Infections and inflammatory diseases as risk factors for venous thrombosis. A systematic review

Association between statin use and acute pulmonary embolism in intensive care unit patients with sepsis: a retrospective cohort study

Introduction

Acute pulmonary embolism (APE) is a life-threatening medical condition that is frequently encountered and associated with significant incidence and mortality rates, posing a substantial threat to patients' well-being and quality of life. Sepsis is prominent independent risk factor for the development of APE. Despite recent investigations indicating a reduced APE risk through statin therapy, its impact on patients with sepsis and APE remains unresolved.

Methods

The Medical Information Mart for Intensive Care (MIMIC)-IV database was utilized to identify patients diagnosed with sepsis and APE, irrespective of statin treatment status, as part of this study. The primary study aim was to assess the risk of APE, which was analyzed using multivariate logistic regression models.

Results

The study encompassed a total of 16,633 participants, with an average age of 64.8 ± 16.2 years. Multivariate logistic regression revealed that septic patients receiving statin therapy in the intensive care unit (ICU) exhibited a 33% reduction in the risk of developing APE (OR = 0.67, 95% CI: 0.52-0.86, p < 0.001). The findings of further analyses, including stratification based on statin usage, dosage, and propensity score matching, consistently reinforced the hypothesis that administering statins to patients with sepsis effectively mitigates their potential APE risk.

Discussion

The results of the study provide compelling evidence in favor of administering statins to septic patients as a prophylactic measure against APE, given that statins may reduce the risk of developing APE, and their anti-APE effect appears to be dose-dependent. Nonetheless, future randomized controlled trials are needed to validate these results.

Association between inflammatory biomarkers and venous thromboembolism: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a common thrombotic vascular disease that has a significant impact on people's well-being and quality of life. A plethora of clinical studies explore the relationship between inflammatory biomarkers and VTE but yield conflicting results. This article proposed to pool these studies to draw a more convincing conclusion.

METHODS

We searched several databases for studies before April 2023. Available data was processed using Stata software (version 15.0 SE) and R (version 4.1.2). This meta-analysis has been registered in PROSPERO (CRD42022321815). The VTE in this review encompassed pulmonary embolism, deep vein thrombosis, and cerebral venous thrombosis.

RESULTS

A total of 25 articles were finally involved in this study. Our results revealed that higher levels of high-sensitivity C-reactive protein (hs-CRP, MD, 0.63, 95%CI, 0.21-1.05) and C-reactive protein (CRP)> 3ug/ml (OR, 1.52, 95%CI, 1.18-1.96) might be regarded as risk factors for future VTE occurrence. The elevated levels of monocyte (MD, 0.03, 95%CI, 0.00-0.05), hs-CRP (0.85, 0.61-1.08), CRP (0.66, 0.20-1.13) and IL-6 (0.47, 0.25-0.70) might represent the previous VTE; a series of markers such as white blood cell (1.43, 0.88-1.98), neutrophil (1.79, 1.02-2.56), monocyte (0.17, 0.14-0.21), hs-CRP (3.72, 1.45-5.99), IL-6 (5.99, 4.52-7.46), platelet-lymphocyte ratio (33.1, 24.45-41.78) and neutrophil-lymphocyte ratio (1.34, 0.95-1.73) increased during the acute phase of VTE.

CONCLUSIONS

In general, activated inflammatory biomarkers might not only be correlated with an increased risk of VTE, but may also give a hint of the occurrence of VTE in clinical settings.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Enoxaparin sodium bone cement displays local anti-inflammatory effects by regulating the expression of IL-6 and TNF-α

Objective

To explore the roles of Enoxaparin Sodium-Polymethyl methacrylate bone cement on inflammatory factors Interleukin-6 and Tumour Necrosis Factor-α in a rabbit knee replacement model. As well as the mechanisms underlying its potential effects on lipopolysaccharide-induced endothelial cell injury.

Methods

A knee replacement model was established using New Zealand rabbits. Forty rabbits were randomly divided into four groups: PMMA, ES-PMMA, sham-operated, and blank control groups (n = 10 in each group). Local tissues around the incision were taken at the 30th, 60th, and 90th minute after the surgical implantation of the corresponding bone cement. Immunohistochemistry in the surgical field was used to measure the expression of local inflammatory factors IL-6 and TNF-α. In the in vitro experiments, 1 cm³ of bone cement was immersed in 3 mL of the medium for 24 h. The bone cement was discarded and diluted to 25% with normal medium. Pre-experiments were screened for the best LPS-inducing concentration of 100 mg/mL, and the most compatible LPS concentration was used for subsequent experiments simulating the primary cultures of rats' Inferior Vena Cava Endothelial Cells. The experiments were divided into four groups: blank control group, LPS induction group, PMMA + LPS group, and ES-PMMA + LPS group. The apoptosis rate was detected by flow cytometry, and the expression levels of TNF-α and IL-6 in the cells and supernatant were measured by ELISA, western blotting, and immunofluorescence.

Results

According to immunohistochemical results, IL-6-positive cells were concentrated in the tissue interstitial space. In the PMMA and sham-operated groups, the number of IL-6-positive cells gradually increased over time. At all time points, IL-6 expression in the ES-PMMA group was much lower than in the PMMA and sham-operated groups. At 30 min, TNF-α positive cells in the ES-PMMA group expressed less than those in the PMMA and sham-operated groups, with no discernible difference between the PMMA and ES-PMMA groups at 60 or 90 min. Using ELISA and flow cytometry, the expression levels of IL-6 and TNF-α were improved and the apoptosis rate was magnified in the LPS-induced group (***P < 0.001) in contrast with the blank control group. Additionally, the expression levels of IL-6 and TNF-α were reduced in the ES-PMMA + LPS group compared with the LPS-induced group (*P < 0.05) and the apoptosis rate was reduced (***P < 0.001), with statistically significant variations. Western blotting and immunofluorescence analysis confirmed that IL-6 and TNF-α protein expression in cells was upregulated in the LPS-induced group compared to the blank control group (***P < 0.001), and the mean fluorescence intensity was enlarged (***P < 0.001). Meanwhile, IL-6 and TNF-α expression in the ES-PMMA + LPS group were down-regulated (**P < 0.01 or *P < 0.05) compared with the LPS-induced group and PMMA + LPS crew protein expression, and the average fluorescence intensity of IL-6 and TNF-α was lowered in the ES-PMMA + LPS group compared to the LPS-induced group (***P < 0.001).

Conclusions

ES-PMMA bone cement reduced the expression levels of local inflammatory factors IL-6 and TNF-α in a rabbit knee model. ES-PMMA bone cement reduced the rate of LPS-induced endothelial cell apoptosis and diminished local inflammatory damage by regulating the secretion of inflammatory factors TNF-α and IL-6.

The effects of pharmacomechanical thrombectomy on novel complete blood count parameters in deep vein thrombosis: A retrospective study

This study aimed to investigate the effects of pharmacomechanical thrombectomy on novel complete blood count parameters in deep venous thrombosis. This retrospective study included 242 patients aged >18 years who were treated for deep venous thrombosis. Patients were grouped as follows: group 1 was accepted as having interventional operations (n = 123) and group 2 was accepted as having only medical advice (n = 119). Routine complete blood count parameters, the neutrophil-to-lymphocyte ratio (NLR), and the platelet-to-lymphocyte ratio (PLR) were compared. There was no difference between the groups in terms of admission hemoglobin, hematocrit, mean platelet volume, NLR and PLR (P = .11, P = .24, P = .55, P = .93, and P = .96, respectively). In the pharmacomechanic thrombectomy group, NLR and PLR were significantly reduced after intervention when compared to the admission values (P < .001 and P < .001, respectively). However, the NLR and PLR values of medically treated patients did not differ significantly from their baseline values (P = .16 and P = .08, respectively). In this study, we effectively removed the thrombus load in blocked proximal veins using pharmacomechanical thrombectomy and observed a significant decrease in NLR and PLR, which are current, inexpensive, and accessible parameters.

D-Dimer Level Associated with Amount of Sinus involvement Using Digital Subtraction Angiography on Cerebral Venous Thrombosis Patients

Background

Cerebral venous sinus thrombosis (CVST) is a form of the cerebrovascular disease characterized by varying degrees of obstruction of veins and cerebral sinuses caused by thrombus. Diagnosis is incredibly challenging due to the wide variety of symptoms and the distinct radiological aspects of affected vessels. In patients with venous thrombosis, the presence of D-Dimer is used as an indicator of the presence of endogenous fibrinolysis. D-Dimer is a by-product of fibrin polymer fragmentation.

Objective

To investigate the relationship between the level of D-Dimer and the number of sinuses in CVST by Digital Subtraction Angiography (DSA).

Methods

Retrospective data from September 2021 to September 2022 were used in this analytical observational with a cross-sectional study design. Chi-Square is used for data processing relationship analysis.

Results

Out of the 54 subjects with elevated levels of D-Dimer, 38 (70.4%) are females, whereas 16 (29.6%) are males. High levels of D-Dimer have been related to a greater risk of sinus thrombosis (p < 0.001). D-Dimer levels were similarly shown to rise in conjunction with the number of sinuses most severely damaged by thrombosis. The most common site for thrombosis to develop in this study were the left sigmoid and left transverse sinuses. Most risk factors were hormonal.

Conclusion

There is a statistically significant relationship between an increase in the D-Dimer level and the greater number of sinuses involved as determined by DSA in individuals diagnosed with CVST.

Long-Term Trends of Coagulation Parameters in People Living With HIV Treated With Combined Antiretroviral Therapy

Trends of coagulation parameters during long-term treatment with combination antiretroviral therapy (cART) are unclear. We followed 40 male subjects living with human immunodeficiency virus (HIV). Plasma levels of procoagulant parameters, factor VIII, von Willebrand factor and D-dimer, and anticoagulant parameter Protein S (PS), were measured before start and 3 months, 1 year, and 9 years after. Analyses were adjusted for cardiovascular risk factors (age, smoking, and hypertension) at baseline. At baseline, procoagulant parameters were markedly elevated and PS was in the lower range of normal. CD4/CD8-ratio improved during the complete follow-up period. In the first year, procoagulant parameters were decreasing, but at year 9 an increase was observed. After correction for cardiovascular risk factors, this increase was no longer present. PS remained stable during the first year and slightly increased from one to 9 years. This study indicates that decreasing immune activation by cART reverses the procoagulant state in HIV partially during the first year. These parameters increase in the long term despite an on-going decrease in immune activation. This increase might be related to established cardiovascular risk factors.

Evaluation of the relationship between monocyte to high-density lipoprotein cholesterol ratio and thrombus burden in patients with deep vein thrombosis

OBJECTIVE

The purpose of this study was to evaluate monocyte count and high-density lipoprotein cholesterol levels and their ratio (monocyte/high-density lipoprotein ratio) in patients with deep venous thrombosis as well as to determine whether this ratio at the time of diagnosis can be an indicator of thrombus burden in terms of thrombus location in deep venous thrombosis.

METHODS

We retrospectively analyzed the patient's diagnosis of deep venous thrombosis confirmed with venous Doppler ultrasound, using a database query for outpatients between 2018 and 2022. Of 378 patients included, blood count results at the time of diagnosis were available for 356. We recruited 300 age- and sex-matched patients with appropriate blood counts, without a diagnosis of deep venous thrombosis, as the control group, by querying the outpatient clinic database. The monocyte/high-density lipoprotein ratio was computed from the ratio of monocyte count to high-density lipoprotein-C. Patients were categorized based on the level of thrombus and the number of vein segments involved as evidenced by Doppler ultrasound findings.

RESULTS

The serum level of monocyte/high-density lipoprotein ratio was significantly higher in the patient group compared to the control group (p<0.01). Patients with proximal deep venous thrombosis had a higher mean monocyte/high-density lipoprotein ratio (19.6±5.1 vs. 17.1±5.5; p<0.01) than patients with distal deep venous thrombosis. Monocyte/high-density lipoprotein ratio increased with the number of vein segments involved (p<0.01).

CONCLUSION

Monocyte/high-density lipoprotein ratio is significantly elevated in patients with deep venous thrombosis when compared to the control group. Monocyte/high-density lipoprotein ratio levels were correlated with disease burden reflected by thrombus location and the number of vein segments involved in deep venous thrombosis patients.

Anticoagulant therapies against sepsis-induced disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a frequent but lethal complication in sepsis. Anticoagulant therapies, such as heparin, antithrombin, activated protein C, and recombinant human-soluble thrombomodulin, were expected to regulate the progression of coagulopathy in sepsis. Although a number of randomized controlled trials (RCTs) have evaluated the survival effects of these therapies over the past few decades, there remains no consistent evidence showing a significant survival benefit of anticoagulant therapies. Currently, anticoagulant therapies are not conducted as a standard treatment against sepsis in many countries and regions. However, most of these RCTs were performed overall in patients with sepsis but not in those with sepsis-induced DIC, who were theoretically the optimal target population of anticoagulants. Actually, multiple lines of evidence from observational studies and meta-analyses of the RCTs have suggested that anticoagulant therapies might reduce mortality only when used in septic DIC. In addition, the severity of illness is another essential factor that maximally affects the efficacy of the therapy. Therefore, to provide evidence on the true effect of anticoagulant therapies, the next RCTs must be designed to enroll only patients with sepsis-induced overt DIC and a high severity of illness. To prepare these future RCTs, a novel scientific infrastructure for accurate detection of patients who can receive maximal benefit from anticoagulant therapies also needs to be established.

Blood hyperviscosity in acute and recent COVID-19 infection

BACKGROUND

Elevated estimated blood viscosity (EBV), derived from hematocrit and globulins, is associated with thrombotic complications, organ failure, and higher mortality in COVID-19 patients. Although informative, EBV does not account for cellular interactions or fibrinogen.

OBJECTIVE

Investigate whether patients with acute and recent COVID-19 have altered whole blood viscosity (WBV) when measured at both high and low shear rates using in vitro blood samples from patients.

METHODS

Cross-sectional study of 58 patients: 15 in the intensive care unit with acute COVID-19, 32 convalescent (9 < 8weeks [W] from acute infection, 23 > 8 W), and 11 controls without COVID-19. WBV was measured at high (300 s-1) and low (5 s-1) shear rates (HSR, LSR) using a scanning capillary viscometer.RESULTSAcute and convalescent patients < 8 W had mean WBV at LSR (16.0 centipoise [cP] and 15.1 cP) and HSR (5.1 cP and 4.7 cP). Mean WBV of convalescent > 8 W and control patients were 12.3 cP and 13.0 cP at LSR, and 4.1 cP and 4.2 cP at HSR. Acute and < 8 W patients had significantly higher WBV at both HSR and LSR compared to patients > 8 W (all p≤0.01). No significant differences in WBV were observed between acute and < 8 W patients, or between patients > 8 W and controls.

CONCLUSIONS

Hyperviscosity provides a possible explanation for thrombotic risk in acute and convalescent (< 8 W) patients. These findings have important implications for thromboprophylaxis.

Not Just Anticoagulation—New and Old Applications of Heparin

In recent decades, heparin, as the most important anticoagulant drug, has been widely used in clinical settings to prevent and treat thrombosis in a variety of diseases. However, with in-depth research, the therapeutic potential of heparin is being explored beyond anticoagulation. To date, heparin and its derivatives have been tested in the protection against and repair of inflammatory, antitumor, and cardiovascular diseases. It has also been explored as an antiangiogenic, preventive, and antiviral agent for atherosclerosis. This review focused on the new and old applications of heparin and discussed the potential mechanisms explaining the biological diversity of heparin.

Plasma lipopolysaccharide-binding protein is a biomarker for future venous thromboembolism: Results from discovery and validation studies

BACKGROUND

Effect-size underestimation impedes biomarker identification. Long follow-up time in prospective studies attenuates effect-size estimates for transient biomarkers, while disease category-specific biomarkers are affected by merging of categories. Venous thromboembolism (VTE) encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE).

OBJECTIVES

(i) To re-analyze untargeted proteomic data to identify biomarker candidates for future VTE that differ between DVT and PE and are attenuated by extended time between sampling and VTE. (ii) To perform targeted candidate validation.

PATIENTS/METHODS

A VTE case-control discovery study and a nested case-control validation study were derived from the general population surveyed in 1994-95. Plasma was obtained at study enrollment, and VTE events were registered until 2007. Untargeted proteomic data were re-analyzed for candidate discovery. Lipopolysaccharide-binding protein (LBP) was validated by enzyme-linked immunosorbent assay.

RESULTS

Elevated LBP was discovered as a candidate DVT biomarker in women with less than 3 years between blood sampling and DVT. In the validation study, the odds ratio (OR) for DVT was 2.03 (95% confidence intervals [CI]: 1.53-2.74) per standard deviation (SD) increase in LBP for women with less than 3 years between blood sampling and DVT. Adjustment for age, body mass index, and C-reactive protein attenuated the OR to 1.79 (95% CI: 1.25-2.62) per SD. In the validation study, we observed an OR for VTE of 0.47 (95% CI: 0.28-0.77) for men in the 25^th to 50^th percentiles when compared to the lowest quartile.

CONCLUSIONS

We discovered and validated increased LBP as a predictive biomarker for DVT in women. We found an increased VTE risk for men in the lowest quartile of LBP.

COVID-19 and Thrombosis Complication in Children

Since it was discovered in Wuhan in December 2019, most studies on COVID-19 have been centered on symptomatic adults. An expanded pro-inflammatory cytokine reaction, abnormal clot formation, overactive platelets, and hypercoagulable state are among the well-known clinical characteristics of endothelial dysfunction that may arise in patients with COVID-19. These conditions can lead to venous thromboembolism, arterial thrombosis, and pulmonary embolism. To date, the predominance of thromboembolic complications in children infected with severe acute respiratory syndrome coronavirus 2 has not been fully documented, and there is no explicit recommendation for the prevention of thrombosis in children.

Association of Peripheral Arterial Occlusive Disease and Deep Venous Thrombosis with Risk of Consequent Sepsis Event: A Retrospective Population-Based Cohort Study

Peripheral artery occlusive disease (PAOD) and deep vein thrombosis (DVT) can cause a variety of acute and chronic vascular complications and put patients at risk of subsequent sepsis. This study aimed to determine whether DVT compared with PAOD patients would increase the risk of sepsis. This study recruited 43,535 patients newly diagnosed as having PAOD and 6932 patients who were newly diagnosed as having DVT from a population of 2 million patients from the Longitudinal Health Insurance Database. Propensity score matching (PSM) between the PAOD and DVT groups was performed for age, sex, comorbidities, and prior antibiotic administration. A total of 4383 patients with PAOD and 4383 patients with DVT were analyzed for risk of sepsis. The incidence density of sepsis per 1000 person years for patients with PAOD was 25.75 (95% CI = 23.90 to 27.74) and 35.61 (95% CI = 33.29 to 38.09) for patients with DVT. After age, sex, associated comorbidities, and antibiotic administration were adjusted for, the risk of sepsis for the DVT group was 1.46-fold (95% CI = 1.32-1.62) higher than that for the PAOD group. In conclusion, patients with DVT were associated with a higher risk of subsequent sepsis than patients with PAOD. Aging was another risk factor.

Venous thromboembolism in chronic gastrointestinal disorders

INTRODUCTION

Chronic gastrointestinal disorders (including autoimmune gastritis, celiac disease, inflammatory bowel disease, and diverticular disease) are highly prevalent disorders, that may be associated with unpredictable, life-threatening complications, such as thromboembolic events. Venous thromboembolism (VTE) is one of the major causes of morbidity and mortality worldwide. Several conditions, including cancer, major trauma, surgery, prolonged immobilization, are well-established risk factors for VTE. Over the past decade, chronic inflammation has also been identified as an independent risk factor for VTE due to the prothrombotic effects of inflammatory cytokines and oxidative stress on the coagulation cascade. Other several mechanisms were shown to be associated with a higher incidence of VTE in patients with gastrointestinal disorders.

AREAS COVERED

We critically discuss the latest insights into the mechanisms responsible for thromboembolic manifestations in chronic gastrointestinal disorders, also focusing on the recognition of risk factors and treatment.

EXPERT OPINION

The occurrence of thrombotic complications is underestimated in patients with chronic gastrointestinal disorders. Identifying potential risk factors and concomitant predisposing conditions and to prevent VTE and guide treatment require a multidisciplinary approach, and this is critically important for clinicians, in order to provide the best care for such patients.

Intestinal IL-33 promotes platelet activity for neutrophil recruitment during acute inflammation

Peripheral serotonin (5-HT) is mainly generated from the gastrointestinal tract and taken up and stored by platelets in the circulation. Although the gut is recognized as a major immune organ, how intestinal local immune responses control whole-body physiology via 5-HT remains unclear. Here, we show that intestinal inflammation enhances systemic platelet activation and blood coagulation. Intestinal epithelium damage induces elevated levels of the alarm cytokine interleukin-33 (IL-33), leading to platelet activation via promotion of gut-derived 5-HT release. More importantly, we found that loss of intestinal epithelial-derived IL-33 lowers peripheral 5-HT levels, resulting in compromised platelet activation and hemostasis. Functionally, intestinal IL-33 contributes to the recruitment of neutrophils to sites of acute inflammation by enhancing platelet activities. Genetic deletion of intestinal IL-33 or neutralization of peripheral IL-33 protects animals from lipopolysaccharide endotoxic shock through attenuated neutrophil extravasation. Therefore, our data establish a distinct role of intestinal IL-33 in activating platelets by promoting 5-HT release for systemic physiology and inflammation.

Case Report: Ulcerative Colitis with Multiple Dural Venous Thrombosis

Background Cerebral sinus vein thrombosis (CVT) is a rare but serious complication associated with ulcerative colitis (UC), an idiopathic autoimmune inflammatory disease of the gastrointestinal tract. Management approaches for CVT remain unclear but may include anticoagulation and surgical thrombectomy. Herein, we report a case of a 23-year-old male who developed CVT with a history of UC. The patient was presented to Howard University Hospital when he slipped and fell. On arrival at the hospital, he complained of a headache with an aching sensation, associated with light/sound sensitivity. The patient had a history of uncontrolled UC. He had positive bloody diarrhea, lower abdominal pain, but denied any other neurological deficit. Computed tomography of the head showed left frontoparietal lobe hypodensities. Neurological exam was nonfocal. Vital signs were within normal range, but the patient experienced some memory loss and personality changes. Subsequent diagnosis of CVT was made with magnetic resonance angiography and magnetic resonance venography. Immediate treatment with low-molecular-weight intravenous heparin (18 IU/kg) was introduced. His UC was managed with methylprednisolone (60 mg IV daily), proton pump inhibitors, mesalamine, ciprofloxacin, and metronidazole. His condition gradually improved. On discharge, he was prescribed prednisone, azathioprine for his UC, levetiracetam for seizure, and warfarin with an INR goal of 2-3. In conclusion, the sudden onset and/or acute worsening of neurological status such as headache and mental confusion in a patient with UC should alert the treating physician about the possibility of CVT so that timely intervention could be employed to prevent disabling and potentially lethal sequelae of this disease.

Elevated plasma D-dimer levels are associated with risk of future incident venous thromboembolism

BACKGROUND

D-dimer, a global biomarker for activation of the coagulation and fibrinolysis systems, is useful in assessing individual risk of venous thromboembolism (VTE) recurrence. However, there is limited information on the association between D-dimer and risk of a first lifetime VTE event.

OBJECTIVES

To investigate the association between plasma D-dimer levels and risk of future incident VTE.

METHODS

A population-based nested case-control study, comprising 414 VTE patients and 843 randomly selected age- and sex-matched controls, was derived from the Tromsø Study (1994-2007). D-dimer was measured in plasma samples collected at cohort baseline (1994-95). Odds ratios (ORs) for VTE with 95% confidence intervals (CIs) were estimated according to quartile cut-offs of D-dimer levels determined in controls.

RESULTS

The risk of VTE increased across quartiles of D-dimer levels (P_trend = 0.014) in the age- and sex-adjusted model. Participants with plasma D-dimer levels in the highest quartile (≥152 ng/mL) had an OR for VTE of 1.65 (95% CI 1.14-2.40) compared with those in the lowest quartile (<94 ng/mL). The ORs were marginally attenuated after additional adjustment for body mass index (BMI) (OR 1.51, 95% CI 1.04-2.20) and C-reactive protein (CRP) (OR 1.34, 95% CI 0.90-1.98). Similar results were obtained for VTE subgroups, i.e. deep vein thrombosis, pulmonary embolism, and provoked/unprovoked events.

CONCLUSION

Our results indicate that elevated plasma D-dimer levels are associated with increased risk of incident VTE. However, the attenuation of risk estimates upon additional adjustment for BMI and CRP suggests that D-dimer partly reflects underlying conditions associated with obesity and an inflammatory state.

Venous Thromboembolism in COVID-19 Compared to Non-COVID-19 Cohorts: A Systematic Review with Meta-Analysis

Background: A high incidence of venous thromboembolism (VTE) is reported in hospitalized COVID-19 patients, in particular in patients admitted to the intensive care unit (ICU). In patients with respiratory tract infections, including influenza A (H1N1), many studies have demonstrated an increased incidence of thromboses, but evidence is lacking regarding the risk difference (RD) of the occurrence of VTE between COVID-19 and non-COVID-19 patients. Methods: In this systematic review with meta-analysis, we evaluated the RD of the occurrence of VTE, pulmonary embolism (PE), and deep venous thrombosis (DVT) between COVID-19 and other pulmonary infection cohorts, in particular H1N1, and in an ICU setting. We searched for all studies comparing COVID-19 vs. non-COVID-19 regarding VTE, PE, and DVT. Results: The systematic review included 12 studies and 1,013,495 patients. The RD for VTE in COVID-19 compared to non-COVID-19 patients was 0.06 (95% CI 0.11–0.25, p = 0.011, I² = 97%), and 0.16 in ICU (95% CI 0.045–0.27, p = 0.006, I² = 80%). The RD for PE between COVID-19 and non-COVID-19 patients was 0.03 (95% CI, 0.006–0.045, p = 0.01, I² = 89%). The RD for PE between COVID-19 and non-COVID-19 patients was 0.021 in retrospective studies (95% CI 0.00–0.04, p = 0.048, I² = 92%) and 0.11 in ICU studies (95% CI 0.06–0.16, p < 0.001, I² = 0%). Conclusions: The growing awareness and understanding of a massive inflammatory response combined with a hypercoagulable state that predisposes patients to thrombosis in COVID-19, in particular in the ICU, may contribute to a more appropriate strategy of prevention and earlier detection of the thrombotic events.

Hemostatic parameters in patients with spinal cord injury in subacute and chronic phase of the rehabilitation

Objective: The goal of this study was to measure hemostatic markers after SCI.Design: Assesing changes in coagulation and fibrynilitic system in SCI patients in different time post injury to Cross-sectional study.Setting: Rehabilitation Department of the Bydgoszcz University Hospital, Poland from 2011 to 2017.Participants: SCI patient during acute and chronic rehabilitation (N = 88).Outcome Measures: Assesing following parameters: platelet counts and levels of D-dimer, antithrombin III (ATIII), tissue factor (TF), tissue factor pathway inhibitor (TFPI) and the inflammatory marker, C-reactive protein (CRP).Interventions: Eighty-eight SCI patients were divided into three groups based on the time elapsed from injury: group I (three weeks to three months), group II (three to twelve months) and group III (more than twelve months). All patients underwent ultrasonography (US) to detect acute or chronic recanalized deep vein thrombosis (DVT). Platelet counts and levels of D-dimer, ATIII, TF, TFPI and CRP were assessed. TF and TFPI levels were measured in the control group of forty healthy individuals without SCI, the rest of the parameters were compared to laboratory norms.Results: D-dimer levels were significantly higher in group I compared to group II (P = .0002) and group III (P < .001). Group II had higher D-dimer levels than group III (P = .032). TFPI levels were higher in group II compared with group III (P = .0041) and control group (P = .000033). TF was significantly higher in all the SCI groups compared with the control group (P < .001).Conclusions: D-dimer and TF levels were still elevated twelve months after SCI. TF levels were also elevated over 12 months after inury. The results may indicate that sub-acute and even chronic SCI patients have disturbed coagulation and fibrynolitic system.

Benign and malignant hematologic manifestations in patients with VEXAS syndrome due to somatic mutations in UBA1

Somatic mutations in UBA1 involving hematopoietic stem and myeloid cells have been reported in patients with the newly defined VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Here, we report clinical hematologic manifestations and unique bone marrow (BM) features in 16 patients with VEXAS. All patients were male and had a history of severe autoinflammatory and rheumatologic manifestations and a somatic UBA1 mutation (p.Met41). Ten patients had hematologic disorders: myelodysplastic syndrome (MDS; 6 of 16), multiple myeloma (2 of 16), monoclonal gammopathy of undetermined significance (2 of 16), and monoclonal B-cell lymphocytosis (2 of 16), and a few of those patients had 2 co-existing clonal processes. Although macrocytic anemia (100%) and lymphopenia (80%) were prevalent in all patients with VEXAS, thrombocytopenia and neutropenia were more common in patients with progression to MDS. All BMs in VEXAS patients had prominent cytoplasmic vacuoles in myeloid and erythroid precursors. In addition, most BMs were hypercellular with myeloid hyperplasia, erythroid hypoplasia, and varying degrees of dysplasia. All patients diagnosed with MDS were lower risk (low blast count, very good to intermediate cytogenetics) according to standard prognostic scoring with no known progression to leukemia. In addition, 10 of 16 patients had thrombotic events, including venous thromboembolism and arterial stroke. Although VEXAS presents symptomatically as a rheumatologic disease, morbidity and mortality are associated with progression to hematologic disease. Given the increased risk of developing MDS and multiple myeloma, surveillance for disease progression is important.

NETosis and the Immune System in COVID-19: Mechanisms and Potential Treatments

NETosis is a form of neutrophil death leading to the release of extracellular chromatin and the assembling of proteins, including antiviral proteins, primed by an initial pathogenic stimulus. Under certain specific conditions, neutrophils can exhibit a double-edged activity. This event has been implicated in COVID-19 among other conditions. Neutrophil extracellular traps (NETs) are involved in the pathogenesis of COVID-19 by promoting a pro-inflammatory and a procoagulant state leading to multiorgan failure. This particular form of host defense promoted by neutrophils is closely related to the well-known cytokine storm observed in severe COVID-19 patients. These two elements therefore represent possible targets for treatment of severe SARS-CoV-2 infections.

Challenges in the diagnostic approach of suspected pulmonary embolism in COVID-19 patients

Accumulating studies on COVID-19 patients report high incidences of thrombotic complications, but guidance on the best diagnostic approach for suspected pulmonary embolism (PE) in COVID-19 patients is lacking. Diagnosing PE in these patients is challenging as signs and symptoms of PE and COVID-19 show wide overlap, D-dimer levels are often elevated in the absence of thrombosis and computed tomography pulmonary angiography (CTPA) may be unfeasible in the case of severe renal impairment and/or hemodynamic instability.This narrative review discusses available literature and guidelines on current diagnostic algorithms for suspected PE in special patient populations, in particular COVID-19. A special focus is on reviewing the literature aimed at identifying symptoms with a high suspicion for PE and on the diagnostic performance of diagnostic algorithms for suspected PE in the setting of COVID-19.Based on available literature, the index of suspicion for PE should be high in the case of unexplained abrupt worsening of respiratory status, typical symptoms of deep-vein thrombosis and/or acute unexplained right ventricular dysfunction. Despite the lack of prospective diagnostic management studies, we propose to adhere to current diagnostic algorithms applying assessment of pretest probability and D-dimer testing as available evidence suggests that these might be considered safe. Preferably, algorithms using adjusted D-dimer thresholds are recommended as it likely improves the yield of the clinical decision rule/D-dimer combination.

The Potency of Seaweed Sulfated Polysaccharides for the Correction of Hemostasis Disorders in COVID-19

Hemostasis disorders play an important role in the pathogenesis, clinical manifestations, and outcome of COVID-19. First of all, the hemostasis system suffers due to a complicated and severe course of COVID-19. A significant number of COVID-19 patients develop signs of hypercoagulability, thrombocytopenia, and hyperfibrinolysis. Patients with severe COVID-19 have a tendency toward thrombotic complications in the venous and arterial systems, which is the leading cause of death in this disease. Despite the success achieved in the treatment of SARS-CoV-2, the search for new effective anticoagulants, thrombolytics, and fibrinolytics, as well as their optimal dose strategies, continues to be relevant. The wide therapeutic potential of seaweed sulfated polysaccharides (PSs), including anticoagulant, thrombolytic, and fibrinolytic activities, opens up new possibilities for their study in experimental and clinical trials. These natural compounds can be important complementary drugs for the recovery from hemostasis disorders due to their natural origin, safety, and low cost compared to synthetic drugs. In this review, the authors analyze possible pathophysiological mechanisms involved in the hemostasis disorders observed in the pathological progression of COVID-19, and also focus the attention of researchers on seaweed PSs as potential drugs aimed to correction these disorders in COVID-19 patients. Modern literature data on the anticoagulant, antithrombotic, and fibrinolytic activities of seaweed PSs are presented, depending on their structural features (content and position of sulfate groups on the main chain of PSs, molecular weight, monosaccharide composition and type of glycosidic bonds, the degree of PS chain branching, etc.). The mechanisms of PS action on the hemostasis system and the issues of oral bioavailability of PSs, important for their clinical use as oral anticoagulant and antithrombotic agents, are considered. The combination of the anticoagulant, thrombolytic, and fibrinolytic properties, along with low toxicity and relative cheapness of production, open up prospects for the clinical use of PSs as alternative sources of new anticoagulant and antithrombotic compounds. However, further investigation and clinical trials are needed to confirm their efficacy.

Risk of thrombotic complications in influenza versus COVID-19 hospitalized patients

Background

Whereas accumulating studies on patients with coronavirus disease 2019 (COVID-19) report high incidences of thrombotic complications, large studies on clinically relevant thrombosis in patients with other respiratory tract infections are lacking. How this high risk in COVID-19 patients compares to those observed in hospitalized patients with other viral pneumonias such as influenza is unknown.

Objectives

To assess the incidence of venous and arterial thrombotic complications in hospitalized patients with influenza as opposed to that observed in hospitalized patients with COVID-19.

Methods

This was a retrospective cohort study; we used data from Statistics Netherlands (study period: 2018) on thrombotic complications in hospitalized patients with influenza. In parallel, we assessed the cumulative incidence of thrombotic complications-adjusted for competing risk of death-in patients with COVID-19 in three Dutch hospitals (February 24 to April 26, 2020).

Results

Of the 13 217 hospitalized patients with influenza, 437 (3.3%) were diagnosed with thrombotic complications, versus 66 (11%) of the 579 hospitalized patients with COVID-19. The 30-day cumulative incidence of any thrombotic complication in influenza was 11% (95% confidence interval [CI], 9.4-12) versus 25% (95% CI, 18-32) in COVID-19. For venous thrombotic (VTC) complications and arterial thrombotic complications alone, these numbers were, respectively, 3.6% (95% CI, 2.7-4.6) and 7.5% (95% CI, 6.3-8.8) in influenza versus 23% (95% CI, 16-29) and 4.4% (95% CI, 1.9-8.8) in COVID-19.

Conclusions

The incidence of thrombotic complications in hospitalized patients with influenza was lower than in hospitalized patients with COVID-19. This difference was mainly driven by a high risk of VTC complications in the patients with COVID-19 admitted to the Intensive Care Unit. Remarkably, patients with influenza were more often diagnosed with arterial thrombotic complications.

Impact of low molecular weight heparin administration on the clinical course of the COVID-19 disease

Background

Lymphopenia is the most important criterion of mortality and discharging feature for patients infected with coronavirus disease 2019 (COVID-19). This study aimed to investigate the clinical impact of a low molecular weight heparin (LMWH) treatment on the clinical course of COVID-19.

Materials and methods

Patients’ clinical symptoms, radiologic outcomes, hematologic, biochemical, D-dimer, and C-reactive protein (CRP) results were obtained from their medical records. Participants were separated into 2 groups: one was treated with LMWH and the other was not. Improvement in the patients was compared before and after treatment.

Results

Ninety-six patients who were diagnosed with COVID-19 between April and May 2020 were retrospectively analyzed. The multivariable analysis showed that the count of lymphocytes, D-dimer, and CRP levels were significantly improved in the LMWH group, as compared to the control group (OR, (95% CI) 0.628 (0.248–0.965), P < 0.001); OR, (95% CI) 0.356 (0.089–0.674), P < 0.001, respectively). The area under the receiver operating characteristic (ROC) curve analysis was AUC: 0.679 ± 0.055, 0.615 ± 0.058, and 0.633 ± 0.057, respectively; the β-value was found to be –1.032, –0.026, and –0.465, respectively.

Conclusion

The LMWH treatment group demonstrated better laboratory findings, including recovery in the lymphocyte count, CRP, and D-dimer results.

The effect of COPD on the incidence and mortality of hospitalized patients with pulmonary embolism: A nationwide population-based study (2016-2018)

BACKGROUND

To examine the incidence, clinical characteristics, and in-hospital outcomes of pulmonary embolism (PE) among hospitalized patients with or without chronic obstructive pulmonary disease (COPD) in Spain, and to identify predictors of in-hospital-mortality (IHM) after PE among patients with and without COPD.

METHODS

We included all patients aged ≥ 40 years who were hospitalised for PE between 2016 and 2018. Data were collected from the Spanish National Hospital Discharge Database.

RESULTS

We identified 47,190 hospitalizations for PE during the study period, 7.49% with COPD. Adjusted incidence of PE was higher in COPD patients than in those without COPD (IRR 1.16; 95%CI 1.13-1.19). Crude IHM was significantly higher in PE hospitalized patients with COPD than in those without COPD (9.86% vs 3.59%; p<0.001). Predictor factors of IHM in COPD patients with PE included older age, higher Charlson comorbidity index, atrial fibrillation, massive PE and dependence on oxygen prior to hospital admission. However, obesity was associated with lower IHM. For PE hospitalized patients, suffering COPD increased the probability of dying in the hospital (adjusted OR 2.84; 95%CI 2.27-3.55).

CONCLUSIONS

Our results revealed that incidence of PE was higher in COPD patients than in those without COPD. Furthermore, COPD was a risk factor for IHM after PE.

Primary Immunodeficiency and Thrombocytopenia

Primary immunodeficiency (PID) or Inborn errors of immunity (IEI) refers to a heterogeneous group of disorders characterized by immune system impairment. Although patients with IEI manifest highly variable symptoms, the most common clinical manifestations are recurrent infections, autoimmunity and malignancies. Some patients present hematological abnormality including thrombocytopenia due to different pathogenic mechanisms. This review focuses on primary and secondary thrombocytopenia as a complication, which can occur in IEI. Based on the International Union of Immunological Societies phenotypic classification for IEI, the several innate and adaptive immunodeficiency disorders can lead to thrombocytopenia. This review, for the first time, describes manifestation, mechanism and therapeutic modalities for thrombocytopenia in different classes of IEI.

Incidence and risk factors for venous thrombosis among patients with inflammatory bowel disease in China: a multicenter retrospective study

Background/Aims

Risk of venous thrombosis is increased in patients with inflammatory bowel disease (IBD); data on Asian IBD patients is limited and status quo of thrombosis screening and prophylaxis are unknown. Therefore, we aimed to investigate the incidence, screening, prophylaxis, and risk factors for venous thrombosis among Asian IBD patients.

Methods

Medical files of patients with Crohn’s disease (CD) and ulcerative colitis (UC) from 17 hospitals across China between 2011 and 2016 were reviewed for venous thrombosis, use of screening and prophylaxis. A case-control study was performed among hospitalized patients with venous thrombosis and their age-, sex-matched IBD controls hospitalized around the same period; disease characteristics and known provoking factors of venous thrombosis were recorded. Risk factors were analyzed in both univariate and logistic regression analyses.

Results

A total of 8,459 IBD patients were followed for 12,373 person-year. Forty-six patients (0.54%) had venous thrombosis, yielding an incidence of 37.18 per 10,000 person-year. Incidence increased with age, especially among CD. Less than 20% of patients received screening tests and 35 patients (0.41%) received prophylaxis. Severe disease flare was an independent risk factor for venous thrombosis (odds ratio [95% confidence interval]: CD, 9.342 [1.813– 48.137]; UC, 5.198 [1.268–21.305]); past use of steroids and extensive involvement were 2 additional risk factors in CD and UC, respectively.

Conclusions

Incidence of venous thrombosis in China was 37.18 per 10,000 person-year (0.54%). Use of screening and prophylaxis were rare. Severe disease flare was an independent risk factor for thrombosis among hospitalized patients.

Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor

Background

The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis.

Methods

A case-control study was performed of patients with PE admitted to our hospital [2010–2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus.

Results

A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95–3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27–2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24–2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02–7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82–34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25–51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06–49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance.

Conclusions

A relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.

Direct oral anticoagulant treatment of deep vein thrombosis reduces IL-6 expression in peripheral mono-nuclear blood cells

Multiple factors play a pathophysiologic role for the venous thromboembolism (VTE) as a multi-factorial disease. Inflammation might play a peculiar role in shifting towards a pro-thrombotic state. Anticoagulant drugs are the first cure line for VTE. The low-molecular-weight heparins (LMWH) show anti-coagulant capability as well as reducing levels of inflammatory factors, including interleukin (IL)-6. The direct oral anticoagulants (DOACs) have shown efficacy in threating VTE, additionally to the anti-activated factor X these drugs seem able to reduce the abnormal release of pro-inflammatory agents. The present study evaluated the capability of DOACs in reducing plasma level of IL-6 in patients suffered from deep vein thrombosis (DVT) of the lower limbs. Our results showed reduced IL-6 expression levels in the peripheral lymphocytes of DVT compared to controls (fold-change, 2.8; P<0.05). We postulate that lowered IL-6 expression in the lymphocytes of DVT patients may mediate the anti-inflammatory action of DOACs. The present study is the first evidence concerning the anti-inflammatory properties of DOACs in specific setting of VTE patients such as DVT.

Management of the thrombotic risk associated with COVID-19: guidance for the hemostasis laboratory

Coronavirus disease 2019 (COVID-19) is associated with extreme inflammatory response, disordered hemostasis and high thrombotic risk. A high incidence of thromboembolic events has been reported despite thromboprophylaxis, raising the question of a more effective anticoagulation. First-line hemostasis tests such as activated partial thromboplastin time, prothrombin time, fibrinogen and D-dimers are proposed for assessing thrombotic risk and monitoring hemostasis, but are vulnerable to many drawbacks affecting their reliability and clinical relevance. Specialized hemostasis-related tests (soluble fibrin complexes, tests assessing fibrinolytic capacity, viscoelastic tests, thrombin generation) may have an interest to assess the thrombotic risk associated with COVID-19. Another challenge for the hemostasis laboratory is the monitoring of heparin treatment, especially unfractionated heparin in the setting of an extreme inflammatory response. This review aimed at evaluating the role of hemostasis tests in the management of COVID-19 and discussing their main limitations.

Injury Characteristics and Outcomes of Patients With Inflammatory Bowel Disease After Trauma: A Propensity Score Matched Analysis

BACKGROUND

The clinical course of patients with inflammatory bowel disease (IBD) after trauma is largely unknown. We sought to compare the clinical course of patients with IBD to those without.

METHODS

We conducted a retrospective case-control study of adult patients admitted to a level-1 trauma center from January 1, 2008, through October 1, 2015. Seventy-five patients with IBD were identified. Cases were matched to controls by age, sex, injury severity, and mechanism using 4:1 propensity score-matching analysis. Injury characteristics, clinical course, and infectious and noninfectious complications were compared using bivariate and multivariate analysis.

RESULTS

Participants had a mean age of 56 years and mean injury severity score of 15. Of the 75 cases, 44% had ulcerative colitis, 44% had Crohn's disease, and 12% had undetermined type. More cases were on an immunosuppressant (19% vs 2%, P < 0.01) or steroids (8% vs 2%, P = 0.02) on admission compared with controls. More cases had prior abdominal surgery (P = 0.01). Cases had fewer brain injuries (P = 0.02) and higher admission Glasgow Coma Scale (P < 0.01) but required more neurosurgical intervention (P = 0.03). Cases required more orthopedic surgeries (P < 0.01) and more pain management consultations (P = 0.04). In multivariable analysis, IBD was associated with increased odds of operative intervention, pain management consultation, venous thromboembolism, and longer hospital stay (P < 0.05). Patients on immunosuppressants had increased odds of requiring surgery (P = 0.04), particularly orthopedic surgery (P < 0.01).

CONCLUSIONS

Baseline factors associated with inflammatory bowel disease may place patients at higher risk for surgery and complications after trauma.

Risk of recurrent venous thromboembolism in patients with HIV infection: A nationwide cohort study

BACKGROUND

Multiple studies have described a higher incidence of venous thromboembolism (VTE) in people living with an HIV infection (PWH). However, data on the risk of recurrent VTE in this population are lacking, although this question is more important for clinical practice. This study aims to estimate the risk of recurrent VTE in PWH compared to controls and to identify risk factors for recurrence within this population.

METHODS AND FINDINGS

PWH with a first VTE were derived from the AIDS Therapy Evaluation in the Netherlands (ATHENA) cohort (2003-2015), a nationwide ongoing cohort following up PWH in care in the Netherlands. Uninfected controls were derived from the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA) follow-up study (1999-2003), a cohort of patients with a first VTE who initially participated in a case-control study in the Netherlands who were followed up for recurrent VTE. Selection was limited to persons with an index VTE suffering from deep vein thrombosis in the lower limbs and/or pulmonary embolism (PE). Participants were followed from withdrawal of anticoagulation to VTE recurrence, loss to follow-up, death, or end of study. We estimated incidence rates, cumulative incidence (accounting for competing risk of death) and hazard ratios (HRs) using Cox proportional hazards regression, adjusting for age, sex, and whether the index event was provoked or unprovoked. When analyzing risk factors among PWH, the main focus of analysis was the role of immune markers (cluster of differentiation 4 [CD4]+ T-cell count). There were 153 PWH (82% men, median 48 years) and 4,005 uninfected controls (45% men, median 49 years) with a first VTE (71% unprovoked in PWH, 34% unprovoked in controls) available for analysis. With 40 VTE recurrences during 774 person-years of follow-up (PYFU) in PWH and 635 VTE recurrences during 20,215 PYFU in controls, the incidence rates were 5.2 and 3.1 per 100 PYFU (HR: 1.70, 95% CI 1.23-2.36, p = 0.003). VTE consistently recurred more frequently per 100 PYFU in PWH in all predefined subgroups of men (5.6 versus 4.8), women (3.6 versus 1.9), and unprovoked (6.0 versus 5.2) or provoked (3.1 versus 2.1) first VTE. After adjustment, the VTE recurrence risk was higher in PWH compared to controls in the first year after anticoagulant discontinuation (HR: 1.67, 95% CI 1.04-2.70, p = 0.03) with higher cumulative incidences in PWH at 1 year (12.5% versus 5.6%) and 5 years (23.4% versus 15.3%) of follow-up. VTE recurred less frequently in PWH who were more immunodeficient at the first VTE, marked by a better CD4+ T-cell recovery on antiretroviral therapy and during anticoagulant therapy for the first VTE (adjusted HR: 0.81 per 100 cells/mm3 increase, 95% CI 0.67-0.97, p = 0.02). Sensitivity analyses addressing potential sources of bias confirmed our principal analyses. The main study limitations are that VTEs were adjudicated differently in the cohorts and that diagnostic practices changed during the 20-year study period.

CONCLUSIONS

Overall, the risk of recurrent VTE was elevated in PWH compared to controls. Among PWH, recurrence risk appeared to decrease with greater CD4+ T-cell recovery after a first VTE. This is relevant when deciding to (dis)continue anticoagulant therapy in PWH with otherwise unprovoked first VTE.

Case Report: Two Cases of Strongyloidiasis Presenting with Thrombotic Events

We report two unusual cases of clinical strongyloidiasis that present as extensive thrombosis: a case of hyperinfection with concurrent eosinophilia and a case of disseminated infection as a complication of immunosuppression. We discuss risk factors for the development of Strongyloides stercoralis infection and thromboembolism, and the recommended management.

Association between D-Dimer Levels and the Prognosis of Terminal Cancer Patients in the Last Hours of Life

Purpose

D-dimer levels are known to be associated with poor outcomes in patients with various cancers, but their significance at the end of life remains unclear. This study investigated D-dimer levels as a prognostic indicator for terminal cancer patients in the last hours of life.

Methods

The retrospective study was conducted at a palliative care unit of a tertiary cancer center, using a database to analyze the records of patients treated from January 1, 2010 to December 31, 2018. In total, 67 terminal cancer patients with available data on D-dimer levels were included. Patients' demographic data, clinical information, and laboratory values, including D-dimer levels, were collected. Survival was analyzed using the Kaplan-Meier method and the log-rank test. A Cox proportional-hazards model was used to identify prognostic factors of poor survival.

Results

The most common site of cancer was the lung (32.8%) and the median survival time was 5 days. Most laboratory results, particularly D-dimer levels, deviated from the normal range. Patients with high D-dimer levels had a significantly shorter survival time than those with low D-dimer levels (4 days vs. 7 days; P=0.012). In the Cox regression analysis, only a high D-dimer level was identified as a predictor of a poor prognosis (hazard ratio, 1.83; 95% confidence interval, 1.09~3.07).

Conclusion

Our results suggest that at the very end of life, D-dimer levels may serve as a prognostic factor for survival in cancer patients.

The Role of Blood Viscosity in Infectious Diseases

Blood viscosity is increased by elevated concentrations of acute phase reactants and hypergammaglobulinemia in inflammation. These increase blood viscosity by increasing plasma viscosity and fostering erythrocyte aggregation. Blood viscosity is also increased by decreased erythrocyte deformability, as occurs in malaria. Increased blood viscosity contributes to the association of acute infections with myocardial infarction (MI), venous thrombosis, and venous thromboembolism. It also increases vascular resistance, which decreases tissue perfusion and activates stretch receptors in the left ventricle, thereby initiating the systemic vascular resistance response. This compensates for the increased vascular resistance by vasodilation, lowering hematocrit, and decreasing intravascular volume. This physiological response causes the anemias associated with malaria, chronic inflammation, and other chronic diseases. Since tissue perfusion is inversely proportional to blood viscosity, anemia may be beneficial as it increases tissue perfusion when erythrocyte aggregating factors or erythrocytes with decreased deformability are present in the blood.

Endothelial Dysfunction in Obesity-Induced Inflammation: Molecular Mechanisms and Clinical Implications

Obesity is characterized by the excessive deposition of fat that may interfere with the normal metabolic process of the body. It is a chronic condition associated with various metabolic syndromes, whose prevalence is grossly increasing, and affects both children and adults. Accumulation of excessive macronutrients on the adipose tissues promotes the secretion and release of inflammatory mediators, including interleukin-6 (IL-6), interleukin 1β, tumor necrotic factor-α (TNF-α), leptin, and stimulation of monocyte chemoattractant protein-1 (MCP-1), which subsequently reduce the production of adiponectin thereby initiating a proinflammatory state. During obesity, adipose tissue synthesizes and releases a large number of hormones and cytokines that alter the metabolic processes, with a profound influence on endothelial dysfunction, a situation associated with the formation of atherosclerotic plaque. Endothelial cells respond to inflammation and stimulation of MCP-1, which is described as the activation of adhesion molecules leading to proliferation and transmigration of leukocytes, which facilitates their increase in atherogenic and thromboembolic potentials. Endothelial dysfunction forms the cornerstone of this discussion, as it has been considered as the initiator in the progression of cardiovascular diseases in obesity. Overexpression of proinflammatory cytokines with subsequent reduction of anti-inflammatory markers in obesity, is considered to be the link between obesity-induced inflammation and endothelial dysfunction. Inhibition of inflammatory mechanisms and management and control of obesity can assist in reducing the risks associated with cardiovascular complications.

Risk factors for venous thromboembolism in total shoulder arthroplasty

Background

Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning.

Methods

All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ² and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE.

Results

The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development.

Conclusion

Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

Clinical relevance of chronic respiratory disease in Korean patients with pulmonary thromboembolism

Background

Data regarding clinical and radiological features of patients with pulmonary thromboembolism (PTE) and concomitant chronic respiratory disease (CRD) are limited. Accordingly, the aim of the present study was to investigate clinico-radiological features of this patient population.

Methods

Patients with PTE were retrospectively classified into one of two groups: those with and without CRD. Clinical characteristics, blood biomarkers, and computed tomographic (CT) findings were compared between the groups.

Results

Of 1,207 PTE patients included, CRD was detected in 128 (11%). The most common CRD was chronic obstructive pulmonary disease [41 (32%)], followed by bronchial anthracofibrosis [32 (25%)]. In multivariate analysis, unprovoked PTE [odds ratio (OR) 1.99, 95% confidence interval (CI): 1.29-3.05, P=0.002], dyspnea (OR 1.54, 95% CI: 1.11-2.34, P=0.041), lower respiratory tract infection (LRTI) (OR 3.90, 95% CI: 2.13-7.14, P<0.001), Pulmonary Embolism Severity Index (PESI) class IV-V (OR 5.24, 95% CI: 3.43-8.00, P<0.001), in-situ pulmonary artery thrombosis (OR 10.62, 95% CI: 3.71-30.45, P<0.001), and pulmonary artery enlargement (OR 1.65, 95% CI: 3.71-30.45, P<0.001) were found to be independent clinical factors related to CRD in patients with PTE. CRD was an independent predictor of PTE-related in-hospital mortality (OR 3.96, 95% CI: 1.32-11.88, P=0.014).

Conclusions

Patients with PTE and concomitant CRD were characterized by higher incidences of dyspnea, LRTI, PESI class IV-V, and in-situ pulmonary artery thrombosis, compared with non-CRD patients. In these patients, CRD was a predictor of PTE-related in-hospital mortality.

Elevated Microparticle Tissue Factor Activity Differentiates Patients With Venous Thromboembolism in Anti-neutrophil Cytoplasmic Autoantibody Vasculitis

Introduction

Venous thromboembolism (VTE) is a life-threatening complication of anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis whose mechanism remains incompletely elucidated. We tested the hypothesis that elevated microparticle tissue factor activity (MPTFa) or anti-plasminogen antibodies (anti-Plg) may identify patients at risk for VTE.

Methods

In this prospective study, patients were enrolled during active disease and followed longitudinally. Twelve patients who experienced a VTE (VTE^pos) were compared with patients without VTE (VTE^neg, n = 29) and healthy controls (HC, n = 70). MPTFa, anti-Plg, interleukin-6, high-sensitivity C-reactive protein (hs-CRP), D-dimer, serum creatinine, and serum albumin were assessed. Fisher’s exact tests and Wilcoxon tests compared categorical and continuous variables, respectively. Cox regression for time to VTE or last follow-up was performed.

Results

VTE^pos patients had higher MPTFa (peak median = 14.0, interquartile range = 4.3–36.6) than HC (0, 0–3.5) and VTE^neg patients (0, 0–1.4). In time-to-event analysis, MPTFa was associated with VTE when measured during both active disease (hazard ratio [HR]; 95% confidence interval [CI]: 1.04; 1.01–1.08) and remission (1.4; 1.11–1.77). Anti-Plg during remission was also associated with VTE (1.17; 1.03–1.33). Each g/dl decrease of serum albumin was associated with a 4-fold increase in VTE risk (4.4; 1.5–12.9). Adjusting for estimated glomerular filtration rate (eGFR), anti-Plg during remission remained significantly associated with VTE.

Conclusion

Elevated MPTFa and increased anti-Plg in remission are strong indicators of VTE independent of renal function. Association of anti-Plg during remission with VTE implies hypercoagulability even during disease quiescence. Hypoalbuminemia strongly portends VTE risk, which is a novel finding in ANCA vasculitis. A thrombotic signature would allow improved management of patients to minimize VTE risk and complications of anticoagulation.

Circulating Platelets as Mediators of Immunity, Inflammation, and Thrombosis

Platelets, non-nucleated blood components first described over 130 years ago, are recognized as the primary cell regulating hemostasis and thrombosis. The vascular importance of platelets has been attributed to their essential role in thrombosis, mediating myocardial infarction, stroke, and venous thromboembolism. Increasing knowledge on the platelets' role in the vasculature has led to many advances in understanding not only how platelets interact with the vessel wall but also how they convey changes in the environment to other circulating cells. In addition to their well-described hemostatic function, platelets are active participants in the immune response to microbial organisms and foreign substances. Although incompletely understood, the immune role of platelets is a delicate balance between its pathogenic response and its regulation of thrombotic and hemostatic functions. Platelets mediate complex vascular homeostasis via specific receptors and granule release, RNA transfer, and mitochondrial secretion that subsequently regulates hemostasis and thrombosis, infection, and innate and adaptive immunity.

Prospective assessment of fibrinolysis in morbid obesity: tissue plasminogen activator resistance improves after bariatric surgery

BACKGROUND

Morbid obesity is associated with an increased risk of thrombotic events, which has been attributed to increased thrombotic activity. Multiple mechanisms have been proposed to explain this increased risk, including an inflammatory state with upregulation of procoagulant and antifibrinolytic proteins. We therefore hypothesize that patients with morbid obesity are hypercoagulable and will revert to normal after bariatric surgery.

OBJECTIVES

To evaluate changes in the hypercoagulable state after bariatric surgery.

SETTING

University Hospital, Bariatric Center of Excellence, United States.

METHODS

Thromboelastography (TEG) data were collected on 72 subjects with morbid obesity, with 36 who had 6 months of follow-up after bariatric surgery. TEG data of 75 healthy subjects (HS) without obesity, recent trauma or surgery, acute infection, or chronic conditions (e.g., liver, cardiovascular, or kidney disease; cancer; diabetes; autoimmune or inflammatory disorders; and disorders of coagulation) were used for comparison. TEG was performed alone and with the addition of 75 and 150 ng/mL tissue plasminogen activator (tPA) to quantify fibrinolysis resistance (tPA-challenged TEG).

RESULTS

The bariatric surgery cohort had a median age of 40.5 years, a median body mass index of 44.6 kg/m², and 90% female patients. Median body mass index reduced significantly 6 months post surgery but remained elevated compared with the HS group (31.4 versus 25.4 kg/m², P < .0001). At 6 months post surgery, subjects had longer reaction time (mean difference, 1.3; P = .02), lower maximum amplitude (-2.4, P = .01), and increased fibrinolysis with low-dose (3.1, P < .0001) and high-dose tPA-challenged TEG (9, P < .0001). Compared with HS, the postsurgery TEG values were still more likely to be abnormal (all P < .05).

CONCLUSIONS

Patients with morbid obesity form stronger clots more rapidly and are more resistant to fibrinolysis than subjects without obesity. Bariatric surgery significantly improved the hypercoagulable profile and fibrinolysis resistance of morbid obesity.

Heparin: An essential drug for modern medicine

Heparin is a life-saving drug, which belongs to few clinically used drugs without defined molecular structures in modern medicine. Heparin is the mostly negatively charged biopolymer with a broad distributions in molecular weight, charge density, and biological activities. Heparin is mainly composed of repeating trisulfated disaccharide units, which is made by mast cells that are enriched in the intestines, lungs or livers of animals. Porcine intestines and bovine lungs are two mostly used sources for heparin isolation. Heparin is well known for its anticoagulant and antithrombotic pharmacological effects. The anticoagulant activity of heparin is attributable to a 3-O-sulfate and 6-O-sulfate containing pentasaccharide sequence or a minimum eight-repeating disaccharide units containing the pentasaccharide sequence that catalyzes the suicidal inactivation of factor Xa or thrombin by a serpin or serine protease inhibitor named antithrombin III, respectively. Thus, heparin is responsible for the simultaneous inhibition of both thrombin generation and thrombin activity in the blood circulation. Moreover, heparin has many pharmacological properties such as anti-inflammatory, anti-viral, anti-angiogenesis, anti-neoplastic, and anti-metastatic effects though high affinity interactions with a variety of proteases, protease inhibitors, chemokines, cytokines, growth factors, and their respective receptors. The one drug multiple molecular targeting properties make heparin a very special drug in that various clinical trials are still conducting worldwide even 100 years after its discovery. In this review, we will summarize the structure-function relationship and the molecular mechanisms of heparin. We will also provide an overview of different clinical and potential clinical applications of heparin.

Incidence of a first venous thrombotic event in people with HIV in the Netherlands: a retrospective cohort study

BACKGROUND

The risk of venous thrombotic events is elevated in people with HIV, but overall risk estimates and estimates specific to immune status and antiretroviral medication remain i mprecise. In this study, we aimed to estimate these parameters in a large cohort of people with HIV in the Netherlands.

METHODS

In this retrospective cohort study, we used the Dutch ATHENA cohort to estimate crude, age and sex standardised, and risk period-specific incidences of a first venous thrombotic event in people with HIV aged 18 years or older attending 12 HIV treatment centres in the Netherlands. Crude and standardised incidences were compared with European population-level studies of venous thrombotic events. We used time-updated Cox regression to estimate the risk of a first venous thrombotic event in association with HIV-specific factors (CD4 cell count, viral load, recent opportunistic infections, antiretroviral medication use) adjusted for traditional risk factors for venous thrombotic events.

FINDINGS

With data collected from Jan 1, 2003, to April 1, 2015, our study cohort included 14 389 people with HIV and 99 762 person-years of follow-up, with a median follow-up of 7·2 years (IQR 3·3-11·1). During this period, 232 first venous thrombotic events occurred, yielding a crude incidence of 2·33 events per 1000 person-years (95% CI 2·04-2·64) and an incidence standardised for age and sex of 2·50 events per 1000 (2·18-2·82). CD4 counts less than 200 cells per μL were independently associated with higher risk of a venous thrombotic event: adjusted hazard ratio (aHR) 3·40 (95% CI 2·28-5·08) relative to counts of 500 cells per μL. A high viral load (aHR 3·15, 95% CI 2·00-5·02; >100 000 copies per mL vs <50 copies per mL) and current or recent opportunistic adverse events (2·80, 1·77-4·44) were also independently associated with higher risk of a venous thrombotic event. There were no associations between any specific antiretroviral drugs and risk of a venous thrombotic event. Rates associated with pregnancy (9·4, 95% CI 4·6-17·3), malignancy (16·7, 10·6-25·1), and hospitalisation (24·4, 19·1-30·6) were lower than primary thromboprophylaxis thresholds suggested by the respective guidelines.

INTERPRETATION

Our findings support neither prescribing primary outpatient thromboprophylaxis nor avoiding any type of antiretroviral medication in people with HIV at high risk of a venous thrombotic event.

FUNDING

Dutch Ministry of Health, Welfare and Sport.

Pylephlebitis: A Case of Inferior Mesenteric Vein Thrombophlebitis in a Patient with Acute Sigmoid Diverticulitis—A Case Report and Clinical Management Review

Pylephlebitis is a rare complication of intra-abdominal infections and describes thrombosis and infection as two different pathophysiological phenomena in the cause of this disease. The nonspecific presentation of disease makes its diagnosis difficult and thus leads to high mortality. The treatment comprises antibiotics and also includes controversial use of anticoagulation in these patients. Here, we present a patient with past medical history of human immunodeficiency virus and past diverticulitis who presented with fever, chills, diarrhea, neck pain, and photophobia. He was diagnosed with acute sigmoid diverticulitis with associated inferior mesenteric vein thrombophlebitis. He improved after intravenous antibiotics and anticoagulation and was discharged. He underwent sigmoid colectomy 3 months after his initial presentation and was advised to take anticoagulation for a total of 6 months.

Expression variations and clinical significance of MMP-1, MMP-2 and inflammatory factors in serum of patients with deep venous thrombosis of lower extremity

Expression levels and clinical significance of matrix metalloproteinase-1 (MMP1), MMP-2 and inflammatory factors in the serum of patients with deep venous thrombosis (DVT) of lower extremity were investigated. Fifty untreated DVT patients were selected as the DVT group, and 50 patients undergoing health examination were enrolled as the normal control group. Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of MMP-1, MMP-2, interleukin-6 (IL-6), IL-8 and tumor necrosis factor-α (TNF-α) in the serum. Western blotting was adopted to detect the expression levels of MMP-1 and MMP-2 proteins. Fluorescent reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was applied to examine the messenger ribonucleic acid (mRNA) expression levels. Moreover, the circumferences of the patients were measured. The difference between the circumference of affected extremity and unaffected extremity was calculated. Correlation analysis was conducted separately for the levels of serum MMP-1, MMP-2, IL-6, IL-8 and TNF-α of patients in the DVT group. In the DVT group, the levels of MMP-1, MMP-2, IL-6, IL-8, and TNF-α at 7 days after treatment were significantly lower than those before treatment (P<0.01). Compared with that before treatment, the circumference difference of the affected and unaffected extremities of the patients was reduced at 7 days after treatment (P<0.01). The levels of IL-6, IL-8 and TNF-α were positively correlated with the levels of MMP-1 and MMP-2, respectively in the DVT group (P<0.05 or P<0.01). MMP-1, MMP-2 and inflammatory factors play an important role in the occurrence and development of DVT, of which the levels of IL-6, IL-8 and TNF-α are positively correlated with the levels of MMP-1 and MMP-2, respectively. Therefore, monitoring the concentration of MMP-1, MMP-2 and inflammatory factors is of significant value for the diagnosis, progression and judgement of treatment effect of DVT in clinical practice.