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Reyes Gil M, Pantanowitz J, Rashidi HH. Venous thromboembolism in the era of machine learning and artificial intelligence in medicine. Thromb Res 2024; 242:109121. [PMID: 39213896 DOI: 10.1016/j.thromres.2024.109121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/19/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
In this review, we embark on a comprehensive exploration of venous thromboembolism (VTE) in the context of medical history and its current practice within medicine. We delve into the landscape of artificial intelligence (AI), exploring its present utility and envisioning its transformative roles within VTE management, from prevention to screening and beyond. Central to our discourse is a forward-looking perspective on the integration of AI within VTE in medicine, advocating for rigorous study design, robust validation processes, and meticulous statistical analysis to gauge the efficacy of AI applications. We further illuminate the potential of large language models and generative AI in revolutionizing VTE care, while acknowledging their inherent limitations and proposing innovative solutions to overcome challenges related to data availability and integrity, including the strategic use of synthetic data. The critical importance of navigating ethical, legal, and privacy concerns associated with AI is underscored, alongside the imperative for comprehensive governance and policy frameworks to regulate its deployment in VTE treatment. We conclude on a note of cautious optimism, where we highlight the significance of proactively addressing the myriad challenges that accompany the advent of AI in healthcare. Through diligent design, stringent validation, extensive education, and prudent regulation, we can harness AI's potential to significantly enhance our understanding and management of VTE. As we stand on the cusp of a new era, our commitment to these principles will be instrumental in ensuring that the promise of AI is fully realized within the realm of VTE care.
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Affiliation(s)
- Morayma Reyes Gil
- Thrombosis and Hemostasis Labs, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Joshua Pantanowitz
- Computational Pathology and AI Center of Excellence, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Hooman H Rashidi
- Computational Pathology and AI Center of Excellence, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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2
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Vernemmen I, Buschmann E, Van Steenkiste G, Demeyere M, Verhaeghe LM, De Somer F, Devreese KMJ, Schauvliege S, Decloedt A, van Loon G. Intracardiac ultrasound-guided transseptal puncture in horses: Outcome, follow-up, and perioperative anticoagulant treatment. J Vet Intern Med 2024; 38:2707-2717. [PMID: 39086137 PMCID: PMC11423474 DOI: 10.1111/jvim.17158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Cardiac catheterizations in horses are mainly performed in the right heart, as access to the left heart traditionally requires an arterial approach. Transseptal puncture (TSP) has been adapted for horses but data on follow-up and closure of the iatrogenic atrial septal defect (iASD) are lacking. HYPOTHESIS/OBJECTIVES To perform TSP and assess postoperative complications and iASD closure over a minimum of 4 weeks. ANIMALS Eleven healthy adult horses. METHODS Transseptal puncture was performed under general anesthesia. Serum cardiac troponin I concentrations were measured before and after puncture. Weekly, iASD closure was monitored using transthoracic and intracardiac echocardiography. Relationship between activated clotting time and anti-factor Xa activity during postoperative enoxaparin treatment was assessed in vitro and in vivo. RESULTS Transseptal puncture was successfully achieved in all horses within a median duration of 22 (range, 10-104) minutes. Balloon dilatation of the puncture site for sheath advancement was needed in 4 horses. Atrial arrhythmias occurred in 9/11 horses, including atrial premature depolarizations (N = 1), atrial tachycardia (N = 5), and fibrillation (N = 3). Serum cardiac troponin I concentrations increased after TSP, but remained under the reference value in 10/11 horses. Median time to iASD closure was 14 (1-35) days. Activated clotting time correlated with anti-factor Xa activity in vitro but not in vivo. CONCLUSIONS AND CLINICAL IMPORTANCE Transseptal puncture was successfully performed in all horses. The technique was safe and spontaneous iASD closure occurred in all horses. Clinical application of TSP will allow characterization and treatment of left-sided arrhythmias in horses.
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Affiliation(s)
- Ingrid Vernemmen
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Eva Buschmann
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Glenn Van Steenkiste
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Marie Demeyere
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Lize-Maria Verhaeghe
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Stijn Schauvliege
- Department of Large Animal Surgery, Anaesthesia and Orthopaedics, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Annelies Decloedt
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Gunther van Loon
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
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3
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Yim W, Jin Z, Chang YC, Brambila C, Creyer MN, Ling C, He T, Li Y, Retout M, Penny WF, Zhou J, Jokerst JV. Polyphenol-stabilized coacervates for enzyme-triggered drug delivery. Nat Commun 2024; 15:7295. [PMID: 39181884 PMCID: PMC11344779 DOI: 10.1038/s41467-024-51218-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 08/01/2024] [Indexed: 08/27/2024] Open
Abstract
Stability issues in membrane-free coacervates have been addressed with coating strategies, but these approaches often compromise the permeability of the coacervate. Here we report a facile approach to maintain both stability and permeability using tannic acid and then demonstrate the value of this approach in enzyme-triggered drug release. First, we develop size-tunable coacervates via self-assembly of heparin glycosaminoglycan with tyrosine and arginine-based peptides. A thrombin-recognition site within the peptide building block results in heparin release upon thrombin proteolysis. Notably, polyphenols are integrated within the nano-coacervates to improve stability in biofluids. Phenolic crosslinking at the liquid-liquid interface enables nano-coacervates to maintain exceptional structural integrity across various environments. We discover a pivotal polyphenol threshold for preserving enzymatic activity alongside enhanced stability. The disassembly rate of the nano-coacervates increases as a function of thrombin activity, thus preventing a coagulation cascade. This polyphenol-based approach not only improves stability but also opens the way for applications in biomedicine, protease sensing, and bio-responsive drug delivery.
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Affiliation(s)
- Wonjun Yim
- Materials Science and Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Zhicheng Jin
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Yu-Ci Chang
- Materials Science and Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Carlos Brambila
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Matthew N Creyer
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Chuxuan Ling
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Tengyu He
- Materials Science and Engineering Program, University of California San Diego, La Jolla, CA, USA
| | - Yi Li
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Maurice Retout
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - William F Penny
- Division of Cardiology, VA San Diego Healthcare System, University of California San Diego, La Jolla, CA, USA
| | - Jiajing Zhou
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA
| | - Jesse V Jokerst
- Materials Science and Engineering Program, University of California San Diego, La Jolla, CA, USA.
- Aiiso Yufeng Li Family Department of Chemical and NanoEngineering, University of California San Diego, La Jolla, CA, USA.
- Department of Radiology, University of California San Diego, La Jolla, CA, USA.
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Beheshtizadeh N, Mohammadzadeh M, Mostafavi M, Seraji AA, Esmaeili Ranjbar F, Tabatabaei SZ, Ghafelehbashi R, Afzali M, Lolasi F. Improving hemocompatibility in tissue-engineered products employing heparin-loaded nanoplatforms. Pharmacol Res 2024; 206:107260. [PMID: 38906204 DOI: 10.1016/j.phrs.2024.107260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
The enhancement of hemocompatibility through the use of nanoplatforms loaded with heparin represents a highly desirable characteristic in the context of emerging tissue engineering applications. The significance of employing heparin in biological processes is unquestionable, owing to its ability to interact with a diverse range of proteins. It plays a crucial role in numerous biological processes by engaging in interactions with diverse proteins and hydrogels. This review provides a summary of recent endeavors focused on augmenting the hemocompatibility of tissue engineering methods through the utilization of nanoplatforms loaded with heparin. This study also provides a comprehensive review of the various applications of heparin-loaded nanofibers and nanoparticles, as well as the techniques employed for encapsulating heparin within these nanoplatforms. The biological and physical effects resulting from the encapsulation of heparin in nanoplatforms are examined. The potential applications of heparin-based materials in tissue engineering are also discussed, along with future perspectives in this field.
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Affiliation(s)
- Nima Beheshtizadeh
- Department of Tissue Engineering, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Mahsa Mohammadzadeh
- Department of Materials Engineering, Isfahan University of Technology, Isfahan 84156-83111, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mehrnaz Mostafavi
- Faculty of Allied Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Abbas Seraji
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada; Department of Polymer Engineering and Color Technology, Amirkabir University of Technology, Tehran, Iran
| | - Faezeh Esmaeili Ranjbar
- Molecular Medicine Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Seyedeh Zoha Tabatabaei
- Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robabehbeygom Ghafelehbashi
- Dental Materials Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; Department of Materials and Textile Engineering, College of Engineering, Razi University, Kermanshah, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maede Afzali
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Farshad Lolasi
- Department of pharmaceutical biotechnology, Faculty of Pharmacy And Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Chornenki NLJ, McPhaden H, Peterson EA, Benjamin Lai CM, Lee AYY. Dual direct oral anticoagulant therapy in challenging thrombosis: a case series. Res Pract Thromb Haemost 2024; 8:102546. [PMID: 39290989 PMCID: PMC11406084 DOI: 10.1016/j.rpth.2024.102546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 09/19/2024] Open
Abstract
Background While anticoagulation therapy is highly effective at treating venous thromboembolism, some patients can develop rapidly progressive thrombosis in multiple organs or sites despite therapeutic anticoagulation. Effective strategies to manage life-threatening thrombosis in these patients are elusive. Objectives We describe our experience using dual direct oral anticoagulant (DOAC) therapy with a factor (F)Xa inhibitor (such as rivaroxaban or apixaban) and a FIIa inhibitor (dabigatran) for refractory cases of thrombosis. Methods A retrospective chart review of all patients treated with simultaneous dabigatran and an oral FXa inhibitor at our institution was conducted. We included all patients over the age of 18. The study was approved by the University of British Columbia Research Ethics Board (REB number: H23-02575). Results Eight patients were included. All patients initiated standard therapeutic anticoagulation upon diagnosis of acute venous thromboembolism with a median of 3 breakthrough thrombotic events prior to dual DOAC use. Five patients had a positive heparin-induced thrombocytopenia screen, but only 2 had heparin-induced thrombocytopenia confirmed on serotonin release assay testing. There were no recurrent deep vein thrombosis, pulmonary embolism, or bleeding events during dual DOAC use. Most patients ultimately transitioned to a single oral FXa inhibitor. Conclusion Dual DOAC therapy may be a useful strategy for managing challenging thrombosis cases resistant to conventional anticoagulation. Further research is warranted to validate these findings and explore the broader applicability of dual DOAC therapy in challenging thrombotic scenarios.
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Affiliation(s)
- Nicholas L J Chornenki
- Division of Hematology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather McPhaden
- Division of Hematology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Erica A Peterson
- Division of Hematology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Chieh Min Benjamin Lai
- Division of Hematology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- The University of British Columbia Centre for Blood Research, Vancouver, British Columbia, Canada
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- The University of British Columbia Centre for Blood Research, Vancouver, British Columbia, Canada
- BC Cancer, Vancouver, British Columbia, Canada
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6
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Chittum JE, Thompson A, Desai UR. Glycosaminoglycan microarrays for studying glycosaminoglycan-protein systems. Carbohydr Polym 2024; 335:122106. [PMID: 38616080 PMCID: PMC11032185 DOI: 10.1016/j.carbpol.2024.122106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024]
Abstract
More than 3000 proteins are now known to bind to glycosaminoglycans (GAGs). Yet, GAG-protein systems are rather poorly understood in terms of selectivity of recognition, molecular mechanism of action, and translational promise. High-throughput screening (HTS) technologies are critically needed for studying GAG biology and developing GAG-based therapeutics. Microarrays, developed within the past two decades, have now improved to the point of being the preferred tool in the HTS of biomolecules. GAG microarrays, in which GAG sequences are immobilized on slides, while similar to other microarrays, have their own sets of challenges and considerations. GAG microarrays are rapidly becoming the first choice in studying GAG-protein systems. Here, we review different modalities and applications of GAG microarrays presented to date. We discuss advantages and disadvantages of this technology, explain covalent and non-covalent immobilization strategies using different chemically reactive groups, and present various assay formats for qualitative and quantitative interpretations, including selectivity screening, binding affinity studies, competitive binding studies etc. We also highlight recent advances in implementing this technology, cataloging of data, and project its future promise. Overall, the technology of GAG microarray exhibits enormous potential of evolving into more than a mere screening tool for studying GAG - protein systems.
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Affiliation(s)
- John E Chittum
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, United States of America; Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, United States of America
| | - Ally Thompson
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, United States of America; Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, United States of America
| | - Umesh R Desai
- Department of Medicinal Chemistry, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, United States of America; Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, VA 23219, United States of America.
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7
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Thalappil V, Anand J, Keepanasseril A, Kar R. Standardization of Anti-Xa Assay and its Comparison with Activated Partial Thromboplastin Time for Monitoring Unfractionated Heparin Therapy. Indian J Hematol Blood Transfus 2024; 40:432-436. [PMID: 39011243 PMCID: PMC11246396 DOI: 10.1007/s12288-023-01718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/16/2023] [Indexed: 07/17/2024] Open
Abstract
Monitoring of anticoagulant activity of unfractionated heparin (UFH) is primarily done with activated partial thromboplastin time (aPTT), which is affected by many factors. Anti-Xa assays are considered to overcome these factors and may provide a better method for monitoring patients on UFH with a narrow therapeutic range. This study aimed to compare the effectiveness of aPTT and anti-Xa assays in UFH monitoring. A prospective non-randomized study was carried out in two stages: first, the anti-Xa assay was standardized using kit instructions; each sample was then analyzed by both tests. The outcomes of the two assays were compared and assessed for agreement of maintaining therapeutic anticoagulant levels. These levels for anti-Xa assay were between 0.3 and 0.7 IU/ml, while it was 1.5-2.5 times the control for aPTT assay. Below this range was regarded as subtherapeutic, and above this as supratherapeutic. A total of 90 samples were tested and analyzed using both assays. Most of them (> 70%) were noted to be in subtherapeutic levels with both tests. The overall concordance was 73.3%, and the estimated kappa value was 0.483 (0.396-0.57). The correlation between aPTT and anti-Xa assay was 0.74 (p < 0.001). With anti-Xa levels in the therapeutic range, aPTT levels were in subtherapeutic in 60% and supratherapeutic in 13.3% cases. Although both the testing strategies had a good agreement and correlation, discordance was observed in interpretative values with anti-Xa levels in therapeutic range and aPTT levels in non-therapeutic range. Its clinical implications need to be evaluated further in future studies.
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Affiliation(s)
- Vijisha Thalappil
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006 India
| | - Jeyanthi Anand
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006 India
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006 India
| | - Rakhee Kar
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006 India
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Wadhwa A, Mensah E, Young M, Ogilvy CS. Variability patterns in dual antiplatelet therapy following endovascular repair of intracranial aneurysms: Insight into regimen heterogeneity and the need for a consensus. Acta Neurochir (Wien) 2024; 166:271. [PMID: 38888678 DOI: 10.1007/s00701-024-06137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024]
Abstract
This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.
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Affiliation(s)
- Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA.
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Víteček J, Vítečková Wünschová A, Thalerová S, Gulati S, Kubala L, Capandová M, Hampl A, Robert Mikulík. Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment. PLoS One 2024; 19:e0302269. [PMID: 38843177 PMCID: PMC11156348 DOI: 10.1371/journal.pone.0302269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/31/2024] [Indexed: 06/09/2024] Open
Abstract
Intravenous thrombolysis with a recombinant tissue plasminogen activator (rt-PA) is the first-line treatment of acute ischemic stroke. However, successful recanalization is relatively low and the underlying processes are not completely understood. The goal was to provide insights into clinically important factors potentially limiting rt-PA efficacy such as clot size, rt-PA concentration, clot age and also rt-PA in combination with heparin anticoagulant. We established a static in vitro thrombolytic model based on red blood cell (RBC) dominant clots prepared using spontaneous clotting from the blood of healthy donors. Thrombolysis was determined by clot mass loss and by RBC release. The rt-PA became increasingly less efficient for clots larger than 50 μl at a clinically relevant concentration of 1.3 mg/l. A tenfold decrease or increase in concentration induced only a 2-fold decrease or increase in clot degradation. Clot age did not affect rt-PA-induced thrombolysis but 2-hours-old clots were degraded more readily due to higher activity of spontaneous thrombolysis, as compared to 5-hours-old clots. Finally, heparin (50 and 100 IU/ml) did not influence the rt-PA-induced thrombolysis. Our study provided in vitro evidence for a clot size threshold: clots larger than 50 μl are hard to degrade by rt-PA. Increasing rt-PA concentration provided limited thrombolytic efficacy improvement, whereas heparin addition had no effect. However, the higher susceptibility of younger clots to thrombolysis may prompt a shortened time from the onset of stroke to rt-PA treatment.
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Affiliation(s)
- Jan Víteček
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Andrea Vítečková Wünschová
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Anatomy, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Sandra Thalerová
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
- Department of Biochemistry, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Sumeet Gulati
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Lukáš Kubala
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Biophysics of Immune System, Institute of Biophysics of the Czech Academy of Sciences, Brno, Czech Republic
| | - Michaela Capandová
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Aleš Hampl
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
- Department of Histology and Embryology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Robert Mikulík
- International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic
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10
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Pizzi R, Cimini LA, Ageno W, Becattini C. Direct Oral Anticoagulants for Pulmonary Embolism. Hamostaseologie 2024; 44:206-217. [PMID: 38467144 DOI: 10.1055/a-2105-8736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.
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Affiliation(s)
- Roberto Pizzi
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ludovica Anna Cimini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cecilia Becattini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
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11
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Samimi MN, Hale A, Schults J, Fischer A, Roberts JA, Dhanani J. Clinical guidance for unfractionated heparin dosing and monitoring in critically ill patients. Expert Opin Pharmacother 2024; 25:985-997. [PMID: 38825778 DOI: 10.1080/14656566.2024.2364057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Unfractionated heparin is a widely used anticoagulant in critically ill patients. It has a well-established safety profile and remains an attractive option for clinicians due to its short half-life and reversibility. Heparin has a unique pharmacokinetic profile, which contributes to significant inter-patient and intra-patient variability in effect. The variability in anticoagulant effect combined with heparin's short half-life mean close monitoring is required for clinical efficacy and preventing adverse effects. To optimize heparin use in critically ill patients, effective monitoring assays and dose adjustment strategies are needed. AREAS COVERED This paper explores the use of heparin as an anticoagulant and optimal approaches to monitoring in critically ill patients. EXPERT OPINION Conventional monitoring assays for heparin dosing have significant limitations. Emerging data appear to favor using anti-Xa assay monitoring for heparin anticoagulation, which many centers have successfully adopted as the standard. The anti-Xa assay appears have important benefits relative to the aPTT for heparin monitoring in critically ill patients, and should be considered for broader use.
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Affiliation(s)
- May N Samimi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Hale
- Discipline of Pharmacy, School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Jessica Schults
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Andreas Fischer
- Pharmacy Department, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jayesh Dhanani
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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12
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Arachchillage DJ, Kitchen S. Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice. Semin Thromb Hemost 2024. [PMID: 38810964 DOI: 10.1055/s-0044-1786990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Unfractionated heparin (UFH) was uncovered in 1916, has been used as an anticoagulant since 1935, and has been listed in the World Health Organization's Model List of Essential Medicines. Despite the availability of many other anticoagulants, the use of heparin (either low molecular weight heparin [LMWH] or UFH) is still substantial. Heparin has pleotropic effects including anticoagulant and several nonanticoagulant properties such as antiproliferative, anti-inflammatory activity, and anticomplement effects. Although UFH has been widely replaced by LMWH, UFH is still the preferred anticoagulant of choice for patients undergoing cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, and patients with high-risk mechanical cardiac valves requiring temporary bridging with a parenteral anticoagulant. UFH is a highly negatively charged molecule and binds many positively charged molecules, hence has unpredictable pharmacokinetics, and variable anticoagulant effect on an individual patient basis. Therefore, anticoagulant effects of UFH may not be proportional to the dose of UFH given to any individual patient. In this review, we discuss the anticoagulant and nonanticoagulant activities of UFH, differences between UFH and LMWH, when to use UFH, different methods of monitoring the anticoagulant effects of UFH (including activated partial thromboplastin time, heparin anti-Xa activity level, and activated clotting time), while discussing pros and cons related to each method and comparison of clinical outcomes in patients treated with UFH monitored with different methods based on available evidence.
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Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
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13
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Ma F, Huang X, Wang Y. Fabrication of a Triple-Layer Bionic Vascular Scaffold via Hybrid Electrospinning. J Funct Biomater 2024; 15:140. [PMID: 38921514 PMCID: PMC11204414 DOI: 10.3390/jfb15060140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024] Open
Abstract
Tissue engineering aims to develop bionic scaffolds as alternatives to autologous vascular grafts due to their limited availability. This study introduces a novel wet-electrospinning fabrication technique to create small-diameter, uniformly aligned tubular scaffolds. By combining this innovative method with conventional electrospinning, a bionic tri-layer scaffold that mimics the zonal structure of vascular tissues is produced. The inner and outer layers consist of PCL/Gelatin and PCL/PLGA fibers, respectively, while the middle layer is crafted using PCL through Wet Vertical Magnetic Rod Electrospinning (WVMRE). The scaffold's morphology is analyzed using Scanning Electron Microscopy (SEM) to confirm its bionic structure. The mechanical properties, degradation profile, wettability, and biocompatibility of the scaffold are also characterized. To enhance hemocompatibility, the scaffold is crosslinked with heparin. The results demonstrate sufficient mechanical properties, good wettability of the inner layer, proper degradability of the inner and middle layers, and overall good biocompatibility. In conclusion, this study successfully develops a small-diameter tri-layer tubular scaffold that meets the required specifications.
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Affiliation(s)
- Feier Ma
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
- Institute of Orthopaedic & Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, The Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
| | - Xiaojing Huang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Yan Wang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
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14
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Bakhsh E. Impact of Replacement Therapy on Pregnancy Outcomes in Hemophilia Carriers: A Historical Cohort Study in Saudi Arabia. Life (Basel) 2024; 14:623. [PMID: 38792643 PMCID: PMC11122275 DOI: 10.3390/life14050623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
This retrospective cohort study evaluates the safety and efficacy of replacement therapy with regard to pregnancy outcomes in hemophilia carriers. Hemophilia carriers face elevated bleeding risks during pregnancy, necessitating meticulous management, including replacement therapy with clotting factors. This research examines the records of 64 pregnant hemophilia carriers at King Fahad Medical City, Riyadh, from January 2010 to December 2023, analyzing their demographic details, hemophilia type and severity, replacement therapy specifics, and pregnancy outcomes. The study found that 62.5% of the participants had hemophilia A, with 43.8% categorized as severe. Most subjects (87.5%) received recombinant factor VIII at a median dosage of 30 IU/kg weekly. Adverse pregnancy outcomes included gestational hypertension (15.6%), preterm labor (18.8%), and postpartum hemorrhage (12.5%). The cesarean section rate was 28.1%. Neonatal outcomes were generally favorable, with median birth weights at 3100 g and mean Apgar scores of 8.2 and 9.1 at 1 and 5 min, respectively. Logistic regression analysis revealed no significant association between adverse events and therapy type or dosage, though a trend towards significance was noted with once-weekly administration (p = 0.082). The study concludes that replacement therapy is a viable method for managing hemophilia in pregnant carriers, leading to generally favorable maternal and neonatal outcomes. However, it underscores the importance of individualized treatment plans and close monitoring to effectively manage the risks associated with hemophilia during pregnancy.
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Affiliation(s)
- Ebtisam Bakhsh
- Internal Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
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15
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Ullalkar N, M V, Pn S, Vaibhavi D, Ca S. To Compare the Effectiveness of Low-Molecular-Weight Heparin and Unfractionated Heparin in Reducing Lower Limb Girth in Deep Vein Thrombosis. Cureus 2024; 16:e59449. [PMID: 38827007 PMCID: PMC11141321 DOI: 10.7759/cureus.59449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 06/04/2024] Open
Abstract
INTRODUCTION Treating deep vein thrombosis (DVT) using a once-daily dose of enoxaparin offers greater convenience and the possibility of home-based care for certain patients, as opposed to a continuous infusion of unfractionated heparin (UFH). The study aimed to determine the most cost-effective thromboprophylaxis between low-molecular-weight heparin (LMWH) and UFH for hospitalized patients. MATERIALS AND METHODS After obtaining clearance from the institutional ethical committee, the study was conducted in the Department of General Surgery, Sri Devaraj Urs Medical College, over a period of six months. Informed consent was obtained from all 46 patients included in this study. The participants were divided into two groups: group A received LMWH and group B received UFH. RESULTS The mean age in group A was 59.8 + 10.6 years and in group B was 54.9 + 12.3 years. There was no significant difference in the girth of the lower limb between the groups during the follow-up period (p > 0.05). In group A, there was a highly significant reduction in lower limb girth from day one to day five (p < 0.0001), day five to day 10 (p < 0.0001), and day one to day 10 (p < 0.0001). In group B, there was no significant reduction from day one to day five (p = 0.06), but there was a significant reduction from day five to day 10 (p = 0.001) and day one to day 10 (p = 0.001). CONCLUSION Treatment with LMWH as an anticoagulant significantly reduced the lower extremity girth and thrombus thickness in cases of DVT when compared to UFH.
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Affiliation(s)
- Neha Ullalkar
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Vedanth M
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Sreeramulu Pn
- Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - D Vaibhavi
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Shashirekha Ca
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
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16
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Neri D. Designing drugs with reversible activity. Nat Biotechnol 2024:10.1038/s41587-024-02242-y. [PMID: 38689026 DOI: 10.1038/s41587-024-02242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Dario Neri
- Philogen SpA, Siena, Italy.
- ETH Zürich, Zurich, Switzerland.
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17
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Dockerill M, Ford DJ, Angerani S, Alwis I, Dowman LJ, Ripoll-Rozada J, Smythe RE, Liu JST, Pereira PJB, Jackson SP, Payne RJ, Winssinger N. Development of supramolecular anticoagulants with on-demand reversibility. Nat Biotechnol 2024:10.1038/s41587-024-02209-z. [PMID: 38689027 DOI: 10.1038/s41587-024-02209-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 03/14/2024] [Indexed: 05/02/2024]
Abstract
Drugs are administered at a dosing schedule set by their therapeutic index, and termination of action is achieved by clearance and metabolism of the drug. In some cases, such as anticoagulant drugs or immunotherapeutics, it is important to be able to quickly reverse the drug's action. Here, we report a general strategy to achieve on-demand reversibility by designing a supramolecular drug (a noncovalent assembly of two cooperatively interacting drug fragments held together by transient hybridization of peptide nucleic acid (PNA)) that can be reversed with a PNA antidote that outcompetes the hybridization between the fragments. We demonstrate the approach with thrombin-inhibiting anticoagulants, creating very potent and reversible bivalent direct thrombin inhibitors (Ki = 74 pM). The supramolecular inhibitor effectively inhibited thrombus formation in mice in a needle injury thrombosis model, and this activity could be reversed by administration of the PNA antidote. This design is applicable to therapeutic targets where two binding sites can be identified.
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Affiliation(s)
- Millicent Dockerill
- Department of Organic Chemistry, NCCR Chemical Biology, Faculty of Sciences, University of Geneva, Geneva, Switzerland
| | - Daniel J Ford
- School of Chemistry, The University of Sydney, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Sydney, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Simona Angerani
- Department of Organic Chemistry, NCCR Chemical Biology, Faculty of Sciences, University of Geneva, Geneva, Switzerland
| | - Imala Alwis
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Luke J Dowman
- School of Chemistry, The University of Sydney, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Jorge Ripoll-Rozada
- Instituto de Biologia Molecular e Celular (IBMC), Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Rhyll E Smythe
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Joanna S T Liu
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Pedro José Barbosa Pereira
- Instituto de Biologia Molecular e Celular (IBMC), Universidade do Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Shaun P Jackson
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Heart Research Institute, Sydney, New South Wales, Australia
| | - Richard J Payne
- School of Chemistry, The University of Sydney, Sydney, New South Wales, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicolas Winssinger
- Department of Organic Chemistry, NCCR Chemical Biology, Faculty of Sciences, University of Geneva, Geneva, Switzerland.
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18
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Thongdee C, Lumkul L, Wongyikul P, Spilles N, Laonapaporn B, Patumanond J, Phinyo P. Optimal volume for the draw-and-return methods to enhance activated partial thromboplastin time ratio accuracy in hemodialysis patients with central venous catheters. Heliyon 2024; 10:e28651. [PMID: 38590898 PMCID: PMC11000023 DOI: 10.1016/j.heliyon.2024.e28651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background Significant errors of activated partial thromboplastin time (aPTT) ratio were frequently observed in blood sampling from central venous dialysis catheter (CVC) of hemodialysis (HD) patients. Following the draw-and-return methods, initial blood withdrawal from the catheter before sampling can reduce the error, but the optimal withdrawal volume remains undetermined. Aim The objective of this study is to determine the optimal blood withdrawal volume for the draw-and-return methods to improve aPTT ratio accuracy in hemodialysis patients with CVC. Methods A prospective study was conducted in patients receiving HD via CVC. Four blood samples were collected from each patient, involving a peripheral venipuncture and three draw-and-return samples (10 ml, 20 ml and 25 ml groups). The aPTT ratio of a peripheral sample was used as a reference to determine the aPTT ratio accuracy for each draw-and-return group. Subsequently, the agreement was illustrated using modified Bland-Altman plot. Results A total of 1,000 samples were obtained from 250 patients. The patients had a mean age of 59.6 ± 15.4 years, with 17.2% using citrate as the CVC's locking agent. The adjusted accuracies of the aPTT ratio varied significantly among the three withdrawal volumes (p-value <0.001). The 25 ml group demonstrated the highest accuracy (43.2%; 95%CI, 38.0-48.4), followed by the 20 ml group (30.0%; 95%CI, 24.9-35.2), and the 10 ml group (18.0%; 95%CI, 12.8-23.2). Additionally, using citrate as a locking agent provided more than 80.0% aPTT ratio accuracy, whereas heparin demonstrated inferior accuracy even in the 25 ml withdrawal group. Conclusion The optimal blood withdraw volume for the draw-and-return methods concluded at 20 ml for citrate locked-CVC and 25 ml for heparin which significantly improved aPTT ratio accuracies. Applying citrate as a locking agent provides clear benefits for aPTT ratio monitoring, while peripheral venipuncture is recommended in cases of heparin-locked CVC.
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Affiliation(s)
- Chitrada Thongdee
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Lalita Lumkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nantana Spilles
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Boonruksa Laonapaporn
- Dialysis Center, Nopparat Rajathanee Hospital, Ministry of Public Health, Bangkok, Thailand
| | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Multidisciplinary Technology for Advanced Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Saeed D, Fuenmayor D, Niño Medina JA, Saleh I, Castiblanco Torres JD, Horn WL, Sosa Quintanilla MH, Leiva KE, Dannuncio V, Viteri M, Rivas M, Kumari N. Unraveling the Paradox: Can Anticoagulation Improve Outcomes in Patients With Heart Failure and Increased Bleeding Risk? Cureus 2024; 16:e57544. [PMID: 38707016 PMCID: PMC11068119 DOI: 10.7759/cureus.57544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Heart failure (HF) patients frequently present with comorbidities such as atrial fibrillation (AF) or other cardiovascular conditions, elevating their risk of thromboembolic events. Consequently, anticoagulation therapy is often considered for thromboprophylaxis, although its initiation in HF patients is complicated by concomitant bleeding risk factors. This review explores the paradoxical relationship between HF, increased bleeding risk, and the potential benefits of anticoagulation. Through an examination of existing evidence from clinical trials, observational studies, and meta-analyses, we aim to elucidate the role of anticoagulation in HF patients with increased bleeding risk. Despite guidelines recommending anticoagulation for certain HF patients with AF or other thromboembolic risk factors, uncertainty persists regarding the optimal management strategy for those at heightened risk of bleeding. The review discusses the pathophysiological mechanisms linking HF and thrombosis, challenges in bleeding risk assessment, and strategies to minimize bleeding risk while optimizing thromboprophylaxis. Shared decision-making between clinicians and patients is emphasized as essential for individualized treatment plans that balance the potential benefits of anticoagulation against the risk of bleeding complications. Furthermore, it examines emerging anticoagulant agents and their potential role in HF management, highlighting the need for further research to delineate optimal management strategies and inform evidence-based practice. In conclusion, while anticoagulation holds promise for improving outcomes in HF patients, careful consideration of patient-specific factors and ongoing research efforts are essential to optimize therapeutic strategies in this population.
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Affiliation(s)
- Danish Saeed
- Internal Medicine, Shaikh Zayed Medical Complex, Lahore, PAK
| | | | - Jose A Niño Medina
- Faculty of Legal and Political Sciences, Universidad de Carabobo, Valencia, VEN
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Inam Saleh
- Pediatrics, University of Kentucky College of Medicine, Lexington, USA
| | | | - Wendys L Horn
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | | | - Karen E Leiva
- General Medicine and Surgery, National Autonomous University of Honduras, Tegucigalpa, HND
| | | | - Maria Viteri
- Metabolic Syndrome Department, Hospital General Ambato, Ambato, ECU
| | - Miguel Rivas
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Neelam Kumari
- Internal Medicine, Jinnah Medical & Dental College, Karachi, PAK
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20
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Kodama Y, Matsumoto K, Kubota H, Furuya O, Kawase Y. A case report of concurrent management of acute myocardial infarction complicated by left ventricular thrombus and ischaemic stroke. Eur Heart J Case Rep 2024; 8:ytae193. [PMID: 38680827 PMCID: PMC11050652 DOI: 10.1093/ehjcr/ytae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
Background Left ventricular thrombus (LVT) formation is a serious complication of acute myocardial infarction (AMI) requiring complicated management strategies and collaboration among cardiologists, cardiovascular surgeons, and neurosurgeons. Case summary We present the case of an 83-year-old female patient with AMI. Emergency coronary angiography revealed subtotal occlusion of the proximal left anterior descending artery, and the patient was successfully treated with a drug-eluting stent. The following day, she suddenly developed loss of consciousness, global aphasia, and right hemiplegia. Brain magnetic resonance imaging revealed acute ischaemic cerebral infarction caused by multiple mobile LVT, as demonstrated by echocardiography. After a heart-brain team discussion, we decided to perform percutaneous mechanical thrombectomy. Successful recanalization was achieved with mechanical thrombectomy 2 h after presentation, which resulted in significant neurological recovery. Immediately after the thrombectomy, she was transferred to a cardiovascular surgery centre for surgical removal of multiple LV apical thrombi. Two weeks after the operation, the patient was discharged with the recovery of LV systolic function. Discussion Although AMI complicated by acute stroke caused by LVT remains a clinical challenge, a multidisciplinary approach is critically important for optimal care. Based on an urgent team discussion, we decided to perform endovascular thrombectomy for ischaemic stroke, followed by surgical removal of the LVT, requiring patient transportation to the cardiovascular surgery centre. Given that the heart and brain team-based approach remains confined to large, specialized centres, it might be beneficial to establish a community-based integrated heart-brain team that can address the growing needs of complex patients.
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Affiliation(s)
- Yuka Kodama
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
| | - Kenji Matsumoto
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
| | - Hisashi Kubota
- Department of Neurosurgery, Kubota Clinic Neurosurgery, Izumi, Japan
| | - Onichi Furuya
- Department of Cardiovascular Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Yoshio Kawase
- Department of Cardiology, Izumi City General Hospital, 4-5-1 Wake-cho, Izumi 594-0073, Japan
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21
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Mruthunjaya AKV, Torriero AAJ. Electrochemical Monitoring in Anticoagulation Therapy. Molecules 2024; 29:1453. [PMID: 38611733 PMCID: PMC11012951 DOI: 10.3390/molecules29071453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/16/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
The process of blood coagulation, wherein circulating blood transforms into a clot in response to an internal or external injury, is a critical physiological mechanism. Monitoring this coagulation process is vital to ensure that blood clotting neither occurs too rapidly nor too slowly. Anticoagulants, a category of medications designed to prevent and treat blood clots, require meticulous monitoring to optimise dosage, enhance clinical outcomes, and minimise adverse effects. This review article delves into the various stages of blood coagulation, explores commonly used anticoagulants and their targets within the coagulation enzyme system, and emphasises the electrochemical methods employed in anticoagulant testing. Electrochemical sensors for anticoagulant monitoring are categorised into two types. The first type focuses on assays measuring thrombin activity via electrochemical techniques. The second type involves modified electrode surfaces that either directly measure the redox behaviours of anticoagulants or monitor the responses of standard redox probes in the presence of these drugs. This review comprehensively lists different electrode compositions and their detection and quantification limits. Additionally, it discusses the potential of employing a universal calibration plot to replace individual drug-specific calibrations. The presented insights are anticipated to significantly contribute to the sensor community's efforts in this field.
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Affiliation(s)
| | - Angel A. J. Torriero
- School of Life and Environmental Sciences, Deakin University, Burwood 3125, Australia
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22
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Zgheib AZ, Jdaidani J, Akl E, Khalil S, Chaabo O, Piazza N, Sawaya FJ, Rebeiz AG. Percutaneous Coronary Intervention with Procedural Unfractionated Heparin without Activated Clotting Time Guidance: A Unique Opportunity to Assess Thrombotic and Bleeding Events. Int J Clin Pract 2024; 2024:6219301. [PMID: 38390376 PMCID: PMC10883739 DOI: 10.1155/2024/6219301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/11/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Background Rates of major bleeding and intraprocedural thrombotic events (IPTE) in the setting of percutaneous coronary intervention (PCI) using weight-adjusted unfractionated heparin (UFH) without activated clotting time (ACT) monitoring are not known. Methods We reviewed 2,748 consecutive patients who underwent coronary angiography at our tertiary care university hospital between January 2017 and December 2020. All patients who underwent PCI with weight-adjusted UFH without ACT guidance were considered for further analysis. Major bleeding complications occurring within 48 hours of PCI were collected from patients' medical records. IPTE were collected independently by two interventional cardiologists after review of coronary angiograms. Results There were 718 patients included in the analysis (65.4 ± 12.2 years old; 81.3% male). In total, 45 patients (7.8%) experienced a major bleed or IPTE. The most common IPTE were slow/no reflow (1.5%) and coronary artery dissection with decreased flow (1.1%). Other IPTE occurred in <1% of cases. Major bleeding occurred in 11 patients (1.5%), of whom 8 required blood transfusion and 3 required vascular intervention. Bleeding complications were more common with femoral compared with radial access (6.6% vs. 0.2%, P < 0.001). Conclusion Weight-adjusted UFH use during PCI without ACT monitoring was related to low rates of major bleeding or IPTE.
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Affiliation(s)
- Ali Z. Zgheib
- American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
- McGill University Health Centre, Division of Cardiology, Montreal, Canada
| | - Jennifer Jdaidani
- American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Elie Akl
- McGill University Health Centre, Division of Cardiology, Montreal, Canada
| | - Suzan Khalil
- University of California at Los Angeles, Division of Cardiology, Los Angeles, California, USA
| | - Omar Chaabo
- American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
- McGill University Health Centre, Division of Cardiology, Montreal, Canada
| | - Nicolo Piazza
- McGill University Health Centre, Division of Cardiology, Montreal, Canada
| | - Fadi J. Sawaya
- American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Abdallah G. Rebeiz
- American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
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Mahto M, Kumar V, Banerjee A, Kumar S, Kumar A. Pre-analytical errors in coagulation testing: a case series. Diagnosis (Berl) 2024; 11:114-119. [PMID: 38154060 DOI: 10.1515/dx-2023-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Prevention of pre-analytical issues in coagulation testing is of paramount importance for good laboratory performance. In addition to common issues like hemolysed, icteric, or lipemic samples, some specific pre-analytical errors of coagulation testing include clotted specimens, improper blood-to-anticoagulant ratio, contamination with other anticoagulants, etc. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are very commonly affected tests due to pre-analytical variables. The impact these parameters possess on surgical decision-making and various life-saving interventions are substantial therefore we cannot afford laxity and casual mistakes in carrying out these critical investigations at all. CASE PRESENTATION In this case series, a total of 4 cases of unexpectedly deranged coagulation profiles have been described which were reported incorrectly due to the overall casual approach towards these critical investigations. We have also mentioned how the treating clinician and lab physician retrospectively accessed relevant information in the nick of time to bring back reassurance. CONCLUSIONS Like every other critical investigation, analytical errors can occur in coagulation parameters due to various avoidable pre-analytical variables. The release of spurious results for coagulation parameters sets alarm bells ringing causing much agony to the treating doctor and patient. Only a disciplined and careful approach taken by hospital and lab staff towards each sample regardless of its criticality can negate these stressful errors to a large extent.
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Affiliation(s)
- Mala Mahto
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Visesh Kumar
- Department of Biochemistry, Mahamaya Rajkiya Allopathic Medical College, Ambedkarnagar, India
| | - Ayan Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Sushil Kumar
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
| | - Anurag Kumar
- Department of Biochemistry, All India Institute of Medical Sciences, Patna, India
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Sulzer TAL, Vacirca A, Mesnard T, Baghbani-Oskouei A, Savadi S, Kanamori LR, van Lier F, de Bruin JL, Verhagen HJM, Oderich GS. How We Would Treat Our Own Thoracoabdominal Aortic Aneurysm. J Cardiothorac Vasc Anesth 2024; 38:379-387. [PMID: 38042741 DOI: 10.1053/j.jvca.2023.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 12/04/2023]
Abstract
This manuscript is intended to provide a comprehensive review of the current state of knowledge on endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The management of these complex aneurysms requires an interdisciplinary and patient-specific approach in high-volume centers. An index case is used to discuss the diagnosis and treatment of a patient undergoing fenestrated-branched endovascular aneurysm repair for a TAAA.
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Affiliation(s)
- Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
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25
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Alemu T, Adule A, Sorato MM, Borsamo A. Incidence and factors associated with deep vein thrombosis among hospitalized adult patients at Hawassa university comprehensive specialized hospital Hawassa city, Sidama, Ethiopia: retrospective cohort study. J Thromb Thrombolysis 2024; 57:164-174. [PMID: 37704907 DOI: 10.1007/s11239-023-02889-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Deep vein thrombosis is a public health problem with substantial morbidity and mortality globally. In Ethiopia, death due to complications of DVT is very significant however its incidence, risk factors, and preventive methods are not well studied. To assess the incidence and factors associated with deep vein thrombosis among hospitalized adult patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia. METHOD Intuitional-based retrospective study design was employed in July1-August 30, 2022 in 660 randomly selected patients' record cards. The patients' record cards were reviewed from 2012 to 2014 at Hawassa University Compressive Specialized Hospital. The data entry and analysis were done by using Epi Info and SPSS version 24. After adjusting covariates at a 95% confidence interval, an independent variable with a P value < 0.05 was declared significantly associated with deep vein thrombosis. An odds ratio was calculated to measure the strength of the relationship independent variable and deep vein thrombosis. RESULTS The overall incidence of DVT was 10.6% [95% CI: 8.5%, 13.1%]. After adjusting for covariates, orthopedic trauma; AOR = 2.6 (95% CI (1.2-5.4), corona virus; AOR = 2.5 (95%CI (1.07-5.1), and hospital stay > 15 days; AOR = 2.2 (95% CI (1.25-3.94) were significantly associated with deep vein thrombosis. CONCLUSION DVT incidence is high among hospitalized patients. An orthopedic trauma, a recent infection of the coronavirus, and a hospital stay above 15 days were a risk to acquire deep vein thrombosis. Early identification and detection of patients at high risk of developing DVT and provision of prophylaxis are recommended.
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Affiliation(s)
- Tsegaye Alemu
- School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Aklilu Adule
- Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
| | - Mende Mensa Sorato
- Department of Pharmacy, School of Medicine, Komar University of Science and Technology, Qularaisi, Sulaimaniyah, KRI, Iraq.
| | - Asfaw Borsamo
- Department of Human Anatomy, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
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26
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Crowley AV, Banfield M, Gupta A, Raj R, Gorantla VR. Role of Surgical and Medical Management of Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review. Cureus 2024; 16:e53336. [PMID: 38435894 PMCID: PMC10907114 DOI: 10.7759/cureus.53336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is underdiagnosed and has recently surfaced as one of the leading triggers of severe pulmonary hypertension. This disease process is described by structural changes of pulmonary arteries such as fibrous stenosis, complete obliteration, or the presence of a resistant intraluminal thrombus, resulting in increased pulmonary resistance and eventually progressing to right-sided heart failure. Hence, this study aims to describe the current treatments for CTEPH and their efficacy in hemodynamic improvement and prevention of recurring thromboembolic episodes in patients. This systematic review promptly follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. On February 13, 2022, our team searched through the following databases: PubMed, ProQuest, and ScienceDirect. The following keywords were used across all databases: CTEPH AND Pulmonary Endarterectomy (PEA), CTEPH AND Balloon Pulmonary Angioplasty (BPA), and CTEPH AND Medical Therapy OR Anticoagulation therapy. Twenty-nine thousand eighty-nine articles on current management techniques (PEA, Balloon angioplasty, anticoagulants) were selected, analyzed, and reviewed with each other. We found 19 articles concerning PEA, 15 concerning BPA, and six regarding anticoagulants. Most papers showed high success rates and promising evidence of PEA and anticoagulants as a post-operative regimen. BPA was the least preferred but is still reputable in patients unfit for invasive techniques. CTEPH is a condition presenting with either fibrous stenosis, complete obliteration of the artery, or a clogged thrombus. Recent studies have shown three techniques that physicians have used to treat CTEPH: balloon-pulmonary angioplasty, PEA, and medical management with anticoagulants. PEA followed by anticoagulants is preferred to balloon pulmonary angioplasties. CTEPH is an ongoing topic in research; as it continues to be researched, we hope to see more management techniques available.
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Affiliation(s)
- Alexandra V Crowley
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Megan Banfield
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Aditi Gupta
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Rhea Raj
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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Roosendaal LC, Radović M, Hoebink M, Wiersema AM, Blankensteijn JD, Jongkind V. The Additional Value of Activated Clotting Time-Guided Heparinization During Interventions for Peripheral Arterial Disease. J Endovasc Ther 2023:15266028231213611. [PMID: 38008930 DOI: 10.1177/15266028231213611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
PURPOSE Unfractionated heparin is widely used to lower the risk of arterial thromboembolic complications (ATECs) during interventions for peripheral arterial disease (PAD), but it is still unknown which heparin dose is the safest in terms of preventing ATECs and bleeding complications. This study aims to evaluate the incidence of complications during interventions for PAD and the relation between this incidence and different heparinization protocols. MATERIALS AND METHODS A retrospective analysis of a prospective multicenter cohort study was performed. Between June 2015 and September 2022, 355 patients who underwent peripheral interventions for PAD were included. All patients who were included before July 2018 received 5000 international units (IU) of heparin (group 1). Starting from July 2018, all included patients received an initial dose of 100 IU/kg, with potential additional heparin doses based on activated clotting time (ACT) values (group 2). Data on ACT values and complications within 30 days post-procedurally were collected. RESULTS In total, 24 ATECs and 48 bleeding complications occurred. In group 1, 8.7% (n=11) of patients suffered from ATEC, compared with 5.7% (n=13) in group 2. Thirteen percent of patients (n=17) in group 1 had a bleeding complication, compared with 14% (n=31) in group 2. Arterial thromboembolic complications were more often found in patients with peak ACT values of <200 seconds, compared with ACT values between 200 and 250 seconds, 15% (n=6) versus 5.9% (n=9), respectively, p=0.048. Patients with peak ACT values >250 seconds had a higher incidence of bleeding complications compared with an ACT between 200 and 250 seconds, 24% (n=21) versus 9.8% (n=15), respectively, p=0.003. Forty-four percent of patients (n=23) in group 1 reached a peak ACT of >200 seconds, compared with 95% (n=218) of patients in group 2 (p=0.001). CONCLUSION ATEC was found in 6.8% (n=24) and bleeding complications in 14% (n=48) of patients who underwent a procedure for PAD. There was a significantly higher incidence of ATECs in patients with a peak ACT value <200 seconds, and a higher incidence of bleeding complications in patients with a peak ACT value >250 seconds. The findings obtained from this study may serve as a basis for conducting future research on heparinization during procedures for PAD, with a larger sample size. CLINICAL IMPACT Heparin is administered during arterial interventions for peripheral arterial disease (PAD) to decrease the risk of arterial (thrombo)embolic complications (ATEC) during or shortly following surgery. The effect of heparin is unpredictable in the individual patient, and the optimal dosage of this anticoagulant has not yet been established. Using the activated clotting time (ACT), the anticoagulatory effect of heparin can be monitored periprocedurally. Previous research on the incidence of both ATEC and bleeding complications, or on the optimal dosage of heparin administration, is scarce. This study aims to investigate the incidence of ATEC and bleeding complications between 2 different dosage protocols of heparin-a standard bolus of 5000 IU or ACT-guided heparinization-and thereby provide clarity on the optimal dose of heparin during peripheral arterial interventions for PAD.
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Affiliation(s)
- Liliane C Roosendaal
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mila Radović
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - Max Hoebink
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Arno M Wiersema
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Microcirculation, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Hardy M, Cabo J, Deliège A, Douxfils J, Gouin-Thibault I, Lecompte T, Mullier F. Reassessment of dextran sulfate in anti-Xa assay for unfractionated heparin laboratory monitoring. Res Pract Thromb Haemost 2023; 7:102257. [PMID: 38193053 PMCID: PMC10772882 DOI: 10.1016/j.rpth.2023.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 01/10/2024] Open
Abstract
Background Anti-Xa assays are used for unfractionated heparin (UFH) monitoring. Dextran sulfate (DS) is used in some assays to overcome the artifactual preanalytical release of platelet factor 4. However, the practical implications of this test modification have not been studied extensively. Objectives To investigate the impact of the presence of DS in the anti-Xa assay for UFH laboratory monitoring. Methods We studied factor Xa inhibition, using an assay without DS (Stago Liquid Anti-Xa), in normal pool plasma spiked with various concentrations of UFH (up to 1 IU/mL) in the presence of increasing concentrations of DS (up to 2560 μg/mL). We also investigated the effect of DS on FXa inhibition measured after the addition of UFH and heparin antagonists (protamine and Polybrene; Sigma Aldrich). Eventually, we compared the anti-Xa levels measured using the assay without DS to those measured with an assay containing DS (BIOPHEN Heparin LRT, Hyphen BioMed). Results DS per se had a detectable anti-Xa effect. FXa inhibition in UFH-spiked plasma linearly increased with increasing concentrations of added DS, with a plateau at approximately 160 μg/mL DS, at which the apparent anti-Xa level had almost doubled. In the presence of heparin antagonists, the addition of DS increased anti-Xa levels, corresponding to the dissociation of the UFH-antagonists complexes in vitro. With the anti-Xa assay containing DS, UFH inhibition was not detected. Conclusion In the presence of high concentrations of DS, FXa inhibition was much higher than that predicted from added UFH amounts, presumably related to the greater availability of UFH for interaction with antithrombin. While the relevance of measuring this "masked" heparin has not been demonstrated, the presence of DS renders the result inaccurate in the presence of protamine or Polybrene.
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Affiliation(s)
- Michael Hardy
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Department of Anesthesiology, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
| | - Julien Cabo
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Antoine Deliège
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | | | - Thomas Lecompte
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- CHU of Rennes, Department of Laboratory Hematology, IRSET-INSERM-1085, Rennes, France
- University of Lorraine, CHRU of Nancy, Nancy, France
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2023; 43:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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30
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Roosendaal LC, van den Ancker W, Wiersema AM, Blankensteijn JD, Jongkind V. Unfractionated heparin and the activated clotting time in non-cardiac arterial procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:488-494. [PMID: 37255497 DOI: 10.23736/s0021-9509.23.12723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Unfractionated heparin is administered during non-cardiac arterial procedures (NCAP) to prevent thromboembolic complications. In order to achieve a safe level of anticoagulation, the effect of heparin can be measured. The aim of this review was to provide an overview on what is known about heparin, suggested tests to monitor the effect of heparin, including the activated clotting time (ACT), and the factors that could influence that ACT. EVIDENCE ACQUISITION A literature search in PubMed was performed. Articles reporting on heparin, clotting time tests (including thrombin time, activated partial thromboplastin time, anti-activated factor X and ACT), and ACT measurement devices were selected. EVIDENCE SYNTHESIS Heparin has a non-predictable effect in the individual patient, which could be measured using the ACT. However, ACT values can be influenced by many factors, such as hemodilution, hypothermia and thrombocytopenia. In addition, a high variation in ACT outcomes is found between measurement devices of different brands. In the sparse literature on the role of ACT during NCAP, no consensus has been reached on optimal target ACT values. An ACT >250 seconds leads to more bleeding complications. Females have a longer ACT after heparin administration, with a higher risk of bleeding complications. CONCLUSIONS The effect of heparin is unpredictable. ACT can be used to monitor the effect of heparin and achieve individualized anticoagulation, tailored to the patient and the specifics of the operative procedure. However, the ACT itself can be affected by several factors and caution must be present, as measured ACT values differ between measurement devices.
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Affiliation(s)
- Liliane C Roosendaal
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | | | - Arno M Wiersema
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands -
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
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31
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Grover SP, Mackman N, Bendapudi PK. Heat shock protein 47 and venous thrombosis: letting sleeping bears lie. J Thromb Haemost 2023; 21:2648-2652. [PMID: 37473845 DOI: 10.1016/j.jtha.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Steven P Grover
- University of North Carolina Blood Research Center, The University of North Carolina at Chapel Hill, North Carolina, USA; Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Nigel Mackman
- University of North Carolina Blood Research Center, The University of North Carolina at Chapel Hill, North Carolina, USA; Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Pavan K Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Center for the Development of Therapeutics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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32
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Amaral S, Lozano-Fernández T, Sabin J, Gallego A, da Silva Morais A, Reis RL, González-Fernández Á, Pashkuleva I, Novoa-Carballal R. End-on PEGylation of heparin: Effect on anticoagulant activity and complexation with protamine. Int J Biol Macromol 2023; 249:125957. [PMID: 37499705 DOI: 10.1016/j.ijbiomac.2023.125957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/20/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023]
Abstract
Heparin is the most common anticoagulant used in clinical practice but shows some downsides such as short half-life (for the high molecular weight heparin) and secondary effects. On the other hand, its low molecular weight analogue cannot be neutralized with protamine, and therefore cannot be used in some treatments. To address these issues, we conjugated polyethylene glycol (PEG) to heparin reducing end (end-on) via oxime ligation and studied the interactions of the conjugate (Hep-b-PEG) with antithrombin III (AT) and protamine. Isothermal titration calorimetry showed that Hep-b-PEG maintains the affinity to AT. Dynamic light scattering demonstrated that the Hep-b-PEG formed colloidal stable nanocomplexes with protamine instead of large multi-molecular aggregates, associated with heparin side effects. The in vitro (human plasma) and in vivo experiments (Sprague Dawley rats) evidenced an extended half-life and higher anticoagulant activity of the conjugate when compared to unmodified heparin.
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Affiliation(s)
- Sandra Amaral
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Tamara Lozano-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Juan Sabin
- AFFINImeter Scientific & Development Team, Software 4 Science Developments, Santiago de Compostela, A Coruña 15782, Spain; Departamento de Física Aplicada, Facultad de Física, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Amanda Gallego
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Alain da Silva Morais
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Rui L Reis
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - África González-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; CINBIO, Universidade de Vigo, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur (IIS-GS), Hospital Alvaro Cunqueiro, Estrada Clara Campoamor, 36312 Vigo, Pontevedra, Spain
| | - Iva Pashkuleva
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
| | - Ramon Novoa-Carballal
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
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Pagani I, Ottoboni L, Panina-Bordignon P, Martino G, Poli G, Taylor S, Turnbull JE, Yates E, Vicenzi E. Heparin Precursors with Reduced Anticoagulant Properties Retain Antiviral and Protective Effects That Potentiate the Efficacy of Sofosbuvir against Zika Virus Infection in Human Neural Progenitor Cells. Pharmaceuticals (Basel) 2023; 16:1385. [PMID: 37895856 PMCID: PMC10609960 DOI: 10.3390/ph16101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023] Open
Abstract
Zika virus (ZIKV) infection during pregnancy can result in severe birth defects, such as microcephaly, as well as a range of other related health complications. Heparin, a clinical-grade anticoagulant, is shown to protect neural progenitor cells from death following ZIKV infection. Although heparin can be safely used during pregnancy, it retains off-target anticoagulant effects if directly employed against ZIKV infection. In this study, we investigated the effects of chemically modified heparin derivatives with reduced anticoagulant activities. These derivatives were used as experimental probes to explore the structure-activity relationships. Precursor fractions of porcine heparin, obtained during the manufacture of conventional pharmaceutical heparin with decreased anticoagulant activities, were also explored. Interestingly, these modified heparin derivatives and precursor fractions not only prevented cell death but also inhibited the ZIKV replication of infected neural progenitor cells grown as neurospheres. These effects were observed regardless of the specific sulfation position or overall charge. Furthermore, the combination of heparin with Sofosbuvir, an antiviral licensed for the treatment of hepatitis C (HCV) that also belongs to the same Flaviviridae family as ZIKV, showed a synergistic effect. This suggested that a combination therapy approach involving heparin precursors and Sofosbuvir could be a potential strategy for the prevention or treatment of ZIKV infections.
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Affiliation(s)
- Isabel Pagani
- Viral Pathogenesis and Biosafety Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Linda Ottoboni
- Neuroimmunology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Paola Panina-Bordignon
- Neuroimmunology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Gianvito Martino
- Neuroimmunology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Guido Poli
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
- Human Immuno-Virology Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Sarah Taylor
- Department of Biochemistry & Systems Biology, ISMIB, University of Liverpool, Liverpool L69 7ZB, UK
| | - Jeremy E Turnbull
- Department of Biochemistry & Systems Biology, ISMIB, University of Liverpool, Liverpool L69 7ZB, UK
- Department of Life Sciences, Keele University, Keele, Staffs ST5 5BG, UK
| | - Edwin Yates
- Department of Biochemistry & Systems Biology, ISMIB, University of Liverpool, Liverpool L69 7ZB, UK
- Department of Life Sciences, Keele University, Keele, Staffs ST5 5BG, UK
| | - Elisa Vicenzi
- Viral Pathogenesis and Biosafety Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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Samanta P, Mishra SK, Pomin VH, Doerksen RJ. Docking and Molecular Dynamics Simulations Clarify Binding Sites for Interactions of Novel Marine Sulfated Glycans with SARS-CoV-2 Spike Glycoprotein. Molecules 2023; 28:6413. [PMID: 37687244 PMCID: PMC10490367 DOI: 10.3390/molecules28176413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
The entry of SARS-CoV-2 into the host cell is mediated by its S-glycoprotein (SGP). Sulfated glycans bind to the SGP receptor-binding domain (RBD), which forms a ternary complex with its receptor angiotensin converting enzyme 2. Here, we have conducted a thorough and systematic computational study of the binding of four oligosaccharide building blocks from novel marine sulfated glycans (isolated from Pentacta pygmaea and Isostichopus badionotus) to the non-glycosylated and glycosylated RBD. Blind docking studies using three docking programs identified five potential cryptic binding sites. Extensive site-targeted docking and molecular dynamics simulations using two force fields confirmed only two binding sites (Sites 1 and 5) for these novel, highly charged sulfated glycans, which were also confirmed by previously published reports. This work showed the structural features and key interactions driving ligand binding. A previous study predicted Site 2 to be a potential binding site, which was not observed here. The use of several molecular modeling approaches gave a comprehensive assessment. The detailed comparative study utilizing multiple modeling approaches is the first of its kind for novel glycan-SGP interaction characterization. This study provided insights into the key structural features of these novel glycans as they are considered for development as potential therapeutics.
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Affiliation(s)
- Priyanka Samanta
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA; (P.S.); (S.K.M.); (V.H.P.)
| | - Sushil K. Mishra
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA; (P.S.); (S.K.M.); (V.H.P.)
| | - Vitor H. Pomin
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA; (P.S.); (S.K.M.); (V.H.P.)
- Research Institute of Pharmaceutical Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA
| | - Robert J. Doerksen
- Department of BioMolecular Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA; (P.S.); (S.K.M.); (V.H.P.)
- Research Institute of Pharmaceutical Sciences, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA
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Liu KT, Quiñones ED, Liu MH, Lin CW, Chen YT, Chiang CC, Wu KCW, Fan YJ, Chuang EY, Yu J. A Biomimicking and Multiarm Self-Indicating Nanoassembly for Site-Specific Photothermal-Potentiated Thrombolysis Assessed in Microfluidic and In Vivo Models. Adv Healthc Mater 2023; 12:e2300682. [PMID: 37289540 DOI: 10.1002/adhm.202300682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/18/2023] [Indexed: 06/10/2023]
Abstract
Thrombolytic and antithrombotic therapies are limited by short circulation time and the risk of off-target hemorrhage. Integrating a thrombus-homing strategy with photothermal therapy are proposed to address these limitations. Using glycol chitosan, polypyrrole, iron oxide and heparin, biomimicking GCPIH nanoparticles are developed for targeted thrombus delivery and thrombolysis. The nanoassembly achieves precise delivery of polypyrrole, exhibiting biocompatibility, selective accumulation at multiple thrombus sites, and enhanced thrombolysis through photothermal activation. To simulate targeted thrombolysis, a microfluidic model predicting thrombolysis dynamics in realistic pathological scenarios is designed. Human blood assessments validate the precise homing of GCPIH nanoparticles to activated thrombus microenvironments. Efficient near-infrared phototherapeutic effects are demonstrated at thrombus lesions under physiological flow conditions ex vivo. The combined investigations provide compelling evidence supporting the potential of GCPIH nanoparticles for effective thrombus therapy. The microfluidic model also offers a platform for advanced thrombolytic nanomedicine development.
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Affiliation(s)
- Kuan-Ting Liu
- Department of Chemical Engineering, National Taiwan University, Taipei, 10617, Taiwan
| | - Edgar Daniel Quiñones
- Department of Chemical Engineering, National Taiwan University, Taipei, 10617, Taiwan
| | - Ming-Hsin Liu
- Department of Chemical Engineering, National Taiwan University, Taipei, 10617, Taiwan
| | - Che-Wei Lin
- School of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
| | - Yan-Ting Chen
- Graduate Institute of Nanomedicine and Medical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
| | - Chia-Che Chiang
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
| | - Kevin Chia-Wen Wu
- Department of Chemical Engineering, National Taiwan University, Taipei, 10617, Taiwan
- Institute of Biomedical Engineering & Nanomedicine, National Health Research Institute, Keyan Road, Zhunan, Miaoli City, 350, Taiwan
| | - Yu-Jui Fan
- School of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
- Center for Precision Health and Quantitative Sciences, Taipei Medical University Hospital, Taipei, 11031, Taiwan
| | - Er-Yuan Chuang
- School of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
- Graduate Institute of Nanomedicine and Medical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
- Cell Physiology and Molecular Image Research Center, Taipei Medical University-Wan Fang Hospital, Taipei, 11696, Taiwan
| | - Jiashing Yu
- Department of Chemical Engineering, National Taiwan University, Taipei, 10617, Taiwan
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36
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Navaei A, Kostousov V, Teruya J. Is it time to switch to bivalirudin for ECMO anticoagulation? Front Med (Lausanne) 2023; 10:1237601. [PMID: 37671395 PMCID: PMC10476497 DOI: 10.3389/fmed.2023.1237601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023] Open
Abstract
For decades, unfractionated heparin (hereafter, heparin) has been the primary anticoagulant used for extracorporeal membrane oxygenation (ECMO) support. More recently, however, bivalirudin, a direct thrombin inhibitor, has emerged as an alternative. This systematic review based on PRISMA guidelines, aims to summarize 16 comparative studies and 8 meta-analysis and review articles published from January, 2011 till May, 2023 which directly compares ECMO courses using heparin versus bivalirudin as the anticoagulant. While this comparison is complicated by the lack of a standardized definition of major bleeding or thrombosis, our overall findings suggest there is no statistical difference between heparin and bivalirudin in incidence of bleeding and thrombosis. That said, some studies found a statistical significance favoring bivalirudin in reducing major bleeding, thrombosis, and the need for transfusions. We also offer essential guidance for appropriately selecting an anticoagulant and monitoring its effect in ECMO settings.
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Affiliation(s)
- Amir Navaei
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Vadim Kostousov
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Jun Teruya
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
- Department of Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
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37
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Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
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Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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38
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Xie Z, Meng Z, Yang X, Duan Y, Wang Q, Liao C. Factor XIa Inhibitors in Anticoagulation Therapy: Recent Advances and Perspectives. J Med Chem 2023; 66:5332-5363. [PMID: 37037122 DOI: 10.1021/acs.jmedchem.2c02130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Factor XIa (FXIa) in the intrinsic pathway of the coagulation process has been proven to be an effective and safe target for anticoagulant discovery with limited or no bleeding. Numerous small-molecule FXIa inhibitors (SMFIs) with various scaffolds have been identified in the early stages of drug discovery. They have served as the foundation for the recent discovery of additional promising SMFIs with improved potency, selectivity, and pharmacokinetic profiles, some of which have entered clinical trials for the treatment of thrombosis. After reviewing the coagulation process and structure of FXIa, this perspective discusses the rational or structure-based design, discovery, structure-activity relationships, and development of SMFIs disclosed in recent years. Strategies for identifying more selective and druggable SMFIs are provided, paving the way for the design and discovery of more useful SMFIs for anticoagulation therapy.
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Affiliation(s)
- Zhouling Xie
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Zhiwei Meng
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Xiaoxiao Yang
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Yajun Duan
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Qin Wang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, P. R. China
| | - Chenzhong Liao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
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39
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Hirsh J, de Vries TAC, Eikelboom JW, Bhagirath V, Chan NC. Clinical Studies with Anticoagulants that Have Changed Clinical Practice. Semin Thromb Hemost 2023; 49:242-254. [PMID: 36603813 DOI: 10.1055/s-0042-1760330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment and prevention of arterial and venous thromboembolism. Taking a historical perspective, starting in the 1960s, and progressing through to 2022, we discuss key clinical trials of anticoagulants that have changed clinical practice, and examine obstacles encountered in bringing these anticoagulants to the clinic. The design of some of the early studies that shaped clinical practice was poor by current standards, but their results were influential because nothing better was available. Both heparin and vitamin K antagonists had been in clinical use for several decades before well-designed trials in the 1980s optimized their dosing and enhanced their safety and efficacy. Low-molecular-weight heparin then replaced unfractionated heparin because it had a more predictable dose-response and a longer half-life, thereby allowing it to be used conveniently in out-of-hospital settings. More recently, direct oral anticoagulants became the oral anticoagulants of choice for most indications because they were shown to be at least as safe and effective as vitamin K antagonists when used in fixed doses without the need for laboratory monitoring. The design of the trials that led to the approval of the direct oral anticoagulants was excellent, but further studies are required to optimize their dosing in selected patients who were underrepresented in these trials.
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Affiliation(s)
- Jack Hirsh
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim A C de Vries
- Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - John W Eikelboom
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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40
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Sharma P, Dwivedi R, Ray P, Shukla J, Pomin VH, Tandon R. Inhibition of Cytomegalovirus by Pentacta pygmaea Fucosylated Chondroitin Sulfate Depends on Its Molecular Weight. Viruses 2023; 15:v15040859. [PMID: 37112839 PMCID: PMC10142442 DOI: 10.3390/v15040859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Many viruses attach to host cells by first interacting with cell surface proteoglycans containing heparan sulfate (HS) glycosaminoglycan chains and then by engaging with specific receptor, resulting in virus entry. In this project, HS–virus interactions were targeted by a new fucosylated chondroitin sulfate from the sea cucumber Pentacta pygmaea (PpFucCS) in order to block human cytomegalovirus (HCMV) entry into cells. Human foreskin fibroblasts were infected with HCMV in the presence of PpFucCS and its low molecular weight (LMW) fractions and the virus yield at five days post-infection was assessed. The virus attachment and entry into the cells were visualized by labeling the purified virus particles with a self-quenching fluorophore octadecyl rhodamine B (R18). The native PpFucCS exhibited potent inhibitory activity against HCMV specifically blocking virus entry into the cell and the inhibitory activities of the LMW PpFucCS derivatives were proportional to their chain lengths. PpFucCS and the derived oligosaccharides did not exhibit any significant cytotoxicity; moreover, they protected the infected cells from virus-induced lytic cell death. In conclusion, PpFucCS inhibits the entry of HCMV into cells and the high MW of this carbohydrate is a key structural element to achieve the maximal anti-viral effect. This new marine sulfated glycan can be developed into a potential prophylactic and therapeutic antiviral agent against HCMV infection.
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Yu Y, Tham SK, Roslan FF, Shaharuddin B, Yong YK, Guo Z, Tan JJ. Large animal models for cardiac remuscularization studies: A methodological review. Front Cardiovasc Med 2023; 10:1011880. [PMID: 37008331 PMCID: PMC10050756 DOI: 10.3389/fcvm.2023.1011880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/20/2023] [Indexed: 03/17/2023] Open
Abstract
Myocardial infarction is the most common cause of heart failure, one of the most fatal non-communicable diseases worldwide. The disease could potentially be treated if the dead, ischemic heart tissues are regenerated and replaced with viable and functional cardiomyocytes. Pluripotent stem cells have proven the ability to derive specific and functional cardiomyocytes in large quantities for therapy. To test the remuscularization hypothesis, the strategy to model the disease in animals must resemble the pathophysiological conditions of myocardial infarction as in humans, to enable thorough testing of the safety and efficacy of the cardiomyocyte therapy before embarking on human trials. Rigorous experiments and in vivo findings using large mammals are increasingly important to simulate clinical reality and increase translatability into clinical practice. Hence, this review focus on large animal models which have been used in cardiac remuscularization studies using cardiomyocytes derived from human pluripotent stem cells. The commonly used methodologies in developing the myocardial infarction model, the choice of animal species, the pre-operative antiarrhythmics prophylaxis, the choice of perioperative sedative, anaesthesia and analgesia, the immunosuppressive strategies in allowing xenotransplantation, the source of cells, number and delivery method are discussed.
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Affiliation(s)
- Yuexin Yu
- USM-ALPS Cardiac Research Laboratory, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
- Henan Key Laboratory of Cardiac Remodeling and Transplantation, Zhengzhou Seventh People's Hospital, China
- Henan Key Laboratory of Medical Tissue Regeneration, Xinxiang Medical University, China
| | | | - Fatin Fazrina Roslan
- USM-ALPS Cardiac Research Laboratory, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Bakiah Shaharuddin
- USM-ALPS Cardiac Research Laboratory, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
| | - Yoke Keong Yong
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Zhikun Guo
- Henan Key Laboratory of Cardiac Remodeling and Transplantation, Zhengzhou Seventh People's Hospital, China
- Henan Key Laboratory of Medical Tissue Regeneration, Xinxiang Medical University, China
- Correspondence: Jun Jie Tan Zhikun Guo
| | - Jun Jie Tan
- USM-ALPS Cardiac Research Laboratory, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
- Correspondence: Jun Jie Tan Zhikun Guo
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Gastrointestinally absorbable lactoferrin-heparin conjugate with anti-angiogenic activity for treatment of brain tumor. J Control Release 2023; 355:730-744. [PMID: 36764526 DOI: 10.1016/j.jconrel.2023.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023]
Abstract
Glioblastoma multiforme (GBM) is a central nervous system disease with poor prognosis. Curative treatments for GBM involve chemotherapy, radiotherapy, and surgical pathways. Recently, antiangiogenic therapy through medications has been tried to slow tumor growth, but the drugs can induce side effects. To overcome these limitations, we developed a new orally absorbable form of heparin that can attenuate angiogenic activity by binding to growth factors around the tumor tissue. We conjugated lactoferrin (Lf) to heparin because Lf can be orally absorbed, and it interacts with the lactoferrin receptor (Lf-R) expressed on the intestine, blood-brain barrier (BBB), and glioma tumor masses. We successfully conjugated Lf and heparin by amide bond formation, as evidenced by advanced physicochemical properties such as pharmacokinetics and stability in acidic condition. This new material inhibited angiogenesis in vitro without toxicity. In addition, Lf-heparin administered orally to GBM orthotopic mice was absorbed in the small intestine and delivered specifically to the brain tumor by receptor transcytosis (Lf-R). Lf-heparin further attenuated angiogenesis progression in GBM orthotopic mice. Based on these results, Lf-heparin shows potential as a new oral medication for treatment of glioblastoma.
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43
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Xia VQ, Ong CM, Zier LS, MacGregor JS, Wu AHB, Chorba JS. Heparin Does Not Regulate Circulating Human PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) in a General Population-Brief Report. Arterioscler Thromb Vasc Biol 2023; 43:352-358. [PMID: 36475702 PMCID: PMC10038152 DOI: 10.1161/atvbaha.122.318556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND PCSK9 (proprotein convertase subtilisin-kexin type 9) chaperones the hepatic LDLR (low-density lipoprotein receptor) for lysosomal degradation, elevating serum LDL (low-density lipoprotein) cholesterol and promoting atherosclerotic heart disease. Though the major effect on the hepatic LDLR comes from secreted PCSK9, the details of PCSK9 reuptake into the hepatocyte remain unclear. In both tissue culture and animal models, HSPGs (heparan sulfate proteoglycans) on hepatocytes act as co-receptors to promote PCSK9 reuptake. We hypothesized that if this PCSK9:HSPG interaction is important in humans, disrupting it with unfractionated heparin (UFH) would acutely displace PCSK9 from the liver and increase plasma PCSK9. METHODS We obtained remnant plasma samples from 160 subjects undergoing cardiac catheterization before and after administration of intravenous UFH. PCSK9 levels were determined using a commercial enzyme-linked immunosorbent assay. RESULTS Median plasma PCSK9 was 113 ng/mL prior to UFH and 119 ng/mL afterward. This difference was not significant (P=0.83 [95% CI, -6.23 to 6.31 ng/mL]). Equivalence testing provided 95% confidence that UFH would not raise plasma PCSK9 by > 4.7%. Among all subgroups, only subjects with the lowest baseline PCSK9 concentrations exhibited a response to UFH (8.8% increase, adj. P=0.044). A modest correlation was observed between baseline plasma PCSK9 and the change in plasma PCSK9 due to UFH (RS=-0.3634; P<0.0001). CONCLUSIONS Administration of UFH does not result in a clinically meaningful effect on circulating PCSK9 among an unselected population of humans. The results cast doubt on the clinical utility of disrupting the PCSK9:HSPG interaction as a general therapeutic strategy for PCSK9 inhibition. However, the observations suggest that in selected populations, disrupting the PCSK9:HSPG interaction could still affect PCSK9 reuptake and offer a therapeutic benefit.
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Affiliation(s)
- Vivian Q. Xia
- Division of Cardiology, Zuckerberg San Francisco General Hospital
- Department of Medicine, University of California San Francisco
| | - Chui Mei Ong
- Clinical Chemistry Laboratory, Zuckerberg San Francisco General Hospital
- Department of Laboratory Medicine, University of California San Francisco
| | - Lucas S. Zier
- Division of Cardiology, Zuckerberg San Francisco General Hospital
- Department of Medicine, University of California San Francisco
| | - John S. MacGregor
- Division of Cardiology, Zuckerberg San Francisco General Hospital
- Department of Medicine, University of California San Francisco
| | - Alan H. B. Wu
- Clinical Chemistry Laboratory, Zuckerberg San Francisco General Hospital
- Department of Laboratory Medicine, University of California San Francisco
| | - John S. Chorba
- Division of Cardiology, Zuckerberg San Francisco General Hospital
- Department of Medicine, University of California San Francisco
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44
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Safani M, Appleby S, Chiu R, Favaloro EJ, Ferro ET, Johannes J, Sheth M. Application of anti-Xa assay in monitoring unfractionated heparin therapy in contemporary antithrombotic management. Expert Rev Hematol 2023; 16:1-8. [PMID: 36637400 DOI: 10.1080/17474086.2023.2169126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Unfractionated heparin remains the most widely used agent in the prevention and acute treatment of thrombosis. Pharmacological complexities of this intriguing agent mandate frequent monitoring of its anticoagulant properties to maintain safe and effective hematological outcomes. Although activated partial thromboplastin time has been the standard test to monitor unfractionated heparin therapy for many decades, the anti-Xa assay has emerged as a substitute or adjunct in many institutions. AREAS COVERED This brief report outlines the key features of anti-Xa assay in monitoring unfractionated heparin in acute management of thrombosis in various contemporary settings, with emphasis on evidence for clinical outcomes. PubMed.gov database was utilized to obtain the pertinent literature. EXPERT OPINION The anti-Xa activity is primarily a reflection of UFH concentration and does not account for other hematological variables frequently present in contemporary anticoagulation management. The advantage of the anti-Xa assay in monitoring UFH therapy is predicated upon its limitations to account for global physiological hemostasis. There are significant disease and drug interactions that may potentially result in false in-vitro analysis of anti-Xa activity. Routine application of the anti-Xa assay is not evidence-based at this time.
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Affiliation(s)
- Michael Safani
- MemorialCare Heart & Vascular Institute Long Beach, CA, USA.,University of California, San Francisco, CA, USA
| | - Steve Appleby
- Interventional Cardiology, Memorial Care Heart and Vascular Institute, Long Beach, CA, USA
| | - Ryan Chiu
- Cardiovascular Surgery, MemorialCare Heart & Vascular Institute Long Beach, CA, USA
| | - Emmanuel J Favaloro
- Institute of Clinical Pathology and Medical Research, Westmead Hospital, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
| | | | - Jimmy Johannes
- Critical Care & Pulmonary Medicine, Memorial Care Long Beach, CA, USA
| | - Milan Sheth
- Hematology, Department of Medicine MemorialCare Long Beach, CA, USA
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Apipongrat D, Police P, Lamool R, Butthep P, Chantkran W. Validation of high concentrated thrombin time assay for unfractionated heparin monitoring. J Clin Lab Anal 2022; 36:e24695. [PMID: 36099012 PMCID: PMC9550976 DOI: 10.1002/jcla.24695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/31/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Background The high concentrated thrombin time (hcTT), a thrombin time modified by increasing the thrombin concentration, is a possible alternative assay to activated partial thromboplastin time (aPTT) in unfractionated heparin (UFH) monitoring. This study aimed to determine the optimal thrombin concentration used in the hcTT assay for UFH monitoring. Methods A total of 30 blood samples obtained from healthy volunteers were included in this study. Thrombin concentrations of 10.0, 15.0, 20.0, and 25.0 IU/ml were used in the hcTT assay. The consistency between the hcTT and anti‐FXa assays was evaluated. To validate the hcTT assay, linearity, repeatability, reproducibility, and diagnostic performance of the assay were assessed. Results The hcTT assay using thrombin concentration of 15.0 IU/ml showed a strong correlation to the anti‐FXa assay with R2 of 0.72 and the Spearman's correlation coefficient (rs) of 0.97 (95% CI, 0.96–0.98). Within‐run and day‐to‐day run variabilities of the assay were satisfactory (all coefficients of variation <10%). We found an excellent correlation between the results which were measured using different reagents with intra‐ or inter‐laboratory instruments. Notably, as compared to the aPTT assay, the hcTT assay showed a significantly better performance in identifying the samples which contain UFH at the supratherapeutic level, with an AUC of 0.97 vs. 0.91, p = 0.049. Conclusion The hcTT assay can be used as an alternative assay for UFH therapy monitoring. A further study using clinical samples is recommended to confirm the appropriateness of the hcTT assay for clinical application.
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Affiliation(s)
- Dollapak Apipongrat
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Pornnapa Police
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rattapan Lamool
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Punnee Butthep
- Department of Medical Technology, Faculty of Allied Health Sciences, Pathumthani University, Pathumthani, Thailand
| | - Wittawat Chantkran
- Department of Pathology, Phramongkutklao College of Medicine, Bangkok, Thailand
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46
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Salter B, Crowther M. A Historical Perspective on the Reversal of Anticoagulants. Semin Thromb Hemost 2022; 48:955-970. [PMID: 36055273 DOI: 10.1055/s-0042-1753485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a landmark shift in the last several decades in the management and prevention of thromboembolic events. From the discovery of parenteral and oral agents requiring frequent monitoring as early as 1914, to the development of direct oral anticoagulants (DOACs) that do not require monitoring or dose adjustment in the late 20th century, great advances have been achieved. Despite the advent of these newer agents, bleeding continues to be a key complication, affecting 2 to 4% of DOAC-treated patients per year. Bleeding is associated with substantial morbidity and mortality. Although specific reversal agents for DOACs have lagged the release of these agents, idarucizumab and andexanet alfa are now available as antagonists. However, the efficacy of these reversal agents is uncertain, and complications, including thrombosis, have not been adequately explored. As such, guidelines continue to advise the use of nonspecific prohemostatic agents for patients requiring reversal of the anticoagulant effect of these drugs. As the indications for DOACs and the overall prevalence of their use expand, there is an unmet need for further studies to determine the efficacy of specific compared with nonspecific pro-hemostatic reversal agents. In this review, we will discuss the evidence behind specific and nonspecific reversal agents for both parenteral and oral anticoagulants.
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Affiliation(s)
- Brittany Salter
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Zhang Y, Zhang M, Xu X, Chan CHH, Peng H, Hill DJT, Fu C, Fraser J, Whittaker AK. Anti-Fouling Surfaces for Extracorporeal Membrane Oxygenation by Surface Grafting of Hydrophilic Sulfoxide Polymers. Biomacromolecules 2022; 23:4318-4326. [PMID: 36048616 DOI: 10.1021/acs.biomac.2c00775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Non-thrombogenic surfaces for extracorporeal membrane oxygenation (ECMO) devices are important to increase their duration of usage and to enable long-term life support. However, the contact of blood with the hydrophobic synthetic ECMO membrane materials such as poly(4-methyl-1-pentene) (PMP) can activate the coagulation cascade, causing thrombosis and a series of consequent complications during ECMO operation. Targeting this problem, we proposed to graft highly hydrophilic sulfoxide polymer brushes onto the PMP surfaces via gamma ray irradiation-initiated polymerization to improve the hemocompatibility of the membrane. Through this chemical modification, the surface of the PMP film is altered from hydrophobic to hydrophilic. The extent of plasma protein adsorption and platelet adhesion, the prerequisite mediators of the coagulation cascade and thrombus formation, are drastically reduced compared with those of the unmodified PMP film. Therefore, the method provides a facile approach to modify PMP materials with excellent antifouling properties and improved hemocompatibility demanded by the applications in ECMO and other blood-contacting medical devices.
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Affiliation(s)
- Yuhao Zhang
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Meili Zhang
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,School of Mechanical and Mining Engineering, The University of Queensland, St Lucia 4072, Queensland, Australia
| | - Xin Xu
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Chris H H Chan
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,School of Engineering and Built Environment, Griffith University, Southport 4222, Queensland, Australia
| | - Hui Peng
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - David J T Hill
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia.,School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia 4072, Queensland, Australia
| | - Changkui Fu
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane 4032, Queensland, Australia.,Faculty of Medicine, The University of Queensland, St Lucia 4072, Queensland, Australia.,School of Medicine, Griffith University, Southport 4215, Queensland, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology and ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, St Lucia, Queensland 4072, Australia
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Drug Utilization and Potential Drug-Drug Interactions within an Intensive Care Unit at a University Tertiary Care Hospital in Egypt. PHARMACY 2022; 10:pharmacy10040096. [PMID: 36005936 PMCID: PMC9416082 DOI: 10.3390/pharmacy10040096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
There are few reports on drug utilization and drug-drug interactions in Intensive Care Units (ICUs) in Egypt. A total of 94 patients participated in this retrospective observational study. Patient's medical records were used to collect demographics, medical history, admission and discharge dates and medications used. The mean ± SD of the Glasgow Coma Scale (GCS) scores was 9.9 ± 4.4 and the median length of stay was 7 days (range 1-47 days). The total number of prescribed medications ranged from 4-29 with a mean ± SD of 14.1 ± 5.5 medications per patient. The top three most prescribed categories belonged to (1) anti-infective agents (23.9%); (2) electrolyte, caloric and water balance agents (14.6%); and (3) blood formation, coagulation and thrombosis (11.3%). The proton pump inhibitor, esomeprazole, was the most frequently prescribed medication accounting for 6.5% of total prescriptions, followed by clindamycin and magnesium sulfate each accounting for 3.5% of total prescriptions. The potential Drug-Drug Interactions (pDDIs) showed a total of 968 pDDIs with a mean ± SD (range) of 10.2 ± 9.4 (0-43) pDDIs per patient: severe (contraindicated) (3), major (178), moderate (618) and minor (169). Overall, the drug utilization patterns in this study were consistent with ICU drug utilization from other countries in the region. The implementation of clinical decision support systems and the involvement of clinical pharmacists may help improve medication safety.
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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Alsagaff MY, Mulia EPB, Maghfirah I, Azmi Y, Rachmi DA, Yutha A, Andira LH, Semedi BP. Low molecular weight heparin is associated with better outcomes than unfractionated heparin for thromboprophylaxis in hospitalized COVID-19 patients: a meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:909-918. [PMID: 35921219 PMCID: PMC9384651 DOI: 10.1093/ehjqcco/qcac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 12/29/2022]
Abstract
AIMS This study aimed to compare the outcomes of the administration of LMWH and UFH in hospitalized COVID-19 patients. METHODS AND RESULTS We systematically searched several databases and included observational studies or clinical trials that compared the outcomes of the administration of LMWH and UFH in hospitalized COVID-19 patients. A total of nine studies comprising 9637 patients were included. Metanalysis showed that LMWH administration was associated with a lower in-hospital mortality and 28/30-day mortality compared with UFH administration {[relative risk (RR) 0.44; 95% confidence interval (95% CI) 0.32-0.61; I2: 87.9%] and (RR 0.45; 95% CI 0.24-0.86; I2: 78.4%), respectively}. Patient with LMWH had shorter duration of hospital and ICU length of stay compared with UFH {[weighted mean difference (WMD) -2.20; 95% CI -3.01 to -1.40; I2:0%] and (WMD -1.41; 95% CI -2.20 to -0.63; I2: 0%), respectively}. The risk of ICU admission or mechanical ventilation was lower in patients who received LMWH than in those who received UFH (RR 0.67; 95% CI 0.55-0.81; I2: 67.3%). However, there was no difference in the incidence of bleeding with LMWH compared with UFH (RR 0.27; 95% CI 0.07-1.01; I2: 64.6%). CONCLUSION Our meta-analysis showed that administration of LMWH was associated with better outcomes compared with UFH in hospitalized COVID-19 patients. Prospective cohorts and RCTs are urgently needed to explore the definitive effect of LMWH to provide direct high-certainty evidence. PROSPERO registration number: CRD42021271977.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Corresponding author: Mochamad Yusuf Alsagaff, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia. E-mail:
| | - Eka Prasetya Budi Mulia
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Irma Maghfirah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Yusuf Azmi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Dita Aulia Rachmi
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Alqi Yutha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Luqman Hakim Andira
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
| | - Bambang Pujo Semedi
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya 60132, Indonesia
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