Inflammation and coagulation

Ovarian vein thrombosis mimicking acute appendicitis: A case report

BACKGROUND

Ovarian vein thrombosis (OVT) is a rare condition that most commonly affects postpartum women. It is particularly prevalent in the first 10 days postpartum, a period when women are more prone to developing this condition. The right ovarian vein is often affected due to its tortuous nature and less competent valves. OVT presents similarly to acute abdominal conditions, such as acute appendicitis, especially when the right ovarian vein is involved. Given the overlap in clinical presentation, diagnosis requires high-quality imaging techniques and a high degree of suspicion.

CASE SUMMARY

Herein, we report a rare case of OVT in a young postpartum female who presented to the emergency department with signs and symptoms of acute abdomen. The patient had a history of pulmonary tuberculosis treatment. A provisional diagnosis of a perforated appendix was made, and a lower midline exploratory laparotomy was planned. During surgery, the appendix and intestines appeared normal, but a distended and thrombosed right ovarian vein was found. The affected ovarian vein was excised, and the patient was placed on anticoagulants postoperatively. The recovery was unremarkable, and anticoagulants were continued for six months.

CONCLUSION

OVT is most commonly seen in the early postpartum period, especially within the first 10 days. Due to its anatomical characteristics, the right ovarian vein is more commonly involved. The clinical presentation of OVT can closely mimic acute abdomen or acute appendicitis, making diagnosis challenging. Accurate diagnosis requires a high index of suspicion and advanced imaging techniques to differentiate OVT from other conditions with similar presentations.

A case report of fatal splenic rupture caused by multiple organ infection following foreign body ingestion in a detainee

Among forensic and clinical cases, infections caused by the ingestion of foreign bodies are common. In general, timely removal of the foreign body and appropriate treatment prevent serious consequences. We herein report a rare case of death due to massive bleeding caused by splenic rupture following foreign body ingestion. To our knowledge, no similar cases have been reported in the Chinese or international literature, making this case particularly noteworthy. In this instance, the decedent was in a detention centre for a criminal offence and swallowed a wire unnoticed. The wire remained in his stomach for >50 days, leading to a severe suppurative infection in the gastric tissue. This resulted in suppurative inflammation affecting multiple organs, including the liver, pancreas, and spleen. The condition ultimately led to the rupture of splenic vessels and the formation of a rare, massive haematoma beneath the splenic capsule. Based on medical records and histopathological findings, we infer that the wire had remained in the stomach for ~50 days, triggering severe suppurative infections in multiple organs. The spleen eventually ruptured, and the victim died of massive haemorrhage.

Hemostatic Manifestations of Invasive Fungal Infections: A Comprehensive Review of Pathophysiological Mechanisms in Sepsis-Induced Hemostatic Disturbances, with a Focus on the Neonatal Population

Sepsis is a life-threatening condition that has challenged many clinicians over the years. The immune and hemostatic systems are the primary pillars of sepsis pathogenesis. Dysregulation of these intricate mechanisms significantly worsens the prognosis. Coagulopathy is a critical aspect of sepsis, with the degree of hemostatic impairment being a key determinant of poor outcomes. Although the concept of sepsis caused by bacteria has been well investigated, the fungal impact in the complexity of sepsis-related hemostatic derangement is not yet fully unraveled. In addition, sepsis occurs in patients across all age groups, with a particular concern for neonates, whose immature and vulnerable systems amplify the challenges. Notably, despite the high incidence of fungal septicemia in neonatal intensive care units (NICUs), along with its significant morbidity, mortality, and adverse neonatal outcomes, the impact of fungal sepsis on the neonatal hemostatic system-an essential determinant of prognosis-remains largely unexplored. The present review delves into the pathophysiologic mechanisms of sepsis-induced coagulopathy attributed to fungal infection, the mechanisms of fungal involvement in the hemostatic derangement, and attempts to contextualize this knowledge within the unique neonatal population. Finally, it aims to raise awareness of the critical need for a deep understanding of this hazardous condition to guide the development of optimal therapeutic strategies.

The Mediating Effect of Intracranial Hemorrhage Status on the Relationship between the INR and Mortality in Patients with Ischemic Stroke

INTRODUCTION

The international normalized ratio (INR) is a biomarker of coagulopathy. The objective of this study was to assess the relationship between the INR and clinical outcomes in patients with large vessel occlusion (LVO) stroke who received endovascular therapy.

METHODS

The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial involving 948 stroke patients from 55 centers across China. We extracted INR data and related data from the BT database, with outcome measures comprising intracranial hemorrhage (ICH) and 90-day mortality. Logistic regression analysis was conducted to examine the associations between the INR and clinical outcomes in the entire patient cohort and across different stratified subgroups.

RESULTS

A total of 885 patients met the study criteria, with 672 exhibiting a normal INR and 213 showing an elevated INR. Multivariable analysis indicated that an elevated INR was linked to an increased risk of ICH (OR 1.65, 95% confidence interval CI 1.17-2.33, P =0.005) and 90-day mortality (OR 1.78, 95% CI 1.17-2.70, P =0.007). Mediation analysis indicated that the association between the INR and 90-day mortality risk was partially mediated by ICH status, with the mediation effect contributing 11.4% to the overall relationship. Subgroup analyses revealed no significant differences between the different subgroups (P for interaction > 0.05). In patients receiving tirofiban, an elevated INR was more strongly associated with an increased 90-day mortality rate (OR 7.75, 95% CI 1.42-42.33, P =0.018).

CONCLUSION

Our findings underscore the critical importance of INR monitoring in patients with LVO stroke undergoing endovascular treatment (EVT). The association between the INR and 90-day mortality was mediated through ICH status. The use of tirofiban strengthened the associated between an elevated INR and a higher 90-day mortality rate. These insights offer valuable guidance for optimizing patient outcomes.

TRIAL REGISTRATION

URL: http://www.chictr.org.cn ; ChiCTR-INR-17014167.

The association between deep vein thrombosis at admission and the time from injury to admission in hip fractures

OBJECTIVE

This study aims to explore the association between deep vein thrombosis (DVT) of the lower limbs at admission and the time from injury to admission (TFITA), providing clinical references for the prevention of DVT at admission.

PATIENTS AND METHODS

Data was collected from patients who were admitted to our hospital for hip fractures between January 2017 and December 2023. Univariable and multivariable logistic regression analyses were conducted to examine the relationship between TFITA and DVT at admission, using both continuous and categorized variables based on thresholds for TFITA. Propensity score matching (PSM) and subanalyses stratified by TFITA and characteristics of DVT at admission were further employed to investigate the relationship. Additionally, restricted cubic splines (RCS) analysis was performed to determine whether a non-linear association exists between TFITA and DVT at admission.

RESULTS

A total of 1230 patients were included in the statistical analysis, comprising 116 patients with DVT at admission and 1114 without. Both Univariable and multivariable logistic regression analyses indicated a positive association between TFITA and DVT at admission before and after matching. Subanalyses revealed significant associations for older age, low-energy injuries, high D-dimer levels, and low platelet counts subgroup with TFITA and DVT at admission. RCS analysis indicated no non-linear relationship between TFITA and DVT at admission.

CONCLUSION

For patients with hip fractures, longer TFITA is positively correlated with the incidence of DVT at admission. These findings support the potential of TFITA as an intervention strategy for managing DVT at admission.

Elevated risk of perioperative ischemic stroke in noncardiac surgery patients with atrial fibrillation: a retrospective cohort study

BACKGROUND

Stroke is still a significant and growing challenge of global health, however, the impact of Atrial Fibrillation (AF) on the risk of perioperative stroke remains unclear.

AIM

This study aims to evaluate the clinical prognostic value of AF in patients undergoing noncardiac surgery, with perioperative ischemic stroke as the primary prognostic indicator.

METHODS

A retrospective cohort study was conducted on patients who underwent noncardiac surgery between January 2008 and August 2019 at The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital. The study included patients with a procedure duration exceeding one hour. Participants were categorized into two groups: an AF group and a non-AF group, based on the presence or absence of AF. The primary outcome was the occurrence of perioperative ischemic stroke. To determine whether AF is an independent prognostic indicator, primary and subgroup analyses were performed. Logistic regression models were used to identify risk factors. Besides, sensitivity analysis, propensity score matching (PSM) analysis were applied to mitigate potential residual confounding effects and assess the robustness of the findings.

RESULTS

The primary analysis demonstrated that patients in the AF group had a significantly higher risk of perioperative ischemic stroke (OR: 6.843; 95% CI: 3.73-11.413; P < 0.001). Further modeling analyses confirmed a significant correlation between AF and perioperative ischemic stroke across various models: model 2 (OR: 1.789; 95% CI: 0.958-3.053; P < 0.05), model 3 (OR: 5.121; 95% CI: 2.749-8.716; P < 0.001), and model 4 (OR: 2.122; 95% CI: 1.123-3.677; P < 0.05). Sensitivity analysis excluding neurosurgeries were conducted. The adjusted OR of perioperative ischemic stroke in neurosurgery patients with the AF was 1.623(95% CI: 0.359-5.165; P = 0.463). While, the association between AF and perioperative ischemic stroke remained stable in those non-neurosurgical patients (OR: 2.154;95% CI: 1.044-3.964; P = 0.023). After PSM adjustments, the association between AF and perioperative ischemic stroke remained significant (OR: 2.106; 95% CI: 1.003-4.159; P < 0.05). Subgroup analyses revealed that AF significantly increased the risk of perioperative ischemic stroke, particularly in males, patients aged ≥ 60.5 years, those with an ASA score ≥ 3, those with hypertension, and those not on antiplatelet medication.

CONCLUSION

Atrial fibrillation is an independent prognostic risk factor for perioperative ischemic stroke in patients undergoing noncardiac surgery, especially pronounced in specific subgroups, including males, elderly patients, those with high ASA scores, with hypertension, and not receiving antiplatelet therapy. These findings emphasize the need for heightened awareness and prompt clinical intervention in these high-risk patients.

Interpretable machine learning model for early prediction of disseminated intravascular coagulation in critically ill children

Disseminated intravascular coagulation (DIC) is a thrombo-hemorrhagic disorder that can be life-threatening in critically ill children, and the quest for an accurate and efficient method for early DIC prediction is of paramount importance. Candidate predictors encompassed demographics, comorbidities, laboratory findings, and therapy strategies. A stepwise logistic regression model was employed to select the features included in the final model. Six machine learning algorithms-logistic regression (LR), extreme gradient boosting (XGB), random forest (RF), support vector machine (SVM), decision tree (DT), and k-nearest neighbor (KNN)-were employed to construct predictive models for DIC in critically ill children. Models were then evaluated by using area under the curve (AUC), accuracy, specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), precision, recall and decision curve analysis (DCA). Interpretation of the optimal model was conducted using shapley additive explanations (SHAP). A total of 6093 critically ill children were encompassed in this study, of whom 681 (11.2%) developed DIC. The RF model exhibited the highest levels of accuracy (0.856), sensitivity (0.866), Kappa (0.472), NPV (0.423), and recall (0.866). However, the XGB model outperformed RF, LR, SVM, DT, and KNN in terms of AUC (0.908), specificity (0.859), PPV (0.978), and precision (0.969). Decision curve analysis (DCA) confirmed the superior clinical utility of the XGB model. Overall, the XGB model demonstrated superior clinical utility compared to RF, LR, SVM, DT, and KNN. We named the final model Alfalfa-PICU-DIC. SHAP analysis identified D-dimer, INR, PT, TT, and PLT count as the top predictors of DIC. Machine learning models can be a reliable tool for predicting DIC in critically ill children, which will facilitate timely intervention, thereby reducing the burden of DIC on patients in the pediatric intensive care unit (PICU).

Constructing an early warning model for elderly sepsis patients based on machine learning

Sepsis is a serious threat to human life. Early prediction of high-risk populations for sepsis is necessary especially in elderly patients. Artificial intelligence shows benefits in early warning. The aim of the study was to construct an early machine warning model for elderly sepsis patients and evaluate its performance. We collected elderly patients from General Hospital of Ningxia Medical University emergency department and intensive care unit from 01 January 2021 to 01 August 2023. The clinical data was divided into a training set and a test set. A total of 2976 patients and 12 features were screened. We used 8 machine learning models to build the warning model. In conclusion, we developed a model based on XGBoost with an AUROC of 0.971, AUPRC of 0.862, accuracy of 0.95, specificity of 0.964 and F1 score of 0.776. Of all the features, baseline APTT played the most important role, followed by baseline lymphocyte count. Higher level of baseline APTT and lower level of baseline lymphocyte count may indicate higher risk of sepsis occurrence. We developed a high-performance early warning model for sepsis in old age based on machine learning in order to facilitate early treatment but also need further external validation.

Jianpi Qingre Tongluo Prescription (Huangqin Qingrechubi Capsule) alleviates inflammation and hypercoagulability by inhibiting the JAK2/STAT3 pathway via CircRNA 104633 downregulation in gouty arthritis

ETHNOPHARMACOLOGICAL RELEVANCE

Gouty arthritis (GA) is characterized by intermittent inflammatory pain, which dramatically compromises the quality of life of patients. Huangqin Qingrechubi Capsule (HQC) is an empirical traditional Chinese medicine prescription used to treat GA for over 20 years, with favorable efficacy. However, little is known about the specific mechanism of action of HQC in GA treatment.

PURPOSE

This study probed the mechanism of action of HQC in the treatment of GA from anti-inflammatory and anticoagulation aspects.

METHODS

Initially, a retrospective clinical analysis was performed to observe the effects of HQC on inflammatory and coagulation indexes in GA patients. Subsequently, the expression of CircRNA 104633 and inflammatory and coagulation factors was detected in peripheral blood mononuclear cells (PBMCs) harvested from recruited GA patients before and after HQC treatment, followed by the analysis of the correlation between CircRNA 104633 and other indexes. The anti-inflammatory and anticoagulation mechanisms of HQC in GA treatment via CircRNA 104633 were further investigated through a co-culture model composed of GA-PBMCs and fibroblast-like synoviocytes (FLSs). Finally, a rat model of monosodium urate-induced GA was established for in vivo verification.

RESULTS

HQC reduced the levels of HCRP, ESR, and D-D in GA patients. In the PBMCs of GA patients, HQC decreased CircRNA 104633 expression, and CircRNA 104633 expression was closely related to inflammatory and coagulation indexes. CircRNA 104633 upregulation fostered inflammation and hypercoagulability in GA by activating the JAK2/STAT3 pathway, whilst HQC reversed the imbalance of inflammatory and coagulation factors by downregulating CircRNA 104633. Furthermore, HQC played anti-inflammatory and anticoagulant roles in GA rats by blocking the JAK2/STAT3 pathway.

CONCLUSION

HQC protects against inflammation and hypercoagulability in GA by inhibiting CircRNA 104633 and the JAK2/STAT3 pathway, which supports the development of therapeutic targets and drugs for GA.

Bullous pemphigoid and hypercoagulability: a review

INTRODUCTION

Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by autoantibodies against hemidesmosomal proteins in the basal membrane zone. The presence of a high incidence of thrombotic events has led to the identification of a hypercoagulable state in BP patients.

AREAS COVERED

This review highlights the interactions between coagulation and immune-inflammatory responses based on the currently available literature, as well as individual changes in characteristic coagulation parameters in BP. This review is based on publications up to August 2024 that were retrieved by a selective search in the PubMed database.

EXPERT OPINION

The hypercoagulable state and bullous pemphigoid (BP) have a reciprocally enhancing effect on each other. For clinicians, it is crucial to closely monitor the fluctuations in circulating coagulation markers among BP patients, such as D-dimer, fibrinogen, and fibrin degradation products (FDP). Furthermore, considering the interplay between coagulation and immune-inflammatory responses in BP, targeting the shared pathways in treatment strategies could be beneficial for patients who exhibit both BP and a hypercoagulable state.

Quantitative methods to improve bivalirudin dosing in pediatric cardiac ICU patients

BACKGROUND

A gap in knowledge exists related to optimal bivalirudin dosing in children. The purpose of our analysis is to use quantitative methods and baseline data to quickly predict the optimal therapeutic bivalirudin dose for children.

METHODS

We developed an internal database of pediatric patients on ECMO or VAD, including baseline patient information, bivalirudin doses, and partial thromboplastin time (PTT) measurements throughout the treatment period. We fit an analysis of covariance (ANCOVA) model to the baseline data to determine the best predictors of therapeutic bivalirudin dose. We used five-fold cross-validation to ensure the model was not overfitting to any specific data subset.

RESULTS

The most notable variables that were statistically significant (p < .05) were: the primary use of bivalirudin for heart failure prophylaxis, no complications before bivalirudin administration, other reasons for bivalirudin use, other race (including Asian, pacific islander, and native American), Hispanic or Latinx ethnicity, primary diagnosis of heart failure, and primary diagnosis of myocarditis. To compare our model-predicted dose and the actual starting dose administered to the patients, we looked at how far off each of those was from the therapeutic dose. The mean of absolute differences was 0.28 mg/kg/hr for the administered starting dose and 0.23 mg/kg/hr for the model-predicted dose; therefore, the model results in an improvement of 18% in the difference from the therapeutic dose.

CONCLUSION

Our model provides an initial framework for determining a starting bivalirudin dose that takes into account patient demographic information and baseline admission data.

Non-classical neutrophil extracellular traps induced by PAR2-signaling proteases

Neutrophil extracellular traps (NETs) are associated with diseases linked to aberrant coagulation. The blood clotting cascade involves a series of proteases, some of which induce NET formation via a yet unknown mechanism. We hypothesized that this formation involves signaling via a factor Xa (FXa) activation of the protease-activated receptor 2 (PAR2). Our findings revealed that NETs can be triggered in vitro by enzymatically active proteases and PAR2 agonists. Intravital microscopy of the liver vasculature revealed that both FXa infusion and activation of endogenous FX promoted NET formation, effects that were prevented by the FXa inhibitor, apixaban. Unlike classical NETs, these protease-induced NETs lacked bactericidal activity and their proteomic signature indicates their role in inflammatory disorders, including autoimmune diseases and carcinogenesis. Our findings suggest a novel mechanism of NET formation under aseptic conditions, potentially contributing to a self-amplifying clotting and NET formation cycle. This mechanism may underlie the pathogenesis of disseminated intravascular coagulation and other aseptic conditions.

Disseminated intravascular coagulation: cause, molecular mechanism, diagnosis, and therapy

Disseminated intravascular coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, resulting in both thrombosis and bleeding. This review aims to provide a comprehensive overview of DIC, emphasizing its clinical significance and the need for improved management strategies. We explore the primary causes of DIC, including sepsis, trauma, malignancies, and obstetric complications, which trigger an overactive coagulation response. At the molecular level, DIC is marked by excessive thrombin generation, leading to platelet and fibrinogen activation while simultaneously depleting clotting factors, creating a paradoxical bleeding tendency. Diagnosing DIC is challenging and relies on a combination of existing diagnostic criteria and laboratory tests. Treatment strategies focus on addressing the underlying causes and may involve supportive care, anticoagulation therapy, and other supportive measures. Recent advances in understanding the pathophysiology of DIC are paving the way for more targeted therapeutic approaches. This review highlights the critical need for ongoing research to enhance diagnostic accuracy and treatment efficacy, ultimately improving patient outcomes in those affected by DIC.

Nattokinase's Neuroprotective Mechanisms in Ischemic Stroke: Targeting Inflammation, Oxidative Stress, and Coagulation

Aims: Nattokinase (NK), a potent serine endopeptidase, has exhibited a variety of pharmacological effects, including thrombolysis, anti-inflammation, and antioxidative stress. Building on previous research highlighting NK's promise in nerve regeneration, our study investigated whether NK exerted protective effects in transient middle cerebral artery occlusion (tMCAO)-induced cerebral ischemia-reperfusion injury and the underlying mechanisms. Results: The rats were administered NK (5000, 10000, 20000 FU/kg, i.g., 7 days before surgery, once daily). We showed that NK treatment dose dependently reduced the infarction volume and improved neurological symptoms, decreased the proinflammatory and coagulation cytokines levels, and attenuated reactive oxygen species (ROS) in the infarcted area of tMCAO rats. We also found that NK could exert neuroprotective effects in a variety of vitro models, including the microglia inflammation model and neuronal oxygen-glucose deprivation/reperfusion (OGD/R) model. Notably, NK effectively countered OGD/R-induced neuron death, modulating diverse pathways, including autophagy, apoptosis, PARP-dependent death, and endoplasmic reticulum stress. Furthermore, the neuroprotection of NK was blocked by phenylmethylsulfonyl fluoride (PMSF), a serine endopeptidase inhibitor. We revealed that heat-inactive NK was unable to protect against tMCAO injury and other vitro models, suggesting NK attenuated ischemic injury by its enzymatic activity. We conducted a proteomic analysis and found inflammation and coagulation were involved in the occurrence of tMCAO model and in the therapeutic effect of NK. Innovation and Conclusion: In conclusion, these data demonstrated that NK had multifaceted neuroprotection in ischemic brain injury, and the therapeutic effect of NK was related with serine endopeptidase activity. Antioxid. Redox Signal. 42, 228-248.

Antithrombin and Activated Protein C in Pediatric Sepsis: Prospective Observational Study of Outcome

OBJECTIVES

To assess antithrombin and activated protein C (aPC) levels in relation to disseminated intravascular coagulation (DIC) and severe outcomes in pediatric sepsis.

DESIGN

Prospective, observational study conducted between April 2023 and October 2024. Coagulation profiles including conventional coagulation, antithrombin activity, and aPC were obtained at PICU admission.

SETTING

PICU in the Vietnam National Children's Hospital, Hanoi, Vietnam.

SUBJECTS

PICU admissions, 1 month to 18 years old, with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty children (78 males; median age 7.5 mo) with mortality 23/130 (17.7%). The prevalence of overt DIC was 37 of 130 (28.5%). Nonsurvival at 28 days, compared with survival, was associated with hemorrhage and/or thrombosis at presentation, and higher number of dysfunctional organs, and overt DIC. Those with overt DIC, compared with not, had longer activated partial thromboplastin time, higher international normalized ratio and d -dimer, and lower antithrombin, and aPC. Activity of antithrombin and aPC correlated inversely with the Vasoactive-Inotropic Score in survivors ( p = 0.002 and 0.009, respectively). Patients with a cutoff value for antithrombin less than 63.5% had a mortality risk with area under the receiver operating characteristic (AUROC) curve 0.64, with sensitivity 0.51 and specificity 0.74, and positive predictive value 0.30. Regarding overt DIC, a cutoff value for antithrombin less than 55.5% had an AUROC 0.78, sensitivity 0.72 and specificity of 0.73, and positive predictive value 0.52.

CONCLUSIONS

In this observational study of pediatric sepsis patients, first 24-hour coagulation data in those who did not-survive to 28 days, vs. survivors showed an associated prior lower level of antithrombin in nonsurvivors. Furthermore, using the outcome of overt DIC and nonovert DIC in the first 72 hours, we found that lower levels of antithrombin or aPC are each associated with overt DIC and nonovert DIC in pediatric sepsis. Further validation work is needed in larger case series of pediatric sepsis.

Association of Social Isolation and Plasma Metabolites With the Risk of Venous Thromboembolism

BACKGROUND

To explore the association of social isolation with venous thromboembolism (VTE) risk and the mediating role of metabolomics on this association.

METHODS

Overall, 236 026 participants free of VTE and with complete metabolomics data at baseline from the UK Biobank were included. Social isolation was constructed based on the frequency of friend/family visits, weekly group activities, and living alone. The study outcome was incident VTE, including deep vein thrombosis or pulmonary embolism. Least absolute shrinkage and selection operator regression was applied to create a social isolation-associated metabolic signature. We estimated hazard ratios of study outcomes in relation to social isolation/metabolic signature and calculated the proportion of social isolation-VTE association mediated by the metabolic signature.

RESULTS

During a median follow-up of 12.5 years, 6681 VTE cases were recorded. Social isolation was positively associated with VTE risk (versus without social isolation; hazard ratio, 1.17 [95% CI, 1.09-1.27]). A metabolic signature for social isolation was constructed using 28 metabolites. This metabolic signature showed significant association with VTE risk (per SD increment; hazard ratio, 1.16 [95% CI, 1.13-1.19]) and mediated 11.0% (95% CI, 7.0-19.8) of the increased VTE risk associated with social isolation. 11 metabolites in the metabolic signature also significantly mediated the association between social isolation and VTE risk, with mediation proportions ranging from 0.5% to 2.6%. Similar results were found for incident deep vein thrombosis and pulmonary embolism, respectively.

CONCLUSIONS

Social isolation was positively associated with VTE risk. The metabolic signature for social isolation, especially the 11 major metabolites included, significantly mediated the association between social isolation and VTE risk.

Inflammation and Coagulation in Neurologic and Psychiatric Disorders

Coagulation factors are intrinsically expressed in various brain cells, including astrocytes and microglia. Their interaction with the inflammatory system is important for the well-being of the brain, but they are also crucial in the development of many diseases in the brain such as stroke and traumatic brain injury. The cellular effects of coagulation are mediated mainly by protease-activated receptors. In this review, we sum up the role of the coagulation cascade in the development of different diseases including psychiatric disorders. In inflammatory diseases such as multiple sclerosis, fibrinogen activates microglia and suppresses the differentiation of oligodendrocytes, leading to axonal damage and suppression of remyelination. In ischemic stroke, thrombin activity is associated with the size of infarction, and the inhibition of either thrombin- or protease-activated receptor 1 promotes neuronal survival and reduces the size of infarction. Patients suffering from Alzheimer's disease express higher levels of thrombin, which in turn damages the endothelium, increases blood-brain barrier permeability, and induces cell apoptosis. In major depressive disorder, a positive correlation is present between prothrombotic states and suicidality. Moreover, both protein S deficiency and antiphospholipid antibodies are associated with schizophrenia and there is an effect of warfarin on psychosis-free intervals. Studying the coagulation in the brain could open a new door in understanding and treating neurological and psychiatric disorders, and extensive research should be conducted in this field.

Predicting severity of inpatient acute cholangitis: combined neutrophil-to-lymphocyte ratio and prognostic nutritional index

The indicators for rapid assessment of the severity of acute cholangitis remain highly debated. Therefore, this study aimed to evaluate the efficacy of various inflammatory and immune-nutritional markers in predicting the severity of acute cholangitis. The prognostic roles of the following markers were investigated: Systemic Immune-Inflammatory Index (SII), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Albumin (Alb), and Prognostic Nutritional Index (PNI). A total of 139 patients with acute cholangitis were included in the study. The inflammatory and immune-nutritional markers with better predictive efficacy were selected to construct a combined predictive score. According to the survival ROC curve analysis, the combined NLR and PNI score, termed PNS, demonstrated the best prognostic performance with an AUC of 0.853. Multivariable survival analysis identified the following independent prognostic factors: PNS (p = 0.010) and Prothrombin Time (PT) (p = 0.003). The results indicate that PNS = 2 is associated with a higher incidence of severe cholangitis.

Hypercoagulation after Hospital Discharge in Acute Severe Ulcerative Colitis: A Prospective Study

BACKGROUND & AIMS

Venous thromboembolism is a serious complication during and following hospitalization with acute severe ulcerative colitis (ASUC). We evaluated serial thrombotic profiles of patients with ASUC from the point of hospitalization up to 12 weeks postdischarge and compared these with control patients with quiescent ulcerative colitis.

METHODS

Twenty-seven patients with ASUC and 25 control patients with quiescent ulcerative colitis were recruited. Thrombin generation (endogenous thrombin potential), rotational thromboelastometry (EXTEM and FIBTEM maximum clot firmness), procoagulant factors, anticoagulant factors, and fibrinolytic markers were assessed for those with ASUC on admission (Day 1), Day 5, 4 weeks, and at 8-12 weeks. These assessments were performed on a single occasion for control patients.

RESULTS

Endogenous thrombin potential and maximum clot firmness were significantly elevated in patients with ASUC compared with control subjects and remained significantly elevated for 4 weeks and for 8-12 weeks after admission (P < .05), respectively. Von Willebrand factor antigen, factor VIII, Clauss fibrinogen concentration, and platelet count were significantly increased from presentation to 8-12 weeks and are likely to account for changes in the global hemostatic profile.

CONCLUSIONS

Global measures of hemostasis demonstrated that patients with ASUC were prothrombotic compared with control subjects with quiescent colitis. This difference was maintained 8-12 weeks after the initial presentation, supporting clinical observations that patients with ASUC have an elevated risk of venous thromboembolism after hospital discharge.

Risk of Uveitis in Dengue Fever Patients: A Population-Based Cohort Study in Taiwan

Dengue-related ocular complications were considered rare, but recent evidence points to a broader spectrum of manifestations, including uveitis. This study utilized the Taiwan National Health Insurance Research Database (NHIRD) to investigate the incidence of uveitis in dengue patients, aiming to fill this research gap. This population-based, retrospective cohort study utilized the Taiwan National Health Insurance Research Database (NHIRD) and included patients with and without Dengue fever. The non-Dengue fever cohort comprised randomly selected control patients who were matched. Hazard ratios and Kaplan-Meier analysis were conducted to compare the incidence of uveitis in the Dengue and non-Dengue cohorts. Subgroup analyses were carried out based on age groups, genders, and comorbidities. A total of 26 950 patients diagnosed with Dengue fever were included in the study (49.6% female, mean age at index 41.63 years). Based on a 1:4 matching ratio, 107 800 control subjects without uveitis (50.03% female, mean age at index 41.41 years) were also included. The adjusted hazard ratio (aHR) of uveitis was higher in the Dengue fever group than in the non-Dengue fever group (aHR = 1.38, p < 0.001). A history of stroke or transient ischemic attack (TIA) was not associated with uveitis. Stratified analyses revealed that patients with Dengue fever had an increased risk regardless of their sex and age. The Kaplan-Meier method with the log-rank test showed a significantly higher cumulative incidence of uveitis in the Dengue fever cohort than in the non-Dengue fever cohort (p < 0.001). In the subgroup analysis for most major comorbidities, the significantly higher risk for uveitis in those patients with Dengue fever, was only demonstrated in the subgroups of those without these major comorbidities. Our findings showed Dengue infection to be associated with increased risk for uveitis. Clinicians should be attentive to a history of stroke or TIA in patients with Dengue fever.

Heparin-binding protein and sepsis-induced coagulopathy: Modulation of coagulation and fibrinolysis via the TGF-β signalling pathway

BACKGROUND

Heparin-binding protein (HBP) levels have been linked to organ failure and may represent an inflammatory biomarker of sepsis. We found disseminated intravascular coagulation (DIC) is associated with higher HBP levels in patients and in in vivo and in vitro models. This prospective, single-center observational study investigated the effects and underlying mechanisms of HBP on the coagulation cascade in sepsis.

METHODS

538 patients with sepsis from June 2016 to December 2019 were enrolled. Mechanisms underlying HBP and the coagulation system were investigated in human umbilical vein endothelial cells (HUVEC) and C57 mice.

RESULTS

Increased HBP was associated with sepsis-induced DIC. The optimal cutoff value was 37.5 ng/mL (sensitivity: 56 %, specificity: 65 %). Antithrombin-III (AT-III) activity, plasmin-a2 plasmin inhibitor complex (PIC), procalcitonin (PCT), hemoglobin, and HBP ≥37.5 ng/mL were associated with of DIC occurrence. In HUVECs &C57 mice models, Western blotting, qPCR, and immunohistochemistry analysis showed that the binding between HBP and TGF-β receptor 2 (TGFBR2) caused elevation of plasminogen activator inhibitor-1 (PAI-1) levels. Furthermore, we found that mice stimulated with HBP had higher levels of fibrinogen and D-dimer in the blood. HBP treatment caused the accumulation of fibrinogen in mice lung tissue. Treatment with TGFBR2-small interfering RNAs inhibited the effects.

CONCLUSION

Patients with sepsis having HBP ≥37.5 ng/mL at admission were more likely to develop DIC. HBP upregulates the expression of fibrinogen and PAI-1 via TGFBR2 and the TGF-β signalling pathway.

Inflammation-Associated Coagulation Reactions are Associated with the Prognosis in Critically Ill Very Old Patients (VOPs) with Infection

Background

Dysregulated host response is an important cause of critical illness. Coagulation reaction is the most primitive response and can be used to assess patient status. Coagulation reactions may be amplified in very old patients (VOPs). This study aimed to demonstrate coagulation reactions in critically ill VOPs by linking cytokines, coagulation, and fibrinolytic processes.

Methods

We analyzed 33 critically ill VOPs admitted to our hospital, with an average age of 91.97. Laboratory test results were collected and double checked. In-hospital mortality, Intensive Care Unit (ICU) stay, and length of in-hospital stay (LOS)-associated variables were assessed using a generalized additive mix model. Smooth curves and interaction tests were used to quantify statistical interactions.

Results

The in-hospital mortality rate was 45.5% in this study. The D-dimer level was correlated with ICU stay [risk ratio (RR), 1.39; 95% confidential interval (CI), 1.16-1.67] and LOS (RR, 1.75; 95% CI, 1.19-2.57). Other function or quantity indices, such as platelet (PLT), prothrombin time (PT), activated partial prothrombin time (APTT), and thrombomodulin (TM), were all correlated with clinical outcomes. After the link between coagulation reaction and the outcomes was constructed, it was revealed that, compared to lower level of IL-6, under high level of IL-6, elevated TM was likely to be associated with tissue plasminogen activator inhibitor complex (t-PAIC) elevation, which probably promoted the production of D-dimer (RR, 3.216; 95% CI, 1.840-4.592).

Conclusion

D-dimer levels are associated with outcomes in VOPs with critical illness. There is a certain link between inflammatory cytokines and the coagulation process. Under high IL-6 levels, the elevated TM may contribute to the increased t-PAIC, which contributes to the higher D-dimer level. Conversely, under low IL-6 levels, elevated TM levels are associated with reduced t-PAIC levels.

Prospective Application of Mesenchymal Stem Cell-Derived Exosomes in the Treatment of Disseminated Intravascular Coagulation

Disseminated intravascular coagulation (DIC) is an acquired disorder characterized by systemic activation of blood coagulation, which can arise from various causes. Owing to its abrupt onset, rapid progression, and high mortality rate, DIC presents a major clinical challenge. Anticoagulant drugs, such as heparin or low-molecular-weight heparin, are the current gold standard of treatment; however, these interventions pose considerable bleeding risks. Thus, safer and more effective therapeutic strategies are urgently required. Owing to their strong anti-inflammatory and tissue repair capabilities, mesenchymal stem cell-derived exosomes (MSC-Exos) have gained considerable attention as novel therapeutic options for numerous disorders, including DIC. Their stability in diverse pathological states highlights their potential as promising candidates for DIC therapy. This review presents the latest insights on the pathogenesis of DIC and anti-inflammatory and anticoagulant properties of MSC-Exos. We aimed to elucidate the potential mechanisms by which MSC-Exos influence DIC pathogenesis. We speculate that MSC-Exos offer a multifaceted approach to DIC treatment by attenuating neutrophil extracellular trap formation, modulating M1/M2 macrophage polarization, altering Nrf2/NF-κB signalling pathway to downregulate pro-inflammatory factors, and correcting imbalances in the coagulation-fibrinolysis system through anticoagulant routes. This suggests that MSC-Exos are a potential paradigm in DIC therapy, offering novel targets and treatment modalities for DIC management.

TRIM28 regulates the coagulation cascade inhibited by p72 of African swine fever virus

In 2018, African swine fever virus (ASFV) emerged in China, causing extremely serious economic losses to the domestic pig industry. Infection with ASFV can cause disseminated coagulation, leading to the consumption of platelets and coagulation factors and severe bleeding. However, the mechanism of virus-induced coagulation has yet to be established. In our study, ASFV downregulated the coagulation process, as detected by D-dimer (D2D) and Factor X (F10) expression in pigs challenged with ASFV HLJ/18. In vitro, ASFV infection increased Factor IX (F9) and Factor XII (F12) expression while downregulating F10 expression in porcine alveolar macrophages (PAMs). African swine fever virus induced both intrinsic and extrinsic coagulation cascades. In addition, several encoded proteins affect the expression of the crucial coagulation protein F10, and among the encoded proteins, p72 inhibits the activity and expression of F10. Proteomic analysis also revealed that p72 is involved in the coagulation cascade. p72 can interact with F10, and its inhibitory functional domains include amino acids 423-432 and amino acids 443-452. Finally, we found that F10 and p72 interact with tripartite motif-containing protein 28 (TRIM28). TRIM28 knockdown resulted in a decrease in F10 expression. Importantly, TRIM28 contributes to the reduction in F10 protein expression regulated by p72. Our findings revealed an inhibitory effect of the viral protein p72 on the ASFV infection-induced coagulation cascade and revealed a role of TRIM28 in reducing F10 expression, revealing a molecular mechanism of ASFV-associated coagulation.

Predictive haemostatic biomarkers and transfusion efficacy, insights from fresh frozen plasma use in surgical patients, preliminary results

The aim of the study was to examine various haemostasis values to identify the most relevant biological indicators for detecting significant haemorrhage, to determine the effectiveness of fresh frozen plasma (FFP) transfusion. Our findings suggest that a low prothrombin time, elevated Von Willebrand Antigen, increased plasma fibrinogen, and reduced Ca2 + levels are associated with challenges in achieving proper haemostasis. However, measurements of factors II, V, VII, VIII, IX, X, XI, XIII, protein C, and protein S do not appear to be linked to difficulties in achieving adequate haemostasis. Additionally, the administration of FFP appears to impact factors V, VII, X, and II.Trial registration EudraCT number: 2019-002898-64.

Mesenchymal stem cells from different sources for sepsis treatment: prospects and limitations

Sepsis is a systemic inflammatory response syndrome in which the host response to infection is dysregulated, leading to circulatory dysfunction and multi-organ damage. It has a high mortality rate and its incidence is increasing year by year, posing a serious threat to human life and health. Mesenchymal stem cells (MSC) have the following properties: hematopoietic support, provision of nutrients, activation of endogenous stem/progenitor cells, repair of tissue damage, elimination of inflammation, immunomodulation, promotion of neovascularization, chemotaxis and migration, anti-apoptosis, anti-oxidation, anti-fibrosis, homing, and many other effects. A large number of studies have confirmed that MSC from different sources have their own characteristics. This article reviews the pathogenesis of sepsis, the biological properties of MSC, and the advantages and disadvantages of different sources of MSC for the treatment of sepsis and their characteristics.

Pathophysiological dynamics in the contact, coagulation, and complement systems during sepsis: Potential targets for nafamostat mesilate

Sepsis is a life-threatening syndrome resulting from a dysregulated host response to infection. It is the primary cause of death in the intensive care unit, posing a substantial challenge to human health and medical resource allocation. The pathogenesis and pathophysiology of sepsis are complex. During its onset, pro-inflammatory and anti-inflammatory mechanisms engage in intricate interactions, possibly leading to hyperinflammation, immunosuppression, and long-term immune disease. Of all critical outcomes, hyperinflammation is the main cause of early death among patients with sepsis. Therefore, early suppression of hyperinflammation may improve the prognosis of these patients. Nafamostat mesilate is a serine protease inhibitor, which can inhibit the activation of the complement system, coagulation system, and contact system. In this review, we discuss the pathophysiological changes occurring in these systems during sepsis, and describe the possible targets of the serine protease inhibitor nafamostat mesilate in the treatment of this condition.

Cerebrospinal fluid markers of neuroinflammation and coagulation in severe cerebral edema and chronic hydrocephalus after subarachnoid hemorrhage: a prospective study

BACKGROUND

Early severe cerebral edema and chronic hydrocephalus are the primary cause of poor prognosis in patients with subarachnoid hemorrhage (SAH). This study investigated the role of cerebrospinal fluid (CSF) inflammatory cytokines and coagulation factors in the development of severe cerebral edema and chronic hydrocephalus in patients with SAH.

METHODS

Patients with SAH enrolled in this study were categorized into mild and severe cerebral edema groups based on the Subarachnoid Hemorrhage Early Brain Edema Score at admission. During long-term follow-up, patients were further classified into hydrocephalus and non-hydrocephalus groups. CSF samples were collected within 48 h post-SAH, and levels of inflammatory cytokines and coagulation factors were measured. Univariate and multivariate logistic regression analyses were performed to identify independent factors associated with severe cerebral edema and chronic hydrocephalus. The correlation between inflammatory cytokines and coagulation factors was further investigated and validated in a mouse model of SAH.

RESULTS

Seventy-two patients were enrolled in the study. Factors from the extrinsic coagulation pathway and inflammatory cytokines were associated with both severe cerebral edema and chronic hydrocephalus. Coagulation products thrombin-antithrombin complexes (TAT) and fibrin, as well as inflammatory cytokines IL-1β, IL-2, IL-5, IL-7, and IL-4, were independently associated with severe cerebral edema. Additionally, Factor VII, fibrin, IL-2, IL-5, IL-12, TNF-α, and CCL-4 were independently associated with chronic hydrocephalus. A positive correlation between extrinsic coagulation factors and inflammatory cytokines was observed. In the SAH mouse model, tissue plasminogen activator was shown to alleviate neuroinflammation and cerebral edema, potentially by restoring glymphatic-meningeal lymphatic function.

CONCLUSIONS

Elevated levels of inflammatory cytokines and extrinsic coagulation pathway factors in the CSF are associated with the development of early severe cerebral edema and chronic hydrocephalus following SAH. These factors are interrelated and may contribute to post-SAH glymphatic-meningeal lymphatic dysfunction.

Interaction between coagulation and inflammatory system in liver disease: re-focus on hematological markers

Aim: This study uses blood routine, coagulation and biochemical indicators to explore the relationship between the hematological parameters of patients with various types of liver diseases.Methods: The Kruskal-Wallis, Chi-squared and Fisher exact tests were used to compare the hematological parameters and clinical characteristics of three groups of patients with different degrees of liver disease. Spearman correlation analysis is used to analyze the correlation between two continuous variables. The logistic regression model evaluated the odds ratio between variables and disease changes. Receiver operating characteristic curve analysis was used to understand the predictive value of each index in relation to the progress of liver disease.Results: There are differences in inflammation and coagulation profiles among different types of liver diseases and there is a correlation between them. In addition to the traditional marker α-fetoprotein, the inflammatory marker c-reactive protein and the coagulation marker D-dimer also have good diagnostic value for liver injury.Conclusion: The coagulation and inflammation systems interact, are connected and play essential roles in the liver.

Nomogram for predicting intolerable postoperative early enteral nutrition following definitive surgery for small intestinal fistula: a cohort study

BACKGROUND

This study was designed to develop and validate a nomogram for predicting intolerable early enteral nutrition (EEN) following definitive surgery (DS) for small intestinal fistula.

METHODS

A total of 377 patients, recruited from January 2016 to September 2023, was randomly allocated into development ( n =251) and validation ( n =126) groups in a 2:1 ratio. Risk factors were identified using the nomogram. Its performance was assessed based on calibration, discrimination, and clinical utility, with validation confirming its effectiveness.

RESULTS

Of the 377 patients, 87 (23.1%) were intolerant to EEN, including 59 (23.1%) in the development cohort and 28 (22.1%) in the validation cohort ( P =0.84). Four factors were identified as predictive of intolerable EEN: severe abdominal adhesion, deciliter of blood loss during DS, human serum albumin (Alb) input >40 g during and within 48 h post-DS, and the visceral fat area (VFA)/total abdominal muscle area index (TAMAI) ratio. The model demonstrated excellent discrimination, with a C-index of 0.79 (95% CI: 0.74-0.87, including internal validation) and robust calibration. In the validation cohort, the nomogram showed strong discrimination (C-index=0.77; 95% CI: 0.64-0.87) and solid calibration. Decision curve analysis affirmed the nomogram's clinical utility.

CONCLUSION

This research introduces a nomogram that enables the individualized prediction of intolerable EEN following DS for small intestinal fistula, demonstrating a possible clinical utility.

Visceral to subcutaneous fat area ratio predicts severe abdominal adhesions in definitive surgery for anastomotic fistula after small intestine resection

Abdominal adhesions manifests following abdominal infections triggered by intestinal fistulas. The severity of such adhesions depends on the extent of fiber deposition and peritoneal fibrinolysis following peritoneal injury, which may be influenced by sustained inflammation within the abdominal cavity. In this regard, the visceral-to-subcutaneous fat area (VFA/SFA) ratio has been implicated as a potential marker of inflammation. This study aimed to explore the relationship between VFA/SFA and abdominal adhesions. This multicenter study was conducted across four tertiary institutions and involved patients who had undergone definitive surgery (DS) for intestinal fistula from January 2009 and October 2023. The presence of abdominal adhesions was determined intraoperatively. VFA/SFA was investigated as a potential risk factor for severe adhesions. The study comprised 414 patients with a median age of 50 [interquartile range (IQR) 35-66] years and a median body mass index of 20.0 (IQR 19.2-22.4) kg/m2, including 231 males with a median VFA/SFA of 1.0 (IQR 0.7-1.2) and 183 females a median VFA/SFA of 0.8 (0.6-1.1). VFA/SFA was associated with severe abdominal adhesions in males [odds ratio (OR) = 3.34, 95% CI 1.14-9.80, p = 0.03] and females (OR = 2.99, 95% CI 1.05-8.53, p = 0.04). J-shaped association between VFA/SFA ratio and severe adhesions was revealed in both sex. The increasing trend can be revealed when OR more than 0.8, and 0.6 in males and females respectively. Preoperative VFA/SFA demonstrates predictive value for statues of severe abdominal adhesions in DS for anastomotic fistula after small intestine resection.

Influencing factors for surgical treatment in neonatal necrotizing enterocolitis: a systematic review and meta-analysis

BACKGROUND

Necrotizing enterocolitis (NEC) is a complex disease characterized by gastrointestinal inflammation and is one of the most common gastrointestinal emergencies in neonates. Mild to moderate cases of NEC require medical treatment, whereas severe cases necessitate surgical intervention. However, evidence for surgical indications is limited and largely dependent on the surgeon's experience, leading to variability in outcomes. The primary aim of this study is to identify the risk factors for surgical intervention in neonatal NEC, which will aid in predicting the optimal timing for surgical intervention.

METHODS

A literature search was conducted in PubMed, Embase, and Web of Science databases for case-control studies exploring risk factors for NEC requiring surgical intervention. The search was completed on June 16, 2024, and data analysis was performed using R Studio 4.3.2.

RESULTS

18 studies were included, comprising 1,104 cases in the surgery group and 1,686 in the medical treatment group. The meta-analysis indicated that high C-reactive protein (CRP) levels [OR = 1.42, 95% CI (1.01, 1.99)], lower gestational age [OR = 0.52, 95% CI (0.3, 0.91)], sepsis [OR = 2.94, 95% CI (1.87, 4.60)], coagulation disorder [OR = 3.45, 95% CI (1.81, 6.58)], lack of enteral feeding [OR = 3.18, 95% CI (1.37, 7.35)], and hyponatremia [OR = 1.22, 95% CI (1.07, 1.39)] are significant risk factors for surgical treatment in neonatal NEC.

CONCLUSIONS

High CRP levels, coagulation disorders, sepsis, lower gestational age, lack of enteral feeding, and hyponatremia are significant risk factors for surgical intervention in neonatal NEC. These findings have potential clinical significance for predicting surgical risk.

Bacterial infection-biased abundance of proteins in the skin mucus of obscure puffer (Takifugu Obscurus)

The skin mucus of fish is equipped with immunological and antimicrobial peptides that confer protection against invading pathogens. The skin mucus has been studied in fish however information regarding its immunological roles in bacterial infection is rare. This study highlighted the proteins and peptides in the skin mucus of Obscure puffer Takifugu obscurus that quantitatively altered against Aeromonas hydrophila infection. We infected the fish through bath immersion, intraperitonially, and treated with PBS (control) then compared the level of proteins in the skin mucus among the groups using liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. The Tandem Mass Tag (TMT) based quantification showed that 4896 proteins were Deferentially Quantified Proteins (DQPs), based on 19,751 unique peptides. Of which 170 were depleted (decreased in abundance) and 69 were abundant in comparison of Bath Treated (BT) vs Control (C) groups. Similarly, 76 DQPs were depleted and 70 were abundant in comparison of Treated (T) vs BT groups. Further, 126 DQPs were depleted, and 34 were abundant in comparison to T vs C groups. The DQPs we report were mostly immunological and were involved in unique biological functions and pathways. The interesting protein we report, where some of the proteins are for the first time in fish, shows the protein-rich structure of the mucus of fish, which may act as a biomarker to be targeted for bacterial disease therapy in fish and ultimately hint to the way of making resistance in fish against bacterial pathogens.

Nomogram established on account of Lasso-logistic regression for predicting hemorrhagic transformation in patients with acute ischemic stroke after endovascular thrombectomy

BACKGROUND

Hemorrhagic transformation (HT) is a common and serious complication in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). This study was performed to determine the predictive factors associated with HT in stroke patients with EVT and to establish and validate a nomogram that combines with independent predictors to predict the probability of HT after EVT in patients with AIS.

METHODS

All patients were randomly divided into development and validation cohorts at a ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal factors, and multivariate logistic regression analysis was used to build a clinical prediction model. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance.

RESULTS

LASSO regression analysis showed that Alberta Stroke Program Early CT Scores (ASPECTS), international normalized ratio (INR), uric acid (UA), neutrophils (NEU) were the influencing factors for AIS with HT after EVT. A novel prognostic nomogram model was established to predict the possibility of HT with AIS after EVT. The calibration curve showed that the model had good consistency. The results of ROC analysis showed that the AUC of the prediction model established in this study for predicting HT was 0.797 in the development cohort and 0.786 in the validation cohort.

CONCLUSION

This study proposes a novel and practical nomogram based on ASPECTS, INR, UA, NEU, which can well predict the probability of HT after EVT in patients with AIS.

Complexities in diesel oil inhalation: case study of respiratory injury and coagulation anomalies

Diesel inhalation poisoning represents a rare yet critical medical condition necessitating prompt medical attention due to its potential to induce severe respiratory distress and coagulation dysfunction. The present case study describes the distinctive clinical presentation of a male patient in his early 40s who experienced acute respiratory distress and manifested coagulation factor VII deficiency subsequent to unintentional inhalation of diesel oil during engine repair. The patient demonstrated symptoms including chest tightness and dyspnea, indicative of chemical aspiration pneumonia, alongside an unforeseen coagulation abnormality. Treatment involved rigorous intervention, comprising endotracheal intubation, mechanical ventilation, and administration of pharmacotherapy, including ambroxol, dihydroxypropylline, and methylprednisolone. Moreover, procedural measures, such as repeated bronchoscopic alveolar lavage, pathogen culture, and targeted antibiotic therapy, were employed to mitigate respiratory complications. The patient's clotting disorder was treated with blood transfusions, and he was discharged with improvement. The present case highlights the imperative nature of immediate medical intervention in instances of diesel inhalation to avert further clinical deterioration and unfavorable outcomes. Additionally, it underscores the necessity for expanded research endeavors aimed at elucidating the indirect repercussions of diesel inhalation on the coagulation cascade, an area that remains relatively underexplored within the medical literature.

The Value of Neutrophil-to-Lymphocyte Ratio in Predicting Mortality After Transjugular Intrahepatic Portosystemic Shunt Placement

Background and Aims

The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS).

Methods

A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality.

Results

The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356).

Conclusion

NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.

Development and internal validation of a model for predicting cefoperazone/sulbactam-associated coagulation disorders in Chinese inpatients

BACKGROUND AND AIM

The use of cefoperazone/sulbactam (CPZ/SAM) could commonly cause vitamin K-dependent coagulation disorders and even hemorrhage sometimes. However, there is a lack of prediction tools estimating the risk for this. This study aimed at developing and internally validating a model for predicting CPZ/SAM-associated coagulation disorders in Chinese inpatients.

METHODS

A case-control study was conducted in 11,092 adult inpatients admitted to a Chinese general hospital between 2020 and 2021 and treated with CPZ/SAM. Patients with CPZ/SAM-associated coagulation disorders were identified through the Adverse Drug Events Active Surveillance and Assessment System-II and subsequent manual evaluation. Controls were selected from eligible patients who didn't develop coagulation disorders after CPZ/SAM therapy, with a 1:1 propensity score matching. The final predictors were obtained by univariable and multivariable logistic regression analyses. Internal validation and calibration for the model were performed using 1000 bootstrap resamplings.

RESULTS

258 patients were identified as CPZ/SAM-associated coagulation disorders in 2184 patients eligible for inclusions and exclusions and the incidence was 11.8%. A final population of 252 cases and 252 controls was included for model development and validation. Malnutrition (OR = 2.41 (1.56-3.77)), history of recent bleeding (OR = 1.95 (1.32-2.90)), treatment duration (OR = 1.10 (1.07-1.14)), combination with carbapenems (OR = 4.43 (1.85-11.88)), and serum creatinine (OR = 1.01 (1.00-1.01)) were identified as final predictors. The model showed good discrimination, calibration, and clinical practicality, with the validated area under the receiver operating characteristic curve being 0.723 (0.683-0.770).

CONCLUSIONS

The model with good performance quantifies the risk for CPZ/SAM-associated coagulation disorders, and may support individual assessment and interventions to mitigate the risk after external validation.

Biologic Impact of Anterior Cruciate Ligament Injury and Reconstruction

Surgical intervention after anterior cruciate ligament (ACL) tears is typically required because of the limited healing capacity of the ACL. However, mechanical factors and the inflammatory response triggered by the injury and surgery can impact patient outcomes. This review explores key aspects of ACL injury and reconstruction biology, including the inflammatory response, limited spontaneous healing, secondary inflammation after reconstruction, and graft healing processes. Understanding these biologic mechanisms is crucial for developing new treatment strategies and enhancing patient well-being. By shedding light on these aspects, clinicians and researchers can work toward improving quality of life for individuals affected by ACL tears.

Heparin Dosing Regimen Optimization in Veno-Arterial Extracorporeal Membrane Oxygenation: A Pharmacokinetic Analysis

BACKGROUND

Unfractionated heparin is administered in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Anticoagulation monitoring is recommended, with an anti-activated factor X (anti-Xa) targeting 0.3 to 0.7 IU/mL. Owing to heparin's heterogeneous pharmacokinetic properties, anti-Xa is unpredictable, generating a challenge in anticoagulation practices. The aim of this study was to build a pharmacokinetic model of heparin accounting for potential confounders, and derive an optimized dosing regimen for a given anti-Xa target.

METHODS

Adult patients undergoing VA-ECMO were included between January 2020 and June 2021. Anticoagulation was managed with an initial 100 IU/kg heparin loading dose followed by a continuous infusion targeting 0.2 to 0.7 IU/mL anti-Xa. The data were split into model development and model validation cohorts. Statistical analysis was performed using a nonlinear mixed effects modeling population approach. Model-based simulations were performed to develop an optimized dosing regimen targeting the desired anti-Xa.

RESULTS

A total of 74 patients were included, with 1703 anti-Xa observations. A single-compartment model best fitted the data. Interpatient variability for distribution volume was best explained by body weight, C-reactive protein and ECMO indication (post-cardiotomy shock or medical cardiogenic shock), and interpatient variability for elimination clearance was best explained by serum creatinine and C-reactive protein. Simulations using the optimized regimen according to these covariates showed accurate anti-Xa target attainment.

CONCLUSION

In adult patients on VA-ECMO, heparin's effect increased with serum creatinine and medical indication, whereas it decreased with body weight and systemic inflammation. We propose an optimized dosing regimen accounting for key covariates, capable of accurately predicting a given anti-Xa target.

Heatstroke Comorbid with SARS-CoV-2 Infection: A Case Report and Literature Review

Background

Hyperthermia and multiple organ dysfunction syndrome (MODS) are the main characteristics of heatstroke and COVID-19. Differentiating between these illnesses is crucial during a summer COVID-19 pandemic, but cases of heatstroke comorbid with COVID-19 are rarely reported.

Case description

We report the first case of heatstroke comorbid with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in a 52-year-old male. After receiving intravenous antibiotics, organ protection measures, and treatment for coagulation disorders, his fever and coma resolved. However, he developed dyspnea and cerebral hemorrhage after several days. This patient experienced a multi-pathogen pulmonary infection and an intractable coagulopathy that ultimately resulted in MODS and death.

Conclusion

The combination of heatstroke and SARS-CoV-2 infection exacerbated inflammation, immune abnormalities, and coagulation disorders. The interaction between inflammation and coagulation disturbances contributed to the underlying mechanism in this case, highlighting the importance of early anti-infection, treatment for coagulopathy, immune regulation, and organ protection as crucial interventions.

Oral symptoms potentially associated with mild-to-moderate COVID-19 in tobacco users

INTRODUCTION

Coronavirus disease (COVID-19) is a worldwide infection characterized by various symptoms. Few studies have examined its oral manifestations. However, there is insufficient information on the oral manifestations of patients with COVID-19 who use tobacco products. Therefore, this cross-sectional study investigated oral symptoms of tobacco-using patients with mild-to-moderate COVID-19.

METHODS

This study used a convenience sample of non-hospitalized patients (aged ≥18 years) with mild-to-moderate COVID-19 diagnosed by polymerized chain reaction (PCR). This study excluded pregnant or lactating women or patients with serious COVID-19 complications, including those who required hospitalization or were on specific medications (antiviral, corticosteroid, antimicrobial, or immunosuppressive). Oral examinations were performed, including labial, buccal, and gingival mucosa, tongue, floor of the mouth, and palate, for any newly developed lesions associated with the onset of COVID-19. The salivary flow was determined using the passive drool collection technique.

RESULTS

Lip dryness, gingivitis, tongue lesions, and taste loss were the most commonly reported oral symptoms in patients with mild-to-moderate COVID-19. The most common general symptoms were tiredness and headache (63.9%), followed by dry cough, myalgia, sore throat, and fever. This study found 139 occurrences of oral symptoms, of which 52 were dry lips (27 tobacco non-users, and 25 tobacco users), and 11 were gingivitis (five non-users, and six tobacco users), and 12 tongue changes (eight non-users, and four tobacco users). Ageusia, or loss of taste sensation, was most commonly reported with or without other oral COVID-19 symptoms (55 occurrences: 36 non-users and 19 tobacco users). No significant differences were found in oral symptoms between tobacco non-users and tobacco users.

CONCLUSIONS

There is a need to expand the routine examination protocol for patients during future respiratory pandemics, as monitoring oral health allows dentists to improve the management of oral sequelae during a pandemic.

A Nonbactericidal Anionic Antimicrobial Peptide Provides Prophylactic and Therapeutic Efficacies against Bacterial Infections in Mice by Immunomodulatory-Antithrombotic Duality

Although bactericidal cationic antimicrobial peptides (AMPs) have been well characterized, less information is available about the antibacterial properties and mechanisms of action of nonbactericidal AMPs, especially nonbactericidal anionic AMPs. Herein, a novel anionic antimicrobial peptide (Gy-CATH) with a net charge of -4 was identified from the skin of the frog Glyphoglossus yunnanensis. Gy-CATH lacks direct antibacterial effects but exhibits significantly preventive and therapeutic capacities in mice that are infected with Staphylococcus aureus, Enterobacteriaceae coli, methicillin-resistant Staphylococcus aureus (MRSA), or carbapenem-resistant E. coli (CREC). In vitro and in vivo investigations proved the regulation of Gy-CATH on neutrophils and macrophages involved in the host immune defense against infection. Moreover, Gy-CATH significantly reduced the extent of pulmonary fibrin deposition and prevented thrombosis in mice, which was attributed to the regulatory role of Gy-CATH in physiological anticoagulants and platelet aggregation. These findings show that Gy-CATH is a potential candidate for the treatment of bacterial infection.

Cytokine storm in human monkeypox: A possible involvement of purinergic signaling

Some evidence has indicated that monkeypox can induce a cytokine storm. Purinergic signaling is a cell pathway related to the cytokine storm. However, the precise mechanisms that lead to cytokine storms in monkeypox infections and the possible involvement of purinergic signaling in the immune response to this virus remain unknown. In this review article, we aimed to highlight a body of scientific evidence that consolidates the role of the cytokine storm in monkeypox infection and proposes a new hypothesis regarding the roles of purinergic signaling in this immune-mediated mechanism. We further suggested some purinergic signaling modulators to mitigate the deleterious and aggravating effects of immune dysregulation in human monkeypox virus infection by inhibiting P2X3, P2X7, P2Y2, and P2Y12, reducing inflammation, and activating A1 and A2A receptors to promote an anti-inflammatory response.

Sepsis induces heterogeneous transcription of coagulation- and inflammation-associated genes in renal microvasculature

BACKGROUND

Acute kidney injury (AKI) in sepsis patients increases patient mortality. Endothelial cells are important players in the pathophysiology of sepsis-associated AKI (SA-AKI), yet knowledge regarding their spatiotemporal involvement in coagulation disbalance and leukocyte recruitment is lacking. This study investigated the identity and kinetics of responses of different microvascular compartments in kidney cortex in response to SA-AKI.

METHODS

Laser microdissected arterioles, glomeruli, peritubular capillaries, and postcapillary venules from kidneys of mice subjected to cecal ligation and puncture (CLP) were analyzed using RNA sequencing. Differential expression and pathway enrichment analyses identified genes involved in coagulation and inflammation. A selection of these genes was evaluated by RT-qPCR in microvascular compartments of renal biopsies from patients with SA-AKI. The role of two identified genes in lipopolysaccharide-induced endothelial coagulation and inflammatory activation were determined in vitro in HUVEC using siRNA-based gene silencing.

RESULTS

CLP-sepsis in mice induced altered expression of approximately 400 genes in the renal microvasculature, with microvascular compartments exhibiting unique spatiotemporal responses. In mice, changes in gene expression related to coagulation and inflammation were most extensive in glomeruli at early and intermediate time points, with high induction of Plat, Serpine1, Thbd, Icam1, Stat3, and Ifitm3. In human SA-AKI, PROCR and STAT3 were induced in postcapillary venules, while SERPINE1 expression was diminished. IFITM3 was increased in arterioles and glomeruli. In vitro studies revealed that STAT3 and IFITM3 partly control endothelial coagulation and inflammatory activation.

CONCLUSION

Renal microvascular compartments in mice and humans exhibited heterogeneous changes in coagulation- and inflammation-related gene expression in response to SA-AKI. Additional research should aim at understanding the functional consequences of the here described heterogeneous microvascular responses to establish the usefulness of identified genes as therapeutic targets in SA-AKI.

D-dimer-to-platelet count ratio as a novel indicator for predicting prognosis in HBV-related decompensated cirrhosis

Background

Hepatitis B virus-related decompensated cirrhosis (HBV-DC) is a critical illness with a low survival rate. Timely identification of prognostic indicators is crucial for risk stratification and personalized management of patients. The present study aimed to investigate the potential of the D-dimer-to-platelet count ratio (DPR) as a prognostic indicator for HBV-DC.

Methods

A retrospective review of medical records was conducted for 164 patients diagnosed with HBV-DC. Baseline clinical and laboratory characteristics were extracted for analysis. The endpoint was 30-day mortality. Disease severity was assessed by the Model for End-stage Liver Disease (MELD) score. A multivariate logistic regression model and receiver operating characteristic curve analysis (ROC) were used to evaluate the predictive value of DPR for mortality.

Results

During the 30-day follow-up period, 30 (18.3%) patients died. Non-survivors exhibited significantly higher DPR values than survivors, and a high DPR had a strong association with increased mortality. Importantly, DPR was identified as an independent risk factor for mortality in HBV-DC patients after adjustments for confounding factors (Odds ratio = 1.017; 95% Confidence interval, 1.006-1.029; p = 0.003). The cut-off value of DPR as a predictor of mortality was>57.6 (sensitivity = 57%, specificity = 86%, p < 0.001). The area under ROC curve for DPR for 30-day mortality was 0.762, comparable to the MELD score (p = 0.100). Furthermore, the combined use of DPR and MELD score further increased the area under the ROC curve to 0.897.

Conclusion

Elevated DPR was demonstrated to have a correlation with unfavorable outcomes in HBV-DC patients, suggesting its potential utility as an effective biomarker for assessment of prognosis in these patients.

Platelet-lymphocyte ratio predicts chemotherapy response and prognosis in patients with gastric cancer undergoing radical resection

Background

Amounting literatures have reported the significance of systemic inflammatory markers for evaluating tumor prognosis. But few studies have systematically compared their superiority and their impact on adjuvant chemotherapy.

Aims

We aimed to investigate the ability of inflammatory markers to predict the efficacy of chemotherapy in GC patients undergoing radical therapy and to identify an effective methodology based on the study's findings that would enable clinicians to differentiate between chemotherapy-responsive populations.

Methods

We retrospectively enrolled 730 GC patients who underwent radical gastrectomy. Fibrinogen (FIB), platelet-lymphocyte ratio (PLR), systemic inflammation response index (SIRI), prognostic nutritional index (PNI), systemic immune-inflammation index (SII), neutrophil-lymphocyte ratio (NLR) and lymph node ratio (LNR) were grouped according to cutoff values. Their clinical significance for GC prognosis was determined by multivariate COX regression analysis in the 730 GC patients and high/low PLR status subgroups. Cases were divided into four groups according to PLR status and adjuvant chemotherapy status and survival was compared among groups.

Results

Multivariate analysis showed that PLR was an independent prognostic factor for overall survival (OS) and disease-free survival (DFS) of GC patients. Adjuvant chemotherapy improved survival more significantly in patients with low PLR than that with high PLR. Among patients receiving adjuvant chemotherapy, low PLR was significantly associated with prolonged survival in TNM stage II, but not in TNM stage III.

Conclusion

Preoperative high PLR is an independent risk factor for GC patients undergoing radical gastrectomy and adversely affects the postoperative chemotherapy effect.

Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed?

The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.

New Directions in Infection-Associated Ischemic Stroke

The relationship between infections and stroke has not been fully characterized, probably delaying the development of specific treatments. This narrative review addresses mechanisms of stroke linked to infections, including hypercoagulability, endothelial dysfunction, vasculitis, and impaired thrombolysis. SARS-CoV-2, the virus that causes COVID-19, may promote the development of stroke, which may represent its most severe neurological complication. The development of specific therapies for infection-associated stroke remains a profound challenge. Perhaps the most important remaining issue is the distinction between infections that trigger a stroke versus infections that are truly incidental. This distinction likely requires the establishment of appropriate biomarkers, candidates of which are elevated levels of fibrin D-dimer and anticardiolipin/antiphospholipid antibodies. These candidate biomarkers might have potential use in identifying pathogenic infections preceding stroke, which is a precursor to establishing specific therapies for this syndrome.