Disseminated intravascular coagulation: epidemiology, biomarkers, and management

Disseminated intravascular coagulation is an underestimated but fatal adverse event associated with blinatumomab therapy: A pharmacovigilance analysis of FAERS

Hematologic adverse events (AEs) are common and serious toxicities in patients with hematologic malignancies undergoing blinatumomab therapy. However, restrictive selection criteria in pivotal clinical trials can lead to an underestimation of rare but fatal toxicities. In this study, we systematically analyzed hematologic AEs associated with blinatumomab using the Food and Drug Administration Adverse Event Reporting System (FAERS) from October 2014 to December 2023. Disproportionate analysis was performed to identify overreported AEs, with a reporting odds ratio (ROR), and a lower bound of the 95% confidence interval (ROR025) exceeding one considered significant. Additionally, adjusted mortality rates and risk ratios (RR) of the top 10 reported hematologic AEs were calculated using a logistic regression model. Among 4745 blinatumomab-related cases, 418 (8.81%) involved hematologic AEs. We identified 22 significantly overreporting hematologic AEs compared to the full database, with myelosuppression (n = 39 [9.33%], ROR025 = 8.04), disseminated intravascular coagulation (DIC, n = 31 [7.42%], ROR025 = 15.14), and bone marrow failure (n = 14 [3.35%], ROR025 = 3.41) notably underestimated in clinical trials. DIC resulted in a substantial mortality rate of 45.16%. Finally, DIC was found to be independently associated with death in a multivariable logistic regression analysis (RR = 2.47 [95% CI: 1.11-3.83]). These findings could aid clinicians in the early detection of these rarely reported but fatal hematologic AEs, thereby reducing the risk of severe toxicities in blinatumomab recipients.

Polydatin mitigates thrombosis by inhibiting PHD2-induced proline hydroxylation on collagen, reducing platelet adhesion

BACKGROUND

Platelet adhesion to collagen, a critical initial step in thrombus formation, remains an underexplored therapeutic target in thrombosis. Current disease treatment strategies primarily focus on platelet activation and aggregation, often overlooking the crucial initial adhesion phase. Reynoutria japonica (Huzhang, HZ), utilized in traditional Chinese medicine to enhance blood circulation and resolve blood stasis, lacks comprehensive insights into its active components and their anti-thrombotic mechanisms.

PURPOSE

This study investigated the antithrombotic effects and mechanisms of polydatin, a stilbene derived from HZ, with a focus on its effect on platelet adhesion.

METHODS

An acute pulmonary infection model was used, along with metabolomic and proteomic analyses, to investigate the antithrombotic efficacy of the active component polydatin and identify its targets. Chemical biology, protein mass spectrometry analyses, and molecular interaction analysis were performed to investigate its mechanism. Multiple models of circulatory disorders, including disseminated intravascular coagulation (DIC) and atherosclerosis in mice, with or without targeted gene knockdown, were employed to assess the role of polydatin in modulating platelet adhesion.

RESULTS

Our investigation revealed that polydatin targets prolyl hydroxylase 2 (PHD2), thereby inhibiting hydroxylation of proline residues on collagen. This disruption in collagen assembly and the von Willebrand factor (VWF)-collagen interaction reduces platelet adhesion, significantly impacting circulation in both DIC and atherosclerosis. This represents a novel mechanism of antithrombotic action, distinct from currently available therapies.

CONCLUSION

Targeting PHD2 to modulate collagen structure and platelet adhesion presents a promising novel therapeutic strategy for thrombosis-related circulatory disorders.

Management of Bleeding Diathesis in Elective and Orthopaedic Trauma: A Review

There is a general need among orthopaedic surgeons for practical advice on managing patients with bleeding disorders. Appropriate diagnosis and management of these disorders is paramount once discovered before, during, or after the patient's surgical course. Bleeding disorders disrupt the body's ability to control bleeding, commonly through platelet function and blood clotting. Normally, the vessel contracts and retracts once disruption of blood vessels occurs, limiting blood loss. Blood platelets adhere to exposed collagen, aggregate at the site, and obstruct blood loss. Because platelet aggregates are temporary, blood clotting is needed to back up the platelet plug and provide a milieu for the healing process that completes the hemostatic events. Disorders that interfere with any of these events can result in hemorrhage, drainage, or rebleeding. Bleeding disorders are a group of conditions, either hereditary or acquired, marked by abnormal or excessive bleeding and/or bruising. The most effective methods for assessing coagulation disorders include a detailed history and a series of blood tests. Clinical examination findings are notable but may be less specific. If a surgical patient has a bleeding disorder discovered preoperatively, postoperatively, or intraoperatively, treatments exist with medications, surgical management, interventional radiology procedures, and replacement therapy.

Disseminated intravascular coagulation: cause, molecular mechanism, diagnosis, and therapy

Disseminated intravascular coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, resulting in both thrombosis and bleeding. This review aims to provide a comprehensive overview of DIC, emphasizing its clinical significance and the need for improved management strategies. We explore the primary causes of DIC, including sepsis, trauma, malignancies, and obstetric complications, which trigger an overactive coagulation response. At the molecular level, DIC is marked by excessive thrombin generation, leading to platelet and fibrinogen activation while simultaneously depleting clotting factors, creating a paradoxical bleeding tendency. Diagnosing DIC is challenging and relies on a combination of existing diagnostic criteria and laboratory tests. Treatment strategies focus on addressing the underlying causes and may involve supportive care, anticoagulation therapy, and other supportive measures. Recent advances in understanding the pathophysiology of DIC are paving the way for more targeted therapeutic approaches. This review highlights the critical need for ongoing research to enhance diagnostic accuracy and treatment efficacy, ultimately improving patient outcomes in those affected by DIC.

ABO Blood Type and Short-Term Mortality in Patients With Infection-Associated Disseminated Intravascular Coagulation

BACKGROUND

Disseminated intravascular coagulation (DIC) is a devastating disease of the coagulation system. We examined the association between ABO blood type and short-term mortality in patients with infection-associated DIC.

METHODS

The study cohort was drawn from the Danish Disseminated Intravascular Coagulation (DANDIC) cohort. Our subcohort was restricted to patients with infection-associated DIC. All-cause 30-day and 90-day mortality were computed by Kaplan-Meier estimates and odds ratios between ABO blood types were examined using logistic regression analysis adjusted for age, sex, comorbidity, and location of infection. Blood type O was used as a reference.

RESULTS

The DANDIC cohort included 3023 patients with DIC. Among these, 1853 (61%) had infection-associated DIC. Data on ABO blood type were unavailable in 34 patients (1.8%), who were excluded. The median age was 68 years and 58.2% were males. The 30-day mortality ranged between 38.6% and 42.5% and the 30-day mortality odds ratios were 1.15 (95% confidence interval (CI), 0.92-1.42) for blood type A; 0.84 (95% CI, 0.49-1.43) for AB; and 0.95 (95% CI, 0.67-1.33) for B compared to blood type O.

CONCLUSIONS

We found no clinically meaningful difference in short-term mortality between the various ABO blood types in patients with infection-associated DIC.

The diagnosis of DIC: a current overview

The name of disseminated intravascular coagulation (DIC) and its diagnostic criteria remain controversial. DIC is a clinical syndrome caused by a variety of etiologies, which determines its high heterogeneity. It is inappropriate to adopt the same diagnostic criteria. DIC has its common characteristics. First, in most DIC, thrombosis and bleeding coexist. Second, DIC is a dynamic process. Third, endothelial cell injury and systemic coagulation activation are the core of DIC. Fourth, DIC is an initiating factor of multiple organ dysfunction syndrome (MODS). There are still controversies about the diagnostic criteria of DIC. First, it relies on clinical manifestations and laboratory tests, which cannot reflect pathophysiology. Second, the clinical manifestations were not sensitive or specific. Third, there is a lack of sensitive biomarkers. Fourth, the parameters in the current diagnostic criteria cannot fully reflect the actual coagulation function. Fifth, it is obviously inappropriate to use the same scoring system for diagnosis of clinical syndromes with different etiologies and pathophysiology. Therefore, it is urgent to re-establish the diagnostic criteria for DIC. In recent years, the understanding of DIC has been continuously improved, including the in-depth understanding of the pathogenesis, the classification of coagulation phenotypes, and the development of the "two-step" diagnosis of DIC, etc. All of these contribute to the establishment of new diagnostic criteria for DIC. In conclusion, it is necessary to develop personalized diagnostic criteria based on etiology, reflecting pathophysiological mechanisms, establishing clear cut-off values for parameters, being clinical applicable, being globally unified, and most importantly, being able to identify therapeutic targets.

Infection type and short-term mortality in patients with infection-associated disseminated intravascular coagulation: a cohort study

BACKGROUND

Severe infection is the most frequent disease underlying disseminated intravascular coagulation (DIC). To improve understanding of the clinical course, we examined the association between infection type and short-term mortality in patients with infection-associated DIC.

METHODS

Patients with infection-associated DIC registered in the Danish Disseminated Intravascular Coagulation (DANDIC) cohort were categorised by infection type: pulmonary, intra-abdominal, urogenital, others, multiple infection sites and unknown foci. The Kaplan-Meier method was used to create survival curves and compute 30-day and 90-day mortality; logistic regression was used to compute odds ratios, as a measure of relative risk, with corresponding 95% confidence intervals. Regression models were adjusted for age, sex, comorbidities and surgery within one week before DIC diagnosis. Pulmonary infection, the most frequent infection type, was used as the reference group.

RESULTS

In total, 1,853 patients had infection-associated DIC. The most common types of infection were pulmonary (35.1%), intra-abdominal (25.6%) and urogenital (12.6%). Thirty-day mortality ranged from 19.7% in patients with urogenital infections to 55.1% in patients with unknown foci. The 30-day mortality odds ratio with respect to pulmonary infection was 0.22 (95% CI, 0.15-0.32) for urogenital infection, 0.57 (95% CI, 0.39-0.82) for other infection types, 0.60 (95% CI, 0.36-1.00) for multiple infection sites, 0.73 (95% CI, 0.56-0.97) for intra-abdominal infections and 1.41 (95% CI, 1.02-1.95) for unknown foci.

CONCLUSION

Infection-associated DIC had a high short-term mortality, which varied among infection types, thus suggesting that infection type is an important predictor of the clinical course of DIC.

Comparison of thromboelastographic profiles and clinical characteristics in children with severe Mycoplasma pneumoniae pneumonia

Background

This study aimed to compare Thromboelastographic (TEG) profiles and clinical characteristics between severe Mycoplasma pneumoniae (MP) pneumonia patients with normal and abnormal TEG parameters.

Methods

The clinical data of 133 children with severe MP pneumonia were retrospectively analyzed. Patients were divided into normal (n = 76) and abnormal (n = 57) TEG groups. Demographic characteristics, clinical manifestations, laboratory findings, imaging features, bronchoscopy results, treatment, complications, and outcomes were compared between groups.

Results

The abnormal TEG group (42.9%) had longer fever duration (median: 8.5 vs. 7.0 days, P < 0.001) and hospital stay (median: 11.5 vs. 10.0 days, P = 0.003). They also showed higher levels of C-reactive protein (median: 30.2 vs. 20.1 mg/L, P < 0.001), lactate dehydrogenase (median: 334.5 vs. 276.0 U/L, P = 0.001), and D-dimer (median: 1.2 vs. 0.5 μg/ml, P < 0.001). HRCT revealed more lobar consolidation or multilobar involvement (36.8% vs. 18.4%, P = 0.016), and bronchoscopy showed more mucous plug obstruction (28.1% vs. 10.5%, P = 0.008) in the abnormal TEG group. TEG parameters indicated a hypercoagulable state with shorter R time (P < 0.001), shorter K time (P < 0.001), and higher MA (P = 0.003). The abnormal TEG group had higher incidences of coagulopathy (P < 0.001), cardiac involvement (elevated cardiac enzymes: 36.8% vs. 17.1%, P = 0.009; pericardial effusion: 10.5% vs. 1.3%, P = 0.017), and plastic bronchitis (P = 0.006). They also required longer azithromycin courses (median: 15 vs. 14 days, P = 0.026).

Conclusion

Children with severe MP pneumonia and abnormal TEG profiles have more severe clinical manifestations, higher inflammatory markers, more extensive lung involvement, and a higher incidence of complications. TEG may help identify high-risk patients and guide management in severe MP pneumonia.

Association between platelet count and 30-day in-hospital mortality among intensive care unit patients with sepsis: a multicenter retrospective cohort study

Background

The relationship between platelet count and sepsis outcomes in intensive care units (ICUs) requires comprehensive investigation through large-scale multicenter studies.

Methods

In this multicenter retrospective cohort study, we analyzed 17,977 sepsis patients from 208 U.S. hospitals (2014-2015) using the eICU Collaborative Research Database v2.0. Analyses were adjusted for demographics, clinical parameters, comorbidities, and treatments. Generalized additive models and two-piecewise linear regression were used to assess the relationship between platelet count and mortality.

Results

A U-shaped relationship was identified with an inflection point at 176 × 10⁹/L. Below this threshold, each 10 × 10⁹/L increase in platelet count was associated with a 6% decrease in mortality risk (adjusted OR 0.94, 95% CI 0.93-0.95, p < 0.0001), while above it, each 10 × 10⁹/L increase was associated with a 1% increase in mortality risk (adjusted OR 1.01, 95% CI 1.00-1.01, p = 0.0153).

Conclusion

This large-scale, multicenter retrospective study has made a significant contribution to understanding the association between platelet count and mortality in patients with sepsis in intensive care units. We identified a critical threshold of 176 × 109/L for platelet count and demonstrated a distinct U-shaped relationship with 30-day in-hospital mortality, providing valuable reference criteria for clinical risk stratification.

Coagulation Parameters in Elderly Patients with Severe Pneumonia: Correlation with Disease Severity and Prognosis

Objective

This study aimed to investigate the levels of coagulation parameters in elderly patients with severe pneumonia and analyse their correlation with disease severity and prognosis.

Methods

A retrospective study was conducted on 207 elderly patients (aged ≥60 years) with severe pneumonia admitted to our hospital between January 2022 and December 2023. Demographic data, clinical characteristics and coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time and fibrinogen (FIB), were collected. Patients were divided into survivor and non-survivor groups based on 28-day mortality. The differences in coagulation parameters between groups and their correlation with disease severity and prognosis were analysed.

Results

The 28-day mortality rate was 52.2%. Non-survivors had significantly higher PT, APTT and D-dimer levels and lower FIB levels than survivors (p < 0.05). Multivariate logistic regression analysis showed that elevated PT (odds ratio [OR] = 1.218, 95% confidence interval [CI]: 1.076-1.379, p = 0.002) and D-dimer (OR = 1.109, 95% CI: 1.032-1.192, p = 0.005) were independent risk factors for 28-day mortality. The combined model using PT and D-dimer showed the highest predictive value for 28-day mortality (area under the curve = 0.801, 95% CI: 0.739-0.863, p < 0.001), with a sensitivity of 0.759 and specificity of 0.758.

Conclusion

Coagulation dysfunction is common in elderly patients with severe pneumonia. Prothrombin time and D-dimer levels are closely associated with disease severity and can be valuable indicators for predicting prognosis in this population.

Relationship between thrombocytopenia and prognosis in children with septic shock: a retrospective cohort study

Septic shock is a life-threatening disease worldwide often associated with thrombocytopenia. Platelets play a crucial role in bridging the gap between immunity, coagulation, and endothelial cell activation, potentially influencing the course of the disease. However, there are few studies specifically evaluating the impact of thrombocytopenia on the prognosis of pediatric patients. Therefore, the study investigates effects of early thrombocytopenia in the prognosis of children with septic shock. Pediatric patients with septic shock from 2015 to 2022 were included monocentrically. Thrombocytopenia was defined as a platelet count of <100 × 109/L during the first 24 hours of septic shock onset. The primary outcome was the 28-day mortality. Propensity score matching was used to pair patients with different platelet counts on admission but comparable disease severity. A total of 419 pediatric patients were included in the analysis. Patients with thrombocytopenia had higher 28-day mortality (55.5% vs. 38.7%, p = .005) compared to patients with no thrombocytopenia. Thrombocytopenia was associated with reduced 28-PICU free days (median value, 0 vs. 13 days, p = .003) and 28-ventilator-free (median value, 0 vs. 19 days, p = .001) days. Among thrombocytopenia patients, those with platelet count ≤50 × 109/L had a higher 28-day mortality rate (63.6% vs. 45%, p = .02). Multiple logistic regression showed that elevated lactate (adjusted odds ratio (OR) = 1.11; 95% confidence interval (CI): 1.04-1.17; P <0.001) and white blood cell (WBC) count (OR = 0.97; 95% CI: 0.95-0.99; p = .003) were independent risk factors for the development of thrombocytopenia. Thrombocytopenia group had increased bleeding events, blood product transfusions, and development of organ failure. In Kaplan-Meier survival estimates, survival probabilities at 28 days were greater in patients without thrombocytopenia (p value from the log-rank test, p = .004). There were no significant differences in the type of pathogenic microorganisms and the site of infection between patients with and without thrombocytopenia. In conclusion, thrombocytopenia within 24 hours of shock onset is associated with an increased risk of 28-day mortality in pediatric patients with septic shock.

Enhanced Hypercoagulability Using Clot Waveform Analysis in Patients with Acute Myocardial Infarction and Acute Cerebral Infarction

Background: Routine activated partial thromboplastin time (APTT) and prothrombin time (PT) measurements do not indicate hypercoagulability in patients with acute myocardial infarction (AMI) and acute cerebral infarction (ACI). Methods: Hypercoagulability in patients with AMI or ACI was evaluated using a clot waveform analysis of the APTT or a small amount of tissue factor activation assay (sTF/FIXa). In the CWA, the derivative peak time (DPT), height (DPH), width (DPW), and area the under the curve (AUC) were evaluated. Results: The APTT did not indicate hypercoagulability, but the second DPT of CWA-sTF/FIXa was significantly shorter in patients with ACI than in healthy volunteers (HVs). The first DPH values of CWA-APTT and CWA-sTF/FIXa in patients with ACI and AMI were significantly higher than in HVs. In the receiver operating characteristic (ROC) analyses of ACI or AMI vs. non-thrombosis, the AUC was >0.800 in the DPHs of CWA-APTT and CWA-sTF/FIXa. The AUC of CWA-APTT and CWA-sTF/FIXa in patients with AMI and ACI was significantly higher than in HVs. The AUC/second DPT of CWA-APTT and CWA-sTF/FIXa in patients with AMI and ACI was significantly higher than in HVs. Regarding the ROC analyses of ACI or AMI vs. HVs, the AUC of ROC was higher than 0.800 in the AUC and AUC/second DPT of CWA-APTT and CWA-sTF/FIXa. Conclusions: The AUC/second DPT of CWA-APTT and CWA-sTF/FIXa may be a useful parameter for detecting a hypercoagulable state in patients with AMI and ACI.

Machine learning models can predict cancer-associated disseminated intravascular coagulation in critically ill colorectal cancer patients

Background

Due to its complex pathogenesis, the assessment of cancer-associated disseminated intravascular coagulation (DIC) is challenging. We aimed to develop a machine learning (ML) model to predict overt DIC in critically ill colorectal cancer (CRC) patients using clinical features and laboratory indicators.

Methods

This retrospective study enrolled consecutive CRC patients admitted to the intensive care unit from January 2018 to December 2023. Four ML algorithms were used to construct predictive models using 5-fold cross-validation. The models' performance in predicting overt DIC and 30-day mortality was evaluated using the area under the receiver operating characteristic curve (ROC-AUC) and Cox regression analysis. The performance of three established scoring systems, ISTH DIC-2001, ISTH DIC-2018, and JAAM DIC, was also assessed for survival prediction and served as benchmarks for model comparison.

Results

A total of 2,766 patients were enrolled, with 699 (25.3%) diagnosed with overt DIC according to ISTH DIC-2001, 1,023 (36.9%) according to ISTH DIC-2018, and 662 (23.9%) according to JAAM DIC. The extreme gradient boosting (XGB) model outperformed others in DIC prediction (ROC-AUC: 0.848; 95% CI: 0.818-0.878; p < 0.01) and mortality prediction (ROC-AUC: 0.708; 95% CI: 0.646-0.768; p < 0.01). The three DIC scores predicted 30-day mortality with ROC-AUCs of 0.658 for ISTH DIC-2001, 0.692 for ISTH DIC-2018, and 0.673 for JAAM DIC.

Conclusion

The results indicate that ML models, particularly the XGB model, can serve as effective tools for predicting overt DIC in critically ill CRC patients. This offers a promising approach to improving clinical decision-making in this high-risk group.

The DANish Disseminated Intravascular Coagulation (DANDIC) Cohort Study: Time Trends in Incidence and Short-Term Mortality

Background: Disseminated intravascular coagulation (DIC) is a severe condition affecting the coagulation system. However, current knowledge regarding its incidence and mortality remains limited. In this study, we examined the incidence and mortality of DIC, including time trends, in Denmark. Methods: In this population-based cohort study, potential DIC cases were identified through the hospital laboratory database in the Central Denmark Region which has a population of approximately 1.3 million residents. Eligibility criteria were age above 18 years, a positive DIC score, and a disease associated with DIC. All eligible patients underwent a review of their medical records. Follow-up started on the date of a patient's first positive DIC score. Age- and sex-standardized incidence rates were calculated using year-specific DIC events as the numerator and the adult population of the Central Denmark Region as the denominator. All-cause 30-day mortality in the DIC cohort was computed based on Kaplan-Meier estimates and the mortality rates between subgroups were examined using logistic regression. Results: Among the 40,534 patients for whom all DIC biomarkers were measured on the same date, 6748 had a positive DIC score. Of these, 2565 were included in the cohort. The median age was 64 years, and 56.1% were men. The overall incidence rate per 100,000 person years declined during the study period, from 33.1 in 2013 to 24.0 in 2020. Thirty-day all-cause mortality was 35% in 2013 and 41.3% in 2020. Conclusions: The overall incidence rate of DIC declined between 2013 and 2020, mainly reflecting a declining incidence among patients with infection-associated DIC. Mortality did not improve.

Heparins May Not Be the Optimal Anticoagulants for Sepsis and Sepsis-Associated Disseminated Intravascular Coagulation

Historically, heparin has had the longest historical use as an anticoagulant and continues this day to be the primary therapeutic option for preventing thrombosis and thromboembolism in critically ill hospitalized patients. Heparin is also used to treat sepsis and sepsis-associated disseminated intravascular coagulation (DIC) in various countries. However, the efficacy and safety of heparin for this indication remains controversial, as adequately powered randomized clinical studies have not demonstrated as yet a survival benefit in sepsis and sepsis-associated DIC, despite meta-analyses and propensity analyses reporting improved outcomes without increasing bleeding risk. Further, activated protein C and recombinant thrombomodulin showed greater improvements in outcomes compared with heparin, although these effects were inconclusive. In summary, further research is warranted, despite the ongoing clinical use of heparin for sepsis and sepsis-associated DIC. Based on Japanese guidelines, antithrombin or recombinant thrombomodulin may be a preferable choice if they are accessible.

Analysis of the diagnostic value of coagulation markers and coagulation function indices on the occurrence of DIC in sepsis and its prognosis

Sepsis is a life-threatening condition that has the potential to multiple organ dysfunction and mortality. One of its frequent complications is disseminated intravascular coagulation (DIC), characterized by hyperactive clotting mechanisms that cause widespread clot formation and tissue damage. This study aimed to investigate early diagnostic markers of sepsis-associated DIC by comparing inflammatory factor levels, 28-day survival rates, coagulation function, and markers between patients with sepsis (non-DIC group) and those with sepsis-induced DIC (DIC group). The study analyzed the diagnostic efficacy of coagulation function and markers in predicting the occurrence and prognosis of sepsis-associated DIC, presenting survival curves. Results indicated significantly increased levels of APTT, TAT, tPAIC, PIC, and sTM in the DIC group compared to the non-DIC group. Sequential Organ Failure Assessment (SOFA) scores on days 1, 3, and 7 were notably lower in the non-DIC group. Correlation analysis revealed positive associations between PT, APTT, TAT, tPAIC, PIC, sTM levels, and SOFA scores, as well as negative associations with Fib and SOFA scores. Survival curves showed substantially lower mortality rates in the non-DIC group, highlighting significant survival disparities between groups. Combining all four coagulation indicators (TAT+ tPAIC + PIC + sTM) showed promising diagnostic value in evaluating disease severity, early DIC diagnosis, and sepsis prognosis.

[How to interpret and pursue a prolonged quick time or APTT]

The standard hemostasis workup [quick time (QT), and activated partial thrombin time (APTT)] is very commonly prescribed but its interpretation is often difficult for practitioners who are not specialized in hemostasis. Here, we review the principles of the diagnostic approach to these tests. Only a very basic knowledge of the coagulation cascade is necessary to identify which clotting factor tests to prescribe and to interpret the results. Deficiency in several clotting factors suggests liver dysfunction, disseminated intravascular coagulation (DIC) or vitamin K deficiency. If a single factor is deficient, we review the different causes of acquired deficiencies and briefly discuss the characteristics of the different congenital defects, which generally require specialized management. Lupus anticoagulant is a common and generally benign cause of prolonged APTT to be aware of, which is not related to a hemorrhagic risk. A good knowledge of the diagnostic approach to abnormal QT or APTT generally allows the resolution of the most common situations.

CHANGES OF HISTIDINE-RICH GLYCOPROTEIN LEVELS IN CRITICALLY ILL SEPTIC PATIENTS

ABSTRACT

Background: Histidine-rich glycoprotein (HRG), a potential prognostic factor in sepsis, lacks clarity regarding its relevance in septic-induced shock, disseminated intravascular coagulation (DIC), and acute respiratory distress syndrome (ARDS) pathogenesis. This study investigated the association between HRG concentrations and these critical conditions. Methods: Blood samples were collected from 53 critically ill patients on days 1, 3, 5, and 7 after ICU admission at the Kyushu University Hospital. Daily clinical and laboratory data were recorded, and patient survival was assessed 28 days after ICU admission. Results: Serum HRG concentrations were significantly reduced on days 3, 5, and 7 in patients with septic shock and DIC but not in those with ARDS. While initial HRG levels on day one were not correlated with survival, nonsurvivors displayed decreased HRG levels, notably on days 3, 5, and 7 post-ICU admissions. The HRG levels remained stable in survivors. A progressive decrease was associated with higher mortality rates, particularly on days 5 and 7. On day 5, an HRG level with a cutoff of 25.5 μg/mL showed a sensitivity of 0.77 and a specificity of 0.75, indicating significantly lower survival rates (log-rank test, P < 0.05). Conclusion: HRG presents a potential intervention for critically ill sepsis patients, providing a novel strategy to enhance outcomes. Further research is needed to explore the therapeutic potential of HRG in sepsis management.

Sepsis-Induced Coagulopathy Score is Associated with an Increased Risk of New-Onset Atrial Fibrillation in Septic Patients: A Two-Centered Retrospective Study

Purpose

New-onset atrial fibrillation (NOAF) and sepsis-induced coagulopathy (SIC) are severe complications in septic patients. However, the relationship between NOAF and SIC score has not been clearly defined. This study aims to investigate the association between SIC score and NOAF, as well as their effect on mortality in sepsis.

Patients and Methods

This study was a two-center retrospective analysis. Medical data were collected from patients diagnosed with sepsis. The patients were divided into NOAF and non-NOAF groups, and the SIC score was calculated for each group. Univariable and multivariable logistic regression analyses were performed to explore the relationship between the SIC score and NOAF, as well as their effects on mortality. The Kaplan-Meier curve was used to assess the survival rate.

Results

A total of 2,280 septic patients were included, with 132 (5.7%) suffering from NOAF. Multivariable logistic regression analyses indicated that age, gender, the Acute Physiology and Chronic Health Evaluation II score (APACHE II), heart rate, renal failure, stroke, chronic obstructive pulmonary disease (COPD), and the SIC score were independent risk factors for NOAF in sepsis. Moreover, NOAF was associated with an increased risk of in-hospital mortality, 28-day mortality, and 90-day mortality. These results were consistent across subgroup analyses.

Conclusion

The SIC score was an independent risk factor for NOAF in septic patients, and NOAF was an independent risk factor for predicting mortality.

Autoimmune Hepatitis Complicated by Undiagnosed Factor VII Deficiency: A Pitfall of Coagulopathy

Prothrombin time (PT) is a key parameter for assessing the severity of liver disease. We present the case of a 37-year-old woman with severe acute liver injury due to autoimmune hepatitis. Although prednisolone drastically improved her hepatocyte function, her PT did not recover to the reference range. A review of her medical records revealed that the patient had normal transaminase levels and prolonged PT 2 years previously. Further examinations of her coagulopathy revealed that she had low factor VII activity, suggesting a diagnosis of factor VII deficiency. Our experience suggests that altered coagulopathy should be considered in cases of liver injury with an extraordinary PT.

Development and validation of a nomogram to predict mortality of patients with DIC in ICU

Background

Disseminated intravascular coagulation (DIC) is a devastating condition, which always cause poor outcome of critically ill patients in intensive care unit. Studies concerning short-term mortality prediction in DIC patients is scarce. This study aimed to identify risk factors contributing to DIC mortality and construct a predictive nomogram.

Methods

A total of 676 overt DIC patients were included. A Cox proportional hazards regression model was developed based on covariates identified using least absolute shrinkage and selection operator (LASSO) regression. The prediction performance was independently evaluated in the MIMIC-III and MIMIC-IV Clinical Database, as well as the 908th Hospital Database (908thH). Model performance was independently assessed using MIMIC-III, MIMIC-IV, and the 908th Hospital Clinical Database.

Results

The Cox model incorporated variables identified by Lasso regression including heart failure, sepsis, height, SBP, lactate levels, HCT, PLT, INR, AST, and norepinephrine use. The model effectively stratified patients into different mortality risk groups, with a C-index of >0.65 across the MIMIC-III, MIMIC-IV, and 908th Hospital databases. The calibration curves of the model at 7 and 28 days demonstrated that the prediction performance was good. And then, a nomogram was developed to facilitate result visualization. Decision curve analysis indicated superior net benefits of the nomogram.

Conclusion

This study provides a predictive nomogram for short-term overt DIC mortality risk based on a Lasso-Cox regression model, offering individualized and reliable mortality risk predictions.

Clot-Targeted Nanogels for Dual-Delivery of AntithrombinIII and Tissue Plasminogen Activator to Mitigate Disseminated Intravascular Coagulation Complications

Disseminated intravascular coagulation (DIC) is a pathologic state that follows systemic injury and other diseases. Often a complication of sepsis or trauma, DIC causes coagulopathy associated with paradoxical thrombosis and hemorrhage. DIC upregulates the thrombotic pathways while simultaneously downregulating the fibrinolytic pathways that cause excessive fibrin deposition, microcirculatory thrombosis, multiorgan dysfunction, and consumptive coagulopathy with excessive bleeding. Given these opposing disease phenotypes, DIC management is challenging and includes treating the underlying disease and managing the coagulopathy. Currently, no therapies are approved for DIC. We have developed clot-targeted therapeutics that inhibit clot polymerization and activate clot fibrinolysis to manage DIC. We hypothesize that delivering both an anticoagulant and a fibrinolytic agent directly to clots will inhibit active clot polymerization while also breaking up pre-existing clots; therefore, reversing consumptive coagulopathy and restoring hemostatic balance. To test this hypothesis, we single- and dual-loaded fibrin-specific nanogels (FSNs) with antithrombinIII (ATIII) and/or tissue plasminogen activator (tPA) and evaluated their clot preventing and clot lysing abilities in vitro and in a rodent model of DIC. In vivo, single-loaded ATIII-FSNs decreased fibrin deposits in DIC organs and reduced blood loss when DIC rodents were injured. We also observed that the addition of tPA in dual-loaded ATIII-tPA-FSNs intensified the antithrombotic and fibrinolytic mechanisms, which proved advantageous for clot lysis and restoring platelet counts. However, the addition of tPA may have hindered wound healing capabilities when an injury was introduced. Our data supports the benefits of delivering both anticoagulants and fibrinolytic agents directly to clots to reduce the fibrin load and restore hemostatic balance in DIC.

Disseminated Intravascular Coagulation in Anaphylaxis

Anaphylaxis is a life-threatening condition that involves severe cutaneous, respiratory, and cardiovascular symptoms. Disseminated intravascular coagulation (DIC) is an acquired, widespread activation of coagulation that can be caused by infectious conditions (e.g., sepsis) and noninfectious conditions. The onset of DIC following anaphylaxis is not commonly known, and information regarding the pathomechanism linking anaphylaxis to DIC is scarce. Further, demographic and clinical data in anaphylaxis-induced DIC are still missing to this day. Triggered by a case of anaphylaxis-induced DIC that seamlessly transitioned to lethal sepsis-induced DIC, we aimed to characterize the patient population affected by anaphylaxis-induced DIC by performing a review of existing literature and expand the discussion to underlying mechanisms. The overall mortality of the patient cohort (n = 30) identified by the literature review was 50%. All patients that died either suffered a bleeding event or a thrombotic event. The majority of patients (n = 25/30; 83%) had bleeding events; thrombotic events were only reported in nonsurvivors (n = 9/15 or 60% of nonsurvivors; vs. n = 0/15 in survivors; p < 0.001). Nonsurvivors of anaphylaxis-induced DIC were on average 25 years older than survivors (p = 0.068). In conclusion, DIC can complicate anaphylaxis and is expected to contribute to poor microvascular perfusion after anaphylaxis. Particularly, elderly patients with known cardiovascular disease and patients who develop thrombotic events are susceptible to lethal outcomes. As a rare and largely uncharacterized disease entity, further research is needed to investigate the link between DIC and anaphylaxis and to potentially identify better treatment strategies.

Continuous veno-venous hemofiltration with oXiris hemofilters for the treatment of Fournier's gangrene: A case report series

Background

Fournier's gangrene (FG) is a severe form of necrotizing fasciitis primarily caused by gram-negative bacteria. FG can rapidly progress to septic shock, resulting in high mortality rates. In the past, the management of the inflammatory response caused by gram-negative bacteria has been limited. Continuous Veno-Venous Hemofiltration with oXiris hemofilters (oXiris-CVVH) has shown promise in adsorbing inflammatory factors and endotoxins, making it an attractive approach for treating FG. This study aims to provide insights into the characteristics of patients with FG and septic shock who have been successfully treated using oXiris-CVVH, based on a series of patient cases.

Results

This study presents the management of 4 cases in the intensive care units of a tertiary hospital in southern China. The use of oXiris-CVVH in patients with septic shock and FG yielded valuable practical insights.

Conclusion

Based on the experience gained from these 4 cases, the utilization of oXiris-CVVH demonstrated potential in reducing the Sequential Organ Failure Assessment (SOFA) score, improving prognosis, and effectively lowering the levels of lactic acid and procalcitonin (PCT) in the blood. Additionally, it facilitated a reduction in the dosage of noradrenaline. Therefore, oXiris-CVVH should be considered as an adjunctive therapy in the treatment of patients with FG and septic shock.

Platelets: Orchestrators of immunity in host defense and beyond

Platelets prevent blood loss during vascular injury and contribute to thrombus formation in cardiovascular disease. Beyond these classical roles, platelets are critical for the host immune response. They guard the vasculature against pathogens via specialized receptors, intracellular signaling cascades, and effector functions. Platelets also skew inflammatory responses by instructing innate immune cells, support adaptive immunosurveillance, and influence antibody production and T cell polarization. Concomitantly, platelets contribute to tissue reconstitution and maintain vascular function after inflammatory challenges. However, dysregulated activation of these multitalented cells exacerbates immunopathology with ensuing microvascular clotting, excessive inflammation, and elevated risk of macrovascular thrombosis. This dichotomy underscores the critical importance of precisely defining and potentially modulating platelet function in immunity.

Risk and adverse clinical outcomes of thrombocytopenia among patients with solid tumors-a Danish population-based cohort study

BACKGROUND

Knowledge about thrombocytopenia among patients with solid tumors is scarce. We examined the risk of thrombocytopenia among patients with solid tumors and its association with adverse outcomes.

METHODS

Using Danish health registries, we identified all patients with incident solid tumors from 2015-2018 (n = 52,380) and a platelet count measurement within 2 weeks prior to or on their cancer diagnosis date. The risk of thrombocytopenia was categorized as grades 0 (any platelet count × 109/L): <150; 1: <100; 2: <75; 3: <50; 4: <25, and 5: <10. To study the outcomes, each patient with thrombocytopenia was matched with up to five cancer patients without thrombocytopenia by age, sex, cancer type, and stage. Cox regression was used to compute hazard ratios (HRs) of bleeding, transfusion, or death, adjusting for confounding factors.

RESULTS

The 1-year risk of thrombocytopenia was 23%, increasing to 30% at 4 years. This risk was higher in patients receiving chemotherapy (43% at 1 year and 49% at 4 years). Overall, patients with thrombocytopenia had higher 30-days rates of bleeding (HR = 1.72 [95% confidence interval, CI: 1.41-2.11]). Thrombocytopenia was also associated with an increased rate of transfusion, and death, but some of the risk estimates were imprecise.

CONCLUSIONS

The risk of thrombocytopenia was substantial among patients with solid tumors and associated with adverse outcomes.

Septic Abortion Complicated by Disseminated Intravascular Coagulation

Audience

This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC).

Introduction

Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality.

Educational Objectives

At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).

Educational Methods

This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows.

Research Methods

Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.

Results

Thirteen learners completed a feedback form out of seventeen participants. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores.

Discussion

This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in.

Topics

Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.

Extracellular ATP contributes to the reactive oxygen species burst and exaggerated mitochondrial damage in D-galactosamine and lipopolysaccharide-induced fulminant hepatitis

Fulminant hepatitis (FH) is a severe clinical syndrome leading to hepatic failure and even mortality. D-galactosamine (D-GalN) plus lipopolysaccharide (LPS) challenge is commonly used to establish an FH mouse model, but the mechanism underlying D-GalN/LPS-induced liver injury is incompletely understood. Previously, it has been reported that extracellular ATP that can be released under cytotoxic and inflammatory stresses serves as a damage signal to induce potassium ion efflux and trigger the NACHT, LRR and PYD domains-containing protein 3 (NLRP3) inflammasome activation through binding to P2X7 receptor. In this study, we tried to investigate whether it contributed to the fulminant hepatitis (FH) induced by D-GalN plus LPS. In an in vitro cellular model, D-GalN plus extracellular ATP, instead of D-GalN alone, induced pyroptosis and apoptosis, accompanied by mitochondrial reactive oxygen species (ROS) burst, and the oligomerization of Drp1, Bcl-2, and Bak, as well as the loss of mitochondrial membrane potential in LPS-primed macrophages, well reproducing the events induced by D-GalN and LPS in vivo. Moreover, these events in the cellular model were markedly suppressed by both A-804598 (an ATP receptor P2X7R inhibitor) and glibenclamide (an ATP-sensitive potassium ion channel inhibitor); in the FH mouse model, administration of A-804598 significantly mitigated D-GalN/LPS-induced hepatic injury, mitochondrial damage, and the activation of apoptosis and pyroptosis signaling, corroborating the contribution of extracellular ATP to the cell death. Collectively, our data suggest that extracellular ATP acts as an autologous damage-associated molecular pattern to augment mitochondrial damage, hepatic cell death, and liver injury in D-GalN/LPS-induced FH mouse model.

Comparison of five different disseminated intravascular coagulation criteria in predicting mortality in patients with sepsis

OBJECTIVE

Even though patients with sepsis and DIC have a higher mortality rate compared to those without DIC, screening for DIC is not currently part of sepsis management protocols. This may be due to a lack of literature on the frequency of DIC occurrence in sepsis patients, as well as the absence of evidence on the optimal DIC criteria to use for identifying DIC and predicting mortality among the five criteria available. To address this gap, this study investigates the predictive value of five different criteria for diagnosing DIC and its relationship to patient outcomes in our population of sepsis patients.

METHODS

In the Medicine department of Aga Khan University Hospital, a retrospective observational study was conducted, enrolling all adult patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding of sepsis and clinical suspicion of DIC between January 2018 and December 2020. To diagnose DIC, five different criteria were utilized, namely the International Society of Thrombosis and Hemostasis (ISTH), the Korean Society on Thrombosis and Hemostasis (KSTH), the Japanese Association for Acute Medicine (JAAM), the revised-JAAM (RJAAM), and the Japanese Ministry of Health and Welfare (JMHW). The study analyzed the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of these five criteria, as well as the overall prediction of mortality.

RESULTS

Of 222 septic patients included in this study with clinical suspicion of DIC, 94.6% of patient had DIC according to KSTH criteria, followed by JAAM (69.4%), ISTH (64.0%), JMHW (53.2%) and lastly R-JAAM (48.6%). KSTH had sensitivity of 95.4% in diagnosing DIC and predicting mortality with a positive predictive value of 70% but specificity of 7.3% only. JAAM had sensitivity of 75.9%, positive predictive value of 75.9% with a specificity of 45.5%. ISTH had sensitivity of 69.4%, positive predictive value 75.3% and specificity of 48.5%.

CONCLUSION

DIC can impose a significant burden on septic patients and its presence can lead to higher mortality rates. Early detection through screening for DIC in septic patients can potentially reduce mortality. However, it is necessary to identify the most appropriate diagnostic criteria for each population, as various criteria have demonstrated different performance in different populations. Establishing a gold standard for each population can aid in accurate diagnosis of DIC.

Pregnancy and the eye: What do we need to watch out for? A review

Pregnancy causes changes in all body systems, including the eye. The eye can undergo physiological and pathological changes in pregnancy. Some changes exacerbate pre-existing eye conditions while other conditions manifest for the first-time during pregnancy. Early recognition and management are essential to prevent sight threatening complications. In addition, some obstetric complications can be associated with ophthalmic signs. Prompt recognition of these eye findings may be life saving for both the mother and the foetus. The aim of this article is to present potential ocular complications in pregnancy and outline the appropriate management to preserve sight and maintain maternal and foetal safety. The safety of the use of common ophthalmological medications will also be discussed.

Treatments and outcomes of neonatal disseminated intravascular coagulation with and without neonatal asphyxia: A retrospective study using nationwide data in Japan

BACKGROUND

Although neonatal disseminated intravascular coagulation (DIC) is associated with high mortality and severe complications, few studies have reported its clinical course. We aimed to describe the characteristics, treatments, and outcomes of neonatal DIC by using a national inpatient database.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified 5533 patients with neonatal DIC who were admitted to neonatal intensive care units between July 2010 and March 2020. We categorized the patients into those with asphyxia (n = 2911) and those without asphyxia (n = 2622). We investigated the patient characteristics, treatments, and outcomes. We further categorized neonates with asphyxia according to its severity.

RESULTS

The gestational age of neonates with asphyxia was significantly lower than that of neonates without asphyxia (P < 0.001). Antithrombin was most commonly used for DIC (40%). Neonates with asphyxia were more likely to receive antithrombin (43% vs. 38%; P < 0.001), recombinant human soluble thrombomodulin (28% vs. 20%; P < 0.001), and fresh frozen plasma transfusion (68% vs. 51%; P < 0.001) than those without asphyxia. Neonates with asphyxia had higher in-hospital mortality (17% vs. 10%; P < 0.001), severe bleeding (11% vs. 6.8%; P < 0.001), and hospitalization costs than those without asphyxia. Additionally, neonates with severe asphyxia were more likely to receive several DIC therapies (such as recombinant human soluble thrombomodulin [30% vs. 24%]) and had higher in-hospital mortality (19% vs. 11%) and hospitalization costs than those with mild asphyxia.

CONCLUSIONS

In this large retrospective study of neonatal DIC, patients with asphyxia received several treatments and demonstrated unfavorable outcomes when compared to those without asphyxia.

Risk factors and an early predictive model for Kawasaki disease shock syndrome in Chinese children

BACKGROUND

Kawasaki disease shock syndrome (KDSS), though rare, has increased risk for cardiovascular complications. Early diagnosis is crucial to improve the prognosis of KDSS patients. Our study aimed to identify risk factors and construct a predictive model for KDSS.

METHODS

This case-control study was conducted from June, 2015 to July, 2023 in two children's hospitals in China. Children initially diagnosed with KDSS and children with Kawasaki disease (KD) without shock were matched at a ratio of 1:4 by using the propensity score method. Laboratory results obtained prior to shock syndrome and treatment with intravenous immunoglobulin were recorded to predict the onset of KDSS. Univariable logistic regression and forward stepwise logistic regression were used to select significant and independent risk factors associated with KDSS.

RESULTS

After matching by age and gender, 73 KDSS and 292 KD patients without shock formed the development dataset; 40 KDSS and 160 KD patients without shock formed the validation dataset. Interleukin-10 (IL-10) > reference value, platelet counts (PLT) < 260 × 109/L, C-reactive protein (CRP) > 80 mg/ml, procalcitonin (PCT) > 1ng/ml, and albumin (Alb) < 35 g/L were independent risk factors for KDSS. The nomogram model including the above five indicators had area under the curves (AUCs) of 0.91(95% CI: 0.87-0.94) and 0.90 (95% CI: 0.71-0.86) in the development and validation datasets, with a specificity and sensitivity of 80% and 86%, 66% and 77%, respectively. Calibration curves showed good predictive accuracy of the nomogram. Decision curve analyses revealed the predictive model has application value.

CONCLUSIONS

This study identified IL-10, PLT, CRP, PCT and Alb as risk factors for KDSS. The nomogram model can effectively predict the occurrence of KDSS in Chinese children. It will facilitate pediatricians in early diagnosis, which is essential to the prevention of cardiovascular complications.

The pathophysiology of sepsis and precision-medicine-based immunotherapy

Sepsis remains a major cause of morbidity and mortality in both low- and high-income countries. Antibiotic therapy and supportive care have significantly improved survival following sepsis in the twentieth century, but further progress has been challenging. Immunotherapy trials for sepsis, mainly aimed at suppressing the immune response, from the 1990s and 2000s, have largely failed, in part owing to unresolved patient heterogeneity in the underlying immune disbalance. The past decade has brought the promise to break this blockade through technological developments based on omics-based technologies and systems medicine that can provide a much larger data space to describe in greater detail the immune endotypes in sepsis. Patient stratification opens new avenues towards precision medicine approaches that aim to apply immunotherapies to sepsis, on the basis of precise biomarkers and molecular mechanisms defining specific immune endotypes. This approach has the potential to lead to the establishment of immunotherapy as a successful pillar in the treatment of sepsis for future generations.

Reply to Ishikura, H. What Does Soluble C-Type Lectin-like Receptor 2 (sCLEC-2) × D-Dimer/Platelet (PLT) (sCLEC-2 × D-Dimer/PLT) Mean for Coagulation/Fibrinolysis Conditions? Comment on "Yamamoto et al. Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2. Diagnostics 2023, 13, 2299"

We would like to thank Dr. Ishikura for his kind comment [...].

Maternal fibrinogen/fibrin degradation products to high density lipoprotein cholesterol ratio for predicting delivery of small and large for gestational age infants: a pilot study

BACKGROUND

The purpose of this pilot study was to investigate associations between fibrinogen/fibrin degradation products (FDP) to high density lipoprotein-cholesterol (HDL-C) ratio (FHR) of mothers and the risk of delivering large/small for gestational age (LGA/SGA) infants and to evaluate the predictive power of FHR on LGA/SGA.

METHODS

This study retrospectively reviewed 11,657 consecutive women whose lipid profiles and FDP levels were investigated at the time of admission for delivery at a specialized hospital. The FHR was calculated, and perinatal outcomes, including clinical parameters, were analyzed.

RESULTS

The prevalence of SGA was 9% (n = 1034), and that of LGA was 15% (n = 1806) in this cohort study. FHR was significantly lower in women who delivered SGA infants (4.0 ± 3.2 vs. 4.7 ± 3.3 mg/mmol, P < 0.01) and higher in women who delivered LGA infants (5.7 ± 3.8 vs. 4.7 ± 3.3 mg/mmol, P < 0.01) compared with those who delivered infants of normal size for their gestational age. Women in the top quartile for FHR (> 5.9 mg/mmol) had a 2.9-fold higher risk of delivering LGA infants [adjusted odds ratio (OR) = 2.9, P < 0.01] and a 47% lower risk of delivering SGA infants (adjusted OR = 0.47, P < 0.01) than those in the bottom quartile (< 2.7 mg/mmol). In addition, adding FHR to the conventional models significantly improved the area under the curve for the prediction of delivering LGA (0.725 vs. 0.739, P < 0.01) and SGA (0.717 vs. 0.727, P < 0.01) infants.

CONCLUSION

These findings suggest that the FHR calculated in late pregnancy is an innovative predictor of delivering LGA and SGA infants. Combining FHR with perinatal parameters could thus enhance the predictive ability for predicting the delivery of LGA/SGA infants.

Development of early prediction model of in-hospital cardiac arrest based on laboratory parameters

BACKGROUND

In-hospital cardiac arrest (IHCA) is an acute disease with a high fatality rate that burdens individuals, society, and the economy. This study aimed to develop a machine learning (ML) model using routine laboratory parameters to predict the risk of IHCA in rescue-treated patients.

METHODS

This retrospective cohort study examined all rescue-treated patients hospitalized at the First Medical Center of the PLA General Hospital in Beijing, China, from January 2016 to December 2020. Five machine learning algorithms, including support vector machine, random forest, extra trees classifier (ETC), decision tree, and logistic regression algorithms, were trained to develop models for predicting IHCA. We included blood counts, biochemical markers, and coagulation markers in the model development. We validated model performance using fivefold cross-validation and used the SHapley Additive exPlanation (SHAP) for model interpretation.

RESULTS

A total of 11,308 participants were included in the study, of which 7779 patients remained. Among these patients, 1796 (23.09%) cases of IHCA occurred. Among five machine learning models for predicting IHCA, the ETC algorithm exhibited better performance, with an AUC of 0.920, compared with the other four machine learning models in the fivefold cross-validation. The SHAP showed that the top ten factors accounting for cardiac arrest in rescue-treated patients are prothrombin activity, platelets, hemoglobin, N-terminal pro-brain natriuretic peptide, neutrophils, prothrombin time, serum albumin, sodium, activated partial thromboplastin time, and potassium.

CONCLUSIONS

We developed a reliable machine learning-derived model that integrates readily available laboratory parameters to predict IHCA in patients treated with rescue therapy.

The International Society of Thrombosis and Hemostasis (ISTH) criteria in intensive care units

BACKGROUND

Disseminated Intravascular Coagulation (DIC) has been assessed by the International Society of Thrombosis and Hemostasis (ISTH) 2001 and the ISTH 2018-modified version. More investigations are needed to assess usability and visibility of those DIC scoring systems in the intensive care units (ICU).

AIMS

This study investigated the predictive performance of the ISTH-Overt DIC versions of 28-day mortality in ICUs compared to SOFA as a gold standard assessment tool of sepsis.

METHODS

A retrospective design (2015-2017) included 220 adult patients enrolled from medical and surgical ICUs in two major hospitals in Jordan. We calculated ISTH-Overt DIC scores and SOFA score on time of DIC diagnosis. Overt DIC was categorized based on a score of ≥ five for ISTH DIC 2001; and ≥ 4 for ISTH DIC 2018. Provided, a score > 12 was categorized as Multiple-Organ- Dysfunction-Syndrome (MODS) for Sequential Organ Failure Assessment (SOFA) score. Then, 28-day mortality follow-up was performed.

RESULTS

More than half of sample died before 28-days of follow-up. The analysis of Receiver Operating Characteristic (ROC) showed that higher scores of ISTH DIC 2001(≥ 5), ISTH DIC 2018 (≥ 4), and SOFA score (>12) were highly associated with 28-day mortality. The ISTH DIC 2001 and SOFA score were superior on the modified ISTH 2018 in predicting 28-day mortality, with an Area Under the Curve (AUC) of (0.724 vs. 0.822 vs. 0.507, respectively). Yet, the accuracy of the SOFA score was better than the ISTH DIC 2001.

CONCLUSION

This study suggests that ISTH DIC 2001 score is helpful when applied on medical and surgical ICU Jordanian populations. It showed better results compared to the Modified ISTH DIC 2018 in mortality prediction, regardless of the underlying diseases.

Association of CDSS score and 60-day mortality in Chinese patients with non-APL acute myeloid leukemia: a retrospective cohort study

Acute myeloid leukemia (AML) is a heterogeneous hematological malignancy, and is one of the triggers of DIC, the latter is an essential factor in the early death of patients with AML. However, the timely identification of DIC remains a challenge. The Chinese DIC Scoring System (CDSS) is a common consensus widely used in China; but, there are few reports on its application in patients with AML. We undertake this retrospective cohort study to investigate the association between CDSS score and 60-day mortality. CDSS scores were evaluated after admission. The outcome was all-cause 60-day mortality. Multivariate Cox regression analyses were performed to calculate the adjusted hazard ratio (HR) and the corresponding 95% confidence interval (CI). Survival curves were plotted by Kaplan-Meier and log-rank analyses. Subgroup analyses were stratified by relevant effect covariates. A total of 570 consecutive patients with primary AML were included. We found an association between a 39% increase in 60-day mortality and a 1 point increase in CDSS score (HR = 1.39, 95% CI 1.25-1.54), which was associated with a 189% increase in 60-day mortality in CDSS scores ≥ 6 compared with that in the CDSS scores < 6 (HR = 2.89, 95% CI 1.91-4.38). After adjusting for all potential con-founders, a 27% and a 198% increase were observed (HR = 1.27, 95% CI 1.01-1.61; HR = 2.98, 95% CI 1.24-7.19), respectively. There is association between 60-day mortality and CDSS score in patients with AML. These findings may help hematologists in making informed treatment decisions.

Decoding Sepsis-Induced Disseminated Intravascular Coagulation: A Comprehensive Review of Existing and Emerging Therapies

Disseminated intravascular coagulation (DIC) is a recurrent complication of sepsis. Since DIC not only promotes organ dysfunction but also represents a strong prognostic factor, it is important to diagnose DIC as early as possible. When coagulation is activated, fibrinolysis is inhibited, blood thinners are consumed, and a condition is created that promotes blood clotting, making it more difficult for the body to remove fibrin or prevent it from being deposited in the blood vessels. This leads to microvascular thrombosis, which plays a role in organ dysfunction. Despite efforts to understand the underlying mechanisms of sepsis-induced DIC, healthcare providers worldwide still face challenges in effectively treating this condition. In this review, we provide an in-depth analysis of the available strategies for sepsis-induced DIC, considering their effectiveness, limitations, and potential for future advances. Corticosteroids (CS), recombinant thrombomodulin (rTM), vitamin C, fibrinolytic therapy, and platelet transfusion are among the treatments discussed in the review. In addition, we are specifically addressing immunomodulatory therapy (IMT) by investigating treatments such as granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-γ), and mesenchymal stem cell therapy (MSC). Finally, we also examined how these therapies might affect COVID-19 cases, which often present with sepsis-induced DIC. The review suggests that targeted experiments with randomization are needed to verify the effectiveness of these treatments and to discover novel approaches to treat sepsis-induced DIC. By increasing our knowledge of sepsis-induced DIC, we can develop targeted treatments that have the potential to save lives and improve outcomes.

Sepsis-induced coagulopathy is associated with new episodes of atrial fibrillation in patients admitted to critical care in sinus rhythm

Background

Sepsis is a life-threatening disease commonly complicated by activation of coagulation and immune pathways. Sepsis-induced coagulopathy (SIC) is associated with micro- and macrothrombosis, but its relation to other cardiovascular complications remains less clear. In this study we explored associations between SIC and the occurrence of atrial fibrillation (AF) in patients admitted to the Intensive Care Unit (ICU) in sinus rhythm. We also aimed to identify predictive factors for the development of AF in patients with and without SIC.

Methods

Data were extracted from the publicly available AmsterdamUMCdb database. Patients with sepsis and documented sinus rhythm on admission to ICU were included. Patients were stratified into those who fulfilled the criteria for SIC and those who did not. Following univariate analysis, logistic regression models were developed to describe the association between routinely documented demographics and blood results and the development of at least one episode of AF. Machine learning methods (gradient boosting machines and random forest) were applied to define the predictive importance of factors contributing to the development of AF.

Results

Age was the strongest predictor for the development of AF in patients with and without SIC. Routine coagulation tests activated Partial Thromboplastin Time (aPTT) and International Normalized Ratio (INR) and C-reactive protein (CRP) as a marker of inflammation were also associated with AF occurrence in SIC-positive and SIC-negative patients. Cardiorespiratory parameters (oxygen requirements and heart rate) showed predictive potential.

Conclusion

Higher INR, elevated CRP, increased heart rate and more severe respiratory failure are risk factors for occurrence of AF in critical illness, suggesting an association between cardiac, respiratory and immune and coagulation pathways. However, age was the most dominant factor to predict the first episodes of AF in patients admitted in sinus rhythm with and without SIC.

Why anticoagulant studies on sepsis fail frequently --- start with SCARLET

The Sepsis Coagulopathy Asahi Recombinant LE Thrombomodulin (SCARLET) trial has many defects, and thus cannot be the terminator of recombinant thrombomodulin (rTM). On the contrary, it provides sufficient evidence for further research. Based on analysis focusing on the failure of SCARLET and several previous anticoagulant studies, it is most important for new studies to grasp the following two points: (1) The enrolled cases should have sufficient disease severity and a clear standard for disseminated intravascular coagulation; (2) Heparin should not be used in combination with the investigated drugs. Multiple post-hoc analyses show that no combination of heparin will not increase the risk of thromboembolism. In fact, the combination of heparin can mask the true efficacy of the investigated drug. Due to the complexity of sepsis treatment and the limitations of clinical studies, the results of all treatment studies should be repeatedly verified, rather than be determined at one stroke. Some research conclusions contrary to disease physiology, pharmacology and clinical practice may be deceptive, and should be cautious rather than be simply accepted. On the other hand, the dissenting voices in the "consensus" scene are often well discussed by the authors and should be highly valued.

A rare case of prostate cancer initially presented by disseminated intravascular coagulation-related subdural hemorrhage

BACKGROUND

Disseminated intravascular coagulation (DIC) has been reported in various solid malignancies and is a common coagulation-related complication in prostate cancer. However, DIC has been rarely reported as the initial presentation of prostate cancer. Herein, we reported a patient referring with subdural hemorrhage (SDH) and DIC with an unexplained cause who was later diagnosed with prostate cancer.

CASE PRESENTATION

We presented a 68-year-old man who was referred to the hospital with a gradual deterioration of consciousness, dyspnea, and edema in the genitalia and lower limbs. His primary laboratory tests showed elevated prothrombin time (PT) and partial thromboplastin time (PTT) and a decreased fibrinogen level of 47 mg/dL [200-400 mg/dL]. The DIC score was 7, which was suggestive of DIC. Moreover, cranial imaging showed SDH. Further work-up revealed elevated prostate-specific antigen and prostate enlargement with a mass effect on the bladder with a bone lesion, which was suggestive of metastatic prostate cancer.

CONCLUSION

This report highlights DIC as a possible initial presentation of an underlying malignancy, as well as the importance of treatment of underlying disease in the management of DIC. A comprehensive and systematic work-up is essential for early diagnosis in patients with DIC to avoid further complications and mortality.

Fibrinolysis in Cardiac Arrest Patients Treated with Hypothermia

Hypothermia affects coagulation, but the effect of hypothermia on fibrinolysis is not clarified. Imbalance in the fibrinolytic system may lead to increased risk of bleeding or thrombosis. Our aim was to investigate if resuscitated cardiac arrest patients treated with hypothermia had an unbalanced fibrinolysis. A prospective cohort study, including 82 patients were treated with hypothermia at 33°C ± 1°C after out-of-hospital cardiac arrest. Blood samples were collected at 24 hours (hypothermia) and at 72 hours (normothermia). Samples were analyzed for fibrin D-dimer, tissue plasminogen activator (tPA), plasminogen, plasminogen activator Inhibitor-1 (PAI-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and an in-house dynamic fibrin clot formation and lysis assay.Compared with normothermia, hypothermia significantly increased plasminogen activity (mean difference = 10.4%, 95% confidence interval [CI] 7.9-12.9), p < 0.001), PAI-1 levels (mean difference = 275 ng/mL, 95% CI 203-348, p < 0.001), and tPA levels (mean difference = 1.0 ng/mL, 95% CI 0.2-1.7, p = 0.01). No differences between hypothermia and normothermia were found in TAFI activity (p = 0.59) or in the fibrin D-dimer levels (p = 0.08). The fibrin clot lysis curves showed three different patterns: normal-, flat-, or resistant clot lysis curve. At hypothermia 45 (55%) patients had a resistant clot lysis curve and 33 (44%) patients had a resistant clot lysis curve at normothermia (p = 0.047). Comatose, resuscitated, cardiac arrest patients treated with hypothermia express an inhibited fibrinolysis even after rewarming. This could potentially increase the thromboembolic risk. ClinicalTrials.gov ID: NCT02258360.

Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2

The scoring systems for disseminated intravascular coagulation (DIC) criteria require several adequate cutoff values, vary, and are complicated. Accordingly, a simpler and quicker diagnostic method for DIC is needed. Under such circumstances, soluble C-type lectin-like receptor 2 (sCLEC-2) received attention as a biomarker for platelet activation.

MATERIALS AND METHODS

The diagnostic usefulness of sCLEC-2 and several formulas, including sCLEC-2xD-dimer, sCLEC-2/platelet count (sCLEC-2/PLT), and sCLEC-2/PLT × D-dimer (sCLEC-2xD-dimer/PLT), were evaluated among 38 patients with DIC, 39 patients with pre-DIC and 222 patients without DIC or pre-DIC (non-DIC).

RESULTS

Although the plasma level of sCLEC-2 alone was not a strong biomarker for the diagnosis of DIC or pre-DIC, the sCLEC-2xD-dimer/PLT values in patients with DIC were significantly higher than those in patients without DIC, and in a receiver operating characteristic (ROC) analysis for the diagnosis of DIC, sCLEC-2xD-dimer/PLT showed the highest AUC, sensitivity, and odds ratio. This formula is useful for the diagnosis of both pre-DIC and DIC. sCLEC-2xD-dimer/PLT values were significantly higher in non-survivors than in survivors.

CONCLUSION

The sCLEC-2xD-dimer/PLT formula is simple, easy, and highly useful for the diagnosis of DIC and pre-DIC without the use of a scoring system.

Sepsis - it is all about the platelets

Sepsis is accompanied by thrombocytopenia and the severity of the thrombocytopenia is associated with mortality. This thrombocytopenia is characteristic of disseminated intravascular coagulation (DIC), the sepsis-associated coagulopathy. Many of the pathogens, both bacterial and viral, that cause sepsis also directly activate platelets, which suggests that pathogen-induced platelet activation leads to systemic thrombosis and drives the multi-organ failure of DIC. In this paper we review the mechanisms of platelet activation by pathogens and the evidence for a role for anti-platelet agents in the management of sepsis.

A Systematic Review and Meta-Analysis of the Proportion Estimates of Disseminated Intravascular Coagulation (DIC) in Malaria

Disseminated intravascular coagulation (DIC) is a potentially life-threatening condition that causes systemic coagulation to be turned on and coagulation factors to be used up. However, the evidence for DIC in malaria patients is still not clear, and small case series and retrospective studies have shown varying results. This meta-analysis was intended for the evaluation of the evidence of DIC among malaria patients using a meta-analysis approach. The protocol for the systematic review was registered at PROSPERO as CRD42023392194. Studies that investigated DIC in patients with malaria were searched in Ovid, Scopus, Embase, PubMed, and MEDLINE. The pooled proportion with 95% confidence intervals (CI) of DIC among malaria patients was estimated using a random-effects model. A total of 1837 articles were identified, and 38 articles were included in the meta-analysis. The overall proportion of DIC in malaria was 11.6% (95% CI: 8.9%-14.3%, I²: 93.2%, 38 studies). DIC in severe falciparum malaria and fatal malaria was 14.6% (95% CI: 5.0-24.3%, I²: 95.5%, 11 studies) and 82.2% (95% CI: 56.2-100%, I²: 87.3, 4 studies). The estimates of DIC among severe malaria patients who had multi-organ dysfunction with bleeding, cerebral malaria, acute renal failure, and ≥2 complications were 79.6% (95% CI: 67.1-88.2%, one study), 11.9% (95% CI: 7.9-17.6%, one study), 16.7% (95% CI: 10.2-23.3%, ten studies), and 4.8% (95% CI: 1.9-7.7%, nine studies), respectively. The proportion estimates of DIC among the patients with malaria depended on the Plasmodium species, clinical severity, and types of severe complications. The information from this study provided useful information to guide the management of malaria patients. Future studies are needed to investigate the association between Plasmodium infection and DIC and to understand the mechanism of malaria-induced DIC.

The pathophysiology, diagnosis, and management of sepsis-associated disseminated intravascular coagulation

BACKGROUND

The International Society on Thrombosis and Haemostasis (ISTH) released overt disseminated intravascular coagulation (DIC) diagnostic criteria in 2001. Since then, DIC has been understood as the end-stage consumptive coagulopathy and not the therapeutic target. However, DIC is not merely a decompensated coagulation disorder, but also includes early stages with systemic activation in coagulation. Thus, the ISTH has recently released sepsis-induced coagulopathy (SIC) criteria that can diagnose compensated-phase of coagulopathy with readily available biomarkers.

MAIN BODY

DIC is a laboratory-based diagnosis due to various critical conditions, although sepsis is the most common underlying disease. The pathophysiology of sepsis-associated DIC is multifactorial, and in addition to coagulation activation with suppressed fibrinolysis, multiple inflammatory responses are initiated by activated leukocytes, platelets, and vascular endothelial cells as part of thromboinflammation. Although overt DIC diagnostic criteria were established by ISTH to diagnose the advanced stage of DIC, additional criteria that can detect an earlier stage of DIC were needed for potential therapeutic considerations. Accordingly, the ISTH introduced SIC criteria in 2019 that are easy to use and require only platelet count, prothrombin time-international normalized ratio, and Sequential Organ Failure Assessment Score. SIC score can be used to evaluate disease severity and determine the timing of potential therapeutic interventions. One of the major disadvantages in treating sepsis-associated DIC is the lack of availability of specific therapeutic approaches beyond treating the underlying infection. Clinical trials to date have failed because included patients who were not coagulopathic. Nevertheless, in addition to infection control, anticoagulant therapy will be the choice for sepsis-associated DIC. Therefore, the efficacy of heparin, antithrombin, and recombinant thrombomodulin has to be proven in future clinical studies.

CONCLUSION

It is necessary to develop a novel therapeutic strategy against sepsis-associated DIC and improve the outcomes. Consequently, we recommend screening and monitoring DIC using SIC scoring system.

Drug-Induced Thrombocytopenia Due to Nintedanib during Treatment of Idiopathic Pulmonary Fibrosis

Nintedanib is a tyrosine kinase inhibitor that was approved for the treatment of patients with idiopathic pulmonary fibrosis in 2014. The most common side effect of Nintedanib is diarrhea, and thrombocytopenia is a rare side effect of Nintedanib. The exact mechanism is unknown, and the literature lacks case reports of this phenomenon. Here, we report the case of a patient who developed thrombocytopenia 12 weeks after starting treatment with Nintedanib. The patient underwent an extensive work up for infectious, hematological, autoimmune, and neoplastic diseases. The patient's thrombocytopenia resolved following cessation of Nintedanib. This case is significant as it reports a rare side effect that might have detrimental consequences if not recognized and treated timely. Additionally, the onset of thrombocytopenia was delayed, 3 months after the initiation of Nintedanib. We also highlight the various literature regarding drug-induced thrombocytopenia and explore the necessary work-up needed to exclude other potential diagnoses. We hope to advocate for multidisciplinary teams to be aware of patients with pulmonary fibrosis on Nintedanib so that this adverse effect can be recognized promptly.

Inflammatory mechanisms and intervention strategies for sepsis-induced myocardial dysfunction

Sepsis-induced myocardial dysfunction (SIMD) is the leading cause of death in patients with sepsis in the intensive care units. The main manifestations of SIMD are systolic and diastolic dysfunctions of the myocardium. Despite our initial understanding of the SIMD over the past three decades, the incidence and mortality of SIMD remain high. This may be attributed to the large degree of heterogeneity among the initiating factors, disease processes, and host states involved in SIMD. Previously, organ dysfunction caused by sepsis was thought to be an impairment brought about by an excessive inflammatory response. However, many recent studies have shown that SIMD is a consequence of a combination of factors shaped by the inflammatory responses between the pathogen and the host. In this article, we review the mechanisms of the inflammatory responses and potential novel therapeutic strategies in SIMD.