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Hochberg JD, Wirth DM, Pokorski JK. Surface-Modified Melt Coextruded Nanofibers Enhance Blood Clotting In Vitro. Macromol Biosci 2022; 22:e2200292. [PMID: 36122179 DOI: 10.1002/mabi.202200292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/28/2022] [Indexed: 01/15/2023]
Abstract
Blood loss causes an estimated 1.9 million deaths per year globally, making new methods to stop bleeding and promote clot formation immediately following injury paramount. The fabrication of functional hemostatic materials has the potential to save countless lives by limiting bleeding and promoting clot formation following an injury. This work describes the melt manufacturing of poly(ε-caprolactone) nanofibers and their chemical functionalization to produce highly scalable materials with enhanced blood clotting properties. The nanofibers are manufactured using a high throughput melt coextrusion method. Once isolated, the nanofibers are functionalized with polymers that promote blood clotting through surface-initiated atom transfer radical polymerization. The functional nanofibers described herein speed up the coagulation cascade and produce more robust blood clots, allowing for the potential use of these functional nonwoven mats as advanced bandages.
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Affiliation(s)
- Justin D Hochberg
- Department of NanoEngineering, Jacobs School of Engineering, University of California San Diego, La Jolla, CA, 92093, USA
| | - David M Wirth
- Department of NanoEngineering, Jacobs School of Engineering, University of California San Diego, La Jolla, CA, 92093, USA
| | - Jonathan K Pokorski
- Department of NanoEngineering, Jacobs School of Engineering, University of California San Diego, La Jolla, CA, 92093, USA
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O’Keefe D, Lim HY, Hui L, Ho P. Risk stratification for pregnancy-associated venous thromboembolism: Potential role for global coagulation assays. Obstet Med 2022; 15:168-175. [PMID: 36262814 PMCID: PMC9574445 DOI: 10.1177/1753495x211025397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 09/03/2023] Open
Abstract
Risk assessment for venous thromboembolism in pregnancy and the puerperium is currently limited to stratifying clinical surrogate risk factors without high-quality evidence. While the absolute risk of pregnancy-associated venous thromboembolism is low for the vast majority of women, associated morbidity and mortality remains significant. As guidelines for thromboprophylaxis vary widely, some women may be under- or over-anticoagulated, contributing to poor outcomes. New global coagulation assays provide a holistic view of coagulation and may have the potential to detect hypercoagulability in pregnancy, unlike clinically available coagulation assays. However, there are major technical challenges to overcome before global coagulation assays can be realistically proposed as an adjunct to risk assessment for pregnancy-associated venous thromboembolism. This review summarises the literature and controversies in the prediction and prevention of pregnancy-associated venous thromboembolism and outlines the new tools in haematology that may assist in our future understanding of hypercoagulability in pregnancy.
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Affiliation(s)
- David O’Keefe
- Department of Obstetrics & Gynaecology, The University of
Melbourne, The University of Melbourne, Parkville, Australia
- Department of Obstetrics & Gynaecology, Northern Health,
Epping, Australia
| | - Hui Yin Lim
- Department of Haematology, Northern Pathology Victoria, Epping,
Australia
- Department of Haematology, Northern Health, Epping,
Australia
| | - Lisa Hui
- Department of Obstetrics & Gynaecology, The University of
Melbourne, The University of Melbourne, Parkville, Australia
- Department of Obstetrics & Gynaecology, Northern Health,
Epping, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Pathology Victoria, Epping,
Australia
- Department of Haematology, Northern Health, Epping,
Australia
- Australian Centre for Blood Diseases, Monash University,
Melbourne, Australia
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Biswas S, Vaishnav M, Pathak P, Gunjan D, Mahapatra SJ, Kedia S, Rout G, Thakur B, Nayak B, Kumar R. Effect of thrombocytopenia and platelet transfusion on outcomes of acute variceal bleeding in patients with chronic liver disease. World J Hepatol 2022; 14:1421-1437. [PMID: 36158909 PMCID: PMC9376768 DOI: 10.4254/wjh.v14.i7.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/13/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Platelet transfusion in acute variceal bleeding (AVB) is recommended by few guidelines and is common in routine clinical practice, even though the effect of thrombocytopenia and platelet transfusion on the outcomes of AVB is unclear.
AIM To determine how platelet counts, platelets transfusions, and fresh frozen plasma transfusions affect the outcomes of AVB in cirrhosis patients in terms of bleeding control, rebleeding, and mortality.
METHODS Prospectively maintained database was used to analyze the outcomes of cirrhosis patients who presented with AVB. The outcomes were assessed as the risk of rebleeding at days 5 and 42, and risk of death at day 42, considering the platelet counts and platelet transfusion. Propensity score matching (PSM) was used to compare the outcomes in those who received platelet transfusion. Statistical comparisons were done using Kaplan-Meier curves with log-rank tests and Cox-proportional hazard model for rebleeding and for 42-d mortality.
RESULTS The study included 913 patients, with 83.5% men, median age 45 years, and Model for End-stage Liver Disease score 14.7. Platelet count < 20 × 109/L, 20-50 × 109/L, and > 50 × 109/L were found in 23 (2.5%), 168 (18.4%), and 722 (79.1%) patients, respectively. Rebleeding rates were similar between the three platelet groups on days 5 and 42 (13%, 6.5%, and 4.7%, respectively, on days 5, P = 0.150; and 21.7%, 17.3%, and 14.4%, respectively, on days 42, P = 0.433). At day 42, the mortality rates for the three platelet groups were also similar (13.0%, 23.2%, and 17.2%, respectively, P = 0.153). On PSM analysis patients receiving platelets transfusions (n = 89) had significantly higher rebleeding rates on day 5 (14.6% vs 4.5%; P = 0.039) and day 42 (32.6% vs 15.7%; P = 0.014), compared to those who didn't. The mortality rates were also higher among patients receiving platelets (25.8% vs 23.6%; P = 0.862), although the difference was not significant. On multivariate analysis, platelet transfusion and not platelet count, was independently associated with 42-d rebleeding. Hepatic encephalopathy was independently associated with 42-d mortality.
CONCLUSION Thrombocytopenia had no effect on rebleeding rates or mortality in cirrhosis patients with AVB; however, platelet transfusion increased rebleeding on days 5 and 42, with a higher but non-significant effect on mortality.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Gyanranjan Rout
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Bhaskar Thakur
- Division of Biostatistics, UT Southwestern Medical Center, Dallas, Texas 75390, United States
| | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 800014, Bihar, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
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Abstract
Snake venoms have evolved primarily to immobilize and kill prey, and consequently, they contain some of the most potent natural toxins. Part of that armory is a range of hemotoxic components that affect every area of hemostasis, which we have harnessed to great effect in the study and diagnosis of hemostatic disorders. The most widely used are those that affect coagulation, such as thrombin-like enzymes unaffected by heparin and direct thrombin inhibitors, which can help confirm or dispute their presence in plasma. The liquid gold of coagulation activators is Russell's viper venom, since it contains activators of factor X and factor V. It is used in a range of clotting-based assays, such as assessment of factor X and factor V deficiencies, protein C and protein S deficiencies, activated protein C resistance, and probably the most important test for lupus anticoagulants, the dilute Russell's viper venom time. Activators of prothrombin, such as oscutarin C from Coastal Taipan venom and ecarin from saw-scaled viper venom, are employed in prothrombin activity assays and lupus anticoagulant detection, and ecarin has a valuable role in quantitative assays of direct thrombin inhibitors. Snake venoms affecting primary hemostasis include botrocetin from the jararaca, which can be used to assay von Willebrand factor activity, and convulxin from the cascavel, which can be used to detect deficiency of the platelet collagen receptor, glycoprotein VI. This article takes the reader to every area of the diagnostic hemostasis laboratory to appreciate the myriad applications of snake venoms available in diagnostic practice.
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Affiliation(s)
- Gary William Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Faculty of Science and Technology, Middlesex University London, London, United Kingdom
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Siddiqui F, Tafur A, Ramacciotti LS, Jeske W, Hoppensteadt D, Ramacciotti E, Iqbal O, Fareed J. Reversal of Factor Xa Inhibitors by Andexanet Alfa May Increase Thrombogenesis Compared to Pretreatment Values. Clin Appl Thromb Hemost 2020; 25:1076029619863493. [PMID: 31298056 PMCID: PMC6714992 DOI: 10.1177/1076029619863493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Recombinant coagulation factor Xa (FXa), inactivated Zh-zo, also known as andexanet alfa (AA), is a modified version of human FXa that has been developed to neutralize FXa inhibitors. We studied the reversal effect of AA for these inhibitors in various anticoagulant and thrombin generation (TG) assays. Individual aliquots of normal human plasma containing 1 µg/mL of apixaban, betrixaban, edoxaban, and rivaroxaban, were supplemented with saline or AA at a concentration of 100 µg/mL. Clotting profiles include prothrombinase-induced clotting time, activated partial thromboplastin time, and prothrombin time. Factor Xa activity was measured using an amidolytic method. Thrombin generation was measured using a calibrated automated thrombogram. Differential neutralization of all 4 anticoagulants was noted in the activated clotting time and other clotting tests. The FXa activity reversal profile varied with an observed decrease in apixaban (22%), betrixaban (56%), edoxaban (28%), and rivaroxaban (49%). Andexanet alfa also led to an increased TG in comparison to saline. The peak thrombin was higher (40%), area under the curve (AUC) increased (15%), whereas the lag time (LT) decreased (17%). Andexanet alfa added at 100 µg/mL to various FXa supplemented systems resulted in reversal of the inhibitory effects, restoring the TG profile; AUC, LT, and peak thrombin levels were comparable to those of unsupplemented samples. Andexanet alfa is capable of reversing anti-Xa activity of different oral FXa inhibitors but overshoots thrombogenesis in both the saline and FXa inhibitor supplemented systems. The degree of neutralization of Xa inhibitor is specific to each agent.
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Affiliation(s)
- Fakiha Siddiqui
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
- Fakiha Siddiqui, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA.
| | - Alfonso Tafur
- Northshore Cardiovascular Institute, NorthShore University HealthSystem, Skokie, IL, USA
| | | | - Walter Jeske
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Debra Hoppensteadt
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Eduardo Ramacciotti
- Vascular and Endovascular Surgery, Santa Casa School of Medicine, São Paulo, Brazil
| | - Omer Iqbal
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Jawed Fareed
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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Lippi G, Favaloro EJ. Laboratory hemostasis: from biology to the bench. Clin Chem Lab Med 2019; 56:1035-1045. [PMID: 29455188 DOI: 10.1515/cclm-2017-1205] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022]
Abstract
Physiological hemostasis is an intricate biological system, where procoagulant and anticoagulant forces interplay and preserves blood fluidity when blood vessels are intact, or trigger clot formation to prevent excessive bleeding when blood vessels are injured. The modern model of hemostasis is divided into two principal phases. The first, defined as primary hemostasis, involves the platelet-vessel interplay, whilst the second, defined as secondary hemostasis, mainly involves coagulation factors, damaged cells and platelet surfaces, where the so-called coagulation cascade rapidly develops. The activation and amplification of the coagulation cascade is finely modulated by the activity of several physiological inhibitors. Once bleeding has been efficiently stopped by blood clot formation, dissolution of the thrombus is essential to restore vessel permeability. This process, known as fibrinolysis, also develops through coordinate action of a vast array of proteins and enzymes. An accurate diagnosis of hemostasis disturbance entails a multifaceted approach, encompassing family and personal history of hemostatic disorders, accurate collection of clinical signs and symptoms, integrated with laboratory hemostasis testing. Regarding laboratory testing, a reasonable approach entails classifying hemostasis testing according to cost, complexity and available clinical information. Laboratory workout may hence initiate with some rapid and inexpensive "screening" tests, characterized by high negative predictive value, then followed by second- or third-line analyses, specifically aimed to clarify the nature and severity of bleeding or thrombotic phenotype. This article aims to provide a general overview of the hemostatic process, and to provide some general suggestions to optimally facilitate laboratory hemostasis testing.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37100 - Verona, Italy
| | - Emmanuel J Favaloro
- Department of Clinical and Laboratory Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Westmead, NSW, Australia
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Salvagno GL, Favaloro EJ, Demonte D, Gelati M, Poli G, Targher G, Lippi G. Influence of hypertriglyceridemia, hyperbilirubinemia and hemolysis on thrombin generation in human plasma. ACTA ACUST UNITED AC 2019; 57:1784-1789. [DOI: 10.1515/cclm-2019-0135] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022]
Abstract
Abstract
Background
Although accumulating evidence suggests that the hemostatic balance is impaired in patients with hypertriglyceridemia, hyperbilirubinemia or hemolytic anemias, little is known on the underlying biological mechanisms. This experimental study was aimed at exploring whether increasing values of triglycerides, bilirubin or cell-free hemoglobin promote thrombin generation in plasma.
Methods
Three different pools were prepared from three different sets of 20 normal routine plasma citrate samples. The native pools were spiked with increasing amounts of exogenous triglycerides (up to 8.8 mmol/L), bilirubin (up to 350 μmol/L) or autologous hemolyzed blood (up to 3.5 g/L cell-free hemoglobin). Using the fully-automated thrombin generation analyzer ST Genesia, we measured the following parameters: lag time (LT), time to peak (TP), peak height (PH) and endogenous thrombin potential (ETP).
Results
A sustained increase of PH and ETP was found in parallel with increasing triglyceride concentrations, peaking in the aliquot with 8.8 mmol/L. Conversely, LT and TP displayed an opposite trend, reaching a maximum decrease in the 8.8 mmol/L aliquot. Increasing bilirubin concentrations promoted remarkable increases of PH and ETP and decreases of TP and LT, up to 211 μmol/L. After this threshold, all parameters tended to return towards baseline values. A constant increase of PH and ETP was also noted in hemolyzed samples, peaking in the 3.5 g/L cell-free hemoglobin aliquot, whereas the TP and LT remained unchanged in all hemolyzed aliquots.
Conclusions
Our findings suggest that hypertriglyceridemia, hyperbilirubinemia and hemolysis may promote a hypercoagulable state in human plasma.
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Affiliation(s)
- Gian Luca Salvagno
- Section of Clinical Biochemistry , University of Verona , Verona , Italy
| | - Emmanuel J. Favaloro
- Haematology , Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital , Westmead, NSW , Australia
| | - Davide Demonte
- Section of Clinical Biochemistry , University of Verona , Verona , Italy
| | - Matteo Gelati
- Section of Clinical Biochemistry , University of Verona , Verona , Italy
| | - Giovanni Poli
- Section of Clinical Biochemistry , University of Verona , Verona , Italy
| | - Giovanni Targher
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism , University of Verona , Verona , Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry , University of Verona , Verona , Italy
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Thrombin generation in different commercial sodium citrate blood tubes. J Med Biochem 2019; 39:19-24. [PMID: 32549773 DOI: 10.2478/jomb-2019-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to verify whether blood drawn into six different commercial coagulation tubes generated comparable results of thrombin generation. Methods Blood was sequentially collected from 20 healthy subjects into different brand and draw volume 3.2% sodium citrate tubes (4.3 mL Sarstedt, 3.0 mL Greiner, 2.7 mL Becton Dickinson, 2.0 mL Kima, 1.8 mL Sarstedt and 1.0 mL Greiner). Thrombin generation was measured in plasma with the fully-automated ST Genesia analyzer using the weakest trigger (STG-BleedScreen). Results Different values of lag time (LT), time to reach thrombin peak (TP), thrombin peak height (PH) and endogenous thrombin potential (ETP) were commonly found in different tubes. Thrombin generation was the lowest in 4.3 mL Sarstedt tubes and the highest in 1.0 mL Greiner tubes. Other tubes displayed intermediate values. In multiple comparisons, LT was significantly different in 6/15 cases (40%), whilst PH, TP and ETP were significantly different in 14/15 (93%), 13/15 (87%) and 13/15 (87%) cases. The mean percent bias of LT, PH, TP and ETP ranged between -6% and +1%, -27% and +116%, -22% and +8%, and between -18% and +65%. The intra-assay imprecision of LT, PH, TP and ETP was exceeded in 0/15 (0%), 13/15 (87%), 6/15 (40%) and 13/15 (87%) comparisons. The correlation of LT, PH, TP and ETP values in different tubes ranged between 0.718-0.971, 0.570-0.966, 0.725-0.977 and 0.101-0.904. Conclusions Blood collection for thrombin generation assays requires local standardization using identical tubes for brand and draw volume, and reference ranges calculated according to type of tubes.
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Al-Samkari H, Croteau SE. Shifting Landscape of Hemophilia Therapy: Implications for Current Clinical Laboratory Coagulation Assays. Am J Hematol 2018; 93:1082-1090. [PMID: 29884997 DOI: 10.1002/ajh.25153] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/16/2018] [Accepted: 05/20/2018] [Indexed: 01/27/2023]
Abstract
Clinical coagulation assays are an integral part of diagnosing and managing patients with hemophilia; however, in this new era of bioengineered factor products and non-factor therapeutics, problems have arisen with use of traditional coagulation tests for the quantification of several of these new products. Discussion over the use of one-stage clotting assays versus chromogenic substrate assays for clinical decision making and potency labeling has been ongoing for many years. Emerging factor concentrates have heightened concern over assay selection and availability. Emicizumab interferes with all aPTT based assays, rendering them unreliable and potentially falsely reassuring to the unaware provider. This review explores considerations for coagulation assays in the clinical setting and highlights how awareness of institutional coagulation assays and potential limitations have never been more critical for providers caring for patients with bleeding disorders. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hanny Al-Samkari
- Center for Hematology, Massachusetts General Hospital Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Hemophilia Center, Boston, MA
- Harvard Medical School, Boston, MA
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