Development Of Thrombotic Events Research Articles

Intravenous high-dose anakinra drops venous thrombosis and acute coronary syndrome in severe and critical COVID-19 patients: a propensity score matched study

In our study, we aimed to evaluate the effect of high-dose intravenous anakinra treatment on the development of thrombotic events in severe and critical COVID-19 patients. This retrospective observational study was conducted at a tertiary referral center in Aksaray, Turkey. The study population consisted of two groups as follows; the patients receiving high-dose intravenous anakinra (anakinra group) added to background therapy and the patients treated with standard of care (SoC) as a historical control group. Age, gender, mcHIS scores, and comorbidities such as diabetes mellitus, hypertension, and coronary heart disease of the patients were determined as the variables to be matched. We included 114 patients in SoC and 139 patients in the Anakinra group in the study. Development of any thromboembolic event (5% vs 12.3%, p = 0.038; OR 4.3) and PTE (2.9% vs 9.6%, p = 0.023; OR 5.1) were lower in the Anakinra group than SoC. No patient experienced cerebrovascular accident and/or clinically evident deep venous thrombosis both in two arms. After 1:1 PS matching, 88 patients in SoC and 88 patients in the Anakinra group were matched and included in the analysis. In survival analysis, the development of any thromboembolic event, pulmonary thromboembolism, and acute coronary syndrome (ACS) were higher in SoC compared to Anakinra. Survival rate was also lower in patients with SoC arm than Anakinra in patients who had any thromboembolic event as well as ACS. In our study, the development of thrombosis was associated with hyperinflammation in patients with severe and critical COVID-19. Intravenous high-dose anakinra treatment decreases both venous and arterial events in patients with severe and critical COVID-19.

Identifying Novel Coagulation Biomarkers for Thrombosis in Patients with Lymphoma

CONCLUSION Thromboembolic events are a common complication of lymphoma, influenced by a number of factors, including status of the disease, patient characteristics and treatment modalities. Recent studies demonstrated presence of hemostatic dysregulation in lymphoma patients with the possible involvement of tissue factor (TF) in the development of thrombotic events; however, more data are needed to link coagulation biomarkers' levels with clinical data and increased thrombotic risk. TF initiates blood coagulation and expressed by nonvascular cells plays a major role in hemostasis, while TF expressed by vascular cells induces intravascular thrombosis. In this study, we aimed to profile coagulation biomarkers and determine the roles of neutrophils, monocytes, platelets and endothelial cells and their interactions in thrombus formation in patients with lymphoma. Patients with newly diagnosed lymphoma were prospectively recruited and followed for all thromboembolic events from the time of diagnosis until 3 months after the last cycle of therapy. Peripheral blood samples were obtained before hematological treatment initiation from 127 patients with lymphoma. The coagulation factors profile (Fibrinogen, P-selectin, FVIII, Thrombin and TF) was measured by enzyme-linked immunosorbent assay (ELISA), while TF expression and monocyte-platelet aggregates were determined by flow cytometry. The isolation, quantification and flow cytometry profiling of extracellular vesicles (EVs) ≤1.0 µm have been done according to the protocol developed by Institute for Medical Research, Belgrade, Serbia. Thromboembolic events were diagnosed objectively based on clinical examination, radiographic studies and laboratory evaluation. The mean patients' age was 55±16 years (range, 18-86 years); 44.9% were males. Most patients (58.2%) had advanced stage disease (III/IV), and 35.4% had ECOG performance status ≥1. More than half of the patients had aggressive forms of lymphoma (64.6%), mostly diffuse large B-cell lymphoma (DLBCL). Thrombosis occurred in 14.3% of patients with lymphoma (18/127), predominantly in patients with aggressive (18.3%) vs. indolent forms (6.8%). Total number of thrombosis was 22 (4 patients had more than one thrombosis site), and venous thrombosis was the most prevalent (72.7%). ThroLy score ≥2 had 72.2% of patients with thrombosis, in contrast to 37% of patients without thrombosis. The median value of TF was higher in patients with thrombosis compared to those without thrombosis (224.41 [93.1-446.0] (median [IQR]) vs. 136.43 [109.4-193.4], p=0.036). The concentration of the other assessed coagulation related cells and biomarkers were not significantly different between patients who developed thrombosis during follow-up and those who did not. In multivariate regression analysis, ThroLy score ≥2 (OR=5.505, 95%CI 1.505‒20.100, p=0.01), TF (OR=1.005, 95%CI 1.002‒1.009, p=0.003), and aggressive form of lymphoma (OR=4.680, 95%CI 1.132‒19.356, p=0.033), were independent prognostic factors for thrombosis occurrence. CD11b +CD16 + neutrophils were increased 8-fold in aggressive (DLBCL) compared to indolent form of lymphoma (p<0.001), as were 2-fold CD61 + platelets and 3-fold CD31 + endothelial cells labelled with TF (CD142 +, p<0.05) procoagulant EVs. The monocyte-platelet aggregates (CD14 +CD45 +CD41 +) were increased 5-fold in DLBCL patients compared to the healthy controls (p<0.001). The presented results support the use of ThroLy score for differentiating the sub-groups of lymphoma patients who are at increased risk for thrombotic events, while profiling coagulation biomarkers in different lymphoma populations may aid in understanding the pathophysiologic mechanisms underlying the thromboembolic events. Special emphasis should be placed on the assessment of TF which might be used as a coagulation biomarker in addition to clinical prediction scores.

Thromboprophylaxis with Intermediate Dose Low Molecular Weight Heparin in Adults Undergoing Induction with L-Asparaginase for Acute Lymphoblastic Leukemia

Introduction Adolescents and young adults (AYA, defined as age 15-39 years) with acute lymphoblastic leukemia (ALL) have a poorer prognosis than their pediatric counterparts. To replicate the success of ALL treatment in children, pediatric-inspired regimens have been incorporated into the treatment of AYA and often include the use of L-asparaginase. Rates of thrombosis in adults receiving L-asparaginase for treatment of ALL have been reported to be as high as 34%, compared to only about 5% in pediatric patients. The risk of thrombosis is elevated primarily during the induction phase of treatment. Several strategies have been studied in adults, including antithrombin III replacement, fresh frozen plasma replacement, and prophylactic dosing of anticoagulation, however no clear guidelines exist on how to prevent thrombosis in these high-risk patients. To prevent L-asparaginase-induced thrombotic events, our institution implemented a standard practice of 1mg/kg/day of low molecular weight heparin (LMWH), a dose in-between prophylactic and therapeutic dosing, administered to all adults with ALL who were treated with L-asparaginase during induction chemotherapy. In this current study, we report data from patients who have been treated with this strategy from 2012 to present, focusing on the antithrombotic efficacy and safety of 1mg/kg/day LMWH in this population. Methods This retrospective chart review included 62 patients who received prophylactic anticoagulation with the LMWH enoxaparin (1mg/kg/day) while undergoing induction chemotherapy with L-asparaginase for ALL at the Oregon Health & Science University from 2012 to present. Anticoagulation with enoxaparin was initiated with the first dose of L-asparaginase and continued until the day of discharge or day 30 of induction. The primary outcome was the incidence of thrombosis within the first 30 days of L-asparaginase administration. Minor and major bleeding events, as defined by the International Society of Thrombosis and Haemostasis (ISTH), were recorded. Statistical analysis with univariate regression models was performed to evaluate the association of thrombotic events with demographic, disease and treatment variables. Results Sixty-two patients received 1mg/kg/day LMWH prophylaxis during ALL induction between January 2012 and June 2023 (43 with B-ALL and 19 with T-ALL). Median age at induction was 25.7 years (range 18-39 years). A majority of patients (83.9%) received the maximum dose of 2500mg/m 2 of L-asparaginase. Four patients (6.5%; 95% CI 1.8%-15.7%) experienced a thrombotic event within the first 30 days of induction with L-asparaginase; 3 of the events were catheter-associated and were treated supportively or with catheter removal, and 1 patient developed a distal lower extremity deep vein thrombosis related to myositis. Median time to thrombosis was 13.5 days (range 11-22 days). There were no significant associations between development of thrombotic events with age, gender, B- or T-cell precursor, or dose of L-asparaginase. No thrombosis-related deaths or major bleeding events occurred. Conclusions Prophylactic anticoagulation with intermediate dose 1mg/kg/day LMWH in adults with ALL undergoing induction chemotherapy with L-asparaginase is a safe and an effective strategy to prevent serious thrombotic events. Our institutional rate of 6.5% of patients experiencing thrombotic events during induction with L-asparaginase, with all of the events being clinically low risk, compares favorably to historically reported rates in adults and approaches the low rates reported in children. Further prospective research is warranted.

Neurological manifestations with jugular vein thrombosis linked to an inflammatory profile may be a sequela of long COVID

AbstractMore than 670 million cases of coronavirus disease 2019 (COVID‐19) have been recorded worldwide in the 3 years since the start of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic. About 45% of survivors of COVID‐19 develop a syndrome known as long‐term COVID, in which symptoms persist even months after the acute infection. About 76% of patients with long COVID experience neurological manifestations. Moreover, patients who have survived COVID‐19 have an increased risk of cerebral venous thrombosis. This case report describes a 41‐year‐old woman who developed neurological manifestations associated with jugular vein thrombosis 24 h after administration of the Oxford–AstraZeneca (ChAdOx1 nCoV‐19) vaccine (AstraZeneca‐Serum Institute of India). She had been infected with SARS‐CoV‐2 three months before vaccination. Although initially suspected to be a case of vaccine‐induced immune thrombotic thrombocytopenia (VITT) in view of her recent vaccination, the patient did not have any hallmarks of VITT, such as thrombocytopenia, an increased d‐dimer level, or antibodies against platelet factor‐4. Moreover, the neurological manifestations were associated with a high concentration of inflammatory cytokines, including interleukin (IL)‐6, IL‐17A, and IL‐21, and elevated neutrophil levels in cerebrospinal fluid, suggesting that inflammatory immune components had a role in the development of thrombotic events and pointing to an alternative diagnosis. In this case, the laboratory results indicated that the neurological manifestations associated with jugular vein thrombosis were not associated with VITT. Therefore, we propose that the thrombosis of the left jugular vein was a sequela of SARS‐CoV‐2 infection.

Electrocardiographic findings and incidence of new-onset atrial arrhythmia among patients with severe leptospirosis who underwent veno-venous extracorporeal membrane oxygenation

Abstract Funding Acknowledgements Type of funding sources: None. Background Leptospirosis is a zoonotic disease caused by Leptospira species that remains endemic in the Philippines. In severe cases, patients present with multiple organ system failure such as acute renal failure and acute respiratory distress syndrome(ARDS) requiring renal replacement therapy, mechanical ventilation, and novel treatment modalities such as extracorporeal membrane oxygenation(ECMO). Cardiac complications such as atrial arrhythmia also occur in cases of severe leptospirosis leading to worse outcomes. There is limited data on the electrocardiographic findings in patients with severe leptospirosis undergoing ECMO along with the incidence of new-onset atrial arrhythmia while managed on this intervention with unique hemodynamic system. Purpose To determine the baseline electrocardiographic(ECG) findings and incidence of new onset atrial arrhythmia among patients with severe leptospirosis during veno-venous(V-V) ECMO. Methods A cross-sectional study among patients with severe leptospirosis and ARDS who underwent V-V ECMO was conducted at a tertiary hospital in the Philippines. Primary outcome was defined as the presence or absence of new-onset atrial arrhythmia during ECMO. Secondary outcomes included in-hospital mortality, length of hospital stay, duration of mechanical ventilation, duration of ECMO, and development of thrombotic events. Results Among 31 patients included, 90.3%(n=28) were male and median age was 33.48±10.0 years. The most common ECG finding was atrial fibrillation with an incidence of 32.3%(n=10), half of which occurred before ECMO, while the other half were noted after cannulation. During ECMO, the incidence of new-onset atrial arrhythmia was found to be at 19.4% (n=6). Patients with new-onset atrial arrhythmia had higher white blood cell, total bilirubin, creatinine, APACHE-II Scores, use of dopamine, lower platelet count and PaO2/Fio2 ratio. Two patients(33.33%) died among those with new-onset atrial arrhythmia, while five patients(20%) died in the other group. There was no noted thrombotic events such as stroke among groups and no difference on the duration on ventilator, ECMO and hospital stay. Conclusions Atrial arrhythmias are under-reported complications during veno-venous ECMO among patients with severe leptospirosis. This study demonstrated a higher mortality among patients with new-onset atrial arrhythmia during ECMO for severe leptospirosis.

Characterization of the impact of immune checkpoint inhibitors on platelet activation and aggregation

Immune checkpoint inhibitors (ICIs) are effective oncological drugs which block cellular check-point receptors typically targeted by tumor immune evasion strategies. Despite their benefits, clinicians have reported treatment-associated thromboembolism during ICI therapy in recent years. Though several theories on this ICI-associated pathogenesis exist, the direct effects of ICIs on platelets remains unknown. We therefore investigated the potential direct and indirect effect of PD-1, PD-L1 and CTLA-4-targeting ICIs on platelet functionality in multifaceted in vitro experiments. Interestingly, we could not observe a clear effect of ICI on platelet aggregation and primary hemostasis in whole blood and platelet concentrate-based assays. Furthermore, the presence of ICIs in toll-like receptor stimulation had no significant impact on platelet surface marker expression. In a second approach, we investigated the indirect immunological impact of ICIs on platelet activation by exposing platelets to supernatants from ICI- and Staphylococcal enterotoxin B-exposed PBMCs. Whereas ICIs affected IL-2 levels in supernatants, we could not detect clear differences in the secretion of pro-thrombogenic factors and platelet responses. The obtained data suggest that the direct influence of ICIs on platelet activation or the influence of altered T cell function on platelet activation cannot be considered a major factor in the development of thrombotic events.

The Predictive Value of Neutrophil-Lymphocyte Ratio in Patients with Polycythemia Vera at the Time of Initial Diagnosis for Thrombotic Events.

Objective To investigate and discuss the predictive value of the neutrophil-to-lymphocyte ratio (NLR) in patients with polycythemia vera (PV) at the time of initial diagnosis, as well as its clinical significance in predicting the occurrence of thrombotic events and the progression of future thrombotic events during follow-ups, with the goal of providing a reference for the early identification of high-risk PV patients and the early intervention necessary to improve the prognosis of PV patients. Method A total of 170 patients diagnosed with PV for the first time were enrolled in this study. The risk factors affecting the occurrence and development of thrombotic events in these patients were statistically analyzed. Results NLR (P = 0.030), WBC count (P = 0.045), and history of previous thrombosis (P < 0.001) were independent risk factors for thrombotic events at the time of initial diagnosis. Age ≥ 60 years (P = 0.004), NLR (P = 0.025), history of previous thrombosis (P < 0.001), and fibrinogen (P = 0.042) were independent risk factors for the progression of future thrombotic events during follow-ups. The receiver operating characteristic curve (ROC curves) showed that NLR was more effective in predicting the progression of future thrombotic events than age ≥ 60 years, history of previous thrombosis, and fibrinogen. Kaplan-Meier survival analysis showed progression-free survival time of thrombotic events in the high NLR value group (NLR ≥ 4.713) (median survival time 22.033 months, 95% CI: 4.226-35.840), which was significantly lower compared to the low NLR value group (NLR < 4.713) (median overall survival time 66.000 months, 95% CI: 50.670-81.330); the observed difference was statistically significant (P < 0.001). The 60-month progression-free survival in the low NLR value group was 58.8%, while it was 32.8% in the high NLR value group. Conclusion Peripheral blood NLR levels in patients with PV resulted as an independent risk factor for the occurrence of thrombotic events at the time of initial diagnosis and for the progression of future thrombotic events during follow-ups. Peripheral blood NLR levels at the time of initial diagnosis and treatment had better diagnostic and predictive value for the progression of future thrombotic events in patients with PV than age ≥ 60 years, history of previous thrombosis, and fibrinogen.

Real-world evidence of lupus anticoagulant testing: simultaneous positivity of diluted Russell’s viper venom time and silica clotting time increases thrombotic risk prediction

Lupus anticoagulant (LA) is composed of heterogeneous autoantibodies, which have a close association with thrombotic events. Due to its heterogeneity, two methods for increasing sensitivity are recommended for LA. An investigation of the thrombotic risk and anticardiolipin (aCL) and anti-β2-glycoprotein I (aB2GPI) antibody profiles was conducted based on the results of using two parallel methods (dilute Russell viper venom time (dRVVT), silica clotting time (SCT)) in a real world clinical laboratory. Of 5120 patients, 684 patients (13%) were LA positive, and 422 patients (8%) experienced thrombotic events including pregnancy complication. Development of thrombotic events was more likely to occur in patients who were positive for both dRVVT and SCT compared with those who were positive for dRVVT or SCT only. In addition, significantly higher positive rates of aCL and aB2GPI and the persistently positive rate of LA at intervals of 12 weeks or longer were observed in patients who were positive for both dRVVT and SCT compared with those who were positive for dRVVT or SCT only. Considering three laboratory tests (LA, aCL, and aB2GPI), high thrombotic risk was observed for patients with both dRVVT and SCT positive LA results. A report on LA results that divides LA positive into two types (LA-single positive and LA-both positive) may be beneficial to clinicians in detection of high-risk thrombotic patients.

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

Endothelial dysfunction and thrombotic events in patients with severe novel coronavirus infection COVID-19

Introduction. The novel coronavirus infection COVID-19 (NCI COVID-19) caused by the COVID-19 virus, which occurs in the most severe forms, is accompanied not only by the development of respiratory failure and acute respiratory distress syndrome, but also by other equally dangerous complications such as covid-associated coagulopathy.The objective was to study the clinical and laboratory features of the development of endothelial dysfunction as the main component of covid-associated coagulopathy in the context of its most common manifestation – thrombotic events.Methods and materials. The medical records of 947 patients with confirmed novel coronavirus infection COVID-19 hospitalized at the Center for the Treatment of Patients with NCI COVID-19 of Pavlov University of the Ministry of Health of the Russian Federation during the so-called «2nd wave» of the pandemic from November 2020 to March 2021.Results. All thrombotic complications were detected only in patients with severe coronavirus infection (561 patients). Predisposing factors for the development of thrombosis in our patients were: advanced age, duration of hospitalization for more than 1 week, comorbidity in the form of coronary artery disease. Standard screening tests of the hemostasis system (platelet microscopy, coagulogram screening) do not reveal any significant features in the presence of thrombotic events, which requires the development of new studies to assess prothrombotic potential in patients with severe NCI COVID-19.Conclusion. The development of thrombotic events is one of the most formidable complications in the severe course of NCI COVID-19, which in turn leads to an increase in respiratory failure due to increased tissue hypoxia, and subsequently to death. The same patients have an increased risk of hemorrhagic events as a possible side effect of the therapy.

330. Evaluating the Relationship Between Comorbidity Treatment Status and In-hospital Mortality Among COVID-19 Patients

BackgroundChronic comorbidities increase the risk of poor outcomes in patients with COVID-19. However, there are insufficient data to determine whether control of chronic comorbidities influences outcomes. The purpose of this study was to determine whether pharmacologic treatment for common comorbidities influences in-hospital mortality.MethodsThis multicenter, retrospective study included adult patients with diabetes, hypertension, and/or dyslipidemia who were hospitalized with COVID-19 in Southwest GA, U.S. Patients were divided into two groups based on treatment status, where treated was defined as documentation in the electronic medical record of outpatient pharmacologic therapy indicated for that specific comorbidity while untreated was defined as no record of pharmacologic therapy for one or more comorbidity. The primary outcome was to compare in-hospital mortality between treated and untreated COVID-19 patients. Secondary outcomes included comparing length of hospital stay, development of thrombotic events, requirement for vasopressors, mechanical ventilation, and transfer to the ICU between groups.ResultsA total of 360 patients were included with a median age of 66 years (IQR 56-75). The majority were African American (83%) and female (61%) with a median Charlson Comorbidity Index of 4 (IQR 2-6). Hypertension, diabetes, and dyslipidemia were present in 91%, 55%, and 45% of patients, respectively, of which 76% (n=274) were treated. Mortality was similar between treated and untreated patients (25% vs 20%, p=0.304). Average length of stay was 9.5 days (SD 8.7) in treated patients compared to 10.6 days (SD 9.1) in untreated patients (p=0.302). No differences were observed in the rates of thrombosis (3% vs 4%, p=0.765), receipt of vasopressors (23% vs 21%, p=0.741), mechanical ventilation (31% vs 27%, p=0.450), or transfer to the ICU (27% vs 14%, p=0.112).ConclusionHospitalized COVID-19 patients being treated for hypertension, diabetes, and/or dyslipidemia have similar rates of complications and mortality compared to untreated patients. Further research is needed to determine whether degree of control of chronic comorbidities impacts COVID-19 outcomes.Disclosures All Authors: No reported disclosures

Vaccine-Induced Thrombotic Thrombocytopenia: Novelty Testing in the Diagnostic Work-up?

COVID-19 vaccination campagnies with several vaccines types are currently undeway. Recently, the ASTRA ZENECA vaccine has raised public alarm with concerns regarding the development of thrombotic events known as vaccine-induced thrombotic thrombocytopenia (VITT). Early and limited studies have implicated an antibody-mediated platelet activation as the mechanism of the clotting events. Aim of this study was to investigate the platelet and coagulation activation using specialized tests. In this study we enrolled 60 patients (40 men, 20 women; mean age 55±10 years) without cardiovascular risk factors or a history of thrombosis who reported having poplitea deep vein thrombosis (35/60) and pulmonary embolism (25/60) revealed with lower-limb ultrasonography and computed tomography (CT) angiography, respectively, 7 days after vaccination with ASTRA ZENECA. All patients were evaluated for initial testing such as platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and D-dimer (DD). Platelets were measured by automated analyzer, PT and APTT by coagulometric test, Fib using Clauss method, and DD using ELISA. Complete blood hemostasis was studied by platelet function assay (PFA-100) on Collagen/ADP (CT-ADP) and Collagen/Epinephrine (CT-EPI) cartridges and Thromboelastometry method on Clotting Time (CT), Clotting Formation Time (CFT), Maximum Clot Firmness (MCF), and clot lysis at 30 minutes (LY-30). All patients had thrombocytopenia (60±5x109/L), longer PT (28±10 s) and PTT (50±10 s), lower Fib (80±20 mg/dl), higher DD ((550±100 mg/l). All patients had shorter C/ADP and C/EPI (C/ADP, n.v. 68-121 s (42±10 s) and C/EPI n.v. 84-160 s (38±5 s) and shorter CT (CT, unit: s. n.v. 100-240 s) (INTEM 30±20 s, EXTEM 18±10 s), shorter CFT (CFT, unit: s, n.v. 30-160 s (INTEM 11±10 s, EXTEM 19±10 s), longer MCF (MCF, unit: mm, n.v. 50-72 mm (INTEM 128±10 mm, EXTEM 110±10 mm), and lower LY-30 (LY-30, %: v.n. 15% (INTEM 0.8%, EXTEM 0.7%). These interesting findings may be the novelty in the diagnostic work-up of the VITT. If these tests may aid in the diagnosis of VITT deserve to be confirmed and need reproducing in other studies. DisclosuresNo relevant conflicts of interest to declare.

Platelet reactivity and immature platelets in patients with Covid-19

Abstract Background Coronavirus disease 2019 (Covid-19) is associated with high incidence of thromboembolic events, both venous and arterial. Currently, there are no clinical or laboratory markers to guide antithrombotic therapy in COVID-19 patients. Immature platelets represent a population of hyper-reactive platelets associated with arterial thrombotic events. Objectives To determine indices of immature platelets and platelet reactivity in Covid-19 patients. Methods This prospective study compared consecutive COVID-19 patients (n=47, median age = 56 years) to patients with acute myocardial infarction (AMI, n=100, median age = 59 years) and a group of stable patients with cardiovascular risk factors (n=64, median age=68 years). Immature platelet fraction (IPF) and immature platelet count (IPC) were determined by the Sysmex XN-3000 auto-analyzer on admission and at subsequent time-points. Results IPF% on admission was higher in the Covid-19 group than the stable group and similar to the AMI group (4.8% [IQR 3.4–6.9], 3.5% [2.7–5.1], 4.55% [3.0–6.75], respectively, p=0.005 for Covid-19 vs. stable). IPC on admission was also higher in the Covid-19 group than the stable group and similar to the AMI group (10.8×109/L [8.3–18.1], 7.35×109/L [5.3–10.5], 10.7×109/L [7.7–16.8], respectively, P&amp;lt;0.0001 for Covid-19 vs. stable). The maximal IPF% among the Covid-19 group was higher than the stable group and similar to the AMI group. The maximal IPC in the Covid-19 group was higher than the maximal IPC in both the stable and AMI groups (Covid-19: 14.4×109/L [9.4–20.9], AMI: 10.9×109/L [7.6–15.2], P=0.0035, Stable: 7.55×109/L [5.55–10.5], P&amp;lt;0.0001). Conclusions Patients with Covid-19 have increased immature platelets indices compared to stable patients with cardiovascular risk factors, and as the disease progresses also compared to AMI patients. Enhanced platelet turnover and reactivity may, therefore, have a role in the development of thrombotic events in Covid-19 patients. Funding Acknowledgement Type of funding sources: None. IPF in COVID-19, AMI and stable groups

Risk of Thromboembolic Disease and Hemorrhage in Patients with Multiform Glioblastoma

Introduction: Glioblastoma Multiforme (GBM) is the most frequent malignant brain tumor, with an aggressive course and a short life expectancy despite standard treatment (chemotherapy and radiotherapy). The possibility of the development of Thrombotic Events (VTE) with this type of cancer is frequent. We designed this study to determine the risk of presenting VTE and hemorrhagic events in patients affected by GBM. Methods: Observational retrospective study of patients with GBM diagnosis at the General University Hospital of Ciudad Real between 2012 and 2015. The demographic characteristics of patients were studied, predictive models were compared, and a survival analysis was performed. Results: 77 patients were studied, 42 (55.3%)/34 (44.7%), men and women respectively, with an average age of 66.42 years. 13 (16.9%) presented VTE; of which 10 (61.54%) in the form of Deep Venous Thrombosis (DVT), 3 (23.08%) Pulmonary Embolism (PE) and 2 (15.38%) mixed events. The quality of life according to the performance status ECOG scale at the moment of diagnosis was 1 in 42 (15.38%) patients, and at the time of VTE, 5 (41.7%) had a value of 2, and 4 (33.3.3 %) registered 3. In the group that developed VTE according to the predictive model of risk for thrombosis in Khorana 5 (38.5%) had low risk and 8 (61.5%) intermediate; on the ASCO 2013 modified scale 5 (38.5%) had an Intermediate risk and 8 (61.5%) high. With a median, 1 year follow-up, 64 (84.2%) patients died, with an average time after the diagnosis of 279.09 days (216.6-341.6) (SE 31,8). 2 (2.6%) of the patients presented a greater haemorrhagic event and 7 (7.9%) cerebral haemorrhage, of which 4 (44.4%) had prophylactic Low Molecular Weight Heparins (LMWHs). In the survival analysis of Kaplan Meyer, patients who received prophylactic treatment with LMWHs had a higher survival rate with an average of 298.5 days compared to 239.3 of those who did not (p &gt;0.05). There were no significant variables in the multivariate analysis for thrombotic or haemorrhagic events. Conclusion and Discussion: The demographic and clinical characteristics of our patients were similar to those reported in other international publications. The predictive scale of Khorana was not validated in our study, in contrast, the modified ASCO 2013 scale was closer to our results. The creation of a precise predictive model would help to delineate the benefit of prophylactic anticoagulation in high-risk patients. Long-term prophylaxis with LMWHs has demonstrated a reduction of thrombotic events without significantly increasing the fatal haemorrhagic episodes, also demonstrating greater long-term survival, independent of thrombotic events. Randomized prospective studies are needed to demonstrate its benefits.

Dissecting the Thrombotic Events in the Presence of Antiphospholipid Antibodies in COVID-19 Spanish Patients

Several thrombotic complications in patients affected with SARS-CoV-2 have been reported. Single-centre pilot study aimed to analyse the coexistence of antiphospholipid antibodies and thrombotic events on SARS-CoV-2 infected patients. Antiphospholipid antibodies were measured by solid phase enzyme immunoassay. Clinical data were collected from electronic history and clinical records. Over 25 patients studied we report four cases of COVID-19 patients who presented circulating antiphospholipid antibodies and arterial or venous thrombotic events. No patient had a previous history of thrombosis. Two cases presented with pulmonary embolism, one with pulmonary embolism and pulmonary infarction and one with a stroke. All of them showed positive anti-cardiolipin antibodies. One patient died and three were discharged. The presence of antiphospholipid antibodies in these patients might represent an epiphenomenon secondary to the immune stimulation by the virus. It could be reasonable to consider measuring antiphospholipid antibodies as part of the study of a thrombotic event in COVID-19 patients to better understand the impact of these antibodies in the development of thrombotic events and we highlight the value of a periodic determination to define the need of long-term anticoagulant therapy. Keywords: Antiphospholipid antibodies, COVID-19, thrombosis

Тромботические события при редких формах генетических тромбофилий

Цель исследования: изучить лабораторный фенотип редких мутаций Лейдена [FVL А(1961)A] и гена протромбина [FII А(20210)A] при их клинической реализации в виде тромбозов. Материалы и методы. Проведено многоцентровое проспективное наблюдательное исследование, включающее 80 носителей редких генетических форм тромбофилий: FVL А(1961)A (n = 31), FII А(20210)A (n = 10) и компаунд FII G(20210)A + FVL G(1691)A (n = 39). У всех пациентов исследована резистентность фактора Va к активированному протеину С (APC-R) по нормализованному отношению (НО) и уровень активности протромбина в плазме крови в состоянии физического здоровья и в случае эпизода тромботического события. Результаты. Определена ассоциативная связь развития тромботических событий со снижением НО при оценке APC-R как у гомозиготных носителей мутации Лейден (Ме = 0,35; 95% ДИ = 0,31–0,37 по НО), так и гетерозиготных компаундов (Ме = 0,43; 95% ДИ = 0,42–0,45 по НО). Заключение. Лабораторный мониторинг пациентов с редкими формами генетических тромбофилий позволяет выделить группу высокого тромбогенного риска, нуждающуюся в пролонгированной тромбопрофилактике. Objectives: to study the laboratory phenotype of rare Leiden mutation [FVL A(1961)A] and the prothrombin gene mutation [FII А(20210)A] implementating clinically as thrombosis. Patients / Methods. A multicenter prospective observational study included 80 carriers of rare genetic kinds of thrombophilia: FVL A(1961)A (n = 31), prothrombin FII А(20210)A (n = 10) and the compound FII G(20210)A + FVL G(1691)A (n = 39). All patients were tested for the factor Va resistance to activated protein C (APC-R), normalized ratio (NR), and the plasma prothrombin activity (%) in healthy conditions and in the case of thrombotic event. Results. An associative relation between the development of thrombotic events and a decrease in NR was determined when assessing APC-R, both in homozygous carriers of the Leiden mutation (Me = 0.35; 95% CI = 0.31–0.37 in NR) and heterozygous compounds (Me = 0.43; 95% СI = 0.42–0.45 in NR). Conclusions. Laboratory follow up for patients with rare kinds of genetic thrombophilias allows to identify a group at high thrombogenic risk requiring prolonged thromboprophylaxis.

Diagnóstico clínico en pacientes con anticuerpos antifosfolípidos positivos

Objective: To know the relationship between the presence of three antiphospholipid antibodies: lupus anticoagulant and the anticardiolipin of isotypes IgM and IgG with the development of thrombotic events and alterations in coagulation and also, study the clinical environment in which those antibodies appear. Material and methods: Cross-sectional descriptive study in which we have analyzed retrospectively, in 123 patients with positive results for at least one of the antiphospholipid antibodies under study, their alterations in coagulation, if they suffer or have suffered any thrombotic event and the clinical environment in which these antibodies appear and. Results: 52,1% of patients with positive lupus anticoagulant have some type of abnormality in coagulation tests, compared with 43,75% of patients with anticardiolipin of isotype IgG and 24,64% of patients with anticardiolipin of isotypes IgM. The most frequent antibody in patients with primary antiphospholipid syndrome is anticardiolipin of isotypes IgM, which appears in 75%, while in the case of patients with secondary antiphospholipid syndrome due to erythematosus systemic lupus, the most frequent antibody is anticardiolipin of isotypes IgG, which is detected in 46,7%. Among the patients who suffered thrombotic event, in 45,94% anticardiolipin of isotypes IgM was detected, compared with 43,24% with lupus anticoagulant, and only 16,22% with anticardiolipin of isotype IgG. Conclusions: The antiphospholipid antibodies that alters coagulation tests to a greater extent is the lupus anticoagulant. Anticardiolipin of isotype IgM antibodies are the most frequent in primary antiphospholipid syndrome while anticardiolipin of isotype IgG are associated in a greater degree with secondary antiphospholipid syndrome, especially in patients with erythematosus systemic lupus. Anticardiolipin of isotype IgM antibodies represent a higher risk of thrombotic events in patients with positive antiphospholipid antibodies.

Thrombotic Risk Detection in Patients with Polycythemia Vera: The Predictive Role of DNMT3A/TET2/ASXL1 Mutations.

The development of thrombotic events is common among patients with polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). We studied the influence of pathogenic mutations frequently associated with myeloid malignancies on thrombotic events using next-generation sequencing (NGS) in an initial cohort of 68 patients with myeloproliferative neoplasms (MPN). As expected, the presence of mutations in DNMT3A, TET2, and ASXL1 (DTA genes) was positively associated with age for the whole cohort (p = 0.025, OR: 1.047, 95% CI: 1.006–1.090). Also, while not related with events in the whole cohort, DTA mutations were strongly associated with the development of vascular events in PV patients (p = 0.028). To confirm the possible association between the presence of DTA mutation and thrombotic events, we performed a case-control study on 55 age-matched patients with PV (including 12 PV patients from the initial cohort, 25 with event vs. 30 no event). In the age-matched case-control PV cohort, the presence of ≥1 DTA mutation significantly increased the risk of a thrombotic event (OR: 6.333, p = 0.0024). Specifically, mutations in TET2 were associated with thrombotic events in the PV case-control cohort (OR: 3.56, 95% CI: 1.15–11.83, p = 0.031). Our results suggest that pathogenic DTA mutations, and particularly TET2 mutations, may be an independent risk factor for thrombosis in patients with PV. However, the predictive value of TET2 and DTA mutations in ET and PMF was inconclusive and should be determined in a larger cohort.

Biomarkers of Hemostatic Dysregulation and Inflammation in Lymphoma: Potential Relevance to Thrombogenesis

INTRODUCTION: The prevalence of thrombotic complications in lymphoma patients ranges from 1.5% up to 59.5%. Lymphoma patients have a 10-fold higher risk for the development of venous thrombosis than patients with lung and gastrointestinal cancers. The pathogenesis of thromboembolic disease in hematological malignancies is complex and multifactorial and can be due to the underlying disorder or related to therapy. A number of biomarkers are associated with the occurence of VTE in cancer patients. Biomarkers reflect activation of coagulation and increased inflammatory potential. This study aimed to profile hemostatic and inflammatory biomarkers in patients with Hodgkin lymphoma, non-Hodgkin lymphoma, and chronic lymphocytic leukemia/ small lymphocytic lymphoma. METHODS: Citrated plasma samples were collected from lymphoma patients (n=96) under an IRB approved protocol Clinic for hematology, Lymphoma Center, University of Belgrade in Serbia. Samples were shipped to Loyola University Chicago and analyzed in batches via commercially available ELISA kits to profile biomarkers of coagulation activation and inflammation. Markers in Coagulation Activation: von Willebrand Factor (vWF), Factor XIIIa, Protein S, β2Glycoprotein I (β2GPI), D-dimer, Microparticles (MP), Urokinase-type Plasminogen Activator Antigen (uPA), Fibronectin. Markers of Inflammation included: Human Tumor Necrosis Factor- α (TNF- α), C-Reactive Protein (CRP), Plasminogen Activator Inhibitor Type 1 (PAI-1). The lymphoma patient population for each biomarker was compared to normal human pooled plasma (repeated 3 times for each biomarker), which consisted of 25 male and 25 females. RESULTS: The mean patients' age was 56 years (range, 19-80 years); 52.4% were males. Most patients were newly diagnosed and had advanced stage disease. A total of 42 patients (43.8%) had high-grade NHL; 17 (17.7%) had low-grade NHL; 24 (25.0%) had HLL; 7(7.3%) had HL; 6 (6.3%) had other forms. Lymphoma patients had significantly dysregulated following markers of coagulation: vWF, β2GPI, D-dimer, MP, uPA, and Fibronectin (Figure 1) (p&lt;0.001 for all in comparison to controls). TNF-α and CRP as markers of inflammation were also significantly increased in lymphoma patients (Figure 1) (p&lt;0.001 for both in comparison to controls). In lymphoma population 12 patients had thrombosis. Patients with thrombosis had significantly higher Factor XIIIa in comparison to lymphoma patients without thrombosis (106±9 vs. 85±256; p&lt;0.001). CONCLUSION: Hemostatic dysregulation and inflammation is present in lymphoma patients, which may reflect increased thrombogenic potential. Further studies are required to link clinical data and biomarker levels, with special emphasis on the involvement of FXIII in the development of thrombotic events in lymphoma patients. Biomarker profiling of lymphoma patients will also help in the understanding of the pathophysiologic mechanisms involved in the observed thrombotic complications and differentiating the sub-groups. Figure 1 Disclosures No relevant conflicts of interest to declare.

Plasminogen activator inhibitor-1 gene polymorphism as a risk factor for vascular complications in type 2 diabetes mellitus

BackgroundDiabetes mellitus (DM) can lead to microvascular and macrovascular damages through hyperglycemia that is the main cause of diabetic complications. Other factors such as hypertension, obesity, and hyperlipidemia may worsen or accelerate the others. Several studies have revealed definitive genetic predispositions to the development of type 2 diabetes mellitus (T2DM) and development of vascular complications. This study aimed to address the association between plasminogen activator inhibitor-1 (PAI-1) gene polymorphism and T2DM, and if this gene polymorphism may have a possible role in the development of vascular complications in T2DM. This study is a case control; it included 200 patients with T2DM, 117 patients had no vascular complications, and 83 had previous vascular complications (VCs). One hundred eighty volunteer blood donors were selected as a healthy control group. All patients and controls were subjected to clinical examination, and laboratory investigations included lipid profile, fasting and 2 h blood glucose, complete blood cell count, d-dimer, PAI-1, thrombin activatable fibrinolysis inhibitor (TAFI), and detection of PAI-1 gene polymorphism by real-time polymerase chain reaction (PCR).ResultsThe most prevalent genotype of PAI-1 gene polymorphism in all studied groups, including controls, was 4G/5G with the highest allele frequency as 4G. The 4G/5G and 4G/4G genotypes were associated with increased risk of DM development as compared to 5G/5G genotype. The 4G/5G and 4G/4G genotypes also had a highly significant increased risk of VCs among diabetic patients, as compared to 5G/5G. The 4G allele also was highly associated with DM with VCs. The d-dimer TAFI, PAI-1 showed the highest levels in 4G/5G genotype followed by 4G/4G genotype. The lowest level was expressed in 5G/5G genotype in diabetic patients with and without VCs. The univariable analysis showed that genotypes 4G/5G and 4G/4G were potentially risk factors for development of VCs with T2DM patients.ConclusionThis study concludes that the PAI-1 4G/5G polymorphism may be associated with T2DM and may be considered as a risk factor for development of thrombotic events. It may also help in selection and dosing of patients being treated with anticoagulant and fibrinolytic agents. Further large-scale studies are recommended to assess the possible role of environmental factors and gene interactions in the development of T2DM vascular risks.