Higher D-dimer Concentrations Research Articles

Incidence of and risk factors for preoperative deep vein thrombosis in elderly patients with end-stage osteoarthritis following total knee arthroplasty: a retrospective cohort study

BackgroundDeep vein thrombosis (DVT) is a common and serious risk in elderly patients with knee osteoarthritis (OA), making preoperative detection crucial. Despite this, identifying OA patients at high risk for preoperative DVT and appropriately targeting them for venous ultrasound screening remains a challenge. There is limited research-based evidence on the risk factors for preoperative DVT in elderly patients with end-stage OA. We examined the incidence of and risk factors for preoperative DVT in elderly patients with end-stage OA scheduled for total knee arthroplasty.MethodsWe retrospectively analyzed the demographic data (age, sex, body mass index, current smoking, alcohol consumption, walking status, and Barthel index score), medical history, and laboratory test indices of 1411 patients with end-stage OA aged ≥ 60 years scheduled for total knee arthroplasty from January 2015 to December 2018. Risk factors for preoperative DVT were evaluated by univariate and multivariate logistic analyses. Receiver operating characteristic analysis was performed to determine optimal cut-off values.ResultsThe incidence of preoperative DVT was 4.5% (63 of 1411 patients). Seven independent risk factors were correlated with preoperative DVT in the multivariate logistic regression: age (odds ratio [OR], 1.073; P = 0.002), D-dimer concentration (OR, 1.173; P = 0.003), hyperlipidemia (OR, 2.038; P = 0.045), atrial fibrillation (OR, 4.004; P = 0.033), chronic renal failure (OR, 6.732; P = 0.008), chronic obstructive pulmonary disease (COPD) (OR, 8.721; P = 0.001), and walking status (wheelchair) (OR, 2.697; P = 0.002). The optimal cut-off values for predicting preoperative DVT were 0.585 µg/mL for the D-dimer concentration (area under the curve [AUC], 0.769; P < 0.001) and 72.5 years for age (AUC, 0.668; P < 0.001).ConclusionAmong elderly patients with end-stage OA, venous ultrasonography to rule out DVT risk should be prioritized in those with a high D-dimer concentration (> 0.585 µg/mL), high age (> 72.5 years), hyperlipidemia, atrial fibrillation, chronic renal failure, COPD, and walking status (wheelchair).

#5401 REAL-WORLD STUDY BETWEEN NEPHROTIC SYNDROME AND VENOUS THROMBOEMBOLISM

Abstract Background and Aims Nephrotic syndrome (NS) is a recognized risk factor of venous thromboembolism (VTE), however, there have been limited comprehensive epidemiologic data on VTE among NS patients. Therefore, we designed our study to assess the epidemiology and clinical correlates of VTE among hospitalized adults with NS in China. Method In this nationwide real-world study of 78,797 hospitalized patients with NS from 18 medical centers across China, VTE was identified by International Classification of Diseases, 10th revision (ICD-10) codes or imagological examinations during hospitalization. Multivariable logistic regression analysis was used to investigate the association between clinical variables and VTE through the R Programming software. Results A total of 1227 VTE cases were identified in the hospitalized NS population and the detection rate was 1.56%. Detection rate of VTE varied significantly in patients with different pathologic types of NS. Patients with membranous nephropathy (MN) had a significantly increased risk of VTE {Odds ratio [OR] 2.11 [95% confidence interval (CI) 1.12–4.36]}. While patients with focal segmental glomerulosclerosis (FSGS) did not show a significant high risk [OR 0.93 (95% CI 0.29–2.60)] compared with minimal change disease. We also found that male [OR 1.44 (95% CI 1.15–1.80)], age [OR 1.09 (95% CI 1.02–1.17)], anemia [OR 1.50 (95% CI 1.15–1.95)], cerebral bleeding [OR 3.23 (95% CI 1.69–6.16)], respiratory tract infection [OR 2.05 (95% CI 1.60–2.63)], respiratory failure [OR 2.24 (95% CI 1.42–3.53)], use of proton pump inhibitors (PPIs) [OR 2.19 (95% CI 1.54–3.12)], use of glucocorticoids [OR 1.46 (95% CI 1.03–2.09)] and immunosuppressants [OR 1.48 (95% CI 1.14–1.93), orthopedic operations [OR 1.97 (95% CI 1.22–3.18)], high-level D-dimer (&amp;gt;0.55 mg/L) [OR 2.62 (95% CI 1.87–3.65)] were associated with increased risk of VTE detection. While 24-hour urine protein quantification &amp;gt;10 g/d [OR 1.24 (95% CI 0.90–1.70)] showed little significant correlation with VTE. Hypertension [OR 0.74 (95% CI 0.58–0.95)] and the use of diuretics [OR 0.72 (95% CI 0.53–0.97)] were found to have a negative correlation with VTE detection. Conclusion The detection rate of VTE among patients with NS during hospitalization was 1.56%. Male, age, MN, anemia, cerebral bleeding, respiratory tract infection, respiratory failure, and use of PPIs, glucocorticoids and immunosuppressants, high D-dimer concentration were associated with VTE detection in NS. While 24-hour proteinuria did not show a significant association with VTE identification.

Hyperferritinemia as a factor associated with poor prognosis in COVID-19 patients

Worldwide, hundreds of millions of people have been infected with COVID-19 since December 2019; however, about 20% or less developed severe symptoms. The main aim of the current study was to assess the relationship between the severity of Covid-19 and different clinical and laboratory parameters. A total number of 466 Arabs have willingly joined this prospective cohort. Out of the total number, 297 subjects (63.7%) had negative COVID-19 tests, and thus, they were recruited as controls, while 169 subjects (36.3%) who tested positive for COVID-19 were enrolled as cases. Out of the total number of COVID-19 patients, 127 (75.15%) presented with mild symptoms, and 42 (24.85%) had severe symptoms. The age range for the participants was 20 to 82 years. Compared with controls, the severity of the disease was associated with significantly high ferritin levels (P &lt; 0.001). The severity of the disease was also associated with a significant increase in C-reactive protein (P &lt; 0.001), D-dimer (P &lt; 0.001), white blood cell count (WBC) (P &lt; 0.01), IgM (P &lt; 0.001), and Granulocytes (P &lt; 0.01). In addition, severe COVID-19 symptoms in the current study were associated with a significant decrease in lymphocytes (P &lt; 0.01). There was a four-fold increase in serum ferritin levels in COVID-19 patients presented with severe symptoms upon admission. The former was associated with significantly high levels of CRP and D-dimer. Thus, hyperferritinemia, together with high CRP and D-dimer concentrations, may serve as reliable predictors for disease severity and poor prognosis in Arabs with COVID-19.

A new machine learning model for predicting severity prognosis in patients with pulmonary embolism: Study protocol from Wenzhou, China.

Pulmonary embolism (PE) is a common thrombotic disease and potentially deadly cardiovascular disorder. The ratio of clinical misdiagnosis and missed diagnosis of PE is very large because patients with PE are asymptomatic or non-specific. Using the clinical data from the First Affiliated Hospital of Wenzhou Medical University (Wenzhou, China), we proposed a swarm intelligence algorithm-based kernel extreme learning machine model (SSACS-KELM) to recognize and discriminate the severity of the PE by patient's basic information and serum biomarkers. First, an enhanced method (SSACS) is presented by combining the salp swarm algorithm (SSA) with the cuckoo search (CS). Then, the SSACS algorithm is introduced into the KELM classifier to propose the SSACS-KELM model to improve the accuracy and stability of the traditional classifier. In the experiments, the benchmark optimization performance of SSACS is confirmed by comparing SSACS with five original classical methods and five high-performance improved algorithms through benchmark function experiments. Then, the overall adaptability and accuracy of the SSACS-KELM model are tested using eight public data sets. Further, to highlight the superiority of SSACS-KELM on PE datasets, this paper conducts comparison experiments with other classical classifiers, swarm intelligence algorithms, and feature selection approaches. The experimental results show that high D-dimer concentration, hypoalbuminemia, and other indicators are important for the diagnosis of PE. The classification results showed that the accuracy of the prediction model was 99.33%. It is expected to be a new and accurate method to distinguish the severity of PE.

Thrombotic Events and Anticoagulation-Related Bleeding Complications in Critically Ill Patients with Coronavirus Disease 2019

Background: Thrombosis (T) is common in coronavirus disease 2019 (COVID-19) patients, and d-dimer concentrations correlate with outcomes. Controversy exists with regards to anticoagulation (AC) for patients. We implemented a full-heparinization AC protocol from the onset of the pandemic and hypothesized that a safety signal would be undetectable. Patients and Methods: Prospective evaluation of 111 patients with COVID-19 critical illness hospitalized from March to June 2020. All patients received therapeutic heparinoid-based AC from admission. Incidences of T, bleeding (B), or both (BT) were noted. The primary outcome was mortality. Kruskal-Wallis test and logistic regression were performed. Results are expressed as n (%), median (interquartile range) and odds ratios with 95% confidence intervals. Alpha was set at 0.05. Results: Thirty-two patients (28%) had T, 23 (20%) had B, and 14 (12%) had BT; 42 (40%) patients were unaffected. Two logistic regression models (outcome = mortality) evaluated BT as T, or BT as B. For BT as T, neither T, B, nor male gender predicted mortality; similarly, for BT as B, neither T, B, nor male gender predicted mortality. Factors associated with higher odds of death included higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.00-1.13; p = 0.0045), higher d-dimer concentration (OR, 1.00; 95% CI, 1.00-1.01; p = 0.043), and higher activated partial thromboplastin time (aPTT; OR, 1.09; 95% CI, 1.02-1.16; p = 0.010). Conclusions: Neither T nor B predicted mortality in this prospective cohort of anticoagulated patients with COVID-19 critical illness. These data support continued full-dose heparinoid prophylaxis.

D-dimer and outcomes in hospitalized heart failure patients across the ejection fraction phenotypes.

The prognostic significance of D-dimer in hospitalized heart failure (HF) patients is incompletely characterized. We aimed to assess the association of D-dimer levels on admission with adverse events at follow-up in patients hospitalized with HF across all ejection fraction (EF) phenotypes. Consecutive patients hospitalized from December 2006 to December 2017 for HF with D-dimer and EF values available (n=1795) were enrolled. Associations between D-dimer and all-cause death were examined at 1-year follow-up. Median age was 57years, 73.4% were male, and the majority (72.1%) were in New York Heart Association Classes III-IV. EF was reduced in 53.3% (HFrEF), mildly reduced in 16.3% (HFmrEF), and preserved in 30.4% (HFpEF). Median (interquartile range) D-dimer on admission was 0.56 (0.27-1.295) μg/mL FEU (fibrinogen-equivalent unit) in the whole cohort, 0.64 (0.28-1.48) μg/mL FEU in HFrEF, 0.50 (0.27-1.03) μg/mL FEU in HFmrEF, and 0.495 (0.25-1.10) μg/mL FEU in HFpEF (P=0.001). At 1-year follow-up, higher D-dimer (D-dimer ≥0.56μg/mL FEU) independently predicted all-cause death in total cohort [hazard ratio (HR) 1.55; 95% confidence interval (CI), 1.15-2.1], in HFrEF (HR, 1.49; P=0.039), and in HFpEF (HR, 2.06; P=0.033). However, no relationship was found for HFrEF or HFmrEF when D-dimer was treated as quartiles. In sensitivity analysis, quantitatively similar but more pronounced association between D-dimer and all-cause death was observed in total cohort and HFpEF cohort. In hospitalized HF patients, higher D-dimer concentration was a significant and independent predictor of 1-year all-cause mortality. Across all HF phenotypes, this effect was most evident in HFpEF patients.

Investigation of two different human d-dimer assays in the horse

BackgroundD-dimer has value as a marker of thrombosis in critically ill horses and can provide additional information about prognosis. However, there are currently no equine species-specific d-dimer assays available, nor has there been any formal investigation of the applicability of human d-dimer assays in horses, so it is unknown, which assay performs best in this species. The aim of this study was therefore to evaluate and compare two human d-dimer assays for their applicability in horses.The study included four groups of horses: clinically healthy horses, horses with gastrointestinal (GI) disease and mild systemic inflammation based on low serum amyloid A (SAA) (low SAA group), horses with GI disease and strong systemic inflammation based on high SAA (high SAA group) and, horses with thrombotic GI disease caused by Strongylus vulgaris (also called non-strangulating intestinal infarction (NSII)) (NSII group). The assays evaluated were the STAGO STA-Liatest D-di + (Stago) and NycoCard™ D-dimer (NycoCard). Intra- and inter-coefficients of variation (CV) were assessed on two d-dimer concentrations, and linearity under dilution was evaluated. A group comparison was performed for both assays across the four groups of horses. A Spaghetti plot, Spearman Correlation, Passing Bablok regression and Bland–Altman plot were used to compare methods in terms of agreement.ResultsTen horses were included in the clinically healthy group, eight in the low SAA group, eight in the high SAA group, and seven in the NSII group. For the Stago assay, intra- and inter-CVs were below the accepted level except for one inter-CV. The NycoCard assay did not meet the accepted level for any of the CVs. The linearity under dilution was acceptable for both the Stago and NycoCard. In the group comparison, both methods detected a significantly higher d-dimer concentration in the high SAA and NSII groups compared to the clinically healthy group. Method agreement showed slightly higher d-dimer concentrations with NycoCard compared to Stago. The overall agreement was stronger for the lower d-dimer concentrations.ConclusionBoth the Stago and the NycoCard were found to be applicable for use in horses but were not directly comparable.

Clinical and Immunological Markers of Pulmonary Impairment Among People With HIV in India.

BackgroundDespite antiretroviral therapy, chronic lung diseases remain an important source of morbidity and mortality in people with HIV (PWH). We sought to identify clinical and immunological markers of pulmonary impairment among PWH in India.MethodsTwo hundred ten adult PWH receiving antiretroviral therapy (ART) were prospectively evaluated for 3 years. Plasma concentrations of interleukin (IL)-6, IL-10, tumor necrosis factor alpha, D-dimer, C-reactive protein, soluble (s)CD14, and sCD163 were measured at enrollment. We used multivariable linear and logistic regression to measure the association of baseline and time-varying clinical and immunological variables with spirometry-defined chronic obstructive pulmonary disease (COPD), restrictive spirometry pattern (RSP), preserved ratio impaired spirometry (PRISm), forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) during the third year of follow-up.ResultsAfter adjusting confounders, females were 7 times more likely to have RSP (95% CI, 2.81 to 17.62; P < .001) and 22 times more likely to have PRISm (95% CI, 7.42 to 69.92; P < .001) compared with men. Higher IL-6 concentrations were associated with lower FEV1 z-scores (β, −0.14 per log-higher; 95% CI, −0.29 to 0.008; P = .06) and higher odds of COPD (adjusted odds ratio [aOR], 2.66 per log-higher; 95% CI, 1.16 to 6.09; P = .02). Higher D-dimer concentrations were associated with lower FVC z-scores (β, −0.40 per log-higher; 95% CI, −0.78 to −0.01; P = .04). Conversely, higher IL-10 concentrations were associated with lower odds of PRISm (aOR, 0.76 per log-higher; 95% CI, 0.59 to 0.99; P = .04).ConclusionsFemale sex, higher concentrations of IL-6 and D-dimer, and lower concentrations of IL-10 were associated with pulmonary impairment in adult PWH receiving ART in India.

Thrombosis Risk History and D-dimer Levels in Asymptomatic Individuals with Prader-Willi Syndrome.

Individuals with Prader–Willi syndrome (PWS) may be at higher risk of developing blood clots as compared to the typical population, but this risk is poorly understood. It is also unclear if laboratory testing of D-dimer concentration might be useful to screen for thrombosis in PWS. Here, we surveyed the thrombosis history of 883 individuals with PWS and evaluated the D-dimer concentration in a subset of 214 asymptomatic individuals, ages 5–55. A history of at least one blood clot was reported by 3.6% of respondents. Thrombosis increased with age, but no significant difference was found on the basis of sex or family history. Genetic subtype was a significant factor when considering only those with a known subtype, and individuals with a history of edema had significantly more blood clots. In the D-dimer sub-study, ≈15% of participants had high D-dimer concentrations, and 3.7% had D-dimer values more than twice the normal upper limit. One participant with a high D-dimer result was found to have a blood clot. No significant differences in D-dimer results were found on the basis of age, sex, genetic subtype, family history of blood clots, edema history, or BMI. The D-dimer test does not appear to be a sensitive and specific screening tool for blood clots in asymptomatic individuals with PWS.

Safety of Tocilizumab in COVID-19 Patients and Benefit of Single-Dose: The Largest Retrospective Observational Study.

Severe acute respiratory coronavirus-2 (SARS-CoV-2) still presents a public threat and puts extra strain on healthcare facilities. Without an effective antiviral drug, all available treatment options are considered supportive. Tocilizumab as a treatment option has to date shown variable results. In this retrospective study, we aimed to assess predictors of mortality of COVID-19 patients (n = 300) on tocilizumab and the clinical effectiveness of this drug. The results showed that ICU admission OR = 64.6 (95% CI: 8.2, 507.4); age of the patient OR = 1.1 (95% CI: 1.0, 1.1); and number of tocilizumab doses administered by the patient OR(two doses) = 4.0 (95% CI: 1.5, 10.9), OR(three doses) = 1.5 (95% CI: 0.5, 5.1), and OR(four doses or more) = 7.2 (95% CI: 2.0, 25.5) presented strong correlation factors that may be linked to COVID-19 mortality. Furthermore, our study showed the beneficial effects of early administration of tocilizumab OR = 1.2 (95% CI: 1.1, 1.4) and longer hospital length of stay OR = 0.974 (95% CI: 0.9, 1.0) in reducing COVID-19 mortalities. High blood D-dimer concentration OR = 1.1 (95% CI: 1.0, 1.2) and reciprocal blood phosphate concentration OR = 0.008 (95% CI: 0.0, 1.2) were correlated to high mortality under SARS-CoV-2 infection. The short-term effect of a single dose of tocilizumab was a significant increase in blood BUN and liver enzymes (ALT, AST, and LDH) above their normal ranges. Furthermore, it significantly reduced CRP blood concentration, but not to normal levels (13.90 to 1.40 mg/dL, p < 0.001). Assessing the effect of different doses of tocilizumab (in terms of the number of doses, total mg, and total mg/kg administered by the patients) indicated that administering more than one dose may lead to increases in ICU length of stay and hospital length of stay of up to 14 and 22 days after the last dose of tocilizumab (6 to 14, p = 0.06, and 10 to 22, p < 0.001), with no improvement in 28- and 90-day mortality, as confirmed by Kaplan–Meier analysis. There were also clear correlations and trends between the number of doses of tocilizumab and increased blood CO2, MCV, RDW, and D-dimer concentrations and between number of doses of tocilizumab and decreased CRP, AST, and hemoglobin concentrations. Microbiology analysis showed a significant increase in the incidence of infection after tocilizumab administration (28 to 119, p < 0.001) with a median time of incidence within 6 days of the first dose of tocilizumab. A significant correlation was also found between the number of tocilizumab doses and the number of incidences of infections after tocilizumab administration r (298) = 0.396, p = 1.028 × 10−12. Based on these results and depending on the pharmacokinetic parameters of the drug, we recommend single-dose administration of tocilizumab as the optimal dosage for COVID-19 patients who do not have active bacterial infection or liver diseases, to be administered as soon as the patient is admitted to the hospital.

High D-Dimer Concentration Is a Significant Independent Prognostic Factor in Patients with Acute Large Vessel Occlusion Undergoing Endovascular Thrombectomy

To investigate prognostic factors that affect the modified Rankin Scale score at 3 months after onset of acute stroke in patients with large vessel occlusion who underwent endovascular thrombectomy. We retrospectively examined 87 consecutive patients who underwent endovascular cerebral thrombectomy for acute anterior circulation large vessel occlusion at Oita University Hospital and Nagatomi Neurosurgery Hospital from January 2014 to December2020. Age, National Institutes of Health Stroke Scale score, and D-dimer concentration on admission were significant univariate prognostic factors related to modified Rankin Scale score at 3 months after stroke onset. Multivariate logistic regression analysis showed that D-dimer concentration was the only significant independent prognostic factor. The area under the receiver operating characteristic curve for D-dimer concentration and modified Rankin Scale score at 3 months was 0.715 (95% confidence interval 0.599-0.831); sensitivity and specificity were 60.6% and 80.0%, respectively, using a 1.9 μg/mL cutoff value. Prognosis may be worse in patients undergoing acute endovascular cerebral thrombectomy with high D-dimer concentration on admission. Other treatment options should be considered for these patients.

Associations of D-Dimer with Computed Tomographic Lung Abnormalities, Serum Biomarkers of Lung Injury, and Forced Vital Capacity: MESA Lung Study.

Rationale: The coagulation cascade may play a role in the pathogenesis of interstitial lung disease through increased production of thrombin and fibrin deposition. Whether circulating coagulation cascade factors are linked to lung inflammation and scarring among community-dwelling adults is unknown. Objectives: To test the hypothesis that higher baseline D-dimer concentrations are associated with markers of early lung injury and scarring. Methods: Using the MESA (Multi-Ethnic Study of Atherosclerosis) cohort (n = 6,814), we examined associations of baseline D-dimer concentrations with high attenuation areas from examination 1 (2000-2002; n = 6,184) and interstitial lung abnormalities from examination 5 computed tomographic (CT) scans (2010-2012; n = 2,227), and serum MMP-7 (matrix metalloproteinase-7) and SP-A (surfactant protein-A) from examination 1 (n = 1,098). We examined longitudinal change in forced vital capacity (FVC) from examinations 3-6 (2004-2018, n = 3,562). We used linear logistic regression and linear mixed models to examine associations and adjust for potential confounders. Results: The mean (standard deviation) age of the cohort was 62 (10) years, and the D-dimer concentration was 0.35 (0.69) ug/ml. For every 10% increase in D-dimer concentration, there was an increase in high attenuation area percentage of 0.27 (95% confidence interval (CI), 0.08-0.47) after adjustment for covariates. Associations were stronger among those older than 65 years (P values for interaction < 0.001). A 10% increase in D-dimer concentration was associated with an odds ratio of 1.05 for interstitial lung abnormalities (95% CI, 0.99-1.11). Higher D-dimer concentrations were associated with higher serum MMP-7 and a faster decline in FVC. D-dimer was not associated with SP-A. Conclusions: Higher D-dimer concentrations were associated with a greater burden of lung parenchymal abnormalities detected on CT scan, MMP-7, and FVC decline among community-dwelling adults.

Prolonged corrected QT interval in hospitalized patients with coronavirus disease 2019 in Dubai, United Arab Emirates: a single-center, retrospective study.

ObjectiveTo evaluate the association of a prolonged corrected QT (QTc) interval in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its association with in-patient mortality.MethodsA cohort of 745 patients were recruited from a single center between 1 March 2020 and 31 May 2020. We analyzed the factors associated with a prolonged QTc and mortality.ResultsA prolonged QTc interval >450 ms was found in 27% of patients admitted with SARS-CoV-2 infection. These patients were predominantly older, on a ventilator, and had hypertension, diabetes mellitus, or ischemic heart disease. They also had high troponin and D-dimer concentrations. A prolonged QTc interval had a significant association with the requirement of ventilator support and was associated with an increased odds of mortality. Patients who died were older than 55 years, and had high troponin, D-dimer, creatinine, procalcitonin, and ferritin concentrations, a high white blood cell count, and abnormal potassium concentrations (hypo- or hyperkalemia).ConclusionsA prolonged QTc interval is common in patients with SARS-CoV-2 infection and it is associated with worse outcomes. Older individuals and those with comorbidities should have an electrocardiogram performed, which is noninvasive and easily available, on admission to hospital to identify high-risk patients.

Maternal thrombin generation and D-dimer levels in obesity and pregnancy: results from the maternal thrombin generation in obesity and pregnancy (MaTOPs) study.

Venous thromboembolic disease (VTE) risk increases five-fold antenatally and 14-fold during the puerperium. Obesity significantly increases this risk. The D-dimer assay and more novel Calibrated Automated Thrombogram (CAT) assay laboratory tests display potential for use in VTE risk stratification in pregnancy, although to date, research in the performance characteristics of these tests in obese and nonobese pregnant populations is limited. The aim of this study was to compare D-dimer and thrombin generation levels in obese and nonobese pregnant women. Pregnant women were recruited and categorised, as obese (BMI ≥30) or nonobese (BMI 18.5-25). Blood was collected at 26-28 weeks' gestation, 36-40 weeks' gestation and 6-12 weeks postpartum and D-dimer concentrations and endogenous thrombin potential (ETP) were determined. Student's t-test was used to analyse differences in mean D-dimer and ETP. At 36-40 weeks, obese pregnant women had higher D-dimer concentrations (P = 0.001) but lower ETP levels compared with nonobese women (P = 0.044). D-dimer was higher in nonobese than in obese women at 6-12 weeks postpartum (P = 0.026). There was no difference in mean D-dimer (P = 0.825) and mean ETP (P = 0.424) between obese and nonobese women at 26-28 weeks. No difference was observed in mean ETP at 6-12 weeks postpartum (P = 0.472). ETP was lower in both obese and nonobese women postpartum than during pregnancy. D-dimer was lower in obese women but not in nonobese women postpartum. D-dimer concentrations and ETP were not significantly different during multiple time points in pregnancy and postpartum between obese and nonobese pregnant women suggesting limited utility in VTE risk assessment in obese pregnant women.

Combination of preoperative fibrinogen and D-dimer as a prognostic indicator in pancreatic ductal adenocarcinoma patients undergoing R0 resection.

BACKGROUNDPatients with malignant tumors frequently exhibit hyperactivation of the coagulation system and secondary increased fibrinolytic activity. Fibrinogen and D-dimer are common indicators that are crucial in the coagulation/fibrinolysis system. Both indicators have been verified to have predictive value in the overall survival (OS) of many patients with solid malignancies.AIMTo explore the prognostic significance of fibrinogen combined with D-dimer in pancreatic ductal adenocarcinoma (PDAC) patients undergoing radical R0 resection.METHODSWe retrospectively analyzed the clinical data of 282 patients with PDAC undergoing radical R0 resection in the Cancer Hospital, Chinese Academy of Medical Sciences, between January 2010 and December 2019. The surv_cutpoint function of R language was used to determine the optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration. Enrolled patients were further divided into the any-high group (high preoperative fibrinogen concentration and/or high preoperative D-dimer concentration) and the low-low group (low preoperative fibrinogen and D-dimer concentrations) according to the optimal cutoff values.RESULTSThe optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration were 3.31 g/L and 0.53 mg/L, respectively. Furthermore, multivariate Cox regression analysis showed that the preoperative fibrinogen concentration (HR: 1.603, 95%CI: 1.201-2.140, P = 0.001) and preoperative D-dimer concentration (HR: 1.355, 95%CI: 1.019-1.801, P = 0.036) exhibited obvious correlations with the OS of PDAC patients undergoing radical R0 resection. A prognostic analysis was further performed based on the subgroup results by using fibrinogen combined with D-dimer. The median OS duration of the low-low group (31.17 mo) was significantly longer than that of the any-high group (15.43 mo). Additionally, multivariate Cox regression analysis revealed that the degree of differentiation (P < 0.001), lymph node metastasis (HR: 0.663, 95%CI: 0.497-0.883, P = 0.005), preoperative CA19-9 level (HR: 1.699, 95%CI: 1.258-2.293, P = 0.001), adjuvant therapy (HR: 1.582, 95%CI: 1.202-2.081, P = 0.001) and preoperative combined grouping (HR: 2.397, 95%CI: 1.723-3.335, P < 0.001) were independent predictors of OS in PDAC patients undergoing radical R0 resection.CONCLUSIONPreoperative fibrinogen combined with D-dimer plays a predictive role in OS, and low preoperative fibrinogen and D-dimer concentrations can indicate prolonged OS in PDAC patients undergoing radical R0 resection.

18F-fluorodeoxyglucose PET/CT findings in a systemic inflammatory response syndrome after COVID-19 vaccine

A 65-year-old woman attended our hospital with a 1-day history of fever and falls, saying that her legs had given out from under her. The patient's symptoms began within 1 day of the first dose of the mRNA-1273 SARS-CoV-2 vaccine. She had a medical history of hypertension and diabetes. On examination in the emergency department, the patient's temperature was 39·1°C, her respiratory rate was 25 breaths per min, and her heart rate was 88 beats per min. As she met the criteria for systemic inflammatory response syndrome (SIRS), an extensive infection work-up was initiated and she was started on broad-spectrum antibiotics. Laboratory investigations found a D-dimer concentration of 5267 ng/mL, erythrocyte sedimentation rate of 69 mm/h, and a C-reactive protein concentration of 63·4 mg/L. The patient's white blood cell count, lactate, urinalysis, respiratory pathogen panel—including SARS-CoV-2—and urine and blood cultures were unremarkable. Due to concerns of exposure to SARS-CoV-2, the PCR test was repeated after 24 h, but this was again negative. CT of the patient's chest showed multiple pulmonary nodules measuring up to 1·1 cm. A small filling defect in a distal subsegmental pulmonary artery was also seen, which we thought was inconsistent with an acute pulmonary embolism and probably artifactual. Doppler ultrasounds of the patient's lower limbs were normal; her head CT was also normal. 4 days after presentation, 18F-fluorodeoxyglucose (18F-FDG) PET/CT was done to characterise the pulmonary nodules; it showed uptake in the fat stranding posterior to the right deltoid (figure); moderately increased uptake within multiple right axillary lymph nodes (figure); and diffusely increased splenic uptake (figure). The pulmonary nodules had no uptake—indicating that they were probably benign. The patient's symptoms resolved 3 days after the vaccination. Given the imaging findings, the temporal relationship of the symptoms to the vaccination, and negative test results from an extensive work-up for malignant and infectious causes, we believe, the diagnosis was a local and systemic immune response following vaccination. However possible masking effects of broad-spectrum antibiotics cannot be excluded. The high D-dimer concentration probably reflected significant concomitant coagulation and fibrinolysis associated with SIRS. The local response was demonstrated by hypermetabolism within the axillary lymph nodes draining the site of intramuscular injection; diffusely increased splenic activity suggests a systemic response—corroborated by elevated inflammatory markers. As the global vaccination effort continues, more patients will undoubtedly require assessment and investigation shortly after immunisation. Imaging and laboratory findings consistent with a systemic immune response might result in further unnecessary evaluation or interventions. However, findings overlap with other diseases—notably those of the 18F-FDG PET/CT scan in patients with malignancies. Recognition of the clinical and imaging features of the systemic immune response to vaccination might become essential in the coming months (video). Contributors AT was the admitting physician treating the patient. JS and AI were involved in interpreting the imaging. We were all involved in drafting, reviewing, and writing the final manuscript. Written consent for publication was obtained from the patient. Declaration of interests We declare no competing interests. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzYjU0YjdkMGRlOWE5YjRjZjE3NTczNTFlMGYwYTE5MiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1MDIwNzk3fQ.FrKm7WPVrBEYc__av88QAKtYcG-LEqw9a4HNT5cWjqdAQd-pxui5ft-V7JsWf9GshC_PMhztK_Dm82QamMvpkGf3XrdBQnfZKg9ybgvg8lU8czKB09lBfyyTnOHwfilUJXrDCmhjFGrkbSyeQE5VXa5JY5y8txPhDfsEX5jlz2K7YL5WkY0Kl1lcQnqyRwQDqh416BrsCgYyy1SgRJcISHSsbjihKsGSKXjvGh_FVevzPS7J3WLK--W7BbBgefHaOMk8j6ua_FwQO4TXBX4bmVWopN1RRZ1ZRGkjOzH9vsJxXisqWxGtGBnkMQmCoC7hm3o9Je2pyGOrpNnCT6H8og Download .mp4 (35.03 MB) Help with .mp4 files Supplementary Video18fluorodeoxyglucose PET/CT shows possible response to COVID-19 vaccineLymph nodes and spleen lighting up after COVID-19 vaccineYoutube: https://youtu.be/Cjf4zUr6mXo

The clinical characteristics and prognosis of COVID-19 patients with comorbidities: a retrospective analysis of the infection peak in Wuhan.

BackgroundThis study aims to determine the clinical characteristics and prognosis of COVID-19 patients with comorbidities and to identify survival factors.MethodsA retrospective study was conducted in Wuhan, China, between February 8, 2020, and March 9, 2020. Based on underlying diseases, patients were assigned to either the comorbidity group or the non-comorbidity group. The clinical characteristics and outcomes of COVID-19 were analyzed and a Kaplan-Meier survival analysis was used to evaluate the prognosis predictive value of each comorbidity.ResultsDuring the study period, 278 COVID-19 patients were enrolled, 175 (62.95%) were assigned to the comorbidity group, and 103 (37.05%) to the non-comorbidity group. Of the patients in the comorbidity group, 34.86% were classified as critical. Further, patients in the comorbidity group had lower lymphocyte cell counts, and higher concentrations of D-dimer, high sensitivity C-reactive protein, interleukin 6, and serum ferritin as well as higher critical illness severity scores than patients in the non-comorbidity group (P<0.05). Patients in the comorbidity group also had higher mortality, acute respiratory distress syndrome, and ventilation treatment rates than patients in the non-comorbidity group (P<0.05). The length of hospital stay was longer in the comorbidity group than in the non-comorbidity group (P<0.05). The most common underlying diseases included hypertension (40.65%), diabetes mellitus (20.5%), and cardiovascular disease (19.42%). Patients with comorbidities were more likely to develop cardiovascular sequelae associated with COVID-19, shock, acute kidney injury, and multiple organ dysfunction syndrome (30.86% vs. 12.62%, P=0.001; 18.86% vs. 8.74%, P=0.023; 24.57% vs. 11.65%, P=0.009; 33.71% vs. 14.56%, P=0.000, respectively). In the Kaplan-Meier survival analysis, older patients (¡Ý65 years) (log-rank test: χ2=4.202, P=0.040) and patients with chronic obstructive pulmonary disease (COPD) (log-rank test: χ2=4.839, P=0.028) or diabetes mellitus (log-rank test: χ2=4.377, P=0.036) had shorter survival than those without comorbidities.ConclusionsPatients with comorbidities were more severely affected and had a higher mortality rate. Age, COPD and diabetes mellitus were the main factors affecting the survival of patients.

Extracorporeal Membrane Oxygenation Therapy for Critically Ill Coronavirus Disease 2019 Patients in Wuhan, China: A Retrospective Multicenter Cohort Study

SummaryCurrently, little in-depth evidence is known about the application of extracorporeal membrane oxygenation (ECMO) therapy in coronavirus disease 2019 (COVID-19) patients. This retrospective multicenter cohort study included patients with COVID-19 at 7 designated hospitals in Wuhan, China. The patients were followed up until June 30, 2020. Univariate and multivariate logistic regression analyses were performed to identify the risk factors associated with unsuccessful ECMO weaning. Propensity score matching was used to match patients who received veno-venous ECMO with those who received invasive mechanical ventilation (IMV)-only therapy. Of 88 patients receiving ECMO therapy, 27 and 61 patients were and were not successfully weaned from ECMO, respectively. Additionally, 15, 15, and 65 patients were further weaned from IMV, discharged from hospital, or died during hospitalization, respectively. In the multivariate logistic regression analysis, a lymphocyte count ≤0.5×109/L and D-dimer concentration >4× the upper limit of normal level at ICU admission, a peak PaCO2 >60 mmHg at 24 h before ECMO initiation, and no tracheotomy performed during the ICU stay were independently associated with lower odds of ECMO weaning. In the propensity score-matched analysis, a mixed-effect Cox model detected a lower hazard ratio for 120-day all-cause mortality after ICU admission during hospitalization in the ECMO group. The presence of lymphocytopenia, higher D-dimer concentrations at ICU admission and hypercapnia before ECMO initiation could help to identify patients with a poor prognosis. Tracheotomy could facilitate weaning from ECMO. ECMO relative to IMV-only therapy was associated with improved outcomes in critically ill COVID-19 patients.

Effect of Asymptomatic Plasmodium falciparum Parasitaemia on Platelets Thrombogenicity in Blood Donors

Currently, blood donors in Ghana are not screened for malaria parasites. Therefore, this study assessed platelet thrombogenicity in blood donors infected asymptomatically with Plasmodium falciparum and the relationship between tumour necrosis factor alpha (TNF-α), 8-iso-prostaglandin F2α oxidative stress biomarker (8-iso-PG2α), C-reactive protein (hs-CRP) and D-dimer, and platelet thrombogenes levels. Haematology analyser was used to enumerate platelet count and platelet indices in 80 P. falciparum infected blood donors and 160 matched non-infected controls. Replicate serum levels of von Willebrand Factor (vWF), platelet factor 4 (PF4), P-selectin thrombogenic factors as well as TNF-α and 8-iso-PG2α were determined using enzyme immuno-assay while high sensitive hs-CRP and D-dimer concentrations were determined by fluorescent immunoassay. The geometric mean of parasite density in malaria infected donors was 1784 parasites/µL (505-2478 parasites/µL). This led to significant increase in the mean levels of 8-iso-PG2α, hs-CRP, TNF-α and D-dimer. However, PF4, P-selectin were significantly lower in infected donors while vWF levels did not differ significantly among the groups even though lower levels were observed in the infected donors. Significant direct relationship existed between both P-selectin and PF4 and platelet count, and plateletcrit and platelet large cell ratio whereas these thrombogenic factors varied inversely to 8-iso-PG2α, TNF-α and hs-CRP. Relative thrombocytopaenia was associated with significant reduction in P-selectin and platelet factor 4 levels together with increased 8-iso-PG2α, hs-CRP, TNF-α and D-dimer levels. Taken together, it is recommended that all P. falciparum infected blood donors should be deferred.

Hemostasis Disorders in Patients with De Novo Acute Leukemias

Aim. To study hemostasis disorders in patients with de novo acute leukemias (AL) prior to chemotherapy. Materials &amp; Methods. The study enrolled 107 patients with newly diagnosed AL, aged 18-80 years and treated at the National Research Center for Hematology. Acute lymphoblastic leukemia (ALL) was identified in 37 patients, acute myeloid leukemia (AML) was diagnosed in 46 patients, and acute promyelocytic leukemia (APL) was reported in 24 patients. Hemorrhagic and thrombotic complications were analyzed; platelet count, APPT, prothrombin and fibrinogen concentration were determined; thromboelastography (TEG; native tests, functional fibrinogen tests) and rotation thromboelastometry (ROTEM; EXTEM, INTEM, FIBTEM, APTEM) were performed. The data were statistically processed using SAS 9.4 software. Results. At AL onset hemorrhagic syndrome was detected in 34 (32 %) out of 107 patients. It was manifested by petechia (n = 16), subcutaneous hematomas (n = 12), gingival (n = 10) and nose (n = 6) bleeding, uterine bleeding (n = 2), hematuria (n = 2), gastrointestinal bleeding (n = 1), brain hemorrhage (n = 6), and periorbital hematoma (n = 1). According to TEG and ROTEM hypocoagulation was more common in APL patients. Hyperfibrinolysis could be detected using only ROTEM in 54 % of APL patients, in 8 % of ALL and 4 % of AML patients. Compared to other AL patients those with APL showed different parameters of fibrinogen concentration of &lt; 1.75 g/L (sensitivity 83.3 %, specificity 83.13 %), D-dimer concentration of &gt; 2686 pg/L (sensitivity 72.73 %, specificity 64.79 %), MCF&lt;sub&gt;FIBTEM&lt;/sub&gt; &lt; 12.5 mm (sensitivity 80 %, specificity 80 %), and MA&lt;sub&gt;FF&lt;/sub&gt; &lt; 9.7 mm (sensitivity 86.96 %, specificity 90.12 %). Conclusion. The parameters that distinguish APL from other categories of AL patients are hypofibrinogenemia, higher D-dimer concentration, ROTEM changes, and hyperfibrinolysis.