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Affiliation(s)
- Francesco Marongiu
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Doris Barcellona
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Marongiu F, Ruberto MF, Marongiu S, Barcellona D. Clot Waveform Analysis: From Hypercoagulability to Hypocoagulability - A Review. Arch Pathol Lab Med 2024:499067. [PMID: 38375736 DOI: 10.5858/arpa.2023-0453-ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 02/21/2024]
Abstract
CONTEXT.— Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are coagulative screening tests used for the diagnosis of several pathologic conditions, such as liver failure, coagulation factor deficiencies, anti-phospholipid antibodies (lupus anticoagulant), and factor VIII inhibitors. A new test was developed several years ago to detect the amount of thrombin generated during plasma clotting, using low tissue factor concentrations and fluorogenic substrates, and it has since been used successfully in conditions ranging from hypocoagulable to hypercoagulable states. However, the test is expensive and difficult to perform in nonspecialized laboratories, and efforts have thus been made to find an economic and easily implementable test suitable for routine use, even in nonspecialist laboratories. OBJECTIVE.— To evaluate clot waveform analysis (CWA) of PT and aPTT, aiming to show the dynamics of clot formation; that is, the "hidden" features of both tests. CWA can be implemented by using an automated coagulometer with dedicated software. The aim of this review was to evaluate whether CWA is able to detect both hypercoagulative and hypocoagulative states. DATA SOURCES.— Using MedLine, we searched and retrieved articles relating to CWA. We only considered articles published in English, but with no limits in terms of article type, publication year, or geography. CONCLUSIONS.— CWA was shown to be a reliable test in patients with both hypercoagulable and hypocoagulable states. It represents a simple and inexpensive global test that can easily provide information on the behavior of the coagulation system. Both the first and second derivatives are computed by using dedicated software implemented with an on-board algorithm in a routine automated coagulometer.
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Affiliation(s)
- Francesco Marongiu
- From the Department of Medical Sciences and Public Health (F Marongiu, Ruberto, Barcellona), University of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- From the Department of Medical Sciences and Public Health (F Marongiu, Ruberto, Barcellona), University of Cagliari, Cagliari, Italy
| | - Silvia Marongiu
- From the Department of Medical Sciences and Public Health (F Marongiu, Ruberto, Barcellona), University of Cagliari, Cagliari, Italy
- Internal Medicine Unit, SS Trinità Hospital of Cagliari, Cagliari, Italy (S Marongiu)
| | - Doris Barcellona
- From the Department of Medical Sciences and Public Health (F Marongiu, Ruberto, Barcellona), University of Cagliari, Cagliari, Italy
- Thrombosis and Haemostasis Unit (Barcellona), University of Cagliari, Cagliari, Italy
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Barcellona D, Marongiu F, Grandone E. Contraceptives and Thrombosis: An Intertwined Revolutionary Road. Semin Thromb Hemost 2024; 50:91-95. [PMID: 36913971 DOI: 10.1055/s-0043-1764382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
The development of oral contraceptives (OCs) began in 1921 and continued in the following years until the first regulatory approval from the Food and Drug Administration was granted in 1960. However, it took several years to realize that OCs presented an important but not frequent risk of venous thrombosis. Several reports ignored this dangerous effect and only in 1967 the Medical Research Council clearly stated this as an important risk. Later, research led to the formulation of second-generation OCs containing progestins, which nevertheless presented an increased thrombotic risk. In early 1980s, OCs containing third-generation progestins were introduced into the market. Only in 1995, it became clear that these new compounds induced a higher thrombotic risk than that related to the second-generation progestins. It appeared clear that the modulating action of progestins was against the procoagulant activity of estrogens. Lastly, at the end of the 2000s, OCs containing natural estrogens and a fourth-generation progestin (dienogest) became available. The prothrombotic effect of those natural products was not different from that of preparations containing second-generation progestins. Moreover, research over the years has produced much data on risk factors associated with OCs use such as age, obesity, cigarette smoking, and thrombophilia. These findings allowed us to better assess the individual thrombotic risk (both arterial and thrombotic) of each woman before offering an OC. Furthermore, research has shown that in high-risk people the use of single progestin is not dangerous as far as thrombosis is concerned. In conclusion, the OCs road has been long and difficult but has led to a great and unthinkable scientific and social enrichment since the 1960s.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Departmental Unit of Thrombosis and Haemostasis, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- Departmental Unit of Thrombosis and Haemostasis, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, FG, Italy
- Department of Obstetrics, Gynaecology and Perinatal Medicine, First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
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Marongiu F, Ruberto MF, Marongiu S, Mameli A, Barcellona D. Do we need more guidance on thrombophilia testing? Challenges and special considerations. Expert Rev Hematol 2024; 17:27-37. [PMID: 38228491 DOI: 10.1080/17474086.2024.2306821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/15/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Thrombophilia testing (TT) is a laboratory procedure designed to detect the risk factors involved in the pathogenesis of vascular occlusions. The role of TT is also controversial because it has a limited impact on the choice and duration of antithrombotic treatments. AREAS COVERED We reviewed, by examining MEDLINE up to October 2023. Accepted and not accepted thrombophilia markers are discussed along with the appropriateness or not of prescribing TT in several conditions such as: provoked and unprovoked venous thromboembolism (VTE), women who are planning a pregnancy whose relatives had VTE or have a hereditary thrombophilia, before assumption of estro-progestins, after multiple pregnant loss, arterial thrombosis, retinal vein occlusion, and splanchnic vein thrombosis. EXPERT OPINION TT is not essential in the management of VTE, but it may be useful for limiting adverse events in case of thrombophilia. We expose our criticism of items afforded by other guidelines by presenting our opinion based on both the scientific evidence and clinical practice. We also deal with common mistakes in prescribing and interpretations of TT hoping to purpose an educational approach on this topic. Finally, we emphasize the creation of the expert in hemostasis and thrombosis who should be present in every hospital.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvia Marongiu
- Internal Medicine department, SS Trinità Hospital, ASL, Cagliari, Italy
| | - Antonella Mameli
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
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Barcellona D, Grandone E, Marongiu F. Hormones and thrombosis: the dark side of the moon. Blood Transfus 2024; 22:46-54. [PMID: 37235737 PMCID: PMC10812887 DOI: 10.2450/bloodtransfus.535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 03/03/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The main drawback of oral contraceptives (OC) and hormone replacement therapy (HRT) is an increased risk of venous and, to a lesser extent, arterial thrombosis. MATERIALS AND METHODS This narrative, case-based review describes the effect of available estrogens and progestogens on the hemostatic system and their potential impact on the risk of thrombosis. Clinical cases are used to illustrate different options for prescribing OC and HRT in the real-word. The aim is to offer discussion topics that could be helpful to guide the choice of different hormonal treatments over a woman's lifetime and in the presence of risk factors. RESULTS We describe physio-pathological changes occurring during the administration of hormonal therapies. Furthermore, we analyze the risk of venous and arterial thrombosis associated with different products, routes of administration and additional risk factors. New hormonal preparations, such as estradiol combined with dienogest, as well as non-oral hormonal therapies, are suggested to decrease thrombotic risk significantly. DISCUSSION The availability of many products and different routes of administration allow most women to safely use contraception, as well as HRT. We encourage careful counselling instead of inflexible or fearful behavior, as expanding options and choices will allow women to make the best decisions for their health.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Italy
| | - Elvira Grandone
- Thrombosis and Hemostasis Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
- Obstetrics/Gynecology Department, University of Foggia, Foggia, Italy
- Obstetrics/Gynecology and Perinatal Medicine Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Francesco Marongiu
- Hemostasis and Thrombosis Unit, AOU of Cagliari, Cagliari, Italy
- Fondazione Arianna, Anticoagulazione.it, Bologna, Italy
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Mameli A, Sestu A, Marongiu F, Barcellona D. Living on Oral Anticoagulants: Duke Anticoagulation Satisfaction Scale Results. J Clin Med 2023; 12:7574. [PMID: 38137642 PMCID: PMC10743469 DOI: 10.3390/jcm12247574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used in patients with atrial fibrillation and venous thromboembolism. The lack of the need for laboratory monitoring and a better safety than vitamin K antagonists (VKAs) has probably changed the quality of life of patients on these oral anticoagulants. This was a real-life prospective observational cohort study. The aim was to evaluate if a long-term treatment with DOACs could offer a better quality of life than VKAs. Moreover, age, gender, education level, time in therapeutic range for VKAs, taking medication once or twice a day for DOACs, the total daily number of medications and thrombotic and bleeding complications were considered as variables probably associated with the quality of life of these patients. METHODS Between January and December 2021, the Duke Anticoagulation Satisfaction Scale (DASS) 25-items was administered as an interview to patients on either VKAs or DOACs therapy. During the follow-up period, all of the patients were closely monitored to evaluate possible bleeding and thrombotic events. RESULTS The analysis included 300 outpatients treated with VKAs and 254 treated with DOACs. In general, the quality of life was better in patients taking DOACs (DASS total score: DOACs = 44.7, 42.9-46.5 vs. VKAs = 51, 49.2-52.8, p < 0.0001) as the daily-life limitations, hassles and burdens and the psychological impact were less important than in patients on VKAs therapy. CONCLUSIONS VKAs negatively influence the daily-life of the patients in terms of both less satisfaction and time-consuming tasks. DOACs confer a better quality of life even if some concerns emerge from not knowing how their therapy is working.
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Affiliation(s)
- Antonella Mameli
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Cagliari, 09123 Cagliari, Italy; (A.M.); (A.S.)
| | - Alessandro Sestu
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Cagliari, 09123 Cagliari, Italy; (A.M.); (A.S.)
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, 09123 Cagliari, Italy;
| | - Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, 09123 Cagliari, Italy;
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Marongiu F, Ruberto MF, Marongiu S, Matucci Cerinic M, Barcellona D. A journey to vasculopathy in systemic sclerosis: focus on haemostasis and thrombosis. Clin Exp Med 2023; 23:4057-4064. [PMID: 37914967 DOI: 10.1007/s10238-023-01222-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/15/2023] [Indexed: 11/03/2023]
Abstract
Systemic sclerosis is a multisystem connective tissue disease, characterized by endothelial autoimmune activation, along with tissue and vascular fibrosis leading to vasculopathy and to a progressive loss of angiogenesis. This condition further deranges the endothelial barrier favouring the opening of the endothelial junctions allowing the vascular leak in the surrounding tissues: this process may induce cell detachment which allows the contact between platelets and collagen present in the exposed subendothelial layer. Platelets first adhere to collagen via glycoprotein VI and then, immediately aggregate because of the release of von Willebrand factor which is a strong activator of platelet aggregation. Activated platelets exert their procoagulant activity, exposing on their membrane phospholipids and phosphatidylserine, enabling the adsorption of clotting factors ready to form thrombin which in turn drives the amplification of the coagulative cascade. An essential role in the activation of blood coagulation is the tissue factor (TF), which triggers blood coagulation. The TF is found abundantly in the subendothelial collagen and is also expressed by fibroblasts providing a haemostatic covering layer ready to activate coagulation when the endothelial injury occurs. The aim of this review is to focus the attention on the underlying mechanisms related to haemostasis and thrombosis pathophysiology which may have a relevant role in SSc as well as on a possible role of anticoagulation in this disease.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Thrombosis and Haemostasis Unit, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvia Marongiu
- Internal Medicine Unit, SS Trinità Hospital of Cagliari, Cagliari, Italy
| | - Marco Matucci Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
- Thrombosis and Haemostasis Unit, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
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Marongiu F, Marongiu S, Ruberto MF, Faa G, Barcellona D. Trace Metals and The Hemostatic System. Clin Chim Acta 2023; 547:117458. [PMID: 37385467 DOI: 10.1016/j.cca.2023.117458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
In this narrative review we report the main relationships between trace metals and the hemostatic system since this aspect has seldom attracted the attention of the scientific community. A basic aspect to be considered is the importance of maintaining the fine control of all trace metals' levels since they have an important impact on the pathophysiology of the hemostatic system. It is worth noting that poor diet habits are responsible for most trace metal deficiencies, while pollution is responsible for dangerous exposure to them with a consequent negative impact on the general population. This appears of paramount importance in planning the implementation of food and nutrient support to ameliorate the hidden hunger and the quality of life of people especially in developing countries and limiting poisons both in the air and food. As it often happens, when damage to certain mechanisms takes a very long time to appear, no attention is paid to the importance of a systematic prevention to avoid late negative outcomes.
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Affiliation(s)
- F Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Haemostasis and Thrombosis Unit, Azienda Ospedaliero-Universitaria (A.O.U.), Cagliari, Cagliari, Italy; Fondazione Arianna, Anticoagulazione.it, Bologna, Italy
| | - S Marongiu
- Department of Medicine, Azienda Tutela della Salute Cagliari, Cagliari, Italy.
| | - M F Ruberto
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Haemostasis and Thrombosis Unit, Azienda Ospedaliero-Universitaria (A.O.U.), Cagliari, Cagliari, Italy
| | - G Faa
- Department of Medical Sciences and Public Health, Division of Pathology, Azienda Ospedaliero-Universitaria (A.O.U.), di Cagliari - University Hospital San Giovanni di Dio, University of Cagliari, Cagliari, Italy; Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, USA
| | - D Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Haemostasis and Thrombosis Unit, Azienda Ospedaliero-Universitaria (A.O.U.), Cagliari, Cagliari, Italy; Fondazione Arianna, Anticoagulazione.it, Bologna, Italy
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Di Pino M, Ruberto MF, Costanzo G, Firinu D, Piras MS, Mura MN, Del Giacco S, Coghe F, Marongiu F, Barcellona D. Chronic spontaneous urticaria: a low-grade disseminated intravascular coagulation only partially reversed by Omalizumab. Clin Exp Med 2023; 23:495-502. [PMID: 35614365 PMCID: PMC10224816 DOI: 10.1007/s10238-022-00838-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/02/2022] [Indexed: 11/03/2022]
Abstract
Chronic spontaneous urticaria (CSU) is a disorder characterized by wheals and/or angioedema. The coagulation cascade and inflammation pathways are closely linked together. The aim of our study was first to investigate the dynamics of clot formation in plasma (Clot Waveform Analysis, CWA) in a group of 47 patients with CSU along with other coagulative parameters dedicated to the study of hypercoagulability, such as D-Dimer, F 1 + 2 peptide, Fibrinogen, Platelet count and Mean Platelet Volume (MPV). Secondly, 23 out of 47 patients were treated with Omalizumab at four administration intervals from T0 to T4. A statistically significant increase in Activated Partial Thromboplastin (aPTT) ratio, D-Dimer, F1 + 2, Platelet count and MPV was found when compared with 53 healthy controls (HC). In contrast, the 2nd Derivative of aPTT showed lower values than those of the HC. No differences were found between 1st derivative of aPTT and Fibrinogen. D-Dimer only showed a significant difference between T0 and T3. An activation of both coagulation and fibrinolysis along with a weaker clot acceleration may be in agreement with a low-grade DIC. The accelerated turnover of platelets expressed by both an increase in platelet count and MPV further supports this pathway in CSU. Omalizumab does not affect the relationship between the immune and the hemostatic systems.
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Affiliation(s)
- Marina Di Pino
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Giulia Costanzo
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy.
| | - Maria Sebastiana Piras
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Mario Nicola Mura
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Ferdinando Coghe
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, and Unit of Internal Medicine, University of Cagliari, Policlinico Universitario - AOU di Cagliari Azienda Ospedaliero Universitaria, SS 554-Bivio Sestu, 09042, Monserrato, CA, Italy
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Ruberto MF, Marongiu F, Barcellona D. Performance and Interpretation of Clot Waveform Analysis. Methods Mol Biol 2023; 2663:163-173. [PMID: 37204709 DOI: 10.1007/978-1-0716-3175-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The prothrombin time (PT) and the activated partial thromboplastin time (aPTT) are two basic tests for routine purposes, which are widely used in the clinical screening of coagulopathies. PT and aPTT are useful tests for detecting both symptomatic (hemorrhagic) and asymptomatic defects, but they are unsuitable for studying hypercoagulable states. However, these tests are available for studying the dynamic process of clot formation by means of the detection of the clot waveform analysis (CWA), which has been introduced several years ago. CWA can provide useful information on both hypocoagulable and hypercoagulable states. Nowadays it is possible to detect the whole clot formation both in the PT and aPTT tubes starting from the initial step of fibrin polymerization by means of specific and dedicated algorithm implemented in a coagulometer. In particular, CWA provides information on the velocity (first derivative), acceleration (second derivative), and density (delta) of clot formation. CWA has been applied to several pathologic conditions such as coagulation factor deficiency (including congenital hemophilia from factor VIII, IX, or XI deficiency), acquired hemophilia, disseminated intravascular coagulation (DIC), sepsis, replacement therapy management, chronic spontaneous urticarial, and liver cirrhosis, in patients with high venous thromboembolic risk before LMWH prophylaxis, and in patients with different hemorrhagic patterns along with an electron microscopy evaluation of the clot density. We report here materials and methods used for detecting the additional clotting parameters available in both PT and aPTT.
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Affiliation(s)
- Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- SHRO, Temple University, Philadelphia, PA, USA
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Falcinelli E, Marcucci R, Gresele P, Accorsi P, Barcellona D, Contino L, D'Angelo A, De Cristofaro R, Di Gregorio P, Falanga A, Gandini G, Grandone E, Guglielmini G, La Raja M, Mameli LA, Martini G, Montaruli B, Napolitano M, Pecci A, Podda GM, Pulcinelli F, Ranieri P, Russo T, Santagada D, Santer P, Santoro R, Testa S, Tosetto A, Tripodi A, Valpreda A. The diagnostics of heparin-induced thrombocytopenia in Italy and the possible impact of vaccine-induced immune thrombotic thrombocytopenia on it. Clin Chem Lab Med 2022; 61:e91-e95. [PMID: 36525641 DOI: 10.1515/cclm-2022-0968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Emanuela Falcinelli
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic Disease, AOU Careggi, University of Florence, Firenze, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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De Pascali F, Squizzato A, Barcellona D, Bucciarelli P, Ciampa A, Grandone E, Malcangi G, Rescigno G, Toschi V, Testa S, Poli D. Management of anticoagulation in hemodialysis: Results from a survey of current clinical practice in the Italian anticoagulation clinics. Thromb Res 2022; 220:97-99. [DOI: 10.1016/j.thromres.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/07/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
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Grandone E, Barcellona D, Intrieri M, Tiscia G, Nappi L, Othman M. The ART of Thromboprophylaxis in the Prevention of Gestational Venous Thromboembolism. Semin Thromb Hemost 2022; 49:330-336. [PMID: 36368688 DOI: 10.1055/s-0042-1758062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractAssisted reproductive techniques (ART) allow infertile couples to conceive. Use of hormones to obtain a controlled ovarian stimulation and an adequate growth of the endometrium preparatory for embryo implantation are not riskless. Among others, thrombotic events can occur during the ovulation induction or pregnancy following ART. As the number of women approaching ART to conceive is steadily increasing, the issue of thrombotic risk in this setting is relevant. Data on the weight of each risk factor and on potential benefit of thromboprophylaxis are largely lacking. In this review, we discuss risk of venous thromboembolism during pregnancy following ART, with a focus on general (i.e.: age, body mass index, thrombophilia, bed rest, transfusions) and ART-specific (i.e., polycystic ovarian syndrome, ovarian hyperstimulation syndrome) risk factors. We also attempt to provide some suggestions to guide clinical practice, based on available data and studies performed outside ART.
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Affiliation(s)
- Elvira Grandone
- Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
- Thrombosis and Haemostasis Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza,” Foggia, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Doris Barcellona
- Thrombosis and Haemostasis Unit, Department of Medical Science and Public Health, University of Cagliari, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Mariano Intrieri
- Department of Medicine and Health Science “V. Tiberio,” University of Molise, Campobasso, Italy
| | - Giovanni Tiscia
- Thrombosis and Haemostasis Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza,” Foggia, Italy
| | - Luigi Nappi
- Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada
- Department of Clinical Pathology, School of Medicine, Mansoura University, Mansoura, Egypt
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14
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Barcellona D, Schirru P, Mameli A, Cornacchini S, Fenu L, Marongiu F. Over-anticoagulation by vitamin K antagonists and gender differences. Int J Cardiol 2022; 362:147-151. [DOI: 10.1016/j.ijcard.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/25/2022]
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15
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Congiu T, Demontis R, Cau F, Piras M, Fanni D, Gerosa C, Botta C, Scano A, Chighine A, Faedda E, Cau R, Van Eyken P, Marongiu F, Barcellona D, Saba L, Orrù G, Coghe F, Suri JS, Faa G, d'Aloja E. Scanning electron microscopy of lung disease due to COVID-19 - a case report and a review of the literature. Eur Rev Med Pharmacol Sci 2022; 25:7997-8003. [PMID: 34982463 DOI: 10.26355/eurrev_202112_27650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The ongoing Coronavirus pandemic (COVID-19) showed similar characteristics with the severe acute respiratory syndrome (SARS). In the most compromised cases, COVID-19 infection leads to death due to severe respiratory complications. COVID-19-related acute respiratory distress syndrome (ARDS) is the primary cause of death in these patients. In the present study, we show an ultrastructural analysis on the lungs of a patient affected by COVID-19. PATIENTS AND METHODS Lung specimens obtained at autopsy from a 63-years old patient affected by COVID-19 were fixed in 1% paraformaldehyde. Slices of 300 µm thickness were dehydrated and dried by Critical Point Drying in CO2. Slices were covered with a conductive gold film approximately 30 nm thick and observed at a Zeiss Sigma 300 SEM FEG in the secondary electron (SE) and backscattered electron (BSE) modes. As case control a lung biopsy from a 60-year-old man was considered. RESULTS At low power in all COVID-19 lung specimens severe changes in the pulmonary architecture were found, due to the collapse of air spaces. Moreover, alveolar cavities were covered by large membranes. At high power, alveolar membranes showed a fibrillar structure, suggestive of a loose network of fibrin. It has been also found that intra-alveolar red blood cells were frequently present in the alveolar spaces, surrounded by a reticular fibrin network, suggestive for fibrin-hemorrhagic alveolitis. Alveolar changes were constantly associated with pathological features related to the pulmonary vessels. Vascular changes were prominent, including endothelial damage and thrombosis of large pulmonary vessels. Fibrinous microthrombi were frequently detected in the inter-alveolar septal capillaries. In addition, it has been frequently detected capillary proliferation in the alveolar septa with finding suggestive for intussusceptive neo-angiogenesis. CONCLUSIONS In conclusion, our electron microscopy analysis showed that COVID-19-related lung disease is characterized by a substantial architectural distortion, with the interactions between alveolar and vascular changes. Intra-alveolar hyaline membranes are associated with macro- and micro-thrombotic angiopathy, ending with capillary proliferation. The new blood vessel formation originates from the septa and extends into the surrounding parenchyma. Our findings confirm previous reports on the specificity of the multiple and complex morphological pattern typical, and apparently specific, of COVID-19-related lung disease.
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Affiliation(s)
- T Congiu
- Department of Medical Sciences and Public Health, Electron Microscopy Laboratory, Division Pathological Anatomy, University of Cagliari, Cagliari, Italy.
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16
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Congiu T, Fanni D, Piras M, Gerosa C, Cau F, Barcellona D, D'Aloja E, Demontis R, Chighine A, Nioi M, Coni P, Ravarino A, Cerrone G, Aimola V, Botta C, Scano A, Orrù G, Coghe F, Van Eyken P, La Nasa G, Saba L, Suri JS, Faa G, Marongiu F. Ultrastructural findings of lung injury due to Vaccine-induced Immune Thrombotic Thrombo- cytopenia (VITT) following COVID-19 vaccination: a scanning electron microscopic study. Eur Rev Med Pharmacol Sci 2022; 26:270-277. [PMID: 35049004 DOI: 10.26355/eurrev_202201_27777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare new syndrome occurring after the ChAdOx1 nCoV-19 vaccine immunization. Patients with VITT are characterized by a variable clinical presentation, likewise also the outcome of these patients is very variable. Here we report the lung ultrastructural findings in the course of VITT of a 58-year-old male patient. Alveoli were mainly dilated, irregular in shape, and occupied by a reticular network of fibrin, while interalveolar septa appeared thickened. The proliferation of small capillaries gave rise to plexiform structures and pulmonary capillary hemangiomatosis-like features. Near the alveoli occupied by a dense fibrin network, the medium-sized arteries showed a modified wall and an intraluminal thrombus. This scenario looks quite similar to that found during COVID-19, where the lungs suffer from the attack of the antigen-antibodies complexes and the virus respectively. In both diseases, the final outcome is a severe inflammation, activation of the haemostatic system and fibrinolysis.
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Affiliation(s)
- T Congiu
- Division of Pathology, Department of Medical Sciences and Public Health, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
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17
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Squizzato A, Poli D, Barcellona D, Ciampa A, Grandone E, Manotti C, Moia M, Toschi V, Tosetto A, Testa S. Management of DOAC in patients undergoing planned surgery or invasive procedure: FCSA position paper. Thromb Haemost 2021; 122:329-335. [PMID: 34875702 PMCID: PMC8899293 DOI: 10.1055/a-1715-5960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. About a quarter of the anticoagulated patients require temporary cessation of direct oral anticoagulants (DOACs) or vitamin K antagonists for a planned intervention within 2 years from anticoagulation inception. Several clinical issues about DOAC interruption remain unanswered: many questions are tentatively addressed daily by thousands of physicians worldwide through an experience-based balancing of thrombotic and bleeding risks. Among possible valuable answers, the Italian Federation of Centers for the diagnosis of thrombotic disorders and the Surveillance of the Antithrombotic therapies (FCSA) proposes some experience-based suggestions and expert opinions. In particular, FCSA provides practical guidance on the following issues: (1) multiparametric assessment of thrombotic and bleeding risks based on patients' individual and surgical risk factor, (2) testing of prothrombin time, activated partial thromboplastin time, and DOAC plasma levels before surgery or invasive procedure, (3) use of heparin, (4) restarting of full-dose DOAC after high risk bleeding surgery, (5) practical nonpharmacological suggestions to manage patients perioperatively. Finally, FCSA suggests creating a multidisciplinary “anticoagulation team” with the aim to define the optimal perioperative management of anticoagulation.
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Affiliation(s)
- Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, Universita degli Studi dell'Insubria, Como, Italy
| | - Daniela Poli
- Department of Critical Care Medicine, Azienda Ospedaliera Universitaria Careggi, Thrombosis Centre, Firenze, Italy
| | | | | | - Elvira Grandone
- ATHEROSCLEROSIS AND THROMBOSIS, IRCCS CASA SOLLIEVO DELLA SOFFERENZA, S.GIOVANNI R., Italy
| | | | - Marco Moia
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Center,, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy, Milano, Italy
| | | | | | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche - ASST Cremona, Cremona, Italy
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18
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Gerosa C, Faa G, Fanni D, Cerrone G, Suri JS, Barcellona D, Coni P, Congiu T, Lai ML, Piras M, Cau F, Coghe F, Balestrieri A, Cau R, Orru' G, Scano A, Van Eyken P, La Nasa G, Campagna M, Castagnola M, Gibo Y, Marongiu F, Saba L. Fetal programming of atherosclerosis: may the barker hypothesis explain the susceptibility of a subset of patients to develop stroke or cardiac infarct? Eur Rev Med Pharmacol Sci 2021; 25:6633-6641. [PMID: 34787867 DOI: 10.26355/eurrev_202111_27107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The risk stratification of young adults between subjects who will develop a mild form of atherosclerosis and subjects who will undergo a severe disease remains inaccurate. In the eighties of the previous century, David JP Barker has demonstrated the relationship between fetal conditions and occurrence of pathologies in adulthood. In this paper, the multiple evidence that might explain the increased susceptibility to severe forms of atherosclerosis, including stroke and cardiac infarct, in subjects who underwent intrauterine growth restriction (IUGR) will be analyzed. Specifically, we will review those inter-connected data indicating an association between a low weight at birth and an adult phenotype which might favor a severe outcome of atherosclerosis. Young and adult subjects born too small (IUGR) or too early (pre-terms) might represent a subgroup of "at risk subjects", more susceptible toward severe forms of atherosclerosis. Given that low birth weight (LBW) may be considered a surrogate of IUGR, this phenotypic feature could be considered among those indispensable clinical data collected in every patient presenting with atherosclerosis, irrespectively of age. According to the hypothesis that structural arterial changes might represent the link between LBW and susceptibility to atherosclerosis later in life, we suggest that the prevention of atherosclerosis should begin at birth. Regenerative and physiological substances such as thymosin Beta-4 could be challenged for a new "arterial regenerative medicine" in the perinatal period. The goal of this new approach should be the reinforcement of the structure of the arterial wall, allowing LBW newborns to avoid the most severe complications of atherosclerosis later in life: a dream that our research could contribute to bringing to life.
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Affiliation(s)
- C Gerosa
- Division of Pathology, Department of Medical Sciences and Public Health, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
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19
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Faa G, Gerosa C, Fanni D, Barcellona D, Cerrone G, Orrù G, Scano A, Marongiu F, Suri J, Demontis R, Nioi M, D'Aloja E, La Nasa G, Saba L. Aortic vulnerability to COVID-19: is the microvasculature of vasa vasorum a key factor? A case report and a review of the literature. Eur Rev Med Pharmacol Sci 2021; 25:6439-6442. [PMID: 34730226 DOI: 10.26355/eurrev_202110_27018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Arterial thromboembolic complications reported in patients with COVID-19 infection suggested that SARS-CoV-2 can trigger atherosclerotic plaque vulnerability. While endothelial cells in healthy subjects protect against thrombus formation, after injury they show prothrombotic activity. In addition, it has been hypothesized that "cytokine storm" might stimulate the production of neo-platelets triggering an abnormal "immunothrombosis" responsible for the hypercoagulable state induced in COVID-19 patients. The aim of this study is to report a case of severe COVID-19 infection characterized by the occurrence of microthrombosis in the vasa vasorum of the aorta. A 67-year-old male patient, in good health status and without comorbidities, who underwent a severe COVID-19 infection with fatal outcome, showed scattered aortic atherosclerotic plaques, characterized by multiple occlusive micro-thromboses in the vasa vasorum, spread out lymphocytic infiltrates and foci of endotheliitis and endothelial detachment. This case report confirms the previously described thrombotic involvement of vasa vasorum in COVID-19. The occurrence of the synchronous damage involving both the lumen surface (endothelial dysfunction, endotheliitis and endothelial detachment) and the adventitia (inflammation and occlusive thrombosis of vasa vasorum) could be the key points related to the fatal outcome of the SARS-CoV-2 patients. In our opinion, vasa vasorum thrombosis may thus initiate an atherogenic process that could be characterized by a much more rapid development.
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Affiliation(s)
- G Faa
- Division of Pathology, Department of Medical Sciences and Public Health, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
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20
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Fanni D, Cerrone G, Saba L, Demontis R, Congiu T, Piras M, Gerosa C, Suri J, Coni P, Caddori A, Piga M, Mancosu G, Barcellona D, Ravarino A, Chighine A, Cau F, Scano A, Balestrieri A, Coghe F, Orrù G, Van Eyken P, La Nasa G, D'Aloia E, Marongiu F, Faa G. Thrombotic sinusoiditis and local diffuse intrasinusoidal coagulation in the liver of subjects affected by COVID-19: the evidence from histology and scanning electron microscopy. Eur Rev Med Pharmacol Sci 2021; 25:5904-5912. [PMID: 34661248 DOI: 10.26355/eurrev_202110_26866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Liver injury has been reported in patients with COVID-19. This condition is characterized by severe outcome and could be related with the ability of SARS-CoV-2 to activate cytotoxic T cells. The purpose of this study is to show the histological and scanning electron microscopy features of liver involvement in COVID-19 to characterize the liver changes caused by the activation of multiple molecular pathways following this infection. PATIENTS AND METHODS Liver biopsies from 4 patients (3 post-mortems and 1 in vivo) with COVID-19 were analyzed with histology and by scanning electron microscopy. RESULTS The liver changes showed significant heterogeneity. The first case showed ground glass hepatocytes and scattered fibrin aggregates in the sinusoidal lumen. The second evidenced intra-sinusoidal thrombi. The third was characterized by sinusoidal dilatation, atrophy of hepatocytes, Disse's spaces dilatation and intra-sinusoidal aggregates of fibrin and red blood cells. The fourth case exhibited diffuse fibrin aggregates in the dilated Disse spaces and microthrombi in the sinusoidal lumen. CONCLUSIONS In COVID-19-related liver injury, a large spectrum of pathological changes was observed. The most peculiar features were very mild inflammation, intra-sinusoidal changes, including sinusoidal dilatation, thrombotic sinusoiditis and diffuse intra-sinusoidal fibrin deposition. These findings suggested that a thrombotic sinusoiditis followed by a local diffuse intra-vascular (intra-sinusoidal) coagulation could be the typical features of the SARS-CoV-2-related liver injury.
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Affiliation(s)
- D Fanni
- Division of Pathology, Department of Medical Sciences and Public Health, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
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21
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Gerosa C, Faa G, Fanni D, Manchia M, Suri JS, Ravarino A, Barcellona D, Pichiri G, Coni P, Congiu T, Piras M, Cerrone G, Cau F, Ledda F, Aimola V, Coghe F, Porcu M, Cau R, Orru' G, Van Eyken P, La Nasa G, Castagnola M, Marongiu F, Saba L. Fetal programming of COVID-19: may the barker hypothesis explain the susceptibility of a subset of young adults to develop severe disease? Eur Rev Med Pharmacol Sci 2021; 25:5876-5884. [PMID: 34604981 DOI: 10.26355/eurrev_202109_26810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The risk stratification of young adults between subjects who will develop a mild form COVID-19 and subjects who will undergo a severe disease remains inaccurate. In this review, we propose that the Barker hypothesis might explain the increased susceptibility to severe forms of COVID-19 in subjects who underwent intrauterine growth restriction (IUGR). In this paper evidence indicating an association between a low birth weight and an adult phenotype which might favor a severe outcome of SARS-CoV-2 infection are presented: lower lung functional capacity; increased respiratory morbidity; changes in fibrinogen and Factor VII serum levels and dysregulation of the hemostasis and thrombosis system; acquisition of a pro-thrombotic phenotype; low nephron number, with decreased ability to sustain renal function and increased renal morbidity; heart remodeling, with a less efficient cardiac function; endothelial dysfunction, a risk factor for the insurgence of the multiple organ failure; remodeling of arteries, with changes in the elastic properties of the arterial wall, predisposing to the insurgence and progression of atherosclerosis; dysfunction of the innate immune system, a risk factor for immune diseases in adulthood. These data suggest that young and adult subjects born too small (IUGR) or too early (pre-terms) might represent a subgroup of "at risk subjects", more susceptible toward severe forms of COVID-19. Given that LBW may be considered a surrogate of IUGR, this phenotypic marker should be included among the indispensable clinical data collected in every patient presenting with SARS-COV-2 infection, irrespectively of his/her age.
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Affiliation(s)
- C Gerosa
- Division of Pathology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
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22
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Ruberto MF, Piras MS, Sorbello O, Civolani A, Usai P, Fanni D, Orrù G, Faa G, Marongiu F, Barcellona D. Chronic intravascular coagulation in liver cirrhosis predicts a high hemorrhagic risk. Eur Rev Med Pharmacol Sci 2021; 25:5518-5524. [PMID: 34533802 DOI: 10.26355/eurrev_202109_26663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE In liver cirrhosis, a complex coagulopathy does exist. The aim was to investigate whether a possible chronic consumption coagulopathy is the underlying phenomenon of the disease. PATIENTS AND METHODS We measured endogenous thrombin generation with and without thrombomodulin (ETP ratio) along with D-Dimer in a group of consecutive 282 cirrhotic patients. Fibrinogen, Platelet count and the Hemorrhagic score were previously computed in the same patients. The ETP ratio represents the resistance to the anticoagulant activity of TM and should be considered as an index of a procoagulant imbalance. RESULTS ETP ratio and D-Dimer showed higher values in the cirrhotic patients when compared to controls thus showing a hypercoagulable state. When the patients were divided based on the Hemorrhagic score >7, we found that Fibrinogen, ETP ratio, D-Dimer and the platelet count were significantly different between the two groups. Again, when we considered ETP ratio >0.88, the median value of the cirrhotic patients, all parameters, were statistically different between the two groups. D-Dimer were higher while fibrinogen and platelet count were statistically lower in cirrhotic patients with higher ETP ratio values. Even when the same patients were divided based on their platelet count (</> 100 x 109/L) the results showed a similar behavior. ROC curves showed significant AUCs when the hemorrhagic score was challenged against Fibrinogen, D-Dimer, Platelet count and ETP ratio. CONCLUSIONS In liver cirrhosis hypercoagulable state is associated with an increase in D-Dimer levels along with a decrease in fibrinogen and platelet count thus indicating a low-grade intravascular coagulation which predicts a high hemorrhagic risk.
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Affiliation(s)
- M F Ruberto
- Hemostasis and Thrombosis Unit, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
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23
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Fanni D, Saba L, Demontis R, Gerosa C, Chighine A, Nioi M, Suri JS, Ravarino A, Cau F, Barcellona D, Botta MC, Porcu M, Scano A, Coghe F, Orrù G, Van Eyken P, Gibo Y, La Nasa G, D'aloja E, Marongiu F, Faa G. Vaccine-induced severe thrombotic thrombocytopenia following COVID-19 vaccination: a report of an autoptic case and review of the literature. Eur Rev Med Pharmacol Sci 2021; 25:5063-5069. [PMID: 34355379 DOI: 10.26355/eurrev_202108_26464] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Vaccine-induced immune thrombocytopenia (VITT) is a new syndrome occurring primarily in healthy young adults, with a female predominance, after receiving the first dose of ChAdOx1 nCoV-19 vaccine. We describe VITT syndrome characterized by severe thrombosis and thrombocytopenia found in our patient, with fatal outcome. CASE REPORT A 58-year-old man, after 13 days from the first administration of ChAdOx1 nCoV-19 vaccine (AstraZeneca), presented with abdominal pain, diarrhea and vomitus. Laboratory tests revealed a severe thrombocytopenia, low fibrinogen serum levels and marked increase of D-dimer serum levels. The patient quickly developed a multiple organ failure, till death, three days after the hospital admission. RESULTS At histology, in the lungs, interalveolar septa appeared thickened with microthrombi in the capillaries and veins. Interalveolar septa appeared thickened and showed vascular proliferation. Thrombi were detected in the capillaries of glomerular tufts. In the hearth, thrombi were observed in veins and capillaries. In the liver, voluminous fibrin thrombi were diffusely observed in the branches of the portal vein. Microthrombi were also found in the vasa vasorum of the wall of abdominal aorta. In the brain, microthrombi were observed in the capillaries of the choroid plexuses. Diffuse hemorrhagic necrosis was observed in the intestinal wall with marked congestion of the venous vessels. CONCLUSIONS In our patient, the majority of data necessary for a VITT final diagnosis were present: thrombocytopenia and thrombosis in pulmonary, portal, hepatic, renal and mesenteric veins, associated with a marked increase of D-dimer serum levels. The finding of cerebral thrombosis in choroid plexuses, is a new finding in VITT. These features are suggestive for a very aggressive form of VITT.
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Affiliation(s)
- D Fanni
- Division of Pathology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
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24
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Grandone E, Tiscia GL, Mastroianno M, Larciprete G, Kovac M, Tamborini Permunian E, Lojacono A, Barcellona D, Bitsadze V, Khizroeva J, Makatsarya A, Cacciola R, Martinelli I, Bucherini E, De Stefano V, Lodigiani C, Colaizzo D, De Laurenzo A, Piazza G, Margaglione M. Findings from a multicentre, observational study on reproductive outcomes in women with unexplained recurrent pregnancy loss: the OTTILIA registry. Hum Reprod 2021; 36:2083-2090. [PMID: 34195794 DOI: 10.1093/humrep/deab153] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/16/2021] [Indexed: 12/20/2022] Open
Abstract
STUDY QUESTION What evaluation and care is offered to women after unexplained recurrent pregnancy loss (RPL) or intra-uterine foetal death (IUFD) and what are the reproductive outcomes? SUMMARY ANSWER Women are assessed for thrombophilia and often treated with low-molecular weight heparin (LMWH) and/or low-dose aspirin (ASA). WHAT IS KNOWN ALREADY Randomized controlled trials (RCTs) on possible efficacy of heparins and/or aspirin have been inconclusive due to limited power to detect a difference and patient heterogeneity. STUDY DESIGN, SIZE, DURATION Prospective multicentre cohort study performed in 12 hospitals in three countries between 2012 and 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS All consecutive pregnant women with recurrent PL (≥3 losses or 2 losses in the presence of at least one euploid foetal karyotype) or at least one IUFD. Eligible women may have undergone thrombophilia testing before conception, at the discretion of local providers. The possible assignment of women to treatments (such as LMWH) was not decided a priori but was determined based on the responsible provider's current practice. Aims of the study were: (i) to evaluate factors associated with pregnancy outcome; (ii) to compare clinical management strategies in women with and without a subsequent successful pregnancy; and (iii) to evaluate characteristics of women who may benefit from antithrombotic therapy. A propensity score matching method was used to balance the differences in baseline characteristics. MAIN RESULTS AND THE ROLE OF CHANCE A matched sample of 265 pregnant women was analysed, with all undergoing thrombophilia screening; 103 out of 119 (86.6%) with and 98/146 (67.1%) without thrombophilia were prescribed with LMWH and/or ASA. Overall, live-births were recorded in 204 cases (77%), PL or IUFD in 61 (23%) pregnancies. Logistic regression showed a significant interaction between thrombophilia and treatment with LMWH (P = 0.03). Findings from sensitivity analysis showed odds ratio (OR) for pregnancy loss in women with inherited or acquired thrombophilia in absence of any treatment was 2.9 (95% CI, 1.4-6.1); the administration of LMWH (with or without ASA) was associated with higher odds of live-birth (OR, 10.6; 95% CI, 5.0-22.3). Furthermore, in women without thrombophilia, the odds of live-birth was significantly and independently associated with LMWH prophylaxis (alone or in association with ASA) (OR, 3.6; 95% CI, 1.7-7.9). LIMITATIONS, REASONS FOR CAUTION While the propensity score matching allows us to balance the differences in baseline characteristics, it does not eliminate all confounding. WIDER IMPLICATIONS OF THE FINDINGS Antithrombotic prophylaxis during pregnancy may be effective in women with otherwise unexplained PL or IUFD, and even more useful in those with thrombophilia. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by Italian Ministry of Health (Ricerca Corrente 2018-2020). Dr G.P. has received research grant support from Bristol Myers Squibb/Pfizer Alliance, Janssen, Boston Scientific Corporation, Bayer, and Portola and consultant fees from Amgen and Agile Therapeutics. Dr E.G. has received consultant fees from Italfarmaco and Sanofi. All other authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER NCT02385461.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy.,Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Giovanni L Tiscia
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Mario Mastroianno
- Scientific Direction, Fondazione 'Casa Sollievo della Sofferenza', S. Giovanni Rotondo (Foggia), Italy
| | - Giovanni Larciprete
- Department of Obstetrics and Gynecology, Fatebenefratelli Isola Tiberina Hospital, Rome, Italy
| | - Mirjana Kovac
- Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | | | - Andrea Lojacono
- Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Doris Barcellona
- Dipartimento di Scienze Mediche Internistiche, University of Cagliari, Cagliari, Italy
| | - Victoria Bitsadze
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Jamilya Khizroeva
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Alexander Makatsarya
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Rossella Cacciola
- Haemostasis Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ida Martinelli
- Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Eugenio Bucherini
- Unit of Vascular Medicine and Angiology, Civic Hospital of Faenza, Faenza, Italy
| | | | - Corrado Lodigiani
- Thrombosis and Hemorrhagic Center, Humanitas Research Hospital and Humanitas University, Rozzano, Italy
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Antonio De Laurenzo
- Thrombosis and Haemostasis Unit, I.R.C.C.S. 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Foggia, Italy
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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25
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Barcellona D, Fenu L, Marongiu F. Clinical history and gastrointestinal bleeding in patients taking oral anticoagulants. Int J Cardiol 2021; 339:134-137. [PMID: 34280423 DOI: 10.1016/j.ijcard.2021.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/19/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Common risk factors for gastrointestinal bleeding (GIB) are advanced age and the use of antiplatelet or anticoagulants drugs for the prevention of cardiovascular diseases. METHODS In this prospective real-world observational study, oral anticoagulated patients were recruited and followed between June 2013 and December 2019. The primary end-point was to evaluate a possible relationship between bleeding events and patients' clinical history of gastrointestinal disease prior to the start of the therapy. The secondary end-points were time of GIB appearance and the percentage of idiopathic or provoked events, i.e., bleeding due to a gastrointestinal disease. In case of GIB event all the patients were studied by means of endoscopic procedures. Cox regression was used to calculate the relative hazard ratios (HRs) of GIB for each considered clinical variable. RESULTS 734 patients on both VKAs or DOACs were studied. Overall, 46 hemorrhagic events were recorded: 6 were major bleeding (0.42/100 patient-years) while 43 were clinically relevant non major bleeding (2.8/100 patient-years). The Cox regression analysis did not show any relationships among GIB and the variables considered. CONCLUSION The patients' clinical history is neither a predictor for GIB bleeding nor a guide to the choice of the oral anticoagulant to be administered. Routinely applying bleeding risk screening, such as occult blood in the stool, should be added to the periodic laboratory checks for early recognition of patients at higher risk of GIB.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
| | - L Fenu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - F Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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26
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Marongiu F, Grandone E, Scano A, Orrù G, Marongiu S, Gerosa C, Fanni D, Faa G, Barcellona D. Infectious agents including COVID-19 and the involvement of blood coagulation and fibrinolysis. A narrative review. Eur Rev Med Pharmacol Sci 2021; 25:3886-3897. [PMID: 34109597 DOI: 10.26355/eurrev_202105_25956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Platelets, blood coagulation along with fibrinolysis are greatly involved in the pathophysiology of infectious diseases induced by bacteria, parasites and virus. This phenomenon is not surprising since both the innate immunity and the hemostatic systems are two ancestral mechanisms which closely cooperate favoring host's defense against foreign invaders. However, the excessive response of these systems may be dangerous for the host itself. MATERIALS AND METHODS We searched and retrieved the articles, using the following electronic database: MedLine and Embase. We limited our search to articles published in English, but no restrictions in terms of article type, publication year, and geography were adopted. RESULTS The hemostatic phenotype of the infectious diseases is variable depending on the points of attack of the different involved pathogens. Infectious diseases which show a prothrombotic phenotype are bacterial sepsis, SARS-CoV-2 and malaria. However, among the bacterial sepsis, Yersinia Pestis is characterized by a profibrinolytic behavior. On the contrary, the hemorrhagic fevers, due to Dengue and Ebola virus, mainly exploit the activation of fibrinolysis secondary to a huge endothelial damage which can release a large amount of t-PA in the early phase of the diseases. CONCLUSIONS Blood coagulation and fibrinolysis are greatly activated based on the strategy of the different infectious agents which exploit the excess of response of both systems to achieve the greatest possible virulence.
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Affiliation(s)
- F Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
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27
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Marongiu F, Ntoukas DM, Barberini L, Ruberto MF, Piras MS, Conti M, Di Martino ML, Mura M, Marongiu S, Vannini ML, Lillu M, Piras M, Fanni D, Fenu L, Porcu C, Barcellona D, Faa G, Congiu T. Clot characterization by multidisciplinary approach: biochemical and imaging parameters in a hypocoagulative setting. A pilot study. J Public Health Res 2021; 10. [PMID: 34036778 PMCID: PMC9136229 DOI: 10.4081/jphr.2021.2358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Clot characterization is, to the present days, a multimodal approach:
scanning the clot by electron microscopy (SEM) is helpful for the
visualization of fibrin structure along with laboratory parameters such as
the clot waveform analysis (CWA) and thrombin generation in different
settings of clot abnormalities. This study aimed to assess whether the
coagulative parameters were consistent with the clot images texture acquired
by SEM, and therefore to propose a more generalist and integrative approach
to clots classification. Design and methods In this pilot study, the examined population consists of eight healthy
subjects, seven patients affected by Acquired Hemophilia A (AHA) and seven
patients treated with Vitamin K Antagonists (VKAs), similar for age and
gender. We studied the velocity and acceleration (1st and
2nd derivative of the aPTT) of clot formation (CWA), the
thrombin generation, and the clots’ scanning by SEM. Images acquired with
SEM were then analyzed with the MATLAB software with the “Texture Analysis”
methods to perform classification. Among the various texture parameters, we
reported Contrast and Energy. Results Significant differences among healthy subjects, patients with AHA and those
treated with VKAs were detected for the coagulative parameters. We found no
differences between VKAs and AHA patients. Contrast and energy highlighted a
significant difference among the three groups in agreement with the
laboratory's parameters. We found no significant differences between VKAs
and AHA patients. Conclusions The use of SEM, CWA and thrombin generation parameters may be a starting
point for studies aimed to demonstrate the general characteristics of clot
formation in different clinical conditions with a multiparametric
approach.
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Affiliation(s)
- Francesco Marongiu
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Dimitrios Marco Ntoukas
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Luigi Barberini
- Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Filomena Ruberto
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Sebastiana Piras
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Maria Conti
- Liver Unit, Department of Internal Medicine, University Hospital of Cagliari.
| | - Maria Luisa Di Martino
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Mario Mura
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Silvia Marongiu
- Internal Medicine Unit, SS Trinità Hospital, Azienda Tutela della Salute, Cagliari.
| | - Maria Luigia Vannini
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Mattia Lillu
- Internal Medicine Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Monica Piras
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Daniela Fanni
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Lara Fenu
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | | | - Doris Barcellona
- Hemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari.
| | - Gavino Faa
- SHRO Temple University, Philadelphia, PA.
| | - Terenzio Congiu
- Anatomic-Pathology Unit, Department of Medical Sciences and Public Health, University of Cagliari.
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28
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Barcellona D, Fanni D, Gerosa C, Congiu T, Orrù G, Faa G, Marongiu F. Heparins and 2019-nCoV infection: a narrative review. Eur Rev Med Pharmacol Sci 2021; 25:3594-3606. [PMID: 34002834 DOI: 10.26355/eurrev_202105_25842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Patients with 2019-nCoV infection have a high risk to develop venous thrombotic events. Several guidelines recommend the use of either unfractionated heparin or low molecular weight heparins in preventing thrombotic events in these patients. However, results from clinical studies, so far published, reached controversial conclusions on heparin efficacy in this kind of patients since the incidence of venous thromboembolism remains high despite prophylaxis. This narrative review aims to provide an overview of the antiviral and anti-inflammatory properties of heparins and their efficacy and safety in SARS-CoV-2 medical ward-patients. Moreover, anatomical findings and ongoing trials are also reported. Finally, this narrative review tries to explain why heparins fail to prevent venous thrombosis. MATERIALS AND METHODS We searched for the most relevant published studies on heparins and 2019-nCoV infected patients using the MEDLINE electronic database in the period between January and December 2020. Articles were preliminarily defined as eligible if they: a) were in English language, b) enrolled 250 or more medical ward-patients and 100 or more ICU-patients, c) reported results on patients treated with heparins in a percentage of at least 70% and d) performed an objectively confirmed diagnosis of VTE. RESULTS Data from medium to large scientific studies show that the incidence of venous thrombotic events in medical ward-patients with SARS-CoV-2 vary between 0% and 8.3%, while this rate is higher, from 6.2% to 49%, in Intensive Care Unit-patients. However, heparins reduce the mortality rate in these patients of about 50%. Histological findings show that thrombosis could affect capillaries, main and small-mid-sized vessels, and it is associated with diffuse alveolar damage. CONCLUSIONS Heparins have anti-inflammatory and anti-viral properties, which may be of help in reducing mortality in SARS-CoV-2 patients. Failure of heparins at prophylactic dosages in preventing VTE, especially in ICU-patients, could be due to the severity of the disease. Data on the use of heparins in an early phase of the 2019-nCoV infection are still lacking.
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Affiliation(s)
- D Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
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29
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Pengo V, Hoxha A, Andreoli L, Tincani A, Silvestri E, Prisco D, Fierro T, Gresele P, Cafolla A, De Micheli V, Ghirarduzzi A, Tosetto A, Falanga A, Martinelli I, Testa S, Barcellona D, Gerosa M, Denas G. Trial of Rivaroxaban in AntiPhospholipid Syndrome (TRAPS): Two-year outcomes after the study closure. J Thromb Haemost 2021; 19:531-535. [PMID: 33128325 DOI: 10.1111/jth.15158] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Trial of Rivaroxaban in AntiPhospholipid Syndrome was a prospective randomized, open-label, noninferiority study conducted in 14 centers in Italy. Rivaroxaban was compared with warfarin for the prevention of thromboembolic events, major bleeding, and vascular death in high-risk, triple-positive patients with antiphospholipid syndrome. OBJECTIVE The aim of this paper is to report the events during the 2-year follow-up after the study closure. METHODS On January 28, 2018, the trial was prematurely stopped by adjudication and safety committee for an excess of events in the rivaroxaban group. Randomized patients were advised on trial results and those randomized to rivaroxaban were solicited to switch to warfarin. All 14 participating centers were asked and accepted to follow their patients for clinical events. This report describes the rate of events that occurred between January 28, 2018, and January 28, 2020. RESULTS Of 120 randomized patients, 115 were available for follow-up. Outcome events were two in six (33.3%) patients who remained on direct oral anticoagulants (DOACs) and six in 109 (5.7%) patients on warfarin (hazard ratio [HR] 6.9; 95% confidence interval [CI] 1.4-34.5, P = .018). The two patients on DOACs (one taking dabigatran and one taking rivaroxaban) suffered from thromboembolic events, whereas of the six patients with composite outcomes on warfarin, three had thromboembolic events (HR for thrombosis 13.3; 95% CI 2.2-79.9, P = .005). CONCLUSION These data further support the use of warfarin in high-risk patients with antiphospholipid syndrome.
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Affiliation(s)
- Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Ariela Hoxha
- Internal Medicine, San Bortolo Hospital, Vicenza, Italy
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology ASST-Spedali Civili di Brescia, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology ASST-Spedali Civili di Brescia, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tiziana Fierro
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Arturo Cafolla
- Department of Translational and Precision Medicine and Hematology, Sapienza University of Rome, Rome, Italy
| | | | - Angelo Ghirarduzzi
- Angiology Unit, Department of Internal Medicine, Santa Maria Nuova Hospital, Reggio Emilia, Italy
| | | | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine and Hemostasis and Thrombosis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, Azienda Socio-Sanitaria Territoriale, Cremona, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Maria Gerosa
- Clincal Rheumatology Unit, Research Center for Adult and Pediatric Diseases, Department of Clinical Sciences and Community Health, ASST Pini-CTO, University of Milan, Milan, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardiac Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova, Italy
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30
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Saba L, Gerosa C, Fanni D, Marongiu F, La Nasa G, Caocci G, Barcellona D, Balestrieri A, Coghe F, Orru G, Coni P, Piras M, Ledda F, Suri JS, Ronchi A, D'Andrea F, Cau R, Castagnola M, Faa G. Molecular pathways triggered by COVID-19 in different organs: ACE2 receptor-expressing cells under attack? A review. Eur Rev Med Pharmacol Sci 2021; 24:12609-12622. [PMID: 33336781 DOI: 10.26355/eurrev_202012_24058] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE In human pathology, SARS-CoV-2 utilizes multiple molecular pathways to determine structural and biochemical changes within the different organs and cell types. The clinical picture of patients with COVID-19 is characterized by a very large spectrum. The reason for this variability has not been clarified yet, causing the inability to make a prognosis on the evolution of the disease. MATERIALS AND METHODS PubMed search was performed focusing on the role of ACE 2 receptors in allowing the viral entry into cells, the role of ACE 2 downregulation in triggering the tissue pathology or in accelerating previous disease states, the role of increased levels of Angiotensin II in determining endothelial dysfunction and the enhanced vascular permeability, the role of the dysregulation of the renin angiotensin system in COVID-19 and the role of cytokine storm. RESULTS The pathological changes induced by SARS-CoV-2 infection in the different organs, the correlations between the single cell types targeted by the virus in the different human organs and the clinical consequences, COVID-19 chronic pathologies in liver fibrosis, cardiac fibrosis and atrial arrhythmias, glomerulosclerosis and pulmonary fibrosis, due to the systemic fibroblast activation induced by angiotensin II are discussed. CONCLUSIONS The main pathways involved showed different pathological changes in multiple tissues and the different clinical presentations. Even if ACE2 is the main receptor of SARS-CoV-2 and the main entry point into cells for the virus, ACE2 expression does not always explain the observed marked inter-individual variability in clinical presentation and outcome, evidencing the complexity of this disorder. The proper interpretation of the growing data available might allow to better classifying COVID-19 in human pathology.
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Affiliation(s)
- L Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (AOU), di Cagliari - Polo di Monserrato, Cagliari, Italy.
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Abstract
Vitamin K-Antagonists (VKAs) are the treatment of choice in patients with indications other than atrial fibrillation and venous thromboembolism. Moreover, some patients still assume VKAs refusing to change their therapy when direct oral anticoagulants (DOACs) are properly indicated. The COVID-19 pandemic has completely changed our lives, nullifying inter-personal relationships to avoid contagion, making difficult the VKAs monitoring. We describe the re-organization of our thrombosis centre (TC) as an example on how to face the emergency due to the COVID-19 pandemic. In the first phase, to avoid overcrowding at the TC, we planned to increase the interval time between INRs checks and to encourage blood sampling at home, especially for elderly patients. Moreover, precise scheduled blood sampling was also organized while telephone and email counselling were guaranteed by two doctors of the TC. In the second phase, to reduce the number of patients who daily attended our TC a switch from VKAs to DOACs was carried out, if no contraindications were identified. In the third phase, to protect patients, healthcare staff and hospital from COVID-19 widespread, telemedicine was strengthened. We tried to extend self-testing at home by means of portable coagulometers to as more patients as possible. To avoid patients staying or coming back to the TC an ad hoc web platform for sending the therapeutic dose adjustment and the next scheduled appointment was developed. The TC re-organization allowed us to monitor anticoagulated patients respecting personal isolation and security measures to avoid possible COVID-19 contagion.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
- SHRO, Temple University, Philadelphia, PA, USA.
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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32
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,SHRO, Temple University, Philadelphia, Pennsylvania, United States
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Poli D, Antonucci E, Vignini E, Martinese L, Testa S, Simioni P, Pengo V, Pignatelli P, Falanga A, Masciocco L, Barcellona D, Ciampa A, Chiarugi P, Paparo C, Ageno W, Palareti G. Anticoagulation resumption after intracranial hemorrhage in patients treated with VKA and DOACs. Eur J Intern Med 2020; 80:73-77. [PMID: 32522446 DOI: 10.1016/j.ejim.2020.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is associated with severe prognosis and recurrent risk. This impacts on the decision to resume anticoagulation in atrial fibrillation (AF) or venous thromboembolism (VTE) patients. Purpose of our study is to evaluate the incidence rate of recurrent ICH in patients with AF or VTE resuming anticoagulation after a first ICH episode. METHODS We report data of two cohorts of AF or VTE after a first ICH. The Vitamin K antagonist (VKA) cohort (166 patients) derives from CHIRONE Study, the direct oral anticoagulant (DOAC) cohort (178 patients) derives from START2-Register RESULTS: The clinical characteristics of the two cohort are similar with the exception of more prevalence of history of previous stroke/TIA in DOAC patients with respect to VKA (p = 0.02) and serum creatinine levels>1.5 mg/dL in VKA patients with respect to DOAC(p = 0.0001). The index ICH was spontaneous in 66.4% and in 33.7% among DOAC and VKAs cohort respectively (p = 0.0001). During follow-up, 14 recurrent ICH were recorded; 9 (rate 2.5 × 100 patient-years) in VKA and 5 (rate 1.3 × 100 patient-years) in DOAC (Relative Risk 1.9; 95% CI 0.6-7.4; p = 0.2). The univariate logistic regression analysis showed that patients with recurrent ICH were more frequently males, hypertensive, with a history of previous Stroke/TIA and older than patients without recurrence. VKA patients showed a higher risk of recurrence with respect to DOAC patients (OR 1.9;95% CI 0.7-6.7). CONCLUSIONS A trend toward fewer ICH recurrences was detected among DOACs patients in comparison to the previously reported rate of patients on warfarin.
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Affiliation(s)
- Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy.
| | | | - Elisa Vignini
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Lucia Martinese
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Sophie Testa
- UO Laboratorio Analisi, Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Paolo Simioni
- UOSD Malattie Trombotiche ed Emorragiche, UOC Medicina Generale, AOU Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Università degli Studi di Padova, Padova, Italy
| | - Pasquale Pignatelli
- Centro Trombosi, Clinica Medica Policlinico Umberto I°, Università la Sapienza Roma, Italy
| | - Anna Falanga
- University Milan Bicocca, Dept. Medicine and Surgery, Monza and UOC SIMT, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lucilla Masciocco
- UOC Medicina Interna, Centro Controllo Coagulazione, Presidio Ospedaliero Lastaria, Lucera (Foggia), Italy
| | - Doris Barcellona
- Struttura Dipartimentale di Emostasi e Trombosi, AOU di Cagliari, Dipartimento di Scienze Mediche e Sanita' Pubblica, Universita' di Cagliari, Cagliari, Italy
| | | | - Paolo Chiarugi
- U.O. Analisi Chimico-Cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carmelo Paparo
- Patologia Clinica, Ospedale Maggiore Chieri (Torino), Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
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Poli D, Tosetto A, Palareti G, Barcellona D, Ciampa A, Grandone E, Manotti C, Moia M, Squizzato A, Toschi V, Testa S. Managing anticoagulation in the COVID-19 era between lockdown and reopening phases. Intern Emerg Med 2020; 15:783-786. [PMID: 32514682 PMCID: PMC7278243 DOI: 10.1007/s11739-020-02391-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/29/2020] [Indexed: 01/20/2023]
Abstract
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. The recent spreadout of the COVID-19 pandemic requires a re-organization of Anticoagulation Clinics to prevent person-to-person viral diffusion and continue to offer the highest possible quality of assistance to patients. In this paper, based on the Italian Federation of Anticoagulation Clinics statements, we offer some advice aimed at improving patient care during COVID-19 pandemic, with particular regard to the lockdown and reopening periods. We give practical guidance regarding the following points: (1) re-thinking the AC organization, (2) managing patients on anticoagulants when they become infected by the virus, (3) managing anticoagulation surveillance in non-infected patients during the lockdown period, and (4) organizing the activities during the reopening phases.
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Affiliation(s)
- Daniela Poli
- Dipartimento Cardiotoracovascolare, Centro Trombosi, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Alberto Tosetto
- UOS Centro Malattie Emorragiche e Trombotiche - Divisione di Ematologia, Ospedale S. Bortolo, Vicenza, Italy
| | | | - Doris Barcellona
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Cagliari, Italy
| | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Cesare Manotti
- Centro Emostasi, Medicina Interna ad indirizzo angiologico e coagulativo, Dipartimento di Medicina Interna e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Vincenzo Toschi
- Department of Hematology and Blood Transfusion, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, Ospedale di Cremona, Cremona, Italy
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Poli D, Tosetto A, Palareti G, Barcellona D, Ciampa A, Grandone E, Manotti C, Moia M, Squizzato A, Toschi V, Testa S. Managing anticoagulation in the COVID-19 era between lockdown and reopening phases. Intern Emerg Med 2020. [PMID: 32514682 DOI: 10.1007/s11739-020-02391-34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. The recent spreadout of the COVID-19 pandemic requires a re-organization of Anticoagulation Clinics to prevent person-to-person viral diffusion and continue to offer the highest possible quality of assistance to patients. In this paper, based on the Italian Federation of Anticoagulation Clinics statements, we offer some advice aimed at improving patient care during COVID-19 pandemic, with particular regard to the lockdown and reopening periods. We give practical guidance regarding the following points: (1) re-thinking the AC organization, (2) managing patients on anticoagulants when they become infected by the virus, (3) managing anticoagulation surveillance in non-infected patients during the lockdown period, and (4) organizing the activities during the reopening phases.
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Affiliation(s)
- Daniela Poli
- Dipartimento Cardiotoracovascolare, Centro Trombosi, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Alberto Tosetto
- UOS Centro Malattie Emorragiche e Trombotiche - Divisione di Ematologia, Ospedale S. Bortolo, Vicenza, Italy
| | | | - Doris Barcellona
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, Cagliari, Italy
| | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Cesare Manotti
- Centro Emostasi, Medicina Interna ad indirizzo angiologico e coagulativo, Dipartimento di Medicina Interna e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Centre on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Vincenzo Toschi
- Department of Hematology and Blood Transfusion, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, Ospedale di Cremona, Cremona, Italy
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Grandone E, Aucella F, Barcellona D, Brunori G, Forneris G, Gresele P, Marietta M, Poli D, Testa S, Tripodi A, Genovesi S. Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell'Emostasi e della Trombosi (SISET). J Nephrol 2020; 34:31-38. [PMID: 32757171 PMCID: PMC7881955 DOI: 10.1007/s40620-020-00768-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism and an increased use of DOAC in daily practice is recorded also in elderly patients. Aging is associated with a reduction of glomerular filtration rate and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. There is uncertainty on the safety profile of DOAC in patients with CKD, particularly in those with severely impaired renal function or end stage renal disease, due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy.,Ob/Gyn Department of the First I.M. Sechenov, Moscow State Medical University, Moscow, Russia
| | - Filippo Aucella
- Nephrology and Dialysis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,SHRO Temple University, Philadelphia, USA
| | | | - Giacomo Forneris
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marco Marietta
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Poli
- Center for Atherothrombotic Diseases, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Simonetta Genovesi
- University of Milan-Bicocca, Milano, Italy. .,Nephrology Unit, San Gerardo Hospital, Monza, Italy.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Elvira Grandone
- Atherosclerosis and Thrombosis Unit, IRCCS Ospedale Casa Sollievo della Sofferenza, Foggia, Italy
- Department of Obstetrics and Gynecology, First Moscow State Medical University, Moscow, Russia
| | - Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Costaggiu D, Pinna E, Serchisu L, Barcellona D, Piano P, Ortu F, Marongiu F, Mandas A. The Repeatable Battery for the Assessment of Neuropsychological Status as a screening strategy for HIV-Associated Neurocognitive Disorders. AIDS Care 2020; 33:357-363. [PMID: 32183560 DOI: 10.1080/09540121.2020.1742859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV-infected people are at risk for neurocognitive impairment (HIV-Associated Neurocognitive Disorders - HAND). To evaluate whether the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), a widely used neurocognitive screening tool, could be a valid instrument for HAND identification, we evaluated 166 HIV-infected subjects. Our results showed that 96 (57.8%) HIV-infected scored RBANS Total Index Score <85 (at least one SD below the normal), 12 (7.2%) of them scored RBANS Total Index Score <70 (at least 2 SD below the normal, indicating a possible HIV-Associated Dementia). The more compromised areas were Immediate and Delayed Memory, and Attention. In the group with RBANS Total Index Score <85, there were significantly lower scores of Mini Mental State Examination (P = 0.0008), Clock Drawing Test (P = 0.0015) and higher score of Geriatric Depression Scale (P = 0.02) compared to the RBANS Total Index Score ≥85 group. Using a stepwise logistic regression, considering RBANS Total Index Score as dependent variable, we found a positive interaction with tenofovir/emtricitabine assumption (P = 0.027), Clock Drawing Test (P = 0.0125) and educational level (P = 0.0054). Being the viro-immunological markers not capable of predicting cognitive decline in HIV-infected individuals, our data suggest that RBANS may be a valid tool for the early identification of HIV-related cognitive impairment.
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Affiliation(s)
- Diego Costaggiu
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Elisa Pinna
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Luca Serchisu
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Paola Piano
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Ortu
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Marongiu
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonella Mandas
- Department of Internal Medicine and Public Health, University of Cagliari, Cagliari, Italy
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Mameli A, Schirru P, Porru M, Marongiu F, Barcellona D. Underuse of anticoagulant therapy in hospitalized older patients: comment on the article of Wojszel et al. J Thromb Thrombolysis 2020; 49:136-137. [DOI: 10.1007/s11239-019-01960-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Marongiu F, Mameli A, Grandone E, Barcellona D. Pulmonary Thrombosis: A Clinical Pathological Entity Distinct from Pulmonary Embolism? Semin Thromb Hemost 2019; 45:778-783. [PMID: 31537029 DOI: 10.1055/s-0039-1696942] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Since Virchow's autopsy studies in the mid-1800s, it has generally been believed that pulmonary embolism (PE) originated from the embolization of fibrin fragments from a deep venous thrombosis (DVT). However, a DVT is often not found in patients with PE (up to 50% of cases). Could fibrin form in the pulmonary vessels without coming from the periphery? In this review, the authors will try to support the hypothesis that a pulmonary thrombosis (PT) may develop. They will do so through different clinical models related to some pathological conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), and asthma, all of which show a close relationship between local inflammation and activation of blood coagulation, two defensive systems that may lead to fibrin deposition in the lungs, thus recognizing the possibility that PT may be a newly recognized entity. An increased risk for PE has been demonstrated in these conditions. Sickle cell disease and assisted reproductive technologies are other very different conditions in which an increased risk for PE has been found. Gaucher's disease is a rare hereditary condition in which the hemostatic system could have a role in the pathogenesis of pulmonary hypertension, which complicates the course of the disease. In particular, the increased risk for PT, common to all these conditions, deserves attention when a patient presents with sudden dyspnea, an unexpected COPD exacerbation, or severe sudden asthmatic dyspnea. As a consequence, prediction scores for venous thromboembolism could be revised.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonella Mameli
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Elvira Grandone
- Atherosclerosis and Thrombosis Unit, IRCCS Ospedale Casa Sollievo della Sofferenza, Foggia, Italy.,Department of Obstetrics and Gynecology, First Moscow State Medical University, Moscow, Russia
| | - Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Barcellona D, Favuzzi G, Vannini ML, Piras SM, Ruberto MF, Grandone E, Marongiu F. A Sardinian Family with Factor XI Deficiency. Hamostaseologie 2019; 39:398-403. [PMID: 31364091 DOI: 10.1055/s-0039-1691752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Factor XI (FXI) deficiency is a bleeding disorder which causes a bleeding tendency after trauma or surgery. An inhibitor may be acquired secondary to replacement therapy. AIM To study on genetical and functional grounds a family admitted to our Haemostasis and Thrombosis Centre for an incidental finding of a prolonged activated partial thromboplastin time (aPTT) in three members. METHODS aPTT mixing test, dosage of FXI activity and antigen, FXI inhibitor titration, DNA analysis and clot waveform analysis (CWA) were performed. RESULTS Patients II.1, II.3 and II.4 showed a severe FXI deficiency (0.7, 0.7 and 1.8%, respectively) and low antigen level. Since the proposita was already treated with plasma, the dosage of the inhibitor was determined to be 6.4 Bethesda units. They were homozygous for the p.Glu117Stop mutation. The other family members were heterozygous. The velocity and the maximum acceleration of the clot formation were lower than those of the other family members and the normal subjects but higher than those of patients with acquired haemophilia A. CONCLUSION A mixing test of a prolonged aPTT should be performed because it will be present both in patients with or without the inhibitor. A molecular analysis in severe FXI deficiency is warranted as it may have prognostic significance. CWA may be helpful for better understanding the pathophysiology of this kind of defect.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Giovanni Favuzzi
- Atherosclerosis and Thrombosis Unit, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Maria Luigia Vannini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Sebastiana Maria Piras
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Elvira Grandone
- Atherosclerosis and Thrombosis Unit, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moskva, Russia
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Loddo A, Cornacchia S, Cane FL, Barcellona D, Marongiu F, Melis GB, Angioni S, Paoletti AM, Neri M. Prophylaxis of peripartum haemorrhage using recombinant factor VIIa (rfVIIa) in pregnant women with congenital factor VII deficiency: A case report and literature review. Eur J Obstet Gynecol Reprod Biol 2019; 235:77-80. [PMID: 30831446 DOI: 10.1016/j.ejogrb.2019.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022]
Abstract
Congenital factor VII deficiency is a rare autosomal recessive disorder associated to different haemorrhagic manifestations. Labour and delivery may cause bleeding risk in patients with this coagulation deficit, thus it is appropriate to clarify whether prophylaxis of peripartum haemorrhage is necessary. To date, there are very few cases in scientific literature which report the management of women with congenital factor VII deficiency during labour, and a consensus for prophylaxis does not exist. In this manuscript we present the management of a 35 years old woman with factor VII deficiency, treated with recombinant factor VIIa before delivery, without haemorrhagic complications either for the woman and for the infant. Therefore, we present a review of similar cases managed with a peripartum prophylaxis with recombinant factor VIIa, and discuss its usefulness and effectiveness, in view of the severity of the deficit and the doses used.
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Affiliation(s)
- Alessandro Loddo
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy.
| | - Stefania Cornacchia
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Fiorenza Lo Cane
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Doris Barcellona
- Internal Medicine and Haemocoagulopathies Unit, University of Cagliari, Italy
| | - Francesco Marongiu
- Internal Medicine and Haemocoagulopathies Unit, University of Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Stefano Angioni
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Anna Maria Paoletti
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Manuela Neri
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
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Ostuni A, Tiscia G, Marongiu F, Barcellona D, Grandone E. Management of Patients Taking Oral Anticoagulants Who Need Urgent Surgery for Hip Fracture. Semin Thromb Hemost 2019; 45:164-170. [DOI: 10.1055/s-0039-1678718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AbstractThe number of hip fractures in anticoagulated patients is predicted to increase, due to people living longer. However, evidence regarding urgent perioperative management of elderly patients with hip fracture who take oral anticoagulants (vitamin K antagonists or direct oral anticoagulants) is scarce. In this article, the authors present a narrative review of the evidence to date supporting the urgent management of hip fracture in anticoagulated elderly patients. They discuss the complexity of managing the high risk of procedure-related bleeding and, at the same time, the high risk of thromboembolism. The role of a bridging procedure and the best strategy of anticoagulation reversal are also reviewed. Further studies are required to improve the evidence in urgent surgery, especially in frail elderly patients.
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Affiliation(s)
- Angelo Ostuni
- UOC Medicina Trasfusionale, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Giovanni Tiscia
- Fondazione, “Casa Sollievo della Sofferenza,” S. Giovanni Rotondo, Foggia, Italy
| | - Francesco Marongiu
- Dipartimento di Scienze Mediche Internistiche, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Dipartimento di Scienze Mediche Internistiche, University of Cagliari, Cagliari, Italy
| | - Elvira Grandone
- Fondazione, “Casa Sollievo della Sofferenza,” S. Giovanni Rotondo, Foggia, Italy
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
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Ruberto MF, Marongiu F, Mandas A, Mameli A, Porru M, Cianchetti E, Barcellona D. The venous thromboembolic risk and the clot wave analysis: a useful relationship? Clin Chem Lab Med 2018; 56:448-453. [PMID: 29031015 DOI: 10.1515/cclm-2017-0678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 09/12/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospitalized patients with acute medical conditions have higher venous thromboembolism (VTE) risk. A patient with a final Padua Prediction Score (PPS) of ≥4 is considered to be at high risk for VTE. The aim of this study was to investigate on a possible relationship between PPS, the dynamics of the clot formation, i.e. the clot waveform analysis (CWA) of aPTT, fibrinogen and D-Dimer in a large group of medical patients. METHODS CWA in terms of velocity (first derivative), acceleration (second derivative), density (Delta) of aPTT, fibrinogen, D-Dimer and PPS for VTE were determined in 801 medical patients divided in three groups (without antithrombotic prophylaxis and high PPS, without antithrombotic prophylaxis and low PPS, with antithrombotic prophylaxis and high PPS) and a group of healthy subjects. RESULTS CWA, fibrinogen and D-Dimer values were higher in the medical patients with high PPS with or without antithrombotic prophylaxis when compared with patients without antithrombotic prophylaxis with low PPS and healthy subjects. The second derivative, fibrinogen and D-Dimer were significantly associated with a high PPS score (≥4): odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.03-2.28; OR = 1.91, 95% CI = 1.3-2.79; OR = 3.16, 95% CI = 2.29-4.36, respectively. Interactions between first derivative and D-Dimer (OR = 2.14, 95% CI = 1.23-3.72) and first derivative and fibrinogen (OR = 1.75, 95% CI = 1.02-2.98) were found. CONCLUSIONS CWA could give useful information to recognize a hypercoagulable state in patients admitted to a medical ward with high and low PPS. First and second derivative aPTT, D-Dimer and fibrinogen levels could be added to PPS to better assess the global thromboembolic risk of these patients.
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Affiliation(s)
- Maria Filomena Ruberto
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Marongiu
- Internal Medicine and Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy, Phone: +39070 6754188
| | - Antonella Mandas
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonella Mameli
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Mariagrazia Porru
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Elisabetta Cianchetti
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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Ruberto MF, Marongiu F, Sorbello O, Civolani A, Demelia L, Barcellona D. Are prothrombin time and clot waveform analysis useful in detecting a bleeding risk in liver cirrhosis? Int J Lab Hematol 2018; 41:118-123. [DOI: 10.1111/ijlh.12934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/25/2018] [Accepted: 09/06/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Maria F. Ruberto
- Department of Medical Science and Public Health University of Cagliari Cagliari Italy
| | - Francesco Marongiu
- Department of Medical Science and Public Health University of Cagliari Cagliari Italy
| | - Orazio Sorbello
- Teaching Hospital “Duilio Casula” Azienda Ospedaliero‐Universitaria di Cagliari Cagliari Italy
| | - Alberto Civolani
- Teaching Hospital “Duilio Casula” Azienda Ospedaliero‐Universitaria di Cagliari Cagliari Italy
| | - Luigi Demelia
- Department of Medical Science and Public Health University of Cagliari Cagliari Italy
| | - Doris Barcellona
- Department of Medical Science and Public Health University of Cagliari Cagliari Italy
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Abstract
Direct oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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Marongiu F, Barcellona D. Has time come for the use of direct oral anticoagulants in the extended prophylaxis of venous thromboembolism in acutely ill medical patients? No. Intern Emerg Med 2018; 13:1015-1018. [PMID: 29594815 DOI: 10.1007/s11739-018-1843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/21/2018] [Indexed: 11/30/2022]
Abstract
Acutely ill hospitalized medical patients are at high risk of venous thromboembolism (VTE). Although thromboprophylaxis in these patients is recommended since 2004 by the American College of Chest Physicians, it is widely underused. The doubt as to whether or not to treat patients at high VTE risk after hospital discharge came from the knowledge that this risk may persist after the hospital admission period. Two meta-analyses comparing extended- versus short-duration prophylaxis are published. The results demonstrate an unfavorable balance between VTE prevention and incidence of major bleeding in patients assigned to extended-duration thromboprophylaxis. Only in the APEX study, betrixaban, a direct inhibitor of factor Xa, shows similar efficacy and safety compared to enoxaparin. However, while it is very promising, oral anticoagulant phase III studies and post-marketing registers are lacking. Moreover, betrixaban has a long half-life, an excretion in the gut by means of P-glycoprotein, and the lack of an antidote. These characteristics and the meta-analysis results prompt us to answer no to the extended thromboprophylaxis in hospitalized medical patients, at least now.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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Poli D, Antonucci E, Pengo V, Grifoni E, Maggini N, Testa S, Lodigiani C, Insana A, Marongiu F, Barcellona D, Paparo C, Bucherini E, Pignatelli P, Palareti G. Risk of reoperation in bioprosthetic valve patients with indication for long-term anticoagulation. Results from the observational retrospective multicentre PLECTRUM study. Open Heart 2018; 5:e000837. [PMID: 30228907 PMCID: PMC6135414 DOI: 10.1136/openhrt-2018-000837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/19/2018] [Accepted: 07/24/2018] [Indexed: 01/15/2023] Open
Abstract
Objective Several factors should be considered when a prosthetic heart valve, bioprosthetic valve (BV) or mechanical valve is to be implanted: thrombogenicity, life expectancy and the risk of reoperation. Methods We conducted an observational retrospective multicentre study among Italian Thrombosis Centers on patients with BV on long-term vitamin K antagonist (VKA) treatment to evaluate the risk of reoperation and the rate of bleeding and thrombotic events. Results We analysed 612 patients (median age 71.8 years) with BV on long-term VKA treatment for the presence of atrial fibrillation (AF) (78.4%) or other indications (21.6%). Thirty-four major bleeding events (rate 1.1×100 patient-years) and 29 thromboembolic events (rate 0.9×100 patient-years) were recorded, and 46 patients (rate 1.5×100 patient-years) underwent reoperation. The rate of reoperation was higher among younger patients: 32.9% in patients <60 years and 3.9% in patients ≥60 years (relative risk (RR) 3.8, 95% CI 2.1 to 7.2; p=0.0001). When patients were analysed according to age <65 or ≥65 years and <75 or ≥70 years, younger patients still were at higher risk for reoperation (RR 3.1, 95% CI 1.7 to 6.0 and 3.7, 95% CI 1.7 to 8.6, respectively). Conclusions Our findings suggest that the threshold of 65 years for implanting a BV should be carefully evaluated, considering the high risk for reoperation and the high risk of AF occurrence with persisting need for long-term anticoagulation. The high risk for reoperation of young patients implanted with BV and the availability of a safer and easier way to conduct VKA treatment, such as the use of point-of-care devices, should be considered when the type of valve must be chosen.
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Affiliation(s)
- Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Vittorio Pengo
- Department of Cardiac Thoracic and Vascular Sciences, Thrombosis Centre, University of Padova, Padova, Italy
| | - Elisa Grifoni
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Niccolò Maggini
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Centre, Hospital of Cremona, Cremona, Italy
| | | | - Antonio Insana
- Servizio Di Patologia Clinica Ospedale S. Croce Moncalieri, Moncalieri, Italy
| | - Francesco Marongiu
- Centro Emostasi, Azienda Ospedaliero Universitaria di Monserrato, Cagliari, Italy
| | - Doris Barcellona
- Centro Emostasi, Azienda Ospedaliero Universitaria di Monserrato, Cagliari, Italy
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Abstract
PURPOSE The aim of this study was to know the patients' point of view on the monitoring of vitamin K-antagonist (VKA) therapy by means of a point of care testing (POCT), ie, using a portable coagulometer by self-testing at home. At first, patients had prothrombin time (PT) international normalized ratio (INR) monitoring at a thrombosis center; afterward, they were shifted to self-testing at home. An interview was done to evaluate the patients' point of view on the two monitoring periods. PATIENTS AND METHODS A total of 92 oral anticoagulated patients were enrolled. The questionnaire contained nine questions that elicited a maximum of five closer answers that were arranged in increasing levels of satisfaction: very little, little, enough, much and completely. Percentage of time in therapeutic range (TTR) and adverse events were compared during the two periods of conventional monitoring and self-testing. RESULTS The period of conventional monitoring was shorter than that of self-testing (p<0.0001), and the median TTR was satisfactory but lower than that of self-testing (p<0.0001). A total of 85% of the patients were satisfied with self-testing at home. In all, 83% and 73% (p=0.06) of patients felt comfortable about side effects while measuring the PT INR at both home and the thrombosis center, respectively. During the self-testing period, quality of life was improved in 87% of the patients. The cost of test strips was medium-high for 89% of the patients, and 75% of them stated that it was worth improving their quality of life. A switch from VKA to a direct oral anticoagulant (DOAC) was proposed to 24% of the patients, but 68% of them declined because they felt more comfortable monitoring their oral anticoagulant therapy by POCT. CONCLUSION VKA monitoring using POCT at home may play a role in improving the patients' quality of life and may be considered as an alternative to the use of DOAC at least in certain settings of patients.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
| | - Diego Mastino
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy,
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Ruberto MF, Marongiu F, Barcellona D. Comparison of prothrombin time INR and clot waveform analysis performed with 129-mmol/L and 105-mmol/L citrate tubes. Int J Lab Hematol 2017; 40:e15-e16. [PMID: 29214750 DOI: 10.1111/ijlh.12769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/14/2017] [Indexed: 11/30/2022]
Affiliation(s)
- M F Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - F Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - D Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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