Direct oral anticoagulants (DOACs) were historically avoided in cirrhosis due to concerns regarding impaired hepatic metabolism, cumulative toxicity, and the systematic exclusion of patients with cirrhosis from pivotal r...Direct oral anticoagulants (DOACs) were historically avoided in cirrhosis due to concerns regarding impaired hepatic metabolism, cumulative toxicity, and the systematic exclusion of patients with cirrhosis from pivotal randomized trials. However, over the past decade, a growing body of retrospective cohorts, meta-analyses, and small prospective studies - including limited randomized comparisons - have evaluated DOACs against vitamin K antagonists (VKAs) for management of venous thromboembolism (VTE), splanchnic vein thrombosis (SVT), and atrial fibrillation (AF) in cirrhosis. In Child-Pugh A and B disease, pharmacokinetic studies demonstrate predictable drug exposure, whereas advanced (Child-Pugh C) cirrhosis may alter metabolism and bleeding risk. Contemporary data increasingly support the use of DOACs in patients with Child-Pugh A or B cirrhosis and AF, with effectiveness comparable to vitamin K antagonists (VKAs) and potentially lower rates of major bleeding and intracranial hemorrhage. In SVT, both retrospective and prospective studies demonstrate that DOACs are associated with higher recanalization rates compared with VKAs, and have comparable, if not lower, bleeding risk. Data on DOAC use for VTE at other sites remains more limited, warranting individualized decision-making. Recent studies focused on DOAC use for primary prophylaxis in cirrhosis allude to favorable effects on portal hypertension-related complications and warrant further investigation of the risk and benefit of DOAC therapy in this context.
BACKGROUND: Anticoagulants are a leading cause of medication-related harm, with bleeding and thrombotic events from suboptimal use causing significant patient morbidity. Antithrombotic Stewardship (ATS) is a coordinated,...BACKGROUND: Anticoagulants are a leading cause of medication-related harm, with bleeding and thrombotic events from suboptimal use causing significant patient morbidity. Antithrombotic Stewardship (ATS) is a coordinated, system-level hospital strategy that can minimise the risk of anticoagulant-related harm. Despite the benefits of ATS, implementation is inconsistent, and qualitative exploration of the real-world experience is limited. OBJECTIVES: To explore the perspectives of clinicians working in hospital-based anticoagulation management and to identify what they consider as core components of successful ATS programs. A secondary aim was to describe quality indicators used to monitor ATS performance. METHODS: Semi-structured interviews were conducted with clinicians working in hospital-based ATS services. Participants were recruited through international thrombosis/haemostasis networks. Interviews were thematically coded. Themes were then mapped to Systems Engineering Initiative for Patient Safety (SEIPS) framework for healthcare facilities. RESULTS: Sixteen clinicians across six countries participated in the study. Core elements under the SEIPS framework were (i) Organisation: dedicated funding and multidisciplinary support, (ii) Individual: clinician commitment and subject matter expertise, (iii) Tasks/Tools and Technology: proactive identification of high-risk clinical scenarios using electronic tools, referral-based consults, and governance activities including guideline development and education and, (iv) Environment: virtual reporting capabilities, while maintaining a visible presence. Nineteen quality indicators were identified monitoring guideline availability, thrombosis/bleeding events, prescribing, interventions, drug expenditure and patient compliance, but these were not consistently used between facilities. CONCLUSION: Successful ATS requires funded, multidisciplinary, expert-led services supported by electronic tools and governance initiatives. The absence of standardised quality indicators highlights the need to develop consensus measures to support ATS implementation.
Atrial fibrillation (AF) is associated with an increased risk of major adverse cardiovascular events (CVEs) including myocardial infarction, ischemic stroke and peripheral arterial ischemic events despite optimal anticoa...Atrial fibrillation (AF) is associated with an increased risk of major adverse cardiovascular events (CVEs) including myocardial infarction, ischemic stroke and peripheral arterial ischemic events despite optimal anticoagulant therapy. Matrix metalloproteinase 2 (MMP-2) levels have been associated with endothelial dysfunction and atherosclerosis, and in AF patients, MMPs seem to play a role in atrial fibrosis but no solid data on the association with CV risk do exist. We measured MMP-2 plasma levels, and its selective naturally occurring inhibitor TIMP-2 in 211 AF patients with (n = 86) or without (n = 125) CVEs, in a nested case-control study from the prospective ATHERO-AF study. The two groups were balanced for clinical characteristics. The median value of MMP-2 was 731 ng/ml in patients with and 953 ng/ml in patients without CVEs (p < 0.05). ROC curve analysis identified a cut-off value of 825 ng/ml associated with CVEs. Patients with MMP-2 above this level had a lower incidence of CVEs (OR: 0.38, CI 0.2-0.6) and stroke (OR 0.37 CI 0.1-0.9). Additionally, multivariable Cox proportional hazards analysis confirmed an inverse association between high levels of MMP-2, CVEs and stroke (HR 0.563, 95%CI 0.358-0.886, p = 0.013 and HR 0.335, 95%CI 0.146-0.771, p = 0.010, respectively). Results were confirmed using continuous values. These data suggest a possible protective role of MMP-2 against CVEs occurrence in patients with AF and highlight the need of further investigations on the potential role of MMP-2 as a prognostic biomarker in non-valvular AF.
BACKGROUND: Patients with pulmonary embolism (PE) at low-risk for early PE-related complications can be treated safely at home. Patient satisfaction with such treatment has hardly been investigated. AIM: To evaluate pati...BACKGROUND: Patients with pulmonary embolism (PE) at low-risk for early PE-related complications can be treated safely at home. Patient satisfaction with such treatment has hardly been investigated. AIM: To evaluate patient satisfaction with PE home treatment. METHODS: We conducted a cross-sectional survey study to assess the experiences of PE patients treated at home. This study included consecutive adult patients diagnosed with PE between April 2024 and July 2025 at the LUMC receiving a direct oral anticoagulant and were discharged directly from the emergency department. The Hestia criteria were used to select patients for home treatment. RESULTS: A total of 47 patients (38%) with PE were treated at home during the study period. The survey was sent out to the 32 eligible patients and 30 completed the survey (94%). Nineteen (63%) patients were male, their mean age was 66 years [52-74], 50% had a prior venous thromboembolism, one had active cancer and 53% had segmental PE. Overall patient satisfaction was good: 28 out of 30 (93%) indicated to be satisfied or very satisfied with the delivered care, and 28 patients (93%) would prefer home treatment again if PE was to recur. Nevertheless, 5 out of 30 (17%) reported to have experienced any degree of anxiety due to the home treatment. CONCLUSION: Our study shows that patient satisfaction with home treatment is high and that the majority of those treated at home would prefer this over admission, demonstrating that avoiding hospitalization is not only cost-efficient but also associated with positive patient experiences.
Thrombus formation in atherosclerosis-related vascular regions is influenced by complex and spatially varying hemodynamic conditions. While low shear stress and flow recirculation have been widely associated with increas...Thrombus formation in atherosclerosis-related vascular regions is influenced by complex and spatially varying hemodynamic conditions. While low shear stress and flow recirculation have been widely associated with increased thrombotic risk, the mechanisms by which geometry-induced hemodynamic features translate into distinct thrombus evolution outcomes remain insufficiently understood, partly due to the lack of quantitatively validated closed-loop models. In this study, we develop a two-dimensional fluid-structure interaction framework that resolves the bidirectional coupling between thrombus growth and the surrounding flow field, as a mechanism-oriented computational model for comparative analysis. Based on the IB2d (Immersed Boundary 2D) framework, a two-stage simulation strategy is implemented in three representative vascular geometries: straight, curved, and bifurcated vessels. In the first stage, thrombus formation is suppressed to obtain a thrombus-free baseline flow field, from which a geometry-dependent risk score is constructed to provide an a priori ranking of thrombotic susceptibility. In the second stage, thrombus formation is activated to systematically simulate thrombus evolution, extract key phenotypic metrics, and construct detachment critical phase diagrams through parametric control. The results indicate that, under identical inlet conditions, bifurcated vessels tend to exhibit earlier thrombus nucleation and a greater propensity for rapid accumulation leading to occlusion, whereas straight and curved geometries preferentially undergo detachment after reaching a critical growth scale. The resulting phase diagrams further delineate distinct phenotypic regimes of thrombus evolution within parameter space and define their critical boundaries, thereby enabling mechanism-based comparative analysis and characterization of critical conditions.
BACKGROUND: Major bleeding is a crucial event in patients with pulmonary embolism (PE) accompanied by high morbidity and mortality. While the major bleeding research focus primarily on intracranial bleeding, research reg...BACKGROUND: Major bleeding is a crucial event in patients with pulmonary embolism (PE) accompanied by high morbidity and mortality. While the major bleeding research focus primarily on intracranial bleeding, research regarding extracranial major bleeding (ECB) is largely underrepresented. METHODS: We used the German nationwide inpatient statistics including all hospitalizations of patients admitted due to PE 2016-2020. Hospitalizations were stratified for occurrence of ECB and risk factors for ECB were investigated. RESULTS: Overall, 283,263 patients were admitted due to PE 2016-2020 in Germany; among them 9378 (3.3%) suffered from ECB. PE patients with ECB were older, more often female, revealed a higher Charlson comorbidity index (CCI; 5.0 [4.0-7.0] vs. 4.0 [2.0-5.0], P < 0.001), were afflicted by prolonged in-hospital stay (13.0 [7.0-22.0] vs 7.0 [4.0-9.0] days, P < 0.001) and higher in-hospital mortality rate (28.3% vs. 7.4%, P < 0.001). ECB was associated with increased in-hospital mortality rate (OR 7.76 [95%CI 7.31-8.24], P < 0.001) and hospitalization costs >20,000€ (OR 24.46 [95%CI 22.25-26.89], P < 0.001). Hospitalization costs were higher in PE with than without ECB (mean: 12.795 vs. 3637€, P < 0.001). Female sex (OR 1.35 [95%CI 1.28-1.42], P < 0.001), higher CCI score (OR 1.25 [95%CI 1.24-1.26], P < 0.001), kidney disease (OR 2.47 [95%CI 2.35-2.60], P < 0.001), heart failure (OR 1.65 [95%CI 1.57-1.73], P < 0.001), cancer (OR 2.01 [95%CI 1.97-2.22], P < 0.001) and hemodynamic instability (OR 12.08 [95%CI 11.38-12.82], P < 0.001) were associated with ECB. CONCLUSIONS: ECB occurred in 3.3% of the PE hospitalizations and is independently associated with 7.8-fold increased in-hospital mortality rate. Independent risk factors for ECB comprise female sex, hemodynamic status and comorbidity burden.
Megakaryopoiesis is an elaborate biological process that primarily occurs in the bone marrow. To gain deeper insights into molecular mechanisms driving normal megakaryopoiesis, we utilized an in vitro human megakaryocyti...Megakaryopoiesis is an elaborate biological process that primarily occurs in the bone marrow. To gain deeper insights into molecular mechanisms driving normal megakaryopoiesis, we utilized an in vitro human megakaryocytic culture system based on mobilized peripheral blood-derived CD34 cells. Following fluorescence-activated cell sorting (FACS) isolation of CD41 and CD41 megakaryocyte (MK) subsets, mature MKs were confirmed through characterization of MK-specific surface markers, ploidy analysis, Giemsa staining, and immunofluorescence. Subsequent bulk RNA sequencing of these distinct populations enabled the identification of differentially expressed genes (DEGs) and enriched pathways. Based on our CD34-derived MK differentiation model, the expression of CD41 was found robustly induced by day 4 and further elevated by day 10. The CD41 population exhibited marked co-expression of CD42b and CD61, a significantly higher proportion of polyploid cells (≥16 N), along with characteristic morphological features of mature MKs, including proplatelet formation, cytoplasmic maturation, and cell size enlargement compared to the CD41 subset. Transcriptomic profiling of these two populations identified 1877 up-regulated and 1817 down-regulated DEGs in CD41 MKs. Protein-protein interaction (PPI) network analysis of the key DEGs revealed hub genes including VWF, PF4V1, SELP, PF4, GP1BA, CD40LG, PPBP, CLEC1B, P2RY12, and THBS1. Functional enrichment underscored the acquisition of migratory, adhesive, and secretory capacities, marked by significant upregulation of platelet activation and wound healing signatures. Pathway analysis further indicated coordinated activation of focal adhesion, cytoskeletal reorganization, glycerolipid metabolism, and neuroactive ligand-receptor interaction during maturation. This study provides an integrative transcriptomic blueprint of human MK maturation and highlights the novel candidate targets for thrombopoiesis.
Thrombosis is a significant complication of childhood acute lymphoblastic leukemia (ALL) associated with both the disease itself and its treatment. This study aimed to predict the thrombotic process with TGA performed at...Thrombosis is a significant complication of childhood acute lymphoblastic leukemia (ALL) associated with both the disease itself and its treatment. This study aimed to predict the thrombotic process with TGA performed at diagnosis and during induction therapy in pediatric ALL cases, to assess the contribution of hereditary risk factors, ALL, and treatment to thrombophilia, and to compare the thrombosis tendency according to ALL risk group. The study included 24 ALL patients and 23 healthy children. TGA was performed before the start of induction chemotherapy (ALL BFM-2009 protocol) and on days 8, 15, and 33 of treatment for ALL patients and once for healthy controls. TGA was conducted using a Thrombinoscope (Calibrated Automated Thrombogram; Maastricht, Netherlands) device and kits from the same company. We found the frequency of thrombosis to be 12.5% in children with ALL. Although the number of thrombosis was small (n = 3), the association of peak thrombin and ETP with thrombosis was encouraging: patients who developed thrombosis had higher mean ETP and peak thrombin values on days 8 and 15 of induction therapy compared to patients without thrombosis, with TGA profiles more comparable to those of the healthy control group. Patients' lag time and time to peak thrombin on days 8, 15, and 33 of induction therapy were significantly longer, in addition peak thrombin and ETP values were significantly lower compared to the control group. The results of this study indicate that changes in hemostatic balance did not cause an increase in the thrombin generation potential, and thrombin generation remained low compared to the healthy control group. Although these findings seem to contradict those of studies showing thrombophilia in ALL patients, our study does not support hypercoagulability alone. Considering the absence of signs of hypercoagulability, thrombophilia in these patients may be secondary to endothelial damage caused by the disease and cytotoxic therapy. Comprehensive studies are needed to elucidate the etiology of thrombosis in ALL.
INTRODUCTION: Direct Oral Anticoagulants (DOACs) are generally not recommended during breastfeeding due to limited data on milk transfer and potential effects on the infant. The main advantages of DOACs over the other an...INTRODUCTION: Direct Oral Anticoagulants (DOACs) are generally not recommended during breastfeeding due to limited data on milk transfer and potential effects on the infant. The main advantages of DOACs over the other anticoagulants are absence of a need for regular laboratory monitoring, rapid onset of action, fewer drug and food interactions, fixed dosing and short half-life. We conducted a systematic review of published evidence aiming to understand the effects of DOACs in breast milk and the consequences for the breastfed infant. METHODS: This systematic review was conducted in adherence to the PRISMA. PubMed, Cochrane, and Embase were systematically searched up to June 2025. Data was descriptively synthesized. RESULTS: Of the 301 citations identified, 21 full-text articles were assessed for eligibility and 5 studies met our inclusion criteria. The studies enrolled 12 lactating women and 3 breastfed infants, with infants evaluated only in one case series. For apixaban, a Relative Infant Dose (RID) of 18% and of 12.78% and a milk-to-plasma ratio of 2.61 was observed. Rivaroxaban does transfer into breast milk, but the RIDs in the women were all below 10%. Plasma rivaroxaban concentrations in the infants, measured 2 h after breastfeeding, were below the lower limit of quantification. Dabigatran did not produce a significant impact on neonatal TT, FIIa, or plasma Clauss-fibrinogen levels. CONCLUSION: Available evidence on the use of DOACs during lactation is extremely limited and of low certainty. Consequently, no definitive conclusions regarding safety or clinical use during breastfeeding can be drawn.
Cai Y, Bosch J, Zhu J
… +14 more, Eikelboom JW, O'Donnell M, Yi Q, Kilickap M, Alings M, Forbes N, Rey A, Verhamme P, Kruger P, Moayyedi P, Avezum A, Vanassche T, Wu C, Liang Y
OBJECTIVE: Gastrointestinal (GI) bleeding is a serious complication among patients with cardiovascular disease (CVD). This study aimed to evaluate sex differences in the odds of GI bleeding. METHODS: We analyzed data fro...OBJECTIVE: Gastrointestinal (GI) bleeding is a serious complication among patients with cardiovascular disease (CVD). This study aimed to evaluate sex differences in the odds of GI bleeding. METHODS: We analyzed data from an international case-control study of adults with CVD (n = 4721; 1807 women and 2914 men), conducted between September 3, 2015, and December 20, 2022. Cases presented with overt GI bleeding; controls had no prior GI bleeding. Baseline characteristics were compared by sex. Sequential multivariable logistic regression was used to assess the association between sex and GI bleeding, followed by sex-stratified analyses and tests for sex×factor interactions. RESULTS: Female sex was independently associated with lower adjusted odds of GI bleeding compared with male sex (aOR 0.82, 95% CI 0.72-0.95). While most established factors were associated with GI bleeding in both sexes, Coronary artery disease was associated with higher odds of GI bleeding only in women (aOR 1.44; P-interaction = 0.004). CONCLUSIONS: Among patients with CVD, female sex is independently associated with lower odds of GI bleeding. Several factors were shared between sexes, although some sex-specific associations were observed.
BACKGROUND: Neutrophil extracellular traps (NETs) are key components of innate immunity, but NETosis research is limited by the absence of standardized biomarkers and analytical protocols. The rapid expansion of NET-rela...BACKGROUND: Neutrophil extracellular traps (NETs) are key components of innate immunity, but NETosis research is limited by the absence of standardized biomarkers and analytical protocols. The rapid expansion of NET-related studies emphasizes the need for a critical evaluation of current measurement approaches. OBJECTIVE: To systematically map and assess methodological strategies used to detect and quantify NETosis, highlighting analytical diversity, limitations, and the need for standardized, validated techniques to improve reproducibility and support clinical translation. METHODS: A Medline search (2004-June 2025) identified 162 studies reporting NETs detection techniques in vitro, ex vivo, or in vivo. Extracted data included biomarkers (cfDNA, MPO, NE, citrullinated histones, PAD4, ROS) and detection methods (fluorometry, microscopy, ELISA, qPCR, flow cytometry, western blot, proteomics). A narrative synthesis identified methodological trends, variability, and gaps. RESULTS: Marked heterogeneity was observed in biomarker choice and analytical methods. cfDNA was the most common marker (106 studies), followed by MPO (58), histones (52), and NE (43). Frequently used techniques included fluorometry (38.7%), microscopy (34.9%), and ELISA (13.2%). Notably, 85-90% of protocols relied on non-validated, home-made assays. Imaging offered structural specificity, whereas high-throughput assays such as fluorometry and ELISA suffered from limited specificity and inter-laboratory variability. Secondary biomarkers (PAD4, ROS, MMP-9) were inconsistently assessed, and no harmonized analytical framework exists. No single biomarker or assay currently enables reliable, standardized NETosis quantification. CONCLUSIONS: NETosis research remains highly fragmented. Standardized, multimodal protocols combining structural (cfDNA, H3Cit), enzymatic (MPO, NE), and regulatory (PAD4, ROS) markers, together with validated assays, are required to enhance reproducibility and support future clinical implementation.
Tarunina M, Amison R, Ponomaryov T
… +12 more, Lam L, Kelis A, Ali S, Humbert C, Erikat A, Williams T, Hernandez D, Watson T, Ramathas V, Pitchford S, Page C, Choo Y
The manufacture of platelets from induced pluripotent stem cells (iPSCs) in a cost-effective, controlled and reproducible manner is a critical challenge for transfusion and regenerative medicine applications. Here we emp...The manufacture of platelets from induced pluripotent stem cells (iPSCs) in a cost-effective, controlled and reproducible manner is a critical challenge for transfusion and regenerative medicine applications. Here we employ a high throughput, combinatorial screening method (CombiCult®) to discover new efficient protocols for generation of mature megakaryocytes (MKs) and platelets from human iPSC (hiPSC) lines. The CombiCult® platform was adapted to encapsulate hiPSCs cells in alginate by electro-spraying and cell differentiation was initiated in alginate beads, circumventing the need for stromal inducer cells, extracellular matrix materials and the process of embryoid body (EB) formation. Both feeder-dependent and feeder-free iPSC lines were multiplexed in one screen, allowing discovery of multiple serum-free feeder-free protocols that direct MK differentiation from diverse cell lines. These protocols provide high yield, high purity and low-cost methods for MK production compatible with large-scale suspension format bioreactor systems. Platelets produced by these methods (iPLT) phenotypically and functionally resemble human donor platelets following in vitro activation by platelet agonists. Furthermore, following transfusion in NOD-SCID mice, resting iPLT showed no evidence of pulmonary thrombo-embolism or heightened tissue accumulation up to 72 h post infusion and exhibited similar responses to donor platelets in a murine model of pulmonary platelet aggregation.
BACKGROUND: The mechanistic link between obesity and venous thromboembolism (VTE) remains poorly understood. The thrombin generation assay (TGA) can be used as a biomarker for hypercoagulability in obesity, which is a ke...BACKGROUND: The mechanistic link between obesity and venous thromboembolism (VTE) remains poorly understood. The thrombin generation assay (TGA) can be used as a biomarker for hypercoagulability in obesity, which is a key mechanism in VTE pathogenesis. However, data on obesity measures and TGA at population level are scarce and limited to Western countries. AIM: To investigate the association between obesity measures and TGA parameters in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: In this cross-sectional study, we performed TGA with the calibrated automated thrombogram method using plasma samples collected at baseline from a subset of the ELSA-Brasil cohort (n = 2688). WHO cut-off values were used to categorize body mass index (BMI) and waist circumference (WC). Mean differences with 95% Confidence Intervals (CIs) in TGA parameters across BMI and WC categories were estimated by linear regression adjusted for age, sex, self-reported race, physical activity, lipids (triglycerides/low-density lipoprotein), and lipid-lowering drugs. RESULTS: Endogenous thrombin potential (ETP), normalized ETP, and peak values increased dose-dependently across BMI categories at low tissue factor (TF) concentration. Mean differences between BMI ≥30 kg/m and BMI <25 kg/m (reference) were 149 nM.min (95% CI:110, 188) for ETP, 0.08 (95% CI:0.06, 0.10) for normalized ETP and 25 nM (95% CI:15, 34) for peak. No consistent associations of BMI with lagtime or time-to-peak were found. Similar results were obtained at high TF concentration and for WC. CONCLUSIONS: ETP and peak values increased dose-dependently across BMI and WC categories, supporting a critical role of hypercoagulability in the pathogenesis of VTE in obesity.
BACKGROUND: Pediatric anticoagulation trials have advanced evidence-based management of pediatric venous thromboembolism, but evidence is limited on the use of endovascular thrombus removal (ETR), particularly regarding...BACKGROUND: Pediatric anticoagulation trials have advanced evidence-based management of pediatric venous thromboembolism, but evidence is limited on the use of endovascular thrombus removal (ETR), particularly regarding clinical indications, modality selection, anticoagulant and thrombolytic dosing, safety, efficacy, and long-term outcomes. This particularly pertains to iliofemoral deep vein thrombosis (IF-DVT), commonly considered for ETR. OBJECTIVE: To characterize the current perspectives of pediatric hematologists on the use of ETR for managing pediatric IF-DVT via an electronic survey. We hypothesized substantial variability on indications, preferred modalities, and anticoagulation management. METHODS: A cross-sectional electronic survey was developed by pediatric hematologists and interventional radiologists as part of the ELITE-Kids (Endovascular Limb Intervention for Thrombosis Eradication in Kids) study and distributed via the Children's Healthcare Advancements in Thrombosis (CHAT) consortium. RESULTS: Thirty-five complete responses (58% response rate) were analyzed, with nearly all respondents considering ETR appropriate for children with severe, symptomatic IF-DVT. Pharmacomechanical and catheter-directed thrombolysis were preferred over mechanical thrombectomy (MT), although MT was associated with acceptable outcomes. Interventional radiologists were the primary proceduralists, with decisions on timing and iliac stent placement occasionally deferred to them. While there was consensus on concurrent anticoagulation during thrombolysis, the duration and intensity of outpatient antithrombotic agents varied greatly. CONCLUSION: Significant heterogeneity exists on the use of ETR and adjunct antithrombotic agents for pediatric IF-DVT among pediatric hematologists. This is likely a reflection of the paucity of pediatric-specific evidence-based guidelines, underscoring the need for pediatric cohort studies to strengthen management decisions.