Mechanisms of thrombosis in obesity

Plasminogen Activator Inhibitor-1 and Vitamin D Association in the Overweight and Obese Pediatric Population

BACKGROUND

Childhood overweight and obesity have been described by the World Health Organization as noncommunicable diseases and among the greatest public health threats since they have reached epidemic proportions. A child with obesity risks becoming an adult with obesity and developing metabolic and hemostatic disorders which are the basis for the development of coronary heart diseases. Recently, a number of clinical reports have demonstrated that both an increase in plasminogen activator inhibitor-1 (PAI-1) and a deficiency in 25OH-vitamin D3 (VD) are associated with an increase in thrombotic episodes.

METHODS

PAI-1 and VD levels were measured in 259 clinically overweight and obese children aged between 2 and 18 years enrolled in the Nutritional Education Program of the Bambino Gesù Children's Hospital and Research Institute of Rome (Italy) and 80 normal-weight subjects.

RESULTS

We observed increased HOMA-IR, PAI-1, and other inflammation indices associated with decreased VD levels when compared to normal-weight children.

CONCLUSIONS

Our results demonstrated that overweight and obesity are correlated with higher levels of the inflammation index. Moreover, our patients show high PAI-1 and low VD levels, confirming the high thrombotic risk in our pediatric population.

The vascular system and associated disorders

The vascular system, also called the circulatory system, is made up of the vessels that carry blood and lymph fluid through the body. The arteries and veins carry blood all over the body, sending oxygen and nutrients to the body tissues and taking away waste materials. This is a complex system in the body and can be affected by diseases with different pathogenic mechanisms. This article describes the pathophysiology of the main diseases of arteries and the venous system.

Impact of body mass index in patients receiving atezolizumab plus bevacizumab for hepatocellular carcinoma

BACKGROUND

Atezolizumab plus bevacizumab (Atezo/Bev) is first line-treatment for unresectable hepatocellular carcinoma (HCC). Body mass index (BMI) has demonstrated predictive value for response to immunotherapy in non-HCC cancer types. Our study investigated the effect of BMI on safety and efficacy of real-life use of Atezo/Bev for unresectable HCC.

METHODS

191 consecutive patients from seven centres receiving Atezo/Bev were included in the retrospective study. Overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and disease control rate (DCR) defined by RECIST v1.1 were measured in overweight (BMI ≥ 25) and non-overweight (BMI < 25) patients. Treatment-related adverse events (trAEs) were evaluated.

RESULTS

Patients in the overweight cohort (n = 94) had higher rates of non-alcoholic fatty liver disease (NAFLD) and lower rates of Hepatitis B compared to non-overweight cohort (n = 97). Baseline Child-Pugh class and Barcelona Clinic Liver Cancer stage were similar between cohorts, with lower rates of extrahepatic spread in the overweight group. Overweight patients had similar OS compared to non-overweight (median OS 15.1 vs. 14.9 months; p = 0.99). BMI did not influence median PFS (7.1 vs. 6.1 months; p = 0.42), ORR (27.2% vs. 22.0%; p = 0.44) and DCR (74.1% vs. 71.9%; p = 0.46). There were higher rates of atezolizumab-related fatigue (22.3% vs. 10.3%; p = 0.02) and bevacizumab-related thrombosis (8.5% vs. 2.1%; p = 0.045) in the overweight patients, but overall trAEs and treatment discontinuation were comparable between cohorts.

CONCLUSION

Atezo/Bev has comparable efficacy in overweight HCC patients, with an increase in treatment-related fatigue and thrombosis. Combination therapy is safe and efficacious to use in overweight patients, including those with underlying NAFLD.

Can We Make Blood Flow Restriction Training More Accessible? Validity of a Low-Cost Blood Flow Restriction Device to Estimate Arterial Occlusion Pressure

ABSTRACT

Keller, M, Faude, O, Gollhofer, A, and Centner, C. Can we make blood flow restriction training more accessible? Validity of a low-cost blood flow restriction device to estimate arterial occlusion pressure. J Strength Cond Res 37(8): 1581-1587, 2023-Evidence indicates that low-load resistance training with blood flow restriction (BFR) results in comparable gains in muscle mass and muscle strength as high-load resistance training without BFR. Low-load BFR training is a promising tool for areas such as rehabilitation because individuals are exposed to low mechanical stress. However, BFR training is only safe and effective when the cuff pressure is individually adjusted to the arterial occlusion pressure (AOP). Generally, thresholds for AOP are typically determined with sophisticated laboratory material, including Doppler ultrasound and tourniquet systems. Therefore, this study investigated the validity of a low-cost BFR product with automatic AOP assessment (AirBands International) compared with the gold standard for determining the individual AOP. Valid measurements were obtained at the arms and legs in 104 healthy volunteers. For the arms ( n = 49), a Bland-Altman analysis revealed a mean difference of 7 ± 13 mm Hg between the 2 methods, with slightly higher pressure levels for the gold standard (131 ± 14 mm Hg) than for the low-cost device (125 ± 17 mm Hg). For the legs ( n = 55), the low-cost device reached its maximum pressure capacity in 70% of subjects during AOP identification, making the results on the legs unreliable. Although the low-cost device is a valid tool for identifying the individual AOP in the arms, the device cannot be recommended for use at the legs because of its limited pressure capacity. When using the low-cost device for BFR training at the arms, it is recommended to apply the cuff pressure to 60% of the individual AOP to meet current BFR training guidelines.

Effectiveness, safety, and costs of thromboprophylaxis with enoxaparin or unfractionated heparin in inpatients with obesity

Background

Obesity is a frequent and significant risk factor for venous thromboembolism (VTE) among hospitalized adults. Pharmacologic thromboprophylaxis can help prevent VTE, but real-world effectiveness, safety, and costs among inpatients with obesity are unknown.

Objective

This study aims to compare clinical and economic outcomes among adult medical inpatients with obesity who received thromboprophylaxis with enoxaparin or unfractionated heparin (UFH).

Methods

A retrospective cohort study was performed using the PINC AI™ Healthcare Database, which covers more than 850 hospitals in the United States. Patients included were ≥18 years old, had a primary or secondary discharge diagnosis of obesity [International Classification of Diseases (ICD)-9 diagnosis codes 278.01, 278.02, and 278.03; ICD-10 diagnosis codes E66.0x, E66.1, E66.2, E66.8, and E66.9], received ≥1 thromboprophylactic dose of enoxaparin (≤40 mg/day) or UFH (≤15,000 IU/day) during the index hospitalization, stayed ≥6 days in the hospital, and were discharged between 01 January 2010, and 30 September 2016. We excluded surgical patients, patients with pre-existing VTE, and those who received higher (treatment-level) doses or multiple types of anticoagulants. Multivariable regression models were constructed to compare enoxaparin with UFH based on the incidence of VTE, pulmonary embolism (PE)---------related mortality, overall in-hospital mortality, major bleeding, treatment costs, and total hospitalization costs during the index hospitalization and the 90 days after index discharge (readmission period).

Results

Among 67,193 inpatients who met the selection criteria, 44,367 (66%) and 22,826 (34%) received enoxaparin and UFH, respectively, during their index hospitalization. Demographic, visit-related, clinical, and hospital characteristics differed significantly between groups. Enoxaparin during index hospitalization was associated with 29%, 73%, 30%, and 39% decreases in the adjusted odds of VTE, PE-related mortality, in-hospital mortality, and major bleeding, respectively, compared with UFH (all p < 0.002). Compared with UFH, enoxaparin was associated with significantly lower total hospitalization costs during the index hospitalization and readmission periods.

Conclusions

Among adult inpatients with obesity, primary thromboprophylaxis with enoxaparin compared with UFH was associated with significantly lower risks of in-hospital VTE, major bleeding, PE-related mortality, overall in-hospital mortality, and hospitalization costs.

Adipose Tissue Remodeling in Obesity: An Overview of the Actions of Thyroid Hormones and Their Derivatives

Metabolic syndrome and obesity have become important health issues of epidemic proportions and are often the cause of related pathologies such as type 2 diabetes (T2DM), hypertension, and cardiovascular disease. Adipose tissues (ATs) are dynamic tissues that play crucial physiological roles in maintaining health and homeostasis. An ample body of evidence indicates that in some pathophysiological conditions, the aberrant remodeling of adipose tissue may provoke dysregulation in the production of various adipocytokines and metabolites, thus leading to disorders in metabolic organs. Thyroid hormones (THs) and some of their derivatives, such as 3,5-diiodo-l-thyronine (T2), exert numerous functions in a variety of tissues, including adipose tissues. It is known that they can improve serum lipid profiles and reduce fat accumulation. The thyroid hormone acts on the brown and/or white adipose tissues to induce uncoupled respiration through the induction of the uncoupling protein 1 (UCP1) to generate heat. Multitudinous investigations suggest that 3,3',5-triiodothyronine (T3) induces the recruitment of brown adipocytes in white adipose depots, causing the activation of a process known as "browning". Moreover, in vivo studies on adipose tissues show that T2, in addition to activating brown adipose tissue (BAT) thermogenesis, may further promote the browning of white adipose tissue (WAT), and affect adipocyte morphology, tissue vascularization, and the adipose inflammatory state in rats receiving a high-fat diet (HFD). In this review, we summarize the mechanism by which THs and thyroid hormone derivatives mediate adipose tissue activity and remodeling, thus providing noteworthy perspectives on their efficacy as therapeutic agents to counteract such morbidities as obesity, hypercholesterolemia, hypertriglyceridemia, and insulin resistance.

Peri-operative anaesthetic management of women with obesity

Obesity in women is prevalent and growing at an alarming pace worldwide, resulting in significant healthcare and socioeconomic consequences. Obesity is a multisystemic disease that is associated with numerous comorbidities, particularly sleep-disordered breathing, hypertension, coronary artery disease, pulmonary hypertension, thromboembolism, and diabetes mellitus. Additionally, obesity poses several peri-operative challenges including difficulty with airway management and mechanical ventilation, challenges with intravenous access or regional blocks, the need for modified anaesthetic drug dosing, the requirement for correctly sized and rated equipment, and appropriate post-operative monitoring. Therefore, early multidisciplinary planning is crucial to identify and address important peri-operative and clinical issues. Parturients with obesity are especially at high risk due to the additional physiological changes and obstetric comorbidities associated with obesity. Antenatal anaesthetic consultation along with close communication and collaboration within the multidisciplinary team are important to improve maternal and neonatal safety.

Exploring effects of Simvastatin on coagulation mediators to alleviate the advancement of high cholesterol diet triggered neurodegeneration

The objectives of our study were to investigate the possible effect of Simvastatin in ameliorating high cholesterol diet (HCD)-induced neurodegeneration and to also investigate its possible action on coagulation mediators. In silico and in vitro studies were performed to evaluate the impact of Simvastatin on prime coagulation mediators. HCD was used to induce neuropathology in wistar rats and histopathological and immunohistochemical studies were performed to evaluate the efficacy of Simvastatin in preventing the advancement of neurodegeneration in obese rats. Biochemical analyses were used to estimate changes in lipid profile, oxidative stress, inflammatory and coagulation markers. Simvastatin showed good theoretical affinity to coagulation proteins, significantly reversed changes in inflammatory and coagulation biomarkers which were induced by HCD. Enhanced fibrinolytic activity of Simvastatin was revealed through in vitro analysis. Immunohistoanalysis showed raised level of Nrf2. Histopathological studies also supported neuroprotective potential of Simvastatin in HCD fed rats. Simvastatin demonstrated reduced hypercoagulation, enhanced fibrinolysis and reversed neurodegeneration in HCD exposed rats suggesting its potential role in preventing the progression of neurodegeneration in obesity.

Heterogeneous Treatment Effects of Therapeutic-Dose Heparin in Patients Hospitalized for COVID-19

IMPORTANCE

Randomized clinical trials (RCTs) of therapeutic-dose heparin in patients hospitalized with COVID-19 produced conflicting results, possibly due to heterogeneity of treatment effect (HTE) across individuals. Better understanding of HTE could facilitate individualized clinical decision-making.

OBJECTIVE

To evaluate HTE of therapeutic-dose heparin for patients hospitalized for COVID-19 and to compare approaches to assessing HTE.

DESIGN, SETTING, AND PARTICIPANTS

Exploratory analysis of a multiplatform adaptive RCT of therapeutic-dose heparin vs usual care pharmacologic thromboprophylaxis in 3320 patients hospitalized for COVID-19 enrolled in North America, South America, Europe, Asia, and Australia between April 2020 and January 2021. Heterogeneity of treatment effect was assessed 3 ways: using (1) conventional subgroup analyses of baseline characteristics, (2) a multivariable outcome prediction model (risk-based approach), and (3) a multivariable causal forest model (effect-based approach). Analyses primarily used bayesian statistics, consistent with the original trial.

EXPOSURES

Participants were randomized to therapeutic-dose heparin or usual care pharmacologic thromboprophylaxis.

MAIN OUTCOMES AND MEASURES

Organ support-free days, assigning a value of -1 to those who died in the hospital and the number of days free of cardiovascular or respiratory organ support up to day 21 for those who survived to hospital discharge; and hospital survival.

RESULTS

Baseline demographic characteristics were similar between patients randomized to therapeutic-dose heparin or usual care (median age, 60 years; 38% female; 32% known non-White race; 45% Hispanic). In the overall multiplatform RCT population, therapeutic-dose heparin was not associated with an increase in organ support-free days (median value for the posterior distribution of the OR, 1.05; 95% credible interval, 0.91-1.22). In conventional subgroup analyses, the effect of therapeutic-dose heparin on organ support-free days differed between patients requiring organ support at baseline or not (median OR, 0.85 vs 1.30; posterior probability of difference in OR, 99.8%), between females and males (median OR, 0.87 vs 1.16; posterior probability of difference in OR, 96.4%), and between patients with lower body mass index (BMI <30) vs higher BMI groups (BMI ≥30; posterior probability of difference in ORs >90% for all comparisons). In risk-based analysis, patients at lowest risk of poor outcome had the highest propensity for benefit from heparin (lowest risk decile: posterior probability of OR >1, 92%) while those at highest risk were most likely to be harmed (highest risk decile: posterior probability of OR <1, 87%). In effect-based analysis, a subset of patients identified at high risk of harm (P = .05 for difference in treatment effect) tended to have high BMI and were more likely to require organ support at baseline.

CONCLUSIONS AND RELEVANCE

Among patients hospitalized for COVID-19, the effect of therapeutic-dose heparin was heterogeneous. In all 3 approaches to assessing HTE, heparin was more likely to be beneficial in those who were less severely ill at presentation or had lower BMI and more likely to be harmful in sicker patients and those with higher BMI. The findings illustrate the importance of considering HTE in the design and analysis of RCTs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT02735707, NCT04505774, NCT04359277, NCT04372589.

Haemophilia B, severe childhood obesity and other extra-haematological features associated with similar 4Mb-deletions on Xq27: Clinical findings, molecular insights and literature update

INTRODUCTION

Haemophilia B (HB) is associated with pathogenic variants in F9. Hemizygous deletions encompassing the entire F9 and proximate genes may express extra-haematological clinical phenotypes.

AIM

To analyse the genotype/phenotype correlations in two unrelated boys with severe early childhood obesity (SCO), global developmental delay (GDD) and similar bleeding phenotype associated with comparable Xq27 deletions spanning the entire F9 and proximate genes, and characterise the pathogenic events estimating the most likely mutational mechanism involved.

METHODS

Entire F9-deletions were detected in three hemizygous unrelated probands with HB: two cases, C#1/C#2, presented SCO and GDD and a control patient (Co), who only had severe bleeding symptoms. Dense SNP-array and case-specific STS walking scan allowed characterisation of the deletion breakpoints. Extensive use of bioinformatics, statistics and clinical databases allowed the investigation of genotype-phenotype associations.

RESULTS

Patients C#1/C#2 and Co resulted in a complete F9 and additional gene deletions of variable extensions on Xq26.3-Xq27.2 (C#1/C#2/Co: 4.3Mb/3.9Mb/160Kb). C#1/C#2 common deleted gene SOX3 is directly associated with SCO, GDD and pituitary hypothyroidism (PH) whilst C#2 extra-deleted gene MAGEC2 indirectly relates to anal atresia (AA). Breakpoint analysis revealed the involvement of the mechanisms of Alu/Alu recombination for the first time in HB and non-homologous or alternative end-joining.

CONCLUSION

Our results represent the first report of unrelated patients with HB, SCO and GDD. This study and the literature update expand the spectrum of clinical findings and molecular insights observed in patients with HB caused by complete F9 and nearby SOX3 and MAGEC2 gene deletions, which may configure a contiguous gene syndrome.

Obesity and cardiovascular disease: An executive document on pathophysiological and clinical links promoted by the Italian Society of Cardiovascular Prevention (SIPREC)

The prevalence of obesity worldwide has increased in recent decades not only among adults, but also in children and adolescents. This phenomenon contributes to an increased risk of cardiovascular diseases (CVD), also after the adjustment for conventional risk factors such as hypertension, diabetes and dyslipidemia. Indeed, obesity contributes to the development of insulin resistance, endothelial dysfunction, sympathetic nervous system activation, increased vascular resistance and inflammatory and prothrombotic state which promote the incidence of major cardiovascular events. On the basis of this evidence, in 2021 obesity has been acknowledged as a definite pathological identity and identified as a recurrent, chronic non-communicable disease. Therapeutic strategies for the pharmacological treatment of obesity include the combination of naltrexone and bupropione and the lipase inhibitor orlistat and they have been recently implemented with the glucagon like peptide-1 receptor agonists semaglutide and liraglutide, which have produced positive and sustained effects on body weight reduction. If drug interventions are not effective, bariatric surgery may be considered, representing an efficacious treatment option for extreme obesity or obesity with comorbidities. The present executive paper is aimed to increase knowledge on the relationships between obesity and CVD, to raise the perception of this condition which is currently insufficient and to support the clinical practice management.

Molecular Mechanisms and Pathophysiological Significance of Eryptosis

Despite lacking the central apoptotic machinery, senescent or damaged RBCs can undergo an unusual apoptosis-like cell death, termed eryptosis. This premature death can be caused by, or a symptom of, a wide range of diseases. However, various adverse conditions, xenobiotics, and endogenous mediators have also been recognized as triggers and inhibitors of eryptosis. Eukaryotic RBCs are unique among their cell membrane distribution of phospholipids. The change in the RBC membrane composition of the outer leaflet occurs in a variety of diseases, including sickle cell disease, renal diseases, leukemia, Parkinson’s disease, and diabetes. Eryptotic erythrocytes exhibit various morphological alterations such as shrinkage, swelling, and increased granulation. Biochemical changes include cytosolic Ca2+ increase, oxidative stress, stimulation of caspases, metabolic exhaustion, and ceramide accumulation. Eryptosis is an effective mechanism for the elimination of dysfunctional erythrocytes due to senescence, infection, or injury to prevent hemolysis. Nevertheless, excessive eryptosis is associated with multiple pathologies, most notably anemia, abnormal microcirculation, and prothrombotic risk; all of which contribute to the pathogenesis of several diseases. In this review, we provide an overview of the molecular mechanisms, physiological and pathophysiological relevance of eryptosis, as well as the potential role of natural and synthetic compounds in modulating RBC survival and death.

The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis

BACKGROUND

The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size.

METHODS

This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m², overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class.

RESULTS

A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients).

CONCLUSION

Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.

Overweight in childhood and young adulthood increases the risk for adult thromboembolic events

BACKGROUND

Approximately one third of thromboembolic (TE) events are related to obesity, but to which extent elevated body mass index (BMI) during the distinct periods of childhood and puberty contributes is not known. We aimed to evaluate the impact of high BMI during childhood and puberty for the risk of adult venous and arterial thromboembolic events (VTE, ATE, respectively) in men.

METHODS

We included 37,672 men from the BMI Epidemiology Study (BEST) Gothenburg with data on weight and height in childhood, young adult age, and on pubertal BMI change. Information on outcomes (VTE [n = 1683], ATE [n = 144], or any first TE event [VTE or ATE; n = 1780]) was retrieved from Swedish national registers. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated by Cox regressions.

RESULTS

Both BMI at 8 years of age and the pubertal BMI change were associated with VTE, independently of each other (BMI at 8: HR 1.06 per standard deviation [SD] increase, 95% CI, 1.01;1.11; pubertal BMI change: HR 1.11 per SD increase, 95% CI, 1.06;1.16). Individuals with normal weight during childhood followed by young adult overweight (HR 1.40, 95% CI, 1.15;1.72), and individuals with overweight at both childhood and young adult age (HR 1.48, 95% CI, 1.14;1.92), had a significantly increased risk of VTE in adult life, compared with the normal weight reference group. Individuals with overweight in childhood and in young adult age had increased risk of ATE and TE.

CONCLUSION

Young adult overweight was a strong determinant, and childhood overweight a moderate determinant, of the risk of VTE in adult men.

Weight-adjusted dosing of tinzaparin for thromboprophylaxis in obese medical patients

Background

The optimal dose of tinzaparin for prophylaxis in obese medical patients is not well defined.

Objectives

To evaluate the anti-Xa activity in obese medical patients on tinzaparin prophylaxis adjusted for actual bodyweight.

Methods

Patients with a body mass index of ≥30 kg/m² treated with 50 IU/kg tinzaparin once daily were prospectively included. Anti-Xa and anti-IIa activity; von Willebrand factor antigen and von Willebrand activity; factor VIII activity; D-dimer, prothrombin fragments; and thrombin generation were measured 4 hours after subcutaneous injection between days 1 and 14 after the initiation of tinzaparin prophylaxis.

Results

We included 121 plasma samples from 66 patients (48.5% women), with a median weight of 125 kg (range, 82-300 kg) and a median body mass index of 41.9 kg/m² (range, 30.1-88.6 kg/m²). The target anti-Xa activity of 0.2 to 0.4 IU/mL was achieved in 80 plasma samples (66.1%); 39 samples (32.2%) were below and 2 samples (1.7%) above the target range. The median anti-Xa activity was 0.25 IU/mL (IQR, 0.19-0.31 IU/mL), 0.23 IU/mL (IQR, 0.17-0.28 IU/mL), and 0.21 IU/mL (IQR, 0.17-0.25 IU/mL) on days 1 to 3, days 4 to 6, and days 7 to 14, respectively. The anti-Xa activity did not differ among the weight groups (P = .19). Injection into the upper arm compared to the abdomen resulted in a lower endogenous thrombin potential, a lower peak thrombin, and a trend to a higher anti-Xa activity.

Conclusion

Dosing of tinzaparin adjusted for actual bodyweight in obese patients achieved anti-Xa activity in the target range for most patients, without accumulation or overdosing. In addition, there is a significant difference in thrombin generation depending on the injection site.

An overview on role of nutrition on COVID-19 immunity: Accumulative review from available studies

The novel coronavirus infection (COVID-19) conveys a serious global threat to health and economy. A common predisposing factor for development to serious progressive disease is presence of a low-grade inflammation, e.g., as seen in diabetes, metabolic syndrome, and heart failure. Micronutrient deficiencies may also contribute to the development of this state. Therefore, the aim of the present study is to explore the role of the nutrition to relieve progression of COVID-19. According PRISMA protocol, we conducted an online databases search including Scopus, PubMed, Google Scholar and web of science for published literatures in the era of COVID-19 Outbreak regarding to the status of nutrition and COVID-19 until December 2021. There were available studies (80 studies) providing direct evidence regarding the associations between the status of nutrition and COVID-19 infection. Adequate nutritional supply is essential for resistance against other viral infections and also for improvement of immune function and reduction of inflammation. Hence, it is suggested that nutritional intervention which secures an adequate status might protect against the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - coronavirus-2) and mitigate its course. We also recommend initiation of adequate nutritional supplementation in high-risk areas and/or soon after the time of suspected infection with SARS-CoV-2. Subjects in high-risk groups should have high priority for applying this nutritive adjuvant therapy that should be started prior to administration of specific and supportive medical measures.

Body Mass Index and Waist Circumference as Determinants of Hemostatic Factors in Participants of a Population-Based Study

Background: In contrast to studies in patients, an association between obesity and blood coagulation factors has not been established in the population. If confirmed it could become a target for primary prevention. Objective: To investigate the relationship between Body Mass Index (BMI) and waist circumference (WC) with plasma concentrations of antithrombin III, D-dimers, fibrinogen D, protein S, factor VIII, activated partial thromboplastin time (aPTT), quick value, and international normalized ratio (INR) in the general population. Materials and Methods: Participants of the Cooperative Health Research in the Region of Augsburg (KORA) S4 study who took part in the KORA Fit follow-up (2018-2019, aged 54-74 years) examination were eligible. Citrate plasma samples were collected in fasted participants. After the exclusion of participants with anticoagulative treatment, 776 participants (420 women and 356 men) with analytic data on hemostatic factors were included in the present analysis. Linear regression models were used to explore the association between BMI or WC with hemostatic markers, adjusted for sex, age, alcohol consumption, education, smoking status, and physical activity. In a second model, additional adjustments were made for the prevalence of stroke, hypertension, myocardial infarction, serum non-HDL cholesterol, and serum triglycerides. Results: In the multivariable models (with or without health conditions), significant positive associations with BMI were obtained for plasma concentrations of D-dimers, factor VIII, fibrinogen D, protein S, and quick value, while INR and antithrombin III were inversely associated. Similar to BMI, WC was significantly associated with all hemostatic factors, except for aPTT. Conclusion: In this population-based study, both increasing BMI and WC affect the blood coagulation system. Thus, modification of a prothrombotic coagulation profile emerged as a potential target for primary prevention in obese subjects.

Association Between Thromboelastometry Identified Hypercoagulability and Thromboembolic Complications After Arthroplasty: A Prospective Observational Study in Patients With Obesity

The prothrombotic state of obesity can increase the risk of thromboembolism. We aimed to investigate if there was an association between baseline hypercoagulable rotational thromboelastometry (ROTEM) profile and thromboembolic complications in arthroplasty patients with obesity. Patients with a body mass index ≥ 25 kg/m2 and/or waist circumference ≥94 cm (M) and 80 cm (F) undergoing hip and knee arthroplasty had pre- and postoperative ROTEM. ROTEM values were compared by outcome status using an independent sample equal-variance t-test. Of the 303 total participants, hypercoagulability defined as extrinsically activated thromboelastometry maximum clot firmness G score ≥ 11 K dyne/cm2, was observed in 90 (30%) of the 300 participants with preoperative ROTEM assays. Clinically significant thromboembolic complications occurred in 5 (1.7%) study participants before discharge and in 10 (3.3%) by 90 days. These included 6 with pulmonary emboli, 3 with deep venous thrombus, and 1 with myocardial infarction. We found no evidence for an association between baseline hypercoagulability and incident thromboembolic events, analysis limited by the number of events. Postoperative decrease in platelets and an increase in fibrinogen were observed. ROTEM parameter changes differed across obesity categories.

"Super" SERPINs-A stabilizing force against fibrinolysis in thromboinflammatory conditions

The superfamily of serine protease inhibitors (SERPINs) are a class of inhibitors that utilise a dynamic conformational change to trap and inhibit their target enzymes. Their powerful nature lends itself well to regulation of complex physiological enzymatic cascades, such as the haemostatic, inflammatory and complement pathways. The SERPINs α2-antiplasmin, plasminogen-activator inhibitor-1, plasminogen-activator inhibitor-2, protease nexin-1, and C1-inhibitor play crucial inhibitory roles in regulation of the fibrinolytic system and inflammation. Elevated levels of these SERPINs are associated with increased risk of thrombotic complications, obesity, type 2 diabetes, and hypertension. Conversely, deficiencies of these SERPINs have been linked to hyperfibrinolysis with bleeding and angioedema. In recent years SERPINs have been implicated in the modulation of the immune response and various thromboinflammatory conditions, such as sepsis and COVID-19. Here, we highlight the current understanding of the physiological role of SERPINs in haemostasis and inflammatory disease progression, with emphasis on the fibrinolytic pathway, and how this becomes dysregulated during disease. Finally, we consider the role of these SERPINs as potential biomarkers of disease progression and therapeutic targets for thromboinflammatory diseases.

Assessment of Lower Limb Deep Vein Thrombosis: Characterization and Associated Risk Factors Using Triplex Doppler Imaging

Background

Deep vein thrombosis (DVT) is a common health problem. Accurate diagnosis of DVT is essential to avoid potentially fatal acute consequences of pulmonary embolism.

Aim

The study aims to assess deep venous thrombosis (DVT) of the lower limbs and to analyze the related risk factors.

Methods

This is a retrospective study including 60 patients who were examined using Triplex Doppler imaging. The patients were referred to the imaging departments with symptoms of lower limb DVT. The risk of DVT was expressed as an odds ratio (OR) with 95% confidence interval. Multiple logistic regression analysis was used to detect the independent risk factors. P value <0.05 was considered a significant statistic.

Results

Among the Saudi patients in Najran, acute DVT was more prevalent than chronic one (56.7% vs 38.3%), while subacute is less frequent (5%). DVTs are more prevalent in females than males (60% vs 40%) and most commonly affect patients older than 40. DVTs affect the left lower limb veins more than the right limb (75% vs 15%) and are less frequent on both sides (10%). The left popliteal vein (PV) and left common femoral vein (CFV) were the most common sites for acute DVTs. Binary logistic analysis revealed the independent risk factors for developing lower extremity DVT; malignancy (OR = 2.84, 95% CI = 0.518-15.513), surgery (OR = 2.66, 95% CI = 0.411-17.281), trauma (OR = 2.30, 95% CI = 0.452-11.658), and diabetes and hypertension (OR = 1.53, 95% CI = 0.335-6.969).

Conclusion

Acute lower limb DVT was more prevalent than chronic one. Malignancy, surgery, trauma, diabetes mellitus, and hypertension were the most common risk factors for lower limb DVTs. Left popliteal and left common femoral veins were the most common sites of acute DVTs.

Comparative effectiveness and safety of extended anticoagulant therapy among Medicare beneficiaries with venous thromboembolism

Guidelines recommend an extended course of anticoagulation therapy for patients who experienced venous thromboembolism (VTE) without transient provocation, however, optimal duration remains uncertain. We assessed effectiveness and safety of extended use of apixaban and warfarin greater than 6 months of initial treatment in patients with VTE. We conducted a retrospective cohort study of Medicare beneficiaries aged greater than or equal to 18 years with deep vein thrombosis or pulmonary embolism. Patients were required to have initiated anticoagulants within 30 days of their first VTE diagnosis, completed 6 months of initial anticoagulant treatment, and received extended phase treatment with apixaban (the apixaban group) or warfarin (the warfarin group) or no extended therapy. Multivariable Cox proportional hazards modeling with inverse probability treatment weighting was used to compare recurrent VTE, mortality, and major bleeding risks among the three groups. Mean extended-treatment duration was up to 10 months and 14 months in apixaban and warfarin groups, respectively. Compared with no extended treatment, apixaban use was associated with decreased risks of recurrent VTE (hazard ratio [HR] = 0.08, [95% confidence interval [CI]: 0.01-0.41]) and mortality (HR = 0.37, [95% CI: 0.27-0.51]) without increased major bleeding risk (HR = 1.29, [95% CI: 0.68-2.45]); warfarin use was associated not with recurrent VTE risk change but with increased major bleeding risk (HR = 2.14, [95% CI: 1.26-3.65]) and decreased mortality risk (HR = 0.39, [95% CI: 0.29-0.51]). Compared with warfarin, apixaban use was associated with decreased recurrent VTE (HR = 0.13, [95% CI: 0.03-0.63]) and major bleeding (HR = 0.56, [95% CI: 0.32-0.98]) risks. Subgroup and sensitivity analyses (e.g., intention-to-treat) findings remained consistent. Compared with warfarin or no extended therapy, extended-apixaban use was associated with reduced risk of recurrent VTE without increased major bleeding risk. Continuing anticoagulant therapy with apixaban greater than 6 months may be effective and safe.

The impact of obesity on total knee arthroplasty outcomes: A retrospective matched cohort study

Background

Total Knee Arthroplasty (TKA) is a common orthopaedic surgery to treat advanced knee arthritis. Post-operative complications can be affected by obesity, defined as a body mass index of 30 kg/m2 or higher. We examine the rates of specific complications, revision rates, and costs of care following TKA and compare them between multifactor matched obese and non-obese patients. We hypothesize these outcomes will be worse in obese patients than in non-obese patients.

Methods

This retrospective study of the PearlDiver database queries for patients who underwent TKA under Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9) codes between January 2011 and January 2020. Patients were matched based on age, gender, and comorbidity indices, and various complications, revision rates, and costs were compared between the matched obese and non-obese patient groups.

Results

Obesity was associated with higher rates of surgical complications, such as wound complications, surgical site infections, need for revision, and higher total cost of care one year after TKA, and medical complications such as, acute kidney injury, deep vein thrombosis, urinary tract infection, and narcotics use, but significantly lower rates of anemia, arrhythmia, cardiac arrest, pneumonia, and transfusion. Obese patients also experienced significantly lower drug costs of care.

Conclusion

Outcomes were not definitively worse in obese patients when compared to matched non-obese patients. Nevertheless, understanding the complications that can arise following TKA will assist in educating patients about potential risks from surgery and guide surgeons in caring for their patients as obesity is predicted to continue increasing in prevalence. As such, future studies should examine underlying mechanisms that cause these complications to develop potential therapies.

Acute Pediatric Pancreatitis Presenting with Splenic Vein Thrombosis

Acute pancreatitis among the pediatric population can result from genetic disorders, anatomic anomalies, gallstones, trauma, and medications; trauma and idiopathic causes being the most common. Although chronic pancreatitis presents with increased severe long-term complications, acute pancreatitis presents with its share of complications such as fistulas, pseudocysts, and venous abnormalities. With an increase in hospitalization rates of acute pancreatitis among the pediatric population, the importance of understanding rare complications and how to further recognize these complications can aid in the diagnosis, medical management, and intervention necessary to optimize a patient's outcome. Our patient presented with a rare complication of splenic vein thrombosis (SVT), which is a complication that can also be observed in adults with acute pancreatitis. SVTs are uncommon in both the adult and pediatric populations, and they have received little attention or research in the pediatric population. We report a case that will highlight a rare case of SVT presenting in a pediatric patient with acute necrotizing gallstone pancreatitis.

Obesity as a Risk Factor for Venous Thromboembolism Recurrence: A Systematic Review

Background and Objectives: Venous thromboembolism (VTE) encompasses Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE). The duration of anticoagulant therapy following a VTE event partly relies on the risk of recurrent VTE which depends on the clinical setting where VTE occurred and the VTE risk factors present. Obesity is considered a minor risk factor and studies in the literature have provided conflicting results on whether obesity influences the development of recurrences. The aim of the present study is to assess the effect of obesity on VTE recurrence in patients that suffered from a previous VTE event. Materials and Methods: We conducted systematic research for English language studies in Medline, Scopus and ProQuest databases in order to identify publications that assess the risk of VTE recurrence in obesity. Inclusion criteria were: 1. Diagnosis of VTE, 2. Definition of obesity as a body mass index ≥30 kg/m², 3. Report of the risk of obesity on VTE recurrence, 4. Adult human population. We did not include case reports, review studies or studies that assessed other forms of thrombosis and/or used other definitions of obesity. We used the Newcastle-Ottawa scale to address the quality of the studies. Results: Twenty studies were included in the analysis, of which 11 where prospective cohort studies, 6 were retrospective cohort studies, 1 was a cross-sectional study, and 2 were post-hoc analysis of randomized clinical trials. Obesity was significantly associated with recurrences in 9 studies and in 3 of them the association was significant only in females. Conclusions: There is heterogeneity between the studies both in their design and results, therefore the effect of obesity on VTE recurrence cannot be adequately estimated. Future randomized clinical studies with appropriately selected population are needed in order to streamline the effect of obesity on VTE recurrence.

Strategies for Therapeutic Amelioration of Aberrant Plasma Zn2+ Handling in Thrombotic Disease: Targeting Fatty Acid/Serum Albumin-Mediated Effects

The initiation, maintenance and regulation of blood coagulation is inexorably linked to the actions of Zn²⁺ in blood plasma. Zn²⁺ interacts with a variety of haemostatic proteins in the bloodstream including fibrinogen, histidine-rich glycoprotein (HRG) and high molecular weight kininogen (HMWK) to regulate haemostasis. The availability of Zn²⁺ to bind such proteins is controlled by human serum albumin (HSA), which binds 70–85% of plasma Zn²⁺ under basal conditions. HSA also binds and transports non-esterified fatty acids (NEFAs). Upon NEFA binding, there is a change in the structure of HSA which leads to a reduction in its affinity for Zn²⁺. This enables other plasma proteins to better compete for binding of Zn²⁺. In diseases where elevated plasma NEFA concentrations are a feature, such as obesity and diabetes, there is a concurrent increase in hypercoagulability. Evidence indicates that NEFA-induced perturbation of Zn²⁺-binding by HSA may contribute to the thrombotic complications frequently observed in these pathophysiological conditions. This review highlights potential interventions, both pharmaceutical and non-pharmaceutical that may be employed to combat this dysregulation. Lifestyle and dietary changes have been shown to reduce plasma NEFA concentrations. Furthermore, drugs that influence NEFA levels such as statins and fibrates may be useful in this context. In severely obese patients, more invasive therapies such as bariatric surgery may be useful. Finally, other potential treatments such as chelation therapies, use of cholesteryl transfer protein (CETP) inhibitors, lipase inhibitors, fatty acid inhibitors and other treatments are highlighted, which with additional research and appropriate clinical trials, could prove useful in the treatment and management of thrombotic disease through amelioration of plasma Zn²⁺ dysregulation in high-risk individuals.

Obesity, Hypovitaminosis D, and COVID-19: the Bermuda Triangle in Public Health

PURPOSE OF REVIEW

The COVID-19 pandemic has challenged public health to a significant extent by markedly increasing morbidity and mortality. Evidence suggests that obesity and hypovitaminosis D constitute important risk factors for SARS-CoV-2 infection, severity of disease, and poor outcomes. Due to their high prevalence globally, obesity and hypovitaminosis D are considered pandemics. This review presents current epidemiologic and genetic data linking obesity, hypovitaminosis D, and COVID-19, highlighting the importance of the convergence of three pandemics and their impact on public health. We also briefly summarize potential mechanisms that could explain these links.

RECENT FINDINGS

Epidemiologic data have shown that obesity is an independent risk factor for COVID-19, severe disease and death, and genetic evidence has suggested a causal association between obesity-related traits and COVID-19 susceptibility and severity. Additionally, obesity is independently associated with hypovitaminosis D, which is highly prevalent in subjects with obesity. Hypovitaminosis D is independently associated with a higher risk for COVID-19, severity, hospitalization, infectious complications, acute respiratory distress syndrome, and poor outcomes. However, genome-wide association studies have not revealed any causal association between vitamin D levels and the risk for COVID-19, while there is no robust evidence for a beneficial role of vitamin D supplementation in the prevention and treatment of COVID-19. In the context of the ongoing COVID-19 pandemic, the epidemiologic impact of obesity and hypovitaminosis D is emphasized. Efforts to increase public awareness and reinforce preventive and therapeutic measures against obesity and hypovitaminosis D are strongly required.

Incidence and Predictors of Recurrence and Mortality Following First Venous Thromboembolism Among the Saudi Population: Single-Center Cohort Study

Background

Little is written about recurrence and mortality rates after a first episode of venous thromboembolism (VTE) among Saudi population.

Aim

Determine incidence rates and assess predictors of recurrence and mortality following the first VTE event.

Patients and Methods

A total of 1124 patients aged ≥18 years with symptomatic VTE confirmed by imaging tests were evaluated. The incidence of VTE recurrence and mortality were assessed. The association between patient characteristics, and VTE recurrence and mortality was explored by estimating the hazard ratio (HR) and 95% confidence interval (CI). The difference between cancer-related, provoked and unprovoked VTE in terms of recurrence and mortality was explored using Kaplan–Meier curves.

Results

The annual incidence rate of the first VTE was 1.7 per 1000 patients. Of 1124 patients with first VTE, 214 (19%) developed recurrent VTE, and 192 (17%) died with overall incidence rates of 15.8 per 100 person-years (95% CI, 13.8–18.0) and 10.0 per 100 person-years (95% CI, 8.7–11.5). Intensive care unit (ICU) admission (HR, 2.15; 95% CI, 1.67–3.10), presence of active cancer (HR, 2.97; 95% CI, 1.87–3.95), immobilization (HR, 2.52; 95% CI, 1.79–3.67), infection (HR, 2.32; 95% CI, 1.94–3.45), and pulmonary embolism ± deep venous thrombosis (HR, 2.22; 95% CI, 1.56–3.16) were found to be independent predictors of recurrent VTE. Recurrence carries a high hazard of mortality (HR, 5.21; 95% CI, 3.61–7.51). The estimated median time to VTE recurrence was lower in cancer-related VTE (18.7 months) compared with provoked (29.0 months) and unprovoked VTE (28.4 months). The estimated survival median time was lower in cancer-related VTE (21.8 months) compared with provoked (30.5 months) and unprovoked VTE (29.8 months).

Conclusion

Immobilization and presence of active cancer, infection, and PE ± DVT were significant predictors of recurrent VTE. Patients who developed recurrent VTE had a 5.2-fold higher hazard of mortality compared with patients with no VTE recurrence.

Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors

Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m², p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.

Association of obesity with COVID-19 diseases severity and mortality: A meta-analysis of studies

Background

The literature on COVID-19 infection is growing every single day, and evidence of presence or absence of association between obesity and COVID-19 adverse outcomes should be revisited. Therefore, this study summarizes the pooled association of obesity with COVID-19 adverse outcomes and mortality.

Methods

We searched PubMed and Science direct databases using specific terms and defined criteria. Data were analyzed using Comprehensive Meta-Analysis V2 (Biostat, Englewood, NJ, USA)) random-effect models were used to calculate the odds ratio (OR) with 95% confidence intervals (95% CIs) of infection severity and mortality associated with obesity.

Results

Results revealed that obesity is not associated with COVID-19 mortality (OR = 1.1; 95%CI: 0.8 to 1.3) but with other adverse outcomes (OR = 2.4; 95%CI: 1.7 to 3.3).

Conclusion

Our findings support previous findings that obesity is associated with COVID-19 severity.

The Impact of Obesity on Total Hip Arthroplasty Outcomes: A Retrospective Matched Cohort Study

Aim

Previous research has shown that obesity is associated with worse postoperative outcomes. We aim to determine how rates of specific complications after total hip arthroplasty (THA) align with obesity status. We hypothesize that obese patients would have higher rates of complications and cost and thus have worse outcomes than non-obese patients.

Methods

Data were collected from a large commercial insurance database between 2011 and 2020. Patients underwent a hip replacement under current procedural terminology (CPT) and International Statistical Classification of Diseases (ICD-9/ICD-10) codes. Obese (defined as having a BMI of 30 kg/m² or higher) and non-obese patients were matched on age, gender, Charlson Comorbidity Index (CCI), and Elixhauser Comorbidity Index (ECI). Standardized complications and costs in one year were compared using unequal variance t-tests.

Results

Under CPT codes, 61,462 obese (45% male) and 61,462 non-obese patients (45% male) underwent a hip replacement. Obese patients had significantly higher rates of surgical site infection (SSI) (OR=1.193, p=0.0001), deep vein thrombosis (DVT) (OR=1.275, p=0.001), wound complication (OR=1.736, p<0.0001), hematoma (OR=1.242, p=0.0001), pulmonary embolism (OR=1.141, p=0.0355), UTI (OR=1.065, p=0.0016), and opioid prescriptions (OR=1.17, p<0.0001), and significantly lower rates of arrhythmia (OR=0.907, p<0.0001), congestive heart failure (CHF) (OR=0.863, p<0.0001), cardiac arrest (OR=0.637 p<0.0001), pneumonia (OR=0.795, p<0.0001), and transfusion (OR=0.777, p<0.0001). Furthermore, obese patients were significantly more likely to undergo revision within 10 years (OR=1.172, p<0.0001). Under ICD codes, 31,922 obese (45% male) and 31,922 non-obese patients (45% male) were included. Obese patients did not have a significant difference in total cost or drug cost.

Conclusions

Obese patients had significantly higher rates of infection, venous thromboembolic event, wound complication, hematoma, and opioid prescriptions but significantly lower rates of cardiac issues, pneumonia, and transfusion, after hip replacement. Additionally, there was no significant difference in total or drug cost. Therefore, this study did not support our hypothesis that obese patients have worse outcomes than non-obese patients, as there neither was a clear significant increase in complication rates nor a significant increase in costs. However, further research should be done to better understand the complex relationship between obesity and postoperative outcomes.

Translating MSC Therapy in the Age of Obesity

Mesenchymal stromal cell (MSC) therapy has seen increased attention as a possible option to treat a number of inflammatory conditions including COVID-19 acute respiratory distress syndrome (ARDS). As rates of obesity and metabolic disease continue to rise worldwide, increasing proportions of patients treated with MSC therapy will be living with obesity. The obese environment poses critical challenges for immunomodulatory therapies that should be accounted for during development and testing of MSCs. In this review, we look to cancer immunotherapy as a model for the challenges MSCs may face in obese environments. We then outline current evidence that obesity alters MSC immunomodulatory function, drastically modifies the host immune system, and therefore reshapes interactions between MSCs and immune cells. Finally, we argue that obese environments may alter essential features of allogeneic MSCs and offer potential strategies for licensing of MSCs to enhance their efficacy in the obese microenvironment. Our aim is to combine insights from basic research in MSC biology and clinical trials to inform new strategies to ensure MSC therapy is effective for a broad range of patients.

Association of Obesity With COVID-19 Severity and Mortality: An Updated Systemic Review, Meta-Analysis, and Meta-Regression

Background

Obesity affects the course of critical illnesses. We aimed to estimate the association of obesity with the severity and mortality in coronavirus disease 2019 (COVID-19) patients.

Data Sources

A systematic search was conducted from the inception of the COVID-19 pandemic through to 13 October 2021, on databases including Medline (PubMed), Embase, Science Web, and Cochrane Central Controlled Trials Registry. Preprint servers such as BioRxiv, MedRxiv, ChemRxiv, and SSRN were also scanned.

Study Selection and Data Extraction

Full-length articles focusing on the association of obesity and outcome in COVID-19 patients were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for study selection and data extraction. Our Population of interest were COVID-19 positive patients, obesity is our Intervention/Exposure point, Comparators are Non-obese vs obese patients The chief outcome of the study was the severity of the confirmed COVID-19 positive hospitalized patients in terms of admission to the intensive care unit (ICU) or the requirement of invasive mechanical ventilation/intubation with obesity. All-cause mortality in COVID-19 positive hospitalized patients with obesity was the secondary outcome of the study.

Results

In total, 3,140,413 patients from 167 studies were included in the study. Obesity was associated with an increased risk of severe disease (RR=1.52, 95% CI 1.41-1.63, p<0.001, I2 = 97%). Similarly, high mortality was observed in obese patients (RR=1.09, 95% CI 1.02-1.16, p=0.006, I2 = 97%). In multivariate meta-regression on severity, the covariate of the female gender, pulmonary disease, diabetes, older age, cardiovascular diseases, and hypertension was found to be significant and explained R2 = 40% of the between-study heterogeneity for severity. The aforementioned covariates were found to be significant for mortality as well, and these covariates collectively explained R2 = 50% of the between-study variability for mortality.

Conclusions

Our findings suggest that obesity is significantly associated with increased severity and higher mortality among COVID-19 patients. Therefore, the inclusion of obesity or its surrogate body mass index in prognostic scores and improvement of guidelines for patient care management is recommended.

Mass spectrometry-based proteomics identify novel serum osteoarthritis biomarkers

Background

Osteoarthritis (OA) is a slowly developing and debilitating disease, and there are no validated specific biomarkers for its early detection. To improve therapeutic approaches, identification of specific molecules/biomarkers enabling early determination of this disease is needed. This study aimed at identifying, with the use of proteomics/mass spectrometry, novel OA-specific serum biomarkers. As obesity is a major risk factor for OA, we discriminated obesity-regulated proteins to target only OA-specific proteins as biomarkers.

Methods

Serum from the Osteoarthritis Initiative cohort was used and divided into 3 groups: controls (n=8), OA-obese (n=10) and OA-non-obese (n=10). Proteins were identified and quantified from the liquid chromatography–tandem mass spectrometry analyses using MaxQuant software. Statistical analysis used the Limma test followed by the Benjamini-Hochberg method. To compare the proteomic profiles, the multivariate unsupervised principal component analysis (PCA) followed by the pairwise comparison was used. To select the most predictive/discriminative features, the supervised linear classification model sparse partial least squares regression discriminant analysis (sPLS-DA) was employed. Validation of three differential proteins was performed with protein-specific assays using plasma from a cohort derived from the Newfoundland Osteoarthritis.

Results

In total, 509 proteins were identified, and 279 proteins were quantified. PCA-pairwise differential comparisons between the 3 groups revealed that 8 proteins were differentially regulated between the OA-obese and/or OA-non-obese with controls. Further experiments using the sPLS-DA revealed two components discriminating OA from controls (component 1, 9 proteins), and OA-obese from OA-non-obese (component 2, 23 proteins). Proteins from component 2 were considered related to obesity. In component 1, compared to controls, 7 proteins were significantly upregulated by both OA groups and 2 by the OA-obese. Among upregulated proteins from both OA groups, some of them alone would not be a suitable choice as specific OA biomarkers due to their rather non-specific role or their strong link to other pathological conditions. Altogether, data revealed that the protein CRTAC1 appears to be a strong OA biomarker candidate. Other potential new biomarker candidates are the proteins FBN1, VDBP, and possibly SERPINF1. Validation experiments revealed statistical differences between controls and OA for FBN1 (p=0.044) and VDPB (p=0.022), and a trend for SERPINF1 (p=0.064).

Conclusion

Our study suggests that 4 proteins, CRTAC1, FBN1, VDBP, and possibly SERPINF1, warrant further investigation as potential new biomarker candidates for the whole OA population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02801-1.

Exploring Alternative Measurements of Cardiorespiratory Fitness in Patients With Mild Ischemic Stroke at Acute Phase

Background

While emerging studies have suggested an association of cardiorespiratory fitness (CRF) with stroke risk and overall health outcomes, little is known regarding the optimum methods of CRF measurement in patients with mild acute ischemic stroke.

Objective

The aim of this study was to explore the association between the 6-min walk distance (6MWD) and other measurements related to CRF in patients with mild ischemic stroke at the acute stage.

Methods

A total of 30 patients with stroke and 71 healthy subjects matched for age and grip strength (GS) were prospectively recruited. All patients were within 14 days after stroke onset and presented mild motor impairment (with a full score of Fugl-Meyer Motor Assessment). Demographic data of both groups and clinical information of the stroke group were documented, and the CRF comparison between the two groups was conducted. Each participant underwent a one-time assessment of 6MWD and a series of measurements related to CRF, including GS, 10-m walk test (10mWT), five-times sit-to-stand time (FTSST), functional reaching test (FRT), Berg Balance Scale (BBS), and waistline. Pearson's product-moment correlation coefficient test and multiple linear regression were performed to explore the indicators of CRF.

Results

Significant moderate correlations (0.3 < r <0.6) were found between 6MWD and GS of left hand (GS-left) (r = 0.573, p = 0.001), GS of right hand (GS-right) (r = 0.524, p = 0.003), FTSST (r = −0.551, p = 0.002), 10mWT (r = 0.554, p = 0.001), and FRT (r = 0.449, p = 0.021) in the patient group. While 6MWD displayed significant moderate correlations with waistline (r = 0.364, p = 0.002), 10mWT (r = 0.512, p < 0.001), FTSST (r = −0.573, p < 0.001), and FRT (r = 0.550, p < 0.001) in the healthy group. All these dependent variables were entered into a stepwise multiple linear regression analysis to evaluate their values in estimating CRF as measured by 6MWD in each group. Analyses suggested that GS-left (p = 0.002) and FTSST (p = 0.003) were the indicators of CRF in the patient group with stroke and explained 51.4% of the variance of 6MWD (R² = 0.514); FTSST (p < 0.001), 10mWT (p < 0.001), and FRT (p = 0.021) were the indicators of CRF in the healthy group and explained 58.9% of variance of 6MWD (R² = 0.589).

Conclusions

Our data confirmed that CRF is impaired in patients with mild ischemic stroke at the acute phase. Moreover, GS-left may be an optional indicator of CRF in patients with mild acute ischemic stroke, but not in healthy people.

Clinical Trial Registration

www.chictr.org.cn, identifier: ChiCTR2000031379.

The Impact of Age and BMI on the VWF/ADAMTS13 Axis and Simultaneous Thrombin and Plasmin Generation in Hospitalized COVID-19 Patients

Aging and obesity independently contribute toward an endothelial dysfunction that results in an imbalanced VWF to ADAMTS13 ratio. In addition, plasma thrombin and plasmin generation are elevated and reduced, respectively, with increasing age and also with increasing body mass index (BMI). The severity risk of Corona Virus Disease 2019 (COVID-19) increases in adults older than 65 and in individuals with certain pre-existing health conditions, including obesity (>30 kg/m²). The present cross-sectional study focused on an analysis of the VWF/ADAMTS13 axis, including measurements of von Willebrand factor (VWF) antigen (VWF:AG), VWF collagen binding activity (VWF:CBA), Factor VIII antigen, ADAMTS13 antigen, and ADAMTS13 activity, in addition to thrombin and plasmin generation potential, in a demographically diverse population of COVID-19 negative (−) (n = 288) and COVID-19 positive (+) (n = 543) patient plasmas collected at the time of hospital presentation. Data were analyzed as a whole, and then after dividing patients by age (<65 and ≥65) and independently by BMI [<18.5, 18.5–24.9, 25–29.9, >30 (kg/m²)]. These analyses suggest that VWF parameters (i.e., the VWF/ADAMTS13 activity ratio) and thrombin and plasmin generation differed in COVID-19 (+), as compared to COVID-19 (−) patient plasma. Further, age (≥65) more than BMI contributed to aberrant plasma indicators of endothelial coagulopathy. Based on these findings, evaluating both the VWF/ADAMTS13 axis, along with thrombin and plasmin generation, could provide insight into the extent of endothelial dysfunction as well as the plasmatic imbalance in coagulation and fibrinolysis potential, particularly for at-risk patient populations.

Clinical Significance of Vascular Occlusive Events following Moderate-to-Severe Traumatic Brain Injury: An Observational Cohort Study

Preventing hemorrhage progression is a potential therapeutic opportunity in traumatic brain injury (TBI) management, but its use has been limited by fear of provoking vascular occlusive events (VOEs). However, it is currently unclear whether VOE actually affects outcome in these patients. The aim of this study was to determine incidence, risk factors, and clinical significance of VOE in patients with moderate-to-severe TBI. A retrospective observational cohort study of adults (≥15 years) with moderate-to-severe TBI was performed. The presence of a VOE during hospitalization was noted from hospital charts and radiological reports. Functional outcome, using the Glasgow Outcome Scale (GOS), was assessed at 12 months posttrauma. Univariate and multivariate logistic regressions were used for endpoint assessment. In total, 848 patients were included, with a median admission Glasgow Coma Scale of 7. A VOE was detected in 54 (6.4%) patients, of which cerebral venous thrombosis was the most common (3.2%), followed by pulmonary embolism (1.7%) and deep vein thrombosis (1.3%). Length of ICU stay (p < 0.001), body weight (p = 0.002), and skull fracture (p = 0.004) were independent predictors of VOE. VOE development did not significantly impact 12-month GOS, even after adjusting for potential confounders using propensity score matching. In conclusion, VOE in moderate-to-severe TBI patients was relatively uncommon, and did not affect 12-month GOS. This suggests that the potential benefit of treating bleeding progression might outweigh the risks of VOE.

Association between obstructive sleep apnea and venous thromboembolism recurrence: results from a French cohort

Background

Growing evidence suggests the relationship between obstructive sleep apnea (OSA) and venous thromboembolism (VTE). Few studies focused on VTE recurrence risk associated with OSA after anticoagulation cessation.

Methods

In a prospective cohort study, patients with documented VTE, were followed for an indefinite length of time and VTE recurrence were documented and adjudicated. The primary outcome was recurrent VTE after anticoagulation discontinuation. Secondary outcomes included all-cause mortality and the clinical presentation of VTE. Univariable and multivariable analyses were performed to identify risk factors for recurrence and mortality.

Results

Among the 2109 patients with documented VTE included, 74 patients had moderate to severe OSA diagnosis confirmed by home sleep test or polysomnography. During a median follow-up of 4.8 (interquartile range 2.5–8.0) years recurrent VTE occurred in 252 patients (9 with OSA and 243 without OSA). The recurrence risk in the univariable and multivariable analysis was not increased in patients with OSA, regardless of the time of diagnosis (before or after index VTE or pooled). VTE phenotype was significantly more often PE with or without associated deep vein thrombosis in the first event and recurrence for OSA patients compared to non-OSA patients. The risk of death was not increased in the OSA population compared to non-OSA patients in multivariable analysis.

Conclusions

In patients with OSA and VTE, the risk of all-cause mortality and VTE recurrence after anticoagulation discontinuation was not increased compared to non-OSA patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-021-00358-8.

Phytochemical and pharmacological investigation of the ethanol extract of Byttneria pilosa Roxb

Background

Traditionally, the herb Byttneria pilosa Roxb. is used for bone fractures, boils, scabies, rheumatalgia, snake bites, syphilis, elephantiasis, poisoning, and eye infection. Scientific reports suggest that it has significant anti-inflammatory, analgesic, anti-diarrheal, anxiolytic, locomotion, sedative and anti-obesity effects. This study aims at the investigation of the phytochemical and pharmacological properties of the ethanol extract of this herb.

Methods

Fresh whole plant was extracted with absolute ethanol. A preliminary phytochemical investigation was followed by the evaluation of thrombolytic, anti-inflammatory, and anti-nociceptive activities by applying human clotted blood lysis, egg albumin, and acetic acid-induced writhing models, respectively.

Results

Phytochemical investigation suggests that B. pilosa possesses alkaloids, flavonoids, glycosides, terpenoids, tannins, saponins, and reducing sugars. The extract exhibited clot lysis and anti-inflammatory effects in a concentration-dependent manner. B. pilosa extract at 250 and 500 mg/kg also showed significant (p < 0.05) dose-dependent anti-nociceptive activity in Swiss albino mice.

Conclusion

The B. pilosa ethanol extract contains many important secondary metabolites and has thrombolytic, anti-inflammatory, and anti-nociceptive activities. More research is necessary on this hopeful medicinal herb.

Triceps skinfold thickness and body mass index and the risk of gestational diabetes mellitus: Evidence from a multigenerational cohort study

BACKGROUND

Pre-pregnancy obesity is a well-recognized risk factor for gestational diabetes mellitus (GDM). There is a continuity of obesity from childhood to adolescence and then adulthood. However, it is unknown whether early childhood obesity predicts GDM.

METHODS

We investigated the prospective association of childhood triceps skinfold thickness and body mass index (BMI) with GDM risk among women from the Mater-University of Queensland Study of Pregnancy (MUSP), a multigenerational cohort study. A multiple logistic regression model was applied to estimate the odds of experiencing GDM by childhood skinfold thickness and BMI.

RESULTS

Out of 552 women in the study for whom data were available on triceps skinfold thickness and BMI at average age 5 (range 3-7) years old, 52 (9.42%) developed GDM by average age 30 (range 28-33) years. We found that the risk of developing GDM was greater among women who had greater skinfold thickness but not greater BMI at age 5 years. Women who were classified as overweight or obese based on skinfold thickness at age 5 years had an increased odds ratio of GDM compared to women who had normal skinfold thickness. This association remained significant after adjustment for the potential confounders (OR 2.74; 95% confidence interval=1.28-5.86).

CONCLUSION

The risk of developing GDM was associated with higher skinfold thickness at age 5 years.

Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis

PURPOSE

This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO).

METHODS

We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs.

RESULTS

Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49-1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08-1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55-7.97]) and medical bleeding, including intracranial (5.71 [4.02-8.09]), pulmonary (2.02 [1.54-2.67]), and gastrointestinal (1.54 [1.2-1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO₂ at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis.

CONCLUSIONS

Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.

Obesity and the increased risk for COVID-19: mechanisms and nutritional management

The global COVID-19 (coronavirus disease 2019) pandemic has become a complex problem that overlaps with a growing public health problem, obesity. Obesity alters different components of the innate and adaptive immune responses, creating a chronic and low-grade state of inflammation. Nutritional status is closely related to a better or worse prognosis of viral infections. Excess weight has been recognised as a risk factor for COVID-19 complications. In addition to the direct risk, obesity triggers other diseases such as diabetes and hypertension, increasing the risk of severe COVID-19. The present review explains the diets that induce obesity and the importance of different foods in this process. We also review tissue disruption in obesity, leading to impaired immune responses and the possible mechanisms by which obesity and its co-morbidities increase COVID-19 morbidity and mortality. Nutritional strategies that support the immune system in patients with obesity and with COVID-19 are also discussed in light of the available data, considering the severity of the infection. The discussions held may contribute to combating this global emergency and planning specific public health policy.

Prevalence and predictors of left atrial thrombosis in atrial fibrillation patients treated with non-vitamin K antagonist oral anticoagulants

BACKGROUND

Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure.

RESULTS

A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA₂DS₂-VASc score > 3 (OR 4.54, 95% CI 1.50 - 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 - 18.50, p value = .001).

CONCLUSIONS

Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA₂DS₂-VASc score > 3 and obesity.

Hypercoagulopathy in Overweight and Obese COVID-19 Patients: A Single-Center Case Series

A case series is presented of five overweight or obese patients with confirmed coronavirus disease 2019 (COVID-19) in South Miami, Florida, United States. A multitude of coagulation parameters was suggestive of a hypercoagulable state among the hospitalized COVID-19 patients. This article reports various manifestations of hypercoagulable states in overweight and obese patients, such as overt bleeding consistent with disseminated intravascular coagulation, venous thromboembolism, gastrointestinal bleeding as well as retroperitoneal hematoma. All of the required admission to the intensive care unit and subsequently patients died. The characteristics of COVID-19-associated coagulopathy are atypical and warrant a further understanding of the pathophysiology to improve clinical outcomes, specifically in overweight or obese patients.

Usefulness of peripheral venous blood gas analyses in cats with arterial thromboembolism

Feline arterial thromboembolism (ATE) is a condition with a high mortality rate. Acid-base abnormalities may be beneficial to the prognosis of cats with ATE. Venous blood gas and electrolytes data on the first day of ATE presentation of 47 cats with ATE were retrospectively reviewed and analysed. The Cox and logistic regression were analysed to evaluate the relationship between acid-base parameters and death. The most common venous acid-base disorder was simple metabolic acidosis. Age, body weight, and partial venous pressure of carbon dioxide (PvCO2) differed between the dead and alive groups within 7 days of the onset of ATE presentation (p < 0.05). Cox-regression showed that increasing age (HR=1.175 [95% CI: 1.027-1.343], p = 0.019), increasing PvCO2 (HR=1.066 [95% CI: 1.010-1.125], p = 0.021) and PvCO2 more than 34 mmHg (HR=7.878 [95% CI: 1.036- 59.915], p = 0.046) were associated with increased hazard of death. Multivariable logistic regression showed that age > 5 years (OR=9.030, 95% CI: 1.258- 64.823; p=0.029), and PvCO2 > 34 mmHg (OR=21.764, 95% CI: 1.747-271.141; p=0.017) were associated with an increased risk of death, while concomitant administration of enoxaparin with clopidogrel (OR=0.111, 95% CI: 0.015-0.795; p=0.029) were associated with a decreased risk of death within 7 days of the onset of ATE presentation. This study demonstrated the power of venous blood gas analysis which may be used as prognostic indicators for cats with ATE.

Exact Association Between Preoperative Blood Viscosity and Postoperative Deep Venous Thrombosis Risk in Knee Osteoarthritis Patients: A 10-Year Retrospective Study

Several lines of evidence have suggested a sustainable relationship between blood viscosity (BV) and deep vein thrombosis (DVT). But there was a lack of data on the association of preoperative BV and postoperative acute DVT. For patients who accepted total knee arthroplasty (TKA) caused by primary knee osteoarthritis (KOA), this study tried to investigate whether preoperative BV relevant parameters might affect DVT risk following TKA. We reviewed a total of 750 consecutive KOA patients treated by unilateral TKA in our hospital from March 2010 to May 2020. All patients undergoing TKA were routinely examined by the color Doppler ultrasound on the third postoperative day and were assigned into DVT and non-DVT groups. Statistical comparisons of BV relevant parameters which mainly including whole BV (low, midst, and high shear rates), plasma viscosity, whole blood reductive viscosity (BRV; low, midst, and high shear rates) were made comprehensively. It could be found that low whole BRV (low shear rate) before TKA was significantly related to postoperative DVT risk in all patients, especially in female patients after stratifying by gender (p < .05). Our results implied that low whole BRV might be a remarkable risk factor of DVT in primary KOA patients after TKA. Timely and effective DVT prophylaxis for these patients is much required.

Optimal enoxaparin dosing strategies for venous thromboembolism prophylaxis and treatment of high body weight patients

OBJECTIVE

Obesity is a risk factor for developing venous thromboembolism (VTE). Optimal dosage of enoxaparin has not been established in the obese population. We aimed to study clinical outcomes and complications with enoxaparin in obese patients.

METHODS

A retrospective, single centre observational study of obese patients treated with enoxaparin for VTE (n = 47) using a body mass index (BMI)-stratified dosing, thromboprophylaxis (n = 46), and non-obese controls (n = 20) was performed. Anti-Xa was used to measure enoxaparin efficacy.

RESULTS

Patients with a median BMI of 36.3 kg/m2 (range 30-52.7) with a median weight of 136 kg (range 68-240) received therapeutic enoxaparin at median 120 mg BID (range 60-200). A median targeted anti-Xa level of 0.79 (95% CI 0.72-1.03) IU/mL was achieved in 58% of patients. Dose reduction, or increase was needed in 25%, and 16% patients respectively. Mild or major haemorrhage, or VTE occurred in 10%, 2% and 2% patients respectively. Patients with a median weight of 160 kg (range 130-245) received thromboprophylaxis with 40 mg BID enoxaparin. Targeted median anti-Xa of 0.22 IU/mL (95% CI 0.19-0.24) was achieved in 59% patients. Mild haemorrhage was seen in 2%, while none developed major haemorrhage or VTE. Control patients who received enoxaparin 40 mg daily did not develop VTE; 5% had minor bleeding events.

CONCLUSIONS

BMI-stratified therapeutic enoxaparin dosing regimen is safe and effective therapy in obese patients. Fixed dosing without monitoring may not be appropriate. Thromboprophylaxis with 40 mg BID in obese patients was efficacious in preventing VTE without excess bleeding compared to control patients.