Coagulopathy and Fibrinolytic Pathophysiology in COVID-19 and SARS-CoV-2 Vaccination

How We Interpret Thrombosis with Thrombocytopenia Syndrome?

Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.

Relating D-Dimer, blood sugars, haemoglobin and liver function among COVID patients with T2DM

It is of interest to evaluate the correlation of D-Dimer, blood sugars, haemoglobin and liver function tests with novel coronavirus in patients with T2DM with and without symptoms. We recruited 200 patients with T2DM and COVID 19 with and without symptoms admitted in Rajarajeshwari Medical College and Hospital, Karnataka. Blood sugars, HbA1c, D-Dimer and also the incidence of T2DM and COVID 19 with and without symptoms were evaluated in all study subjects. There was a significant increased levels of biochemical parameters in T2DM and COVID 19 with symptoms when compared to T2DM and COVID 19 without symptoms (P<0.05). The D-Dimer levels was positively correlated with CT values, (r=0.518, P<0.05). Based on the study findings, the novel coronavirus enhances the insulin resistance, hyper-glycemia, abnormality in the liver and thrombolysis. Additionally, we also suggest that the subjects with T2DM and COVID 19 with and without symptoms require continuous monitoring of D-DIMER and LFT.

Navigating Vaccine Uncertainty: Anxiety and Fourth Dose Hesitancy Among Saudi Adults

Background The continuous evolution of new variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and early evidence of declining effectiveness of the third dose over time have generated anxiety and hesitancy regarding vaccinations. The current study aimed to assess anxiety levels and the willingness to receive a fourth dose of the SARS-CoV-2 vaccine. Potential factors leading to this reluctance were also assessed. Methodology This was a cross-sectional cohort study conducted among the adult Saudi population. A questionnaire including demographic data, questions regarding Generalized Anxiety Disorder (GAD-7) assessment, and questions related to accepting the vaccine and reasons for hesitancy was employed. Results Of the 1,924 participants who responded, 1,033 were males, and 891 were females. Among the respondents, a significant level of anxiety toward receiving the fourth dose of the SARS-CoV-2 vaccine was reported in 1,097 cases, representing 57% of the total, with varying degrees of anxiety. Both gender and age were identified as co-factors contributing to this anxiety. A substantial portion of the participants, 1,369 individuals, accounting for 71.2%, exhibited vaccine hesitancy and reluctance to receive the fourth dose. Conclusions Our findings underscore the pressing need for targeted interventions to combat vaccine hesitancy and alleviate associated anxieties, particularly among the adult Saudi population. As we persist in confronting the ongoing challenges brought about by the evolving pandemic, it is crucial that we customize our vaccination campaigns and communication strategies to tackle the apprehensions and hesitations of the Saudi population directly.

Endothelium dysfunction and thrombosis in COVID-19 with type 2 diabetes

SARS-CoV-2 can directly or indirectly damage endothelial cells. Endothelial injury, especially phosphatidylserine (PS) exposure on the outer membrane of cells, can more easily promote thrombosis. Type 2 diabetes(T2D) patients were more susceptible to COVID-19, they had more severe symptoms, higher risk of thrombotic complications, and longer duration of post-COVID-19 sequelae. This review provided a detailed overview of the mechanisms underlying endothelial dysfunction in T2D patients with COVID-19 (including long COVID), which may be influenced by hyperglycemia, hypoxia, and pro-inflammatory environments. The mechanisms of thrombosis in T2D patients with COVID-19 are also explored, particularly the effects of increased numbers of PS-exposing particles, blood cells, and endothelial cells on hypercoagulability. Given the high risk of thrombosis in T2D patients with COVID-19, early antithrombotic therapy can both minimize the impact of the disease on patients and maximize the chances of improvement, thereby alleviating patient suffering. We provided detailed guidance on antithrombotic drugs and dosages for mild, moderate, and severe patients, emphasizing that the optimal timing of thromboprophylaxis is a critical factor in influencing prognosis. Considering the potential interactions between antidiabetic, anticoagulant, and antiviral drugs, we proposed practical and comprehensive management recommendations to supplement the incomplete efficacy of vaccines in the diabetic population, reduce the incidence of post-COVID-19 sequelae, and improve patient quality of life.

Pulmonary Embolism of COVID-19: A Year of Reflection

Introduction The coronavirus disease 2019 (COVID-19) pandemic has brought about significant changes in the medical field. While primarily characterized as a respiratory syndrome, COVID-19 is also associated with vascular events, particularly thrombotic complications. These events can manifest as initial presentations or develop as complications during the course of the disease, predominantly driven by immune-mediated mechanisms. Methods Patients with thrombotic complications followed in the post-COVID-19 thrombosis consult of 2021 were retrospectively analyzed and assessed for predisposing factors for pulmonary embolism (PE), including thrombophilias. Patients underwent reassessments over a minimum six-month period following diagnosis to evaluate vascular reperfusion and the potential discontinuation of anticoagulant therapy. Results All patients with PE exhibited segmental or subsegmental PE. Pulmonary CT angiography revealed that only one patient did not show complete reperfusion after six months of anticoagulant therapy alone. There were no instances of recurrent thrombotic events observed during this observation period. Among the studied patients, hypertension, diabetes, and obesity were identified as the most prevalent predisposing factors. No patients were diagnosed with thrombophilias or other relevant factors. Despite extensive research on the predisposing mechanisms of this complication in recent years, limited data exist regarding patients with this specific complication. Discussion and conclusion Continued research into COVID-19 patients and their complications is crucial for understanding the pathophysiological mechanisms and risk factors associated with these complications. The findings of this study support the existence of a multifactorial mechanism, with a significant pro-inflammatory component exacerbated by pre-existing risk factors, rather than a purely prothrombotic mechanism.

COVID-19 Vaccine-Associated Immune Thrombosis and Thrombocytopenia (VITT): Diagnostic Discrepancies and Global Implications

Vaccine-induced immune thrombotic thrombocytopenia (VITT) has been reported in association with the coronavirus disease 2019 preventative adenovirus vector-based vaccines ChAdOx1 nCoV-19 (Oxford/AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson) in hundreds of recipients across the globe. VITT is characterized by thrombosis, typically at unusual sites, low fibrinogen, and elevated plasma D-dimer, generally manifesting between 4 and 28 days following vaccination. Detection of anti-platelet factor antibodies using an enzyme-linked immunosorbent assay (ELISA) is often confirmatory. Although several similar principles subside in most diagnostic criteria for VITT, the presentation of a positive ELISA assay, use of expert hematology and neurology opinion, and exclusion of possible VITT cases outside the "standard" 4 to 28-day timeframe have contributed a lack of global standardization for defining VITT. Accordingly, the global and regional incidence of VITT differs according to the diagnostic pathway and case definition used. This has influenced the public perception of VITT's severity and the decision to use adenovirus vector-based vaccines for limiting severe acute respiratory syndrome coronavirus 2 infection. We hereby delineate the recognized pathogenic mechanisms, global incidence, discrepancies in diagnostic criteria, recommended treatments, and global implications to vaccine hesitancy from this coagulopathy.

Low molecular weight heparin in COVID-19: benefits and concerns

Since its emergence, the COVID-19 pandemic had a dramatic impact on the public health worldwide and it scarred the medical, economical, and social determinants of health. Even after the significant vaccination advances, the disease of SARS-CoV-2 can manifest in severe presentations with life-threatening thromboembolic and multi-organ complications leading to notable morbidity and mortality. Clinicians and researchers are on continuous pursuit of investigating different approaches in the attempt to prevent the infection and minimize its severity. Although the COVID-19's pathophysiology remains relatively unclear, it is well established now that coagulopathy, systemic thrombotic propensity, and a robust immunoinflammatory response are some of the most important determinants of its morbidity and mortality. Accordingly, research efforts have focused on addressing the inflammatory and hematological cascades using available agents to avoid thromboembolic events. Several studies and investigators have emphasized the importance of Low molecular weight heparin (LMWH), namely, Lovenox, in addressing these sequelae of the COVID-19 disease, either prophylactically or therapeutically. This review explores the benefits and concerns of employing LMWH, a widely used anticoagulant, in COVID-19 disease. It delves into Enoxaparin as a molecule, along with its pharmacology, mechanism of action, and clinical uses. It also reviews the current high-quality clinical evidence that highlight the role of enoxaparin in SARS-CoV-2 infection.

CGRP Plasma Levels Correlate with the Clinical Evolution and Prognosis of Hospitalized Acute COVID-19 Patients

SARS-CoV-2 is the etiological agent of COVID-19, an extremely heterogenous disease that can cause severe respiratory failure and critical illness. To date, reliable biomarkers allowing for early patient stratification according to disease severity are still lacking. Calcitonin gene-related peptide (CGRP) is a vasoactive neuropeptide involved in lung pathophysiology and immune modulation and is poorly investigated in the COVID-19 context. In this observational, prospective cohort study, we investigated the correlation between CGRP and clinical disease evolution in hospitalized moderate to severe COVID-19 patients. Between January and May 2021 (Italian third pandemic wave), 135 consecutive SARS-CoV-2 patients were diagnosed as being eligible for the study. Plasma CGRP level evaluation and routine laboratory tests were performed on blood samples collected at baseline and after 7 days of hospitalization. At baseline, the majority our patients had a moderate to severe clinical presentation, and higher plasma CGRP levels predicted a higher risk of in-hospital negative evolution (odds-ratio OR 2.84 [IQR 1.07-7.51]) and were correlated with pulmonary intravascular coagulopathy (OR 2.92 [IQR 1.19-7.17]). Finally, plasma CGRP levels were also correlated with plasma IP10 levels. Our data support a possible crosstalk between the lung and the neuroimmune axis, highlighting a crucial role for plasma CGRP in sustaining COVID-19-related hyperinflammation.