Thrombosis Journal最新文献

Background: The optimal dosing strategy for recombinant human soluble thrombomodulin (rhTM) in clinical practice for sepsis-induced disseminated intravascular coagulation (DIC) has not been comprehensively evaluated. This study aimed to investigate whether different rhTM dosing strategies influence mortality outcomes in patients with sepsis-induced DIC.

Methods: This retrospective, single-center cohort study included hospitalized patients aged ≥ 18 years who were diagnosed with sepsis and received rhTM for DIC treatment between 2011 and 2024. The primary outcome was in-hospital mortality across different rhTM dosing strategies (standard-dose or reduced-dose). The distribution of mortality between the two groups was compared using the log-rank test, and mortality estimates were analyzed using Cox proportional hazards analysis. To address confounding bias, we employed a double robust method that adjusted the model with covariates while accounting for inverse probability weighting of the treatment.

Results: A total of 167 patients were included in the analysis. Of these, 84 patients were in the standard-dose group and 83 patients were in the reduced-dose group. The median rhTM dosage for the entire cohort was 328 U/kg/day, with estimated plasma trough concentrations of 1622 ng/mL and 835 ng/mL in the standard-dose and reduced-dose groups, respectively. The mortality rate was 30% in the standard-dose group and 42% in the reduced-dose group, showing significantly better outcomes (adjusted hazard ratio: 0.561; 95% confidence interval, 0.323-0.973; P = 0.039).

Conclusions: This study demonstrated that a kidney function-based dose reduction strategy for rhTM administration is associated with inferior mortality outcomes in patients with sepsis-induced DIC. Although our findings are limited by the retrospective nature of this study, they provide valuable insights for future verification.

Background: Coronavirus Disease 2019 (COVID-19) has been linked to thromboembolic complications, especially in severely ill patients. Intracardiac thrombi are uncommon and pose a very high risk. Coinfection with tuberculosis (TB) may worsen the prothrombotic state and complicate treatment. A 21-year-old male patient from Afghanistan developed active pulmonary tuberculosis (TB) and COVID-19. He had a large, mobile thrombus in the right atrium and an acute pulmonary embolism (PE), but no deep vein thrombosis (DVT). He received remdesivir, anti-TB medication, anticoagulation, and underwent a successful surgical embolectomy. At a nine-month follow-up, he remained symptom-free.

Conclusion: This case highlights the rare occurrence of a right atrial thrombus in COVID-19, possibly exacerbated by TB co-infection. Early detection and tailored treatment, including surgery, are crucial to lowering mortality in these high-risk patients, but further research is needed to establish optimal management strategies and confirm the role of TB in thrombotic complications.

Background: To identify early diagnostic biomarkers for sepsis-induced disseminated intravascular coagulation, we investigated the relationship between the novel coagulation biomarkers and antithrombin with the development of Disseminated intravascular coagulation post-admission, as well as the prognosis of patients with sepsis.

Methods: We retrospectively collected data from septic patients admitted to the Emergency Intensive Care Unit (EICU) of a teaching hospital between October 2021 and September 2023. Multivariate logistic regression analysis was performed to identify risk factors, and receiver operating characteristic (ROC) curve analysis was used to assess the performance of the predictive model. In addition, non-parametric bootstrap analysis with 1,000 replications was conducted to evaluate the internal stability and empirical power of the predictive models, particularly given the limited sample size.

Results: Among 91 septic patients, 15 were diagnosed with DIC. Soluble thrombomodulin (OR: 1.28, 95% CI: 1.033-1.586, P = 0.024) and antithrombin activity (OR: 0.887, 95% CI: 0.792-0.994, P = 0.039) were identified as independent risk factors for the development of DIC in septic patients. The area under the curve (AUC) for soluble thrombomodulin and antithrombin was 0.788 and 0.757, respectively. When combined, the AUC increased to 0.858. Prothrombin Time (HR: 1.058, 95% CI: 1.016-1.102, P = 0.007) and APACHE II score (HR: 1.071, 95% CI: 1.005-1.141, P = 0.035) were identified as independent risk factors for 28-day mortality in septic patients. When combined, the AUC increased to 0.834. Bootstrap validation demonstrated strong discriminatory performance of both models, with a mean bootstrap AUC of 0.865 (empirical power = 0.994) for the DIC prediction model, and 0.836 (empirical power = 0.996) for the 28-day mortality model, further supporting the robustness and reliability of the findings despite the small sample size.

Conclusion: Elevated soluble thrombomodulin and decreased antithrombin may be associated with the early onset of disseminated intravascular coagulation in sepsis, but showed limited predictive value for 28-day mortality.

Objective: We aimed to evaluate the predictive value of the post-injury D-dimer decrease rate for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI). Additionally, we sought to establish a practical and efficient prediction model using a machine-learning algorithm to facilitate the early identification of high-risk individuals for VTE following TBI.

Methods: This study encompassed patients over the age of 18 with TBI who were admitted to our trauma center, between May 2018 and December 2021. The participants were allocated into training (70%) and validation (30%) cohorts. Within the training cohort, predictive models were developed using the generalized linear model (GLM), least absolute shrinkage and selection operator model (LSM), and random forest model (RFM), based on the clinical characteristics of the patients. The predictive accuracy of these models was assessed through the area under the receiver operating characteristic curve (AUROC). The stability and clinical practicability of the models were evaluated using a calibration curve and a clinical impact curve. The repeatability and reliability of the models were confirmed through a validation dataset.

Results: A total of 1,108 patients aged over 18 years with TBI who met the inclusion criteria were included in this study. Post-injury D-dimer on the third day (PDD3) and the post-injury D-dimer decreasing rate on the third day (PDDR3) were common predictors across the three models and were closely related to VTE for patients with TBI. The area under the receiver operating characteristic curve (AUROC) for the GLM, LSM, and RFM in the training cohort were 0.84 (95% confidence interval [CI]: 0.80-0.87), 0.85 (95% CI: 0.82-0.88), and 0.82 (95% CI: 0.78-0.86), respectively. In the verification cohort, the AUROC values were 0.85 (95% CI: 0.79-0.90), 0.85 (95% CI: 0.79-0.91), and 0.79 (95% CI: 0.73-0.86), respectively. The calibration curves of the three prediction models agree well with the actual observed results. All models showed a high clinical net income in the decision and clinical impact curves.

Conclusion: PDD3 and PDDR3 emerged as effective indices for predicting VTE in patients with TBI. We formulated a practical predictive model based on PDDR3, demonstrating satisfactory performance in forecasting VTE, which will assist clinicians in the early identification and initiation of PTP treatment for TBI patients.

Background: The dose of warfarin varies between individuals. Several formulas for predicting the maintenance dose of warfarin have been developed; however, most are complicated and not practical for clinical use.

Objective: To determine factors that predict warfarin dosage and the relationship between clinical variables and the maintenance dose of warfarin, and to develop a simple formula for predicting the maintenance dose of warfarin that is particularly useful for identifying patients with atrial fibrillation (AF) who are at higher risk of bleeding, without relying on pharmacogenetic data.

Materials and methods: This was a retrospective cohort study carried out between 2011 and 2021. All patients are started on warfarin with a target INR of 2.0 to 3.0. The prediction models for the maintenance dose were developed using a first-order equation. Correlation and performance of the formula were examined in training and validation cohorts.

Results: A training cohort consisted of 520 patients with a mean age of 69 ± 12 years. The proposed warfarin dosing formula was 3+(0.02×body weight (kg))-(0.02×age (years))-(0.4×serum creatinine (mg/dL)).When compared with a warfarin dosing formula, a 3-mg dose was associated with overdosing with an odds ratio [OR] of 3.31 (95%CI 2.26-4.84, p < 0.0001) in patients whose body weight was < 60 kg, OR 3.08 (95%CI 2.15-4.40, p < 0.0001) in patients aged ≥ 70 years and OR 2.39 (95% CI 1.67-3.44, p < 0.0001) in patients with eGFR < 50 mL/min. The findings in the validation cohort of 632 patients were concordant with the training cohort.

Conclusion: A simple warfarin dosing formula incorporating age, body weight, and serum creatinine reduced the risk of warfarin overdose in a high-risk population.

Background: Caprini score, the most commonly used assessment tool for predicting postoperative venous thromboembolism (VTE) risk has shown poor predictive value in colorectal cancer surgery. Recent risk assessment models (RAMs) Sir-Run-Run-Shaw VTE RAM, Risk of Venous Thromboembolism Algorithm (RVTA) score, and Colorectal Cancer - Venous Thromboembolism (CRC-VTE) score, which were specific for colorectal cancer, were developed and had good VTE predictive performance. We sought to externally validate for their generalizability and accuracy in Chinese patients undergoing colorectal cancer surgery.

Materials and methods: A retrospective analysis was conducted to predict the 6-month postoperative VTE risk in patients undergoing colorectal cancer surgery from January 2020 to December 2023. Demographic characteristics, clinical data, and 6-month postoperative VTE status of the patients were collected based on Sir-Run-Run-Shaw VTE RAM, RVTA score, CRC-VTE score, and Caprini score. We estimated the four VTE RAMs' discrimination of 6-month postoperative VTE risk by using the area under the receiver operating characteristic curve (AUROC). Calibration plots, Hosmer-Lemeshow test, and decision curve analysis were also explored to assess the predictive performance of the four VTE RAMs.

Results: A total of 323 patients were included. The median age of our cohort was 66 years (range, 58-73 years), and 182 (56.3%) patients were male. VTE occurred in 68 (21.1%) cases within 6 months after operation, with 5 cases of pulmonary embolism and 63 cases of deep vein thrombosis, of which 45 (66.2%) cases experienced VTE within 4 weeks after operation. Sir-Run-Run-Shaw VTE RAM, RVTA score, CRC-VTE score and Caprini score demonstrated possibly helpful discrimination, with AUCs of 0.691 (95%CI: 0.624-0.758), 0.638 (95%CI: 0.564-0.713), 0.728 (95%CI: 0.663-0.793), and 0.661 (95%CI: 0.596-0.725), respectively. The Hosmer-Lemeshow test indicated a lack of fit for Sir-Run-Run-Shaw VTE RAM, RVTA score, and CRC-VTE score (P < 0.05). Furthermore, decision curve analysis revealed that CRC-VTE score provided greater net benefits than the other VTE RAMs.

Conclusion: External validation of the four VTE RAMs for predicting postoperative VTE in a real-world cohort of colorectal cancer patients showed that CRC-VTE score outperformed the other VTE RAMs. It can help clinicians identify patients with high risk of VTE, thereby facilitating timely prophylactic interventions and close monitoring.

Objective: We aimed to ascertain the efficacy of hyperbaric oxygen therapy (HBOT) combined with dual antiplatelet therapy (DAPT) in elderly patients with acute cerebral infarction (ACI) and its impact on nerve factors.

Methods: A total of 122 patients were randomly assigned (1:1) to either the observation group or the control group. Patients in the control group received DAPT, And those in the observation group received HBOT combined with DAPT. Treatment was administered in 3 consecutive daily sessions starting from the date of admission. All patients were evaluated for efficacy after treatment. Before and after treatment, the National Institutes of Health Stroke Scale (NIHSS), and the Chinese Stroke Scale (CSS) were assessed; the levels of serum neuron-specific enolase (NSE) and plasma β-amyloid-42 (Aβ-42), hemorheology indices (whole blood viscosity and plasma viscosity), coagulation indicators [activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), and fibrinogen (Fbg)], and inflammatory factor [matrix metalloproteinase-9 (MMP-9), interleukin-6 (IL-6), and C-reactive protein (CRP)] were measured; the Barthel Index (BI) scores were recorded.

Results: After treatment, the observation group exhibited higher total effective rate, longer APTT, PT and TT, and higher BI score compared to the control group (all P < 0.05), while lower NIHSS, CSS scores, lower levels of NSE, Aβ-42, and Fbg, lower whole blood viscosity, plasma viscosity, MMP-9, IL-6 and CRP compared to the control group (all P < 0.05).

Conclusion: HBOT combined with DAPT can enhance efficacy, ameliorate neurologic impairments, enhance the effect of thrombolysis, reduce inflammatory response, and improve activities of daily living in elderly patients with ACI.

Background: Antithrombin deficiency (ATD) in pregnant patients significantly increases the risk of venous thromboembolism (VTE), but guidelines for managing anticoagulation during pregnancy, labour, and postpartum in patients with ATD are limited.

Case presentation: A pregnant woman with ATD suffered recurrent VTE in the 20^th week of pregnancy despite therapeutic doses of low-molecular-weight heparin (LMWH). The acute VTE was treated with argatroban and then with warfarin until delivery. LMWH with antithrombin (AT) concentrate was introduced before and shortly after delivery, followed by warfarin, which was continued also postpartum. No further complications occurred during the remainder of pregnancy, delivery, and two-year follow-up.

Conclusion: Our case highlights the challenges of anticoagulant treatment in pregnant patients with ATD. Standard weight-based LMWH dosing can lead to inadequate anticoagulation, as demonstrated by an acute VTE event in our patient. In our case, the use of argatroban proved to be safe and effective in the acute setting, followed by warfarin in the 2^nd and 3^rd trimester, and subsequent co-administration of LMWH and AT concentrate before and after delivery. Concomitant use of LMWH and AT concentrate allows for achieving target anti-Xa levels. Measurement of both anti-Xa and AT activity is advisable in this scenario to ensure reliable anticoagulant management. ATD is a heterogeneous disorder; therefore, each successfully managed pregnancy advances clinical practice.

Background: Heparin-induced thrombocytopenia (HIT) is a serious complication associated with heparin use in orthopedic surgery. However, its incidence and risk factors in total knee arthroplasty (TKA) and revision TKA (RTKA) remain unclear. This study aimed to evaluate how preoperative comorbidities, hospital characteristics, and patient demographics influence the incidence of HIT in patients who underwent TKA and RTKA. Differences in postoperative complications, mortality, hospital length of stay, HIT-related costs, and changes in HIT risk following revision surgery were examined.

Methods: This retrospective study examined data from the National Inpatient Sample (NIS) on patients with TKA and RTKA from 2010 to 2019, categorizing them by the incidence of HIT. Demographics (race, sex, and age) and hospital (admission type, insurance, hospital size, teaching status, and region) details were analyzed. Mortality, comorbidities, and perioperative complications were assessed, and logistic regression analyses were performed to identify potential risk factors.

Results: Pulmonary circulatory disorders were strongly associated with HIT in both TKA (P < 0.01, OR = 3.43) and RTKA (P < 0.01, OR = 4.13) groups. Teaching hospitals were associated with lower odds of HIT in the TKA group (P = 0.01, OR = 0.62). Risk factors in RTKA included valvular heart disease (OR = 2.50, 95% CI 1.12-5.57). Common complications among HIT cases included deep vein thrombosis, acute myocardial infarction, and acute renal failure. Pulmonary embolism, postoperative pneumonia, procedural pain, and prosthetic joint infection were more common in TKA group, whereas dyspnea was more prevalent in RTKA group.

Conclusions: Certain preoperative comorbidities and baseline characteristics are associated with increased HIT risk following TKA. RTKA is associated with higher odds of HIT and a greater incidence of adverse clinical outcomes. These findings may support the need for improved risk stratification and postoperative planning to reduce complications and enhance recovery.