1
|
Zinellu A, Mangoni AA. A systematic review and meta-analysis of the association between the D-dimer and rheumatic diseases. Immun Inflamm Dis 2024; 12:e1349. [PMID: 39056561 PMCID: PMC11273555 DOI: 10.1002/iid3.1349] [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: 03/30/2024] [Revised: 05/30/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION There is good evidence that specific autoimmune rheumatic diseases (RDs), for example, rheumatoid arthritis and systemic lupus erythematosus (SLE), are associated with a state of hypercoagulability and an increased risk of venous thromboembolism (VTE). However, limited information regarding this association is available for other autoimmune or autoinflammatory RDs. We sought to address this issue by conducting a systematic review and meta-analysis of the association between the d-dimer, an established marker of hypercoagulability and VTE, and RDs and the possible clinical and demographic factors mediating this association. METHODS We searched the electronic databases PubMed, Web of Science, and Scopus from inception to January 31, 2024. The risk of bias and the certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and GRADE, respectively. RESULTS In 31 studies selected for analysis (2724 RD patients and 3437 healthy controls), RD patients had overall significantly higher d-dimer concentrations when compared to controls (standard mean difference = 0.93, 95% CI 0.76-1.10, p < .001; I2 = 86.1%, p < .001; moderate certainty of evidence). The results were stable in a sensitivity analysis. Significant associations were observed between the effect size of the between-group differences in d-dimer concentration and age, specific RD and RD category, RD duration, fibrinogen, plasminogen activator inhibitor, C-reactive protein, and erythrocyte sedimentation rate. CONCLUSIONS Overall, patients with RDs have significantly higher d-dimer concentrations when compared with healthy controls, indicating a state of hypercoagulability. The alterations in d-dimer concentrations are mediated by age, specific RD and RD category, RD duration, and markers of anticoagulation and inflammation. Further research is warranted to investigate d-dimer concentrations across the spectrum of RDs and their utility in predicting and managing VTE in these patients (PROSPERO registration number: CRD42024517712).
Collapse
Affiliation(s)
- Angelo Zinellu
- Department of Biomedical SciencesUniversity of SassariSassariItaly
| | - Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public HealthFlinders UniversityAdelaideAustralia
- Department of Clinical PharmacologyFlinders Medical Centre, Southern Adelaide Local Health NetworkAdelaideAustralia
| |
Collapse
|
2
|
Khubrani AM, Alobaidi HA, Alzahrani IA, Alelyani RH, Wani MS, AlThubaiti GA. Microvascular Thrombosis in Celiac Disease: Is Free Flap an Option? Case Presentation and Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5890. [PMID: 38859805 PMCID: PMC11164015 DOI: 10.1097/gox.0000000000005890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/24/2024] [Indexed: 06/12/2024]
Abstract
Celiac disease is an autoimmune disease that occurs due to gluten intolerance. The prevalence of breast cancer among celiac disease patients is the same as in the general population. It is of note that breast cancer is the most common type of cancer in women. Following mastectomy, these patients visit plastic surgeons for breast reconstruction. Based on various factors, autologous reconstruction using abdominal-based flaps is the best option. Patients with celiac disease have a high incidence of thromboembolic disorders, which may prevent plastic surgeons from doing breast reconstruction with free flaps. We present a case of a patient with celiac disease who underwent a free flap for breast reconstruction with an uneventful course after using our routine postoperative protocol. This case report highlights that patients with celiac disease cannot be denied the option of breast reconstruction with free flaps.
Collapse
Affiliation(s)
- Abdullah Mohammed Khubrani
- From the Department of Plastic Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Department of Scholarship, Ministry of Health, Riyadh, Saudi Arabia
| | - Hussain Amin Alobaidi
- Department of Plastic Surgery and Burns, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Rakan H. Alelyani
- Department of Plastic Surgery and Burns, King Saud Medical City, Riyadh, Saudi Arabia
| | - Musaib Shabeer Wani
- Department of Plastic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ghazi A. AlThubaiti
- Department of Plastic Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
3
|
Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
Collapse
Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| |
Collapse
|
4
|
Menichelli D, Cormaci VM, Marucci S, Franchino G, Del Sole F, Capozza A, Fallarino A, Valeriani E, Violi F, Pignatelli P, Pastori D. Risk of venous thromboembolism in autoimmune diseases: A comprehensive review. Autoimmun Rev 2023; 22:103447. [PMID: 37714419 DOI: 10.1016/j.autrev.2023.103447] [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: 05/30/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023]
Abstract
Autoimmune diseases have specific pathophysiologic mechanisms leading to an increased risk of arterial and venous thrombosis. The risk of venous thromboembolism (VTE) varies according to the type and stage of the disease, and to concomitant treatments. In this review, we revise the most common autoimmune disease such as antiphospholipid syndrome, inflammatory myositis, polymyositis and dermatomyositis, rheumatoid arthritis, sarcoidosis, Sjogren syndrome, autoimmune haemolytic anaemia, systemic lupus erythematosus, systemic sclerosis, vasculitis and inflammatory bowel disease. We also provide an overview of pathophysiology responsible for the risk of VTE in each autoimmune disorder, and report current indications to anticoagulant treatment for primary and secondary prevention of VTE.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito Maria Cormaci
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Marucci
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Giovanni Franchino
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Francesco Del Sole
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandro Capozza
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessia Fallarino
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele Valeriani
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| |
Collapse
|
5
|
彭 清, 刘 佳, 刘 焱, 尚 华, 唐 果, 韩 雅, 龙 丽. [Application of Padua prediction score and serum albumin level in evaluating venous thromboembolism in rheumatic inpatients]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:625-630. [PMID: 37534642 PMCID: PMC10398766 DOI: 10.19723/j.issn.1671-167x.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To investigate the status of venous thromboembolism (VTE) in rheumatic inpatients, and to explore the efficiency of Padua prediction score (PPS) in the patient population. In addition, to analyze the relationship between serum albumin and VTE in rheumatic inpatients. METHODS Data of inpatients with rheumatology were retrospectively collected and analyzed at Sichuan Provincial People's Hospital from September 2018 to September 2019. Occurrence of VTE was compared between high (PPS≥4) and low (PPS < 4) risk groups. PPS were analyzed in the VTE and non-VTE patients. Multivariate Logistic regression model was used to analyze the risk factors in PPS and the relationship between serum albumin and VTE. RESULTS A total of 1 547 patients were included in this study, and 27 (1.7%) had symptomatic VTE. Among the symptomatic VTE cases, 19 (1.2%) had deep vein thrombosis (DVT) only, 6 (0.4%) had pulmonary thromboembolism (PTE) only, and 2 (0.1%) were diagnosed with DVT and PTE. PPS in the VTE and non-VTE groups were 3.33±1.78 and 1.80±0.97 respectively (P < 0.05).The number of patients with PPS≥4 in the VTE group and non-VTE group was 37.0% and 4.3% respectively (P < 0.01). The average serum albumin level in the VTE group was lower than that in non-VTE group [(29.79±6.36) g/L vs. (35.17±6.31) g/L, P < 0.001]. Seventy-six cases was divided into high-risk group of VTE, while 1 471 cases were in the low-risk group, and the incidence of VTE was 13.2% and 1.2% respectively (P < 0.001). Logistic regression analysis showed that ongoing hormonal treatment, age≥70 years, trauma and/or surgery ≤30 d, reduced mobility and previous VTE were risk factors of VTE in the rheumatology patients, OR values were 7.11, 7.07, 3.40, 2.40 and 2.00, respectively. Lower serum albumin level was the risk factor of VTE in the rheumatology patients [OR=0.88 (95%CI: 0.82-0.94)]. CONCLUSION The incidence of VTE was relatively higher in the hospitalized patients in Department of Rheumatology and Immunology. Glucocorticoid therapy was the highest risk factor of VTE and lower serum albumin level also was the risk factor. Although the PPS can reflect the risk of VTE in rheumatic inpatients to some extent, its effectiveness is limited. PPS can be optimized for quantitative VTE risk assessment of rheumatic inpatients in the future.
Collapse
Affiliation(s)
- 清 彭
- 成都市第二人民医院风湿免疫科, 成都 610000Department of Rheumatology and Immunology, Chengdu Second People's Hospital, Chengdu 610000, China
- 遵义医科大学第一临床学院, 贵州遵义 563000Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - 佳君 刘
- 遵义医科大学第一临床学院, 贵州遵义 563000Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - 焱 刘
- 遵义医科大学第一临床学院, 贵州遵义 563000Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - 华 尚
- 遵义医科大学第一临床学院, 贵州遵义 563000Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - 果 唐
- 重庆市璧山区人民医院风湿免疫科, 重庆 402760Department of Rheumatology and Immunology, The Bishan Hospital of Chongqing, Chongqing 402760, China
| | - 雅欣 韩
- 成都市温江区人民医院风湿免疫科, 成都 610000Department of Rheumatology and Immunology, The Wenjiang Hospital of Chengdu, Chengdu 610000, China
| | - 丽 龙
- 遵义医科大学第一临床学院, 贵州遵义 563000Zunyi Medical University, Zunyi 563000, Guizhou, China
- 四川省人民医院风湿免疫科, 成都 610000Department of Rheumatology and Immunology, Sichuan Provincial People's Hospital, Chengdu 610000, China
| |
Collapse
|
6
|
Cohen AT, Sah J, Dhamane AD, Hines DM, Lee T, Rosenblatt L, Emir B, Keshishian A, Yuce H, Luo X. Effectiveness and Safety of Apixaban vs Warfarin in Patients with Venous Thromboembolism with Risk Factors for Bleeding or for Recurrences. Adv Ther 2023; 40:1705-1735. [PMID: 36811795 PMCID: PMC10070226 DOI: 10.1007/s12325-023-02440-1] [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: 08/19/2022] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Patients at increased risk of bleeding and recurrent VTE who develop venous thromboembolism (VTE) present challenges for clinical management. This study evaluated the effectiveness and safety of apixaban vs warfarin in patients with VTE who have risk factors for bleeding or recurrences. METHODS Adult patients with VTE initiating apixaban or warfarin were identified from five claims databases. Stabilized inverse probability treatment weighting (IPTW) was used to balance characteristics between cohorts for the main analysis. Subgroup interaction analyses were conducted to evaluate treatment effects among patients with and without each of the conditions that increased the risk of bleeding (thrombocytopenia and history of bleed) or recurrent VTE (thrombophilia, chronic liver disease, and immune-mediated disorders). RESULTS A total of 94,333 warfarin and 60,786 apixaban patients with VTE met selection criteria. After IPTW, all patient characteristics were balanced between cohorts. Apixaban (vs warfarin) patients were at lower risk of recurrent VTE (HR [95% confidence interval (CI) 0.72 [0.67-0.78]), major bleeding (MB) (HR [95% CI] 0.70 [0.64-0.76]), and clinically relevant non-major (CRNM) bleeding (HR [95% CI] 0.83 [0.80-0.86]). Subgroup analyses showed generally consistent findings with the overall analysis. For most subgroup analyses, there were no significant interactions between treatment and subgroup strata on VTE, MB and CRNM bleeding. CONCLUSION Patients with prescription fills for apixaban had lower risk of recurrent VTE, MB, and CRNM bleeding compared with warfarin patients. Treatment effects of apixaban vs warfarin were generally consistent across subgroups of patients at increased risk of bleeding/recurrences.
Collapse
Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, UK.
| | | | | | | | | | | | | | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | | |
Collapse
|
7
|
Walker RF, Zakai NA, Mason SM, MacLehose RF, Norby FL, Evensen LH, Alonso A, Lutsey PL. Autoimmune disease and risk of postpartum venous thromboembolism. Res Pract Thromb Haemost 2023; 7:100091. [PMID: 36970127 PMCID: PMC10031534 DOI: 10.1016/j.rpth.2023.100091] [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: 10/30/2022] [Revised: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 02/25/2023] Open
Abstract
Background The risk of pregnancy-related mortality in the United States has nearly doubled since 1990, with venous thromboembolism (VTE) accounting for approximately 10% of these deaths. Objectives The objective of this study was to assess whether preexisting autoimmune disease is a risk factor for postpartum VTE. Methods Using the MarketScan Commercial and Medicare Supplemental administrative databases, a retrospective cohort study analyzed whether postpartum persons with autoimmune disease had a higher risk of postpartum VTE incidence than postpartum persons without autoimmune disease. Using International Classification of Diseases codes, we identified 757,303 individuals of childbearing age who had a valid delivery date with at least 12 weeks of follow-up. Results Individuals were, on average, 30.7 years old (SD, 5.4), and 3.7% (N = 27,997 of 757,303) of them had evidence of preexisting autoimmune disease. In covariate-adjusted models, postpartum persons with preexisting autoimmune disease had higher rates of postpartum VTE than postpartum persons without autoimmune disease (hazard ratio [HR], 1.33; 95% CI, 1.07-1.64). When analyzed by individual autoimmune disease, those with systemic lupus erythematosus (HR, 2.49; 95% CI, 1.47-4.21) and Crohn's disease (HR, 2.49; 95% CI, 1.34-4.64) were at an elevated risk of postpartum VTE compared with those without autoimmune disease. Conclusion Autoimmune disease was associated with a higher rate of postpartum VTE, with evidence that the association was most pronounced among individuals with systemic lupus erythematosus and Crohn's disease. These findings suggest that postpartum persons of childbearing age with autoimmune disease may require more monitoring and prophylactic care after delivery to prevent potentially fatal VTE events.
Collapse
Affiliation(s)
- Rob F. Walker
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neil A. Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Susan M. Mason
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Richard F. MacLehose
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Faye L. Norby
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Line H. Evensen
- K.G. Jebsen - Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Pamela L. Lutsey
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
8
|
Vidyanti AN, Maulida Awaliyah MTN, Fauzi AR, Harahap ISK, Mulya DP. Dementia in a patient with autoimmune disease and hypercoagulable state worsened by COVID-19 vaccination: A case report. Ann Med Surg (Lond) 2022; 78:103886. [PMID: 35677525 PMCID: PMC9163025 DOI: 10.1016/j.amsu.2022.103886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background Systemic autoimmune disorders are associated with an increased risk of hypercoagulability. The hypercoagulable state in people with systemic autoimmune disorders has lately gained attention. Presentation of case We presented a 44-year-old male with a chief complaint of progressive difficulty concentrating, memory impairment, and weakness in all limbs. Seven months before admission to our Memory Clinic, the patient began to have infrequent short-term memory loss and sometimes got lost when he went for a drive. Three months later, he complained of feeling dizzy when in a crowd, being unable to watch television for a long time, and easily forgetting. Computed tomography (CT) scan showed brain infarction. After receiving the first dose of COVID-19 vaccine (Sinovac), the patient had difficulty communicating verbally and could only point at objects, as well as tetraparesis. These conditions severely intervened in his daily activities. The patient was then referred to an immunologist and diagnosed with autoimmune disease. In our Memory Clinic, his performances of attention, memory, language, visuospatial, and executive function were very poor. We diagnosed him with autoimmune dementia. The administration of methylprednisolone, mycophenolate mofetil, vitamin D3, donepezil, and memantine could improve his condition. Discussion Autoimmune disease can cause microvascular thrombosis and microembolism at the central nervous system level, which would cause vascular damage and cognitive impairment leading to brain infarction and dementia. Conclusion There seems to be a link between autoimmune disease, hypercoagulable state, and dementia, although the magnitude of this link and the underlying processes are not fully understood. Systemic autoimmune disorders are associated with an increased risk of hypercoagulability. Autoimmune diseases may develop cognitive impairment and vascular damage. Autoimmune disease can lead to brain infarction and dementia.
Collapse
Affiliation(s)
- Amelia Nur Vidyanti
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia
- Corresponding author. Neurobehavior Division, Department of Neurology Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital Jl. Kesehatan No. 1, Yogyakarta, 55281, Indonesia.
| | - Mira Tamila Nurul Maulida Awaliyah
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia
| | - Aditya Rifqi Fauzi
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia
| | - Indra Sari Kusuma Harahap
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia
| | - Deshinta Putri Mulya
- Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, 55281, Indonesia
| |
Collapse
|
9
|
Celiac Disease and Thrombotic Events: Systematic Review of Published Cases. Nutrients 2022; 14:nu14102162. [PMID: 35631302 PMCID: PMC9144428 DOI: 10.3390/nu14102162] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.
Collapse
|
10
|
Adachi S, Oshikata C, Kaneko T, Tsurikisawa N. Rituximab and dupilumab improve eosinophilic granulomatosis with polyangiitis with multiple pulmonary thrombi. Allergy Asthma Clin Immunol 2022; 18:18. [PMID: 35219344 PMCID: PMC8882302 DOI: 10.1186/s13223-021-00639-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by a necrotizing vasculitis with tissue and peripheral blood eosinophilia affecting small and medium-sized arteries, capillaries, and veins. Venous thromboembolic events are uncommon in EGPA. Moreover, there are only a few reported cases of EGPA complicated by pulmonary embolism or infarction. Case presentation We report the case of a 43-year-old woman with eosinophilic granulomatosis with polyangiitis and acute respiratory and heart failure due to bilateral pulmonary artery thrombosis and left femoral vein thrombosis 12 years after disease onset. She also had cardiac involvement (myocarditis, pericardial effusion, and diastolic dysfunction), gastrointestinal symptoms, and peripheral neuropathy. The condition was refractory to treatment with systemic corticosteroids, intravenous cyclophosphamide, and mepolizumab, but the thrombosis and associated acute cardiac failure, as well as the cardiac and gastrointestinal symptoms and multiple polyneuropathy, improved after a switch to rituximab. However, the heart failure did not improve sufficiently and the patient continued to need inhaled oxygen at 1 L/min and asthma exacerbations occurred. We then swapped the patient’s mepolizumab treatment for dupilumab. Not only did she have no further asthma attacks after switching to dupilumab, but also her vasculitis symptoms improved. Oxygen therapy was discontinued as the heart failure improved 5 months after starting the dupilumab. Conclusions This may be the first case report of the successful treatment by rituximab of pulmonary thromboembolism associated with EGPA. In addition, in this patient, treatment with dupilumab was effective not only for the asthma symptoms but also for the symptoms of vasculitis and heart failure.
Collapse
Affiliation(s)
- Sei Adachi
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan
| | - Chiyako Oshikata
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan.,Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Naomi Tsurikisawa
- Department of Allergy and Respirology, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka, Kanagawa, 254-0065, Japan. .,Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| |
Collapse
|
11
|
Wu YY, Tan Y, Yan M, Cheng Z, Pan XT. Analysis of CRP, Antithrombin, Fibrinogen, and Hematological Changes in 433 Patients with PTE. Int J Gen Med 2021; 14:7181-7185. [PMID: 34737613 PMCID: PMC8558423 DOI: 10.2147/ijgm.s333747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/30/2021] [Indexed: 02/04/2023] Open
Abstract
Objective To investigate the characteristics of coagulation indicators, such as C-reactive protein (CRP), antithrombin (AT), and fibrinogen (FB) in patients with pulmonary thromboembolism (PTE) and their relationship with PTE. Methods The clinical characteristics, CRP, AT, FB, plasma D-dimer (D-D) and platelet (PLT) counts, and blood coagulation indicators of 433 patients with PTE diagnosed by computed tomographic pulmonary angiography (CTPA) were comprehensively analyzed, and the relevant clinical significance was discussed. Results The total incidence of PTE was 1.60% (433/270,983 cases), and the age group with the highest incidence was over 60 years old. D-D increased in 412 (95.2%) patients. PLT was normal in 331 (76.4%) cases, but decreased in 53 (12.3%) cases and increased in 49 (11.3%) cases. CRP increased in 76.0% (288/379 cases) and was normal in 24.0% (91/379 cases). AT decreased in 109 (25.2%) cases and FB increased in 102 (23.6%) cases. There were no significant changes in other coagulation indexes. CRP was positively correlated with PLT and FB (r = 0.1026, t = 2.0118, P < 0.05, and r = 0.5360, t = 12.2963, P < 0.01, respectively). CRP was negatively correlated with AT (r = –0.2005, t = 4.0100, P < 0.01). Conclusion The incidence of PTE was higher in hospitalized patients. Most patients with PTE have increased CRP and FB and decreased AT, and these levels may be related to the occurrence of PTE.
Collapse
Affiliation(s)
- Yu-Yan Wu
- Department of Hematology, Taicang Hospital of Soochow University, Taicang, Jiangsu, People's Republic of China
| | - Yong Tan
- Department of Hematology, Taicang Hospital of Soochow University, Taicang, Jiangsu, People's Republic of China
| | - Min Yan
- Department of Hematology, Taicang Hospital of Soochow University, Taicang, Jiangsu, People's Republic of China
| | - Zhen Cheng
- Department of Hematology, Taicang Hospital of Soochow University, Taicang, Jiangsu, People's Republic of China
| | - Xiang-Tao Pan
- Department of Hematology, Taicang Hospital of Soochow University, Taicang, Jiangsu, People's Republic of China
| |
Collapse
|
12
|
Merkel PA, Niles JL, Mertz LE, Lehane PB, Pordeli P, Erblang F. Long-Term Safety of Rituximab in Granulomatosis With Polyangiitis and in Microscopic Polyangiitis. Arthritis Care Res (Hoboken) 2021; 73:1372-1378. [PMID: 32475029 PMCID: PMC8457173 DOI: 10.1002/acr.24332] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/19/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The present study was undertaken to conduct a phase IV, open-label, prospective study to characterize the long-term safety of rituximab in a 4-year observational registry of adult patients with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) within the US. METHODS Patients initiating treatment with rituximab were evaluated every 6 months for up to 4 years. Outcomes included the incidence of serious adverse events (SAEs), infusion-related reactions (IRRs), and SAEs of specific interest, including serious infections, serious cardiac events, serious vascular events, and malignancies. RESULTS Overall, 97 patients (72 with GPA and 25 with MPA) received rituximab through a median of 8 (range 1-28) infusions and were followed up for a median of 3.94 years (range 0.05-4.32 years). The estimated incidence rates (95% confidence interval [95% CI]) of serious infections, serious cardiac events, and serious vascular events were 7.11 (4.55-10.58), 5.03 (2.93-8.06), and 2.37 (1.02-4.67) per 100 patient-years (PYs), respectively. No IRRs or SAEs occurred within 24 hours of an infusion of rituximab. None of the 9 deaths reported (crude mortality rate 2.67 [95% CI 1.22-5.06] per 100 PYs) were considered to be related to use of rituximab. CONCLUSION The safety profile of long-term treatment with rituximab in patients with GPA or MPA was consistent with that of rituximab administered for shorter durations and with rituximab's known safety profile in other autoimmune diseases for which it has received regulatory approval. These findings provide clinicians with long-term, practice-level safety data for rituximab in the treatment of GPA or MPA.
Collapse
|
13
|
Tan Y, Yan M, Cheng Z, Pan X. Pulmonary Thromboembolism in Immune Thrombocytopenia: A Report of Five Cases and a Review of the Literature. Int J Gen Med 2021; 14:4479-4483. [PMID: 34413675 PMCID: PMC8370587 DOI: 10.2147/ijgm.s323146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/22/2021] [Indexed: 01/06/2023] Open
Abstract
Objective To provide a reference for the diagnosis and treatment of patients with immune thrombocytopenia (ITP) complicated with pulmonary thromboembolism (PTE) by analyzing the clinical characteristics of five such patients. Methods This paper summarizes the clinical manifestations and hematological indexes of five patients with ITP complicated with pulmonary embolism. Results In this study, the incidence of ITP complicated with PTE was 2.75%. All five cases were elderly patients with nonspecific clinical manifestations. Platelet counts were different when PTE occurred. The time from the diagnosis of ITP to the occurrence of PTE was from 5 to 24 months, with an average of 12.8 months. There was no significant change in hemoglobin, white blood cell levels, prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen levels, or the international normalized ratio. Four patients had significantly increased D-dimer levels, while D-dimer was only slightly increased in one patient. Antithrombin (AT) was significantly decreased in four cases (less than 70%), and C-reactive protein (CRP) was increased in all five cases. Conclusion PTE may be related to AT and CRP in patients with ITP, which is of great clinical significance to the diagnosis and treatment of ITP complicated with PTE.
Collapse
Affiliation(s)
- Yong Tan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Min Yan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Zhen Cheng
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Xiangtao Pan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| |
Collapse
|
14
|
Lopes de Bragança R, Gorito V, Cibele DG, Ricca Gonçalves L, Ribeiro A, Baptista MJ, Azevedo I. Pulmonary embolism in pediatric age: A retrospective study from a tertiary center. Pediatr Pulmonol 2021; 56:2751-2760. [PMID: 34133850 DOI: 10.1002/ppul.25527] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Pediatric pulmonary embolism (PE) is rare but associated with adverse outcomes. We aimed to characterize PE cases admitted in a tertiary hospital and to evaluate sensitivity of selected PE diagnostic prediction tools. METHODS Retrospective, descriptive study of PE cases admitted from 2008 to 2020 using data collected from hospital records. Patients were grouped according to PE severity and setting (outpatients vs. inpatients). Links and correlation with demographic characteristics, risk factors, clinical presentation, management, and outcomes were analyzed. PE diagnostic prediction tools were applied. RESULTS Twenty-nine PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and split between massive or submassive. One was diagnosed in autopsy. Twenty outpatients, all adolescents, were admitted for classic PE symptoms; in half of them the diagnosis had been previously missed. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and auto-immunity (20%). Eight inpatients, diagnosed during cardiorespiratory deterioration (n = 5), or through incidental radiological findings (n = 3), were younger and had immobilization (87.5%), complex chronic diseases (75%), infections (75%) and central venous catheter (62.5%) as risk factors. Retrospectively, d -dimer testing and adult scores performed better than pediatric scores (sensitivity 92.9%-96% vs. 85.7%-92.9%). Both pediatric scores missed a case with a positive family history. DISCUSSION Pediatric PE diagnosis is often delayed or missed. Development of pediatric prediction tools from validated adult scores merits being explored. We argue clinical presentation and risk factors may be different in inpatients and outpatients and propose broader reliance on family history.
Collapse
Affiliation(s)
- Raquel Lopes de Bragança
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Vanessa Gorito
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,EpiUnit Division, Institute of Public Health, University of Porto, Porto, Portugal
| | - Diana Gonçalves Cibele
- Department of Immuno-hemotherapy, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Luciana Ricca Gonçalves
- Department of Immuno-hemotherapy, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Augusto Ribeiro
- Department of Pediatric Intensive Care, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Maria João Baptista
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Pediatric Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Inês Azevedo
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,EpiUnit Division, Institute of Public Health, University of Porto, Porto, Portugal.,Pediatric Pneumology Unit, Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| |
Collapse
|
15
|
Simion C, Campello E, Bensi E, Bellio A, Pontarin A, Spiezia L, Simioni P. Use of Glucocorticoids and Risk of Venous Thromboembolism: A Narrative Review. Semin Thromb Hemost 2021; 47:654-661. [PMID: 33893633 DOI: 10.1055/s-0040-1722270] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Glucocorticoids are potent anti-inflammatory agents that are widely used for the treatment of many inflammatory, autoimmune, and neoplastic disorders. However, their beneficial effect is associated with several side effects, including an increased risk of cardiovascular complications, such as myocardial infarction and stroke. Whether their use also contributes to a procoagulant state, and therefore increases the risk of venous thromboembolism (VTE), is still a matter of debate. As an increased risk of venous thrombotic events is described in patients with Cushing's syndrome, which is characterized by endogenous hypercortisolism, it is reasonable to speculate that the chronic administration of glucocorticoids may induce a hypercoagulable state. However, it seems virtually impossible to separate the role of the drug from the underlying condition, which itself predisposes to the development of VTE. Actually, some evidence suggests that the use of exogenous glucocorticoids for the treatment of underlying disease and its exacerbations may further amplify the risk of VTE. Moreover, a procoagulant state has also been reported in healthy participants receiving oral glucocorticoids versus placebo. We have performed a concise narrative review on available data on the influence of exogenous glucocorticoids on hemostasis and their clinical impact on the risk of VTE.
Collapse
Affiliation(s)
- Chiara Simion
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Elisa Bensi
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Andrea Bellio
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Anna Pontarin
- Division of Geriatrics, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| |
Collapse
|
16
|
Koster MJ, Warrington KJ, Matteson EL. Morbidity and Mortality of Large-Vessel Vasculitides. Curr Rheumatol Rep 2020; 22:86. [DOI: 10.1007/s11926-020-00963-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
17
|
Nasonov EL, Beketova TV, Reshetnyak TM, Lila AM, Ananieva LP, Lisitsyna TA, Soloviev SK. Coronavirus disease 2019 (COVID-19) and immune-mediated inflammatory rheumatic diseases: at the crossroads of thromboinflammation and autoimmunity. RHEUMATOLOGY SCIENCE AND PRACTICE 2020. [DOI: 10.47360/1995-4484-2020-353-367] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammation and coagulation are key basic mechanism of protection against all potentially pathogenic mechanical and biological factors targeting human organism from inner and outer environment. On the other hand, uncontrolled inflammation results in hypercoagulation, inhibition of anticoagulation and alteration of mechanisms responsible for resolution of inflammation, while production of “procoagulant” mediators (thrombin, tissue factor and others), activation of platelets and of vascular endothelial cells maintains inflammation. All factors taken together serve as the basis for a pathological process called thromboinflammation or immunothrombosis. Currently thromboinflammation is considered in the broad sense as a universal pathogenetic mechanism of numerous widespread acute and chronic conditions, including immune-mediated (autoimmune) inflammatory rheumatic diseases, oftentimes complicated by severe irreversible damage to vital organs. Thromboinflammation gained specific attention during СОVID-19 (coronavirus disease 2019) pandemic, caused by SARS-Cov-2 (severe acute respiratory syndrome Coronavirus-2). COVID-19 is considered currently as systemic thromboinflammation syndrome, manifesting via generalized thrombosis of arterial and venous macro- and microvasculature, termed as COVID-19-coagulopathy. The paper discusses common pathogenetic coagulopathy mechanisms in COVID-19 and immune-mediated (autoimmune) inflammatory rheumatic diseases (IMRDs), associated with overproduction of antiphospholipid antibodies, activation of the complement system, and dis-regulated synthesis of proinflammatory cytokines, etc. Delineating the autoimmune subtype of thromboinflammation, identification of genetic (i.e., genes encoding the complement system and others) and molecular-biologic biomarkers associated with higher occurrence of COVID-19-coagulopathy are the most relevant undertakings for the current practice. Gaining insights into mechanisms of thromboinflammation and converting them into potential pharmacotherapies of IMDs would facilitate and accelerate the drafting of effective therapeutic strategies for COVID-19.
Collapse
Affiliation(s)
- E. L. Nasonov
- VA Nasonova Research Institute of Rheumatology;
I.M. Sechenov First Moscow State Medical University, MOH (Sechenov University)
| | | | - T. M. Reshetnyak
- VA Nasonova Research Institute of Rheumatology;
Russian Medical Academy of Continuing Prefessional Education, Ministry of Health of Russia
| | - A. M. Lila
- VA Nasonova Research Institute of Rheumatology
| | | | | | | |
Collapse
|
18
|
Claudel SE, Tucker BM, Kleven DT, Pirkle JL, Murea M. Narrative Review of Hypercoagulability in Small-Vessel Vasculitis. Kidney Int Rep 2020; 5:586-599. [PMID: 32405580 PMCID: PMC7210611 DOI: 10.1016/j.ekir.2019.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 01/08/2023] Open
Abstract
Pauci-immune necrotizing and crescentic glomerulonephritis (GN) is the most common etiology of rapidly progressive GN. Clinical presentation in those afflicted is usually related to rapid loss of kidney function. We report the case of a 70-year-old woman who came to medical attention for signs and symptoms related to lower-extremity deep vein thrombosis (DVT). At presentation, the patient had biochemical abnormalities consistent with active GN, which quickly progressed to rapid loss in kidney function requiring renal replacement therapy. Kidney biopsy revealed small-vessel vasculitis with glomerular crescents. Serologic studies were negative for antineutrophil cytoplasmic antibody antibodies and other causes of acute GN. Plasmapheresis, immunosuppressive, and anticoagulant therapies were prescribed. Absence of other apparent end-organ involvement with vasculitis pointed toward renal-limited small-vessel vasculitis, yet presence of unprovoked DVT argues for systemic vascular inflammation. This case illustrates that venous thrombosis can be the presenting manifestation in patients with vasculitis and silent, severe end-organ involvement. The epidemiology and pathophysiology of venous thromboembolism in small-vessel vasculitis are discussed in this report.
Collapse
Affiliation(s)
| | - Bryan M. Tucker
- Department of Internal Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel T. Kleven
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - James L. Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| |
Collapse
|
19
|
Andrianova IA, Ponomareva AA, Mordakhanova ER, Le Minh G, Daminova AG, Nevzorova TA, Rauova L, Litvinov RI, Weisel JW. In systemic lupus erythematosus anti-dsDNA antibodies can promote thrombosis through direct platelet activation. J Autoimmun 2020; 107:102355. [PMID: 31732191 PMCID: PMC10875727 DOI: 10.1016/j.jaut.2019.102355] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 12/20/2022]
Abstract
Systemic lupus erythematosus (SLE) is associated with a high risk of venous and arterial thrombosis, not necessarily associated with prothrombotic antiphospholipid antibodies (Abs). Alternatively, thrombosis may be due to an increased titer of anti-dsDNA Abs that presumably promote thrombosis via direct platelet activation. Here, we investigated effects of purified anti-dsDNA Abs from the blood of SLE patients, alone or in a complex with dsDNA, on isolated normal human platelets. We showed that anti-dsDNA Abs and anti-dsDNA Ab/dsDNA complexes induced strong platelet activation assessed by enhanced P-selectin expression and dramatic morphological and ultrastructural changes. Electron microscopy revealed a significantly higher percentage of platelets that lost their discoid shape, formed multiple filopodia and had a shrunken body when treated with anti-dsDNA Abs or anti-dsDNA Ab/dsDNA complexes compared with control samples. In addition, these platelets activated with anti-dsDNA Ab/dsDNA complexes typically contained a reduced number of secretory α-granules that grouped in the middle and often merged into a solid electron dense area. Many activated platelets released plasma membrane-derived microvesicles and/or fell apart into subcellular cytoplasmic fragments. Confocal microscopy revealed that platelets treated with anti-dsDNA Ab/dsDNA complex had a heterogeneous distribution of septin2 compared with the homogeneous distribution in control platelets. Structural perturbations were concomitant with mitochondrial depolarization and a decreased content of platelet ATP, indicating energetic exhaustion. Most of the biochemical and morphological changes in platelets induced by anti-dsDNA Abs and anti-dsDNA Ab/dsDNA complexes were prevented by pre-treatment with a monoclonal mAb against FcγRIIA. The aggregate of data indicates that anti-dsDNA Abs alone or in a complex with dsDNA strongly affect platelets via the FcγRIIA receptor. The immune activation of platelets with antinuclear Abs may comprise a prothrombotic mechanism underlying a high risk of thrombotic complications in patients with SLE.
Collapse
Affiliation(s)
- Izabella A Andrianova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation.
| | - Anastasiya A Ponomareva
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation; Kazan Institute of Biochemistry and Biophysics, Kazan Scientific Center of the Russian Academy of Sciences, Kazan, Russian Federation.
| | - Elmira R Mordakhanova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation.
| | - Giang Le Minh
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation.
| | - Amina G Daminova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation; Kazan Institute of Biochemistry and Biophysics, Kazan Scientific Center of the Russian Academy of Sciences, Kazan, Russian Federation.
| | - Tatiana A Nevzorova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russian Federation.
| | - Lubica Rauova
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Rustem I Litvinov
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - John W Weisel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
20
|
Alipanahzadeh H, Ghulamreza R, Shokouhian M, Bagheri M, Maleknia M. Deep vein thrombosis: a less noticed complication in hematologic malignancies and immunologic disorders. J Thromb Thrombolysis 2019; 50:318-329. [PMID: 31808122 DOI: 10.1007/s11239-019-02005-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Deep vein thrombosis (DVT) is a common complication in hematologic malignancies and immunologic disorders that coagulation and inflammatory factors play a crucial role in its occurrence. The content used in this article has been obtained by PubMed database and Google Scholar search engine of English-language articles (1980-2019) using the "Deep vein thrombosis," "Hematologic malignancies," "Immunologic disorders" and "Treatment." Increased levels of coagulation factors, the presence of genetic disorders, or the use of thrombotic drugs that stimulate coagulation processes are risk factors for the development of DVT in patients with hematologic malignancies. Inflammatory and auto-anti-inflammatory factors, along with coagulant factors, play an essential role in the formation of venous thrombosis in patients with immunological disorders by increasing the recruitment of inflammatory cells and adhesion molecules. Therefore, anti-coagulants in hematologic malignancies and immunosuppressants in immune disorders can reduce the risk of developing DVT by reducing thrombotic and inflammatory activity. Considering the increased risk of DVT due to impaired coagulation and inflammation processes, analysis of coagulation and inflammatory factors have prognostic values in patients with immunologic deficiencies and hematologic malignancies. Evaluation of these factors as diagnostic and prognostic biomarkers in the prediction of thrombotic events could be beneficial in implementing effective treatment strategies for DVT.
Collapse
Affiliation(s)
- Hassan Alipanahzadeh
- Department of Anatomy, Faculty of Medicine, Kabul University Medical Science, Kabul, Afghanistan
| | - Reza Ghulamreza
- Department of Abdominal Surgery, Faculty of Medicine, Kabul University Medical Science, Kabul, Afghanistan
| | - Mohammad Shokouhian
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Marziye Bagheri
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Maleknia
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. .,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| |
Collapse
|
21
|
Srivastava S, Garg I, Kumari B, Rai C, Singh Y, Kumar V, Yanamandra U, Singh J, Bansal A, Kumar B. Diagnostic potential of circulating micro RNA hsa-miR-320 in patients of high altitude induced deep vein thrombosis: An Indian study. GENE REPORTS 2019. [DOI: 10.1016/j.genrep.2019.100550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
22
|
Jin QQ, Sun JH, Du QX, Lu XJ, Zhu XY, Fan HL, Hölscher C, Wang YY. Integrating microRNA and messenger RNA expression profiles in a rat model of deep vein thrombosis. Int J Mol Med 2017; 40:1019-1028. [PMID: 28848993 PMCID: PMC5593457 DOI: 10.3892/ijmm.2017.3105] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/21/2017] [Indexed: 01/10/2023] Open
Abstract
Deep vein thrombosis (DVT) is a disease involving multiple genes and systems. MicroRNAs (miRNAs) represent a class of non-coding small RNAs that post-transcriptionally suppress their target genes. The expression patterns of miRNA and messenger RNA (mRNA) in DVT remain poorly characterized. The aim of the present study was to evaluate miRNA and mRNA expression profiles in a stasis-induced DVT rat model. Male SD rats were randomly divided into three groups as follows: DVT, sham and control. The inferior vena cava (IVC) of rats was ligated to construct stasis-induced DVT models. Rats were sacrificed three days after ligation, and morphological changes in the vein tissues were observed by hematoxylin and eosin and Masson staining. The miRNA and mRNA expression profiles were evaluated by microarrays, followed by bioinformatics analysis. The microarray analysis identified 22 miRNAs and 487 mRNAs that were significantly differentially expressed between the experimental and control groups, and between the experimental and sham groups, but not between the control and sham groups (P≤0.05; ≥2.0-fold change). By subsequent bioinformatics analysis, a 19 miRNA-98 mRNAs network was constructed in the stasis-induced DVT rat model. Notably, the majority of these miRNAs and mRNAs are reported to be expressed by endothelial cells (ECs) and are associated with the function of ECs. The results provide evidence indicating that the regulatory association of miRNA and mRNA points to key roles played by ECs in thrombosis. These findings advance our understanding of the molecular regulatory mechanisms underlying the pathophysiology of DVT.
Collapse
Affiliation(s)
- Qian-Qian Jin
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Jun-Hong Sun
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Qiu-Xiang Du
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Xiao-Jun Lu
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Xi-Yan Zhu
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Hao-Liang Fan
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Christian Hölscher
- Biochemical and Life Sciences, Lancaster University, Lancaster, Lancashire LA1 4YQ, UK
| | - Ying-Yuan Wang
- Department of Forensic Pathology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| |
Collapse
|
23
|
|
24
|
Beer JH. Antibiotic use associated with VTE and its implications: a new trigger for thromboprophylaxis and for reclassification of some unprovoked to provoked VTE's? Br J Haematol 2017; 176:847-848. [DOI: 10.1111/bjh.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 12/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jürg H. Beer
- Department of Medicine; Cantonal Hospital of Baden and Molecular Cardiology; University Hospital of Zurich; Switzerland
| |
Collapse
|
25
|
De Caterina R, D'Ugo E, Libby P. Inflammation and thrombosis - testing the hypothesis with anti-inflammatory drug trials. Thromb Haemost 2016; 116:1012-1021. [PMID: 27535617 DOI: 10.1160/th16-03-0246] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/16/2016] [Indexed: 12/17/2022]
Abstract
The hypothesis of atherosclerosis as an inflammatory process has been a leitmotiv in cardiology for the past 20 years, and has now led to the launch of clinical trials aimed at testing whether drugs that primarily target inflammation can reduce cardiovascular events. Inflammation indeed drives all phases of atherosclerosis, from inception, through progression, and ultimately acute thrombotic complications (plaque rupture and probably plaque erosion). Since plaque rupture and erosion cause most acute coronary syndromes, appropriately tuned anti-inflammatory treatments should limit myocardial infarction and cardiovascular death. Beyond interrupting inflammation-related plaque disruption, such treatments might, however, also ameliorate the propensity to thrombosis once the trigger (plaque rupture or erosion) has occurred. Several lines of evidence support this view: experimental data document the role of inflammation in platelet activation, tissue factor-mediated coagulation, hyperfibrinogenaemia, impaired activity of natural anticoagulants (including those expressed by endothelial cells), and reduced fibrinolytic activity. Supporting evidence also derives from the involvement of inflammation in venous thrombosis, a process that commonly occurs in the absence of traditional risk factors for atherosclerosis but is associated with several inflammatory diseases including obesity. Ongoing trials, in addition to evaluating effects on primary outcomes, will afford the opportunity to probe the possibility that anti-inflammatory interventions that yield salutary changes in biomarkers of the thrombotic/fibrinolytic balance also translate into reduction of clinical events.
Collapse
Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, C/o Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, Tel.: +39 0871 41512, Fax: +39 0871 402817, E-mail:
| | | | | |
Collapse
|
26
|
Abstract
During apoptosis or activation, cells can release a subcellular structure, called a membrane microvesicle (also known as microparticle) into the extracellular environment. Microvesicles bud-off as a portion of cell membrane with its associated proteins and lipids surrounding a cytosolic core that contains intracellular proteins, lipids, and nucleic acids (DNA, RNA, siRNA, microRNA, lncRNA). Biologically active molecules on the microvesicle surface and encapsulated within can act on recipient cells as a novel mode of intercellular communication. Apoptosis has long been known to be involved in the development of diseases of autoimmunity. Abnormally persistent microvesicles, particularly apoptotic microvesicles, can accelerate autoimmune responses locally in specific organs and tissues as well as systemically. In this review, we focus on studies implicating microvesicles in the pathogenesis of autoimmune diseases and their complications.
Collapse
|
27
|
Crickx E, Machelart I, Lazaro E, Kahn JE, Cohen-Aubart F, Martin T, Mania A, Hatron PY, Hayem G, Blanchard-Delaunay C, de Moreuil C, Le Guenno G, Vandergheynst F, Maurier F, Crestani B, Dhote R, Silva NM, Ollivier Y, Mehdaoui A, Godeau B, Mariette X, Cadranel J, Cohen P, Puéchal X, Le Jeunne C, Mouthon L, Guillevin L, Terrier B. Intravenous Immunoglobulin as an Immunomodulating Agent in Antineutrophil Cytoplasmic Antibody-Associated Vasculitides: A French Nationwide Study of Ninety-Two Patients. Arthritis Rheumatol 2016; 68:702-12. [PMID: 26473632 DOI: 10.1002/art.39472] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/01/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Intravenous immunoglobulin (IVIG) represents a therapeutic alternative in antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but its efficacy has been evaluated in only 2 small prospective trials. The aim of this study was to evaluate the efficacy and safety of IVIG in patients with AAV. METHODS We conducted a nationwide retrospective study of patients who received IVIG as immunomodulatory therapy for AAV. RESULTS A total of 92 patients (mean age 51 years) presenting with either granulomatosis with polyangiitis (Wegener's) (68%), eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (22%), or microscopic polyangiitis (10%) received at least 1 course of IVIG. Antineutrophil cytoplasmic antibodies were present in 72% during the flare that required IVIG, as determined by immunofluorescence assay. IVIG was initiated because of relapsing disease in 83% of cases. IVIG was given for a median of 6 months (range 1-156 months) and in combination with corticosteroids in 21% of the patients or with other immunosuppressive agents in 77%. Efficacy of IVIG was assessed in the entire population and in a subset of 34 patients with unmodified background therapy. Remission rates at 6 months were 56% in the entire population and 58% in the unmodified background therapy group. Refractory disease and treatment failure at 6 months were observed in 7% and 18% in the whole population and 3% and 21% in the unmodified background therapy group, respectively. Adverse events (AEs) occurred in 33%, including serious AEs in 12% and AEs leading to discontinuation of IVIG in 7%. CONCLUSION This large study shows the clinical benefit of IVIG as adjunctive therapy, with an acceptable tolerance profile, and thus supports its use in AAV patients with refractory or relapsing disease.
Collapse
Affiliation(s)
- Etienne Crickx
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Irène Machelart
- Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Estibaliz Lazaro
- Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | | | - Fleur Cohen-Aubart
- Groupe Hospitalier Pitié Salpêtrière, AP-HP, and Université Pierre et Marie Curie, Paris, France
| | - Thierry Martin
- CHU de Strasbourg and National Referral Center for Rare Autoimmune and Systemic Diseases, Strasbourg, France
| | | | | | - Gilles Hayem
- Hôpital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | | | | | | | | | | | | | | | | | | | - Anas Mehdaoui
- Centre Hospitalier Intercommunal Eure et Seine, Evreux, France
| | | | - Xavier Mariette
- Hôpitaux Universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | | | - Pascal Cohen
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Xavier Puéchal
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Claire Le Jeunne
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Luc Mouthon
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Loïc Guillevin
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| | - Benjamin Terrier
- National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, AP-HP, and Université Paris Descartes, Paris, France
| |
Collapse
|
28
|
Habe K, Wada H, Matsumoto T, Ohishi K, Ikejiri M, Tsuda K, Kondo M, Kamimoto Y, Ikeda T, Katayama N, Mizutani H. Plasma ADAMTS13, von Willebrand Factor (VWF), and VWF Propeptide Profiles in Patients With Connective Tissue Diseases and Antiphospholipid Syndrome. Clin Appl Thromb Hemost 2016; 23:622-630. [PMID: 26759371 DOI: 10.1177/1076029615625832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) frequently develops in patients with connective tissue diseases (CTDs). ADAMTS13 and von Willebrand factor (VWF) are closely related to the onset of TTP. We investigated the roles of ADAMTS13 and VWF in thrombotic events of patients with CTD. ADAMTS13 activity and VWF and VWF propeptide (VWFpp) levels in CTD, primary antiphospholipid antibody syndrome (pAPS), and controls were measured to examine their relationship with thrombosis. ADAMTS13 activity levels were significantly low in the patients with CTD but not in the patients with pAPS. No significant difference in the ADAMTS13 activity levels among the various CTD subgroups was found. The levels of VWF and VWFpp were significantly elevated in the patients with pAPS and CTD compared with that of control groups. Eleven patients with CTD developed TTP, and their ADAMTS13 activity levels were significantly lower than patients having CTD without TTP. However, the ADAMTS13 activity levels showed no difference between the patients having CTD with and without thrombotic events. The VWF antigen levels were significantly high in the patients having CTD with TTP. There were no significant differences in the VWF levels of the patients having CTD with TTP and thrombosis. The VWFpp levels were significantly high in the patients having CTD with TTP and thrombosis. The VWF and VWFpp levels were significantly high in the patients with pAPS. Decreased ADAMTS13 activity and elevated VWF and VWFpp levels were observed in patients with CTD. These abnormalities in patients with CTD may represent the increased risk of thrombosis in CTD.
Collapse
Affiliation(s)
- Koji Habe
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Hideo Wada
- 2 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Matsumoto
- 3 Blood Transfusion Service, Mie University Hospital, Mie, Tsu, Japan
| | - Kohshi Ohishi
- 3 Blood Transfusion Service, Mie University Hospital, Mie, Tsu, Japan
| | - Makoto Ikejiri
- 4 Central laboratory, Mie University Hospital, Tsu, Japan
| | - Kenshiro Tsuda
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Makoto Kondo
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Yuki Kamimoto
- 5 Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Tomoaki Ikeda
- 5 Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Naoyuki Katayama
- 6 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Hitoshi Mizutani
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| |
Collapse
|
29
|
Madsen PH, Hess S. Symptomatology, Clinical Presentation and Basic Work up in Patients with Suspected Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:33-48. [DOI: 10.1007/5584_2016_104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
|