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Lasne D, Toussaint-Hacquard M, Delassasseigne C, Bauters A, Flaujac C, Savard P, Mouton C, De Maistre E, Stepanian A, Eschwège V, Delrue M, Georges JL, Gros A, Mansour A, Leroy G, Jouffroy R, Mattei M, Beurton A, Pontis A, Neuwirth M, Nedelec-Gac F, Lecompte T, Curis E, Siguret V, Gouin-Thibault I. Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin. Thromb Haemost 2023; 123:1105-1115. [PMID: 37321244 DOI: 10.1055/s-0043-1770096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.
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Affiliation(s)
- Dominique Lasne
- AP-HP, Laboratoire d'hématologie générale, Hôpital Necker, INSERM, Univ. Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | | | - Anne Bauters
- CHU Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - Claire Flaujac
- Laboratoire de Biologie Médicale (Secteur Hémostase), Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | | | - Christine Mouton
- Laboratoire Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, France
| | | | - Alain Stepanian
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | | | - Maxime Delrue
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Jean-Louis Georges
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Antoine Gros
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes; Univ Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | | | - Romain Jouffroy
- AP-HP, Service de réanimation adulte, Hôpital Necker, Paris, France
| | - Matthieu Mattei
- Unité d'Anesthésie et Réanimation Cardiaque & Réanimation Médicale Brabois, CHRU Nancy, Nancy, France
| | - Antoine Beurton
- Department of Cardiovascular Anaesthesia and Critical care, Surgical Medical Center Magellan, Haut-Lévêque Hospital, Pessac, France
| | - Adeline Pontis
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Marie Neuwirth
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Fabienne Nedelec-Gac
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Thomas Lecompte
- Department of Pharmacy, Faculté de médecine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Lorraine & Université de Namur, Namur, Belgium
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Emmanuel Curis
- UR 7537 BioSTM, faculté de pharmacie de Paris, université Paris Cité, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Virginie Siguret
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Isabelle Gouin-Thibault
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
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Zuily S, Lefèvre B, Sanchez O, Empis de Vendin O, de Ciancio G, Arlet JB, Khider L, Terriat B, Greigert H, Robert CS, Louis G, Trinh-Duc A, Rispal P, Accassat S, Thiery G, Montani D, Azarian R, Meneveau N, Soudet S, Le Mao R, Maurier F, Le Moing V, Quéré I, Yelnik CM, Lefebvre N, Martinot M, Delrue M, Benhamou Y, Parent F, Roy PM, Presles E, Goehringer F, Mismetti P, Bertoletti L, Rossignol P, Couturaud F, Wahl D, Thilly N, Laporte S. Effect of weight-adjusted intermediate-dose versus fixed-dose prophylactic anticoagulation with low-molecular-weight heparin on venous thromboembolism among noncritically and critically ill patients with COVID-19: the COVI-DOSE trial, a multicenter, randomised, open-label, phase 4 trial. EClinicalMedicine 2023; 60:102031. [PMID: 37350990 PMCID: PMC10250778 DOI: 10.1016/j.eclinm.2023.102031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Background Venous thromboembolism is a major complication of coronavirus disease 2019 (COVID-19). We hypothesized that a weight-adjusted intermediate dose of anticoagulation may decrease the risk of venous thromboembolism COVID-19 patients. Methods In this multicenter, randomised, open-label, phase 4, superiority trial with blinded adjudication of outcomes, we randomly assigned adult patients hospitalised in 20 French centers and presenting with acute respiratory SARS-CoV-2. Eligible patients were randomly assigned (1:1 ratio) to receive an intermediate weight-adjusted prophylactic dose or a fixed-dose of subcutaneous low-molecular-weight heparin during the hospital stay. The primary outcome corresponded to symptomatic deep-vein thrombosis (fatal) pulmonary embolism during hospitalization (COVI-DOSE ClinicalTrials.gov number: NCT04373707). Findings Between May 2020, and April 2021, 1000 patients underwent randomisation in medical wards (noncritically ill) (80.1%) and intensive care units (critically ill) (19.9%); 502 patients were assigned to receive a weight-adjusted intermediate dose, and 498 received fixed-dose thromboprophylaxis. Symptomatic venous thromboembolism occurred in 6 of 502 patients (1.2%) in the weight-adjusted dose group and in 10 of 498 patients (2.1%) in the fixed-dose group (subdistribution hazard ratio, 0.59; 95% CI, 0.22-1.63; P = 0.31). There was a twofold increased risk of major or clinically relevant nonmajor bleeding: 5.9% in the weight-adjusted dose group and 3.1% in the fixed-dose group (P = 0.034). Interpretation In the COVI-DOSE trial, the observed rate of thromboembolic events was lower than expected in patients hospitalized for COVID-19 infection, and the study was unable to show a significant difference in the risk of venous thromboembolism between the two low-molecular-weight-heparin regimens. Funding French Ministry of Health, CAPNET, Grand-Est Region, Grand-Nancy Métropole.
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Affiliation(s)
- Stéphane Zuily
- Vascular Medicine Division, Université de Lorraine, CHRU-Nancy, Rare Vascular and Systemic Autoimmune Diseases Regional Referral Center, France
- Inserm, UMR 1116 DCAC, F-54000 Nancy, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
| | - Benjamin Lefèvre
- Department of Infectious and Tropical Diseases, Université de Lorraine, CHRU-Nancy, APEMAC, F-54000 Nancy, France
| | - Olivier Sanchez
- Department of Respiratory and Intensive Care Medicine, Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- Inserm, Innovative Therapies in Haemostasis, Paris, France
| | | | | | - Jean-Benoît Arlet
- Internal Medicine Department, AP-HP, Hôpital Européen Georges Pompidou, APHP, F-75015 Paris, France
| | - Lina Khider
- Vascular Medicine Department, Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Béatrice Terriat
- Department of Vascular Medicine and Angiology, Dijon University Hospital, F-21000 Dijon, France
| | - Hélène Greigert
- Department of Vascular Medicine and Angiology, Dijon University Hospital, F-21000 Dijon, France
| | - Céline S Robert
- Department of Infectious Diseases, CHR Metz-Thionville, F-57000 Metz, France
| | - Guillaume Louis
- Intensive Care Unit, CHR Metz-Thionville, F-57000 Metz, France
| | - Albert Trinh-Duc
- Internal Medicine Department, CH St Esprit, F-47000 Agen, France
| | - Patrick Rispal
- Internal Medicine Department, CH St Esprit, F-47000 Agen, France
| | - Sandrine Accassat
- Department of Vascular Medicine, CHU Saint-Etienne, F-42000 Saint-Etienne, France
| | - Guillaume Thiery
- Medical Intensive Care Unit, CHU Saint-Etienne, F-42000 Saint-Etienne, France
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Université Paris-Saclay, AP-HP, Hôpital Bicêtre, Pulmonary Hypertension National Referral Center, F-94270 Le Kremlin-Bicêtre, France
| | - Réza Azarian
- Department of Respiratory Medicine, CH Versailles, F-78150 Le Chesnay, France
| | - Nicolas Meneveau
- Department of Cardiology, Université de Franche-Comté, CHU Jean Minjoz, EA 3929, F-25000 Besancon, France
| | - Simon Soudet
- Department of Vascular Medicine, CHU Amiens-Picardie, F-80000 Amiens, France
| | - Raphaël Le Mao
- Department of Internal Medicine, Vascular Medicine and Pulmonology, CHU Brest, F-29200 Brest, France
| | - François Maurier
- Department of Internal Medicine, UNEOS, F-57070 Metz-Vantoux, France
| | - Vincent Le Moing
- Department of Infectious and Tropical Diseases, CHRU Montpellier, F-34000 Montpellier, France
| | - Isabelle Quéré
- Department of Vascular Medicine, CHU Montpellier, IDESP, F-34000 Montpellier, France
| | - Cécile M Yelnik
- Department of Internal Medicine and Clinical Immunology, Université de Lille, CHU Lille, Inserm UMR 1167, North and North-West Systemic and Autoimmune Disease National Referral Center (CeRAINO), F-59000 Lille, France
| | - Nicolas Lefebvre
- Department of Tropical and Infectious Diseases, Hôpitaux Universitaires de Strasbourg, F-67000 Strasbourg, France
| | - Martin Martinot
- Department of Tropical and Infectious Diseases, Hôpitaux Civils de Colmar, F-68000 Colmar, France
| | - Maxime Delrue
- Hematology Laboratory and Thrombosis Unit, Lariboisière Hospital, APHP, Paris, France
| | - Ygal Benhamou
- Department of Internal Medicine, Normandie Université, Université de Rouen Normandie, Inserm UMR 1096, F-76000 Rouen, France
| | - Florence Parent
- Department of Respiratory and Intensive Care Medicine, Université Paris-Saclay, AP-HP, Hôpital Bicêtre, Pulmonary Hypertension National Referral Center, F-94270 Le Kremlin-Bicêtre, France
| | - Pierre-Marie Roy
- Department of Emergency Medicine, Université d'Angers, CHU Angers, F-49000 Angers, France
| | - Emilie Presles
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, France
| | - François Goehringer
- Department of Infectious and Tropical Diseases, CHRU-Nancy, F-54000 Nancy, France
| | - Patrick Mismetti
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, Service de Médecine Vasculaire et Thérapeutique, France
| | - Laurent Bertoletti
- Université Jean Monnet, Inserm, CIC-1408, CHU Saint-Etienne, Service de Médecine Vasculaire et Thérapeutique, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm, CIC-P 1433, CHRU-Nancy, Inserm UMR 1116, F-CRIN INI-CRCT, F-54000 Nancy, France
- Department of Medical Specialties and Nephrology-Hemodialysis, Princess Grace Hospital, and Centre d'Hémodialyse Privé de Monaco, Monaco
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Université de Bretagne Occidentale, CHU Brest, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- Inserm UMR 1304 GETBO, F-29200 Brest, France
| | - Denis Wahl
- Vascular Medicine Division, Université de Lorraine, CHRU-Nancy, Rare Vascular and Systemic Autoimmune Diseases Regional Referral Center, France
| | - Nathalie Thilly
- Département Méthodologie, Promotion, Investigation, Université de Lorraine, CHRU-Nancy, APEMAC, , F-54000 Nancy, France
| | - Silvy Laporte
- Université Jean Monnet, Inserm, U1059 SAINBIOSE, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
- CHU Saint-Etienne, Unité de Recherche Clinique, Innovation, Pharmacologie, France
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3
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Foulon-Pinto G, Lafuente-Lafuente C, Jourdi G, Guen JL, Tall F, Puymirat E, Delrue M, Rivière L, Ketz F, Gouin-Thibault I, Mullier F, Gaussem P, Pautas E, Lecompte T, Curis E, Siguret V. Assessment of DOAC in GEriatrics (Adage Study): Rivaroxaban/Apixaban Concentrations and Thrombin Generation Profiles in NVAF Very Elderly Patients. Thromb Haemost 2023; 123:402-414. [PMID: 36395818 PMCID: PMC10060059 DOI: 10.1055/a-1981-1763] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although a growing number of very elderly patients with atrial fibrillation (AF), multiple conditions, and polypharmacy receive direct oral anticoagulants (DOACs), few studies specifically investigated both apixaban/rivaroxaban pharmacokinetics and pharmacodynamics in such patients. AIMS To investigate: (1) DOAC concentration-time profiles; (2) thrombin generation (TG); and (3) clinical outcomes 6 months after inclusion in very elderly AF in-patients receiving rivaroxaban or apixaban. METHODS Adage-NCT02464488 was an academic prospective exploratory multicenter study, enrolling AF in-patients aged ≥80 years, receiving DOAC for at least 4 days. Each patient had one to five blood samples at different time points over 20 days. DOAC concentrations were determined using chromogenic assays. TG was investigated using ST-Genesia (STG-ThromboScreen, STG-DrugScreen). RESULTS We included 215 patients (women 71.1%, mean age: 87 ± 4 years), 104 rivaroxaban and 111 apixaban, and 79.5% receiving reduced-dose regimen. We observed important inter-individual variabilities (coefficient of variation) whatever the regimen, at C max [49-46%] and C min [75-61%] in 15 mg rivaroxaban and 2.5 mg apixaban patients, respectively. The dose regimen was associated with C max and C min plasma concentrations in apixaban (p = 0.0058 and p = 0.0222, respectively), but not in rivaroxaban samples (multivariate analysis). Moreover, substantial variability of thrombin peak height (STG-ThromboScreen) was noticed at a given plasma concentration for both xabans, suggesting an impact of the underlying coagulation status on TG in elderly in-patients. After 6-month follow-up, major bleeding/thromboembolic event/death rates were 6.7%/1.0%/17.3% in rivaroxaban and 5.4%/3.6%/18.9% in apixaban patients, respectively. CONCLUSION Our study provides original data in very elderly patients receiving DOAC in a real-life setting, showing great inter-individual variability in plasma concentrations and TG parameters. Further research is needed to understand the potential clinical impact of these findings.
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Affiliation(s)
- Geoffrey Foulon-Pinto
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Carmelo Lafuente-Lafuente
- Service de gériatrie à orientation cardiologique et neurologique, AP-HP, Sorbonne Université, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France.,CEpiA Team (Clinical Epidemiology and Ageing), Université Paris Est Créteil, INSERM, IMRB, Créteil, France
| | - Georges Jourdi
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Research Center, Institut de Cardiologie de Montréal - Université de Montréal, Montréal, QC, Canada
| | - Julien Le Guen
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Fatoumata Tall
- Service de Gériatrie, AP-HP. Université Paris Cité, Hôpital Rothschild, Paris, France
| | - Etienne Puymirat
- Service de Cardiologie, AP-HP. Université de Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Maxime Delrue
- Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
| | - Léa Rivière
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Flora Ketz
- Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Isabelle Gouin-Thibault
- INSERM, CIC 1414 (Centre d'Investigation Clinique de Rennes), Université de Rennes, CHU de Rennes, Rennes, France.,Service d'Hématologie Biologique, CHU de Rennes, Rennes, France
| | - François Mullier
- Department of Laboratory Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, Yvoir, Belgium.,Hematology-Hemostasis Laboratory, CHU UCL Namur, Yvoir, Belgium
| | - Pascale Gaussem
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
| | - Eric Pautas
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service de gériatrie aiguë polyvalente, Hôpital Charles-Foix, AP-HP Sorbonne Université, Ivry-sur-Seine, France, UFR Médecine Sorbonne Université, Paris, France
| | - Thomas Lecompte
- Service d'Hématologie Biologique, CHU de Rennes, Rennes, France.,Université de Lorraine, Faculté de médecine de Nancy, Nancy, France
| | - Emmanuel Curis
- Université de Paris Cité, UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie, Paris, France
| | - Virginie Siguret
- Université Paris Cité, INSERM UMR-S-1140, Innovations Thérapeutiques en Hémostase, Paris, France.,Service d'Hématologie Biologique, AP-HP. Université Paris Cité, Hôpital Lariboisière, Paris, France
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4
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Brakta C, Stépanian A, Reiner P, Delrue M, Mazighi M, Curis E, Siguret V. Practical Nomogram Predicting Apixaban or Rivaroxaban Concentrations from Low-Molecular-Weight Heparin Anti-Xa Values: Special Interest in Acute Ischemic Stroke Patients. J Stroke 2023; 25:126-131. [PMID: 36592965 PMCID: PMC9911839 DOI: 10.5853/jos.2022.03034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) using a direct oral factor-Xa anticoagulant (DOAC) during the last 48 hours, a fixed plasma heparin-calibrated anti-Xa activity (0.5 IU/mL) was proposed as a threshold below which patients could be eligible for thrombolysis and/or thrombectomy. Besides, specific DOAC-calibrated anti-Xa thresholds up to 50 ng/mL have been proposed. However, specific DOAC assays are not widely available contrarily to low-molecularweight heparin (LMWH) anti-Xa activity. We developed and validated a nomogram for predicting apixaban and rivaroxaban concentrations based on LMWH anti-Xa assay. METHODS Our prospective study included apixaban (n=325) and rivaroxaban (n=276) patients. On the same sample, we systematically measured specific DOAC concentration and LMWH anti-Xa activity, using STA®-Liquid-Anti-Xa (Stago) and specific DOAC- or LMWH-calibrators, respectively. The nomogram was built using quantifiable values for both assays on the derivation cohorts with a log-linear regression model. Model performances including sensitivity, specificity, and true positive rate for different thresholds were checked on the validation cohorts. RESULTS The models built from the derivation cohorts predicted that values <30 ng/mL and <50 ng/ mL DOAC thresholds corresponded to LMWH-anti-Xa values <0.10 IU/mL and <0.64 IU/mL for apixaban; <0.10 IU/mL and <0.71 IU/mL for rivaroxaban. The model accurately predicted apixaban/ rivaroxaban concentrations in the validation cohort. CONCLUSIONS This easy-to-use nomogram, developed with our reagent, allowed accurately predicting DOAC concentrations based on LMWH-anti-Xa results in emergency situations such as AIS when drug-specific assessments are not rapidly available. Using DOAC <50 ng/mL equivalent threshold, instead of the fixed LMWH <0.5 IU/mL one, would allow proposing thrombolysis to more patients.
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Affiliation(s)
- Charlyne Brakta
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Alain Stépanian
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,EA 3518, Université de Paris Cité, Paris, France
| | - Peggy Reiner
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Maxime Delrue
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Mikaël Mazighi
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Emmanuel Curis
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Virginie Siguret
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,INSERM UMRS-1140, Université de Paris Cité, Paris, France,Correspondence: Virginie Siguret Department of Hematology, Thrombosis Unit, Lariboisière Hospital (AP-HP), INSERM UMRS-1140, University Paris Cité, 2 rue Ambroise Paré 75010, Paris, France Tel: +33-6-63-53-37-55 Fax: +33-1-49-95-64-11 E-mail:
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5
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Andelfinger G, Zenker M, Norrish G, Russell M, Meisner J, Peng D, Prendiville T, Kleinmahon J, Kantor P, Sen DG, Human D, Ewert P, Krueger M, Reber D, Donner B, Hart C, Odri-Komazec I, Rupp S, Hahn A, Hanser A, Hofbeck M, Draaisma J, Udink ten Cate F, Mussa A, Ferrero G, Vaujois L, Raboisson M, Delrue M, Marquis C, Théorêt Y, Kaski J, Gelb B, Wolf C. MAPK AND AKT/MTOR INHIBITION IMPROVES CHILDHOOD RASOPATHY-ASSOCIATED CARDIOMYOPATHY. Can J Cardiol 2022. [DOI: 10.1016/j.cjca.2022.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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6
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Delrue M, Stépanian A, Voicu S, Nassarmadji K, Sène D, Bonnin P, Kevorkian JP, Sellier PO, Molina JM, Neuwirth M, Vodovar D, Mouly S, Mebazaa A, Mégarbane B, Siguret V. No VTE Recurrence After 1-Year Follow-Up of Hospitalized Patients With COVID-19 and a VTE Event: A Prospective Study. Chest 2022; 162:226-229. [PMID: 35398318 PMCID: PMC8986540 DOI: 10.1016/j.chest.2022.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/20/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
- Maxime Delrue
- Hematology Laboratory & Thrombosis unit, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; EA 3518, Université Paris Cité, Paris, France
| | - Alain Stépanian
- Hematology Laboratory & Thrombosis unit, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; EA 3518, Université Paris Cité, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-1144, Université Paris Cité, Paris, France
| | - Kladoum Nassarmadji
- Department of Internal Medicine, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Damien Sène
- Department of Internal Medicine, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Philippe Bonnin
- Laboratory of Clinical Physiology, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-1148, Université Paris Cité, Paris, France
| | - Jean-Philippe Kevorkian
- Department of Diabetology-Endocrinology, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Pierre-Olivier Sellier
- Department of infectious disease, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Jean-Michel Molina
- Department of infectious disease, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Marie Neuwirth
- Hematology Laboratory & Thrombosis unit, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-1140, Université Paris Cité, Paris, France
| | - Dominique Vodovar
- INSERM UMRS-1144, Université Paris Cité, Paris, France; Paris Poison Control Center, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Stéphane Mouly
- INSERM UMRS-1144, Université Paris Cité, Paris, France; Department of Internal Medicine, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-942, Université Paris Cité, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-1144, Université Paris Cité, Paris, France
| | - Virginie Siguret
- Hematology Laboratory & Thrombosis unit, Université Paris Cité, Hospital group Lariboisière-Fernand Widal, APHP, Paris, France; INSERM UMRS-1140, Université Paris Cité, Paris, France.
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Delrue M, Chevillard L, Stépanian A, Dragoni A, Camoin-Jau L, Voicu S, Malissin I, Deye N, Gainnier M, Siguret V, Mégarbane B. Case series of massive direct oral anticoagulant ingestion-Treatment and pharmacokinetics data. Eur J Clin Invest 2022; 52:e13746. [PMID: 35000196 DOI: 10.1111/eci.13746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/19/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are widely used due to favourable benefit/risk ratio. However, consequences of massive ingestion have been poorly investigated. OBJECTIVES We aimed to report outcome and pharmacokinetic parameters in patients who massively ingested DOACs. METHODS We conducted a 5-year cohort study including consecutive massive DOAC ingestion patients admitted to two critical care departments. Patients were managed in accordance with standards of care. We collected the main history, clinical, laboratory, management and outcome data. The time-course of plasma DOAC concentrations measured using specific assays was modelled. RESULTS Twelve patients (3F/9M; age, 55 years [41-63], median [25th-75th percentiles]) were included. Ingestions involved rivaroxaban (n = 7), apixaban (n = 3) and dabigatran (n = 2), with presumed doses of 9.4-fold [5.0-22.0] the full daily dose. Six patients received activated charcoal but no antidote nor blood-derived product. No bleeding was observed. One patient died due to refractory cardiogenic shock related to bisoprolol co-intoxication. Highest observed peak plasma concentrations were 1720 ng/ml (rivaroxaban), 750 ng/ml (apixaban) and 644 ng/ml (dabigatran). Times to reach DOAC concentration below 50 ng/ml were ~20-45 h (rivaroxaban), ~125 h (apixaban) and ~30-50 h (dabigatran). Elimination half-lives were 2.5-25.5 h (rivaroxaban), 22.0 and 36.5 h (apixaban), and 5.8 and 15.5 h (dabigatran), with substantial interindividual variability and prolongation in case of cardiovascular failure related to co-intoxicants. Charcoal administration, even if delayed, may have contributed to limit toxicity, possibly by reducing absorption and/or enteroenteric recycling. CONCLUSION No bleeding was observed in this series of massive DOAC ingestions despite elevated plasma concentrations. No patient required specific haemostatic agents. Charcoal administration should be considered to limit toxicity.
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Affiliation(s)
- Maxime Delrue
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Alain Stépanian
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Alessandra Dragoni
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | | | - Sébastien Voicu
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France
| | - Marc Gainnier
- Department of Critical Care, APHM, la Timone Hospital, Marseille, France
| | - Virginie Siguret
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS-1140, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
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8
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Delrue M, Stephanian A, Neuwirth M, Voicu S, Chousterman B, Bonnin P, Joly B, Brumpt C, Veyradier A, Sène D, Megarbane B, Siguret V. Étude prospective des événements thromboemboliques veineux chez les patients hospitalisés pour COVID-19 : anomalies associées de l’hémostase et suivi clinicobiologique à 6 mois. JMV-Journal de Médecine Vasculaire 2021. [PMCID: PMC8464164 DOI: 10.1016/j.jdmv.2021.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction La COVID-19 est associée à un risque élevé d’événement thromboembolique veineux (ETEV), thrombose veineuse profonde (TVP) et/ou embolie pulmonaire (EP) en particulier chez les patients hospitalisés. Objectifs Caractériser le déséquilibre de la balance hémostatique chez ces patients et décrire la prise en charge et l’évolution à 6 mois des patients avec ETEV. Méthodes Étude prospective incluant des patients consécutifs hospitalisés en réanimation ou en médecine pour COVID-19, avec : – un écho-Doppler veineux systématique à l’admission en réanimation puis 7 jours plus tard en cas de négativité et en cas de symptômes de TVP en service de médecine ; – un angioscanner thoracique réalisé en cas de suspicion d’EP ; – un bilan d’hémostase réalisé à l’admission ; – le suivi des patients ayant présenté un ETEV à 1, 3 et 6 mois afin de colliger les événements thrombotiques et hémorragiques. Résultats Du 17.03 au 11.04.2020, 133 patients d’âge médian 65 ans (72 % hommes) ont été hospitalisés pour COVID-19. Trente-huit patients ont présenté un ETEV (63 % TVP, 24 % EP, 13 % TVP + EP) dont 9 sont décédés pendant l’hospitalisation, 2 ont été transférés et 26 suivis. Nos résultats montrent : – un taux de D-dimères > 3300 ng/mL prédictif d’un ETEV avec une VPP 66 % (IC95 % : 51–79) et VPN 80 % (IC95 % : 65–90) en réanimation ; – une discordance significative entre les activités anticoagulante/chromogénique de la protéine C (p = .002 chez les patients ETEV+) évocatrice d’une résistance acquise à la protéine C activée ; – une association entre les taux de facteur Willebrand et d’ADAMTS13 et les ETEV (p = .05 et p = .005 respectivement) d’une part et entre les taux d’ADAMTS13/D-dimères et la mortalité d’autre part ; – des anticorps antiphospholipides présents chez 88 % des patients en réanimation, non associés à la survenue d’ETEV. Les 26 patients suivis avec ETEV ont été traités par apixaban (22), rivaroxaban (2) ou tinzaparine (2) durant 3 à 6 mois. Un infarctus du myocarde et 2 saignements mineurs ont été recensés. Aucune récidive d’ETEV n’a été observée. Conclusions La fréquence élevée d’ETEV chez les patients hospitalisés pour COVID-19 est associée à un profil biologique de thrombo-inflammation, avec un déséquilibre marqué entre facteurs prothrombotiques/inhibiteurs naturels de la coagulation et de l’axe VWF/ADAMTS13. Le traitement par anticoagulant oral direct est une option thérapeutique possible pour le traitement d’un ETEV lié à une hospitalisation pour COVID-19.
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Coutrot M, Delrue M, Joly BS, Siguret V. Unexpected acute pulmonary embolism in an old COVID-19 patient with warfarin overdose: a case report. Eur Heart J Case Rep 2021; 5:ytab206. [PMID: 34104863 PMCID: PMC8178933 DOI: 10.1093/ehjcr/ytab206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/02/2021] [Accepted: 05/12/2021] [Indexed: 01/07/2023]
Abstract
Background Severe acute respiratory syndrome coronavirus 2 disease is strongly associated with a high incidence of thrombotic events. Anticoagulation could be a cornerstone in successfully managing severe forms of coronavirus disease 2019 (COVID-19). However, optimal anticoagulant dosing in elderly patients is challenging because of high risk of both thrombosis and bleeding. Case summary We present here the case of an 89-year-old patient receiving warfarin for atrial fibrillation and valvular heart disease, admitted to the intensive care unit for respiratory failure due to COVID-19. The patient presented with a severe epistaxis associated with warfarin overdose [international normalized ratio (INR) > 10]. After a successful initial reversal using vitamin K per os, INR values greatly fluctuated up to 10, requiring repeated administrations of vitamin K. Despite starting low-molecular-weight heparin therapy at therapeutic dose as soon as INR value was below 2.0, the patient further developed an acute bilateral and proximal pulmonary embolism concomitantly with a sharp D-dimer increase. The combination of azithromycin intake, a known inhibitor of CYP2C9, with the presence of CYP2C9*2 and −1639G>A VKORC1, two variants associated with warfarin hypersensitivity, have likely contributed to explain the warfarin overdose and the difficulty to reverse warfarin effect in this patient. Discussion This case report illustrates the complexity of COVID-19 pathophysiology and its management for physicians, especially in patients receiving vitamin K antagonists (VKAs). Infection, concurrent medication use, and pharmacogenetic factors involved in VKA metabolism and pharmacodynamics may lead to a loss of control of anticoagulation. Pulmonary embolism should still be considered in COVID-19 patients even with effective or overdosed anticoagulant therapy.
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Affiliation(s)
- Maxime Coutrot
- Department of Anaesthesiology, Critical Care Medicine and Burn Unit, AP-HP, Saint Louis and Lariboisière University Hospitals, 1 Avenue Claude Vellefaux, 75010 Paris, France.,INSERM UMR-S 942, 41 boulevard de la Chapelle, 75475 Paris Cedex 10, Lariboisière Hospital, Paris, France.,FHU PROMICE, 2 Rue Ambroise Paré, 75010 Paris, France
| | - Maxime Delrue
- Service d'hématologie biologique, Hôpital Lariboisière, 2rue Ambroise Pare ´,75010 Paris, Université de Paris, Paris, France.,EA 3518, Institut de Recherche Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, Université de Paris, Paris, France
| | - Bérangère S Joly
- Service d'hématologie biologique, Hôpital Lariboisière, 2rue Ambroise Pare ´,75010 Paris, Université de Paris, Paris, France.,EA 3518, Institut de Recherche Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, Université de Paris, Paris, France
| | - Virginie Siguret
- Service d'hématologie biologique, Hôpital Lariboisière, 2rue Ambroise Pare ´,75010 Paris, Université de Paris, Paris, France.,INSERM UMR-S 1140 Innovations thérapeutiques en Hémostase, Faculté de Pharmacie, 4 avenue de l'Observatoire, 75270 Paris CEDEX 06, Université de Paris, Paris, France
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10
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Galland J, Thoreau B, Delrue M, Neuwirth M, Stepanian A, Chauvin A, Dellal A, Nallet O, Roriz M, Devaux M, London J, Martin-Lecamp G, Froissart A, Arab N, Ferron B, Groff MH, Queyrel V, Lorut C, Regard L, Berthoux E, Bayer G, Comarmond C, Lioger B, Mekinian A, Szwebel TA, Sené T, Amador-Boreiro B, Mangin O, Sellier PO, Mouly S, Kevorkian JP, Siguret V, Vodovar D, Sene D. White blood count, D-dimers, and ferritin levels as predictive factors of pulmonary embolism suspected upon admission in noncritically ill COVID-19 patients: The French multicenter CLOTVID retrospective study. Eur J Haematol 2021; 107:190-201. [PMID: 34288162 PMCID: PMC8239942 DOI: 10.1111/ejh.13638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/15/2022]
Abstract
Background A high prevalence of pulmonary embolism (PE) has been described during COVID‐19. Our aim was to identify predictive factors of PE in non‐ICU hospitalized COVID‐19 patients. Methods Data and outcomes were collected upon admission during a French multicenter retrospective study, including patients hospitalized for COVID‐19, with a CT pulmonary angiography (CTPA) performed in the emergency department for suspected PE. Predictive factors significantly associated with PE were identified through a multivariate regression model. Results A total of 88 patients (median [IQR] age of 68 years [60‐78]) were analyzed. Based on CTPA, 47 (53.4%) patients were diagnosed with PE, and 41 were not. D‐dimer ≥3000 ng/mL (OR 8.2 [95% CI] 1.3‐74.2, sensitivity (Se) 0.84, specificity (Sp) 0.78, P = .03), white blood count (WBC) ≥12.0 G/L (29.5 [2.3‐1221.2], Se 0.47, Sp 0.92, P = .02), and ferritin ≥480 µg/L (17.0 [1.7‐553.3], Se 0.96, Sp 0.44, P = .03) were independently associated with the PE diagnosis. The presence of the double criterion D‐dimer ≥3000 ng/mL and WBC ≥12.0 G/L was greatly associated with PE (OR 21.4 [4.0‐397.9], P = .004). Conclusion The white blood count, the D‐dimer and ferritin levels could be used as an indication for CTPA to confirm PE on admission in non‐ICU COVID‐19 patients.
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Affiliation(s)
- Joris Galland
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | - Benjamin Thoreau
- University of Paris, Paris, France.,Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP-HP, Université de Paris, Paris, France.,INSERM U1016, CNRS UMR 8104, Cochin Institute, Paris, France
| | - Maxime Delrue
- Hematology Laboratory, Lariboisière Hospital, AP-HP, University of Paris, Paris, France.,EA 3518, Paris University, Paris, France
| | - Marie Neuwirth
- Hematology Laboratory, Lariboisière Hospital, AP-HP, University of Paris, Paris, France.,INSERM UMRS U1140, Paris University, Paris, France
| | - Alain Stepanian
- Hematology Laboratory, Lariboisière Hospital, AP-HP, University of Paris, Paris, France.,EA 3518, Paris University, Paris, France
| | - Anthony Chauvin
- University of Paris, Paris, France.,Emergency Department, Lariboisière Hospital, AP-HP, University of Paris, Paris, France
| | - Azeddine Dellal
- Department of Rheumatology and Internal Medicine, Le Raincy-Montfermeil Hospital, Montfermeil, France
| | - Olivier Nallet
- Department of Cardiology, Le Raincy-Montfermeil Hospital, Montfermeil, France
| | - Melanie Roriz
- Department of Internal Medicine, Hospital Center of Agen, Agen, France
| | - Mathilde Devaux
- Department of Internal Medicine, Hospital Center of Poissy-Saint Germain, Saint Germain en Laye, France
| | - Jonathan London
- Department of Internal Medicine, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | | | - Antoine Froissart
- Department of Internal Medicine, Intermunicipal Hospital Center of Créteil, Créteil, France
| | - Nouara Arab
- Department of Internal Medicine, Intermunicipal Hospital Center of Créteil, Créteil, France
| | - Bertrand Ferron
- Department of Internal Medicine, Hospital Center of Sens, Sens, France
| | - Marie-Helene Groff
- Department of Internal Medicine, Hospital Center of Nord-Mayenne, Mayenne, France
| | - Viviane Queyrel
- Department of Internal Medicine, University Hospital of Nice, Nice, France
| | - Christine Lorut
- Department of Pneumology, Cochin Hospital, AP-HP, Université de Paris, Paris, France
| | - Lucile Regard
- Department of Pneumology, Cochin Hospital, AP-HP, Université de Paris, Paris, France
| | - Emilie Berthoux
- Department of Internal Medicine, Saint Luc-Saint Joseph Hospital, Lyon, France
| | - Guillaume Bayer
- Department of Internal Medicine, Claude Galien Hospital, Quincy sous Senart, France
| | - Chloe Comarmond
- Department of Internal Medicine, Pitié-Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France.,Sorbonne University, Paris, France
| | - Bertrand Lioger
- Department of Internal Medicine, Simone Veil Hospital, Blois, France
| | - Arsène Mekinian
- Sorbonne University, Paris, France.,Department of Internal Medicine, Saint Antoine Hospital, APHP, Paris, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP-HP, Université de Paris, Paris, France
| | - Thomas Sené
- Department of Internal Medicine, Fondation Rothschild, Paris, France
| | - Blanca Amador-Boreiro
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | - Olivier Mangin
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | | | - Stephane Mouly
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | | | - Virginie Siguret
- University of Paris, Paris, France.,Hematology Laboratory, Lariboisière Hospital, AP-HP, University of Paris, Paris, France.,INSERM UMRS U1140, Paris University, Paris, France
| | | | - Dominique Vodovar
- University of Paris, Paris, France.,Centre Anti-Poison, Fernand Widal Hospital, AP-HP, University of Paris, Paris, France.,INSERM UMRS 1144, Paris, France
| | - Damien Sene
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
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Legrand F, Fernex de Mongex A, Delrue M, Ghaffari P, Jaillette C, Yannoutsos A, Emmerich J, Priollet P. Foot ischemia related to essential thrombocytemia and atherosclerosis. J Med Vasc 2021; 46:123-128. [PMID: 33990286 DOI: 10.1016/j.jdmv.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
We report two cases of foot ischemia combining microvascular thrombosis related to essential thrombocytemia (ET) and a proximal ulcerating atherosclerotic plaque. This suggests that myeloproliferative neoplasms could also trigger distal embolism from an unstable atherosclerotic plaque by creating a prothrombotic status. These distal ischemic events were the first ET manifestation and therefore lead to myeloproliferative neoplasm diagnosis. In ET, thrombosis event can occur with a normal platelet count. Furthermore, hemogram should be regularly controlled among JAK2 muted patients considering the frequent evolution from isolated JAK2 mutation to ET.
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Affiliation(s)
- F Legrand
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France.
| | | | - M Delrue
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France; Université de Paris, EA 3518, Saint-Louis Hospital, Paris, France
| | - P Ghaffari
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France
| | - C Jaillette
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France
| | - A Yannoutsos
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France; Université de Paris, INSERM CRESS UMR 1153, 75005 Paris, France
| | - J Emmerich
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France; Université de Paris, INSERM CRESS UMR 1153, 75005 Paris, France
| | - P Priollet
- Vascular medicine department, GH Paris Saint-Joseph, Paris, France
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12
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Thoreau B, Galland J, Delrue M, Neuwirth M, Stepanian A, Chauvin A, Dellal A, Nallet O, Roriz M, Devaux M, London J, Martin-Lecamp G, Froissart A, Arab N, Ferron B, Groff MH, Queyrel V, Lorut C, Regard L, Berthoux E, Bayer G, Comarmond C, Lioger B, Mekinian A, Szwebel TA, Sené T, Amador-Borrero B, Mangin O, Sellier PO, Siguret V, Mouly S, Kevorkian JP, Vodovar D, Sene D. D-Dimer Level and Neutrophils Count as Predictive and Prognostic Factors of Pulmonary Embolism in Severe Non-ICU COVID-19 Patients. Viruses 2021; 13:v13050758. [PMID: 33926038 PMCID: PMC8146364 DOI: 10.3390/v13050758] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 01/08/2023] Open
Abstract
The incidence of pulmonary embolism (PE) is high during severe Coronavirus Disease 2019 (COVID-19). We aimed to identify predictive and prognostic factors of PE in non-ICU hospitalized COVID-19 patients. In the retrospective multicenter observational CLOTVID cohort, we enrolled patients with confirmed RT-PCR COVID-19 who were hospitalized in a medicine ward and also underwent a CT pulmonary angiography for a PE suspicion. Baseline data, laboratory biomarkers, treatments, and outcomes were collected. Predictive and prognostics factors of PE were identified by using logistic multivariate and by Cox regression models, respectively. A total of 174 patients were enrolled, among whom 86 (median [IQR] age of 66 years [55–77]) had post-admission PE suspicion, with 30/86 (34.9%) PE being confirmed. PE occurrence was independently associated with the lack of long-term anticoagulation or thromboprophylaxis (OR [95%CI], 72.3 [3.6–4384.8]) D-dimers ≥ 2000 ng/mL (26.3 [4.1–537.8]) and neutrophils ≥ 7.0 G/L (5.8 [1.4–29.5]). The presence of these two biomarkers was associated with a higher risk of PE (p = 0.0002) and death or ICU transfer (HR [95%CI], 12.9 [2.5–67.8], p < 0.01). In hospitalized non-ICU severe COVID-19 patients with clinical PE suspicion, the lack of anticoagulation, D-dimers ≥ 2000 ng/mL, neutrophils ≥ 7.0 G/L, and these two biomarkers combined might be useful predictive markers of PE and prognosis, respectively.
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Affiliation(s)
- Benjamin Thoreau
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP-HP, University of Paris, CEDEX 14, 75679 Paris, France;
- INSERM U1016, Cochin Institute, Paris, University of Paris, CNRS UMR 8104, 75014 Paris, France
- Correspondence: ; Tel.: +33-1-58-41-14-36; Fax: +33-1-58-41-14-50
| | - Joris Galland
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP) Université de Paris, 75010 Paris, France; (J.G.); (B.A.-B.); (O.M.); (S.M.); (D.S.)
| | - Maxime Delrue
- Haemostasis Laboratory, Lariboisière Hospital, AP-HP, University of Paris, 75010 Paris, France; (M.D.); (M.N.); (A.S.); (V.S.)
| | - Marie Neuwirth
- Haemostasis Laboratory, Lariboisière Hospital, AP-HP, University of Paris, 75010 Paris, France; (M.D.); (M.N.); (A.S.); (V.S.)
| | - Alain Stepanian
- Haemostasis Laboratory, Lariboisière Hospital, AP-HP, University of Paris, 75010 Paris, France; (M.D.); (M.N.); (A.S.); (V.S.)
| | - Anthony Chauvin
- Emergency Department, Lariboisière Hospital, AP-HP, University of Paris, 75010 Paris, France;
| | - Azeddine Dellal
- Department of Rheumatology and Internal Medicine, Le Raincy-Montfermeil Hospital, 93370 Montfermeil, France;
| | - Olivier Nallet
- Department of Cardiology, Le Raincy-Montfermeil Hospital, 93370 Montfermeil, France;
| | - Melanie Roriz
- Department of Internal Medicine, Hospital Center of Agen, 47923 Agen, France;
| | - Mathilde Devaux
- Department of Internal Medicine, Hospital Center of Poissy-Saint Germain, 78300 Saint Germain en Laye, France;
| | - Jonathan London
- Department of Internal Medicine, Diaconesses Croix Saint-Simon Hospital, 75012 Paris, France;
| | | | - Antoine Froissart
- Department of Internal Medicine, Intermunicipal Hospital Center of Créteil, 94000 Créteil, France; (A.F.); (N.A.)
| | - Nouara Arab
- Department of Internal Medicine, Intermunicipal Hospital Center of Créteil, 94000 Créteil, France; (A.F.); (N.A.)
| | - Bertrand Ferron
- Department of Internal Medicine, Hospital Center of Sens, 89100 Sens, France;
| | - Marie-Helene Groff
- Department of Internal Medicine, Hospital Center of Nord-Mayenne, 53100 Mayenne, France;
| | - Viviane Queyrel
- Department of Rheumatology, University Hospital of Nice, 06000 Nice, France;
| | - Christine Lorut
- Department of Pneumology, Cochin Hospital, AP-HP, Université de Paris, 75014 Paris, France; (C.L.); (L.R.)
| | - Lucile Regard
- Department of Pneumology, Cochin Hospital, AP-HP, Université de Paris, 75014 Paris, France; (C.L.); (L.R.)
| | - Emilie Berthoux
- Department of Internal Medicine, Saint Luc-Saint Joseph Hospital, 69007 Lyon, France;
| | - Guillaume Bayer
- Department of Internal Medicine, Claude Galien Hospital, 91480 Quincy sous Senart, France;
| | - Chloe Comarmond
- Department of Internal Medicine, Pitié-Salpétrière Hospital, AP-HP, Sorbonne University, 75013 Paris, France;
| | - Bertrand Lioger
- Department of Internal Medicine, Simone Veil Hospital, 41000 Blois, France;
| | - Arsène Mekinian
- Department of Internal Medicine, Saint Antoine Hospital, APHP, 75012 Paris, France;
| | - Tali-Anne Szwebel
- Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, AP-HP, University of Paris, CEDEX 14, 75679 Paris, France;
| | - Thomas Sené
- Department of Internal Medicine, Fondation Rothschild, 75019 Paris, France;
| | - Blanca Amador-Borrero
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP) Université de Paris, 75010 Paris, France; (J.G.); (B.A.-B.); (O.M.); (S.M.); (D.S.)
| | - Olivier Mangin
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP) Université de Paris, 75010 Paris, France; (J.G.); (B.A.-B.); (O.M.); (S.M.); (D.S.)
| | - Pierre O. Sellier
- Department of Infectious Disease, Lariboisière Hospital, APHP, 75010 Paris, France;
| | - Virginie Siguret
- Haemostasis Laboratory, Lariboisière Hospital, AP-HP, University of Paris, 75010 Paris, France; (M.D.); (M.N.); (A.S.); (V.S.)
| | - Stéphane Mouly
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP) Université de Paris, 75010 Paris, France; (J.G.); (B.A.-B.); (O.M.); (S.M.); (D.S.)
| | | | | | - Dominique Vodovar
- Centre Anti-Poison, Fernand Widal Hospital, AP-HP, University of Paris, 75010 Paris, France;
- INSERM UMRS 1144, 75006 Paris, France
| | - Damien Sene
- Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, (AP-HP) Université de Paris, 75010 Paris, France; (J.G.); (B.A.-B.); (O.M.); (S.M.); (D.S.)
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13
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Delrue M, Baylatry MT, Joly A, Corre E, Marjanovic Z, El‐Khoury‐Hanna N, Féger F, Suner L, Veyradier A, Stépanian A, Coppo P. Efficacy of subcutaneous preemptive rituximab in immune-mediated thrombotic thrombocytopenic purpura: Experience from the first 12 cases. Am J Hematol 2021; 96:E26-E29. [PMID: 33068040 DOI: 10.1002/ajh.26022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maxime Delrue
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
| | - Minh Tam Baylatry
- Hôpital Saint‐Antoine, Pharmacie AP‐HP. Sorbonne Université Paris France
| | | | - Elise Corre
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Zora Marjanovic
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
| | | | - Frédéric Féger
- Hôpital Saint‐Antoine, Service d'Hématologie biologique AP‐HP. Sorbonne Université Paris France
| | - Ludovic Suner
- Hôpital Saint‐Antoine, Service d'Hématologie biologique AP‐HP. Sorbonne Université Paris France
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSA Paris France
| | - Agnès Veyradier
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Alain Stépanian
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Paul Coppo
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
- INSERM UMRS 1138, Centre de Recherche des Cordeliers Paris France
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Delrue M, Siguret V, Neuwirth M, Joly B, Beranger N, Sène D, Chousterman BG, Voicu S, Bonnin P, Mégarbane B, Stépanian A. von Willebrand factor/ADAMTS13 axis and venous thromboembolism in moderate-to-severe COVID-19 patients. Br J Haematol 2020; 192:1097-1100. [PMID: 33368196 DOI: 10.1111/bjh.17216] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Maxime Delrue
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Virginie Siguret
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1140, Paris University, Paris, France
| | - Marie Neuwirth
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1140, Paris University, Paris, France
| | - Bérangère Joly
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Nicolas Beranger
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Damien Sène
- Department of Internal Medicine, Lariboisière Hospital, Paris University, Paris, France
| | - Benjamin G Chousterman
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 942, Université de Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1144, Paris University, Paris, France
| | - Philippe Bonnin
- Department of Clinical Physiology, Lariboisière Hospital, Paris University, Paris, France.,INSERM U1265, INSERM, Université de Paris, Paris, France.,INSERM U1148-Laboratory for Vascular and Translational Science, Université de Paris, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS 1144, Paris University, Paris, France
| | - Alain Stépanian
- Department of Hematology, Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
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Delrue M, Siguret V, Neuwirth M, Brumpt C, Voicu S, Burlacu R, Sène D, Chousterman BG, Mohamedi N, Lecompte T, Mégarbane B, Stépanian A. Contrast between Prevalence of HIT Antibodies and Confirmed HIT in Hospitalized COVID-19 Patients: A Prospective Study with Clinical Implications. Thromb Haemost 2020; 121:971-975. [PMID: 33296940 DOI: 10.1055/a-1333-4688] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Maxime Delrue
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Virginie Siguret
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM UMRS 1140, Paris University, Paris, France
| | - Marie Neuwirth
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM UMRS 1140, Paris University, Paris, France
| | - Caren Brumpt
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM UMRS 1144, Paris University, Paris, France
| | - Ruxandra Burlacu
- Department of Internal Medicine, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | - Damien Sène
- Department of Internal Medicine, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | - Benjamin G Chousterman
- Department of Anesthesiology and Critical Care, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM UMRS 942, Université de Paris, Paris, France
| | - Nassim Mohamedi
- Department of Clinical Physiology, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | - Thomas Lecompte
- Département de Médecine, Service d'Angiologie et d'Hémostase, Hôpitaux Universitaires de Genève, Genève, Switzerland.,Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève, Geneva, Switzerland
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM UMRS 1144, Paris University, Paris, France
| | - Alain Stépanian
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
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Voicu S, Delrue M, Chousterman BG, Stépanian A, Bonnin P, Malissin I, Deye N, Neuwirth M, Ketfi C, Mebazaa A, Siguret V, Mégarbane B. Imbalance between procoagulant factors and natural coagulation inhibitors contributes to hypercoagulability in the critically ill COVID-19 patient: clinical implications. Eur Rev Med Pharmacol Sci 2020; 24:9161-9168. [PMID: 32965009 DOI: 10.26355/eurrev_202009_22866] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Coronavirus Disease-2019 (COVID-19) predisposes patients to thrombosis which underlying mechanisms are still incompletely understood. We sought to investigate the balance between procoagulant factors and natural coagulation inhibitors in the critically ill COVID-19 patient and to evaluate the usefulness of hemostasis parameters to identify patients at risk of venous thromboembolic event (VTE). PATIENTS AND METHODS We conducted an observational study recording VTEs defined as deep vein thrombosis or pulmonary embolism using lower limb ultrasound (92% of the patients), computed tomography pulmonary angiography (6%) and both tests (2%). We developed a comprehensive analysis of hemostasis. RESULTS Ninety-two consecutive mechanically ventilated COVID-19 patients (age, 62 years [53-69] (median [25th-75th percentiles]); M/F sex ratio, 2.5; body-mass index, 28 kg/m2 [25-32]; past hypertension (52%) and diabetes mellitus (30%)) admitted to the Intensive Care Unit (ICU) from 03/11/2020 to 5/05/2020, were included. When tested, patients were receiving prophylactic (74%) or therapeutic (26%) anticoagulation. Forty patients (43%) were diagnosed with VTE. Patients displayed inflammatory and prothrombotic profile including markedly elevated plasma fibrinogen (7.7 g/L [6.1-8.6]), D-dimer (3,360 ng/mL [1668-7575]), factor V (166 IU/dL [136-195]) and factor VIII activities (294 IU/dL [223-362]). We evidenced significant discrepant protein C anticoagulant and chromogenic activities, combined with slightly decreased protein S activity. Plasma D-dimer >3,300 ng/mL predicted VTE presence with 78% (95%-confidence interval (95% CI), 62-89) sensitivity, 69% (95% CI, 55-81) specificity, 66% (95% CI, 51-79) positive predictive value and 80% (95% CI, 65-90) negative predictive value [area under the ROC curve, 0.779 (95%CI, 0.681-0.859), p=0.0001]. CONCLUSIONS Mechanically ventilated COVID-19 patients present with an imbalance between markedly increased factor V/VIII activity and overwhelmed protein C/S pathway. Plasma D-dimer may be a useful biomarker at the bedside for suspicion of VTE.
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Affiliation(s)
- S Voicu
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Université de Paris, Paris, France.
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Delrue M, Marthe A, Ostrowka C, Grasland A, Faucon A, Azarine A, Mahe I, Aslangul E. Une pyélonéphrite atypique…. Rev Med Interne 2016. [DOI: 10.1016/j.revmed.2016.04.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Florent X, Niel F, Lacombe D, Riss I, Mortemousque B, Malet F, Dale V, Delrue M, Touboul D, Colin J. 264 Mise en place de l’analyse génétique à visée diagnostique du gène de la myociline chez des patients atteints de glaucome primitif à angle ouvert de forme juvénile et de type adulte de forme familiale. J Fr Ophtalmol 2005. [DOI: 10.1016/s0181-5512(05)74662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
A method is described for the determination of erythromycin estolate by liquid chromatography. A C18 reversed-phase column (25 x 0.46 cm i.d.) was used with acetonitrile-tetrabutylammonium sulphate (pH 6.5, 0.2 M)-phosphate buffer (pH 6.5, 0.2 M)-water [x:5:5:(90-x), v/v/v/v] as mobile phase. The proportion of acetonitrile (x) has to be adapted to the type of stationary phase used. For RSil C18 LL 42.5% (v/v) was used. The column was heated at 35 degrees C, the flow rate was 1.5 ml min-1 and UV detection was performed at 215 nm. The main component, erythromycin A propionate, was separated from all other components which were present in commercial samples. The impurities most frequently observed were the propionate ester of erythromycin C and the amide N-propionyl-N-demethyl-erythromycin A. Erythromycin A was shown to be present in specialties.
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Affiliation(s)
- T Cachet
- Katholieke Universiteit Leuven, Laboratorium voor Farmaceutische Chemie, Instituut voor Farmaceutische Wetenschappen, Belgium
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