Low Molecular Weight Heparin Treatment Research Articles

The effect of tinzaparin on biomarkers in FIGO stages III-IV ovarian cancer patients undergoing neoadjuvant chemotherapy - the TABANETOC trial: study protocol for a randomized clinical multicenter trial.

Tinzaparin, a low-molecular weight heparin (LMWH), has shown anti-neoplastic properties in animal models and in in vitro studies of human cancer cell lines. The reduction of CA-125 levels during neoadjuvant chemotherapy (NACT) in patients with epithelial ovarian cancer (EOC) co-varies with the prognosis; the larger the decrease in CA-125, the better the prognosis. This study aims to evaluate the potential anti-neoplastic effects of tinzaparin by investigating changes in serum CA-125 levels in advanced EOC patients who receive NACT. This is an open randomized multicenter pilot trial. Forty patients with EOC selected to receive NACT will be randomized 1:1 to receive daily addition of tinzaparin or no tinzaparin. The processing and treatment of the patients will otherwise follow the recommendations in the Swedish National Guidelines for Ovarian Cancer. Before every cycle of chemotherapy, preoperatively, and 3 weeks after the last cycle of chemotherapy, a panel of biomarkers, including CA-125, will be measured. Inclusion criteria are women aged 18 years or older, World Health Organization performance status 0-1, histologically confirmed high-grade serous, endometrioid or clear cell EOC, International Federation of Gynecology and Obstetrics (FIGO) stages III-IV. In addition, a CA-125 level of ≥ 250 kIE/L at diagnosis. Exclusion criteria are contraindications to LMWH, ongoing or recent treatment with unfractionated heparin, LMWH, warfarin or non-vitamin K antagonist oral anticoagulants. This study will make an important contribution to the knowledge of the anti-neoplastic effects of tinzaparin in EOC patients and may thus guide the planning of a future study on the impact of tinzaparin on survival in EOC.

Effectiveness and safety of continuous low-molecular-weight heparin versus switching to direct oral anticoagulants in cancer-associated venous thrombosis

Given the existing uncertainty regarding the effectiveness and safety of switching from low-molecular-weight heparin (LMWH) to direct oral anticoagulants (DOACs) in patients with cancer-associated venous thrombosis (CAT), we conducted a comprehensive population-based cohort study utilizing electronic health database in Hong Kong. A total of 4356 patients with CAT between 2010 and 2022 were included, with 1700 (39.0%) patients switching to DOAC treatment. Compared to continuous LMWH treatment, switching to DOACs was associated with a significantly lower risk of hospitalization due to venous thromboembolism (HR: 0.49 [95% CI = 0.35–0.68]) and all-cause mortality (HR: 0.67 [95% CI = 0.61–0.74]), with no significant difference in major bleeding (HR: 1.04 [95% CI = 0.83–1.31]) within six months. These findings provide reassurance regarding the effectiveness and safety of switching from LMWH to DOACs among patients with CAT, including vulnerable patient groups.

LMWH prevents thromboinflammation in the placenta via HBEGF-AKT signaling

AbstractLow molecular weight heparins (LMWH) are used to prevent or treat thromboembolic events during pregnancy. Although studies suggest an overall protective effect of LMWH in preeclampsia (PE), their use in PE remains controversial. LMWH may convey beneficial effects in PE independent of their anticoagulant activity, possibly by inhibiting inflammation. Here, we evaluated whether LMWH inhibit placental thromboinflammation and trophoblast NLRP3 inflammasome activation. Using an established procoagulant extracellular vesicle–induced and platelet-dependent PE-like mouse model, we show that LMWH reduces pregnancy loss and trophoblast inflammasome activation, restores altered trophoblast differentiation, and improves trophoblast proliferation in vivo and in vitro. Moreover, LMWH inhibits platelet-independent trophoblast NLRP3 (NLR family pyrin domain containing 3) inflammasome activation. Mechanistically, LWMH activates via heparin-binding epidermal growth factor (HBEGF) signaling the PI3-kinase-AKT pathway in trophoblasts, thus preventing inflammasome activation. In human PE placental explants, inflammasome activation and PI3-kinase-AKT signaling events were reduced with LMWH treatment compared with those without LMWH treatment. Thus, LMWH inhibits sterile inflammation via the HBEGF signaling pathway in trophoblasts and ameliorates PE-associated complications. These findings suggest that drugs targeting the inflammasome may be evaluated in PE and identify a signaling mechanism through which LMWH ameliorates PE, thus providing a rationale for the use of LMWH in PE.

Serum concentration of placental growth factor in pregnancy screening for placental dysfunction and low molecular weight heparin treatment

Serum concentration of placental growth factor in pregnancy screening for placental dysfunction and low molecular weight heparin treatment

The incidence of venous thromboembolism after curative colon cancer surgery within an enhanced recovery after surgery programme

AimBased on three randomised controlled trials performed more than a decade ago, several national guidelines recommend prolonged venous thromboprophylaxis for 28 days following elective surgery for colon cancer. None of these studies were conducted within enhanced recovery after surgery setting. Newer studies indicate that prolonged prophylaxis might not be necessary with enhanced recovery after surgery. We aimed to provide further evidence to this unresolved discussion. MethodRetrospective study of patients undergoing elective surgery for colon cancer stage I-III with enhanced recovery after surgery in the Capital Region of Denmark from 2014 to 2017. Patients were excluded if discharged on postoperative day 28 or later, dying before discharge, undergoing concomitant rectum resection, or discharged with vitamin K antagonists, direct-oral anticoagulants, or low molecular weight heparin treatment. All patients received only low-dose low molecular weight heparin as prophylaxis during their admission.The primary endpoint was symptomatic lower limb deep venous thrombosis or pulmonary embolism diagnosed within 60 days postoperatively. ResultsOut of the included population of 1806 patients, only three experienced a symptomatic venous thromboembolic event; none was fatal. Two had pulmonary embolism associated with pneumonia, while one patient was diagnosed with lower limb deep venous thrombosis at postoperative day 15 after an uncomplicated course with first discharge at postoperative day 2. ConclusionThe risk of symptomatic venous thromboembolism after elective surgery for colon cancer with enhanced recovery after surgery seems negligible even without prolonged prophylaxis. The current guidelines need to be reconsidered.

Superior sagittal sinus thrombosis in the course of mixed phenotype acute leukaemia treated with acute lymphoblastic leukaemia-like therapy—a case report

Mixed phenotype acute leukaemia (MPAL) is associated with worse overall survival, compared with other acute leukaemias in adults. Lack of clear treatment guidelines makes the therapy challenging. ALL-like induction and consolidation treatment followed by allo-HSCT is the preferred first-line treatment. We present a case of a 36-year-old woman diagnosed with MPAL (EGIL Myelo/B) with KMT2A rearrangement, treated with the PALG-ALL-7 (including PEG-asparaginase) protocol. On day 25 after the induction therapy initiation, numbness of limbs and dizziness were observed. Therefore, the imaging studies (CT and MRI) were performed and a diagnosis of thrombosis of superior sagittal sinus of the brain was established. Routinely performed blood coagulation tests showed prolonged APTT and PT, decreased antithrombin III activity and decreased free protein S concentration. LMWH treatment and substitutional therapy with antithrombin III were started, which resulted in a significant reduction in the thrombosis associated symptoms and improvement of the neurological status after 3 days. After induction and consolidation therapy, the patient obtained complete haematological remission and negative measurable residual disease. Six months after the diagnosis, allo-HSCT was successfully performed. During the 4 months follow-up, the patient remained MRD negative and thrombotic symptoms free. To the best of our knowledge, our communication has been the first report of such complication in an MPAL patient treated with PEG-asparaginase containing protocol in adults. We recommend increased vigilance in patients manifesting any mild neurological symptoms and early decision about the MRI study performance.

Bridging therapy and risk of major bleeding and thrombosis in continuous-flow left ventricular assist device patients: a quasi-experimental study

Abstract Background Bridging with low molecular weight heparin (LMWH) on top of vitamin K antagonist treatment is recommended in continuous-flow left ventricular assist device (CF-LVAD) patients during subtherapeutic anticoagulation. However, the consequence of bridging on the risk of bleeding and thrombosis are unknown. Aim To assess the risk of major bleeding and thrombosis associated with bridging in CF-LVAD patients, through a regression discontinuity (RD) design, a quasi-experimental design. Methods We included CF-LVAD patients implanted at our university medical center between 2010-2021. Outcomes were major bleeding (INTERMACS type 3, 4, 5) and thromboembolic events (pump thrombosis, arterial non-central nervous system and venous thromboembolism). We estimated incidence rates and hazard ratios (HR) with 95% confidence intervals (95%CI) by time-dependent Cox regression. Using an RD design, a quasi-experimental design, we compared patients using LMWH due to a subtherapeutic international normalized ratio (INR) to patients with no LMWH and an INR just in target range. As LMWH treatment is initiated based on an INR threshold (i.e., when INR is below the lower target range) and INR is subject to random variability, patients just below and in the INR target range are comparable, mimicking a randomized trial. Analyses were performed five times including INRs±0.1, ±0.2, ±0.3, ±0.4 and ±0.5 around the INR threshold. Results 77 patients were included, with a median age at implantation of 69 years, 60 (78%) were male, 45 (58%) had ischemic heart failure and 35 (45%) had INTERMACS classification 3. We included 35,466 INRs during 91 patient-years of follow-up. Bridging was associated with increased major bleeding rates compared to no-bridging in all analyses (Figure 1). In particular, the risk of major bleeding was 6.9-fold increased (95%CI 1.2-38.9) during bridging compared to no-bridging considering INR+0.1, and 3.4-fold (95%CI 1.4-8.2) considering INR±0.5 (Figure 2A). While thrombotic events were infrequent, the risk of thrombosis was around unity during bridging compared to no-bridging considering INR±0.5 (HR 1.1, 95%CI 0.1-9.9, Figure 2B). Conclusions During bridging with LMWH, CF-LVAD patients had a 6.9-fold increased risk of major bleeding, while the risk of thrombosis was around unity compared to no-bridging.Incidence ratesHazard ratios

Abstract 12787: Efficacy and Safety of Apixaban versus Low Molecular Weight Heparin for the Treatment of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis

Introduction: Current guidelines recommend the use of low molecular weight heparin (LMWH) for the management of venous thromboembolism (VTE) in cancer patients. However, direct oral anticoagulants (DOACs) have emerged as promising alternative for reducing VTE events. Moreover, apixaban shows a higher safety profile among DOACs. Hypothesis: This study aims to compare the efficacy and safety of apixaban versus LMWH (Enoxaparin or Dalteparin) in the treatment of venous thromboembolism in cancer patients. Methods: A systematic search was conducted in electronic databases (Pubmed, Embase, Scopus, and Cochrane libraries) from inception until June 2023, using appropriate Mesh terms for ‘apixaban’, ‘LMWH’, and ‘VTE’. Pooled risk ratios (RR) with their corresponding 95% confidence intervals (CI) were calculated using random effects models. A p-value of <0.005 was considered statistically significant. Results: Five randomized trials involving 2311 patients (apixaban: 1088 and LMWH: 1223) with mean ages of 64.5±11.45 and 64.2±10.8, respectively, were included in the analysis. At a median follow-up of six months, the occurrence of clinically relevant non-major bleeding (CRNMB) (OR, 1.04, 95% CI: 0.66 - 1.64, I2=37.72%, p=0.87), composite of major and CRNMB (OR, 1.11, 95% CI: 0.84 - 1.46, I2=0.00%, p=0.47), were higher with apixaban treatment. However, the rates of recurrent VTE (OR, 0.72, 95% CI: 0.50 - 1.04, I2=3.91%, p=0.08), major bleeding (OR, 0.83, 95% CI: 0.55 - 1.25, I2=0.00%, p=0.38), and mortality (OR, 0.91, 95% CI: 0.79 - 1.05, I2=0.00%, p=0.19) were lower with apixaban compared to LMWH treatment. However, none of the observed differences reached statistical significance. Conclusions: In cancer patients with VTE, apixaban demonstrates non-inferior efficacy and a comparable safety profile to LMWH. Further randomized trials are warranted to confirm these findings.

Abstract 14280: Real-World Study of Fondaparinux in Chinese Non-ST-Segment Elevation Acute Coronary Syndrome Patients: REFOCAS

Introduction: In NSTE-ACS patients, fondaparinux appears to have superior benefits than LWMH, however its application in patients with different risk stratification is still not obvious. Hypothesis: The use of fondaparinux or LMWH has an impact on prognosis in NSTE-ACS patients with different ischemic and bleeding risks. Methods: A multicenter, prospective, open-label, real-world study was conducted in 8066 adult patients with non-emergency PCI at 89 hospitals from July 2019 to July 2021. Patients received fondaparinux (2.5 mg/d) or LMWH (1 mg/kg, twice/day) , they were followed-up within 6-month. The GRACE and CRUSADE scores were used to stratify the included patients. The primary outcome was the incidence of NACCE (all-cause death, reinfarction, nonfatal stroke, or BARC≥type 2 bleeding) at 30 days, and secondary endpoints included BARC≥type 2 bleeding or MACE during hospitalization, 30 days, and six months. Results: In total, 5430 patients received fondaparinux treatment and 2636 received LMWH treatment, with 4976 and 2477 completed the trial respectively. The primary outcome occurred in 136 patients (2.7%) receiving fondaparinux and in 110 patients (4.4%) in LMWH [HR=0.608(0.471,0.785), p<0.001]. The rate of BARC≥2 bleeding at 30-day was significantly lower in the fondaparinux group compared with the LMWH group[68(1.4%) vs. 66(2.6%), HR=0.509(0.361,0.716), P<0.001]. Reduction in rate of NACCE and BARC ≥ type 2 bleeding were still observed during hospitalization and at six-month follow-up in fondaparinux group. In low bleeding risk individuals (CRUSADE score≤40), fondaparinux reduced the rate of BARC≥2 bleeding at 30-day by 0.9% compared with LMWH, which decreased by 3.1% in high bleeding risk individuals(CRUSADE score>40). Among patients with low ischemic risk (GRACE score≤140 ), fondaparinux significantly reduced the incidence of NACCE, MACE, and BARC ≥ 2 bleeding at each follow-up visits. Conclusions: In Chinese patients with NSTE-ACS, fondaparinux reduced the incidence of the composite endpoint event of bleeding and ischemia of 30 days compared with LMWH. Meanwhile, fondaparinux exhibited better safety in patients with high bleeding risk, and in the low ischemic risk group, the overall efficacy and safety were also better than LMWH.

Platelet-Based Dose-Adjusted Low Molecular Weight Heparin Treatment Is Efficacious and Safe in Newly Diagnosed Acute Leukemia Patients with Catheter-Related Thrombosis

Introduction: Catheter-related thrombosis (CRT) is a major complication in patients with acute leukemia. Severe thrombocytopenia related to either the concomitant disease or therapy underscores the challenge of CRT management, resulting in the use of suboptimal anticoagulation, potentially leading to high rates of short-term complications, including recurrent thromboembolism and hemorrhage. Due to the paucity of data regarding the impact of reduced-dose anticoagulation on this clinical setting, the current study aimed to assess the safety and efficacy of this treatment approach to CRT management in this challenging patient population. Methods: In this retrospective, case-control study, all adult (age ≥18 years) acute leukemia patients, who had arrived at the Rambam Health Care Campus (RHCC, Haifa, Israel) between 1.11.2004-30.6.2022 to receive anti-leukemia therapy via a peripherally inserted central catheter (PICC) line were screened. The inclusion criteria were: patients with acute myeloid, promyelocytic and lymphoid leukemia (AML, APL, and ALL, respectively) and CRT confirmed by Doppler ultrasound within 3 months of leukemia diagnosis. Patients were divided into full- (i.e., 1 mg/kg bid) vs. partial-dose low molecular weight heparin (LMWH) groups. The LMWH dose was based on the platelet count with a cutoff of 50K/L, distinguishing between the selected doses. Primary endpoints: A record of venous thromboembolism (VTE; including pulmonary embolism (PE), deep vein thrombosis (DVT), and catheter-related thrombosis (CRT) recurrence within 12 months as well as a major hemorrhage (including intracranial, retinal and gastrointestinal hemorrhage) within 6 months. Secondary endpoints: blood product requirement (unit/day) before and after the CRT diagnosis (from leukemia diagnosis till CRT identification and 90 days or death (if prior) from the event, respectively) assessed in a self-controlled case series manner. Data were collected from the hospital electronic medical records. Chi-square and paired samples Wilcoxon tests were utilized for statistical analysis. Results: Overall,195 patients [aged 54±15 years; 103 (53%) males], diagnosed with CRT were included. The most frequent leukemia diagnosis was AML (n=149; 76%), with ALL and APL established in 23 (12%) patients each. CRT was diagnosed in the left upper limb in 136 (70%) patients, with 99 (46%) patients suffering from DVT. Eighty-eight (45%) patients were treated with full-dose LMWH. Recurrent VTE was identified in 11(12.5%) patients treated with full-dose LMWH vs. 9 (8.4%) receiving partial-dose LMWH (p-value 0.484), while major hemorrhage was diagnosed in 12 (13.6%) patients from the former group vs. 14 (13.0%) patients from the latter group (table 1). Similar results were documented upon stratification to deep vs. superficial CRT, and the leukemia type. The packed red blood cell (RBC) administration rate was lower in the post-CRT phase (0.12 units/day, IQR 0.06-0.20) compared to the pre-CRT phase (0.20 units/day, IQR 0-0.36; p-value <0.0001). Platelet utilization rates were similar in both the pre-CRT and post-CRT phases (0.05 units/day, IQR 0-0.24 and 0.06 units/day, IQR 0.01-0.16, respectively; p-value 0.126). Comparable results were observed in both full and partial-dose LMWH groups. Conclusion: LMWH dose adjustment based on platelet counts, in newly diagnosed acute leukemia patients with CRT, is not associated with higher rates of VTE recurrence. Moreover, this strategy does not result in major hemorrhagic complications even in patients with severe thrombocytopenia. Notably, RBC infusion requirements were lower in the post-CRT diagnosis phase, while platelet transfusion was similar during the pre- and post-CRT phases. This analysis, including a large number of patients, demonstrates that the adjusted therapy is safe and efficient in this challenging clinical scenario.

Tumor-infiltrating platelets promote the growth of lung adenocarcinoma

PurposePlatelets could promote tumor growth and metastasis. However, the role of platelets in different subtypes of non-small cell lung cancer (NSCLC) and platelet infiltration in local tumor tissue remain unclear. MethodsInitially, platelet infiltration in lung adenocarcinoma (ADC) and lung squamous cell carcinoma (SCC) was estimated by CD41 expression using immunohistochemistry. Subsequently, co-incubation of NSCLC cell lines and platelets was performed to compare the ability of binding platelets. Subcutaneous tumor models were established to assess the ability of platelets to promote tumor growth. Then, RNA-seq data of NSCLC was used to identify differentially expressed genes and enriched pathways. Lastly, a clinical cohort comprising of ADC and SCC patients as well as meta-analysis was analyzed to compare the difference of coagulation associated clinical parameters. ResultsWe found high platelet infiltration in ADC, especially of advanced disease and metastases, whereas few platelets were observed in SCC. Moreover, ADC cell lines exhibited strong ability of binding platelets compared with SCC cell lines. Platelets could also promote the growth of ADC cell lines in vivo. Furthermore, coagulation cascades and fibrinogen were upregulated in ADC. And chemical inhibition of GPIIb/IIIa-fibrinogen axis reduced the binding of ADC cells and platelets. ADC patients were also in a hypercoagulable state characterized by higher d-dimer level and shorter clotting time. Finally, meta-analysis identified a higher risk of venous thromboembolism (VTE) in ADC patients and low molecular weight heparin (LMWH) treatment was effective at reducing this risk. ConclusionsThis study identified the differences of platelet infiltration and coagulation between ADC and SCC patients, which may inform the development of anticoagulation therapies for NSCLC.

The effect of renal impairment and obesity on anti-Xa peak and trough levels in patients receiving therapeutic doses of nadroparin: a comparison with control patients.

Anti-Xa peak level monitoring is recommended during LMWH treatment in renal impairment or obesity. The trough level has been proposed as marker for bleeding. We studied the influence of renal impairment and obesity on anti-Xa levels. Peak and trough levels were collected during therapeutic nadroparin treatment in patients with renal impairment, obese patients, and controls. 27 patients (n = 68 samples) were evaluated and combined with published data (n = 319 samples from 35 patients) using population pharmacokinetic (popPK) modelling. Median peak level was 0.44 and 0.95IU/mL in renal impairment with and without dose reduction and 0.60 and 0.43IU/mL in obesity and controls, respectively. Trough levels were < 0.5IU/mL in all patients with renal impairment with dose reduction and in 5/6 control patients. In the popPK model, total body weight and eGFR were covariates for clearance and lean body weight for distribution volume. Model-based evaluations demonstrated peak levels below the therapeutic window in controls and increased levels in renal impairment. Dose reductions resulted in a different effect on peak and trough levels. Obese patients (BMI up to 32kg/m2) had similar levels upon weight-based dosing. In renal impairment, anti-Xa peak levels after dose reduction are comparable to those in controls. Weight-based dosing is suitable for obese patients. Aiming for peak levels between 0.6 and 1.0IU/mL in these patients would result in overexposure compared to controls. Considering the association of trough levels and bleeding risk and our findings, trough monitoring seems to be a suitable parameter to identify nadroparin accumulation.

Clinical analysis of 31 cases of fetal umbilical artery thrombosis

Objective: To analyze the ultrasonic manifestations, clinical features, high risk factors and key points of pregnancy management in prenatal diagnosis of umbilical artery thrombosis (UAT). Methods: The data of 31 pregnant women of UAT diagnosed by prenatal ultrasonography and confirmed after birth from July 2017 to July 2022 at the Women's Hospital, Zhejiang University School of Medicine were retrospectively analyzed, including the maternal characteristics, pregnancy outcomes and fetal complications. In addition, the baseline data and pregnancy outcomes were compared in 21 patients who continued pregnancy after diagnosis of UAT. Of the 21 UAT cases that continued pregnancy, 10 cases were treated with low molecular weight heparin (LMWH; LMWH treatment group), while the other 11 patients had expectant treatment(expectant treatment group). Results: The age of the 31 pregnant women was (30.2±4.7) years, of which 5 cases (16%,5/31) were advanced age pregnant women. The gestational age at diagnosis was (32.9±4.0) weeks, and the gestational age at termination of pregnancy was (35.6±2.9) weeks. In 31 fetuses with UAT, 15 cases (48%) had fetal distress, 11 cases (35%) had fetal growth restriction, and 3 cases (10%) had intrauterine stillbirth. There were 28 cases of live births, including 26 cases by cesarean section and 2 cases by vaginal delivery. There were also 3 stillbirths, all delivered vaginally. Four neonates had mild asphyxia and two newborns had severe asphyxia. Among the 31 cases, 10 cases were terminated immediately after diagnosis, the gestational age at diagnosis was (35.9±2.9) weeks. Another 21 pregnancies continued, and their gestational age at diagnosis was (31.4±3.7) weeks. The median prolonged gestational age in LMWH treatment group was 7.9 weeks (4.6-9.4 weeks), and all were live births. The median prolonged gestational age in the expectant treatment group was 0.6 weeks (0.0-1.0 weeks), and 2 cases were stillbirths. There was a statistically significant difference in prolonged gestational age (P=0.002). Conclusions: Ultrasound is the preferred method for prenatal detection of UAT. Clinicians need to be vigilant for UAT when a newly identified single umbilical artery is detected by ultrasound in the second or third trimesters. The decision to continue or terminate the pregnancy depends on the gestational age and the condition of fetus. Attention should be paid to fetal movements as the pregnancy continues. The treatment of LMWH as soon as possible after diagnosis of UAT may improve the pregnancy outcome.

P-506 Administration of low molecular weight heparin alleviate immune physiology in recurrent implantation failure modulating CCL2-CCR2 axis during frozen embryo transfer: effort from clinic to bench

Abstract Study question Does low molecular-weight heparin (LMWH) administration modulate CCL2-CCR2 axis in recurrent implantation failure (RIF) patients undergoing frozen embryo transfer (FET) to improve pregnancy salvage? Summary answer LMWH treatment attests beneficial immunological tolerance in vivo and in vitro through modulation of CCL2-CCR2 axis suggesting possible restoration of weak pro-inflammatory response in RIF. What is known already Immune imbalance in proportion of activated macrophages (M1) and alternatively activated macrophages (M2) impede endometrial receptivity and contribute to RIF. CCL2 (M2-asscociated) - CCR2 (t-helper-2 associated) axis orders macrophage polarization by influencing expression of functionally relevant and polarization associated genes and down-modulate pro-inflammatory cytokine production. Immunological effects of LMWH regulate pregnancy-promoting processes at foetal-maternal interface to provide an appropriate implantation process; outcomes being controversial. We aim to investigate the potential immunoregulatory properties of LMWH in patients with RIF undergoing FET, with particular regard to effects on macrophages and T-helper (Th) cells; two key players in promoting immune tolerance during pregnancy. Study design, size, duration This prospective cohort study constituted 121 women with RIF (≥3 failed embryo transfer) undergoing FET at Institute of Reproductive Medicine between January to October 2022. An incremental dose (4-12mg/day) of estradiol with (Group A; n = 62) or without (Group B; n = 59) LMWH (40 mg/day) from d2 to d12 with sequential ultrasound following intra-muscular progesterone (100mg/day) for 4 days was administered in all participants. Blood samples were collected to isolate plasma and peripheral-blood-mononuclear-cells (PBMCs). Participants/materials, setting, methods Monocytes were purified from PBMCs and cultured with GM-CSF or M-CSF to analyze factor/s which control CCL2-CCR2 expression along macrophage polarization by flow cytometry. Influence of CCL2 on GM-CSF-cultured macrophages (GM-MØ) and M-CSF-cultured macrophages (M-MØ) specific gene markers was analysed using quantitative RT-PCR (qRT-PCR). To assess immunological effects of LMWH in-vivo, Th-specific cytokine profile/s and respective chemokines were measured from plasma by Luminex xMAP technology. Statistical significance was set at p &amp;lt; 0.05. Main results and the role of chance The clinical pregnancy rate was higher in group A. (A vs B: 37.09% vs. 27.11%, p = 0.24). LMWH exposure significantly decreased the secretion of CCL2 (p &amp;lt; 0.01) and CCL22 (p &amp;lt; 0.001) in GM-CSF-cultured macrophages, while it increased CCL2, CCL20 production (p &amp;lt; 0.001) in both GM-MØ and M-MØ. However, expression of CCL7 was significantly lower (p &amp;lt; 0.01) in M-MØ and GM-MØ generated from CD14+ CD16+ monocytes and CD14 ++ CD16- monocytes respectively under LMWH exposure. qPCR analysis revealed a significant increase (p &amp;lt; 0.01) in the expression of various GM-MØ–specific genes including EGLN3, and SERPINE1 in macrophage supernatant post LMWH treatment. Expression of various M-MØ-specific marker/s such as IGF1, FOLR2, and HTR2B, is significantly up-regulated (p &amp;lt; 0.01) in Group B. Group A, although documented a decreased concentration/s (pg/ml) of Th17-type cytokine/s (IL-6 (1.88 ± 0.65 vs. 0.91 ± 0.43; p &amp;lt; 0.04 and IL-23 (17.94 ± 9.76 vs. 7.78 ± 3.43; p &amp;lt; 0.01)), at end of treatment, concentration of TGF-β was significantly higher (3909.05 ± 1248.35 vs. 2469.83 ± 1058.71; p &amp;lt; 0.01) which cue to probable maintenance in balance of inflammatory response at the time of implantation. No differences were observed in Th1-type cytokine level/s (IFN-γ and TNF-α). CXCL10, CXCL11, CXCL1, CXCL8, CCL17, CCL22 do not differ in vivo. Limitations, reasons for caution Beneficial effects of LMWH administration with a good sample size are clearly needed to confirm this hypothesis; hence result/s should be dealt with caution. Further to this, inclusion of other arm/s (corticosteroids, intralipid and/or intravenous immunoglobulin) will make the study much robust and conclusive. Wider implications of the findings The identification of atypical Th1-associated pro-inflammatory effects of LMWH drives to evaluate modulation of CCL2 expression to limit or potentiate macrophage activation in RIF; especially where anticoagulant effect is not the primary goal. Further, modification of cytokine expression/s might potentiate novel strategy derived from deregulated macrophage polarization. Trial registration number Not Applicable

Low-molecular-weight heparin therapy reduces 28-day mortality in patients with sepsis-3 by improving inflammation and coagulopathy.

Sepsis is a syndromic response to infection and is associated with high mortality, thus imposing a significant global burden of disease. Although low-molecular-weight heparin (LMWH) has been recommended to prevent venous thromboembolism, its anticoagulant and anti-inflammatory effects in sepsis remain controversial. Owing to the modification of the Sepsis-3 definition and diagnostic criteria, further evaluation of the efficacy and benefit population of LMWH is required. We performed a retrospective cohort study to assess whether LMWH improved the inflammation, coagulopathy, and clinical outcomes against Sepsis-3 and to identify the target patients. All patients diagnosed with sepsis at the First Affiliated Hospital of Xi'an Jiaotong University (the largest general hospital in northwest China) from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria. After 1:1 propensity score matching, 88 pairs of patients were categorized into the treatment and control groups based on subcutaneous LMWH administration. Compared with the control group, a significantly lower 28-day mortality was observed in the LMWH group (26.1 vs. 42.0%, p = 0.026) with a comparable incidence of major bleeding events (6.8 vs. 8.0%, p = 0.773). Cox regression analysis showed that LMWH administration was the independent protective factor for septic patients (aHR, 0.48; 95% CI, 0.29-0.81; p = 0.006). Correspondingly, the LMWH treatment group showed a significant improvement in inflammation and coagulopathy. Further subgroup analysis showed that LMWH therapy was associated with favorable outcomes in patients younger than 60 years and diagnosed with sepsis-induced coagulopathy (SIC), ISTH overt DIC, non-septic shock, or non-diabetics and in patients included in the moderate-risk group (APACHE II score 20-35 or SOFA score 8-12). Our study results showed that LMWH improves 28-day mortality by improving inflammatory response and coagulopathy in patients meeting Sepsis-3 criteria. The SIC and ISTH overt DIC scoring systems can better identify septic patients who are likely to benefit more from LMWH administration.

Low Molecular Weight Heparin Treatment Patterns and Outcomes in Cancer Patients with Acute Venous Thromboembolism: A Nationwide Cohort Study in France.

Patients with cancer have an increased risk of developing venous thromboembolism (VTE) and an increased risk of death from VTE. Until recently, the standard of care for treatment of VTE in cancer patients was low molecular weight heparins (LMWH). To determine treatment patterns and outcomes, we performed an observational study using a nationwide health database. Treatment patterns, rates of bleeding, and VTE recurrence at 6 and 12 months were assessed in cancer patients with VTE in France prescribed LMWH in 2013-2018. Of 31,771 patients administered LMWH (mean age 66.3 years), 51.0% were male, 58.7% had pulmonary embolism, and 70.9% had metastatic disease. At 6 months LMWH persistence was 81.6%, VTE recurrence had occurred in 1256 patients (4.0%) at a crude rate per 100 person-months (PM) of 0.90, and bleeding had occurred in 1124 patients (3.5%) at a crude rate per 100 PM of 0.81. At 12 months, VTE recurrence had occurred in 1546 patients (4.9%) at a crude rate per 100 PM of 0.71 and bleeding had occurred in 1438 patients (4.5%) at a crude rate per 100 PM of 0.66. Overall, VTE-related clinical event rates were high among patients administered LMWH, suggesting an unmet medical need.

Intracardiac Aspergilloma in a Case with Premature Birth: A Case Report

Aspergillus species, which are common in nature, can cause a highly variable spectrum from allergy to invasive disease, depending on the host's immunity and the presence of underlying lung disease. Isolated cardiac aspergilloma is extremely rare without fungal sepsis. In this case, cardiac aspergilloma in a preterm baby has presented. This premature baby born thirty-two weeks and 1000 gr, and hospitalized due to sepsis. She was operated after a mass and thrombus were detected in the echocardiography while receiving antibiotic therapy. During the operation, an intracardiac mass excision was made in the right atrium, starting from the inferior vena cava, measuring 9 x 10 mm (18 mm with the stem). The pathology result was compatible with aspergilloma, and Aspergillus colonization was detected in the myocardial tissue, which was also supported by the pathology laboratory. No growth was detected in blood cultures, and immunological examinations were found to be normal. Low molecular weight heparin and levatirecetam treatments were given to the patient who developed cardiac arrest, seizures, and multiple thrombi during the follow-up. At the end of eight months, the patient was discharged without sequelae, and voriconazole treatment was completed for 12 months. Outpatient follow-up continues. The immaturity of the phagocytic system and T cell-mediated immune system of premature babies, their need for long-term parenteral nutrition, the use of broad-spectrum antibiotics and steroids put these babies at risk for invasive fungal infections

Low molecular weight heparin treatment reduced apoptosis and oxidative cytotoxicity in the thrombocytes of patients with recurrent pregnancy loss and thrombophilia: Involvements of TRPM2 and TRPV1 channels.

Recurrent pregnancy loss (RPL) is known to be associated with increased thrombophilia and oxidative toxicity. However, the mechanism of thrombophilia apoptosis and oxidative toxicity is still unclear. In addition, the treatment of heparin induced regulator roles on intracellular free Ca2+ ([Ca2+ ]i ) and cytosolic reactive oxygen species (cytROS) concentrations in several diseases. TRPM2 and TRPV1 channels are activated by different stimuli, including oxidative toxicity. Theaim of this study was to investigate the effects of low molecular weight heparin (LMWH) via modulation of TRPM2 and TRPV1 on calcium signaling, oxidative toxicity, and apoptosis in the thrombocytes of RPL patients. Thrombocyte and plasma samples collected from 10 patients with RPL and 10 healthy controls were used in the currentstudy. The [Ca2+ ]i concentration, cytROS (DCFH-DA), mitochondrial membrane potential (JC-1), apoptosis, caspase-3, and caspase-9 levelswere high in the plasma and thrombocytesof RPL patients, although they were diminished by the treatments of LMWH, TRPM2 (N-(p-amylcinnamoyl)anthranilic acid) and TRPV1 (capsazepine) channel blockers. The current study results suggest that the treatment of LMWH is useful against apoptotic cell death and oxidative toxicity in the thrombocytes of patients with RPL, which seem to be dependent on increased levels of [Ca2+ ]i concentrationvia the activation of TRPM2 and TRPV1.

Meta-Analysis of the Efficacy of Low Molecular Weight Heparin and Aspirin in the Treatment of Thrombosis During Pregnancy and Effects on Coagulation Function.

At present, there is no comprehensive evaluation of the efficacy and safety of low molecular weight heparin (LMWH) for the treatment of thrombophilia during pregnancy in clinical practice. This study aimed to systematically evaluate the efficacy of LMWH in the treatment of patients and its effects on coagulation function, thereby providing a reference for the clinical treatment and prognosis evaluation of thrombophilia during pregnancy. Database PubMed, Web of Science and Embase as well as China National Knowledge Infrastructure and Wanfang Database were applied for the search of data. A comparative study on the efficacy of LMWH in the treatment of gestational thrombophilia was enrolled. Stata 16.0 software (Stata, College Station, TX, USA) was utilized to conduct the meta-analysis. A total of 487 relevant articles were retrieved and 14 studies were finally included. Patients in the LMWH combined with the low-dose aspirin group had a significantly higher live birth rate than those in the aspirin or LMWH treat group (OR (odds ratio) = 4.54, 95% CI (confidence interval): 2.76, 7.45). The adverse effects rate was lower in the LMWH combined with the low-dose aspirin group than in the aspirin or LMWH treatment group (OR = 0.40, 95% CI: 0.29, 0.56). After treatment, patients in the LMWH combined with the low-dose aspirin group had significantly lower D-dimer (SMD (standardized mean differences) = -1.50, 95% CI: -2.19, 0.80) and platelet count (PLT; SMD = -0.13, 95% CI: -0.35, 0.09) than those in the aspirin or LMWH treatment group. However, activated partial thromboplastin time (APTT; SMD = 0.16, 95% CI: -0.10, 0.42), thrombin time (TT; SMD = 0.60, 95% CI: -0.14, 1.34), plasma prothrombin time (PT; SMD = 0.42, 95% CI: -0.71, 1.56), and fibrin values (FIB; SMD = -0.92, 95% CI: -2.12, 0.28) were significantly higher in the LMWH combined with low-dose aspirin group than those in the aspirin or LMWH treatment group. LMWH heparin combined with low-dose aspirin can effectively correct coagulation function in pregnant women, improve prothrombotic state and increase the live birth rate, which has high clinical value.

Thrombin Generation Decrease After LMWH Administration in an Antithrombin-Deficient Pregnant Woman With a Homozygous HBS II Mutation.

The cases of antithrombin (AT)-deficient pregnant women with a homozygous HBS II mutation are relatively rare and are accompanied by an increased thrombophilic risk, which is manifested by increased thrombin generation (TG). It is very difficult to ensure their prophylactic treatment during pregnancy. We aimed to determine the utility of the thrombin generation assay (TGA) and anti-factor Xa (anti-FXa) test to monitor the effects of a prophylactic dose of low-molecular-weight heparin (LMWH) in a 28-year-old woman with homozygous AT deficiency caused by mutation c.391C > T#, (p.Leu131Phe†) in the SERPINC1 gene and to compare the findings with those from a group of pregnant and non-pregnant women also treated with LMWH. TG monitoring was chosen due to severe AT deficiency that was manifested by low levels of anti-FXa activity when monitoring the efficacy of LMWH treatment. A significant decrease in TG was detected in all monitored groups (P < .05). There were no thrombotic complications during the whole pregnancy of the woman with AT deficiency. Consistent monitoring of TG with LMWH anticoagulant therapy administration during pregnancy together with AT administration before and after delivery may improve the overall condition of pregnant women and the quality of their care.