Coagulopathy in COVID-19

Clinical Characteristics of COVID-19-Related Reversible Cerebral Vasoconstriction Syndrome: A Systematic Review of Case Series

Background and Objectives: Although reversible cerebral vasoconstriction syndrome (RCVS) is a rare disease, the condition may occur with COVID-19 infection. We aimed to investigate the clinical characteristics of RCVS through a systematic review of case reports and case series that reported on COVID-19-related RCVS. Methods: A literature search was performed in PubMed (MEDLINE), SCOPUS, and Web of Science. The search was confined to articles published between 17 November 2019 and 14 August 2024. The search terms were ("COVID-19" OR "SARS CoV-2") AND ("RCVS" OR "Reversible cerebral vasoconstriction syndrome"). The search protocol was registered in PROSPERO (CRD42024491818). A total of twenty-four cases were included, nine case series consisting of nineteen cases and five cases from our hospital. Clinical characteristics were investigated, including risk factors, symptoms, brain and angiographic findings, treatment options, and prognoses. Results: The average age was 37.1 years, and females comprised 70.8% of the cohort. COVID-19 vaccination was administered in five cases. Vasoconstriction was most frequently noted in middle cerebral arteries (90.9%). Among the included patients, 12 (50.0%) experienced strokes as a complication of RCVS, and the mortality rate was 9.1%. Follow-up imaging findings were available for 14 of the 24 cases (58.3%). Among these, vasoconstriction was fully improved in 64.3%, partially improved in 28.6%, and aggravated in 7.1%. Conclusions: While the recovery rate of vasoconstriction on brain angiographic findings was not uncommon, our systematic review indicates a potential for a relatively poor neurological prognosis in COVID-19-related RCVS.

COVID-19 vaccines: Immune correlates and clinical outcomes

Severe disease due to COVID-19 has declined dramatically as a result of widespread vaccination and natural immunity in the population. With the emergence of SARS-CoV-2 variants that largely escape vaccine-elicited neutralizing antibody responses, the efficacy of the original vaccines has waned and has required vaccine updating and boosting. Nevertheless, hospitalizations and deaths due to COVID-19 have remained low. In this review, we summarize current knowledge of immune responses that contribute to population immunity and the mechanisms how vaccines attenuate COVID-19 disease severity.

Clinical practice guidelines for management of disseminated intravascular coagulation in Japan 2024. Part 1: sepsis

The Japanese Society on Thrombosis and Hemostasis (JSTH) published the first-ever disseminated intravascular coagulation (DIC) guidelines in 2009. Fifteen years later, the JSTH developed new guidelines covering DIC associated with various underlying conditions. These guidelines were developed in accordance with the GRADE system to determine the strength of the recommendations and certainty of the evidence. This article was drafted as Part 1 of an overall DIC guideline covering various underlying conditions, with sepsis as the subject. In this section, seven key clinical issues (questions) are set. Question 1, regarding DIC diagnosis, introduces several diagnostic criteria, such as the JAAM-2, ISTH overt, SIC, and JSTH DIC criteria and recommends choosing the appropriate diagnostic criteria for DIC based on an understanding of their diagnostic properties. For pharmacotherapy in DIC patients with sepsis, we recommend the administration of antithrombin (Question 2) and recombinant thrombomodulin (Question 3) (both GRADE 1B). However, we do not make a clear recommendation regarding the administration of heparin (Question 6) and serine protease inhibitors (Question 7) because of the lack of evidence. Combination therapy, order of administration, and other administration methods for antithrombin and recombinant thrombomodulin are proposed as important future research questions (Questions 4 and 5).

Increased circulating platelet-derived extracellular vesicles in severe COVID-19 disease

Coagulation disturbances are major contributors to COVID-19 pathogenicity, but limited data exist on the involvement of extracellular vesicles (EVs) and residual cells (RCs). Fifty hospitalized COVID-19 patients stratified by their D-dimer levels into high (>1.5 mg/L, n = 15) or low (≤1.5 mg/l, n = 35) and 10 healthy controls were assessed for medium-sized EVs (mEVs; 200-1000 nm) and large EVs/RCs (1000-4000 nm) by high sensitivity flow cytometry. EVs were analyzed for CD61, CD235a, CD45, and CD31, commonly used to detect platelets, red blood cells, leukocytes or endothelial cells, respectively, whilst phosphatidyl serine EVs/RCs were detected by lactadherin-binding implicating procoagulant catalytic surface. Small EV detection (sEVs; 50-200 nm) and CD41a (platelet integrin) colocalization with general EV markers CD9, CD63, and CD81 were performed by single particle interferometric reflectance imaging sensor. Patients with increased D-dimer exhibited the highest number of RCs and sEVs irrespective of cell origin (p < .05). Platelet activation, reflected by increased CD61+ and lactadherin+ mEV and RC levels, associated with coagulation disturbances. Patients with low D-dimer could be discriminated from controls by tetraspanin signatures of the CD41a+ sEVs, suggesting the changes in the circulating platelet sEV subpopulations may offer added prognostic value during COVID progression.

Correlation of Triethylamine N-oxide (TMAO), LPS, and TNF-Alpha Levels With Clinical Features of the Disease in Patients With and Without Septic Shock Infected With COVID-19 Virus

BACKGROUND

Inflammation is a response of the immune system to protect the body against various diseases or injuries. Serum trimethylamine N-oxide (TMAO) levels may vary depending on age, gender, habits, comorbidities, and microbiota.

AIMS

In this study, we investigated whether TMAO levels have diagnostic significance and their potential as a marker in the early diagnosis of the disease. Another aim of the research was to identify changes in TMAO levels as a reflection of the deterioration in the microflora, and IL-6, IL-10, IL-1β, TNF-alpha, and LPS levels in patient groups. Then, we recognized relationships between these parameters in patients infected with COVID-19 without septic shock and with COVID-19 who were without transmission of COVID-19 in septic shock.

STUDY DESIGN

A total of 160 patients were investigated, including 40 patients infected with COVID-19 without septic contact, 40 patients with COVID-19 positive septic shock, 40 patients with COVID-19 negative septic shock, and 40 healthy individuals as the control group.

RESULTS

TNF-α and IL-1β levels were significantly lower (P < 0.001) and IL-6 and IL-10 levels were significantly higher (P < 0.001) in patient groups than in control groups. IL-1β showed a significant decrease, especially in the groups infected with COVID-19. Although IL-6, increased even more in the groups infected with COVID-19.

CONCLUSIONS

LPS level was remarkably high in the sepsis group infected with COVID-19 compared to the other groups. TMAO level was significantly higher (P < 0.001) in the sepsis group. Therefore, TMAO is a potential biomarker in sepsis and septic shock.

Does COVID-19 Trigger the Risk for the Development of Parkinson's Disease? Therapeutic Potential of Vitamin C

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which was proclaimed a pandemic by the World Health Organization (WHO) in March 2020. There is mounting evidence that older patients with multimorbidity are more susceptible to COVID-19 complications than are younger, healthy people. Having neuroinvasive potential, SARS-CoV-2 infection may increase susceptibility toward the development of Parkinson's disease (PD), a progressive neurodegenerative disorder with extensive motor deficits. PD is characterized by the aggregation of α-synuclein in the form of Lewy bodies and the loss of dopaminergic neurons in the dorsal striatum and substantia nigra pars compacta (SNpc) of the nigrostriatal pathway in the brain. Increasing reports suggest that SARS-CoV-2 infection is linked with the worsening of motor and non-motor symptoms with high rates of hospitalization and mortality in PD patients. Common pathological changes in both diseases involve oxidative stress, mitochondrial dysfunction, neuroinflammation, and neurodegeneration. COVID-19 exacerbates the damage ensuing from the dysregulation of those processes, furthering neurological complications, and increasing the severity of PD symptomatology. Phytochemicals have antioxidant, anti-inflammatory, and anti-apoptotic properties. Vitamin C supplementation is found to ameliorate the common pathological changes in both diseases to some extent. This review aims to present the available evidence on the association between COVID-19 and PD, and discusses the therapeutic potential of vitamin C for its better management.

MLKL-mediated endothelial necroptosis drives vascular damage and mortality in systemic inflammatory response syndrome

The hypersecretion of cytokines triggers life-threatening systemic inflammatory response syndrome (SIRS), leading to multiple organ dysfunction syndrome (MODS) and mortality. Although both coagulopathy and necroptosis have been identified as important factors in the pathogenesis of SIRS, the specific cell types that undergo necroptosis and the interrelationships between coagulopathy and necroptosis remain unclear. In this study, we utilized visualization analysis via intravital microscopy to demonstrate that both anticoagulant heparin and nonanticoagulant heparin (NAH) pretreatment protect mice against TNF-α-induced mortality in SIRS. Moreover, the deletion of Mlkl or Ripk3 resulted in decreased coagulation and reduced mortality in TNF-α-induced SIRS. These findings suggest that necroptosis plays a key role upstream of coagulation in SIRS-related mortality. Furthermore, using a genetic lineage tracing mouse model (Tie2-Cre;Rosa26-tdT), we tracked endothelial cells (ECs) and verified that EC necroptosis is responsible for the vascular damage observed in TNF-α-treated mice. Importantly, Mlkl deletion in vascular ECs in mice had a similar protective effect against lethal SIRS by blocking EC necroptosis to protect the integrity of the endothelium. Collectively, our findings demonstrated that RIPK3-MLKL-dependent necroptosis disrupted vascular integrity, resulting in coagulopathy and multiorgan failure, eventually leading to mortality in SIRS patients. These results highlight the importance of targeting vascular EC necroptosis for the development of effective treatments for SIRS patients.

Post-translational modifications of fibrinogen: implications for clotting, fibrin structure and degradation

Fibrinogen, a blood plasma protein with a key role in hemostasis and thrombosis, is highly susceptible to post-translational modifications (PTMs), that significantly influence clot formation, structure, and stability. These PTMs, which include acetylation, amidation, carbamylation, citrullination, dichlorination, glycation, glycosylation, guanidinylation, hydroxylation, homocysteinylation, malonylation, methylation, nitration, oxidation, phosphorylation and sulphation, can alter fibrinogen biochemical properties and affect its functional behavior in coagulation and fibrinolysis. Oxidation and nitration are notably associated with oxidative stress, impacting fibrin fiber formation and promoting the development of more compact and resistant fibrin networks. Glycosylation and glycation contribute to altered fibrinogen structural properties, often resulting in changes in fibrin clot density and susceptibility to lysis, particularly in metabolic disorders like diabetes. Acetylation and phosphorylation, influenced by medications such as aspirin, modulate clot architecture by affecting fiber thickness and clot permeability. Citrullination and homocysteinylation, although less studied, are linked to autoimmune conditions and cardiovascular diseases, respectively, affecting fibrin formation and stability. Understanding these modifications provides insights into the pathophysiology of thrombotic disorders and highlights potential therapeutic targets. This review comprehensively examines the current literature on fibrinogen PTMs, their specific sites, biochemical pathways, and their consequences on fibrin clot architecture, clot formation and clot lysis.

Dietary Antioxidants and Natural Compounds in Preventing Thrombosis and Cardiovascular Disease

Reactive oxygen species (ROS) contribute to endothelial dysfunction, platelet activation, and coagulation abnormalities, promoting thrombus formation. Given the growing interest in non-pharmacological approaches to modulate oxidative stress, we examine the potential of various dietary interventions and antioxidant supplementation in reducing oxidative damage and preventing thrombotic events. Key dietary patterns, such as the Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and ketogenic diets, as well as antioxidant-rich supplements like curcumin, selenium, and polyphenols, demonstrate promising effects in improving oxidative stress markers, lipid profiles, and inflammatory responses. This review highlights recent advances in the field, drawing from in vitro, ex vivo, and clinical studies, and underscores the importance of integrating dietary strategies into preventive and therapeutic approaches for managing thrombosis and cardiovascular health. Further research is needed to better understand long-term effects and personalize these interventions for optimizing patient outcomes.

Prognostic model for gastric cancer patients with COVID-19 and network pharmacology study on treatment by lentinan

Patients with gastric cancer (GC) are more susceptible to coronavirus disease 2019 (COVID-19), which further worsens their already challenging prognosis. However, there are no effective treatment options for these patients. Lentinan is a potent bioactive component with antiviral and antitumor effects. We hypothesized that lentinan might exert powerful pharmacological effects in patients with GC and COVID-19. In this study, a prognostic model of patients with GC/COVID-19 was constructed and used to apply a network pharmacology approach to reveal biological functions, drug targets, and molecular mechanisms of the action of lentinan against GC/COVID-19. Clinical analysis revealed key prognostic genes in patients with GC/COVID-19. The results of network pharmacology analysis suggested that the therapeutic effect of lentinan on GC/COVID-19 mainly involves the modulation of several neutrophil-related biological processes, as well as the nucleotide-binding and oligomerization domain-like receptor and interleukin-17 signaling pathways. In addition, C-X-C motif chemokine ligand 8, vascular endothelial growth factor A, ribonuclease 3, and F2 were identified as key genes of lentinan against GC/COVID-19. Key prognostic genes were identified in patients with GC/COVID-19 through the construction of a prognostic model. Pharmacological functions and signaling pathways of lentinan against GC/COVID-19 were revealed. These included the regulation of neutrophils and NOD-like receptor signaling pathways. The findings provide the first published evidence of the potential value of lentinan as a complementary therapy for GC/COVID-19.

Incidence of heparin resistance and heparin failure in patients receiving extracorporeal membrane oxygenation: an exploratory retrospective analysis

BACKGROUND

Unfractionated heparin (UFH) is used in most centers for extracorporeal membrane oxygenation (ECMO) anticoagulation. When standard doses do not achieve desired target values, heparin resistance is reported, most commonly defined as doses of UFH > 35 000 IU/d.

OBJECTIVES

To study the incidence of heparin resistance and its association with thromboembolic complications in patients requiring ECMO support.

METHODS

In this observational cohort study, we included adults who received venovenous, venoarterial ECMO and extracorporeal carbon dioxide removal between January 2010 and May 2022. Main risk factor was heparin resistance (UFH, > 35 000 IU/d or > 20 IU/kg/h); the outcome was thromboembolism. Multivariable Poisson regression was used to estimate the effects of heparin resistance, adjusted for several clinical variables on the thromboembolism rate per 100 ECMO patient-days.

RESULTS

Of the 197 patients included, 33 (16.8%) required UFH > 35 000 IU/d and 14 (7.1%) required UFH > 20 IU/kg/h. Thromboembolic complications occurred at a rate of 5.89/100 ECMO d. Heparin resistance was not associated with thromboembolic events (incidence rate ratio [IRR], 0.93; 95% CI, 0.14-5.82), whereas COVID-19 (IRR, 2.33; 95% CI, 1.4-3.96; P < .001) and ECMO type (venoarterial ECMO: IRR, 2.29; 95% CI, 1.34-3.92; P = .002; extracorporeal carbon dioxide removal: IRR, 2.89; 95% CI, 1.46-5.59; P = .002; reference venovenous ECMO) were significantly associated with the risk of thromboembolic events.

CONCLUSION

A significant proportion of patients fulfilled the common definition of heparin resistance. However, this did not influence the occurrence of thromboembolic events.

Heparin therapy in sepsis and sepsis-associated disseminated intravascular coagulation: a systematic review and meta-analysis

BACKGROUND

Sepsis is a life-threatening condition that affects 49 million people annually. Managing sepsis-associated coagulopathy poses a significant challenge due to its high mortality rates in intensive care. Recent reports suggest that administering heparin may offer potential survival benefits in sepsis and coronavirus disease cases. However, there is currently no established evidence supporting the use of heparin for sepsis. Thus, in this study, we aimed to assess the efficacy of heparin administration in patients with sepsis.

METHODS

A systematic review was conducted following the PRISMA guidelines. The searches included MEDLINE, Cochrane, and Japanese databases up to January 2023. The inclusion criteria consisted of randomized control trials (RCTs) involving adult sepsis patients receiving heparin. The risk of bias was assessed using RoB2, and the data extraction included 28-day mortality and bleeding complications.

RESULTS

Out of 1733 initial articles, only three studies met the inclusion criteria. The analysis, which included 426 patients, showed no significant difference in 28-day and in-hospital mortality between the heparin and control groups (risk ratio [RR] = 0.86, 95% confidence interval [CI]: 0.60-1.24). Subgroup analysis of sepsis-associated disseminated intravascular coagulation (DIC) patients (n = 109) also did not show a significant reduction in mortality (RR = 0.84, 95% CI: 0.51-1.38). Heterogeneity was zero, and no publication bias was observed. Additionally, there was significant difference in bleeding complications (RR = 0.49, 95% CI: 0.24-0.99, p = 0.047).

CONCLUSIONS

This meta-analysis did not demonstrate a survival benefit of heparin administration in patients with sepsis and sepsis-associated DIC. Further investigation into the potential benefits of heparin is warranted. Moreover, the analysis revealed no increase in bleeding risks with heparin administration; instead, a significant reduction in the risk of bleeding was noted.

TRIAL REGISTRATION

This review was preregistered with PROSPERO (registration: CRD42023385091).

Chemical Synthesis and Structure-Activity Relationship Studies of the Coagulation Factor Xa Inhibitor Tick Anticoagulant Peptide from the Hematophagous Parasite Ornithodoros moubata

Tick Anticoagulant Peptide (TAP), a 60-amino acid protein from the soft tick Ornithodoros moubata, inhibits activated coagulation factor X (fXa) with almost absolute specificity. Despite TAP and Bovine Pancreatic Trypsin Inhibitor (BPTI) (i.e., the prototype of the Kunitz-type protease inhibitors) sharing a similar 3D fold and disulphide bond topology, they have remarkably different amino acid sequence (only ~24% sequence identity), thermal stability, folding pathways, protease specificity, and even mechanism of protease inhibition. Here, fully active and correctly folded TAP was produced in reasonably high yields (~20%) by solid-phase peptide chemical synthesis and thoroughly characterised with respect to its chemical identity, disulphide pairing, folding kinetics, conformational dynamics, and fXa inhibition. The versatility of the chemical synthesis was exploited to perform structure-activity relationship studies on TAP by incorporating non-coded amino acids at positions 1 and 3 of the inhibitor. Using Hydrogen-Deuterium Exchange Mass Spectrometry, we found that TAP has a remarkably higher conformational flexibility compared to BPTI, and propose that these different dynamics could impact the different folding pathway and inhibition mechanisms of TAP and BPTI. Hence, the TAP/BPTI pair represents a nice example of divergent evolution, while the relative facility of TAP synthesis could represent a good starting point to design novel synthetic analogues with improved pharmacological profiles.

ADAMTS13 or Caplacizumab Reduces the Accumulation of Neutrophil Extracellular Traps and Thrombus in Whole Blood of COVID-19 Patients under Flow

BACKGROUND

 Neutrophil NETosis and neutrophil extracellular traps (NETs) play a critical role in pathogenesis of coronavirus disease 2019 (COVID-19)-associated thrombosis. However, the extents and reserve of NETosis, and potential of thrombus formation under shear in whole blood of patients with COVID-19 are not fully elucidated. Neither has the role of recombinant ADAMTS13 or caplacizumab on the accumulation of NETs and thrombus in COVID-19 patients' whole blood under shear been investigated.

METHODS

 Flow cytometry and microfluidic assay, as well as immunoassays, were employed for the study.

RESULTS

 We demonstrated that the percentage of H3Cit + MPO+ neutrophils, indicative of NETosis, was dramatically increased in patients with severe but not critical COVID-19 compared with that in asymptomatic or mild disease controls. Upon stimulation with poly [I:C], a double strain DNA mimicking viral infection, or bacterial shigatoxin-2, the percentage of H3Cit + MPO+ neutrophils was not significantly increased in the whole blood of severe and critical COVID-19 patients compared with that of asymptomatic controls, suggesting the reduction in NETosis reserve in these patients. Microfluidic assay demonstrated that the accumulation of NETs and thrombus was significantly enhanced in the whole blood of severe/critical COVID-19 patients compared with that of asymptomatic controls. Like DNase I, recombinant ADAMTS13 or caplacizumab dramatically reduced the NETs accumulation and thrombus formation under arterial shear.

CONCLUSION

 Significantly increased neutrophil NETosis, reduced NETosis reserve, and enhanced thrombus formation under arterial shear may play a crucial role in the pathogenesis of COVID-19-associated coagulopathy. Recombinant ADAMTS13 or caplacizumab may be explored for the treatment of COVID-19-associated thrombosis.

Protein C and S activities in COVID-19: A systematic review and meta-analysis

COVID-19 has been associated with alterations in coagulation. Recent reports have shown that protein C and S activities are altered in COVID-19. This may affect the complications and outcome of the disease. However, their exact role in COVID-19 remains uncertain. The aim of the current study was therefore to analyze all papers in the literature on protein C and S activities in COVID-19. We searched three medical electronic databases. Of the 2442 papers, 28 studies were selected for the present meta-analysis. For the meta-analysis, means ± standard deviations with 95% confidence intervals (CI) for protein C and S activities were extracted. Pooled p values were calculated using STATA software. Protein C and S activities were significantly lower in COVID-19 patients than in healthy controls (pooled p values: 0.04 and 0.02, respectively). Similarly, protein C activities were considerably lower in nonsurviving patients (pooled p value = 0.00). There was no association between proteins C or S and thrombosis risk or ICU admission in COVID-19 patients (p value > 0.05). COVID-19 patients may exhibit lower activities of the C and S proteins, which might affect disease outcome; however, additional attention should be given when considering therapeutic strategies for these patients.

Early postoperative COVID infection is associated with significantly increased risk of venous thromboembolism after metabolic and bariatric surgery

BACKGROUND

Patients who undergo metabolic and bariatric surgery (MBS) are at risk for thromboembolism. Patients are susceptible to coronavirus throughout the perioperative period, which also has a well-known association with thrombotic complications.

OBJECTIVES

To identify and define the association between venous thromboembolism (VTE) and postoperative coronavirus diagnosis in bariatric surgery patients.

SETTING

United States.

METHODS

We conducted a retrospective cohort study using the MBS Accreditation and Quality Improvement Program (MBSAQIP) 2021 database to analyze the incidence of VTE within 30 days of surgery. VTE was a composite variable defined as either postoperative pulmonary embolism or postoperative venous thrombus requiring treatment. Cohorts were stratified by whether the patient was diagnosed with postoperative coronavirus. We created a multivariable logistic regression model to determine the adjusted odds of postoperative VTE based on various factors. Additionally, we conducted subset analyses of sleeve gastrectomy and Roux-en-Y bypass cases, the 2 most frequent bariatric operations in the United States.

RESULTS

Patients diagnosed with postoperative coronavirus were significantly more likely to develop postoperative VTE (1.1% versus .3%, P < .001). In our logistic regression model, the adjusted odds of postoperative VTE for patients with postoperative coronavirus was 3.55 (95% CI: 2.15-5.87, P < .001). For patients who underwent Roux-en-Y bypass, the adjusted odds was even greater at 5.69 (95% CI: 2.76-11.70, P < .001).

CONCLUSIONS

Early postoperative coronavirus infection after MBS is associated with higher odds of postoperative VTE. This persisted on subset analyses of the 2 most common procedures and appeared particularly important for Roux-en-Y bypass. COVID infection after MBS may warrant prolonged VTE prophylaxis.

Impaired instructive and protective barrier functions of the endothelial cell glycocalyx pericellular matrix is impacted in COVID-19 disease

The aim of this study was to review the roles of endothelial cells in normal tissue function and to show how COVID-19 disease impacts on endothelial cell properties that lead to much of its associated symptomatology. This places the endothelial cell as a prominent cell type to target therapeutically in the treatment of this disorder. Advances in glycosaminoglycan analytical techniques and functional glycomics have improved glycosaminoglycan mimetics development, providing agents that can more appropriately target various aspects of the behaviour of the endothelial cell in-situ and have also provided polymers with potential to prevent viral infection. Thus, promising approaches are being developed to combat COVID-19 disease and the plethora of symptoms this disease produces. Glycosaminoglycan mimetics that improve endothelial glycocalyx boundary functions have promising properties in the prevention of viral infection, improve endothelial cell function and have disease-modifying potential. Endothelial cell integrity, forming tight junctions in cerebral cell populations in the blood-brain barrier, prevents the exposure of the central nervous system to circulating toxins and harmful chemicals, which may contribute to the troublesome brain fogging phenomena reported in cognitive processing in long COVID disease.

Are COVID-19 Polymorphisms in ACE and ACE2 Prognosis Predictors?

Regardless of the containment of the SARS-CoV-2 pandemic, it remains paramount to comprehensively understand its underlying mechanisms to mitigate potential future health and economic impacts, comparable to those experienced throughout the course of the pandemic. The angiotensin-converting enzyme 2 (ACE2) provides anchorage for SARS-CoV-2 binding, thus implicating that ACE and ACE2 might contribute to the variability in infection severity. This study aimed to elucidate predisposing factors influencing the disease course among people infected by SARS-CoV-2, focusing on angiotensin-converting enzyme (ACE) and ACE2 polymorphisms. Notably, despite similar demographics and comorbidities, COVID-19 patients exhibit substantial differences in prognosis. Genetic polymorphisms in ACE and ACE2 have been implicated in disease progression, prompting our investigation into their role in COVID-19 evolution. Using next-generation sequencing (NGS), we analyzed ACE and ACE2 genes in a sample group comprising six subjects infected by SARS-CoV-2. Our findings revealed a correlation between specific polymorphisms and COVID-19 outcomes. Specifically, ACE and ACE2 intronic deletions were observed in all deceased patients, suggesting a potential association with mortality. These results highlight the significance of genetic factors in shaping the clinical course of COVID-19, emphasizing the importance of further research into the impact of genetic variations on COVID-19 severity.

Total plasma N-glycomic signature of SARS-CoV-2 infection

Total plasma protein N-glycosylation (TPNG) changes are a hallmark of many diseases. Here, we analyzed the TPNG of 169 COVID-19 patients and 12 healthy controls, using mass spectrometry, resulting in the relative quantification of 85 N-glycans. We found a COVID-19 N-glycomic signature, with 59 glycans differing between patients and controls, many of them additionally differentiating between severe and mild COVID-19. Tri- and tetra-antennary N-glycans were increased in patients, showing additionally elevated levels of antennary α2,6-sialylation. Conversely, bisection of di-antennary, core-fucosylated, nonsialylated glycans was low in COVID-19, particularly in severe cases, potentially driven by the previously observed low levels of bisection on antibodies of severely diseased COVID-19 patients. These glycomic changes point toward systemic changes in the blood glycoproteome, particularly involvement of acute-phase proteins, immunoglobulins and the complement cascade. Further research is needed to dissect glycosylation changes in a protein- and site-specific way to obtain specific functional leads.

Endothelial biomarkers (Von willebrand factor, BDCA3, urokinase) as predictors of mortality in COVID-19 patients: cohort study

BACKGROUND

SARS-CoV-2 is a systemic disease that affects endothelial function and leads to coagulation disorders, increasing the risk of mortality. Blood levels of endothelial biomarkers such as Von Willebrand Factor (VWF), Thrombomodulin or Blood Dendritic Cell Antigen-3 (BDCA3), and uUokinase (uPA) increase in patients with severe disease and can be prognostic indicators for mortality. Therefore, the aim of this study was to determine the effect of VWF, BDCA3, and uPA levels on mortality.

METHODS

From May 2020 to January 2021, we studied a prospective cohort of hospitalized adult patients with polymerase chain reaction (PCR)-confirmed COVID-19 with a SaO2 ≤ 93% and a PaO2/FiO2 ratio < 300. In-hospital survival was evaluated from admission to death or to a maximum of 60 days of follow-up with Kaplan-Meier survival curves and Cox proportional hazard models as independent predictor measures of endothelial dysfunction.

RESULTS

We recruited a total of 165 subjects (73% men) with a median age of 57.3 ± 12.9 years. The most common comorbidities were obesity (39.7%), hypertension (35.4%) and diabetes (30.3%). Endothelial biomarkers were increased in non-survivors compared to survivors. According to the multivariate Cox proportional hazard model, those with an elevated VWF concentration ≥ 4870 pg/ml had a hazard ratio (HR) of 4.06 (95% CI: 1.32-12.5) compared to those with a lower VWF concentration adjusted for age, cerebrovascular events, enoxaparin dose, lactate dehydrogenase (LDH) level, and bilirubin level. uPA and BDCA3 also increased mortality in patients with levels ≥ 460 pg/ml and ≥ 3600 pg/ml, respectively.

CONCLUSION

The risk of mortality in those with elevated levels of endothelial biomarkers was observable in this study.

Role of microbiota-derived corisin in coagulation activation during SARS-CoV-2 infection

BACKGROUND

Coagulopathy is a major cause of morbidity and mortality in COVID-19 patients. Hypercoagulability in COVID-19 results in deep vein thrombosis, thromboembolic complications, and diffuse intravascular coagulation. Microbiome dysbiosis influences the clinical course of COVID-19. However, the role of dysbiosis in COVID-19-associated coagulopathy is not fully understood.

OBJECTIVES

The present study tested the hypothesis that the microbiota-derived proapoptotic corisin is involved in the coagulation system activation during SARS-CoV-2 infection.

METHODS

This cross-sectional study included 47 consecutive patients who consulted for symptoms of COVID-19. A mouse acute lung injury model was used to recapitulate the clinical findings. A549 alveolar epithelial, THP-1, and human umbilical vein endothelial cells were used to evaluate procoagulant and anticoagulant activity of corisin.

RESULTS

COVID-19 patients showed significantly high circulating levels of corisin, thrombin-antithrombin complex, D-dimer, tumor necrosis factor-α, and monocyte-chemoattractant protein-1 with reduced levels of free protein S compared with healthy subjects. The levels of thrombin-antithrombin complex, D-dimer, and corisin were significantly correlated. A monoclonal anticorisin-neutralizing antibody significantly inhibited the inflammatory response and coagulation system activation in a SARS-CoV-2 spike protein-associated acute lung injury mouse model, and the levels of corisin and thrombin-antithrombin complex were significantly correlated. In an in vitro experiment, corisin increased the tissue factor activity and decreased the anticoagulant activity of thrombomodulin in epithelial, endothelial, and monocytic cells.

CONCLUSION

The microbiota-derived corisin is significantly increased and correlated with activation of the coagulation system during SARS-CoV-2 infection, and corisin may directly increase the procoagulant activity in epithelial, endothelial, and monocytic cells.

Pulmonary perfusion in long-term survivors of COVID-19-related severe acute respiratory distress syndrome treated by extracorporeal membrane oxygenation

COVID-19 associates with a hypercoagulant state and an increased risk for venous thromboembolic events (VTEs). Whether severe COVID-19 infection requiring extracorporeal membrane oxygenation (ECMO) support might lead to chronic pulmonary perfusion abnormalities and chronic thromboembolic pulmonary disease/hypertension remains unclear. The purpose of this study was to evaluate chronic pulmonary perfusion abnormalities in long-term survivors of COVID-19-related severe acute respiratory distress syndrome (ARDS) treated by ECMO at our institution. Pulmonary perfusion was examined by ventilation/perfusion (V/Q) single-photon emission computed tomography or V/Q planar scintigraphy at least 3 months after ECMO explantation, comorbidities and incidence of thromboembolic events were recorded as well. Of 172 COVID-19 patients treated by ECMO for severe COVID-19 pneumonia between March 2020 and November 2021, only 80 were successfully weaned from ECMO. Of those, 37 patients were enrolled into the present analysis (27% female, mean age 52 years). Median duration of ECMO support was 12 days. In 24 (65%) patients VTE was recorded in the acute phase (23 patients developed ECMO cannula-related deep vein thrombosis, 5 of them had also a pulmonary embolism, and one thrombus was associated with a central catheter). The median duration between ECMO explantation and assessment of pulmonary perfusion was 420 days. No segmental or larger mismatched perfusion defects were then detected in any patient. In conclusion, in long-term survivors of COVID-19-related ARDS treated by ECMO, no persistent pulmonary perfusion abnormalities were detected although VTE was common.

Evaluation of the Efficacy of Therapeutic and Prophylactic Anticoagulation in COVID-19 Patients With Venous Catheter and Its Correlation With Clinical Outcomes

Introduction

The COVID-19 disease was first detected in December 2019, and since then, various treatments have been used to manage it. One such treatment method is therapeutic plasma exchange. This method involves implanting a venous catheter, which increases the risk of venous thromboembolism (VTE). Other risk factors for VTE include infections like COVID-19, inflammation, or malignancy.

Materials and Methods

In this retrospective study, patients with acute respiratory syndrome caused by COVID-19 who were hospitalized and had venous catheters inserted for therapeutic plasma exchange were enrolled. The prophylactic anticoagulant dose was started for all patients, and after the diagnosis of VTE, it was changed to the therapeutic dose. Patients' information, including demographic data, clinical information, and laboratory findings, was extracted from patients' records and recorded in a checklist designed for each patient.

Results

From a total of 168 patients, 26 were diagnosed with VTE (pulmonary embolism in 5 patients and deep vein thrombosis in 21 patients). The prevalence of VTE in COVID-19 patients with the venous catheter was 15.4%. The right femoral vein was the most used route for catheterization and had the highest occurrence of venous thromboses. The patients diagnosed with thrombosis showed a lower mortality rate, higher D-dimer and lactate dehydrogenase levels, and lower platelet counts.

Conclusions

This study showed a higher risk of VTE and subclinical thrombosis in COVID-19 patients with venous catheters. Continuous screening, higher doses of anticoagulants, and early removal of venous catheters are critical in preventing VTE and mortality.

Four years into the pandemic, managing COVID-19 patients with acute coagulopathy: what have we learned?

Coagulopathy alongside micro- and macrovascular thrombotic events were frequent characteristics of patients presenting with acute COVID-19 during the initial stages of the pandemic. However, over the past 4 years, the incidence and manifestations of COVID-19-associated coagulopathy have changed due to immunity from natural infection and vaccination and the appearance of new SARS-CoV-2 variants. Diagnostic criteria and management strategies based on early experience and studies for COVID-19-associated coagulopathy thus require reevaluation. As many other infectious disease states are also associated with hemostatic dysfunction, the coagulopathy associated with COVID-19 may be compounded, especially throughout the winter months, in patients with diverse etiologies of COVID-19 and other infections. This commentary examines what we have learned about COVID-19-associated coagulopathy throughout the pandemic and how we might best prepare to mitigate the hemostatic consequences of emerging infection agents.

Logistic regression analysis of the value of biomarkers, clinical symptoms, and imaging examinations in COVID-19 for SARS-CoV-2 nucleic acid detection

The detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) nucleic acid detection provides a direct basis for diagnosing Coronavirus Disease 2019. However, nucleic acid test false-negative results are common in practice and may lead to missed diagnosis. Certain biomarkers, clinical symptoms, and imaging examinations are related to SARS-CoV-2 nucleic acid detection and potential predictors. We examined nucleic acid test results, biomarkers, clinical symptoms, and imaging examination data for 116 confirmed cases and asymptomatic infections in Zhuhai, China. Patients were divided into nucleic acid-positive and -false-negative groups. Predictive values of biomarkers, symptoms, and imaging for the nucleic acid-positive rate were calculated by Least Absolute Shrinkage and Selection Operators regression analysis and binary logistic regression analysis, and areas under the curve of these indicators were calculated. Hemoglobin (OR = 1.018, 95% CI: 1.006-1.030; P = .004) was higher in the respiratory tract-positive group than the nucleic acid-negative group, but platelets (OR = 0.996, 95% CI: 0.993-0.999; P = .021) and eosinophils (OR = 0.013, 95% CI: 0.001-0.253; P = .004) were lower; areas under the curve were 0.563, 0.614, and 0.642, respectively. Some biomarkers can predict SARS-CoV-2 viral nucleic acid detection rates in Coronavirus Disease 2019 and are potential auxiliary diagnostic tests.

Fetal Diaphragmatic Excursion Is Decreased in Hospitalized Pregnant Women Infected with COVID-19 during the Second and Third Trimesters

OBJECTIVE

In the present study, we aimed to evaluate coronavirus disease 2019 (COVID-19) infection effects on fetal diaphragm thickness and diaphragmatic excursion, which together show the quality of diaphragmatic contractions.

STUDY DESIGN

One hundred and ninety-two pregnant women were included in this prospective case-control study. Patients were divided into four groups according to their COVID-19 infection history in their second or third trimester: hospitalized COVID-19-infected pregnant women group (n = 48), outpatient COVID-19-infected pregnant women group (n = 48), common cold (COVID-19 polymerase chain reaction negative) pregnant women group (n = 48), and noninfected healthy controls (n = 48). The number of patients was determined by power analysis following the pilot study. All participants underwent an ultrasound examination to determine fetal diaphragm parameters at 32 to 37 weeks of gestation.

RESULTS

Demographic characteristics were similar among the four groups. The gestational age at ultrasound examination and gestational age at delivery were similar among the groups. Neonatal intensive care unit (NICU) admission rate was significantly higher in the hospitalized COVID-19-infected pregnant women group than the other groups. The fetal diaphragm thickness during inspiration and expiration, and fetal costophrenic angles at inspiration and expiration were similar among the groups. Fetal diaphragmatic excursion was significantly decreased in the hospitalized COVID-19-infected pregnant women group compared with the other groups.

CONCLUSION

Our results indicated that moderate maternal COVID-19 infection decreased fetal diaphragmatic excursion, and ultrasonographic evaluation of fetal diaphragmatic excursion before delivery can provide critical information to predict whether infants will require NICU admission.

KEY POINTS

· Diaphragm ultrasound as a new technique for characterizing the diaphragm's structure and function.. · Fetal diaphragmatic excursion is decreased in the presence of moderate COVID-19 infection.. · Ultrasonographic evaluation of fetal diaphragmatic excursion provides critical information to predict NICU admission..

Modulation in serum and hematological parameters as a prognostic indicator of COVID-19 infection in hypertension, diabetes mellitus, and different cardiovascular diseases

SARS-CoV-2 infection affects and modulates serum as well as hematological parameters. However, whether it modifies these parameters in the existing disease conditions, which help in the erection of specific treatments for the disease, is under investigation. Here, we aimed to determine whether serum and hematological parameters alteration in various diseases, diabetes mellitus (DM), hypertension (HTN), ischemic heart disease (IHD) and myocardial infarction (MI) conditions correlate and signal SARS-CoV-2 infection, which could be used as a rapid diagnosis tool for SARS-CoV-2 infection in disease conditions. To assess the projected goals, we collected blood samples of 1,113 male and female patients with solo and multiple disease conditions of DM/HTN/IHD/MI with severe COVID-19, followed by biochemical analysis, including COVID-19 virus detection by RT-qPCR. Furthermore, blood was collected from age-matched disease and healthy individuals 502 and 660 and considered as negative control. In our results, we examined higher levels of serum parameters, including D-dimer, ferritin, hs-CRP, and LDH, as well as hematological parameters, including TLC in sole and multiple diseases (DM/HTN/IHD/MI) conditions compared to the control subjects. Besides, the hematological parameters, including Hb, RBC, and platelet levels, decreased in the patients. In addition, we found declined levels of leukocyte count (%), lymphocyte (%), monocyte (%), and eosinophil (%), and elevated level of neutrophil levels (%) in all the disease patients infected with SARS-CoV-2. Besides, NLR and NMR ratios were also statistically significantly (p < 0.05) high in the patients with solo and multiple disease conditions of DM/HTN/IHD/MI infected with the SARS-CoV-2 virus. In conclusion, rapid alteration of sera and hematological parameters are associated with SARS-CoV-2 infections, which could help signal COVID-19 in respective disease patients. Moreover, our results may help to improve the clinical management for the rapid diagnosis of COVID-19 concurrent with respective diseases.

How we manage a high D-dimer

D-dimer, a soluble fibrin degradation product that originates from plasmin-induced degradation of cross-linked fibrin, is an important biomarker of coagulation activation and secondary fibrinolysis that is routinely used to rule out venous thromboembolism (VTE), and to evaluate the risk of VTE recurrence, as well as the optimal duration of anticoagulant therapy. Besides VTE, D-dimer may be high due to physiologic conditions, including aging, pregnancy, and strenuous physical activity. In addition, several disorders have been associated with increased D-dimer levels, ranging from disseminated intravascular coagulation to infectious diseases and cancers. Thus, it is far from unusual for hematologists to have to deal with ambulatory individuals with increased D-dimer without signs or symptoms of thrombus formation. This narrative review is dedicated to the management of these cases by the hematologist.

Risk of post-tonsillectomy hemorrhage among COVID-19 positive pediatric patients

OBJECTIVE

COVID-19 infection has been demonstrated to increase risk for post-operative bleeding. This study investigated the impact of COVID-19 infection on post-tonsillectomy hemorrhage in pediatric patients, a potentially devastating complication.

STUDY DESIGN

Retrospective cohort study.

METHODS

The TriNetX database was queried for pediatric patients who underwent tonsillectomy and evaluated for outcomes of primary and secondary post-tonsillectomy hemorrhage.

RESULTS

Among subjects 18 years and younger, 1226 were COVID-19 positive and 38,241 were COVID-19 negative in the perioperative period. There was statistically significant increased risk of bleeding with perioperative COVID-19 infection at postoperative days 1, 5, and 10. Additionally, when assessing the role of COVID-19 infection before or after surgery, the risk of bleeding remained statistically significant at all three time points, however these results did not suggest that infection before surgery confers more/less risk compared to infection after.

CONCLUSION

The results of this investigation suggest that the presence of COVID-19 in the perioperative period may pose an increased risk for acute or delayed post tonsillectomy hemorrhage. This study employed a large, diverse population and is the first to address this clinical question.

Investigation of the relationship between coagulation parameters and mortality in COVID-19 infection

This study, which included patients over the age of 18 who were diagnosed with coronavirus disease 2019 (COVID-19) in the emergency clinic, aims to determine the relationship between coagulation parameters and mortality. Epidemiologic data such as age, gender, medical history, vital parameters at emergency department admission, clinical findings, coagulation parameters such as d-dimer, prothrombin time (PT), active partial thromboplastin time (aPTT), international normalized ration (INR), fibrinogen, and platelet were evaluated. Patients with positive computerized tomography (CT) findings and positive polymerase chain reaction (PCR) together were included in the study. It was revealed that d-dimer, fibrinogen, INR, and PT values were higher in the elderly group. It was shown that there was a significant relationship between hospitalization days (ward or intensive care unit) and d-dimer levels. It was observed that d-dimer, fibrinogen elevation was significantly associated with prognosis by increasing mortality, and that platelet and aPTT values were also associated with prognosis and were lower in the mortality group. On the other hand, in receiver operating characteristic (ROC) analysis, the sensitivity and specificity data were 80.3%/80.0% for d-dimer, 70.5%/72.2% for fibrinogen, 58.2%/59.4% for aPTT, and 59.7%/59.2% for platelet, respectively. The overall classification success was 88.6% and mortality prediction success was 37.7% in the regression model of some coagulation parameters (d-dimer, fibrinogen, aPTT, and platelet) which were effective on prognosis. In conclusion, it was determined that d-dimer, fibrinogen, aPTT, and platelet parameters were directly associated with mortality and when these coagulation parameters were used together with the clinical, vital, and demographic data of the patients, the success of mortality prediction increased significantly.

The fluorochrome-to-protein ratio is crucial for the flow cytometric detection of tissue factor on extracellular vesicles

Extracellular vesicles (EVs) have crucial roles in hemostasis and coagulation. They sustain coagulation by exposing phosphatidylserine and initiate clotting by surface expression of tissue factor (TF) under inflammatory conditions. As their relevance as biomarkers of coagulopathy is increasingly recognized, there is a need for the sensitive and reliable detection of TF+ EVs, but their flow cytometric analysis is challenging and has yielded controversial findings for TF expression on EVs in the vascular system. We investigated the effect of different fluorochrome-to-protein (F/P) ratios of anti-TF-fluorochrome conjugates on the flow cytometric detection of TF+ EVs from activated monocytes, mesenchymal stem cells (MSCs), and in COVID-19 plasma. Using a FITC-labeled anti-TF antibody (clone VD8), we show that the percentage of TF+ EVs declined with decreasing F/P ratios. TF was detected on 7.6%, 5.4%, and 1.1% of all EVs derived from activated monocytes at F/P ratios of 7.7:1, 6.6:1, and 5.2:1. A similar decline was observed for EVs from MSCs and for EVs in plasma, whereas the detection of TF on cells remained unaffected by different F/P ratios. We provide clear evidence that next to the antibody clone, the F/P ratio affects the flow cytometric detection of TF+ EVs and should be carefully controlled.

Small Molecules for the Treatment of Long-COVID-Related Vascular Damage and Abnormal Blood Clotting: A Patent-Based Appraisal

People affected by COVID-19 are exposed to, among others, abnormal clotting and endothelial dysfunction, which may result in deep vein thrombosis, cerebrovascular disorders, and ischemic and non-ischemic heart diseases, to mention a few. Treatments for COVID-19 include antiplatelet (e.g., aspirin, clopidogrel) and anticoagulant agents, but their impact on morbidity and mortality has not been proven. In addition, due to viremia-associated interconnected prothrombotic and proinflammatory events, anti-inflammatory drugs have also been investigated for their ability to mitigate against immune dysregulation due to the cytokine storm. By retrieving patent literature published in the last two years, small molecules patented for long-COVID-related blood clotting and hematological complications are herein examined, along with supporting evidence from preclinical and clinical studies. An overview of the main features and therapeutic potentials of small molecules is provided for the thromboxane receptor antagonist ramatroban, the pan-caspase inhibitor emricasan, and the sodium-hydrogen antiporter 1 (NHE-1) inhibitor rimeporide, as well as natural polyphenolic compounds.

Prevalence and Predictive Factors of Rhabdomyolysis in COVID-19 Patients: A Cross-sectional Study

Introduction

The aim of the present prospective observational study was to demonstrate the prevalence and predictive factors of rhabdomyolysis in coronavirus disease 2019 (COVID-19) patients.

Methods

The study was performed on reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 patients admitted to the emergency department between March 2020 and March 2021. Peak creatinine phosphokinase (CPK) levels were used to define rhabdomyolysis. A CPK level equal to or more than 1000 IU/L was defined as the presence of moderate to severe rhabdomyolysis. We developed a COVID-19-related Rhabdomyolysis Prognostic rule (CORP rule) using the independent predictors of rhabdomyolysis in COVID-19 patients.

Results

Five hundred and six confirmed COVID-19 patients (mean age 58.36 ± 17.83 years, 56.32% male) were studied. Rhabdomyolysis occurred in 44 (8.69%) cases throughout their hospitalization. Male gender (odds ratio [OR] = 2.78, 95% confidence interval [CI]: 1.28, 6.00), hyponatremia (OR = 2.46, 95% CI: 1.08, 5.59), myalgia (OR = 3.04, 95% CI: 1.41, 6.61), D-dimer >1000 (OR = 2.84, 95% CI: 1.27, 6.37), and elevated aspartate aminotransferase level (three times higher than normal range) (OR = 3.14, 95% CI: 1.52, 6.47) were the significant preliminary predictors of rhabdomyolysis. The area under the curve of the CORP rule was 0.75 (95% CI: 0.69, 0.81), indicating the fair performance of it in the prognosis of rhabdomyolysis following COVID-19 infection. The best cutoff of the CORP rule was 3, which had a sensitivity of 72.9% and a specificity of 72.7%.

Conclusion

This prospective study showed that 8.69% of patients developed rhabdomyolysis following COVID-19 infection. The CORP rule with optimal cutoff can correctly classify 72.8% of COVID-19 patients at risk of developing rhabdomyolysis.

Report of the ISTH registry on pregnancy and COVID-19-associated coagulopathy (COV-PREG-COAG)

Background

Concerns about COVID-19-associated coagulopathy (CAC) in pregnant individuals were raised in early pandemic.

Methods

An ISTH-sponsored COVID-19 coagulopathy in pregnancy (COV-PREG-COAG) international registry was developed to describe incidence of coagulopathy, VTE, and anticoagulation in this group.

Results

All pregnant patients with COVID-19 from participating centers were entered, providing 430 pregnancies for the first pandemic wave. Isolated abnormal coagulation parameters were seen in 20%; more often with moderate/severe disease than asymptomatic/mild disease (49% vs 15%; p < 0.0001). No one met the ISTH criteria for disseminated intravascular coagulopathy (DIC), though 5/21 (24%) met the pregnancy DIC score. There was no difference in antepartum hemorrhage (APH) with asymptomatic/mild disease versus moderate/severe disease (3.4% vs 7.7%; p = 0.135). More individuals with moderate/severe disease experienced postpartum hemorrhage (PPH) (22.4% vs 9.3%; p = 0.006). There were no arterial thrombotic events. Only one COVID-associated venous thromboembolism (VTE) was reported.

Conclusions

Low rates of coagulopathy, bleeding, and thrombosis were observed among pregnant people in the first pandemic wave.

Long peripheral cannula in COVID-19 patients: 769 catheter days experience from a semi-intensive respiratory COVID unit

BACKGROUND

In the daily management of peripheral venous access, the health emergency linked to the COVID-19 pandemic led to re-examining the criteria for choosing, positioning and maintaining the different types of peripheral venous access.

OBJECTIVES

This study aimed to observe the dwell time of long peripheral cannula (LPC, also known as mini-midline) in patients affected by COVID 19 related pneumonia. The secondary objective is to study any complications due to mini-midline insertion.

MATERIALS AND METHODS

We conducted a prospective observational study on COVID19 patients who arrived at our Semi-Intensive Respiratory Unit from territorial ED between January and April 2021, to whom were positioned an LPC at the time of admission following the SIPUA protocol (Safe Insertion of Peripheral Ultrasound-guided Access). We used Vygon™ Leader-Cath© 18G in polyethylene and 8 cm long catheter.

RESULTS

We enrolled 53 consecutive patients, reaching 769 catheter days. The procedure was performed without immediate complications in 37 patients out of 53 (69.8%). In 14 patients (26.4%), we observed a local hematoma (no one led to a failure or early removal of the device) and in two patients (3.7%) was not possible to draw blood. The average catheter dwell time was 14.5 days, from 3 to 41 days. In 42 patients (79.2%), the device was removed at the end of use. In 11 patients out of 53 (20.8%), the device was removed early due to complications: seven accidental removals, one obstruction, two vein thrombosis, and one superficial thrombophlebitis.

CONCLUSIONS

The ultrasound-guided implantation of an 18G LPC in COVID19 patients, regardless of the state of their venous heritage, would seem to be an excellent strategy for these patients, reducing the number of venipunctures and CVC implantation, as well as allowing multiple and high pressure (contrast) infusions.

Extracellular vesicles in plasma and cerebrospinal fluid in patients with COVID-19 and neurological symptoms

INTRODUCTION

Increased levels of extracellular vesicles (EVs) are associated with haemostatic disturbances in various clinical settings. However, their role in COVID-19 patients is still not fully clear. In the present study we investigated EVs in plasma from patients with COVID-19 and neurological symptoms in relation to the activation of coagulation.

METHODS

Nineteen COVID-19 patients with neurological symptoms and twenty-three aged-matched healthy individuals were included. Global coagulation assays were performed and levels of EVs were determined by flow-cytometry in plasma and cerebrospinal fluid (CSF).

RESULTS

A procoagulant state characterized by significantly increased overall coagulation- (OCP) and overall haemostatic potential (OHP), diminished overall fibrinolytic potential (OFP) together with a denser fibrin structure was found in patients with COVID-19. Flow cytometry revealed elevated levels of plasma circulating EVs derived from neutrophils (MPO+) and platelets (CD61+), as well as EVs expressing phosphatidylserine (PS+) and complement component C5b-9 (TCC+) in patients with COVID-19 compared with controls. The concentrations of PS+, CD61+ and TCC+ EVs were positively correlated with OCP and OHP in COVID-19 patients. Moreover, we identified CD61+, MPO+ and endothelial cell-derived EVs, as well as EVs exposing PS and TCC in the CSF of patients suffering from neurological symptoms during COVID-19.

CONCLUSION

The unique finding in this study was the presence of EVs in the CSF of COVID-19 patients with neurologic manifestations as well as higher expression of complement protein on circulating plasma EVs. EVs may indicate blood-brain barrier damage during SARS-COV-2 infection.

COVID-19: Not a thrombotic disease but a thromboinflammatory disease

While Coronavirus Disease in 2019 (COVID-19) may no longer be classified as a global public health emergency, it still poses a significant risk at least due to its association with thrombotic events. This study aims to reaffirm our previous hypothesis that COVID-19 is fundamentally a thrombotic disease. To accomplish this, we have undertaken an extensive literature review focused on assessing the comprehensive impact of COVID-19 on the entire hemostatic system. Our analysis revealed that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection significantly enhances the initiation of thrombin generation. However, it is noteworthy that the thrombin generation may be modulated by specific anticoagulants present in patients' plasma. Consequently, higher levels of fibrinogen appear to play a more pivotal role in promoting coagulation in COVID-19, as opposed to thrombin generation. Furthermore, the viral infection can stimulate platelet activation either through widespread dissemination from the lungs to other organs or localized effects on platelets themselves. An imbalance between Von Willebrand Factor (VWF) and ADAMTS-13 also contributes to an exaggerated platelet response in this disease, in addition to elevated D-dimer levels, coupled with a significant increase in fibrin viscoelasticity. This paradoxical phenotype has been identified as 'fibrinolysis shutdown'. To clarify the pathogenesis underlying these hemostatic disorders in COVID-19, we also examined published data, tracing the reaction process of relevant proteins and cells, from ACE2-dependent viral invasion, through induced tissue inflammation, endothelial injury, and innate immune responses, to occurrence of thrombotic events. We therefrom understand that COVID-19 should no longer be viewed as a thrombotic disease solely based on abnormalities in fibrin clot formation and proteolysis. Instead, it should be regarded as a thromboinflammatory disorder, incorporating both classical elements of cellular inflammation and their intricate interactions with the specific coagulopathy.

Cerebral venous thrombosis: a practical review

The evolution of the Coronavirus Disease-2019 pandemic and its vaccination raised more attention to cerebral venous thrombosis (CVT). Although CVT is less prevalent than arterial stroke, it results in larger years of life lost. CVT is more common in women and young patients. Predisposing factors are categorized as transient factors such as pregnancy, puerperium, oral contraceptive pills, trauma, and dehydration; and permanent factors such as neoplastic, vasculitic, thrombophilic, hematologic conditions, infectious causes such as severe acute respiratory syndrome coronavirus-2 infection and HIV. The most common manifestations are headache, seizures, focal neurologic deficits, altered level of consciousness, and cranial nerve palsies. The most common syndromes are stroke-like, raised-intracranial-pressure (ICP), isolated-headache, and encephalopathy, which may have overlaps. Diagnosis is mostly based on computed tomography, magnetic resonance imaging, and their respective venous sequences, supported by blood results abnormalities such as D-dimer elevation. Treatment includes the prevention of propagation of current thrombus with anticoagulation (heparin, or low molecular weight heparinoids and then warfarin, or direct oral anticoagulants), decreasing ICP (even by decompressive craniotomy), and treatment of specific underlying diseases.

Venous Thromboembolism in Patients Hospitalized for COVID-19 in a Non-Intensive Care Unit

Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) may contribute to venous thromboembolism (VTE) with adverse effects on the course of COVID-19. The purpose of this study was to investigate an incidence and risk factors for VTE in patients hospitalized for COVID-19 in a non-intensive care unit (non-ICU). Consecutive adult patients with COVID-19 hospitalized from November 2021 to March 2022 in the isolation non-ICU at our center were included in the study. Incidence of VTE including pulmonary embolism (PE) and deep vein thrombosis (DVT), clinical characteristics, and D-dimer plasma levels during the hospitalization were retrospectively evaluated. Among the 181 patients (aged 68.8 ± 16.2 years, 44% females, 39% Delta SARS-CoV-2 variant, 61% Omicron SARS-CoV-2 variant), VTE occurred in 29 patients (VTE group, 16% of the entire cohort). Of them, PE and DVT were diagnosed in 15 (8.3% of the entire cohort) and 14 (7.7%) patients, respectively. No significant differences in clinical characteristics were observed between the VTE and non-VTE groups. On admission, median D-dimer was elevated in both groups, more for VTE group (1549 ng/mL in VTE vs. 1111 ng/mL in non-VTE, p = 0.09). Median maximum D-dimer was higher in the VTE than in the non-VTE group (5724 ng/mL vs. 2200 ng/mL, p < 0.005). In the univariate analysis, systemic arterial hypertension and the need for oxygen therapy were predictors of VTE during hospitalization for COVID-19 (odds ratio 2.59 and 2.43, respectively, p < 0.05). No significant associations were found between VTE risk and other analyzed factors; however, VTE was more likely to occur in patients with a history of VTE, neurological disorders, chronic pulmonary or kidney disease, atrial fibrillation, obesity, and Delta variant infection. Thromboprophylaxis (83.4% of the entire cohort) and anticoagulant treatment (16.6%) were not associated with a decreased VTE risk. The incidence of VTE in patients hospitalized in non-ICU for COVID-19 was high despite the common use of thromboprophylaxis or anticoagulant treatment. A diagnosis of arterial hypertension and the need for oxygen therapy were associated with an increased VTE risk. Continuous D-dimer monitoring is required for the early detection of VTE.

Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States

BACKGROUND

During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists.

METHODS

The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals.

RESULTS

150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock.

CONCLUSIONS

Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.

Femoral nerve palsy as a complication due to COVID-19 coagulopathy and iliopsoas muscle hematoma - case report

BACKGROUND

COVID-19 (Coronavirus disease 2019) pandemic is the main medical problem around the world from the end of 2019. We found until now many symptoms of this disease, but one of the most problematic was thrombosis. Wide recommendation on COVID-19 treatment was pharmacological thromboprophylaxis. In some papers we found that clinicians face the problem of bleeding in those patients. Is still unknown that coronavirus could led to the coagulopathy.

CASE PRESENTATION

We described case report of patient who with COVID-19 disease present femoral nerve palsy caused by the iliopsoas hematoma. There were no deviations in coaguology parameters, patient got standard thromboprophylaxis, besides above probably COVID-19 was risk factor of hematoma formation. Non-operative treatment was applied, thrombophylaxis was discontinued. In the follow up in the radiological exam we saw reduction of the haematoma and patient report decrease of symptoms.

CONCLUSIONS

We should assess individually patient with COVID-19 according to thrombosis risk factors. Probably we should be more careful in ordering thrombophylaxis medications in COVID-19 patients.

Perioperative complications among head and neck surgery patients with COVID-19

BACKGROUND

Patients undergoing surgery for head and neck cancer (HNC) have potentially high perioperative complication rates. Recent studies indicate that preoperative COVID-19 infection poses increased risk for postoperative complications in other fields. However, to date, there has not been data showing the effect of COVID-19 on complication rates for HNC. Here, a large database was employed to assess if perioperative COVID-19 increased the risk of perioperative complications among those undergoing HNC surgery.

METHODS

A retrospective investigation was conducted using a multi-institutional research database. Subjects who underwent HNC surgery from January 2020 to September 2022 were identified using the International Classification of Diseases and Current Procedure Terminology codes. Thirty-day surgical and medical complications were assessed for those diagnosed with COVID-19 infection from 7 days before or after surgery compared to those who were COVID-19 negative. Cohorts were propensity scores matched by age, sex, and race.

RESULTS

Perioperative COVID-19 was present in n = 208 and absent in n = 15 158 subjects that underwent HNC surgery. For unmatched analyses, there was a statistically significant increased risk in the 30-day postoperative period in COVID-19-positive patients for the following surgical complications: surgical site fistula, free tissue transfer (FTT) complication, FTT failure, and death. Additionally, there was a statistically significant increased risk in the 30-day postoperative period in COVID-19-positive patients for the following medical complications: ventilator support, pneumonia, vasopressor, acute renal failure, and myocardial infarction.

CONCLUSION

This large, retrospective populational study suggests HNC patients are at increased risk for death and several perioperative complications. This investigation is the first to address this clinical question.

Outcomes of Patients Undergoing Major Surgery for Cancer with COVID-19 in the Postoperative Period

The aim of our study was to report about the clinical outcomes of patients who underwent major surgery for cancer and developed COVID-19 in the postoperative period. A retrospective and observational study was done in the Surgical Oncology Division of a tertiary care cancer hospital in North-East India. The study period was from 1st April 2020 to 31st December 2021. Patients with a confirmed diagnosis of cancer who underwent a major surgery and developed COVID-19 in the postoperative period, within the same hospital stay were included in the study. Data was obtained from a prospectively maintained database and case records. Descriptive statistics were used to state the results in median values, range and percentages. A total of 22 patients developed COVID-19 in the postoperative period during the study period out of a total of 1402 patients operated during that time period (1.57%). The have been followed up for a median period of 16 months (range 2 to 18 months). The median age at presentation was 50 years (range 25 to 74 years). The incidence of co-morbidities was 27.3%. The median duration of ICU stay was 3 days (range 0 to 9 days) and median duration of hospital stay was 22 days (range 9 to 55 days).. The postoperative mortality rate was 18.2%. COVID-19 in the postoperative period in patients undergoing major abdominal and thoracic surgeries for cancer caused high postoperative mortality and prolonged hospital stay.

Diagnosis and treatment of coagulopathy using thromboelastography with platelet mapping is associated with decreased risk of pulmonary failure in COVID-19 patients

INTRODUCTION

Treatment of coronavirus disease 2019 (COVID-19) patients may require antithrombotic and/or anti-inflammatory medications. We hypothesized that individualized anticoagulant (AC) management, based on diagnosis of coagulopathy using thromboelastography with platelet mapping (TEG-PM), would decrease the frequency of pulmonary failure (PF) requiring mechanical ventilation (MV), mitigate thrombotic and hemorrhagic events, and, in-turn, reduce mortality.

METHODS

Hospital-admitted COVID-19 patients, age 18 or older, with escalating oxygen requirements were included. Prospective and supplemental retrospective chart reviews were conducted during a 2-month period. Patients were stratified into two groups based on clinician-administered AC treatment: TEG-PM guided vs. non-TEG guided.

RESULTS

Highly-elevated inflammatory markers (D-dimer, C-reactive protein, ferritin) were associated with poor prognosis but did not distinguish coagulopathic from noncoagulopathic patients. TEG-guided AC treatment was used in 145 patients vs. 227 treated without TEG-PM guidance. When managed by TEG-PM, patients had decreased frequency of PF requiring MV (45/145 [31%] vs. 152/227 [66.9%], P  < 0.0001), fewer thrombotic events (2[1.4%] vs. 39[17.2%], P  = 0.0019) and fewer hemorrhagic events (6[4.1%] vs. 24[10.7%], P  = 0.0240), and had markedly reduced mortality (43[29.7%] vs. 142[62.6%], P  < 0.0001). Platelet hyperactivity, indicating the need for antiplatelet medications, was identified in 75% of TEG-PM patients. When adjusted for confounders, empiric, indiscriminate AC treatment (not guided by TEG-PM) was shown to be an associated risk factor for PF requiring MV, while TEG-PM guided management was associated with a protective effect (odds ratio = 0.18, 95% confidence interval 0.08-0.4).

CONCLUSIONS

Following COVID-19 diagnosis, AC therapies based on diagnosis of coagulopathy using TEG-PM were associated with significantly less respiratory decompensation, fewer thrombotic and hemorrhagic complications, and improved likelihood of survival.

Outcomes of SARS-CoV-2 infection among patients with orthopaedic fracture surgery in the National COVID Cohort Collaborative (N3C)

BACKGROUND

The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2.

METHODS

This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality.

RESULTS

The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18).

CONCLUSION

COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates.

LEVEL OF EVIDENCE

Level III.

From haemadin to haemanorm: Synthesis and characterization of full-length haemadin from the leech Haemadipsa sylvestris and of a novel bivalent, highly potent thrombin inhibitor (haemanorm)

Hirudin from Hirudo medicinalis is a bivalent α-Thrombin (αT) inhibitor, targeting the enzyme active site and exosite-I, and is currently used in anticoagulant therapy along with its simplified analogue hirulog. Haemadin, a small protein (57 amino acids) isolated from the land-living leech Haemadipsa sylvestris, selectively inhibits αT with a potency identical to that of recombinant hirudin (KI  = 0.2 pM), with which it shares a common disulfide topology and overall fold. At variance with hirudin, haemadin targets exosite-II and therefore (besides the free protease) it also blocks thrombomodulin-bound αT without inhibiting the active intermediate meizothrombin, thus offering potential advantages over hirudin. Here, we produced in reasonably high yields and pharmaceutical purity (>98%) wild-type haemadin and the oxidation resistant Met5 → nor-Leucine analogue, both inhibiting αT with a KI of 0.2 pM. Thereafter, we used site-directed mutagenesis, spectroscopic, ligand-displacement, and Hydrogen/Deuterium Exchange-Mass Spectrometry techniques to map the αT regions relevant for the interaction with full-length haemadin and with the synthetic N- and C-terminal peptides Haem(1-10) and Haem(45-57). Haem(1-10) competitively binds to/inhibits αT active site (KI  = 1.9 μM) and its potency was enhanced by 10-fold after Phe3 → β-Naphthylalanine exchange. Conversely to full-length haemadin, haem(45-57) displays intrinsic affinity for exosite-I (KD  = 1.6 μM). Hence, we synthesized a peptide in which the sequences 1-9 and 45-57 were joined together through a 3-Glycine spacer to yield haemanorm, a highly potent (KI  = 0.8 nM) inhibitor targeting αT active site and exosite-I. Haemanorm can be regarded as a novel class of hirulog-like αT inhibitors with potential pharmacological applications.

Targeting the cGAS-STING pathway as an inflammatory crossroad in coronavirus disease 2019 (COVID-19)

CONTEXT AND OBJECTIVE

The emerging pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has imposed significant mortality and morbidity on the world. An appropriate immune response is necessary to inhibit SARS-CoV-2 spread throughout the body.

RESULTS

During the early stages of infection, the pathway of stimulators of interferon genes (STING), known as the cGAS-STING pathway, has a significant role in the induction of the antiviral immune response by regulating nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and Interferon regulatory factor 3 (IRF3), two key pathways responsible for proinflammatory cytokines and type I IFN secretion, respectively.

DISCUSSION

During the late stages of COVID-19, the uncontrolled inflammatory responses, also known as cytokine storm, lead to the progression of the disease and poor prognosis. Hyperactivity of STING, leading to elevated titers of proinflammatory cytokines, including Interleukin-I (IL-1), IL-4, IL-6, IL-18, and tissue necrosis factor-α (TNF-α), is considered one of the primary mechanisms contributing to the cytokine storm in COVID-19.

CONCLUSION

Exploring the underlying molecular processes involved in dysregulated inflammation can bring up novel anti-COVID-19 therapeutic options. In this article, we aim to discuss the role and current studies targeting the cGAS/STING signaling pathway in both early and late stages of COVID-19 and COVID-19-related complications and the therapeutic potential of STING agonists/antagonists. Furthermore, STING agonists have been discussed as a vaccine adjuvant to induce a potent and persistent immune response.

Omics Signatures of Tissue Injury and Hemorrhagic Shock in Swine

OBJECTIVE

Advanced mass spectrometry methods were leveraged to analyze both proteomics and metabolomics signatures in plasma upon controlled tissue injury (TI) and hemorrhagic shock (HS)-isolated or combined-in a swine model, followed by correlation to viscoelastic measurements of coagulopathy via thrombelastography.

BACKGROUND

TI and HS cause distinct molecular changes in plasma in both animal models and trauma patients. However, the contribution to coagulopathy of trauma, the leading cause of preventable mortality in this patient population remains unclear. The recent development of a swine model for isolated or combined TI+HS facilitated the current study.

METHODS

Male swine (n=17) were randomized to either isolated or combined TI and HS. Coagulation status was analyzed by thrombelastography during the monitored time course. The plasma fractions of the blood draws (at baseline; end of shock; and at 30 minutes, 1, 2, and 4 hours after shock) were analyzed by mass spectrometry-based proteomics and metabolomics workflows.

RESULTS

HS-isolated or combined with TI-caused the most severe omic alterations during the monitored time course. While isolated TI delayed the activation of coagulation cascades. Correlation to thrombelastography parameters of clot strength (maximum amplitude) and breakdown (LY30) revealed signatures of coagulopathy which were supported by analysis of gene ontology-enriched biological pathways.

CONCLUSION

The current study provides a comprehensive characterization of proteomic and metabolomic alterations to combined or isolated TI and HS in a swine model and identifies early and late omics correlates to viscoelastic measurements in this system.