Prophylaxis and Incidence of Symptomatic Deep Vein Thrombosis in Indian Patients with Sepsis: DETECT-Deep Vein Thrombosis Registry

Crosstalk between septic shock and venous thromboembolism: a bioinformatics and immunoassay analysis

Background

Herein, we applied bioinformatics methods to analyze the crosstalk between septic shock (SS) and venous thromboembolism (VTE), focusing on the correlation with immune infiltrating cells.

Methods

Expression data were obtained from the Gene Expression Omnibus (GEO) database, including blood samples from SS patients (datasets GSE64457, GSE95233, and GSE57065) and VTE patients (GSE19151). We used the R package "limma" for differential expression analysis (p value<0.05,∣logFC∣≥1). Venn plots were generated to identify intersected differential genes between SS and VTE and conducted Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) Enrichment analysis. The protein-protein interaction (PPI) network of intersected genes was constructed by Cytoscape software. The xCell analysis identified immune cells with significant changes in VTE and SS and correlated them with significant molecular pathways of crosstalk. Finally, we validated the mRNA expression of crosstalk genes by qPCR, while Matrix Metalloprotein-9 (MMP-9) protein levels were assessed through Western blotting (WB) and Immunohistochemistry (IHC) in human umbilical vein endothelial cells (HUVECs) and mice.

Results

In the present study, we conducted a comparison between 88 patients with septic shock and 55 control subjects. Additionally, we compared 70 patients with venous thromboembolism to 63 control subjects. Twelve intersected genes and their corresponding three important molecular pathways were obtained: Metabolic, Estrogen, and FOXO signaling pathways. The resulting PPI network has 194 nodes and 388 edges. The immune microenvironment analysis of the two diseases showed that the infiltration levels of M2 macrophages and Class-switched memory B cells were correlated with the enrichment scores of metabolic, estrogen, and FOXO signaling pathways. Finally, qPCR confirmed that the expression of MMP9, S100A12, ARG1, SLPI, and ANXA3 mRNA in the SS with VTE group was significantly elevated. WB and IHC experiments revealed that MMP9 protein was significantly elevated in the experimental group.

Conclusion

Metabolic, estrogen, and FOXO pathways play important roles in both SS and VTE and are related to the immune cell microenvironment of M2 macrophages and Class-switched memory B cells. MMP9 shows promise as a biomarker for diagnosing sepsis with venous thrombosis and a potential molecular target for treating this patient population.

A review of venous thromboembolism risk assessment models for different patient populations: What we know and don't!

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in hospitalized patients. Globally, it is also the third leading vascular disease, after myocardial infarction and stroke. The incidence of VTE is reportedly higher in Western countries than in Asian countries. However, recent reports suggest an increasing incidence of VTE in Asian countries, including India. Since VTE is largely a preventable disease, early identification of risk factors can lead to disease prevention or the adoption of appropriate prophylactic measures. To this end, several VTE risk assessment models (RAMs) have been developed and validated for different populations who are at risk of developing VTE, such as hospitalized patients with medical illness/surgical indication, patients with cancer, and pregnant women. Evidence indicates that the systematic use of RAMs improves prophylaxis rates and lowers the burden of VTE. Given the increasing burden of VTE in the Indian population and poor prophylaxis rates, the implementation of systematic RAMs in routine clinical practice might ameliorate the disease burden in the country. We have assessed the evidence-based utilities of available RAMs and have delineated the most common and suitable RAMs for different populations including coronavirus disease 2019 affected patients. This review depicts the current status of implementation and validation of RAMs in the Indian scenario. It also highlights the need for additional validation studies, improved awareness, and implementation of RAMs in clinical practice for lowering the burden of VTE.

Strategies for sustained release of heparin: A review

Heparin, a sulfate-containing linear polysaccharide, has proven preclinical and clinical efficacy for a variety of disorders. Heparin, including unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and ultra-low-molecular-weight heparin (ULMWH), is administered systematically, in the form of a solution in the clinic. However, it is eliminated quickly, due to its short half-life, especially in the case of UFH and LMWH. Frequent administration is required to ensure its therapeutic efficacy, leading to poor patient compliance. Moreover, heparin is used to coat blood-contacting medical devices to avoid thrombosis through physical interaction. However, the short-term durability of heparin on the surface of the stent limits its further application. Various advanced sustained-release strategies have been used to prolong its half-life in vivo as preparation technologies have improved. Herein, we briefly introduce the pharmacological activity and mechanisms of action of heparin. In addition, the strategies for sustained release of heparin are comprehensively summarized.

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit

Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options.

How to cite this article

Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.

Approach to Thromboprophylaxis for Prevention of Venous Thromboembolism in COVID-19: Global Updates and Clinical Insights from India

Venous thromboembolism (VTE) frequently occurs in patients with coronavirus disease-19 (COVID-19) and is associated with increased mortality. Several global guidelines recommended prophylactic-intensity anticoagulation rather than intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19-related acute or critical illness without suspected or confirmed VTE. Even though standard doses of thromboprophylaxis are received, many cases of thrombotic complications are reported; hence, appropriate and adequate thromboprophylaxis is critical for the prevention of VTE in COVID-19. In spite of an increased prevalence of VTE in Indian patients, sufficient data on patient characteristics, diagnosis, and therapeutic approach for VTE in COVID is lacking. In this article, we review the available global literature (search conducted up to 31 May 2021) and provide clinical insights into our approach towards managing VTE in patients with COVID-19. Furthermore, in this review, we summarize the incidence and risk factors for VTE with emphasis on the thromboprophylaxis approach in hospitalized patients and special populations with COVID-19 and assess clinical implications in the Indian context.