Background Evans syndrome (ES) is a rare autoimmune disorder characterized by the coexistence of immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Beyond bleeding and infections complications, ES is increasingly recognized as a prothrombotic condition, particularly in the presence of multiple risk factors such as hemolysis, thrombocytopenia-related immune dysregulation, splenectomy, and exposure to thrombopoietin receptor agonists. However, the importance of antiphospholipid antibodies is less well established in ES patients. Case presentation We report the case of a 53-year-old male with a long-standing history of AIHA, later complicated by ITP and diagnosed as ES, who presented with acute deep vein thrombosis of the right lower extremity despite severe thrombocytopenia. His medical history was notable for prior splenectomy, recurrent venous thromboembolic events, cerebral venous sinus thrombosis, and recent exposure to eltrombopag. Laboratory evaluation revealed evidence of compensated hemolysis and persistent lupus anticoagulant positivity, while other antiphospholipid antibodies were negative. Due to profound thrombocytopenia, anticoagulation was initiated following platelet count recovery achieved with intravenous immunoglobulin and corticosteroids. Platelet counts were subsequently maintained with eltrombopag, allowing continuation of therapeutic anticoagulation without bleeding complications. Conclusions This case highlights the complex interplay between thrombosis and thrombocytopenia in ES. Rather than a single etiologic factor, thrombotic events in ES appear to result from the accumulation of multiple prothrombotic conditions, including immune cytopenias, prior splenectomy, and treatment-related factors, with antiphospholipid antibodies potentially acting as an additional risk amplifier. Recognition of this multifactorial risk profile is essential for tailored management and prevention of thrombotic complications in patients with ES.

Background/Objectives: Tissue factor (TF)-expressing cancer cells and their extracellular vesicles (CaCe-dEVs) are key drivers of cancer-associated hypercoagulability and vascular dysfunction. While low-molecular-weight heparins (LMWHs) and direct FXa inhibitors are standard therapies for cancer-associated thrombosis, their direct effects on cancer cell procoagulant potential and endothelial responses remain incompletely defined. This study compared the impact of LMWHs (enoxaparin, tinzaparin), apixaban, and quercetin on cancer cell viability, thrombin generation, and CaCe-dEVs-induced endothelial injury. Methods: Pancreatic (BXPC3) and breast (MCF7) cancer cells and their vesicles were analyzed for TF expression and thrombin generation. Human umbilical vein endothelial cells (HUVECs) were pretreated with each agent prior to vesicle exposure. Cell viability, thrombin generation, and endothelial morphology were assessed using standard assays and microscopy. Results: Tinzaparin and quercetin significantly reduced cancer cell viability, whereas enoxaparin and apixaban showed no cytotoxicity. None of the agents affected HUVEC viability. All suppressed TF-mediated thrombin generation induced by cancer cells, with tinzaparin being most effective in BXPC3 cells. Quercetin exhibited a partial and limited protective effect on endothelial cells against CaCe-dEVs-induced dysfunction, while LMWHs and apixaban did not prevent endothelial damage. Conclusions: These findings suggest that LMWHs, apixaban, and quercetin modulate cancer-cell-driven hypercoagulability beyond anticoagulation, with quercetin and tinzaparin showing additional cytotoxic potential. Such dual effects may reduce thrombosis risk while impacting tumor progression, meriting further investigation.

Background Defibrotide is a DNA-derived polyelectrolyte with anti-ischemic and antithrombotic effects, primarily used in post-bone marrow transplantation (BMT) veno-occlusive disease (VOD). Currently, it is produced from porcine mucosal tissue, which presents cultural, economic, and supply limitations. Aim This study compared coagulation activity, molecular profiles, and DNA content of porcine- versus ovine-derived defibrotide. Methods Active pharmaceutical ingredient (API) samples of 19 porcine and 9 ovine defibrotide batches were dissolved in saline (1 mg/mL) and added to pooled plasma and whole blood (100 µg/mL). Coagulation was assessed using activated partial thromboplastin time (aPTT) and thrombin time (TT). Anti-Xa and anti-IIa activities were measured by amidolytic assays. DNA content was quantified via the heparin red method, and molecular weight was determined by size exclusion chromatography. Results Neither porcine nor ovine preparations showed anticoagulant effects in aPTT. Both produced mild, comparable anticoagulant activity in TT. Anti-Xa and anti-IIa values were similar across sources. Molecular weight profiles were also comparable (ovine: 16.8 ± 0.24 kDa vs porcine: 18.02 ± 0.32 kDa). DNA content showed no significant difference (ovine: 75.78 μg vs porcine: 79 μg/10 μg API). Conclusion Ovine- and porcine-derived defibrotide demonstrated equivalent coagulation, molecular, and DNA content profiles. These findings suggest ovine mucosa is a viable alternative source for defibrotide, potentially improving accessibility, reducing cost, and addressing dietary restrictions associated with porcine-derived products.

Background/Objectives: Tissue factor (TF)-expressing cancer cells and their extracellular vesicles (CaCe-dEVs) are key drivers of cancer-associated hypercoagulability and vascular dysfunction. While low-molecular-weight heparins (LMWHs) and direct FXa inhibitors are standard therapies for cancer-associated thrombosis, their direct effects on cancer cell procoagulant potential and endothelial responses remain incompletely defined. This study compared the impact of LMWHs (enoxaparin, tinzaparin), apixaban, and quercetin on cancer cell viability, thrombin generation, and CaCe-dEVs–induced endothelial injury. Methods: Pancreatic (BXPC3) and breast (MCF7) cancer cells and their vesicles were analyzed for TF expression and thrombin generation. Human umbilical vein endothelial cells (HUVEC) were pretreated with each agent prior to vesicle exposure. Cell viability, thrombin generation, and endothelial morphology were assessed using standard assays and microscopy. Results: Tinzaparin and quercetin significantly reduced cancer cell viability, whereas enoxaparin and apixaban showed no cytotoxicity. None of the agents affected HUVEC viability. All suppressed TF-mediated thrombin generation induced by cancer cells, with tinzaparin being most effective in BXPC3 cells. Quercetin consistently protected endothelial cells from CaCe-dEVs–induced dysfunction, while LMWHs and apixaban did not prevent endothelial damage. Conclusions: These findings suggest that LMWHs, apixaban, and quercetin modulate cancer cell-driven hypercoagulability beyond anticoagulation, with quercetin and tinzaparin showing additional cytotoxic potential. Such dual effects may reduce thrombosis risk while impacting tumor progression, meriting further investigation.

Background:Despite advances in diagnosis and treatment, pulmonary embolism (PE) remains a challenging condition with high mortality. Current prognostic models lack integration of the biological underpinnings driving adverse outcomes. Objectives:This study profiles thromboinflammation and hemostatic biomarkers in patients with PE to evaluate their association with 30-day mortality. Methods:In a prospective-specimen collection, retrospective-blinded evaluation study, plasma samples from 500 patients collected at time of diagnosis were analyzed. Biomarkers reflecting endothelial dysfunction, platelet activation, coagulation imbalance, impaired fibrinolysis, and inflammation were quantified. Hematological indices (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], and systemic immune-inflammation index [SII]) were calculated. Receiver operating characteristics analysis, multivariable logistic regression, and Chi-square automatic interaction detection (CHAID) recursive partitioning tree were used to assess predictors of mortality. Results:Of 500 patients (median age, 64 years; 52% males), 48 (9.7%) died within 30 days. Levels of von Willebrand factor, P-selectin, tissue factor, tissue-type plasminogen activator, plasminogen activator inhibitor (PAI)-1, D-dimer, C-reactive protein, interleukin 6, tumor necrosis factor (TNF)-α, NLR, PLR, and SII were significantly higher, while FVII, FX, FXIIIA, and thrombin-activatable fibrinolysis inhibitor levels were significantly lower in 30-day nonsurvivors. Multivariable analysis revealed that elevated von Willebrand factor, E-selectin, tissue factor, tissue-type plasminogen activator, PAI-1, D-dimer, C-reactive protein, interleukin 6, TNF-α, and NLR, and decreased FVII, FX, FXIIIA, and TAFI levels, were independently associated with 30-day mortality. Chi-squared automatic interaction detection analysis identified elevated NLR, PAI-1, and TNF-α as key predictors of mortality. Conclusion:Current PE scoring systems have a low positive predictive value for clinical deterioration and mortality. This study uniquely integrates endothelial, platelet, coagulation, fibrinolytic, inflammatory, and hematologic biomarkers to identify novel mortality-predictive thresholds, highlighting the value of thromboinflammation, and hemostatic activation biomarkers associated with the pathobiology of PE for enhancing risk stratification of patients with PE.

Introduction: Arterial thrombotic events (ATE) represent a serious but underreported complication in lymphoma patients, potentially impacting morbidity and mortality. The prevalence of ATE among lymphoma patients shows considerable variation across studies, influenced by multiple factors and consequently dynamic during the course of the disease. The reason lies in marked heterogeneity of lymphoma, with unique characteristics depending on the specific subtype, status of the disease, patient characteristics and treatment modalities. The systematic review and meta-analysis aimed to provide the pooled prevalence of ATE in lymphoma patients and identify associated risk factors. Methods: A systematic review and meta-analysis were performed following PRISMA guideline. The search for studies included several electronic databases: PubMed, Web of Science, Cochrane Library, Scopus - all up to June 2024. The inclusion criteria were adult study population, with any type of newly diagnosed, relapsed or previous diagnosis of Hodgkin or non-Hodgkin's lymphoma. Extracted data implied: basic study characteristics, participant characteristics, intervention details and outcomes. The Newcastle-Ottawa scale was used to analyse the quality of included studies. For the pooling of single proportions, we used the inverse variance methods with logit transformation. Confidence intervals for individual studies were estimated using the Clopper-Pearson method. The heterogeneity between studies was explored using Cochran's Q test and r2 statistics, the Baujat plot, and quantified with the l2 statistic. Univariate meta-regression analyses were used to identify potential predictors. Publication bias was assessed using the funnel plot and Egger's test. Sensitivity analysis was performed by excluding studies that might influence the results of the meta-analysis. A significance level of 0.05 was applied. Results: Final analysis included six studies comprising 9293 patients. Across the studies, 63 ATE were reported. The pooled estimation of events was 1.23% (95% CI: 0.47% to 3.20%) under the random-effects model, with the prediction interval ranged from 0.04% to 28.61%, demonstrating significant heterogeneity (I² = 92.4%). According to Baujat plot, only one study had a disproportionate influence on heterogeneity. Sensitivity analysis excluding the influential study revealed a slight increase in the pooled rate (1.82%), with reduced heterogeneity (I² = 81.2%). Disproportion of the overall heterogeneity has arisen probably due to methodological or population differences. However, the value of the pooled effect remained consistent. A symmetrical funnel plot (Egger's test p = 0.809) showed no significant publication bias. Univariate meta-regression analysis revealed that increasing mean age was significantly associated with a higher prevalence of arterial thrombosis. Variables as follow-up duration and female gender proportion didn't show a significant association with event rates. Conclusions: ATE are less common than venous thrombotic events in lymphoma but remain clinically relevant. This meta-analysis identifies a low pooled event rate of ATE and increasing mean age as a significant associated variable, emphasizing the need for proper risk-adapted thromboprophylaxis strategies in lymphoma patients.

Introduction: Acute pulmonary embolism (PE) is the third leading cause of death with a mortality rate upwards of 30% if left untreated. Although some biomarkers have been shown to be useful in the diagnosis and risk stratification of patients with acute PE, currently their clinical utility remains undefined. The interplay of endothelial damage, inflammation, and anti-PF4 antibodies have been shown to contribute to outcomes in acute PE. This study focused on the interrelationship between endothelial dysfunction and inflammatory biomarkers along with anti-PF4 antibodies and their role in acute PE pathophysiology. Additionally, the relationship of these biomarkers to blood cellular indices and clinical characteristics was investigated. Material and Methods: Blood samples from 66 patients with confirmed PE diagnosis were collected under a pre-approved IRB project through Loyola University Medical Center's Pulmonary Embolism Response Team (PERT) registry. Control samples of normal human plasma were collected from 18 healthy individuals. Biomarker analysis included IL-2, IL-4, IL-6, IL-8, IL-10, VEGF, IFN, TNF-, IL-1, IL-1ß, MCP-1 and EGF using Sandwich Chemiluminescence Biochip Array from Randox Technology. ELISA methods included Tissue Factor (TF), von Willebrand Factor (vWF), anti-PF4 antibody, and endocan. Blood cellular indices, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lyphocyte ratio (PLR), monocyte-to-lyphocyte ratio (MLR), and systemic immune-inflammation index (SII), were calculated using the complete blood count. Clinical data, including obesity and PE risk severity, were collected using EPIC chart review. Statistical analyses were performed using Excel and GraphPad Prism software. Results: Our cohort of 66 patients with PE was comprised of 43.9% female and 56.1% male, with a median age of 66.5-years. Under AHA guidelines for PE risk severity, and combining high-intermediate and low-intermediate patients into one group, 5 were high-risk, 33 were intermediate-risk, and 28 were low-risk. In terms of obesity, 59.1% of patients had a BMI ≥30. PE patients exhibited higher inflammatory cytokines including IL-2 (p=0.0145), IL-6 (p=<0.0001), IL-8 (p=<0.0001), IL-10 (p=0.0494), MCP-1 (p=0.0054), and TNF- (p=0.0084). Markers of endothelial dysfunction were elevated in PE patients as compared to healthy controls, including vWF (p=<0.0001), anti-PF4 (p=0.0475), TF (p=0.0329), VEGF (p=0.0033), and EGF (p=<0.0001). Notable positive correlations include MCP-1 vs. IL-1ß (r=0.74), IFN vs. TNF- (r=0.50), and MCP-1 vs. TNF- (r=0.49). Notable negative correlations include endocan vs. EGF (r=-0.34) and anti-PF4 vs. TF (r=-0.30). When stratified by PE risk severity, IL-6 was elevated in intermediate-risk patients compared to low-risk (p=0.0284). Additionally, IL-1ß was higher in intermediate-risk compared to low risk (p=0.0329) and high-risk compared to low-risk patients (p=0.0092). For biomarkers of endothelial dysfunction, vWF showed elevated levels in intermediate-risk patients as compared to low-risk (p=0.0279). An increase in both NLR (p=0.0163) and MLR (p=0.0321) was noted in the intermediate-risk patients as compared to low-risk. Interestingly, when stratified by BMI, obese patients showed a decrease in both IL-6 (p=0.0136) and IL-10 (p=0.0094).Conclusion: This study analyzed biomarkers of inflammation, endothelial dysfunction, and anti-PF4 antibodies within patients with acute PE. These results provide further evidence of the role in which endothelial damage and inflammation play in the pathophysiology of acute PE, while also highlighting their potential use as diagnostic and prognostic tools. Correlation analysis implies that there may be a coordinated pro-inflammatory response in these patients, while also indicating that distinct thromboinflammatory pathways may be activated. Elevations in IL-6 and IL-1ß in intermediate and high-risk patients, demonstrates a progressive increase in systemic inflammation with worsening PE severity. Higher inflammatory blood cellular indices (NLR, MLR) in intermediate-risk patients indicates a heightened innate immune response, while also emphasizing their potential prognostic value. Similarly, higher vWF levels in intermediate-risk patients show a possible increase in vascular stress and thrombotic burden in more severe PE cases. Lastly, lower levels of IL-6 and IL-10 in obese patients reflects a potentially dampened or dysregulated immune response.

End-stage renal disease (ESRD) is often associated with thromboinflammatory complications. Besides the biomarkers of thrombin generation such as D-dimer (DD) and peak thrombin (PT) levels, cellular indices (CI's) have been reported to change with the severity of ESRD. Such CI's as neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic immune-inflammation index (SII), lymphocyte to monocyte ratio (LMR), neutrophil to monocyte ratio (NMR) and their relevance with biomarkers such as DD and PT were profiled in ESRD patients. Citrated plasma samples from patients with confirmed ESRD were collected in the Hemodialysis Clinic at Loyola University Medical Center. 50 healthy plasma samples served as control. Commercially available sandwich ELISA methods were used for DD levels, and PT was quantified by using a fluorogenic method. Blood CI's were extracted from complete blood counts. Applicable statistical methods were performed and P < 0.05 were considered significant. The ESRD group comprised 56.9% males and 43.1% females, with a median age of 66 years. Comparing controls to ESRD cohort, DD increased significantly from 7.1 to 905.8 ng/mL (P < 0.05) while PT levels decreased from 138.4 to 109.9nM (P < 0.05). NLR increased from 1.6 to 3.4, SII increased from 444.5 to 583.2, and LMR decreased from 4.1 to 2.4 (P < 0.05). PLR and NMR showed no significant difference. Table 1 represents the composite results. There was no correlation between DD and PT. There were varying degrees of correlation between cellular indices. These studies suggest that beside thromboinflammatory biomarkers, CI's may provide additional prognostic parameters in the risk stratification of ESRD. All of the CI's included in this study are increased except for LMR. CI's represent an emerging tool to risk stratify ESRD patients.

BACKGROUND:Obesity is associated with substantial thromboembolic risk; however, no standard laboratory method exists to stratify risk for postoperative thrombotic events. Our aim was to evaluate preoperative prothrombotic biomarkers and thromboelastometry in relationship to clinical venothromboembolism stratification in bariatric patients. STUDY DESIGN:Preoperative blood samples were assessed for rotational thromboelastometry, D-dimer, C-reactive protein (CRP), plasminogen activator inhibitor-1, von Willebrand factor, and P-selectin, and compared with 50 normal control (NC) samples. Patients were stratified into Caprini Risk Score (CRS) groups: moderate (3 to 4), high (5 to 8), and very high (greater than 8) venothromboembolism risk. RESULTS:One hundred bariatric patients were assessed and risk stratified to CRS 3 to 4 (23), CRS 5 to 8 (67), and CRS greater than 8 (10). D-dimer, plasminogen activator inhibitor-1, and CRP were increased compared with NC, all p < 0.001, and P-selectin and von Willebrand factor demonstrated no differences compared with NC. D-dimer demonstrated significant differences between moderate, high, and very high-risk groups (all p < 0.05), and positive correlation with CRS ( r = 0.44, p < 0.001). On thromboelastometry, clot formation time (CFT) was faster than normal in 18% of patients, with maximum clot firmness higher than normal in 54% of patients. No difference was found comparing thromboelastometry between CRS groups. Significant correlations were found between CRP and CFT ( r = -0.44), α-angle ( r = 0.40), and maximum clot firmness ( r = 0.44), all p < 0.05, respectively. D-dimer negatively correlated with CFT ( r = -0.34, p < 0.05), and clotting time ( r = -0.78, p < 0.05) in very high-risk patients. CONCLUSIONS:Preoperative D-dimer and CRP are significantly increased in bariatric patients and correlate with prothrombotic features on thromboelastometry. No significant differences were found comparing viscoelastic tests among CRS groups, which suggests patients with marked prothrombotic findings are not being differentiated into higher-risk categories by clinical assessment alone.

Background With the widespread use of direct oral anticoagulants (DOACs), there is an urgent need for a rapid assay to exclude clinically relevant plasma levels. Accurate and rapid determination of DOAC levels would guide medical decision-making to (1) determine the potential contribution of the DOAC to spontaneous or trauma-induced hemorrhage; (2) identify appropriate candidates for reversal, or (3) optimize the timing of urgent surgery or intervention. Methods and Results The DOAC Dipstick test uses a disposable strip to identify factor Xa- or thrombin inhibitors in a urine sample. Based on the results of a systematic literature search followed by an analysis of a simple pooling of five retrieved clinical studies, the test strip has a high sensitivity and an acceptably high negative predictive value when compared with levels measured with liquid chromatography tandem mass spectrometry or calibrated chromogenic assays to reliably exclude plasma DOAC concentrations ≥30 ng/mL. Conclusion Based on these data, a simple algorithm is proposed to enhance medical decision-making in acute care indications useful primarily in hospitals not having readily available quantitative tests and 24/7. This algorithm not only determines DOAC exposure but also differentiates between factor Xa and thrombin inhibitors to better guide clinical management.