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Direct oral anticoagulants (DOACs) are increasingly used for the treatment of thrombosis. While inhibitors of factor IIa and factor Xa have shown effectiveness, the risk of bleeding remains a significant concern. Recently, direct factor XIa inhibitors—including asundexian and milvexian—have emerged as potential anticoagulation therapies, based on clinical observations that patients with factor XIa deficiencies seldom present with spontaneous bleeding tendencies. The interferences associated with DOACs in routine and specialised coagulation assays are well-described; however, the interferences associated with emerging FXIa inhibitors are largely uncharacterised. Here, we briefly report the impact of asundexian and milvexian in routine coagulation assays using in vitro plasma-based systems. Asundexian and milvexian induce concentration-dependent prolongations in APTT-based assays with curvilinear regressions, which may be suitable for the measurement of pharmacodynamic effects at peak levels ex vivo. We also report differential sensitivities of APTT-based assays—particularly at higher FXIa inhibitor concentrations—highlighting the clinical need for an extensive evaluation of interferences associated with FXIa inhibitors in coagulation assays. [ABSTRACT FROM AUTHOR]

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented global healthcare crisis. While SARS-CoV-2-associated COVID-19 affects primarily the respiratory system, patients with COVID-19 frequently develop extrapulmonary manifestations. Notably, changes in the hematological system, including lymphocytopenia, neutrophilia and significant abnormalities of hemostatic markers, were observed early in the pandemic. Hematological manifestations have since been recognized as important parameters in the pathophysiology of SARS-CoV-2 and in the management of patients with COVID-19. In this narrative review, we summarize the state-of-the-art regarding the hematological and hemostatic abnormalities observed in patients with SARS-CoV-2-associated COVID-19, as well as the current understanding of the hematological system in the pathophysiology of acute and chronic SARS-CoV-2-associated COVID-19. [ABSTRACT FROM AUTHOR]

Background: External compression, thrombosis, or stenosis of the superior vena cava can lead to superior vena cava syndrome, a diagnosis that should be considered swiftly in patients presenting with classic symptoms such as facial and neck swelling, plethora, and distended neck veins. Case Presentation: We report a case of acute port-a-cath associated superior vena cava thrombosis in a longstanding, previously uncomplicated vascular access device in a patient with stable ER+/PR+/HER2+ metastatic breast cancer. After initial treatment, there was limited clinical improvement with subcutaneous low molecular weight heparin (LMWH). Following multidisciplinary team discussion, catheter-directed thrombolysis was performed, which resulted in complete symptom resolution. Conclusion: The recognition of signs and symptoms is crucial in diagnosing acute superior vena cava syndrome, particularly in patients with a malignancy history or a central venous access device in situ. The thrombotic complications of port-a-cath symptoms can occur at any time and management should be guided by multidisciplinary discussion. In appropriately selected patients, catheter-directed thrombolysis can be successful and can lead to rapid symptom resolution. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is a serious adverse event associated with tamoxifen use, with a 2 to 3-fold increase incidence in users. We aimed to reduce the incidence of venous thromboembolism in patients undergoing breast related surgery by implementing a risk stratifying algorithm for the perioperative management of tamoxifen. A retrospective control cohort was compared to a prospective interventional cohort to validate the algorithm which was created by a multidisciplinary team. The algorithm classed patients as low, moderate, high, or very high risk, based on patient factors, and then managed their tamoxifen accordingly during the perioperative period. Each case was then analysed for the presence of a symptomatic, diagnosed venous thromboembolic event up to 60 days post operatively. A total of 446 (n = 446) consecutive patients were analysed between May 2015 and July 2018 with a 3.36% (15/446) incidence of venous thromboembolism. The retrospective arm consisting of 306 cases, not subjected to the algorithm, showed a 4.58% (14/306) event rate while the prospective arm of 140 cases, managed with the algorithm, showed an event rate of 0.71% (1/ 140). Analysis with Fisher's exact test showed a significant reduction in VTE using the algorithm (p = 0.0447, CI = 0.95). T he cessation of tamoxifen was more rationalised (no algorithm-18.1 days, low risk-0.125 days, moderate risk-14.988 days, high risk-29.6 days, very high risk-32.5 days) and stopped for 11.6% fewer days when using the algorithm. The use of this algorithm significantly reduces the risk of venous thromboembolism in this population while reducing the number of omitted tamoxifen doses. • Risk stratifying algorithm aimed at reducing venous thromboembolism in peri-operative patients using tamoxifen. • Protocol driven management of perioperative tamoxifen reduces venous thromboembolism rates. • Use of algorithm reduces number of missed doses of tamoxifen. • Verified perioperative tamoxifen management algorithm. [ABSTRACT FROM AUTHOR]

The link between myeloma and thrombosis is well established. Monoclonal gammopathy of undetermined significance (MGUS) has also been associated with an increased risk of thrombosis. It was recently demonstrated that patients with myeloma display changes in thromboelastometry that may indicate a prothrombotic state. There is little data with regard to changes in thromboelastography in patients with myeloma or MGUS. The aim of this study was to investigate the differing coagulation profiles of patients of patients with myeloma and MGUS by means of conventional coagulation tests and thromboelastography. Blood was taken by direct venepuncture from patients with myeloma, MGUS and normal controls. Routine coagulation tests were performed in an accredited hospital laboratory. Thromboelastography (TEG(®)) was performed as per the manufacturer's protocol. Eight patients were recruited in each group. Patients with myeloma had a significantly lower mean haemoglobin level than patients with MGUS or normal controls (p < 0.001). Patients with myeloma had a significantly more prolonged mean prothrombin time than normal controls (p = 0.018) but not patients with MGUS. Patients with myeloma had significantly higher median D-dimer levels than normal controls (p = 0.025), as did patients with MGUS (p = 0.017). Patients with myeloma had a significantly higher mean factor VIII level than normal controls (p = 0.009) and there was a non-significant trend towards patients with MGUS having higher factor VIII levels than normal controls (p = 0.059). There was no significant difference in thromboelastographic parameters between the three groups. Patients with MGUS appear to have a distinct coagulation profile which is intermediate between patients with myeloma and normal controls.