-19 strokes is compelling. Further, in this article, we review the various treatment approaches that have emerged as they relate to the proposed pathomechanisms. Finally, we briefly cover the logistical challenges, such as delays in treatment, faced by providers and health systems; the innovative approaches utilized, including the role of tele-stroke; and the future directions in COVID-19-associated stroke research and healthcare delivery.
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Affiliation(s)
- Brian Stamm
- Department of Neurology, School of Medicine, Northwestern University Feinberg, Chicago, IL 60611, USA; (D.H.); (J.L.)
| | - Deborah Huang
- Department of Neurology, School of Medicine, Northwestern University Feinberg, Chicago, IL 60611, USA; (D.H.); (J.L.)
| | - Regina Royan
- Department of Emergency Medicine, School of Medicine, Northwestern University Feinberg, Chicago, IL 60611, USA;
| | - Jessica Lee
- Department of Neurology, School of Medicine, Northwestern University Feinberg, Chicago, IL 60611, USA; (D.H.); (J.L.)
| | - Joshua Marquez
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM 87144, USA;
| | - Masoom Desai
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, NM 87144, USA;
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103
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Murala S, Nagarajan E, Bollu PC. Infectious Causes of Stroke. J Stroke Cerebrovasc Dis 2022; 31:106274. [PMID: 35093633 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/11/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022] Open
Abstract
Stroke is one of the primary causes of mortality and morbidity worldwide. It can be ischemic or hemorrhagic, and the former can be due to an in-situ thrombus or a distant embolus. Despite being a rare cause, stroke can also be caused in the setting of infection. Bacterial agents are the most common cause of stroke, among other infectious agents. Until the antibiotic era, rheumatic heart disease was a predisposing risk factor of infective endocarditis. VZV is the most common cause of strokes in pediatric and adult populations. Cryptococcus and Candida spp are the most common yeasts involved in CNS infections, especially in immunocompromised patients. In COVID-19 patients, ischemic strokes are more common than hemorrhagic strokes. In this review, we will discuss the most common infectious agents, with particular emphasis on COVID-19.
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Affiliation(s)
- Sireesha Murala
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.
| | - Elanagan Nagarajan
- Department of Neurology, Erlanger Health System, University of Tennessee School of Medicine, Chattanooga, TN, United States
| | - Pradeep C Bollu
- Department of Neurology, Prisma Health, Midlands/University of South Carolina School of Medicine, Columbia, SC, United States
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104
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Iba T, Nishida O, Levy JH, Levi M. Nevertheless, the importance of coagulation abnormalities should be emphasized in international sepsis guidelines. J Intensive Care 2022; 10:4. [PMID: 35063025 PMCID: PMC8778504 DOI: 10.1186/s40560-022-00596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
It is generally accepted that a coagulation/fibrinolysis disorder is involved in the pathogenesis of sepsis, and the association of disseminated intravascular coagulation (DIC) and poor outcomes have been reported. Based on these findings, recently released "Japanese Surviving Sepsis Campaign guidelines 2020" recommend the diagnosis of DIC and the application of anticoagulants for sepsis-associated DIC. Meanwhile, the updated "International Guidelines for the Management of Sepsis and Septic Shock 2021" did not mention coagulation abnormalities or DIC. Because management strategies continue to evolve to provide improved outcomes in sepsis, the role of adjunctive anticoagulant treatment should be included in subsequent international guidelines.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Kutsukake-Machi, Toyoake, 471-11 Japan
| | - Jerrold H. Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC USA
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-Metabolic Programme-NIHR UCLH/UCL BRC London, Tottenham Court Road, London, UK
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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105
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AYYILDIZ A, ÇOBANER N, YELKEN B. Sepsis induced coagulopathy score and D-dimer levels in COVID-19 patients followed in intensive care; what has changed in COVID era? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.992132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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106
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Aquino L, Muniz JC, Laufer PM, Prieto LR. Gore Cardioform ASD device thrombus weeks after COVID-19 infection. Catheter Cardiovasc Interv 2022; 99:1161-1164. [PMID: 35018709 PMCID: PMC9015617 DOI: 10.1002/ccd.30067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 11/20/2022]
Abstract
Device‐related thrombosis and device‐related endocarditis after atrial septal defect (ASD) transcatheter closure are extremely rare. It is known that COVID‐19 infection could lead to a thrombotic microangiopathy‐like phenomenon. We present the case of a 14‐year‐old female who developed fever and was found to have a thrombus on the right atrial side of the ASD closure device weeks after an asymptomatic COVID‐19 infection and negative COVID‐19 test 2 days before transcatheter ASD closure. Although there is no certainty that the thrombus was related to the prior COVID‐19 infection, the possibility of an ongoing COVID‐19‐related hypercoagulable state should be entertained.
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Affiliation(s)
- Liliam Aquino
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Juan Carlos Muniz
- Division of Cardiology, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Pablo Marcelo Laufer
- Division of Infectious Disease, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Lourdes R Prieto
- Division of Cardiology, Nicklaus Children's Hospital, Miami, Florida, USA
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107
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Ikeda N, Wada H, Ichikawa Y, Ezaki M, Tanaka M, Hiromori S, Shiraki K, Moritani I, Yamamoto A, Shimpo H, Shimaoka M. D-dimer kit with a High FDP/D-Dimer Ratio is Useful for Diagnosing Thrombotic Diseases. Clin Appl Thromb Hemost 2022; 28:10760296211070584. [PMID: 34994210 PMCID: PMC8753237 DOI: 10.1177/10760296211070584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction Although D-dimer is a useful biomarker of thrombosis, there are many D-dimer kits, with high and low fibrinogen and fibrin degradation products (FDP)/ D-dimer ratios. Methods Plasma D-dimer levels were measured using three different kits in critically ill patients to examine the usefulness of such measurements for detecting the thrombotic diseases and determining the correlation with the FDP and FDP/D-dimer ratio. Results Although three D-dimer kits showed marked utility for diagnosing disseminated intravascular coagulation (DIC) and peripheral arterial and venous thromboembolism (PAVTE), the D-dimer levels determined using the three kits varied among diseases. Indeed, one D-dimer kit showed a high FDP/D-dimer ratio, and another kit showed a low FDP/D-dimer ratio. D-dimer kit with low FDP/D-dimer ratio tended to have high cut-off values and low specificity for diagnosing DIC and PAVTE. In D-dimer kit with high FDP/D-dimer ratio, FDP/D-dimer ratios in patients with thrombosis was significantly higher than that in patients without thrombosis. Conclusion All three D-dimer kits show utility for detecting thrombotic diseases. However, the D-dimer levels determined using the kits varied due to differences in the FDP/D-dimer ratio. In combination with the FDP level, a D-dimer kit with a high FDP/D-dimer ratio may be useful.
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Affiliation(s)
- Nozomi Ikeda
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hideo Wada
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yuhuko Ichikawa
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Minoru Ezaki
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Motoko Tanaka
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Shinya Hiromori
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Katsuya Shiraki
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Isao Moritani
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | | | - Hideto Shimpo
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
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108
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García-Escobar A, Vera-Vera S, Jurado-Román A, Jiménez-Valero S, Galeote G, Moreno R. Calcium Signaling Pathway Is Involved in the Shedding of ACE2 Catalytic Ectodomain: New Insights for Clinical and Therapeutic Applications of ACE2 for COVID-19. Biomolecules 2022; 12:biom12010076. [PMID: 35053224 PMCID: PMC8774087 DOI: 10.3390/biom12010076] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 02/04/2023] Open
Abstract
The angiotensin-converting enzyme 2 (ACE2) is a type I integral membrane that exists in two forms: the first is a transmembrane protein; the second is a soluble catalytic ectodomain of ACE2. The catalytic ectodomain of ACE2 undergoes shedding by a disintegrin and metalloproteinase domain-containing protein 17 (ADAM17), in which calmodulin mediates the calcium signaling pathway that is involved in ACE2 release, resulting in a soluble catalytic ectodomain of ACE2 that can be measured as soluble ACE2 plasma activity. The shedding of the ACE2 catalytic ectodomain plays a role in cardiac remodeling and endothelial dysfunction and is a predictor of all-cause mortality, including cardiovascular mortality. Moreover, considerable evidence supports that the ACE2 catalytic ectodomain is an essential entry receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Additionally, endotoxins and the pro-inflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNFα) all enhanced soluble catalytic ectodomain ACE2 shedding from the airway epithelia, suggesting that the shedding of ACE2 may represent a mechanism by which viral entry and infection may be controlled such as some types of betacoronavirus. In this regard, ACE2 plays an important role in inflammation and thrombotic response, and its down-regulation may aggravate COVID-19 via the renin-angiotensin system, including by promoting pathological changes in lung injury. Soluble forms of ACE2 have recently been shown to inhibit SARS-CoV-2 infection. Furthermore, given that vitamin D enhanced the shedding of ACE2, some studies reported that vitamin D treatment is associated with prognosis improvement in COVID-19. This is an updated review on the evidence, clinical, and therapeutic applications of ACE2 for COVID-19.
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Affiliation(s)
- Artemio García-Escobar
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-917-27-70-00
| | - Silvio Vera-Vera
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Alfonso Jurado-Román
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Santiago Jiménez-Valero
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Guillermo Galeote
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Raúl Moreno
- Cardiology Department, Interventional Cardiology Section, University Hospital La Paz, 28046 Madrid, Spain; (S.V.-V.); (A.J.-R.); (S.J.-V.); (G.G.); (R.M.)
- Instituto de Investigación Hospital La Paz (IDIPAZ), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
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109
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Non-linear and Interaction Analyses of Biomarkers for Organ Dysfunctions as Predictive Markers for Sepsis: A Nationwide Retrospective Study. J Pers Med 2022; 12:jpm12010044. [PMID: 35055359 PMCID: PMC8778987 DOI: 10.3390/jpm12010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
Abstract
The Sequential Organ Failure Assessment (SOFA) score is predominantly used to assess the severity of organ dysfunction in sepsis. However, differences in prognostic value between SOFA subscores have not been sufficiently evaluated. This retrospective observational study used a large-scale database containing about 30 million patients. Among them, we included 38,869 adult patients with sepsis from 2006 to 2019. The cardiovascular and neurological subscores were calculated by a modified method. Associations between the biomarkers of the SOFA components and mortality were examined using restricted cubic spline analyses, which showed that an increase in the total modified SOFA score was linearly associated with increased mortality. However, the prognostic association of subscores varied widely: platelet count showed a J-shaped association, creatinine showed an inverted J-shaped association, and bilirubin showed only a weak association. We also evaluated interaction effects on mortality between an increase of one subscore and another. The joint odds ratios on mortality of two modified SOFA subscores were synergistically increased compared to the sum of the single odds ratios, especially in cardiovascular-neurological, coagulation-hepatic, and renal-hepatic combinations. In conclusion, total modified SOFA score was associated with increased mortality despite the varied prognostic associations of the subscores, possibly because interactions between subscores synergistically enhanced prognostic accuracy.
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110
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Fattorutto M, Bouckaert Y, Brauner J, Franck S, Bouton F, Heuse D, Bouckaert C, Bruyneel A. Pragmatic study of a thromboprophylaxis algorithm in critically ill patients with SARS-COV-2 infection. J Thromb Thrombolysis 2022; 53:58-66. [PMID: 34173169 PMCID: PMC8233177 DOI: 10.1007/s11239-021-02514-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 01/08/2023]
Abstract
The optimal thromboprophylactic strategy for patients affected by Coronavirus disease 2019 (COVID-19) has been debated among experts. This study evaluated the safety and efficacy of a thromboprophylaxis algorithm. This was a retrospective, single-center study in critically ill patients admitted to the intensive care unit (University affiliated Hospital) for acute respiratory failure due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). From March 16 to April 9, 2020, thromboprophylaxis was adjusted according to weight (control group, n = 19) and after this date, thromboprophylaxis depended on an algorithm based on thrombotic and hemorrhagic risk factors (protocol group, n = 13). With regard to safety (number of major bleeding events and blood transfusions), the groups were not significantly different. With regard to efficacy, the number of thrombotic events decreased from 37 to 0%, p = 0.025 after implementation of the algorithm. Also, peak fibrinogen dropped from 8.6 (7.2-9.3) to 6.5 (4.6-8.4) g/L, p = 0.041 and D-dimers from 2194 (1464-3763) to 1486 (900-2582) ng/mL, p = 0.0001. In addition, length of stay declined from 19 (10-31) to 5 (3-19) days, p = 0.009. In conclusion, a tailored thromboprophylaxis algorithm (risk stratification based on clinical parameters and biological markers) reduce thrombotic phenomena in critically ill COVID-19 patients without increasing major bleeding.
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Affiliation(s)
- Maurizio Fattorutto
- Department of Anesthesiology, Centre Hospitalier Universitaire Tivoli, Avenue Max Buset 34, 7100, La Louvière, Belgium.
| | - Yves Bouckaert
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Jonathan Brauner
- Department of Clinical Biology/Blood Bank, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Stéphane Franck
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Fabrice Bouton
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Danielle Heuse
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | | | - Arnaud Bruyneel
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
- School of Public Health, Université Libre Bruxelles, Brussels, Belgium
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111
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Allen A, Hoang C, Sangha R. COVID-19-Associated Coagulopathy in the Peripartum Setting: A Case Report. AJP Rep 2022; 12:e33-e35. [PMID: 35141033 PMCID: PMC8816627 DOI: 10.1055/s-0041-1742237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/08/2021] [Indexed: 11/13/2022] Open
Abstract
Sepsis-induced coagulopathy (SIC) scoring and D-dimer can be used to recognize COVID-19-induced coagulopathy, but the utility of these is largely unknown in the peripartum setting and leaves anticoagulation guidance unclear. We present the case of a critically ill postpartum patient with COVID-19 infection. This patient presented with clinical signs of COVID-19 infection and developed acute respiratory failure requiring invasive mechanical ventilation and subsequent cesarean delivery at 34 weeks. She initially improved postoperatively but deteriorated after postoperative day 5. She was found to have a very elevated D-dimer of 58 μg/mL and anticoagulation was escalated to full dosing. She required prolonged mechanical ventilation and deceased after developing gram-positive cocci bacteremia. This case demonstrates that recognition and management of COVID-19-associated coagulopathy can be confusing in the peripartum period and studies are needed to validate D-dimer and SIC scoring in this population of patients.
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Affiliation(s)
- Ashley Allen
- Department of Obstetrics and Gynecology, John Peter Smith Hospital, Fort Worth, Texas
| | - Christine Hoang
- Department of Obstetrics and Gynecology, John Peter Smith Hospital, Fort Worth, Texas
| | - Roopina Sangha
- Department of Obstetrics and Gynecology, John Peter Smith Hospital, Fort Worth, Texas
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112
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Hamad AS. Non-vitamin K antagonist oral anticoagulants for COVID-19 thrombosis. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.362812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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113
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Inflammatory response in relation to COVID-19 and other prothrombotic phenotypes. REUMATOLOGÍA CLÍNICA (ENGLISH EDITION) 2022; 18:1-4. [PMID: 35090606 PMCID: PMC7561343 DOI: 10.1016/j.reumae.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/11/2020] [Indexed: 12/24/2022]
Abstract
The haemostatic system acts in concert with inflammation, so that after inflammatory response various mediators activate the haemostatic system through endothelial dysfunction, platelet activation and coagulation promoting thrombosis, which is termed thromboinflammation. In this process, the inflammasome acquires special relevance; its stimulation promotes innate and adaptive immune responses. Inflammasome activation plays an important physiopathological role in several disorders with inflammatory and thrombotic phenomena. The role of thromboinflammation has become relevant in the COVID-19 pandemic, in which a cytokine storm has been described as one of the mechanisms responsible.
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114
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Reis S, Popp M, Schmid B, Stegemann M, Metzendorf MI, Kranke P, Meybohm P, Weibel S. Safety and Efficacy of Intermediate- and Therapeutic-Dose Anticoagulation for Hospitalised Patients with COVID-19: A Systematic Review and Meta-Analysis. J Clin Med 2021; 11:57. [PMID: 35011804 PMCID: PMC8745419 DOI: 10.3390/jcm11010057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND COVID-19 patients are at high thrombotic risk. The safety and efficacy of different anticoagulation regimens in COVID-19 patients remain unclear. METHODS We searched for randomised controlled trials (RCTs) comparing intermediate- or therapeutic-dose anticoagulation to standard thromboprophylaxis in hospitalised patients with COVID-19 irrespective of disease severity. To assess efficacy and safety, we meta-analysed data for all-cause mortality, clinical status, thrombotic event or death, and major bleedings. RESULTS Eight RCTs, including 5580 patients, were identified, with two comparing intermediate- and six therapeutic-dose anticoagulation to standard thromboprophylaxis. Intermediate-dose anticoagulation may have little or no effect on any thrombotic event or death (RR 1.03, 95% CI 0.86-1.24), but may increase major bleedings (RR 1.48, 95% CI 0.53-4.15) in moderate to severe COVID-19 patients. Therapeutic-dose anticoagulation may decrease any thrombotic event or death in patients with moderate COVID-19 (RR 0.64, 95% CI 0.38-1.07), but may have little or no effect in patients with severe disease (RR 0.98, 95% CI 0.86-1.12). The risk of major bleedings may increase independent of disease severity (RR 1.78, 95% CI 1.15-2.74). CONCLUSIONS Certainty of evidence is still low. Moderately affected COVID-19 patients may benefit from therapeutic-dose anticoagulation, but the risk for bleeding is increased.
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Affiliation(s)
- Stefanie Reis
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
| | - Benedikt Schmid
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt—Universität zu Berlin, 10117 Berlin, Germany;
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine—University Düsseldorf, 40225 Düsseldorf, Germany;
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (S.R.); (M.P.); (B.S.); (P.K.); (P.M.)
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Cui R, Hua W, Qu K, Yang H, Tong Y, Li Q, Wang H, Ma Y, Liu S, Lin T, Zhang J, Sun J, Liu C. An Interpretable Early Dynamic Sequential Predictor for Sepsis-Induced Coagulopathy Progression in the Real-World Using Machine Learning. Front Med (Lausanne) 2021; 8:775047. [PMID: 34926518 PMCID: PMC8678506 DOI: 10.3389/fmed.2021.775047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Sepsis-associated coagulation dysfunction greatly increases the mortality of sepsis. Irregular clinical time-series data remains a major challenge for AI medical applications. To early detect and manage sepsis-induced coagulopathy (SIC) and sepsis-associated disseminated intravascular coagulation (DIC), we developed an interpretable real-time sequential warning model toward real-world irregular data. Eight machine learning models including novel algorithms were devised to detect SIC and sepsis-associated DIC 8n (1 ≤ n ≤ 6) hours prior to its onset. Models were developed on Xi'an Jiaotong University Medical College (XJTUMC) and verified on Beth Israel Deaconess Medical Center (BIDMC). A total of 12,154 SIC and 7,878 International Society on Thrombosis and Haemostasis (ISTH) overt-DIC labels were annotated according to the SIC and ISTH overt-DIC scoring systems in train set. The area under the receiver operating characteristic curve (AUROC) were used as model evaluation metrics. The eXtreme Gradient Boosting (XGBoost) model can predict SIC and sepsis-associated DIC events up to 48 h earlier with an AUROC of 0.929 and 0.910, respectively, and even reached 0.973 and 0.955 at 8 h earlier, achieving the highest performance to date. The novel ODE-RNN model achieved continuous prediction at arbitrary time points, and with an AUROC of 0.962 and 0.936 for SIC and DIC predicted 8 h earlier, respectively. In conclusion, our model can predict the sepsis-associated SIC and DIC onset up to 48 h in advance, which helps maximize the time window for early management by physicians.
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Affiliation(s)
- Ruixia Cui
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wenbo Hua
- School of Mathematics and Statistics, Xi'an Jiaotong University, Xi'an, China
| | - Kai Qu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Heran Yang
- School of Mathematics and Statistics, Xi'an Jiaotong University, Xi'an, China
| | - Yingmu Tong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qinglin Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hai Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yanfen Ma
- Department of Clinical Laboratory, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Sinan Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ting Lin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingyao Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Biobank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jian Sun
- School of Mathematics and Statistics, Xi'an Jiaotong University, Xi'an, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of SICU, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Biobank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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116
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Voigtlaender M, Langer F. Management of Vascular Thrombosis in Patients with Thrombocytopenia. Hamostaseologie 2021; 42:19-28. [PMID: 34933376 DOI: 10.1055/a-1675-7824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. While low platelet counts increase the risk of bleeding, antithrombotic drugs, including anticoagulants and antiplatelet agents, are used to treat thromboembolic events. Thus, the management of thrombosis in patients with low platelet counts is challenging with hardly any evidence available to guide treatment. Recognition of the underlying cause of thrombocytopenia is essential for assessing the bleeding risk and tailoring therapeutic options. A typical clinical scenario is the occurrence of venous thromboembolism (VTE) in cancer patients experiencing transient thrombocytopenia during myelosuppressive chemotherapy. In such patients, the severity of thrombocytopenia, thrombus burden, clinical symptoms, and the timing of VTE relative to thrombocytopenia must be considered. In clinical practice, distinct hematological disorders characterized by low platelet counts and a thrombogenic state require specific diagnostics and treatment. These include the antiphospholipid syndrome, heparin-induced thrombocytopenia (HIT) and (spontaneous) HIT syndromes, disseminated intravascular coagulation, and paroxysmal nocturnal hemoglobinuria.
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Affiliation(s)
- Minna Voigtlaender
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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117
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Hosseini SF, Behnam-Roudsari S, Alavinia G, Emami A, Toghyani A, Moradi S, Zadeh MM, Mohseni S, Shafiee MA. Diagnostic and prognostic value of Sepsis-Induced coagulopathy and International Society on Thrombosis and Hemostasis scoring systems in COVID-19-associated disseminated intravascular coagulopathy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2021; 26:102. [PMID: 34899940 PMCID: PMC8607173 DOI: 10.4103/jrms.jrms_1295_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/30/2020] [Accepted: 03/25/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) presents various phenotypes from asymptomatic involvement to death. Disseminated intravascular coagulopathy (DIC) is among the poor prognostic complications frequently observed in critical illness. To improve mortality, a timely diagnosis of DIC is essential. The International Society on Thrombosis and Hemostasis (ISTH) introduced a scoring system to detect overt DIC (score ≥5) and another category called sepsis-induced coagulopathy (SIC) to identify the initial stages of DIC (score ≥4). This study aimed to determine whether clinicians used these scoring systems while assessing COVID-19 patients and the role of relevant biomarkers in disease severity and outcome. MATERIALS AND METHODS An exhaustive search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using Medline, Embase, Cochrane, CINAHL, and PubMed until August 2020. Studies considering disease severity or outcome with at least two relevant biomarkers were included. For all studies, the definite, maximum, and minimum ISTH/SIC scores were calculated. RESULTS A total of 37 papers and 12,463 cases were reviewed. Studies considering ISTH/SIC criteria to detect DIC suggested a higher rate of ISTH ≥5 and SIC ≥4 in severe cases and nonsurvivors compared with nonsevere cases and survivors. The calculated ISTH scores were dominantly higher in severe infections and nonsurvivors. Elevated D-dimer was the most consistent abnormality on admission. CONCLUSION Higher ISTH and SIC scores positively correlate with disease severity and death. In addition, more patients with severe disease and nonsurvivors met the ISTH and SIC scores for DIC. Given the high prevalence of coagulopathy in COVID-19 infection, dynamic monitoring of relevant biomarkers in the form of ISTH and SIC scoring systems is of great importance to timely detect DIC in suspicious patients.
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Affiliation(s)
- Sayyideh Forough Hosseini
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Sahar Behnam-Roudsari
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Ghazal Alavinia
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Anahita Emami
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Arash Toghyani
- Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sanaz Moradi
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Mahtab Mojtahed Zadeh
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Sana Mohseni
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Mohammad Ali Shafiee
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
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118
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Spyropoulos AC, Goldin M, Giannis D, Diab W, Wang J, Khanijo S, Mignatti A, Gianos E, Cohen M, Sharifova G, Lund JM, Tafur A, Lewis PA, Cohoon KP, Rahman H, Sison CP, Lesser ML, Ochani K, Agrawal N, Hsia J, Anderson VE, Bonaca M, Halperin JL, Weitz JI. Efficacy and Safety of Therapeutic-Dose Heparin vs Standard Prophylactic or Intermediate-Dose Heparins for Thromboprophylaxis in High-risk Hospitalized Patients With COVID-19: The HEP-COVID Randomized Clinical Trial. JAMA Intern Med 2021; 181:1612-1620. [PMID: 34617959 PMCID: PMC8498934 DOI: 10.1001/jamainternmed.2021.6203] [Citation(s) in RCA: 311] [Impact Index Per Article: 103.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Hospitalized patients with COVID-19 are at risk for venous and arterial thromboembolism and death. Optimal thromboprophylaxis dosing in high-risk patients is unknown. OBJECTIVE To evaluate the effects of therapeutic-dose low-molecular-weight heparin (LMWH) vs institutional standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The HEP-COVID multicenter randomized clinical trial recruited hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater from May 8, 2020, through May 14, 2021, at 12 academic centers in the US. INTERVENTIONS Patients were randomized to institutional standard prophylactic or intermediate-dose LMWH or unfractionated heparin vs therapeutic-dose enoxaparin, 1 mg/kg subcutaneous, twice daily if creatinine clearance was 30 mL/min/1.73 m2 or greater (0.5 mg/kg twice daily if creatinine clearance was 15-29 mL/min/1.73 m2) throughout hospitalization. Patients were stratified at the time of randomization based on intensive care unit (ICU) or non-ICU status. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause, and the principal safety outcome was major bleeding at 30 ± 2 days. Data were collected and adjudicated locally by blinded investigators via imaging, laboratory, and health record data. RESULTS Of 257 patients randomized, 253 were included in the analysis (mean [SD] age, 66.7 [14.0] years; men, 136 [53.8%]; women, 117 [46.2%]); 249 patients (98.4%) met inclusion criteria based on D-dimer elevation and 83 patients (32.8%) were stratified as ICU-level care. There were 124 patients (49%) in the standard-dose vs 129 patients (51%) in the therapeutic-dose group. The primary efficacy outcome was met in 52 of 124 patients (41.9%) (28.2% VTE, 3.2% ATE, 25.0% death) with standard-dose heparins vs 37 of 129 patients (28.7%) (11.7% VTE, 3.2% ATE, 19.4% death) with therapeutic-dose LMWH (relative risk [RR], 0.68; 95% CI, 0.49-0.96; P = .03), including a reduction in thromboembolism (29.0% vs 10.9%; RR, 0.37; 95% CI, 0.21-0.66; P < .001). The incidence of major bleeding was 1.6% with standard-dose vs 4.7% with therapeutic-dose heparins (RR, 2.88; 95% CI, 0.59-14.02; P = .17). The primary efficacy outcome was reduced in non-ICU patients (36.1% vs 16.7%; RR, 0.46; 95% CI, 0.27-0.81; P = .004) but not ICU patients (55.3% vs 51.1%; RR, 0.92; 95% CI, 0.62-1.39; P = .71). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, therapeutic-dose LMWH reduced major thromboembolism and death compared with institutional standard heparin thromboprophylaxis among inpatients with COVID-19 with very elevated D-dimer levels. The treatment effect was not seen in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04401293.
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Affiliation(s)
- Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Dimitrios Giannis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Wassim Diab
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Janice Wang
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sameer Khanijo
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Andrea Mignatti
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Eugenia Gianos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Marc Cohen
- Department of Medicine, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Gulru Sharifova
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | | | - Alfonso Tafur
- Department of Medicine, Cardiovascular Institute, NorthShore University HealthSystem, Evanston, Illinois.,Division of Cardiology, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | | | - Kevin P Cohoon
- Division of Cardiovascular Medicine, Department of Medicine, Froedtert & the Medical College of Wisconsin, Milwaukee
| | - Husneara Rahman
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Cristina P Sison
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Martin L Lesser
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kanta Ochani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Nirav Agrawal
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Judith Hsia
- Colorado Prevention Center (CPC) Clinical Research, Aurora.,Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Aurora
| | | | - Marc Bonaca
- Colorado Prevention Center (CPC) Clinical Research, Aurora.,Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Aurora
| | - Jonathan L Halperin
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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119
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Innocenti F, Lazzari C, Ricci F, Paolucci E, Agishev I, Pini R. D-Dimer Tests in the Emergency Department: Current Insights. Open Access Emerg Med 2021; 13:465-479. [PMID: 34795538 PMCID: PMC8593515 DOI: 10.2147/oaem.s238696] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Francesca Innocenti
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Cristian Lazzari
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Francesca Ricci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Elisa Paolucci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Ilya Agishev
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Riccardo Pini
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
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120
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Neuenfeldt FS, Weigand MA, Fischer D. Coagulopathies in Intensive Care Medicine: Balancing Act between Thrombosis and Bleeding. J Clin Med 2021; 10:5369. [PMID: 34830667 PMCID: PMC8623639 DOI: 10.3390/jcm10225369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Patient Blood Management advocates an individualized treatment approach, tailored to each patient's needs, in order to reduce unnecessary exposure to allogeneic blood products. The optimization of hemostasis and minimization of blood loss is of high importance when it comes to critical care patients, as coagulopathies are a common phenomenon among them and may significantly impact morbidity and mortality. Treating coagulopathies is complex as thrombotic and hemorrhagic conditions may coexist and the medications at hand to modulate hemostasis can be powerful. The cornerstones of coagulation management are an appropriate patient evaluation, including the individual risk of bleeding weighed against the risk of thrombosis, a proper diagnostic work-up of the coagulopathy's etiology, treatment with targeted therapies, and transfusion of blood product components when clinically indicated in a goal-directed manner. In this article, we will outline various reasons for coagulopathy in critical care patients to highlight the aspects that need special consideration. The treatment options outlined in this article include anticoagulation, anticoagulant reversal, clotting factor concentrates, antifibrinolytic agents, desmopressin, fresh frozen plasma, and platelets. This article outlines concepts with the aim of the minimization of complications associated with coagulopathies in critically ill patients. Hereditary coagulopathies will be omitted in this review.
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Affiliation(s)
| | | | - Dania Fischer
- Department of Anaesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (F.S.N.); (M.A.W.)
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121
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Suastika NKW, Suega K. The Optimal Cutoff Value of D-dimer Levels to Predict in Hospital Mortality in Severe Cases of Coronavirus Disease 2019. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Coronavirus disease 2019 (Covid-19) can cause coagulation parameters abnormalities such as an increase of D-dimer levels especially in severe cases. The purpose of this study is to determine the differences of D-dimer levels in severe cases of Covid-19 who survived and non-survived and determine the optimal cut-off value of D-dimer levels to predict in-hospital mortality.
Method: Data were obtained from confirmed Covid-19 patients who were treated from June to September 2020. The Mann-Whitney U test was used to determine differences of D-dimer levels in surviving and non-surviving patients. The optimal cut-off value and area under the curve (AUC) of the D-dimer level in predicting mortality were obtained by the receiver operating characteristic curve (ROC) method.
Results: A total of 80 patients were recruited in this study. Levels of D-dimer were significantly higher in non-surviving patients (median 3.346 mg/ml; minimum – maximum: 0.939 – 50.000 mg/ml) compared to surviving patients (median 1.201 mg/ml; minimum – maximum: 0.302 – 29.425 mg/ml), p = 0.012. D-dimer levels higher than 1.500 mg/ml are the optimal cut-off value for predicting mortality in severe cases of Covid-19 with a sensitivity of 80.0%; specificity of 64.3%; and area under the curve of 0.754 (95% CI 0.586 - 0.921; p = 0.010).
Conclusions: D-dimer levels can be used as a predictor of mortality in severe cases of Covid-19.
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122
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Jamil Z, Khan AA, Khalid S, Asghar M, Muhammad K, Waheed Y. Beneficial Effects of Anticoagulants on the Clinical Outcomes of COVID-19 Patients. Antibiotics (Basel) 2021; 10:antibiotics10111394. [PMID: 34827332 PMCID: PMC8615249 DOI: 10.3390/antibiotics10111394] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Severe coronavirus disease can be complicated by a hypercoagulable state in conjunction with sepsis, increasing the risk of venous thromboembolism. This study aimed to observe the effect of anticoagulants on 30-day high-dependency unit (HDU) outcomes of moderate to severe coronavirus disease 2019 (COVID-19) patients of a tertiary care hospital at Rawalpindi, Pakistan. (2) Methods: A retrospective propensity-based case-control study was carried out to examine COVID-19 patients admitted to the HDU. Patient groups who did and did not receive anticoagulants were labeled as "anticoagulant" and "non-anticoagulant", respectively. Case-control matching (1:1) was performed via propensity scores (calculated by a regression model). Kaplan-Meier and logrank analyses were used to study survival probability. Single predictors of outcomes were determined by Cox regression analysis. (3) Results: The anticoagulant group had elevated D-dimers, advanced age, more comorbidities and a higher frequency of severe disease compared to the non-anticoagulant group (p < 0.05). Therefore, 47 cases and 47 matched controls were selected based on their propensity scores. The primary endpoint was outcome (survived vs. died). The 30-day in-HDU mortality was 25.5% for cases and 61.7% for controls (p = 0.0004). The median time from admission to death was 16 days for the case group and 7 days for the control group (p < 0.0001). The 30-day mortality was 19.1% for the enoxaparin group and 16.4% for the heparin group (p > 0.05). Enoxaparin (therapeutic and prophylactic doses) and heparin (prophylactic dose) were found to be independent factors affecting the outcomes of these patients (p < 0.001). (4) Conclusions: Anticoagulants play a beneficial role in reducing mortality among COVID-19 patients. Both anticoagulant formulations, enoxaparin (therapeutic and prophylactic doses) and heparin (prophylactic dose), were associated with improving survival among these patients.
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Affiliation(s)
- Zubia Jamil
- Department of Medicine, Foundation University Medical College, Foundation University Islamabad, Islamabad 44000, Pakistan; (Z.J.); (S.K.)
| | - Azmat Ali Khan
- Pharmaceutical Biotechnology Laboratory, Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Samreen Khalid
- Department of Medicine, Foundation University Medical College, Foundation University Islamabad, Islamabad 44000, Pakistan; (Z.J.); (S.K.)
| | - Muhammad Asghar
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden;
- Department of Infectious Diseases, Karolinska University Hospital, 17164 Stockholm, Sweden
| | - Khalid Muhammad
- Department of Biology, College of Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates;
| | - Yasir Waheed
- Multidisciplinary Lab, Foundation University Medical College, Foundation University Islamabad, Islamabad 44000, Pakistan
- Correspondence:
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Varikasuvu SR, Varshney S, Dutt N, Munikumar M, Asfahan S, Kulkarni PP, Gupta P. D-dimer, disease severity, and deaths (3D-study) in patients with COVID-19: a systematic review and meta-analysis of 100 studies. Sci Rep 2021; 11:21888. [PMID: 34750495 PMCID: PMC8576016 DOI: 10.1038/s41598-021-01462-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/22/2021] [Indexed: 12/15/2022] Open
Abstract
Hypercoagulability and the need for prioritizing coagulation markers for prognostic abilities have been highlighted in COVID-19. We aimed to quantify the associations of D-dimer with disease progression in patients with COVID-19. This systematic review and meta-analysis was registered with PROSPERO, CRD42020186661.We included 113 studies in our systematic review, of which 100 records (n = 38,310) with D-dimer data) were considered for meta-analysis. Across 68 unadjusted (n = 26,960) and 39 adjusted studies (n = 15,653) reporting initial D-dimer, a significant association was found in patients with higher D-dimer for the risk of overall disease progression (unadjusted odds ratio (uOR) 3.15; adjusted odds ratio (aOR) 1.64). The time-to-event outcomes were pooled across 19 unadjusted (n = 9743) and 21 adjusted studies (n = 13,287); a strong association was found in patients with higher D-dimers for the risk of overall disease progression (unadjusted hazard ratio (uHR) 1.41; adjusted hazard ratio (aHR) 1.10). The prognostic use of higher D-dimer was found to be promising for predicting overall disease progression (studies 68, area under curve 0.75) in COVID-19. Our study showed that higher D-dimer levels provide prognostic information useful for clinicians to early assess COVID-19 patients at risk for disease progression and mortality outcomes. This study, recommends rapid assessment of D-dimer for predicting adverse outcomes in COVID-19.
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Affiliation(s)
| | | | - Naveen Dutt
- Department of Respiratory Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Manne Munikumar
- Department of Bioinformatics, ICMR-National Institute of Nutrition, Hyderabad, 500007, India
| | - Shahir Asfahan
- Department of Respiratory Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Paresh P Kulkarni
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005, India
| | - Pratima Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, 249203, India
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Shafiee MA, Hosseini SF, Mortazavi M, Emami A, Mojtahed Zadeh M, Moradi S, Shaker P. Anticoagulation therapy in COVID-19 patients with chronic kidney disease. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:63. [PMID: 34729071 PMCID: PMC8506255 DOI: 10.4103/jrms.jrms_875_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/05/2020] [Accepted: 09/24/2020] [Indexed: 01/04/2023]
Abstract
Coagulopathy and derangements in the coagulation parameters are significant features of COVID-19 infection, which increases the risk of disseminated intravascular coagulation, thrombosis, and hemorrhage in these patients, resulting in increased morbidity and mortality. In times of COVID-19, special consideration should be given to patients with concurrent chronic kidney disease (CKD) and COVID-19 (CKD/COVID-19 patients) as renal dysfunction increases their risk of thrombosis and hemorrhage, and falsely affects some of the coagulation factors, which are currently utilized to assess thrombosis risk in patients with COVID-19. Hence, we believe extra attention should be given to determining the risk of thrombosis and bleeding and optimizing the timing and dosage of anticoagulant therapy in this unique population of patients. CKD/COVID-19 patients are considered a high-risk population for thrombotic events and hemorrhage. Furthermore, effects of renal function on paraclinical and clinical data should be considered during the evaluation and interpretation of thrombosis risk stratification. Individualized evaluation of clinical status and kidney function is necessary to determine the best approach and management for anticoagulant therapy, whereas there is a lack of studies about the population of CKD/COVID-19 patients who need anticoagulant therapy now.
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Affiliation(s)
- Mohammad Ali Shafiee
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Sayyideh Forough Hosseini
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Mojgan Mortazavi
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Anahita Emami
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Mahtab Mojtahed Zadeh
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Sanaz Moradi
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
| | - Pouyan Shaker
- Department of Medicine, Division of General Internal Medicine, Toronto General Hospital, Toronto, Canada
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Tomioka K, Aoki T, Matsuda K, Enami Y, Fujimori A, Koizumi T, Kusano T, Date H, Yamashita T, Ariyoshi T, Goto S, Yamazaki K, Watanabe M, Otsuka K, Murakami M. Clinical Treatment of Perioperative Disseminated Intravascular Coagulation in Patients Who Underwent Gastrointestinal and Hepato-Biliary-Pancreatic Surgery. Am Surg 2021:31348211054702. [PMID: 34730467 DOI: 10.1177/00031348211054702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unclear how effective recombinant thrombomodulin (rTM) treatment is in disseminated intravascular coagulation (DIC) during the perioperative period of gastrointestinal and hepato-biliary-pancreatic surgery. The current study aimed to evaluate the therapeutic outcomes of rTM for perioperative DIC. METHODS We enrolled 100 consecutive patients diagnosed with perioperative DIC after gastrointestinal surgery, and hepato-biliary-pancreatic including emergency procedures, between January 2012 and May 2021. Patients received routine rTM treatment immediately after DIC diagnosis. Then, the DIC, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated and used for evaluation. The outcomes of rTM treatment and the predictors of survival were evaluated. RESULTS The causative diseases of DIC were as follows: perforated peritonitis, n = 38; intestinal ischemia, n = 23; intra-abdominal abscess, n = 13; anastomotic leakage, n = 7; pneumonia, n = 7; cholangitis, n = 4; and others, n = 6. The 30-day mortality rate was 18.0%. There were significant differences in the platelet count (13.78 vs 10.41, P = .032) and the SOFA score (5.22 vs 9.89, P<.0001) at the start of DIC treatment between the survivor and non-survivor groups (day 0). The survivor group had a significantly lower DIC score (3.13 vs 4.93, P = .0006) and SOFA score (4.94 vs 12.14, P < .0001) and a higher platelet count (13.50 vs 4.34, P < .0001) than the non-survivor group on day 3. CONCLUSIONS Comprehensive and systemic treatment is fundamentally essential for DIC, in which rTM may play an important role in the treatment of perioperative DIC.
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Affiliation(s)
- Kodai Tomioka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Takeshi Aoki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Kazuhiro Matsuda
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Yuta Enami
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Akira Fujimori
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Tomotake Koizumi
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Tomokazu Kusano
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Hiromi Date
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Takeshi Yamashita
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Tomotake Ariyoshi
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Satoru Goto
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Kimiyasu Yamazaki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Makoto Watanabe
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Koji Otsuka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
| | - Masahiko Murakami
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, 13059Showa University, Shinagawa, Tokyo, Japan
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Lin H, Chen H, Qi B, Jiang Y, Lian N, Zhuang X, Yu Y. Brain-derived extracellular vesicles mediated coagulopathy, inflammation and apoptosis after sepsis. Thromb Res 2021; 207:85-95. [PMID: 34583153 DOI: 10.1016/j.thromres.2021.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The activation of coagulation, inflammation and other pathways is the basic response of the host to infection in sepsis, but this response also causes damage to the host. Brain-derived extracellular vesicles (BDEVs) have been reported to cause a hypercoagulable state that can rapidly develop into consumptive coagulopathy, which is consistent with the pathophysiological process of sepsis-induced coagulopathy. However, the role of BDEVs in sepsis-induced coagulopathy remains unclear. MATERIALS AND METHODS Male Sprague-Dawley (SD) rats were used for sepsis modeling using cecal ligation puncture (CLP). Flow cytometry was used to measure the levels of circulating BDEVs. Enzyme-linked immunosorbent assay (ELISA) was used to measure the serum levels of plasminogen activator inhibitor type 1 (PAI-1), thrombin-antithrombin (TAT), D-dimer, fibrinogen(Fib), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β and IL-6. Nanoparticle tracking analysis (NTA) and Transmission electron microscopy (TEM) were used to identify BDEVs. Western blot (WB) was used to determine the expression of glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE), bax, bcl-2 and cleaved caspase-3. Hematoxylin-eosin (HE) and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining were performed to detect tissue injury. Survival was monitored over the course of 168 h. RESULTS We found that a large number of BDEVs were released into the circulating blood in septic rats. Moreover, we observed that BDEVs injection activated the systemic coagulation reaction and induced lung, liver and kidney inflammation and apoptosis(P < .05). Compared with BDEVs from sham-operated rats, BDEVs from septic rats exacerbated this process(P < .05). CONCLUSIONS This finding suggests that inhibiting BDEVs may yield therapeutic benefits in the treatment of sepsis-induced coagulopathy.
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Affiliation(s)
- Huaying Lin
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Hongguang Chen
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Bo Qi
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yi Jiang
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Naqi Lian
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xiaoli Zhuang
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yonghao Yu
- Department of Anesthesia, Tianjin Medical University General Hospital, Tianjin 300052, China; Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China.
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Antoniello A, Brophy A, Opsha Y. Evaluation of Hospitalized Patient Outcomes in COVID-19 Infection for Continued versus Discontinued Use of Preadmission Antiplatelet Regimen. J Pharm Pract 2021; 36:508-513. [PMID: 34693824 DOI: 10.1177/08971900211053294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In SARS-CoV-2 (COVID-19) infection, it is unclear if continuation of preadmission antiplatelet regimens upon hospitalization will improve hypercoagulability outcomes. METHODS This retrospective cohort study analyzed adult patients hospitalized with confirmed COVID-19 infection for a 6-week period from March 13, 2020, to April 27, 2020. Preadmission antiplatelet regimen continuation for less than 75% of admission was compared to continuation for at least 75% of admission. Pregnancy, either death or withdrawal of care within 24 hours of admission, and admission beyond the studied timeframe were excluded. The primary endpoint was difference in World Health Organization COVID-19 Ordinal Scale for Clinical Improvement values (World Health Organization [WHO] scores) between maximum score during admission to that upon discharge. Secondary endpoints were mechanical ventilation requirement, mortality, radiologically confirmed venous thromboembolism, major bleeding, and length of stay. RESULTS This study included 171 patients. Patients failing to continue antiplatelet regimens for at least 75% of admission (n = 76) had significantly worse WHO score differences than those who did (n = 95) (median -1 vs 2; P < .05). Mechanical ventilation requirement (57% vs 27%; P < .05) and mortality (58% vs 29%; P < .05) also favored antiplatelet continuation. All other endpoints were not significantly different. CONCLUSION Significantly improved WHO scores, mechanical ventilation requirement, and mortality occurred in patients continuing preadmission antiplatelet regimens in COVID-19 infection. Future prospective studies of COVID-19 patients with consistently collected baseline hypercoagulability markers (platelets, D-dimer, fibrinogen, and coagulation studies) and similar severe disease risk factors are required to confirm potential benefits of antiplatelet therapy during hospitalization.
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Affiliation(s)
- Angela Antoniello
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA
| | - Alison Brophy
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA
| | - Yekaterina Opsha
- Saint Barnabas Medical Center - Department of Pharmacy, Livingston, NJ, USA.,24056Rutgers University - Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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Cellular and molecular mechanisms in COVID-19 coagulopathy: role of inflammation and endotheliopathy. J Thromb Thrombolysis 2021; 53:282-290. [PMID: 34687400 PMCID: PMC8536904 DOI: 10.1007/s11239-021-02583-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Coronavirus 2 (CoV-2) infection or coronavirus disease 2019 (COVID-19) is frequently associated with microvascular thrombosis.The microthrombosis in COVID-19 is the result of the interplay between inflammation and endotheliopathy. Elevated interleukin-6 (IL-6) characterizes COVID-19 inflammation resulting in endotheliopathy and coagulopathy marked by elevated D-dimer (DD). Aim of this study is to identify and to describe the coagulation changes in 100 moderate COVID-19 patients having lung involvement and to determine the association of coagulopathy with the severity and prognosis. METHODS Inflammation, endothelial and coagulation molecules were measured in moderate and mild disease. RESULTS IL-6 and tumor necrosis factor-α (TNF-α) and tissue factor (TF), von Willebrand factor (VWF), and tissue factor pathway inhibitor (TFPI) significantly increased in moderate disease as well as D-dimer, thrombin antithrombin complex (TAT), Fibrinogen (Fib), platelet factor-4 (PF4), β-thromboglobulin (β-TG), P-selectin, and platelet adhesion. Shortened clotting time (CT) and clot formation time (CFT), high maximum clot firmness (MCF) and low LY at 30 min were present in 100% of moderate COVID-19 patients compared with mild COVID-19 patients. CONCLUSIONS These findings demonstrate that moderate COVID-19 has a profound inflammation associated with severee ndotheliopathy and intense coagulation activation uncontrolled by TFPI. Attention should be paid to coagulopathy in COVID-19. Closely monitoring of coagulation and application of appropriate anticoagulation may improve the prognosis of moderate COVID-19 and to prevent the progression to severe COVID-19 disease.
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de Lorenzo A, Espinel L, Revilla Á, Corbalán T, Martins J, Naya MT, Cubas A. [Ischaemic stroke associated with COVID-19 in dialysis patients]. Nefrologia 2021; 41:590-593. [PMID: 34629598 PMCID: PMC7543731 DOI: 10.1016/j.nefro.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Alberto de Lorenzo
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - Laura Espinel
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, España
| | | | - Teresa Corbalán
- Servicio de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - Judith Martins
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - María Teresa Naya
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - Alfonso Cubas
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, España
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Zabolotnaya SV, Bogolepova AN, Tairova RT. [COVID-19-associated stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:5-10. [PMID: 34553575 DOI: 10.17116/jnevro20211210825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neurological complications of COVID-19 occur in almost a third of patients. According to various studies, the frequency of cerebrovascular manifestations in patients with a positive test result for SARS-CoV-2 ranges from 1% to 3%. The most common manifestation was acute ischemic stroke. Cerebrovascular complications in COVID-19 patients are likely multifactorial. They can be associated with coagulopathy, systemic inflammatory response, endothelial dysfunction and microthrombosis, as well as organ failure, impaired cardiac functions. The peculiarities of stroke in patients with COVID-19 include occlusion of large vessels, involvement of several vascular pools, a high incidence of damage to the vertebrobasilar system, a cryptogenic nature and a high severity of the course with high mortality and disability. Particular attention should be paid to impaired cognitive functions as a clinical manifestation of the consequences of stroke associated with a new coronavirus infection.
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Affiliation(s)
- S V Zabolotnaya
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - A N Bogolepova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
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The Cross-Talk between Thrombosis and Inflammatory Storm in Acute and Long-COVID-19: Therapeutic Targets and Clinical Cases. Viruses 2021; 13:v13101904. [PMID: 34696334 PMCID: PMC8540492 DOI: 10.3390/v13101904] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) commonly complicates with coagulopathy. A syndrome called Long-COVID-19 is emerging recently in COVID-19 survivors, characterized, in addition to the persistence of symptoms typical of the acute phase, by alterations in inflammatory and coagulation parameters due to endothelial damage. The related disseminated intravascular coagulation (DIC) can be associated with high death rates in COVID-19 patients. It is possible to find a prothrombotic state also in Long-COVID-19. Early administration of anticoagulants in COVID-19 was suggested in order to improve patient outcomes, although exact criteria for their application were not well-established. Low-molecular-weight heparin (LMWH) was commonly adopted for counteracting DIC and venous thromboembolism (VTE), due to its pharmacodynamics and anti-inflammatory properties. However, the efficacy of anticoagulant therapy for COVID-19-associated DIC is still a matter of debate. Thrombin and Factor Xa (FXa) are well-known components of the coagulation cascade. The FXa is known to strongly promote inflammation as the consequence of increased cytokine expression. Endothelial cells and mononuclear leucocytes release cytokines, growth factors, and adhesion molecules due to thrombin activation. On the other hand, cytokines can activate coagulation. The cross-talk between coagulation and inflammation is mediated via protease-activated receptors (PARs). These receptors might become potential targets to be considered for counteracting the clinical expressions of COVID-19. SARS-CoV-2 is effectively able to activate local and circulating coagulation factors, thus inducing the generation of disseminated coagula. LMWH may be considered as the new frontier in the treatment of COVID-19 and Long-COVID-19. Indeed, direct oral anticoagulants (DOACs) may be an alternative option for both early and later treatment of COVID-19 patients due to their ability to inhibit PARs. The aim of this report was to evaluate the role of anticoagulants—and DOACs in particular in COVID-19 and Long-COVID-19 patients. We report the case of a COVID-19 patient who, after administration of enoxaparin developed DIC secondary to virosis and positivity for platelet factor 4 (PF4) and a case of Long-COVID with high residual cardiovascular risk and persistence of blood chemistry of inflammation and procoagulative state.
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de Lorenzo A, Espinel L, Revilla Á, Corbalán T, Martins J, Naya MT, Cubas A. Ischaemic stroke associated with COVID-19 in dialysis patients. Nefrologia 2021; 41:590-593. [PMID: 36165142 PMCID: PMC8580842 DOI: 10.1016/j.nefroe.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/09/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Alberto de Lorenzo
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, Spain.
| | - Laura Espinel
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | | | - Teresa Corbalán
- Servicio de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Judith Martins
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - María Teresa Naya
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Alfonso Cubas
- Servicio de Nefrología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
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Hu B, Cao J, Hu Y, Qin Z, Wang J. The Association Between Serum Anion Gap and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis. Int J Gen Med 2021; 14:4535-4544. [PMID: 34429638 PMCID: PMC8379146 DOI: 10.2147/ijgm.s318334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/07/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose Studies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. Therefore, we conducted this study to investigate whether the serum anion gap (AG) was independently related to all-cause mortality of DIC patients. Methods We used the data from Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2,654 DIC patients were included. The main outcomes were in-hospital, 30-day, and 90-day all-cause mortality. The AG was measured upon ICU admission and its association with mortality was evaluated using the Cox proportional-hazards regression model. The generalized additive model and the smooth curve fitting were introduced to examine the non-linear association. Results After adjusting for potential covariates, the in-hospital, 30-day, and 90-day all-cause mortality were positively correlated with AG. The hazard ratio (HR), confidence intervals (CI), and P were 1.05 (1.04–1.07) <0.0001, 1.06 (1.04–1.07) <0.0001, and 1.05 (1.03–1.07) <0.0001, respectively. We did not find an obvious non-linear relationship between AG and in-hospital, 30-day, and 90-day mortality, which indicated that the association between AG and all-cause mortality of DIC patients was nearly linear. Conclusion Serum AG is positively related with all-cause mortality in DIC patients.
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Affiliation(s)
- Bin Hu
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Jinxia Cao
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Yangyang Hu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Zuoan Qin
- Department of Cardiovascular Medicine, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Jun Wang
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). J Intensive Care 2021; 9:53. [PMID: 34433491 PMCID: PMC8384927 DOI: 10.1186/s40560-021-00555-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Affiliation(s)
- Moritoki Egi
- Department of Surgery Related, Division of Anesthesiology, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ku, Kobe, Hyogo, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Medical School, Yamadaoka 2-15, Suita, Osaka, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuaki Atagi
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Joji Kotani
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Hosokawa
- Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mai Inada
- Member of Japanese Association for Acute Medicine, Tokyo, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Support and Practice, Hiroshima University Hospital, Hiroshima, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Japan
| | | | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine/Infectious Disease, Hitachi General Hospital, Hitachi, Japan
| | - Kei Hayashida
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Shinya Miura
- The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kohkichi Andoh
- Division of Anesthesiology, Division of Intensive Care, Division of Emergency and Critical Care, Sendai City Hospital, Sendai, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yusuke Ito
- Department of Infectious Disease, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akemi Utsunomiya
- Human Health Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Akira Ouchi
- College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Masayuki Ozaki
- Department of Emergency and Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Satoshi Ono
- Gastroenterological Center, Shinkuki General Hospital, Kuki, Japan
| | | | | | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | | | - Akira Shimoyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Tokai University School of Medicine, Isehara, Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, Nagasaki, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei Takahashi
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Goro Tajima
- Nagasaki University Hospital Acute and Critical Care Center, Nagasaki, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Tani
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaharu Nagae
- Department of Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | | | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shin Nunomiya
- Department of Anesthesiology and Intensive Care Medicine, Division of Intensive Care, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoki Hara
- Department of Pharmacy, Yokohama Rosai Hospital, Yokohama, Japan
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Hirotaka Furusono
- Department of Rehabilitation, University of Tsukuba Hospital/Exult Co., Ltd., Tsukuba, Japan
| | - Yujiro Matsuishi
- Doctoral program in Clinical Sciences. Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Minematsu
- Department of Clinical Engineering, Osaka University Hospital, Suita, Japan
| | - Ryoichi Miyashita
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuji Miyatake
- Department of Clinical Engineering, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Megumi Moriyasu
- Division of Respiratory Care and Rapid Response System, Intensive Care Center, Kitasato University Hospital, Sagamihara, Japan
| | - Toru Yamada
- Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuhei Yoshida
- Nursing Department, Osaka General Medical Center, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Asai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masami Ishikawa
- Department of Anesthesiology, Emergency and Critical Care Medicine, Kure Kyosai Hospital, Kure, Japan
| | - Go Ishimaru
- Department of General Internal Medicine, Soka Municipal Hospital, Soka, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryuta Itakura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hisashi Imahase
- Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Kenji Uehara
- Department of Anesthesiology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Noritaka Ushio
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yuko Egawa
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Takanori Ohno
- Department of Emergency and Critical Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Okamoto
- Department of ER, Hashimoto Municipal Hospital, Hashimoto, Japan
| | - Hiroshi Okuda
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takayuki Ogura
- Tochigi prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Yu Onodera
- Department of Anesthesiology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yuhta Oyama
- Department of Internal Medicine, Dialysis Center, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Motoshi Kainuma
- Anesthesiology, Emergency Medicine, and Intensive Care Division, Inazawa Municipal Hospital, Inazawa, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya-City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Kanaya
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Keita Kanehata
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, Onga Hospital, Fukuoka, Japan
| | - Kazuya Kikutani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Kimura
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyuki Koami
- Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, USA
| | - Daisuke Kobashi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Iwao Saiki
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Masahito Sakai
- Department of General Medicine Shintakeo Hospital, Takeo, Japan
| | - Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tetsuya Sato
- Tohoku University Hospital Emergency Center, Sendai, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Manabu Shimoto
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Shimoyama
- Department of Pediatric Cardiology and Intensive Care, Gunma Children's Medical Center, Shibukawa, Japan
| | - Tomohisa Shoko
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Yokohama City University, Yokohama, Japan
| | - Atsunori Sugita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Intensive Care, Okayama University Hospital, Okayama, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Takahashi
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Yoko Takahashi
- Department of General Internal Medicine, Koga General Hospital, Koga, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yuuki Tanaka
- Fukuoka Prefectural Psychiatric Center, Dazaifu Hospital, Dazaifu, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Taichiro Tsunoyama
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenichi Tetsuhara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kentaro Tokunaga
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshihiro Tomioka
- Department of Anesthesiology and Intensive Care Unit, Todachuo General Hospital, Toda, Japan
| | - Kentaro Tomita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukitoshi Toyoda
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshimi Nakamura
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuki Nakamori
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoya Nishimura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kei Nishiyama
- Division of Emergency and Critical Care Medicine Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Katsuhiko Hashimoto
- Research Associate of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshiaki Hamasaki
- Department of Emergency Medicine, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuya Hayashi
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Atsuki Hayamizu
- Department of Emergency Medicine, Saitama Saiseikai Kurihashi Hospital, Kuki, Japan
| | - Go Haraguchi
- Division of Intensive Care Unit, Sakakibara Heart Institute, Tokyo, Japan
| | - Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Ryo Fujii
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Foundation Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Masahito Horiguchi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Jun Maki
- Department of Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Naohisa Masunaga
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan
| | - Takuya Mayumi
- Department of Internal Medicine, Kanazawa Municipal Hospital, Kanazawa, Japan
| | - Keisuke Minami
- Ishikawa Prefectual Central Hospital Emergency and Critical Care Center, Kanazawa, Japan
| | - Yuya Miyazaki
- Department of Emergency and General Internal Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, Tokyo, Japan
| | - Teppei Murata
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takao Yano
- Department of Critical Care and Emergency Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tomonori Yamamoto
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shodai Yoshihiro
- Pharmaceutical Department, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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135
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Tutino R, Bonariol L, Caratozzolo E, Massani M. Massive late postoperative bleeding after abdominal surgery in a haematologic patient with postoperative CoV-2 infection. BMJ Case Rep 2021; 14:14/8/e243744. [PMID: 34429289 PMCID: PMC8386227 DOI: 10.1136/bcr-2021-243744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The role of viral infection in extrapulmonary postoperative complications in CoV-2 patients is still debated. Perioperative bleeding is rare compared with thrombotic events, but can be related to a haemorrhagic CoV-2-associated disseminated intravascular coagulopathy-like syndrome.
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Affiliation(s)
- Roberta Tutino
- Chirurgia 1, Azienda ULSS 2 Marca Trevigiana, Ospedale Regionale Treviso, Treviso, Italy .,Dipartimento di discipline chirurgiche, oncologiche e stomatologiche, Università degli Studi di Palermo, Palermo, Italy
| | - Luca Bonariol
- Chirurgia 1, Azienda ULSS 2 Marca Trevigiana, Ospedale Regionale Treviso, Treviso, Italy
| | - Ezio Caratozzolo
- Chirurgia 1, Azienda ULSS 2 Marca Trevigiana, Ospedale Regionale Treviso, Treviso, Italy
| | - Marco Massani
- Chirurgia 1, Azienda ULSS 2 Marca Trevigiana, Ospedale Regionale Treviso, Treviso, Italy
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136
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Li T, Chen H, Shi X, Yin L, Tan C, Gu J, Liu Y, Li C, Xiao G, Liu K, Liu M, Tan S, Xiao Z, Zhang H, Xiao X. HSF1 Alleviates Microthrombosis and Multiple Organ Dysfunction in Mice with Sepsis by Upregulating the Transcription of Tissue-Type Plasminogen Activator. Thromb Haemost 2021; 121:1066-1078. [PMID: 33296942 DOI: 10.1055/a-1333-7305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Sepsis is a life-threatening complication of infection closely associated with coagulation abnormalities. Heat shock factor 1 (HSF1) is an important transcription factor involved in many biological processes, but its regulatory role in blood coagulation remained unclear. We generated a sepsis model in HSF1-knockout mice to evaluate the role of HSF1 in microthrombosis and multiple organ dysfunction. Compared with septic wild-type mice, septic HSF1-knockout mice exhibited a greater degree of lung, liver, and kidney tissue damage, increased fibrin/: fibrinogen deposition in the lungs and kidneys, and increased coagulation activity. RNA-seq analysis revealed that tissue-type plasminogen activator (t-PA) was upregulated in the lung tissues of septic mice, and the level of t-PA was significantly lower in HSF1-knockout mice than in wild-type mice in sepsis. The effects of HSF1 on t-PA expression were further validated in HSF1-knockout mice with sepsis and in vitro in mouse brain microvascular endothelial cells using HSF1 RNA interference or overexpression under lipopolysaccharide stimulation. Bioinformatics analysis, combined with electromobility shift and luciferase reporter assays, indicated that HSF1 directly upregulated t-PA at the transcriptional level. Our results reveal, for the first time, that HSF1 suppresses coagulation activity and microthrombosis by directly upregulating t-PA, thereby exerting protective effects against multiple organ dysfunction in sepsis.
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Affiliation(s)
- Tao Li
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
- Department of Pathophysiology, Medical College of Jiaying University, Meizhou, Guangdong, China
| | - Huan Chen
- Postdoctoral Research Station of Clinical Medicine and Department of Hematology, the Third Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Xueyan Shi
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Leijing Yin
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Chuyi Tan
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Jia Gu
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Yanjuan Liu
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Caiyan Li
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Gui Xiao
- Department of Nursing, Hainan Medical University, Haikou, Hainan, China
| | - Ke Liu
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Meidong Liu
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Sipin Tan
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Zihui Xiao
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Huali Zhang
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Xianzhong Xiao
- Key Laboratory of Sepsis Translational Medicine of Hunan, Department of Pathophysiology, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
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137
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Shaw RJ, Bradbury C, Abrams ST, Wang G, Toh CH. COVID-19 and immunothrombosis: emerging understanding and clinical management. Br J Haematol 2021; 194:518-529. [PMID: 34114204 DOI: 10.1111/bjh.17664] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic has been the most significant health crisis in recent global history. Early studies from Wuhan highlighted COVID-19-associated coagulopathy and a significant association with mortality was soon recognised. As research continues across the world, more evidence is emerging of the cross-talk between the innate immune system, coagulation activation and inflammation. Immunothrombosis has been demonstrated to play a key role in the pathophysiology of severe COVID-19, with extracellular histones and neutrophil extracellular traps detected in the plasma and cardiopulmonary tissues of critically ill patients. Targeting the components of immunothrombosis is becoming an important factor in the treatment of patients with COVID-19 infection. Recent studies report outcomes of intermediate and therapeutic anticoagulation in hospitalised patients with varying severities of COVID-19 disease, including optimal dosing and associated bleeding risks. Immunomodulatory therapies, including corticosteroids and IL-6 receptor antagonists, have been demonstrated to significantly reduce mortality in COVID-19 patients. As the pandemic continues, more studies are required to understand the driving factors and upstream mechanisms for coagulopathy and immunothrombosis in COVID-19, and thus potentially develop more targeted therapies for SARS-CoV-2 infection, both in the acute phase and in those who develop longer-term symptom burden.
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Affiliation(s)
- Rebecca J Shaw
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
- The Roald Dahl Haemostasis and Thrombosis Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Simon T Abrams
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Guozheng Wang
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
- The Roald Dahl Haemostasis and Thrombosis Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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138
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Iba T, Umemura Y, Wada H, Levy H. The Roles of Coagulation Disorder and Microthrombosis in Sepsis: Pathophysiology, Diagnosis, and Treatment. Arch Med Res 2021; 52:788-797. [PMID: 34344558 DOI: 10.1016/j.arcmed.2021.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022]
Abstract
The diagnostic criteria of overt disseminated intravascular coagulation (DIC) were established by the International Society on Thrombosis and Haemostasis (ISTH) in 2001. Since then, DIC has long been associated with adverse outcomes. However, recent advances in sepsis shed light on the role of coagulation disorders in the progression of sepsis. Currently, inflammation and coagulation are recognized as the two drivers that promote organ dysfunction in sepsis and septic shock. The ISTH has published new diagnostic criteria for improved management, namely sepsis-induced coagulopathy (SIC), in 2017. SIC is a pragmatic scoring system composed of platelet count, prothrombin time, and organ dysfunction score to detect the early-stage of sepsis-associated DIC. Since overt DIC represents an uncompensated coagulation disorder, a two-step approach using SIC and overt DIC criteria is a novel strategy to evaluate the severity and manage this challenging complication. Although there is no globally agreed on anticoagulant therapy for DIC, the Japanese Surviving Sepsis Campaign Guidelines 2020 recommend using antithrombin and recombinant thrombomodulin for sepsis associated DIC. Since research in this area has been previously reported, an international collaborative study is necessary to develop future diagnostic tools and treatment strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate, School of Medicine, Tokyo, Japan.
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan; Department of Traumatology and Acute Critical Medicine, Osaka, University Graduate School of Medicine, Osaka, Japan
| | - Hideo Wada
- Department of General Medicine, Mie Prefectural General Medical Center, Mie, Japan
| | - H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University, School of Medicine, Durham, NC, USA
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139
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Levy JH, Iba T, Olson LB, Corey KM, Ghadimi K, Connors JM. COVID-19: Thrombosis, thromboinflammation, and anticoagulation considerations. Int J Lab Hematol 2021; 43 Suppl 1:29-35. [PMID: 34288441 PMCID: PMC8444926 DOI: 10.1111/ijlh.13500] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 12/13/2022]
Abstract
Vascular endothelial injury is a hallmark of acute infection at both the microvascular and macrovascular levels. The hallmark of SARS‐CoV‐2 infection is the current COVID‐19 clinical sequelae of the pathophysiologic responses of hypercoagulability and thromboinflammation associated with acute infection. The acute lung injury that initially occurs in COVID‐19 results from vascular and endothelial damage from viral injury and pathophysiologic responses that produce the COVID‐19–associated coagulopathy. Clinicians should continue to focus on the vascular endothelial injury that occurs and evaluate potential therapeutic interventions that may benefit those with new infections during the current pandemic as they may also be of benefit for future pathogens that generate similar thromboinflammatory responses. The current Accelerating COVID‐19 Therapeutic Interventions and Vaccines (ACTIV) studies are important projects that will further define our management strategies. At the time of writing this report, two mRNA vaccines are now being distributed and will hopefully have a major impact on slowing the global spread and subsequent thromboinflammatory injury we see clinically in critically ill patients.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Lyra B Olson
- Duke University School of Medicine, Durham, NC, USA
| | - Kristen M Corey
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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140
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Ichkawa Y, Wada H, Ezaki M, Tanaka M, Hiromori S, Shiraki K, Moritani I, Yamamoto A, Tashiro H, Shimpo H, Shimaoka M. Elevated D-Dimer Levels Predict a Poor Outcome in Critically Ill Patients. Clin Appl Thromb Hemost 2021; 26:1076029620973084. [PMID: 33347372 PMCID: PMC7755937 DOI: 10.1177/1076029620973084] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
D-dimer is a biomarker of thrombosis and recently been considered to predict a poor outcome in patients with infectious diseases. Plasma D-dimer levels were measured in critically ill patients to examine their relationship with the poor outcome. The plasma D-dimer levels were markedly higher in the patients with various underlying disease especially venous thromboembolism in comparison to those without severe underlying diseases. The plasma D-dimer levels in non-survivors were significantly higher than those in survivors. In a receiver operating characteristic analysis, the area under the curve was high for the disseminated intravascular coagulation (DIC) score, the D-dimer value, and the prothrombin time-international normalize ratio (PT-INR). Adequate cut-off values for predicting the outcome were 3 as follows: DIC score, 3 points; D-dimer, 4.2 mg/L; and PT-INR, 1.08. D-dimer, which is a biomarker for thrombosis, is increased in various underlying diseases and predicts a poor outcome.
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Affiliation(s)
- Yuhuko Ichkawa
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hideo Wada
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Tsu, Japan
| | - Minoru Ezaki
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Motoko Tanaka
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Shinya Hiromori
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Katsuya Shiraki
- Department of Central Laboratory, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Tsu, Japan
| | - Isao Moritani
- Department of General Medicine, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Akitaka Yamamoto
- Department of Emergency and Critical Care Center, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Haruhiko Tashiro
- Department of Emergency and Critical Care Center, 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hideto Shimpo
- 36941Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan
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141
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Cheves JW, DeMarinis S, Sorin C, Carino G, Sweeney JD. Causes of an elevated international normalized ratio in the intensive care unit and the implications for plasma transfusion. Transfusion 2021; 61:2862-2868. [PMID: 34292616 DOI: 10.1111/trf.16599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The presence of an elevated international normalized ratio (INR) is common in patients in the intensive care unit (ICU), but the cause rarely determined. These patients are at risk to receive prophylactic plasma prior to invasive procedures. STUDY DESIGN AND METHODS Samples from patients with an INR of 1.5 or greater were frozen and subsequently thawed and assayed for procoagulant and anticoagulant clotting factors and anti-Xa to determine the likely cause of the INR. Samples showing a low FVII, FX, PC, and PS were categorized as a vitamin K deficiency pattern. Samples showing a low FV, low or normal fibrinogen, and high FVIII were categorized as a liver disease pattern. Samples showing an anti-Xa >0.01 IU/ml were assayed for anti-Xa DOACs. Samples which could not be categorized were grouped as equivocal. RESULTS A total of 48 samples were obtained over a 6-month period. Nineteen showed a Vitamin K deficiency pattern, 17 a liver disease pattern, 7 showed an anti-Xa DOAC and 5 were equivocal. High FVIII and D-dimers and reduced levels of the anticoagulant proteins were present in the majority of the samples. FVII levels correlated inversely with the INR (r = -0. 81), as did FX (r = -0.67) but not FV (r = -0.04) nor fibrinogen (r = -0.15). CONCLUSION Transfusion of plasma to reverse an elevated INR in the ICU should be discouraged since such a practice is either avoidable by the use of vitamin K or inappropriate in the case of liver disease or an anti-Xa DOAC.
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Affiliation(s)
- Jared W Cheves
- Intensive Care Department, The Miriam Hospital, Providence, Rhode Island, USA
| | - Sandra DeMarinis
- Department of Coagulation and Transfusion Medicine, The Miriam Hospital, Providence, Rhode Island, USA
| | - Claudia Sorin
- Intensive Care Department, The Miriam Hospital, Providence, Rhode Island, USA
| | - Gerardo Carino
- Intensive Care Department, The Miriam Hospital, Providence, Rhode Island, USA
| | - Joseph D Sweeney
- Department of Coagulation and Transfusion Medicine, The Miriam Hospital, Providence, Rhode Island, USA
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142
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Rho-Proteins and Downstream Pathways as Potential Targets in Sepsis and Septic Shock: What Have We Learned from Basic Research. Cells 2021; 10:cells10081844. [PMID: 34440613 PMCID: PMC8391638 DOI: 10.3390/cells10081844] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 01/19/2023] Open
Abstract
Sepsis and septic shock are associated with acute and sustained impairment in the function of the cardiovascular system, kidneys, lungs, liver, and brain, among others. Despite the significant advances in prevention and treatment, sepsis and septic shock sepsis remain global health problems with elevated mortality rates. Rho proteins can interact with a considerable number of targets, directly affecting cellular contractility, actin filament assembly and growing, cell motility and migration, cytoskeleton rearrangement, and actin polymerization, physiological functions that are intensively impaired during inflammatory conditions, such as the one that occurs in sepsis. In the last few decades, Rho proteins and their downstream pathways have been investigated in sepsis-associated experimental models. The most frequently used experimental design included the exposure to bacterial lipopolysaccharide (LPS), in both in vitro and in vivo approaches, but experiments using the cecal ligation and puncture (CLP) model of sepsis have also been performed. The findings described in this review indicate that Rho proteins, mainly RhoA and Rac1, are associated with the development of crucial sepsis-associated dysfunction in different systems and cells, including the endothelium, vessels, and heart. Notably, the data found in the literature suggest that either the inhibition or activation of Rho proteins and associated pathways might be desirable in sepsis and septic shock, accordingly with the cellular system evaluated. This review included the main findings, relevance, and limitations of the current knowledge connecting Rho proteins and sepsis-associated experimental models.
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143
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Clinical insights into the origins of thrombosis in myeloproliferative neoplasms. Blood 2021; 137:1145-1153. [PMID: 33237986 DOI: 10.1182/blood.2020008043] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs), polycythemia vera, essential thrombocythemia, and primary myelofibrosis, are hematopoietic stem cell disorders that are defined by activating mutations in signal transduction pathways and are characterized clinically by the overproduction of platelets, red blood cells, and neutrophils, significant burden of disease-specific symptoms, and high rates of vascular events. The focus of this review is to critically reevaluate the clinical burden of thrombosis in MPNs, to review the clinical associations among clonal hematopoiesis, JAK2V617F burden, inflammation, and thrombosis, and to provide insights into novel primary and secondary thrombosis-prevention strategies.
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144
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Al-Ghafry M, Vagrecha A, Malik M, Levine C, Uster E, Aygun B, Appiah-Kubi A, Vlachos A, Capone CA, Rajan S, Palumbo N, Misra N, Mitchell EC, Wolfe LC, Lipton JM, Shore-Lesserson L, Acharya SS. Multisystem inflammatory syndrome in children (MIS-C) and the prothrombotic state: Coagulation profiles and rotational thromboelastometry in a MIS-C cohort. J Thromb Haemost 2021; 19:1764-1770. [PMID: 33872443 PMCID: PMC9906141 DOI: 10.1111/jth.15340] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Adults infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have had high rates of thrombosis. A novel condition in children infected with SARS-CoV-2, multisystem inflammatory syndrome in children (MIS-C), has limited data on their prothrombotic state or need for thromboprophylaxis. OBJECTIVES We aimed to analyze the prothrombotic state using coagulation profiles, rotational thromboelastometry (ROTEM) parameters and clinical outcomes, to determine if this could aid in risk stratification for thromboprophylaxis. METHODS This analysis included patients (<21 years of age) with a diagnosis of MIS-C (n = 40) and controls (presenting with suspicion of MIS-C but later ruled out; n = 26). RESULTS MIS-C patients had higher levels of inflammatory markers including D-dimer (p < .0001), compared with controls, along with evidence of hypercoagulability on ROTEM with elevated evaluation of fibrinogen activity (FIBTEM) maximum clot firmness (MCF) (p < .05). For MIS-C patients with D-dimers >1000 ng/ml, there was a significant correlation of FIBTEM MCF (p < .0001) with a mean value of 37.4 (standard deviation 5.1). D-dimer >2144 ng/ml was predictive of intensive care unit admission (area under the curve [AUC] 0.80; 95% confidence interval, 0.60-0.99; p < .01; sensitivity: 82%, specificity: 75%), and elevated FIBTEM MCF (AUC 1 for >2500 ng/ml). MIS-C patients (50%) received enoxaparin thromboprophylaxis (in addition to aspirin) with significant improvement in their inflammatory and ROTEM parameters upon outpatient follow-up; none developed symptomatic thrombosis. CONCLUSIONS Despite an observed prothrombotic state, none of the MIS-C patients (on aspirin alone or in combination with enoxaparin) developed symptomatic thrombosis. ROTEM, in addition to coagulation profiles, may be helpful to tailor thromboprophylaxis in critically ill MIS-C patients.
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Affiliation(s)
- Maha Al-Ghafry
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Anshul Vagrecha
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Marium Malik
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Chana Levine
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Eliza Uster
- Division of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Banu Aygun
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Abena Appiah-Kubi
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Adrianna Vlachos
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Christine A Capone
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Disease, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Nancy Palumbo
- Division of Pediatric Hospital Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Nilanjana Misra
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Elizabeth C Mitchell
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Lawrence C Wolfe
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Jeffrey M Lipton
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | - Suchitra S Acharya
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
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145
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Wang Z, Gao X, Miao H, Ma X, Ding R. Understanding COVID-19-associated coagulopathy: From PIC to SIC or DIC. JOURNAL OF INTENSIVE MEDICINE 2021; 1:35-41. [PMID: 36943814 PMCID: PMC7997848 DOI: 10.1016/j.jointm.2021.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 12/15/2022]
Abstract
Coagulopathy, characterized by a high D-dimer level, is a common pathological occurrence in coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. Severe cases with COVID-19 is associated with a significantly higher risk of deep vein thrombosis and acute pulmonary embolism. Pulmonary intravascular coagulopathy is the characteristic coagulopathy in COVID-19. Unlike sepsis-induced coagulopathy and disseminated intravascular coagulation, which are manifestations of systemic coagulopathy, pulmonary intravascular coagulopathy is a manifestation of a local coagulation disorder in the lung. The progression from pulmonary intravascular coagulopathy to sepsis-induced coagulopathy or disseminated intravascular coagulation in the context of COVID-19 may indicate that the patient's coagulation dysfunction has progressed from local to systemic. Exploring the associated coagulation disease will aid in the understanding of the pathophysiological mechanisms underlying severe COVID-19.
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Affiliation(s)
| | | | | | | | - Renyu Ding
- Corresponding author: Renyu Ding, Department of Critical Care Medicine, The First Hospital of China Medical University, North Nanjing Street 155, Shenyang, Liaoning 110001, China.
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146
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ALICI G, HARBALIOĞLU H, GENÇ Ö, ALLAHVERDİYEV S, YILDIRIM A, ER F, KURT İH, QUİSİ A. High-sensitivity cardiac troponin I and D-dimer are risk factors for in-hospital mortality of adult patients with COVID-19: A retrospective cohort study. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.950576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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147
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Luo C, Hu H, Gong J, Zhou Y, Chen Z, Cai S. The Value of Thromboelastography in the Diagnosis of Sepsis-Induced Coagulopathy. Clin Appl Thromb Hemost 2021; 26:1076029620951847. [PMID: 32870718 PMCID: PMC7469719 DOI: 10.1177/1076029620951847] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Thromboelastography (TEG) is regularly used for monitoring abnormalities of the coagulation system in patients with sepsis. However, it is unclear whether TEG parameters are associated with sepsis-induced coagulopathy (SIC). Thus, we aimed to assess the diagnostic value of TEG for SIC. The medical records of patients who underwent TEG from January 2016 to December 2016 were analyzed retrospectively. The patients were divided into sepsis group and non-sepsis group. Baseline patient characteristics and coagulation function indexes were compared. Receiver–operating characteristic curve analysis was used to determine predictors of SIC. A total of 167 patients were included, of whom 84 had sepsis. The clot formation speed (K) was significantly higher(P < 0.001), and the maximum amplitude (MA) and angle were significantly lower (both P < 0.001) in the sepsis group than that in non-sepsis group. Patients with SIC had higher Sepsis-related Organ Failure Assessment scores than those patients without SIC (P < 0.001). The area under the curve of K for diagnosing SIC was 0.910. The area under the curve of angle and MA for excluding SIC was 0.895 and 0.882, respectively. Thus, TEG parameters have good diagnostic value for SIC.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Hongbin Hu
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Gong
- Department of Critical Care Medicine, The Third People' Hospital of Long Gang Distric, Shenzhen, China
| | - Yun Zhou
- Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shumin Cai
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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148
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Reyes M, Filbin MR, Bhattacharyya RP, Sonny A, Mehta A, Billman K, Kays KR, Pinilla-Vera M, Benson ME, Cosimi LA, Hung DT, Levy BD, Villani AC, Sade-Feldman M, Baron RM, Goldberg MB, Blainey PC, Hacohen N. Plasma from patients with bacterial sepsis or severe COVID-19 induces suppressive myeloid cell production from hematopoietic progenitors in vitro. Sci Transl Med 2021; 13:eabe9599. [PMID: 34103408 PMCID: PMC8432955 DOI: 10.1126/scitranslmed.abe9599] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/17/2020] [Accepted: 05/28/2021] [Indexed: 12/16/2022]
Abstract
Bacterial sepsis and severe COVID-19 share similar clinical manifestations and are both associated with dysregulation of the myeloid cell compartment. We previously reported an expanded CD14+ monocyte state, MS1, in patients with bacterial sepsis and validated expansion of this cell subpopulation in publicly available transcriptomics data. Here, using published datasets, we show that the gene expression program associated with MS1 correlated with sepsis severity and was up-regulated in monocytes from patients with severe COVID-19. To examine the ontogeny and function of MS1 cells, we developed a cellular model for inducing CD14+ MS1 monocytes from healthy bone marrow hematopoietic stem and progenitor cells (HSPCs). We found that plasma from patients with bacterial sepsis or COVID-19 induced myelopoiesis in HSPCs in vitro and expression of the MS1 gene program in monocytes and neutrophils that differentiated from these HSPCs. Furthermore, we found that plasma concentrations of IL-6, and to a lesser extent IL-10, correlated with increased myeloid cell output from HSPCs in vitro and enhanced expression of the MS1 gene program. We validated the requirement for these two cytokines to induce the MS1 gene program through CRISPR-Cas9 editing of their receptors in HSPCs. Using this cellular model system, we demonstrated that induced MS1 cells were broadly immunosuppressive and showed decreased responsiveness to stimulation with a synthetic RNA analog. Our in vitro study suggests a potential role for systemic cytokines in inducing myelopoiesis during severe bacterial or SARS-CoV-2 infection.
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Affiliation(s)
- Miguel Reyes
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael R Filbin
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Roby P Bhattacharyya
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Arnav Mehta
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Kyle R Kays
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mayra Pinilla-Vera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Maura E Benson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lisa A Cosimi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bruce D Levy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexandra-Chloe Villani
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Moshe Sade-Feldman
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marcia B Goldberg
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Bacterial Pathogenesis, Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul C Blainey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA, USA
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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149
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Hesam-Shariati S, Fatehi P, Abouzaripour M, Fathi F, Hesam-Shariati N, Hesam Shariati MB. Increased pulmonary embolism in patients with COVID-19: a case series and literature review. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2021; 7:16. [PMID: 34118995 PMCID: PMC8196288 DOI: 10.1186/s40794-021-00145-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/06/2021] [Indexed: 01/08/2023]
Abstract
There is some recent evidence that the coronavirus disease 2019 (COVID-19) increases the risk of venous thromboembolism by creating a prothrombotic state. COVID-19 and pulmonary embolism (PE) are both associated with tachypnoea, hypoxemia, dyspnoea, and increased D-dimer. Diagnosis of pulmonary embolism in a patient with COVID-19 compared to an individual without it, using the conventional clinical and biochemical evidence is challenging and somehow impossible. In this study, we reported four male cases affected by COVID-19 and admitted to hospitals in Sanandaj, Iran. The patients were all older adults (ranging between 56 and 95 years of age). Fever, chills, muscle pain, and cough were evident in all the cases. Red blood cell levels were low, and pulmonary embolism was clearly detected on spiral computed tomographic (CT) angiography of the pulmonary circulation of all patients. These cases demonstrated that COVID-19 may lead to pulmonary embolism by causing blood coagulation problems. As COVID-19 continues to cause considerable mortality, more information is emerging which reveals its complicated pathogenicity. In the meantime, venous thromboembolism remains an uncommon finding in patients with COVID-19. It is essential that health care providers perform the necessary diagnostic evaluations and provide appropriate treatment for patients.
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Affiliation(s)
- Sonia Hesam-Shariati
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Poya Fatehi
- Department of Radiology, Tohid Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Morteza Abouzaripour
- Department of Anatomical Sciences, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Fardin Fathi
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Negin Hesam-Shariati
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
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150
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Betz T, Steinbauer M, Toepel I, Uhl C. Midterm outcome of biosynthetic collagen prosthesis for treating aortic and peripheral prosthetic graft infections. Vascular 2021; 30:690-697. [PMID: 34112039 DOI: 10.1177/17085381211025380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To report the midterm outcomes of treating prosthetic peripheral and aortic graft infections using a biosynthetic collagen prosthesis in a tertiary vascular center. METHODS A retrospective analysis of all patients with prosthetic peripheral and aortic graft infections who underwent in situ reconstruction using a biosynthetic collagen prosthesis between March 2015 and November 2020 was conducted. Perioperative and midterm outcomes were analyzed. RESULTS A biosynthetic collagen prosthesis was used in 19 patients (14 males, median age 66 years) to reconstruct the femoral artery (n = 6), iliac artery (n = 1), and infrarenal aorta (n = 12). All patients were treated for a prosthetic vascular graft infection. The median follow-up period was 26.6 months (range 1-66 months). The 30-day graft failure rate was 15.7% (n = 3), leading to a major amputation in one patient (5.3%). All grafts were occluded aortofemoral reconstructions in patients with occluded superficial femoral artery and were treated by immediate thrombectomy. The 30-day mortality rate was 5.3% (n = 1), and survival after 3 years was 63.2%. The reinfection rate was 5.3% (n = 1). At 13.6 months, the occlusion of a femoral graft was detected in 5.3% (n = 1) and was treated with a new interposition graft. We observed no graft rupture or degeneration during follow-up. CONCLUSIONS Although results of in situ repair with autologous vein seem to be superior with little or none reinfection and low number of occlusions, biosynthetic collagen prostheses show acceptable midterm outcomes in terms of graft occlusion and mortality after prosthetic peripheral and aortic graft infections. Similar to other xenogenous materials, the reinfection rate is low with this prosthesis. With regard to immediate availability and easy handling, the use of a biosynthetic collagen prosthesis might be favorable compared to other replacement materials while treating prosthetic graft infections.
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Affiliation(s)
- Thomas Betz
- Department of Vascular Surgery, 155897Barmherzige Brüder Hospital, Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, 155897Barmherzige Brüder Hospital, Regensburg, Germany
| | - Ingolf Toepel
- Department of Vascular Surgery, 155897Barmherzige Brüder Hospital, Regensburg, Germany
| | - Christian Uhl
- Department of Vascular Surgery, 155897Barmherzige Brüder Hospital, Regensburg, Germany
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