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Darok M, Daly A, Walter V, Krawiec C. Association of medical comorbidities in obese subjects diagnosed with heparin-induced thrombocytopenia. SAGE Open Med 2024; 12:20503121241247471. [PMID: 38711468 PMCID: PMC11072068 DOI: 10.1177/20503121241247471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives Heparin-induced thrombocytopenia can occur in obese subjects. The medical comorbidities associated with obesity may contribute to the pathogenesis of this disease. It is unknown, however, which specific medical comorbidities and if higher odds of thrombosis are present in obese heparin-induced thrombocytopenia patients. We sought to determine whether obese heparin-induced thrombocytopenia subjects had higher odds of both comorbidities and thrombosis, hypothesizing that this patient population would have higher odds of both these conditions. Methods This was a multi-center retrospective study utilizing TriNetX©, an electronic health record database, in subjects aged 18-99 years diagnosed with heparin-induced thrombocytopenia. The cohort was divided into two groups (1) non-obese (body mass index < 30 kg/m2) and (2) obese (body mass index ⩾ 30 kg/m2). We evaluated patient characteristics, diagnostic, laboratory, medication, and procedure codes. Results A total of 1583 subjects (696 (44.0%) non-obese and 887 (56.0%) obese) were included. Obese subjects had higher odds of diabetes with complications (OR = 1.73, 95% CI = 1.35-2.22, p < 0.001) and without complications (OR = 1.81, 95% CI = 1.47-2.22, p < 0.001). This association was still present after correcting for demographic and clinical factors. There were no increased odds of thrombosis observed in the obesity group. Conclusions Our study found that obese heparin-induced thrombocytopenia subjects had higher odds of having a diabetes mellitus comorbidity, but did not have higher odds of thrombosis. Given obesity is considered a hypercoagulable state, further study may be needed to understand why obese subjects diagnosed with heparin-induced thrombocytopenia do not have higher rates of thrombosis.
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Affiliation(s)
- Matthew Darok
- Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Alexander Daly
- Hospital Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Vonn Walter
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
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Lüsebrink E, Scherer C, Binzenhöfer L, Hoffmann S, Höpler J, Kellnar A, Thienel M, Joskowiak D, Peterß S, Petzold T, Deseive S, Hein R, Brunner S, Kääb S, Braun D, Theiss H, Hausleiter J, Hagl C, Massberg S, Orban M. Heparin-Induced Thrombocytopenia in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J Clin Med 2023; 12:jcm12010362. [PMID: 36615162 PMCID: PMC9821297 DOI: 10.3390/jcm12010362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated adverse drug reaction to unfractionated heparin (UFH) affecting also patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Although the association between VA-ECMO support and the development of thrombocytopenia has long been known and discussed, HIT as one underlying cause is still insufficiently understood. Therefore, the purpose of this study was to further investigate the epidemiology, mortality, diagnosis, and clinical management of HIT occurring in VA-ECMO patients treated with UFH. Methods: We conducted a retrospective single-center study including adult patients (≥18 years) with VA-ECMO support in the cardiac intensive care unit (ICU) of the University Hospital of Munich (LMU) between January 2013 and May 2022, excluding patients with a known history of HIT upon admission. Differences in baseline characteristics and clinical outcome between excluded HIT (positive anti-platelet factor 4 (PF4)/heparin antibody test but negative functional assay) and confirmed HIT (positive anti-PF4/heparin antibody test and positive functional assay) VA-ECMO patients as well as diagnosis and clinical management of HIT were analysed. Results: Among the 373 patients included, anti-PF4/heparin antibodies were detected in 53/373 (14.2%) patients. Functional HIT testing confirmed HIT in 13 cases (3.5%) and excluded HIT in 40 cases (10.7%), corresponding to a prevalence of confirmed HIT of 13/373 (3.5%) [1.6, 5.3] and a positive predictive value (PPV) of 24.5% for the antibody screening test. The platelet course including platelet recovery following argatroban initiation was similar between all groups. One-month mortality in patients with excluded HIT was 14/40 (35%) and 3-month mortality 17/40 (43%), compared to 5/13 (38%) (p > 0.999), and 6/13 (46%) (p > 0.999) in patients with confirmed HIT. Neurological outcome in both groups measured by the cerebral performance category of survivors on hospital discharge was similar, as well as adverse events during VA-ECMO therapy. Conclusions: With a prevalence of 3.5%, HIT is a non-frequent complication in patients on VA-ECMO and was not associated with a higher mortality rate. HIT was ultimately excluded by functional essay in 75% of VA-ECMO patients with clinical suspicion of HIT and positive anti-PF4/heparin antibody test. Argatroban seems to be an appropriate and safe therapeutic option for confirmed HIT-positive patients on VA-ECMO support.
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Affiliation(s)
- Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
- Correspondence:
| | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Leonhard Binzenhöfer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sabine Hoffmann
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Julia Höpler
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Antonia Kellnar
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Manuela Thienel
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Dominik Joskowiak
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sven Peterß
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Ralph Hein
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Daniel Braun
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Hans Theiss
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
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Kaur J, Arsene C, Yadav SK, Ogundipe O, Malik A, Sule AA, Krishnamoorthy G. Risk Factors in Hospitalized Patients for Heparin-Induced Thrombocytopenia by Real World Database: A New Role for Primary Hypercoagulable States. J Hematol 2021; 10:171-177. [PMID: 34527113 PMCID: PMC8425805 DOI: 10.14740/jh876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background The aims of the study were to identify predictors of heparin-induced thrombocytopenia (HIT) in hospitalized adults, and to find additional factors associated with higher odds of HIT in primary hypercoagulable states. Methods A retrospective matched case-control study using discharge data from National Inpatient Sample database (2012 - 2014) was conducted. In primary outcome analysis, hospitalized patients with and without HIT were included as cases and controls, both matched for age and gender. In secondary outcome analysis, hospitalized patients with primary hypercoagulable states with and without HIT were included as cases and controls, both matched for age and gender. The statistical analyses were performed using Statistical Package for Social Sciences version 25. Results There are several predictors of HIT in hospitalized patients, such as obesity, malignancy, diabetes, renal failure, major surgery, congestive heart failure, and autoimmune diseases. In patients with primary hypercoagulable states, the presence of renal failure (odds ratio (OR) 2.955, 95% confidence interval (CI) 1.994 - 4.380), major surgery (OR 1.735, 95% CI 1.275 - 2.361), congestive heart failure (OR 4.497, 95% CI 2.466 - 8.202), or autoimmune diseases (OR 1.712, 95% CI 1.120 - 2.618) further increases the odds of HIT. Conclusions In hospitalized patients with primary hypercoagulable states, especially in association with renal failure, major surgery, congestive heart failure, or autoimmune diseases, unfractionated heparin should be used with caution.
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Affiliation(s)
- Jasmeet Kaur
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Camelia Arsene
- Department of Medical Education, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Sumeet Kumar Yadav
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Olusola Ogundipe
- Department of Infectious Diseases, William Beaumont Hospital, Royal Oak, MI, USA
| | - Ambreen Malik
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Anupam Ashutosh Sule
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
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Lee EY, Srinivasan Y, de Anda J, Nicastro LK, Tükel Ç, Wong GCL. Functional Reciprocity of Amyloids and Antimicrobial Peptides: Rethinking the Role of Supramolecular Assembly in Host Defense, Immune Activation, and Inflammation. Front Immunol 2020; 11:1629. [PMID: 32849553 PMCID: PMC7412598 DOI: 10.3389/fimmu.2020.01629] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
Pathological self-assembly is a concept that is classically associated with amyloids, such as amyloid-β (Aβ) in Alzheimer's disease and α-synuclein in Parkinson's disease. In prokaryotic organisms, amyloids are assembled extracellularly in a similar fashion to human amyloids. Pathogenicity of amyloids is attributed to their ability to transform into several distinct structural states that reflect their downstream biological consequences. While the oligomeric forms of amyloids are thought to be responsible for their cytotoxicity via membrane permeation, their fibrillar conformations are known to interact with the innate immune system to induce inflammation. Furthermore, both eukaryotic and prokaryotic amyloids can self-assemble into molecular chaperones to bind nucleic acids, enabling amplification of Toll-like receptor (TLR) signaling. Recent work has shown that antimicrobial peptides (AMPs) follow a strikingly similar paradigm. Previously, AMPs were thought of as peptides with the primary function of permeating microbial membranes. Consistent with this, many AMPs are facially amphiphilic and can facilitate membrane remodeling processes such as pore formation and fusion. We show that various AMPs and chemokines can also chaperone and organize immune ligands into amyloid-like ordered supramolecular structures that are geometrically optimized for binding to TLRs, thereby amplifying immune signaling. The ability of amphiphilic AMPs to self-assemble cooperatively into superhelical protofibrils that form structural scaffolds for the ordered presentation of immune ligands like DNA and dsRNA is central to inflammation. It is interesting to explore the notion that the assembly of AMP protofibrils may be analogous to that of amyloid aggregates. Coming full circle, recent work has suggested that Aβ and other amyloids also have AMP-like antimicrobial functions. The emerging perspective is one in which assembly affords a more finely calibrated system of recognition and response: the detection of single immune ligands, immune ligands bound to AMPs, and immune ligands spatially organized to varying degrees by AMPs, result in different immunologic outcomes. In this framework, not all ordered structures generated during multi-stepped AMP (or amyloid) assembly are pathological in origin. Supramolecular structures formed during this process serve as signatures to the innate immune system to orchestrate immune amplification in a proportional, situation-dependent manner.
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Affiliation(s)
- Ernest Y Lee
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States.,UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yashes Srinivasan
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jaime de Anda
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States
| | - Lauren K Nicastro
- Department of Microbiology and Immunology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Çagla Tükel
- Department of Microbiology and Immunology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Gerard C L Wong
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Chemistry and Biochemistry, University of California, Los Angeles, Los Angeles, CA, United States.,California Nano Systems Institute, University of California, Los Angeles, Los Angeles, CA, United States
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Developing a mortality risk score for long-term surgical ICU patients: A pilot study. Am J Surg 2020; 220:1368-1369. [PMID: 32471556 DOI: 10.1016/j.amjsurg.2020.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/22/2022]
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