Procoagulant State Research Articles

Thrombosis Risk Assessment in Myeloproliferative Neoplasm-Is There a Role for Viscoelastic Testing?

Philadelphia chromosome-negative myeloproliferative neoplasms include polycythemia vera, essential thrombocythemia, and myelofibrosis. They are associated with increased thrombotic events, and the primary goal of therapy, in particular those with polycythemia vera and essential thrombocythemia, is the prevention of thrombotic complications typically with antiplatelet therapy and/or cytoreduction. While several patient-, disease-, and genomic-related factors have been identified to influence thrombotic risks, there are no routine laboratory investigations to date that are sufficiently accurate to assess the underlying procoagulant state and predict the thrombotic risks. Conventional coagulation testing only measures time to clot formation and cannot reliably predict bleeding and thrombotic risks. Global coagulation assays such as thromboelastography, thrombin, and fibrin generation may provide a more thorough assessment of hemostatic function. Thromboelastography and thromboelastometry are viscoelastic tests which measure the mechanical properties of the hemostatic process, including the global dynamics of clot formation, stabilization, and dissolution. While viscoelastic testing is gaining traction in the investigations of coagulopathies and goal-directed blood product replacement in trauma and massive transfusion settings, the role of these assays in thrombosis is less well defined. Here, we provide a review of the current evidence of the role of viscoelastic testing in myeloproliferative neoplasm, particularly in the thrombotic risk assessment.

Skin capillary alterations in patients with acute SarsCoV2 infection.

Acute SarsCov2 infection is associated with endothelial dysfunction and 'endothelitis', which might explain systemic microvascular impairment. The presence of endothelial damage may promote vasoconstriction with organ ischemia, inflammation, tissue oedema and a procoagulant state resulting in an increase in the incidence of cardiovascular and cerebrovascular events. Microvascular thrombosis has been demonstrated in postmortem autopsy of COVID-19 patients; however, few data are available about skin capillary alterations in these patients. We evaluated skin microvascular alteration in 22 patients admitted to our hospital with SarsCov2 infection. Capillary density was evaluated by capillaroscopy in the nailfold and the dorsum of the finger in the acute phase of the disease. Capillaroscopy was repeated after 3 months (recovery phase). In addition, blood chemistry parameters and inflammatory markers were obtained during acute infection and at the recovery after 3 months. Patients with COVID-19 showed skin microvascular complications, such as thrombosis, microhaemorrhages and neoangiogenesis, which were not detected after 3 months from the discharge. A significant reduction of capillary density in the dorsum was observed after 3 months from the acute infection (97.2 ± 5.3 vs. 75.81 ± 3.9 n/mm 2P < 0.05). A significant inverse correlation between C-reactive protein and capillary density was observed in patients with acute SarsCov2 infection ( r = 0.44, P < 0.05). Conversely a direct correlation between capillary density during the acute phase and lymphocyte number was detected ( r = 0.49, P < 0.05). This is the first in-vivo evidence of skin capillary thrombosis, microhaemorrhages and angiogenesis in patients with acute SarsCov2 infection, which disappeared after 3 months, supporting the presence of endothelial dysfunction and inflammation. Capillary alterations might reflect systemic vascular effects of viral infection.

P-025: ABNORMAL MITOCHONDRIA RETENTION IN MATURE RED BLOOD CELLS OCCURS NOT ONLY IN SS BUT ALSO SC PATIENTS AND IS ASSOCIATED WITH HEMOLYTIC MARKERS

Purpose: Sickle cell disease (SCD), the most frequent genetic disease worldwide, results from a unique point mutation leading to the synthesis of the abnormal hemoglobin S (HbS). Under hypoxic condition, HbS polymerization causes a mechanical distortion of red blood cells (RBCs) called sickling, which is accompanied by a decrease of their deformability and their life span. SCD is characterized by a wide variability of clinical expression and a complex pathophysiology including vaso-occlusive processes, intravascular hemolysis as well as pro-inflammation, pro-coagulant and vaso-constrictive states. Recently, the abnormal mitochondria retention in mature RBCs has been documented in small series of SS patients but the biological consequences of this abnormality have not been fully documented and not been documented in other sickle cell syndromes. In the present study, we analyzed mature RBC mitochondria retention in both SS and SC patients, the second most frequent sickle cell syndrome, taking into account the biological/clinical features associated with these abnormal RBCs. Materials and methods: Eighty-nine adult SCD patients were included: 35 SS patients treated with hydroxyurea (HU), 15 SS patients not treated with HU and 39 SC patients. All of them were at steady-state and regularly followed by the sickle center of Guadeloupe. Twenty-one Guadeloupean adult controls (AA) were also included. Mature RBCs containing mitochondria were identified by flow cytometry using MitoTracker® probe as well as thiazole orange and anti-CD71 antibody to discriminate total and stress reticulocytes respectively. Correlations between the percentage of mature mitochondria+-RBCs and the following parameters were then analyzed: RBC deformability (Ektacytometry), reticulocytes (both total and CD71+) counts and levels of hemoglobin, total bilirubin, aminotransferase aspartate and lactate dehydrogenase levels using routine procedures. The impact of splenic function was evaluated using Howell-Jolly bodies, assessed by classic May-Grünwald Giemsa smears, as a marker of splenic dysfunction. We also analyzed the relationships between mitochondria+-RBCs and HU treatment as well as the rates of hyper vaso-occlusive (painful vaso-occlusion, acute chest syndrome, osteonecrosis) and hyper hemolytic (micro/macro-albuminuria, leg ulcer) complications. Results: Abnormal mitochondria+ RBCs were detected not only in SS but also in SC patients, although at a less extend. In both sickle cell syndromes, positive correlations with mitochondria+ RBCs were detected with hemolysis markers (percentage of total and stress reticulocytes). In addition, a negative relationship with hemoglobin level was detected in SS patients. A negative correlation was also detected between these abnormal mitochondria+ RBCs and RBC deformability. In contrast, no association between the presence of this RBC sub-population and clinical manifestations, hydroxyurea treatment or Howell-Jolly bodies was detected. Conclusion: In the present report, we demonstrated that abnormal retention of mitochondria in mature RBCs occurred not only in SS but also in SC patients. We also presented evidence that this phenotype could be related to hemolysis rate. Further studies are warranted to reveal the molecular mechanisms involved. E. BERNIT declares a conflict of interest: Consultancy, Expert: for NOVARTIS PHARMA SAS

Identification of early derangements of coagulation, hematological and biochemical profiles in patients with acute pancreatitis

BackgroundAcute pancreatitis (AP) is a severe disease involving various pathological processes. We aimed to use rapid -thromboelastography (r-TEG) combined with conventional coagulation assays (CCAs) and other laboratory tests, to identify early derangements in coagulation, hematological, and biochemical profiles in patients with AP. MethodsWe enrolled 177 patients diagnosed with AP and 121 controls. Blood samples were analyzed using r-TEG, CCAs, and hematological and biochemical tests within 2 h of patient admission. All testing parameters were compared between the patients and the controls. Pearson’s correlation coefficient was used to determine the correlation between the parameters among the patients. Logistic regression analysis was performed to evaluate the effects of the variables (demographic, coagulation, hematological and biochemical) on AP. ResultsUsing r-TEG and CCAs, we observed differences in coagulation parameters between the patients with AP and the controls. The r-TEG results showed a pro-coagulant state and increased platelet activation in AP patients. Pearson’s correlation analysis showed that inflammatory indicators were strongly correlated with coagulation/platelets in the pathological process of AP. Logistic regression analysis revealed that age, K, neutrophil (NEUT), triglyceride (TG) and blood amylase (AMY) were significantly associated with the development of AP. ConclusionCoagulation profile and platelet play essential roles in the pathogenesis of AP. Pro-coagulant state and increased platelet activation in patients with AP were demonstrated using r-TEG. The r-TEG parameter K, age, NEUT, TG, and AMY may be used as potential indicators of AP.

The Role of Extracellular Vesicles in COVID-19 Pathology.

Extracellular vesicles (EVs) have become a trending topic in recent years; they constitute a new intercellular communication paradigm. Extracellular vesicles are 30–4000 nanometers in diameter particles that are limited by a phospholipid bilayer and contain functional biomolecules, such as proteins, lipids, and nucleic acids. They are released by virtually all types of eukaryotic cells; through their cargoes, EVs are capable of triggering signaling in recipient cells. In addition to their functions in the homeostatic state, EVs have gained attention because of their roles in pathological contexts, eventually contributing to disease progression. In the Coronavirus disease 2019 (COVID-19) pandemic, aside from the scientific race for the development of preventive and therapeutic interventions, it is critical to understand the pathological mechanisms involved in SARS-CoV-2 infection. In this sense, EVs are key players in the main processes of COVID-19. Thus, in this review, we highlight the role of EVs in the establishment of the viral infection and in the procoagulant state, cytokine storm, and immunoregulation of innate and adaptive immune responses.

PROPHYLAXIS COMPLEX OF PLACENTAL DYSFUNCTION AFTER THE INFLUENZA TRANSFERRED IN THE EARLY STAGES OF PREGNANCY

Aim of the research: to increase the effectiveness of tactics for the presence of placental dysfunction in the background of influenza by developing and implementing a pathogenetically sound set of treatment and prevention measures.&#x0D; Materials and methods. Test the effectiveness of the proposed set of treatment-and-prophylactic measures, 80 pregnant women were selected after influenza transferred to early pregnancy: 40 women whose pregnancies were optimized tactics (main group) and 40 women (comparison group), which were conducted according to clinical protocols of the Ministry of Health. The cytotoxicity of natural killers (NK) was assessed by flow cytometry. The level of cytokines in peripheral blood was studied by enzyme-linked immunosorbent assay: interleukin-1 (IL-1), interleukin-10 (IL-10). The study of 25-hydroxyvitamin D, 25- (OH) D was performed by enzyme-linked immunosorbent assay. Determination of serum hormones was performed using standard kits for immunoradiometric determination.&#x0D; Results. Homeostasis in the first trimester of pregnancy after influenza is characterized by disorders that reflect further plantar dysfunction: a list of NK cytotoxicity, proinflammatory changes in the cytokine profile, the procoagulant state of the hemostasis system. Optimization of conservation in such tactics is the use of pathogenetic and preventive measures, treatment and prevention measures to prevent placental insufficiency and reduce the negative effects of hyperimmune reactions (aspirin, dipyridamole, progestogens, intravenous immunoglobulin, vitamin D). The use of the recommended set of measures has a positive effect on hormonal functions of the placenta (normalization of progesterone and estradiol levels). Immunity also improved: one month after starting treatment with NK lysis 1:10 decreased from 24 [15; 30] to 17 [13; 21] (p &lt;0.05), the balance of the cytokine profile was manifested in a decrease in the ratio of IL-1 / IL-1 from 1.36 [1.12; 2.51] to 0.82 [0.42; 1.16] (p &lt;0.05). The proportion of women with suboptimal vitamin D levels decreased significantly from 87.5% to 37.5% (p &lt;0.05), and in cases of deficient conditions it was possible to bring the level of vitamin D in the blood to optimal or suboptimal. Reduction of Willebrand factor from 1.54 [1.38; 1.74] to 0.92 [0.68; 1.08] IU / ml (p &lt;0.05) indicates an improvement in endothelial function, which in turn creates favorable conditions for the development of the feto-placental complex. The use of the recommended management of pregnant women after influenza in early pregnancy has reduced the incidence of placental insufficiency by almost 2 times, which was diagnosed in 13 (35.0%) women in the main group against 25 (62.5%) patients in the comparison group p &lt;0.05).&#x0D; Conclusions. The use of the recommended set of measures has a positive effect on hormonal functions of the placenta (normalization of progesterone and estradiol levels), immune status (reduction of NK cytotoxicity, cytokine profile balance), elimination of vitamin D deficiency and reduction of procoagulation potential of hemostasis. Creating favourable conditions for the development of gestation can reduce the incidence of placental insufficiency by almost 2 times to 35.0% vs. 62.5%.

Hypercoagulability in COVID-19: from an unknown beginning to future therapies.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health concern and is characterized by an exaggerated inflammatory response that can lead to a large variety of clinical manifestations such as respiratory distress, sepsis, coagulopathy, and death. While it was initially considered primarily a respiratory illness, different data suggests that COVID-19 can lead to a pro-inflammatory milieu and a hypercoagulable state. Several mechanisms attempt to explain the pro-coagulant state seen in COVID-19 patients, including increased fibrinogen concentration, different receptor binding, exhausted fibrinolysis, cytokine storm, and endothelial dysfunction. Some hematological parameters, such as elevated D-dimers and other fibrinolytic products, indicate that the essence of coagulopathy is massive fibrin formation. Moreover, elevated D-dimer levels have emerged as an independent risk factor for a worse outcome, including death, indicating a potential risk for deep vein thrombosis and pulmonary thromboembolism. Prophylactic anticoagulation is recommended in all in-patients with COVID-19 to reduce the incidence of thrombosis. Those with elevated D-dimer values or with a higher risk of developing thromboembolic events should be treated with higher doses of anticoagulant. Anticoagulation may not be enough in some circumstances, highlighting the need for alternative therapies. An understanding of the complex cross-talk between inflammation and coagulopathy is necessary for developing direct appropriate interventional strategies.

P1680: INFLUENCE OF D-DIMERS ON THROMBOEMBOLIC RISK IN PATIENTS WITH SARS-COV-2 IN AN INTENSIVE CARE UNIT

Background: Patients with COVID-19 have a higher incidence of thromboembolic events (TE) probably due to endothelial injury caused by the binding of SARS-CoV-2 to the ACE-2 receptors. The current literature showed that these patients have a tendency to a procoagulation state, and D-dimers (D-d) may be a global marker of hemostasis activation. In this way, the increase in D-d levels prompted the need to assess them at hospital admission and start anticoagulation (AC) prophylaxis, especially in intensive care unit (ICU) hospitalizations. Further, there is no consensus about the levels of D-d that could predict new TE. Aims: This study intends to determine whether D-d levels at hospital admission are related with an increased risk for TE during ICU hospitalization and determine an eventual cut-off level that could predict the risk of these events. Methods: Retrospective, observational, single-center study of patients with an established diagnosis of COVID-19, who underwent hospitalization in the ICU of a tertiary care hospital between December 2020 and January 2021. Clinical, analytical and demographic data were collected through clinical medical records. The data analysis was executed using IBM SPSS Statistics 28. To evaluate the predictive value of D-d on TE risk and survival in patients at ICU admission, a logistic regression and a ROC analysis were performed. Results: A total of 116 patients were included, 38 (32.8%) females and 78 (67.2%) males, with a median age of 62 (27-86) years old, 15 (12.9%) of them with a previous AC therapy. The mean number of days spent in the ICU was 16 (13-18) days. Out of the 116 patients, 46 (39.7%) patients passed away during ICU stay and 17 (14.7%) patients presented with thromboembolic events (2 of them with 2 TE). Out of the 19 total TE, there were 8 (42.1%) deep vein thrombosis, 3 (15.8%) pulmonary embolisms, 3 (15.8%) arterial strokes, 3 (15.8%) upper limb infarctions and 1 (5.3%) myocardial infarction. The logistic regression model shows that the D-d levels at ICU admission are statistically significant on the likelihood to have TE (χ2(2)=9.089, p=.011). The model explained 13.9% (Nagelkerke R2) of the variance in TE and correctly classified 86.1% of cases. Increasing levels of D-d at an ICU admission were associated with a slightly increased likelihood of exhibiting those events (relative risk=1.000051750). Another logistic regression was performed to evaluate whether D-d levels at ICU admission influenced prognosis (survivor vs non-survivor), however we didn´t find any differences statistically significant (p=0.727). Furthermore, the ROC analysis executed to determine the cut-off D-d level at ICU admission that would better predict the TE determined a value of 763.5 ng/mL with a sensibility of 76.5% and a specificity of 63.7%. Summary/Conclusion: D-d levels at ICU admission are a risk factor to account for on the likelihood of future TE on COVID-19 patients, although the relative risk is low. Despite the lack of consensus for predicting D-d levels, our results suggest that D-d values, at ICU admission, can be predictive of future TE. In spite of this finding, D-d levels at admission are not correlated to survival. At the moment, despite AC therapy during ICU stay, there were still patients with TE, which means that the current prophylaxis isn’t totally effective. Further investigation is needed to establish criteria for an upgraded AC, for a lower ICU stay time and to improve the prognosis.

Mast Cell Activation Syndrome in COVID-19 and Female Reproductive Function: Theoretical Background vs. Accumulating Clinical Evidence.

Coronavirus disease 2019 (COVID-19), a pandemic disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can affect almost all systems and organs of the human body, including those responsible for reproductive function in women. The multisystem inflammatory response in COVID-19 shows many analogies with mast cell activation syndrome (MCAS), and MCAS may be an important component in the course of COVID-19. Of note, the female sex hormones estradiol (E2) and progesterone (P4) significantly influence mast cell (MC) behavior. This review presents the importance of MCs and the mediators from their granules in the female reproductive system, including pregnancy, and discusses the mechanism of potential disorders related to MCAS. Then, the available data on COVID-19 in the context of hormonal disorders, the course of endometriosis, female fertility, and the course of pregnancy were compiled to verify intuitively predicted threats. Surprisingly, although COVID-19 hyperinflammation and post-COVID-19 illness may be rooted in MCAS, the available clinical data do not provide grounds for treating this mechanism as significantly increasing the risk of abnormal female reproductive function, including pregnancy. Further studies in the context of post COVID-19 condition (long COVID), where inflammation and a procoagulative state resemble many aspects of MCAS, are needed.

Full Characterization of Thrombotic Events in All Hospitalized COVID-19 Patients in a Spanish Tertiary Hospital during the First 18 Months of the Pandemic.

The presence of a procoagulant state, COVID-19-related coagulopathy, and an increased rate of thrombotic events (TEs) is widely known about. However, descriptive studies are scarce. Here, we conducted a large retrospective study including 2894 hospitalized COVID-19 patients followed up during the first 18 months of the pandemic to completely characterize any TE. Major TEs showed a 3.45% incidence rate. TEs were associated with increased intubation/90-day mortality risk [OR = 1.71, 95% CI (1.12–2.61), p < 0.013]. Venous thrombotic events (VTEs) were more frequent than arterial thrombotic events (ATEs) (72% vs. 28%), associated with enhanced levels of D-dimer (cross-linked fibrin derivatives formed during thrombolysis), which were related to mortality but more useful for early detection of thrombosis. In this regard, D-dimer plasma levels above 2014 µg/mL at hospital admission identify TEs with 91% accuracy (AUC = 0.91, p < 0.001), rising to almost 95% (AUC = 0.94, p < 0.001) with a cut-off value of 2666 µg/mL in VTEs. Moreover, 41% of TEs occurred in patients receiving LMWH thromboprophylactic treatments in hospital or domiciliary therapies. SARS-CoV-2 infection along with a sedentary lifestyle derived from the confinement in 2020 could be more determinant than a procoagulant state in patients with risk factors for TEs. Furthermore, the normal results obtained from the thrombophilia study after the acute process are linked to this independent procoagulant state and to SARS-CoV-2-derived coagulopathy.

Role of CD39 in COVID-19 Severity: Dysregulation of Purinergic Signaling and Thromboinflammation

CD39/NTPDase1 has emerged as an important molecule that contributes to maintain inflammatory and coagulatory homeostasis. Various studies have hypothesized the possible role of CD39 in COVID-19 pathophysiology since no confirmatory data shed light in this regard. Therefore, we aimed to quantify CD39 expression on COVID-19 patients exploring its association with severity clinical parameters and ICU admission, while unraveling the role of purinergic signaling on thromboinflammation in COVID-19 patients. We selected a prospective cohort of patients hospitalized due to severe COVID-19 pneumonia (n=75), a historical cohort of Influenza A pneumonia patients (n=18) and sex/age-matched healthy controls (n=30). CD39 was overexpressed in COVID-19 patients' plasma and immune cell subsets and related to hypoxemia. Plasma soluble form of CD39 (sCD39) was related to length of hospital stay and independently associated with intensive care unit admission (adjusted odds ratio 1.04, 95%CI 1.0-1.08, p=0.038), with a net reclassification index of 0.229 (0.118-0.287; p=0.036). COVID-19 patients showed extracellular accumulation of adenosine nucleotides (ATP and ADP), resulting in systemic inflammation and pro-coagulant state, as a consequence of purinergic pathway dysregulation. Interestingly, we found that COVID-19 plasma caused platelet activation, which was successfully blocked by the P2Y12 receptor inhibitor, ticagrelor. Therefore, sCD39 is suggested as a promising biomarker for COVID-19 severity. As a conclusion, our study indicates that CD39 overexpression in COVID-19 patients could be indicating purinergic signaling dysregulation, which might be at the basis of COVID-19 thromboinflammation disorder

8-OR: Plasminogen Deficiency Protects against Nonalcoholic Fatty Liver Disease and Insulin Resistance, but Not Diet-Induced Obesity

Obesity affects over 40% of the US population and predisposes individuals to metabolic syndrome, which is associated with a 50% increase in the risk of cardiovascular events. A documented clinical manifestation of obesity is a procoagulant and anti-fibrinolytic state. Elevated levels of circulating plasminogen activator inhibitor (PAI) -1 are correlated with metabolic syndrome, and PAI-1-deficient mice are protected from diet-induced obesity (DIO) . However, an unresolved question is whether plasminogen itself influences the development of obesity and associated disease sequelae? Here, we analyzed the impact of genetically-imposed plasminogen deficiency on the development of DIO and associated pathologies. Over the course of 20 weeks, plasminogen-deficient (Plg-) mice gained as much weight as the control mice (Plg+) on HFD, although HFD-fed Plg- mice had larger epididymal white adipose tissues than those of HFD-fed Plg+ mice. In contrast, while HFD-fed Plg+ animals displayed a fatty liver disease phenotype characterized by histological evidence of steatosis, elevated triglyceride content, and hepatocellular injury, HFD-fed Plg- mice were protected from developing each of these pathologies. HFD-fed Plg+ mice also developed hypercholesterolemia, whereas circulating cholesterol levels in Plg- mice were comparable to LFD-fed mice. Intriguingly, while the brown adipose tissue mass was comparable between diet and genotype, there was an upregulation of uncoupling protein-1 (Ucp1) expression in BAT of HFD-fed Plg- mice. Notably, whereas HFD-fed Plg+ mice showed evidence of insulin resistance as revealed by compromised glucose clearance, HFD-fed Plg- mice were partially protected. Collectively, our data suggest that plasmin (ogen) contributes to HFD-induced fatty liver disease and insulin resistance, and that plasminogen deficiency imposes a state of metabolically healthy obesity. Disclosure W.S.Hur: None. Y.Nguyen: None. Y.Patel: None. K.C.King: None. M.J.Flick: None. Funding National Institutes of Health (RDK112778)

FEATURES OF THE PARAMETERS OF RED BLOOD CELLS AND HEMOSTASIS IN PATIENTS WITH STROKES ASSOCIATED WITH CORONAVIRUS INFECTION

Objective: The purpose is to identify the peculiarities of the parameters of red blood cells (RBC) and hemostasis in patients with strokes associated with coronavirus infection. Design and method: A total of 124 patients (48.5 + 1.9 years) with impairments of cerebral circulation due to COVID-19 (confirmed by positive PCR test) had been examined. Among them, 74 patients had ischemic stroke, 25– transient ischaemic attack, 17– intracerebral hemorrhage, 8– subarachnoid hemorrhage. The parameters of hemostasis were measured by standard methods, electrical, viscoelastic parameters of RBC - by dielectrophoresis. Results: 71 patients (the 1st group) showed signs of intravascular coagulation and thrombosis: accelerated platelet-leukocyte aggregation, increased levels of coagulation products, reduced fibrinolysis activity (p = 0.001–0.04). The levels of D-dimer, fibrinogen, ESR, platelet count were higher in this group compared to the second one (p &lt; 0.01). A moderate increase of RBC summarized rigidity, viscosity was noted. The level of RBC hemolysis was associated with platelet count (r = 0.735,p = 0.03), D-dimer (r = 0.482, p &lt; 0.05), fibrinogen level (r = 0.374, p = 0.04). In 2nd group (53 persons), the markers of thrombosis had moderate deviations. Sharply reduced RBC deformability with increased summarized rigidity, viscosity was dominant coupled with the background of high electrical conductivity of cell membranes compared to the indicators in the 1st group (p &lt; 0.01). There was a decrease of membrane capacity, surface charge, cell dipole moment, polarizability than those in the 1st group (p = 0.0001–0.05). A sharp decrease of RBC deformability creates obstacles to overcoming small-diameter capillaries, leading to violations of microcirculatory blood flow. RBC deformability was associated with levels of ferritin (r = 0.451, p = 0.02), HbA1c (r = 0.480, p = 0.03), uric acid (r = -0.371, p &lt; 0.05), LDL cholesterol (r = 0.461, p = 0.02). Incubation of blood samples in vitro for 10 min with riboflavin, nicotinamide, inosine, which ensures RBC energy metabolism, restored the reduced RBC deformability (p &lt; 0.01), altered cell morphology (p = 0.04), decreased RBC aggregation (p &lt; 0.001). Conclusions: The revealed features of parameters of RBC hemostasis in stroke patients with coronavirus infection are associated with two independent pathogenetic mechanisms: thrombotic and hemorheologic. The thrombotic variant is due to procoagulant state and an activity of inflammation. The hemorheologic variant is caused by decrease of RBC energy metabolism, activity of enzymes.

Hemolytic uremic syndrome: An updated review

Hemolytic uremic syndrome (HUS) is a microangiopathic thrombotic disease. HUS is classified into typical, secondary, and atypical types. All types are characterized by thrombocytopenia, acute kidney impairment, and hemolysis. Infection with Shiga toxin from Escherichia coli causes typical HUS. Atypical HUS is frequently caused by abnormal complement activation via the alternative pathway because of gene mutations or autoantibodies synthesis. Secondary HUS accompanies post-transplantation, autoimmunity, cancer, etc. Endothelial cell injury initiates cells destruction stimulates procoagulant state, which activates platelet and thrombus generation, producing ischemic tissue injury.&#x0D; HUS pathogenesis is the result of an ineffective complement activation cycle that causes endothelial cells damage, activating platelet and thrombus formation. In some atypical HUS cases, interrupting the pathogenesis cycle of HUS by inhibiting complement activation might be beneficial, but not in those with gene mutations and patients with typical or secondary HUS. Hence, the pathogenesis of HUS types understanding is required; therefore, a comprehensive review of the differences and resemblances between the HUS types will be discussed and updated.

Mitral valvuloplasty with left atrial appendage closure and pacemaker implantation in a dog with severe myxomatous mitral valve degeneration: a case report

BackgroundMitral valvuloplasty (MVP) has been widely recognized as a treatment option for myxomatous mitral valve disease (MMVD). However, postoperative complications such as thromboembolism, arrhythmia, and pancreatitis in some cases have resulted in death. We treated a dog with severe MMVD complicated by impaired sinus function with MVP and pacemaker implantation. Also, due to an intrinsic procoagulant state and severe arrhythmia after the MVP, left atrial appendage (LAA) closure was performed to reduce the postoperative risk of thrombosis.Case presentationAn 11-year-old castrated 7.5-kg male Miniature Schnauzer with a history of congestive heart failure was brought to Shiraishi Animal Hospital for MMVD surgical treatment. Echocardiography revealed an enlarged left atrium and ventricle secondary to MMVD. Sinus arrest with 2 to 3-second periods of asystole was identified by electrocardiogram. Mitral valvuloplasty was performed with cardiopulmonary bypass to treat the MMVD. After coronary reperfusion, there was no spontaneous electrical activity. Cardiac arrest continued. Based on this surgical outcome, a permanent pacemaker was implanted. In addition, LAA closure with an AtriClip was performed to prevent intra-atrial thrombus formation. Cardiac remodeling and congestion were ameliorated after surgery. Sinus rhythm was restored 5 days postoperatively; however, the patient continued pacemaker dependent. All cardiac drugs were discontinued 3 months after surgery. The owner reported no postoperative complications (i.e., thrombosis), and the patient was brought for a check-up 4 months after the operation in good health.ConclusionsFor surgical MMVD cases complicated with impaired sinus function, the chances of spontaneous sinus rhythm are low, requiring pacemaker implantation. LAA closure may be considered to protect against decreased atrial function after mitral valvuloplasty and prevent intra-atrial thrombus formation.

Impaired Vagal Activity in Long-COVID-19 Patients.

Long-COVID-19 refers to the signs and symptoms that continue or develop after the “acute COVID-19” phase. These patients have an increased risk of multiorgan dysfunction, readmission, and mortality. In Long-COVID-19 patients, it is possible to detect a persistent increase in D-Dimer, NT-ProBNP, and autonomic nervous system dysfunction. To verify the dysautonomia hypothesis in Long-COVID-19 patients, we studied heart rate variability using 12-lead 24-h ECG monitoring in 30 Long-COVID-19 patients and 20 No-COVID patients. Power spectral analysis of heart rate variability was lower in Long-COVID-19 patients both for total power (7.46 ± 0.5 vs. 8.08 ± 0.6; p < 0.0001; Cohens-d = 1.12) and for the VLF (6.84 ± 0.8 vs. 7.66 ± 0.6; p < 0.0001; Cohens-d = 1.16) and HF (4.65 ± 0.9 vs. 5.33 ± 0.9; p = 0.015; Cohens-d = 0.76) components. The LF/HF ratio was significantly higher in Long-COVID-19 patients (1.46 ± 0.27 vs. 1.23 ± 0.13; p = 0.001; Cohens-d = 1.09). On multivariable analysis, Long-COVID-19 is significantly correlated with D-dimer (standardized β-coefficient = 0.259), NT-ProBNP (standardized β-coefficient = 0.281), HF component of spectral analysis (standardized β-coefficient = 0.696), and LF/HF ratio (standardized β-coefficient = 0.820). Dysautonomia may explain the persistent symptoms in Long COVID-19 patients. The persistence of a procoagulative state and an elevated myocardial strain could explain vagal impairment in these patients. In Long-COVID-19 patients, impaired vagal activity, persistent increases of NT-ProBNP, and a prothrombotic state require careful monitoring and appropriate intervention.

Gender differences in hemostatic potential in coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Clinical presentation and contribution of different risk factors in coronary artery disease (CAD) vary between genders. Women are known to be generally older, have more comorbidities and are more likely to present with atypical symptoms. Previous research suggests there are important gender differences in the pathophysiology of CAD. One of the important mechanisms for atherothrombotic events seems to be increased coagulation, for which differences in presentation between genders is not yet fully documented. Purpose Our aim was to investigate a possible correlation between gender and coagulation appraised by overall hemostatic, coagulation and fibrinolytic potentials (OHP, OCP and OFP) in patients with CAD. Methods Consecutive patients after a recent acute myocardial infarction (within 90 days from inclusion) had fasting blood samples withdrawn. OHP, OCP and OFP were determined using thrombin and recombinant tissue-type plasminogen activator by absorbance measurements at 405 nm in 1-minute intervals for 40 minutes. Areas under the curve were constructed for OCP and OHP with the obtained measurements, OFP was calculated as the difference between the two areas: OFP = [(OHP – OCP) / OCP] x 100 (%). Baseline data and cardiovascular risk factors profiles were collected. Proportions were compared using χ2 test, means were compared using t-test, medians were compared using Mann-Whitney U test, linear regression models were constructed for the multivariate analysis. Results We included 117 patients (mean age 56 ± 10 years), 23 (20%) were women. Arterial hypertension was present in 86 (73.5%), diabetes mellitus in 10 (8.5%), dyslipidemia in 75 (64.1%), family history in 46 (39.3%) patients, 54 (46.2%) were active smokers (within 2 years). There were no significant differences in mean age and risk factors presence between genders. Median OCP and median OHP were significantly higher in women (25.1 (interquartile range [IQR] 5.8) vs 21.8 (IQR 5.7), p=0.035; and 9.5 (IQR 4.3) vs 7.8 (IQR 3.1), p=0.032, respectively) while median OFP were similar. Female gender retained its significant predictive value after multivariate adjustment for age and traditional risk factors for OCP (R2 0.25; ANOVA for regression p&amp;lt;0.001; Beta 2.96 [0.61-5.31], p=0.014) and OHP (R2 0.24; ANOVA for regression p&amp;lt;0.001; Beta 2.04 [0.76-3.32], p=0.002). Conclusion In patients after acute myocardial infarction women seem to have a higher procoagulant state, as determined by OCP and OHP. Our findings suggest different pathophysiology of CAD in women, further research is needed to fully understand and address gender differences in CAD.

Pulmonary Endothelial Activation with COVID‐19: Possible Role of Reactive Oxygen Species

IntroductionRecent research suggests that endothelial activation plays a role in COVID‐19 pathogenesis by promoting a pro‐coagulative and pro‐inflammatory state. However, the mechanism by which the endothelium is activated in COVID‐19 is unclear.ObjectiveTo investigate the mechanism by which COVID‐19 activates the pulmonary endothelium.HypothesisThe pulmonary endothelium generates reactive oxygen species (ROS) upon exposure to the “inflammatory load” of the systemic circulation.MethodsCOVID‐19 was recreated in vitro and ex vivo, by exposing human lung endothelial cells (EC) or donor human lung slices (human precision‐cut lung slices or huPCLS) to medium supplemented with serum from COVID‐19 affected subjects. Sera were acquired from patients with COVID‐19 infection admitted to the Intensive Care Unit of the Hospital at the University of Pennsylvania. ROS (fluorescent dye, CellROX) and intercellular adhesion molecule (ICAM‐1) levels were assessed by fluorescence labeling and imaging.ResultsBoth EC activation (as monitored by ROS production) and pro‐inflammatory phenotype (as assessed by ICAM‐1), were significantly higher with COVID‐19 as compared to normal subjects.ConclusionsThe endothelium is activated with COVID‐19 via ROS production; thus, the ROS produced drive a pro‐inflammatory phenotype by inducing the expression of ICAM‐1, a pivotal marker of endothelium inflammation. As ROS mediates EC activation and inflammation during COVID‐19, ROS blockade could be a therapeutic target in maintaining vascular health.

Changes in plasma levels of IL-6 and D-dimer in high-risk thrombosis cancer patients undergoing chemotherapy

Background: Cancer and chemotherapy are venous thromboembolism (VTE) risk factors. The immune system and inflammation are essential in cancer-associated thrombosis's pathogenesis. Chemotherapy can induce inflammatory conditions that trigger the nuclear factor kappa B (NF-κB) signaling pathway to produce proinflammatory cytokines. Interleukin 6 (IL-6) improves procoagulant status primarily by inducing tissue factor (TF) expression. Tissue factor expression triggers the coagulation system, characterized by increased levels of D-dimer. This study assessed the change in plasma levels of IL-6 and D-dimer changed in high-risk thrombosis cancer patients undergoing chemotherapy. Methods: This study was a prospective cohort study of 54 newly diagnosed high-risk thrombosis cancer patients undergoing chemotherapy in Dr. Kariadi General Hospital from January 2021 to September 2021 based on inclusion and exclusion criteria. IL-6 and D-dimer concentrations were collected a day before and after chemotherapy. IL-6 measured by ELISA method and D-dimer measured by the turbidimetry chromogenic immunoassay method. We did correlation test, compared mean, and subgroup analysis. The p-value&lt;0.05 was significant. Results: There was a positive correlation between plasma levels of IL-6 and D-dimer both pre- and post-chemotherapy (r=0.36; 95% CI (0.1-0.6); p=0.006 and r=0.45; 95% CI (0.2-0.6); p=&lt;0.001, respectively). Post-chemotherapy plasma IL-6 (61.0±84.9 pg/mL) was significantly lower (p=0.022) than pre-chemotherapy (102.4±141.6 pg/mL). Subgroup analysis based on risks of thrombosis showed a significant decrease in plasma levels of IL-6 in the higher risk cancer group of thrombosis post-chemotherapy compared with the low risk cancer group (77.7±144.1 pg/mL vs -0.9±127.8 pg/mL; p=0.037). There was an increase in D-dimer plasma levels post-chemotherapy, but it was not statistically significant (2598.1±2487.8 µg/ml vs 3098.6±3547.4 µg/ml; p=0.512). The subgroup analysis based on blood type, tumor stage, chemotherapy regimen, and risk of thrombosis showed no significant differences in delta plasma IL-6 and D-Dimer levels pre- and post-chemotherapy. Conclusion: In high-risk thrombosis cancer patients who underwent chemotherapy, there was a statistically significant decrease in plasma levels of IL-6 post-chemotherapy. There was an increase in D-dimer plasma levels post-chemotherapy, but it was not statistically significant.

Direct oral anticoagulant administration in cirrhotic patients with portal vein thrombosis: What is the evidence?

In recent years, the traditional concept that cirrhosis-related coagulopathy is an acquired bleeding disorder has evolved. Currently, it is known that in cirrhotic patients, the hemostatic system is rebalanced, which involves coagulation factors, fibrinolysis and platelets. These alterations disrupt homeostasis, skewing it toward a procoagulant state, which can lead to thromboembolic manifestations, especially when hemodynamic and endothelial factors co-occur, such as in the portal vein system in cirrhosis. Portal vein thrombosis is a common complication of advanced liver cirrhosis that negatively affects the course of liver disease, prognosis of cirrhotic patients and success of liver transplantation. It is still debated whether portal vein thrombosis is the cause or the consequence of worsening liver function. Anticoagulant therapy is the mainstay treatment for acute symptomatic portal vein thrombosis. In chronic portal vein thrombosis, the role of anticoagulant therapy is still unclear. Traditional anticoagulants, vitamin K antagonists and low-molecular-weight heparin are standard-of-care treatments for portal vein thrombosis. In the last ten years, direct oral anticoagulants have been approved for the prophylaxis and treatment of many thromboembolic-related diseases, but evidence on their use in cirrhotic patients is very limited. The aim of this review was to summarize the evidence about the safety and effectiveness of direct oral anticoagulants for treating portal vein thrombosis in cirrhotic patients.