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This review focuses on significant advances in the field of pediatric hemostasis and thrombosis, with a focus on published studies within the past decade. The evaluation and management of patients with excessive bleeding remain cornerstones of consultative hematology. We will describe the development of validated bleeding assessment tools relevant to pediatric practice, laboratory advances in the evaluation of von Willebrand disease, and a shift in clinical practice regarding the interpretation of normal coagulation studies in patients with significant bleeding phenotypes. There have also been critical advances in the management of hemostatic disorders. This review highlights new treatment paradigms in hemophilia and the rise of multidisciplinary medical homes for women living with bleeding disorders. Given the continued increase in the incidence of thrombosis, particularly in the hospital setting, a full call to arms against pediatric venous thromboembolism is now essential. We will describe recently completed clinical trials of direct oral anticoagulants in children and adolescents and ongoing work to elucidate the appropriate duration of therapy for children with provoked thrombosis. Recent work regarding the prevention of pediatric venous thromboembolism is highlighted, including studies of thromboprophylaxis and the development of risk prediction models for hospital-acquired thrombosis. Finally, we review advances in our understanding of thrombotic sequelae and the need for continued refinement of our evaluation tools. Despite the significant advances in pediatric hemostasis and thrombosis over the past decade, many unanswered questions remain for the next generation of investigators.

Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a “rebalanced” state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.

The objective of this study was to quantify intraoperative bleeding in patients with cirrhosis and correlate it with clinical characteristics and laboratory coagulation tests.A case-control study was carried out with 74 patients with cirrhosis who were submitted to preoperative coagulation tests (complete blood count, platelet count, prothrombin time/international normalized ratio, thrombin time, activated partial thrombin time, platelet aggregation, fibrinogen, protein C, protein S, antithrombin, and von Willebrand factor level and activity). The levels of nitrogen compounds that can affect the platelet function were determined in saliva and blood by using automated enzymatic-colorimetric assays.Patients with cirrhosis had changes in almost all coagulation tests. The average volumes of intraoperative bleeding and blood lost per minute in the study group (5.36 mL/min and 0.19 mL/min, respectively) were greater than those in the control group (3.05 mL/min and 0.11 mL/min, respectively; P.05). In the control group, ascites (P = .012) and presence of periapical lesion (0.034) were positively correlated with bleeding (mL/min). With regard to coagulation tests and nitrogen compounds, only a positively moderate correlation with the platelet aggregation test was observed.No patients had hemorrhagic events and it was not possible to correlate a greater amount of bleeding with coagulation tests or nitrogen compounds in the study group.

Objective Posttonsillectomy bleeding is a dreadful complication that may be life-threatening. Preoperative coagulation tests have not been shown to be effective in predicting this complication. The Pediatric Bleeding Questionnaire (PBQ) is a validated and sensitive tool in diagnosing children with abnormal hemostatic functions, and the objective of our study was to assess its utility as a preoperative screening tool for predicting posttonsillectomy bleeding. Study design Prospective single-blinded cohort study. Setting Tertiary care hospital system. Methods All children scheduled for tonsil surgery between 2017 and 2019 in the Galilee Medical Center were included. The PBQ was completed by the caregivers prior to surgery, and all children underwent coagulation tests. Each PBQ item is scored on a scale of -1 to 4, and the total score per candidate is based on summation of all items. Results An overall 272 patients were included in the study with a mean age of 5.2 years; 57.7% were boys. The main finding was that in a multivariable model adjusted to age, a PBQ score of 2 is correlated with increased postoperative bleeding risk (odds ratio, 10.018 [95% CI, 1.20-82.74]; P = .046). The results of the PBQ demonstrated better predictive ability when compared with abnormal coagulation test results (odds ratio, 1.76 [95% CI, 0.63-4.80]; P = .279). Sex was not found to be significant (odds ratio, 1.45 [95% CI, 0.70-3.18]; P = .343). Conclusions This study demonstrated that a PBQ score ≥2 has a higher yield for detecting children at risk for posttonsil surgery bleeding as compared with coagulation studies.

Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) is considered to have multiple roles in the development of atherosclerosis, which is recently reported to participate in the thrombotic process. We aimed to examine the relationship between PCSK9 concentration, coagulation indexes and cardiovascular events. Methods A total of 2293 consecutive patients with angina-like chest pain and without lipid-lowering drugs treatment were enrolled and followed up for major adverse cardiovascular events (MACEs). Circulating PCSK9 concentration was determined by ELISA. The routine coagulation tests including activated partial thromboplastin time (APTT), prothrombin time (PT) and thrombin time were performed. The associations between PCSK9 concentration, routine coagulation indicators and MACEs were analyzed. Results Patients with high PCSK9 levels had lower PT and APTT levels (all p p Conclusions Our study firstly suggested that PCSK9 concentration was negatively correlated with plasma levels of PT. Furthermore, high PCSK9 and low PT were associated with MACEs and the combination of PCSK9 with PT had an addictive effect on predicting cardiovascular outcomes in patients with chest pain, which was useful for further subdivision of cardiovascular risks.

Background We aim to determine the clinical utility of reflex coagulation investigations (RCI) for prolonged lupus insensitive activated partial thromboplastin time (aPTT) at our institution. Methods We retrospectively reviewed all potential RCI (lupus insensitive aPTT of ≥32s) from April 2014 to June 2019. Our diagnostic algorithm requires completion of RCI only if samples had no interfering medications to explain a prolonged aPTT and were either from a preoperative sample or from a patient presenting with unexplained bleeding. Appropriate RCI samples undergo further investigations with one-stage factor activity testing for factors 8(FVIII), 9(FIX), and 11(FXI) reflexively. Data were obtained through electronic medical records to capture clinical characteristics, laboratory findings, prophylactic hemostatic replacement, and bleeding outcomes. Results Three thousand and three hundreds seventeen samples from 2940 distinct patients were considered as potential RCI during the study period. 263/3317 (8%) samples had RCI completed. Of those, 55/263 (21%) had abnormal factor testing, with the majority from preoperative setting (43/55; 78%). 5/43 (12%) patients were referred to hematology for preoperative evaluation. 5/43 patients received preoperative hemostatic support. A total of 5 patients (5/43) developed postop bleeding. Six patients (6/55) had RCI for unexplained bleeding, and five patients (83%) had a newly identified clinically significant bleeding disorder. Conclusion Reflex coagulation investigations benefited patients presenting with unexplained bleeding as this expedited the diagnosis and management of clinically significant bleeding disorders. RCI for preoperative evaluation infrequently led to additional hemostatic support/referral to hematology. The lack of additional workup for an abnormal factor activity level suggests laboratory alert fatigue as a potential contributory factor.

Intraperitoneal administration of BromAc (bromelain + acetylcysteine) is currently undergoing a phase 1 clinical trial for pseudomyxoma peritonei at our institution. This study reports on analysis of routine blood parameters before and after treatment for a series of 25 patients in this trial. Blood parameters assessed included full blood count, electrolytes, urea, and creatinine, liver function tests, coagulation studies, as well as inflammatory markers (CRP). Certain parameters such as CRP, and white cell count, were significantly elevated after treatment whilst serum albumin level was reduced indicating an inflammatory reaction. However, liver enzymes, coagulation studies, and other parameters were not affected. Therefore, there are no additional safety signals evident upon analysis of routine blood parameter testing.

Background Patients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients. Case presentation A 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful. Conclusion Cardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.

Objectives: To determine the influence of prolonged exposure to radiation based on dosimeter readings on hematological parameters among radiologic technologists (RTs) in Saudi Arabia. Methods: The study was specifically conducted on selected RTs with experience of more than 10 years and the highest thermoluminescent dosimeter (TLD) readings among all RTs in the Radiological Department, Sabya General Hospital, Ministry of Health, Saudi Arabia from August to October 2020. The RTs group was compared with a control group of non-irradiated participants. Blood samples were collected for hematological and coagulation profile evaluation. Results: The acquired radiation dose analysis revealed that the average accumulated dose in 10 years is 7.6 mSv. The medians of prothrombin time (PT) and activated partial thromboplastin time (APTT) of the RTs group were significantly lower when compared to the control group. In addition, RTs group exhibited a significant reduction in neutrophil count and an elevation in lymphocyte count. Conclusion: Chronic exposure to radiation revealed a significant change in blood tests and may reflect an effect on RTs tissues, leading to serious health problems. However, further investigation in a large cohort to study the association between alteration in hematological parameters and chronic radiation exposure is required.

Beta thalassemia major is associated with a subclinical hypercoagulable state. Endothelial activation markers like soluble Intercellular adhesion molecule (sICAM-1) and E-selectin have been implicated in the pathogenesis of endothelial dysfunction and hemostatic alterations. In this study we aimed to study serum levels of sICAM-1 and E-selectin in polytransfused children with β thalassemia major and their association with serum ferritin and D-dimer levels. Sixty-two polytransfused β-thalassemia major children aged between 5 and 17 years and 26 age and gender matched healthy controls were enrolled in the study. Complete blood count with peripheral smear, liver function tests, serum ferritin, coagulation tests [PT, APTT, D-dimer] and endothelial activation marker tests [ICAM-1 and E-selectin] were performed. PT, APTT and D-dimer levels were significantly higher in beta-thalassemia major patients than in control group (p = 0.003, p

Early descriptions of COVID-19 associated coagulopathy identified it as a disseminated intravascular coagulation (DIC). However, recent studies have highlighted the potential role of endothelial cell injury in its pathogenesis, and other possible underlying mechanisms are being explored. This study aimed to analyse the coagulation parameters of critically and noncritically ill patients with COVID-19 bilateral pneumonia, determine if coagulation factors consumption occurs and explore other potential mechanisms of COVID-19 coagulopathy. Critically and noncritically ill patients with a diagnosis of COVID-19 bilateral pneumonia were recruited. For each patient, we performed basic coagulation tests, quantification of coagulation factors and physiological inhibitor proteins, an evaluation of the fibrinolytic system and determination of von Willebrand Factor (vWF) and ADAMTS13. Laboratory data were compared with clinical data and outcomes. The study involved 62 patients (31 ICU, 31 non-ICU). The coagulation parameters assessment demonstrated normal median prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (APTT) in our cohort and all coagulation factors were within normal range. PAI-1 median levels were elevated (median 52.6 ng/ml; IQR 37.2-85.7), as well as vWF activity (median 216%; IQR 196-439) and antigen (median 174%; IQR 153.5-174.1). A mild reduction of ADAMTS13 was observed in critically ill patients and nonsurvivors. We demonstrated an inverse correlation between ADAMTS13 levels and inflammatory markers, D-dimer and SOFA score in our cohort. Elevated vWF and PAI-1 levels, and a mild reduction of ADAMTS13 in the most severe patients, suggest that COVID-19 coagulopathy is an endotheliopathy that has shared features with thrombotic microangiopathy.

Algorithms for treatment of diffuse bleeding in cardiac surgery are based on intervention thresholds of coagulation tests, such as rotational thromboelastometry (ROTEM) or conventional laboratory tests. The relationship between these two approaches is unclear in patients with increased risk of coagulation abnormalities. We retrospectively analyzed the data of 248 patients undergoing major cardiac and/or aortic surgery. ROTEM and conventional laboratory tests were performed simultaneously after termination of cardiopulmonary bypass and protamine administration to investigate the extrinsic and intrinsic system, and to determine deficiencies in platelets and fibrinogen. We evaluated the association between ROTEM and conventional tests by linear regression analysis and compared the frequency of exceeding established thresholds for clinical intervention. Significant linear associations between ROTEM 10 min after the start of coagulation, and plasma fibrinogen concentration or platelet count (FIBTEM A10, R2 = 0.67, p 2 = 0.47, p 3–122 × 103/µL platelets at the intervention threshold of EXTEM A10 = 40 mm). The association between EXTEM and INR (R2 = 0.23), and INTEM and aPTT (R2 = 0.095) was poor. The frequency of exceeding intervention thresholds and, consequently, of triggering treatment, varied markedly between ROTEM and conventional tests (p

Background Gallbladder mucocele (GBM) is a common biliary disorder in dogs. Limited information is available on the coagulation status of dogs with GBM. Hypothesis/objectives To determine patterns of coagulation alterations in dogs with GBM and correlate them with clinicopathologic abnormalities and ultrasonographic findings of disease severity. Animals Twenty-three dogs with GBM identified on ultrasound examination were prospectively enrolled. Methods At the time of GBM identification, blood and urine were collected for CBC, serum biochemical panel, urinalysis, prothrombin time, activated partial thromboplastin time (aPTT), factor VIII, protein C (PC), von Willebrand's factor (vWF), antithrombin activity, fibrinogen, D-dimers, and thromboelastrography (TEG). Gallbladder mucoceles were classified into ultrasound types 1 to 5. Medical records were reviewed for clinical presentation, underlying conditions and to determine if systemic inflammatory response syndrome (SIRS) was present. Results Based on TEG parameters, maximal amplitude, and G, 19/23 (83%) of dogs with GBM had evaluations consistent with hypercoagulability. On plasma-based coagulation testing, dogs with GBM had increased total PC activity (20/23, 87%), fibrinogen (9/23, 39%), platelet count (9/23, 39%), and D-dimers (6/15, 40%) as well as prolongations in aPTT (9/22, 41%) and low vWF activity (5/21, 24%). No correlation was found between TEG G value and any coagulation or clinical pathology variables, ultrasound stage of GBM or disease severity as assessed by the presence of SIRS. Conclusions and clinical importance Dogs with ultrasonographically identified GBM have changes in whole blood kaolin-activated TEG supporting a hypercoagulable state although traditional plasma-based coagulation testing suggests that a complex state of hemostasis exists.

Background Coagulopathy is the major cause of mortality and morbidity throughout the world. Globally, about 26–45% of healthy people have a history of bleeding symptoms, which may be a result of thrombocytopenia, factor deficiency, or pathological inhibitory. Objective To assess coagulopathy and its associated factors among patients with bleeding diathesis at the University of Gondar Specialized Referral Hospital from January to May 2020. Method A cross-sectional study was conducted on 384 study participants with bleeding diathesis recruited by using a convenient sampling technique. Socio-demographic and clinical characteristics were collected by using questioners. Then 6 ml venous blood was collected with a needle and syringe method. About 3 ml blood was transferred to EDTA test tube for platelet count and 2.7 ml blood was transferred to a test tube containing 0.3 ml of 3.2% sodium citrated anticoagulant for coagulation test. For those study participants with prolonged coagulation tests, a mixing test was done. Blood film and stool examination were also done for malaria and intestinal parasite identification, respectively. The data were entered into EPI-Info version 3.5.3 and then transferred to SPSS version-20 for analysis. Descriptive statistics were summarized as percentages, means, and standard deviations. Bivariate and multivariate logistic regression was used to identify the associated factors, and a P-value less than 0.05 was considered statistically significant. Results In this study, the prevalence of coagulopathy was 253/384 (65.9%; 95% CI: 61.16, 70.64). From them, 21.3% (54/253), 51.4% (130/253), and 27.3% (69/253) had only thrombocytopenia, only prolonged coagulation test, and mixed abnormality, respectively. Among participants with prolonged coagulation time, the prevalence of factor deficiency was 21.1% (42/199). Cardiac disease (AOR = 4.80; 95% CI: 2.65, 23.1), and other chronic diseases (AOR = 8.1; 95% CI: 1.84, 35.58) were significantly associated with coagulopathy. Conclusion In this study, coagulopathy due to inhibitory was a public health problem. The participants with cardiac and other chronic diseases were at high risk for coagulopathy. Therefore, mixing tests could be done for all prolonged coagulation tests and it could be considered as a routine laboratory test.

Hemostasis is a complex physiological process based on the balance between pro-coagulant and anticoagulant systems to avoid pathological bleeding or thrombosis. The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder, and cirrhotic patients were considered naturally anticoagulated. In the light of the new evidence, the theory of rebalanced hemostasis replaced the old concept. According to this model, the hemostatic alteration leads to a unique balance between pro-coagulant, anticoagulant, and fibrinolytic systems. But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors. The standard coagulation tests [INR (international normalized ratio), platelet count and fibrinogen] only explore parts of the hemostasis, not offering an entire image of the process. Rotational thromboelastometry (ROTEM) and thromboelastography (TEG) are both point of care viscoelastic tests (VET) that provide real-time and dynamic information about the entire hemostasis process, including clot initiation (thrombin generation), clot kinetics, clot strength, and clot stability (lysis). Despite prolonged PT/INR (international normalized ratio of prothrombin time) and low platelet counts, VET is within the normal range in many patients with both acute and chronic liver disease. However, bleeding remains the dominant clinical issue in patients with liver diseases, especially when invasive interventions are required. VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests, leading to decrial use of blood products transfusion. Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET. Although VET has shown its benefit, more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.

OBJECTIVES Fibrinolytic shutdown is associated with poor prognosis in adult sepsis, but data in the pediatric population are sparse. This study aimed to identify the association between impaired fibrinolysis and mortality in pediatric septic shock. DESIGN A prospective, observational study conducted between August 2019 and August 2020. SETTING PICU at a pediatric tertiary hospital in Hanoi, Vietnam. PATIENTS Fifty-six pediatric patients who met septic shock criteria were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Conventional coagulation tests and rotational thromboelastometry were performed at diagnosis. The fibrinolytic activity on extrinsic pathway thromboelastometry was negatively correlated with the Vasoactive-Inotropic Score at 24 hours post-PICU admission, peak lactate level during the first 24 hours, Pediatric Logistic Organ Dysfunction-2 score, and Pediatric Risk of Mortality-III score (all p < 0.05). Compared with patients with nonovert disseminated intravascular coagulation, dysfunction of less than two organs, and who survived, patients with overt disseminated intravascular coagulation, dysfunction of greater than two organs, and who died showed significantly lower fibrinolytic activity, represented by significantly higher lysis indexes (%) and lower maximum lysis (%) (all p < 0.05). The threshold values for prediction of mortality were lysis index 60 minutes greater than 97.5 (area under the curve = 0.86; sensitivity = 73%; specificity = 90%), maximum lysis less than 6.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 87%), and lysis index 45 minutes greater than 99.5 (area under the curve = 0.83; sensitivity = 73%; specificity = 85%). Hypofibrinolysis was associated with prolonged PICU length of stay in survivors and with early mortality in nonsurvivors. CONCLUSIONS Fibrinolytic shutdown in pediatric septic shock is associated with an increase in disease severity and mortality. This highlights the need for further investigations regarding whether fibrinolytic therapy improved the outcome of pediatric septic shock.

The pathogenesis of hypercoagulability in HIV infection is multifactorial and usually more than one factor is responsible for a thromboembolic episode. The present study was conducted to evaluate the effect of HIV infection and antiretroviral therapy on various coagulation parameters in paediatric patients. Forty two newly diagnosed paediatric patients with HIV infection who were enrolled at the Anti-Retro viral Therapy (ART) centre of Kalawati Saran Children’s Hospital were included in the study. The patients were grouped into 4 clinical stages according to the WHO clinical staging of HIV disease. Coagulation tests [PT, aPTT, fibrinogen, D-Dimer and coagulation inhibitors i.e. Protein C (PC), Protein S (PS) and antithrombin III (AT III), Lupus anticoagulant (LA) and Anti phospholipid antibody (APLA)] were performed in all the patients at the time of diagnosis and repeated after 6 months. All the patients were started on antiretroviral therapy within 2 months of their diagnosis. At the time of diagnosis, prolonged PT and aPTT were observed in 30.9% and 23% of the cases respectively. Hyperfibinogenemia was seen in 11.9% of patients. D-Dimer was raised in 83.3% of patients. PS, PC & AT activities were reduced in 90.4%, 42.8% & 11.9% of cases respectively. A reduction in the PC and AT activity was seen from clinical stage 1 to 4, but the change was not statistically significant. On follow up after 6 months, a statistically significant reduction in the level of fibrinogen and D-Dimer was seen. Even though there was improvement in the activity of all the coagulation inhibitor after 6 months, statistically significant improvement was seen only for PS. The current study shows that HIV produces a hypercoagulable state in children. Raised d-dimer level and deficiency of natural anticoagulants contribute to the thrombophilic state.

Objectives Use of viscoelastic testing, such as thromboelastography (TEG), is recommended in cardiac surgery to monitor coagulation and to guide the transfusion of blood products. The Quantra QPlus System is a novel point-of-care platform that uses ultrasonic pulses to characterize dynamic changes in viscoelastic properties of a blood sample during coagulation. Despite the ability to assess similar aspects of clot formation, limited studies addressing the interchangeability of viscoelastic testing parameters exist. The primary aim of the present study was to assess the correlation and agreement between Quantra and TEG5000 results using blood samples from cardiac surgery patients. Design Tertiary care, academic medical center. Setting Prospective observational study. Participants Twenty-eight patients undergoing elective cardiac surgery undergoing cardiopulmonary bypass were evaluated. Measurements and Main Results Perioperative blood samples were collected and assessed using Quantra, and results were compared with TEG and conventional coagulation testing. Method comparison analysis demonstrated that Quantra parameters (Quantra clot time, clot stiffness, and fibrinogen contribution to clot stiffness) significantly correlated with TEG R and TEG G after induction of anesthesia, during cardiopulmonary bypass, and after rewarming (rs = 0.83, rs = 0.84, and rs = 0.73, respectively). However, Quantra parameters demonstrated poor agreement compared with equivalent TEG5000 parameters. Conclusions The Quantra QPlus System significantly correlated with TEG5000, suggesting that this test may be used in a similar clinical context. Despite the strength of correlation between Quantra and TEG parameters, measurements are not interchangeable.

Graphical abstract Many patients develop coagulation abnormalities due to chronic and hereditary disorders, infectious disease, blood loss, extracorporeal circulation, and oral anticoagulant misuse. These abnormalities lead to bleeding or thrombotic complications, the risk of which is assessed by coagulation analysis. Current coagulation tests pose safety concerns for neonates and small children due to large sample volume requirement and may be unreliable for patients with coagulopathy. This study introduces a containerless drop-of-blood method for coagulation analysis, termed “integrated quasi-static acoustic tweezing thromboelastometry” (i-QATT™), that addresses these needs. In i-QATT™, a single drop of blood is forced to levitate and deform by the acoustic radiation force. Coagulation-induced changes in drop turbidity and firmness are measured simultaneously at different instants. The parameters describing early, intermediate, and late stages of the coagulation process are evaluated from the resulting graphical outputs. i-QATT™ rapidly ( 0.9) was established between fibrinogen concentration and two i-QATT™ parameters: maximum clot firmness and maximum fibrin level. Factor XIII activity was uniquely measured by the fibrin network formation time (r2 = 0.9). Reaction time, fibrin formation rate, and time to firm clot formation were linearly correlated with heparin concentration (r2 > 0.7). tPA-induced hyperfibrinolysis was detected in the clot firmness output at 10 min. i-QATT™ provides comprehensive coagulation analysis in point-of-care or laboratory settings, well suited to the needs of neonatal and pediatric patients and adult patients with anemia or blood collection issues. Supplementary Information The online version contains supplementary material available at 10.1007/s00216-021-03278-8.

Background Accumulating evidence indicates toward an association between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and procoagulatory state in blood. Thromboelastographic investigations are useful point-of-care devices to assess coagulation and fibrinolysis.Objectives We investigated the hypothesis that the procoagulatory state in COVID-19 patients is associated with impaired fibrinolysis system.Methods Altogether, 29 COVID-19 patients admitted to normal wards or to the intensive care unit (ICU) were included in this descriptive study. Whole blood samples were investigated by thromboelastography to assess coagulation and fibrinolysis. Additionally, standard routine coagulation testing and immunoassays for factors of fibrinolysis as plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA), plasminogen activity and α2-antiplasmin (A2AP) were performed.Results A significantly increased lysis resistance and a significantly longer time of lysis after adding tissue plasminogen activator were observed in blood samples from ICU COVID-19 patients compared with healthy controls (maximal lysis: 3.25 ± 0.56 vs. 6.20 ± 0.89%, p = 0.0127; lysis time: 365.7 ± 44.6 vs. 193.2 ± 16.3 seconds, p = 0.0014). PAI-1 activity was significantly higher in plasma samples of ICU COVID-19 patients (PAI-1: 4.92 ± 0.91 vs. 1.28 ± 0.33 U/mL, p = 0.001). A positive correlation between the activity of PAI-1 and lysis time of the formed clot (r = 0.70, p = 0.0006) was observed.Conclusion Our data suggest that severe SARS-CoV-2 infection is associated with impaired fibrinolytic activity in blood, where fibrinolytic inhibitors are elevated leading to an increased resistance to clot lysis. Thromboelastography could offer a tool to investigate the contribution of the fibrinolytic status to the procoagulatory condition in COVID-19.

During COVID-19 pandemic, a wide variety of stroke typologies have been described in patients affected by SARS-CoV-2. Investigating the case reports of acute stroke in COVID-19 patients, published since the beginning of the pandemic, we tried to trace the pathogenic mechanisms of stroke during SARS-CoV-2 infection. We conducted a systematic review analyzing demographic data, cerebrovascular risk factors, NIHSS score, vascular territory involvement and laboratory findings of 168 patients described in 89 studies, from a pool of 1243 records. Based on our results, we have identified different stroke profiles: (1) cerebral large vessel disease (CLVD) profile with a low disability, simultaneous onset of COVID-19 and stroke symptoms, good outcome and low serum levels of D-dimer and CRP; (2) intracranial bleeding (IB) profile with high disability, poor outcome and low levels of serum markers of inflammation and coagulopathy; (3) CLVD profile with a short time-lapse between COVID-19 symptoms and stroke onset, high neurological disability and very high systemic inflammatory markers; (4) multiple thrombo-embolic disease (MTED) profile with older patients, many comorbidities, disabling stroke, poor outcome, evident alteration of coagulation tests and high serum levels of both D-dimer and CRP. We therefore summarized these different profiles in a spectrum similar to that of visible light, where the violet–blue band included IB and CSVD with low inflammation and prothrombotic activity, the green–yellow band included CLVD with high inflammation and moderate prothrombotic activity and the orange–red band for MTED with moderate-high levels of inflammation and very high prothrombotic activity.

Objective:The objectives of the present study were to determine whether there was any association between the grade of heart failure, as expressed by preoperative levels of brain natriuretic peptide and Ross score, and the preoperative coagulation status in patients with non-restrictive ventricular shunts and determine whether there were any postoperative disturbances of the coagulation system in these patients, as measured by thromboelastometry and standard laboratory analyses of coagulation.Design:Perioperative coagulation was analysed with laboratory-based coagulation tests and thromboelastometry before, 8 hours after, and 18 hours after cardiac surgery. In addition, brain natriuretic peptide was analysed before and 18 hours after surgery.Patients:40 children less than 12 months old with non-restrictive congenital ventricular or atrio-ventricular shunts scheduled for elective repair of their heart defects.Results:All coagulation parameters measured were within normal ranges preoperatively. There was a significant correlation between brain natriuretic peptide and plasma fibrinogen concentration preoperatively. There was no statistically significant correlation between brain natriuretic peptide and INTEM-MCF, FIBTEM-MCF, plasma fibrinogen, activated partial thromboplastin time, prothrombin time, or platelet count at any other time point, either preoperatively or postoperatively. Postoperatively, fibrinogen plasma concentration and FIBTEM-MCF decreased significantly at 8 hours, followed by a large increase at 18 hours to higher levels than preoperatively.Conclusions:There was no evidence of children with non-restrictive shunts having coagulation abnormalities before cardiac surgery. Brain natriuretic peptide levels or Ross score did not correlate with coagulation parameters in any clinically significant way.

Objective To reduce diagnostic blood loss by using small volume tubes for routine laboratory testing throughout the hospital, as blood loss from laboratory testing can be substantial for patients and may lead to hospital-acquired anemia. Patients and Methods Diagnostic blood loss was evaluated in hospitalized patients between April 1, 2017, and June 1, 2018. The preintervention, during intervention, and postintervention mean diagnostic blood loss per hospitalized patient was compared across the floors and for each type of tube for hematology, basic metabolic panel, and coagulation tests. Mean hemoglobin levels, blood transfusions per hospitalized patient, and percent redraws were also compared. Results The total volume of blood drawn for all the 3 tests decreased across each implementation phase; however, only patients admitted to the transplant and critical care (T/CC) units had increased hemoglobin levels. In addition, there was a significant reduction in transfusions across implementation phases. The incidence risk ratio for transfusion reduced even more in patients admitted to the T/CC units. Finally, there was no significant difference in the overall percent redraws across all the units. Conclusion The use of small volume tubes in exchange for standard sized tubes markedly decreased diagnostic blood loss by 25.7% in all the units and 22.9% in the T/CC units. Also, the number of transfusions decreased across units, with the greatest decrease in the T/CC units. An increase in mean hemoglobin levels was observed specifically in patients admitted to the T/CC units, with no corresponding change in percent redraws across all the units.

In patients with decompensated cirrhosis, procedure‐related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure‐related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure‐related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure‐related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k‐time (4.5 minutes vs. 2.2 minutes; P = 0.02), α‐angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life‐threatening bleeding (all with MA 30 mm), whereas a platelet count

Introduction Recent in vitro data have shown that the hemostatic profile of whole blood (WB) degrades significantly after 14 days, yet the optimal storage remains debated. We hypothesized that arrival coagulation studies would be improved in patients receiving younger WB in the prehospital setting. Methods This study was approved by our institutional institutional review board. We evaluated all trauma patients who received prehospital blood products by our helicopter service between July 2017 and July 2019. "Young" WB was defined as 14 days or less. Patients who received at least 1 U of young WB were classified as YOUNG, while the remainder was classified as OLD. Continuous data are presented as medians (25th-75th interquartile range) with comparisons performed using Wilcoxon rank sum. Assessments of clinical hemostatic potential included arrival platelet cell count and rapid thrombelastography. Multivariate regression analysis was also performed (Stata 12.1; College Station, TX). Results A total of 220 patients received prehospital WB during the study period. Of these, 153 patients received YOUNG WB, while 67 were transfused only OLD WB units. There were no differences in demographics, prehospital or arrival physiology, or Injury Severity Score among the two groups. The measures of clot initiation (activated clotting time) and kinetics (k time) were improved, as were the measures of clot acceleration/fibrinogen function (angle) and platelet function (maximum amplitude). As well, arrival platelet count was higher in the YOUNG cohort. No significant differences in postarrival transfusion were noted (p = 0.220). Multivariate analysis showed the greatest differences in maximum amplitude and α angle but failed to reach significance. Conclusion Previous in vitro data have suggested deterioration of platelet function in cold-stored WB after 14 days. The current study demonstrated decreased global hemostasis by clinically available laboratory tests, especially related to fibrinogen and platelet interactions on univariate, but not multivariate analysis. This did not translate into increased transfusion requirements. Further studies are needed to determine the optimal storage duration for cold-stored WB for transfusion in the bleeding trauma patient, as well as rule out the presence of confounding variables. Level of evidence Therapeutic, level IV.

COVID-19 associated coagulopathy is a dysfunction of severe SARS-CoV-2 infection, characterized by significantly increased fibrinogen, D-dimer and C reactive protein and normal to near-normal prothrombin time, activated partial thromboplastin time and platelet count. Hypercoagulopathy and hypofibrinolysis coexist and are detected by viscoelastic tests. These features, when associated with immobilization and intrinsic risk factors (age, obesity, comorbidities, drugs) of the patient, can trigger thromboembolic events, despite thromboprophylaxis. The lungs are the first and most severely damaged organ. To date, most patients have exhibited hypercoagulability on viscoelastic tests not detected by standard coagulation tests. A high rate of thrombotic events was reported, suggesting that it should be considered as a cause of clinical deterioration in intensive care and potentially other clinical settings. In advanced stage, COVID-19 associated coagulopathy, fibrinogen and platelet count can decrease significantly, depending on the severity of clinical status resembling consumptive coagulopathy. In this stage, bleeding events can occur, especially if the patient is under extracorporeal membrane oxygenation (ECMO). Viscoelastic tests are very useful tools to assess hypercoagulability and hypofibrinolysis (not detectable by standard coagulation tests) in critically ill SARS-CoV-2 patients with COVID-19 associated coagulopathy and look like very promising tools for anticoagulation management. However, further research needs to be carried out to determine whether abnormal viscoelastic tests alone or in combination with other clinical or laboratory findings can identify patients at increased thrombotic risk. Clinical trials to evaluate hypercoagulability using viscoelastic tests and the need for personalized dosage of anticoagulation in SARS-CoV-2 patientsare quickly emerging.A coagulopatia associada à COVID-19 é uma disfunção associada à infeção SARS-CoV-2 grave, caraterizada por aumento significativo do fibrinogénio, D-dímeros e Proteína C reativa, e por valores normais/muito pouco alterados do tempo de protrombina, tempo de tromboplastina parcial ativado, e número de plaquetas. A hipercoagulabilidade e a hipofibrinólise coexistem e são detetadas por testes viscoelásticos. Quando associadas à imobilização e aos fatores de risco intrínsecos do doente (idade, obesidade, comorbilidades, drogas) potenciam eventos tromboembólicos, apesar da tromboprofilaxia. Os pulmões são o órgão inicialmente e mais gravemente afetado. Até à data, a maioria dos doentes apresentou hipercoagulabilidade nos testes viscoelásticos, não detetada pelos testes de coagulação de rotina, e foi reportada uma elevada taxa de eventos trombóticos, sugerindo que esta deveria ser considerada uma das causas de deterioração clínica, não só em cuidados intensivos. Na coagulopatia associada à COVID-19 avançada, o número de plaquetas e o fibrinogénio podem diminuir significativamente, dependendo da gravidade clínica da infeção, assemelhando-se o quadro a uma coagulopatia de consumo. Nesta fase pode haver hemorragia, especialmente se o doente estiver sob extracorporeal membrane oxygenation. Os testes viscoelásticos afiguram-se muito úteis para avaliar a hipercoagulabilidade e a hipofibrinólise em doentes críticos SARS-CoV-2 com coagulopatia associada à COVID-19, parecendo também promissores para a gestão da anticoagulação. No entanto, é necessária mais investigação para determinar se testes viscoelásticos alterados, individualmente ou quando combinadoscom outros resultados clínicos/laboratoriais, podem identificar os doentes com risco trombótico acrescido. Estão a emergir rapidamente ensaios clínicos para avaliação da hipercoagulabilidade por testes viscoelásticos e da necessidade de personalização da anticoagulação em doentes SARS-CoV-2.

Objective: This study aimed to identify the predictive value of simple markers in routine blood and coagulation tests for the severity of coronavirus disease 2019 (COVID-19). Methods: A total of 311 consecutive COVID-19 patients, including 281 patients with mild/moderate COVID-19 and 30 patients with severe/life-threatening COVID-19, were retrospectively enrolled. Logistic modeling and ROC curve analyses were used to assess the indexes for identifying disease severity. Results: Lymphocyte and eosinophil counts of COVID-19 patients in the severe/life-threatening group were significantly lower than those of patients in the mild/moderate group (P < 0.001). Coagulation parameters, high-sensitivity C-reactive protein (hsCRP) levels and procalcitonin levels were higher in the severe/life-threatening group compared with the mild/moderate group (all P < 0.05). Univariate and multivariate logistic models revealed that hsCRP and fibrinogen degradation products (FDPs) were predictors of severe COVID-19 (OR = 1.072, P = 0.036; and OR = 1.831, P = 0.036, respectively). The AUROCs of hsCRP and FDP for predicting severe/life-threatening COVID-19 were 0.850 and 0.766, respectively. The optimal cutoffs of hsCRP and FDP for the severe/life-threatening type of COVID-19 were 22.41 mg/L and 0.95 µg/ml, respectively. Conclusion: Serum CRP and FDP levels are positively related to the severity of COVID-19. This finding indicates that CRP and FDP levels may potentially be used as early predictors for severe illness and help physicians triage numerous patients in a short time.

Introduction: For over 30 years, ascites has been postulated to facilitate fibrinolysis in patients with liver cirrhosis. In contrast to previous research employing conventional coagulation tests, this study aimed to characterize hemostatic interactions between blood and ascites using the rotational thromboelastometry (ROTEM). Methods: Blood samples – pure or mixed with ascites in a ratio of 1:1 – from cirrhotic patients (n = 10) were subjected to ROTEM analysis. In addition, a negative control group was built with cirrhotic patients (n = 10) whose blood was mixed with physiologic sodium chloride (0.9% NaCl) solution in a ratio of 1:1. Subsequently, ROTEM measurements were subjected to statistical analysis. Results: During ascites challenge, clotting time (CT, measured in seconds) was significantly prolonged in EXTEM (blood: 70.40 ± 20.40 vs. ascites/blood: 109.8 ± 47.7) and APTEM (blood: 66.50 ± 14.55 vs. ascites/blood: 138.7 ± 105.8), likely reflecting a dilution effect. However, CT in INTEM remained unchanged, suggesting a sustained intrinsic pathway function. Maximal clot firmness (measured in millimeters) in FIBTEM decreased significantly (blood: 14.70 ± 9.55 vs. ascites/blood: 6.00 ± 5.66), thus indicating depletion of fibrinogen in ascites. Strikingly, maximum lysis (measured in %) significantly decreased in EXTEM (blood: 9.30 ± 2.79 vs. ascites/blood: 5.50 ± 2.84), APTEM (blood: 8.50 ± 3.10 vs. ascites/blood: 5.60 ± 2.88), and INTEM (blood: 7.50 ± 2.27 vs. ascites/blood: 5.10 ± 3.48). Conclusions: ROTEM provided new evidence that ascites may not primarily induce fibrinolysis in cirrhotic patients. This finding seems to be of significant importance for the clinical management of cirrhotic patients experiencing complications, for example, abdominal hemorrhage after liver biopsy or paracentesis; here, replacement of prothrombin complex concentrates and/or fibrinogen concentrates may prove more beneficial than the use of fresh frozen plasma or antifibrinolytic drugs.

Background and Aims: Coagulation dynamics after donor hepatectomy are complex. Having complete knowledge of the actual changes in the coagulation status during donor hepatectomy is important to prevent complications such as pulmonary embolism, deep vein thrombosis, and bleeding. Hence, the present study aimed to study the coagulation dynamics following open donor hepatectomy both by thromboelastography (TEG) and conventional coagulation tests (CCT). Methods: A total of 50 prospective liver donors were included. TEG and CCT [activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalised ratio (INR), fibrinogen, and platelet counts] were performed for each patient before surgery (baseline), on postoperative day (POD) 0, 1, 2, 3, 5, and 10. Results: TEG showed hypercoagulability in 28%, 38%, 30%, 46%, 42%, and 48% patients; in contrast INR showed hypocoagulability in 58%, 63%, 73%, 74%, 20%, and 0% patients on POD 0,1,2,3,5, and 10, respectively. Patients demonstrating hypercoagulability on TEG had significantly decreased reaction time (P = 0.004), significantly increased maximum amplitude (P < 0.001), and alpha angle value (P < 0.001). Postoperatively, INR, PT, and aPTT values increased significantly, while platelets and fibrinogen levels decreased significantly when compared to their baseline values. There was no coagulation-related postoperative complication in any of the patients. Conclusion: Hypercoagulability after donor hepatectomy is common. TEG showed hypercoagulability and did not show any hypocoagulability as suggested by the CCT. In patients undergoing donor hepatectomy, CCT may not reflect the actual changes incoagulation status and tests such as TEG should be performed to know the correct nature of changes in coagulation following donor hepatectomy.

CONTEXT: Globally, trauma is the leading cause of death in young adult population, with approximately accounting for 10% of all deaths. Trauma-induced coagulopathy (TIC) is an independent predictor of morbidity and mortality. AIMS: The aim of the study was to find the prevalence of abnormal test results of coagulation on admission to a trauma center and correlate them with mortality. SETTINGS AND DESIGN: This was a cross-sectional observational study conducted on patients admitted to a trauma center of a tertiary care hospital. SUBJECTS AND METHODS: A total of 149 patients with an Injury Severity Score >15 were included in the study. Blood samples of the patients were collected within 24 h of trauma and 2 h of admission and tested for platelet (PLT) count, prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen (FIB) level. The patients were stratified into two groups – presence/absence of TIC and followed for 2 weeks for mortality. STATISTICAL ANALYSIS USED: Data analysis was done using Microsoft Excel and statistics software SPSS 20 version. RESULTS: Among the 149 patients, 84 had TIC, out of which 71.43% of the patients showed mortality. Of the remaining patients who had no TIC, 35.38% reported mortality. If all the four parameters, that is, PT, APTT, FIB, and PLTs, were considered together, then the percentage of mortality increased to 89.47%. If PT and APTT were studied together, then the percentage of mortality increased to 85.71%. If PT, APTT, and FIB were studied together, the mortality was 84.62%, whereas for parameters PT, APTT, and PLTs together, the mortality was 80%. CONCLUSIONS: Coagulopathy is a strong predictor of mortality in major trauma patients. Basic coagulation tests appear to be sensitive tools for identifying patients at high risk of early death and can be used for early minute diagnosis of TIC. Patients with TIC should be managed aggressively to prevent mortality.

We report a case of a 56-year-old woman with a history of idiopathic thrombocytopenic purpura (ITP) following splenectomy on mycophenolate mofetil (MMF), who developed moderate bleeding after stopping MMF. Her laboratory testing suggested the presence of an abnormal circulating heparin-like anticoagulant with demonstrable anti-Xa activity. She was initially treated with antifibrinolytic therapy and was subsequently started on MMF alongside intravenous immunoglobulin, which significantly improved her bleeding symptoms. The presence of abnormal circulating heparin-like anticoagulants is a rare cause of coagulopathy. Few cases exist in the literature, with nearly all occurring in the setting of hematologic or solid-organ malignancy. The mechanism by which these endogenous anticoagulants develop is unclear. Clinical manifestations range from mild bleeding and bruising to life-threatening hemorrhage refractory to conventional therapy. Diagnosis of a heparin-like anticoagulant is based on coagulation testing as well as exclusion of other exogenous anticoagulants, acquired inhibitors, and/or factor deficiencies.

Introduction: The liver is the corner stone of the coagulation system and patients with liver disease are at a substantially increase risk of both thrombosis and haemorrhage. Liver acts as a reticulo endothelial system and regulates coagulation and fibrinolysis by removing these coagulation factors from the circulation. Coagulation disorders in liver disease are usually measured by the prolongation of global screening tests such as the prothrombin time and the activated partial thromboplastin time. Ingeneral, PT determines vitamin K dependent extrinsic factors VII, X, II, V and fibrinogen. The aPTT measures the activities of intrinsic and common pathways of coagulation cascade most sensitive to factor VIII, IX, XI, XII and those of the contact system. Aims and Objectives: To study the alteration in coagulation profile in various liver diseases, to evaluate the risk of bleeding in patients with liver disease and to study the association of coagulation abnormality with the extent of liver disease. Material and Methods: The study included 100 patients with liver diseases attending Medicine and Paediatric department clinics in a teaching tertiary care hospital. These patients were divided into three groups: (1) 40 cases of cirrhosis, (2) 40 cases of viral hepatitis and (3) 20 cases of obstructive jaundice. All these patients were screened for different coagulation tests like Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT), Fibrinogen and Platelet count. Conclusion: Various abnormalities of coagulation tests vary greatly with different liver disorders, duration of the disorders, and their severity. There are more chances of bleeding when coagulation parameters are altered in cases of cirrhosis but more studies are required in this field to evaluate the thrombotic events seen in patients with liver diseases. Keywords: Bleeding time, Coagulation, Cirrhosis, Hepatitis, Obstructive jaundice.

High prevalence of thrombotic events in severely ill COVID-19 patients have been reported. Pulmonary embolism as well as microembolization of vital organs may in these individuals be direct causes of death. The identification of patients at high risk of developing thrombosis may lead to targeted, more effective prophylactic treatment. The primary aim of this study was to test whether rotational thromboelastometry (ROTEM) at admission indicates hypercoagulopathy and predicts the disease severity, assessed as care level, in COVID-19 patients. The study was designed as a prospective, observational study where COVID-19 patients over 18 years admitted to hospital were eligible for inclusion. Patients were divided into two groups depending on care level: (1) regular wards or (2) wards with specialized ventilation support. Conventional coagulation tests, blood type and ROTEM were taken at admission. 60 patients were included; age 61 (median), 67% men, many with comorbidities (e.g. hypertension, diabetes). The ROTEM variables Maximum Clot Firmness (EXTEM-/FIBTEM-MCF) were higher in COVID-19 patients compared with in healthy controls (p

Purpose: Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). Methods: This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). Results: Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76–1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54–1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84–5.34). Conclusion: There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.

Introduction Inherited bleeding disorders vary in prevalence due to genetic disparity and ethnicity. Little is known about the prevalence of coagulation factor deficiency and bleeding disorders in middle-eastern population. Methods Young Saudi adults with at least one positive bleeding symptom reported in semi-structured validated condensed MCMDM-1vWD questionnaire were tested for complete blood count, routine and special coagulation tests, serum ferritin level, and capillary zone electrophoresis. After initial testing, those with prolonged prothrombin time (PT) or activated prothrombin time (APTT) had further testing to evaluate coagulation factors level. Platelet function was tested through platelet function analyzer (PFA)-100, and multiplate aggregometer (MEA) on patients suspected of having platelet disorders. Results Six-hundred-forty patients (male = 347, 54.2%) were included. A possible platelet function defect was diagnosed in three patients with one matching Glanzmann's thrombasthenia trait pattern, and one that of Bernard-Soulier trait pattern. One patient was diagnosed with von Willebrand disease. Deficiencies in coagulation factor levels were revealed as F-VIII in 14 (7.4%), F-IX in 15 (7.6%), F-II in two (3.3%), F-V in 17 (26.1%), FVII in two (3.1%), and F-X in one (1.8%) of study subjects; low vWF activity ( Conclusion The current study reports a higher prevalence of coagulation factors deficiency in Saudi population than reported in the western population.

Comparative analysis of the impact of blood collection systems on the results of routine coagulation tests. The aim of this study was to conduct comparative analysis of the effects of blood collection systems on the results of routine coagulation tests. The study involved practically healthy women over 18 years of age female (n=30). Inclusion criteria: practically healthy individuals. Exclusion criteria: taking non-steroidal anti-inflammatory drugs, or oral contraceptives. Blood collection was carried out in the following systems: 1 system-Vacuette Premium,2 system- Improvacuter, 3 system- BD Vacutainer® Plus. Before and after centrifugation, visual assessment of tubes was performed.No signs for the presence of clots, hemolysis, or insufficient filling was observed. In each sample we measured prothrombin time (PV, sec), activated partial thromboplastin time (APTT, sec), and fibrinogen (F, g/l) by clotting method on the automatic coagulometer «Sta Compact» («Diagnostica Stago», France). The results of laboratory analyses were processed using parametric and non - parametric statistics using The Statistica 12.0 software. At the preanalytical laboratory stage, there were no differences when using systems for blood sampling: the clots and hemolysis were not detected in the samples, the level of filling of the sistems was sufficient. Comparative analysis revealed small, though statistically significant, differences for: PT when comparing Improvacuter wiht Vacuette Premium or BD Vacutainer®; APPT when comparing Improvacuter wiht Vacuette Premium. No differences were observed for Fg levels. Our results support the data available in the literature on the effects of blood-taking systems on hemostasis , which should be taken into account when purchasing blood collection systems.

INTRODUCTION Factor XIII (FXIII) deficiency may cause bleeding under certain clinical circumstances. Therapeutic plasma exchange (TPE) may lead to a transient deficiency. OBJECTIVES To describe the clinical evolution of patients with acquired FXIII deficiency secondary to TPE. METHODS We respectively studied a cohort of consecutive patients from 2014 to 2019 who were treated with TPE with FXIII levels

Background There are acute settings where assessing the anticoagulant effect of direct oral anticoagulants (DOACs) can be useful. Due to variability among routine coagulation tests, there is an unmet need for an assay that detects DOAC effects within minutes in the laboratory or at the point of care. Methods We developed a novel dielectric microsensor, termed ClotChip, and previously showed that the time to reach peak permittivity (T peak) is a sensitive parameter of coagulation function. We conducted a prospective, single-center, pilot study to determine its clinical utility at detecting DOAC anticoagulant effects in whole blood. Results We accrued 154 individuals: 50 healthy volunteers, 49 rivaroxaban patients, 47 apixaban, and 8 dabigatran patients. Blood samples underwent ClotChip measurements and plasma coagulation tests. Control mean T peak was 428 seconds (95% confidence interval [CI]: 401–455 seconds). For rivaroxaban, mean T peak was 592 seconds (95% CI: 550–634 seconds). A receiver operating characteristic curve showed that the area under the curve (AUC) predicting rivaroxaban using T peak was 0.83 (95% CI: 0.75–0.91, p Conclusion This diagnostic study using samples from “real-world” DOAC patients supports that ClotChip exhibits high sensitivity at detecting DOAC anticoagulant effects in a disposable portable platform, using a miniscule amount of whole blood (

Factor XIII (FXIII) levels may decrease because of surgical consumption. Acquired FXIII deficiency could be a cause of postoperative hemorrhage usually underdiagnosed in clinical practice. To determine the diagnosis confirmation rate of acquired FXIII deficiency in postsurgical patients with clinical suspicion and to compare the characteristics and evolution of patients with or without FXIII deficiency. We performed a retrospective cohort study, which included 49 inpatients who were attended at our university hospital from 2014 to 2018 with suspicion of acquired FXIII deficiency because of disproportionate postoperative hemorrhage. FXIIIA levels less than 50% was considered a deficiency. Persistence of bleeding for more than 48 h, drop in hematocrit points, red blood cells transfused units, hemoglobin levels 12-36 h after bleeding, and time elapsed from the procedure to the bleeding were assessed as outcome variables. Logistic regression was employed for both univariate and multivariate analyses. Of the 49 patients included, 27(55%) had FXIII deficiency, with a median level of 34% [interquartile range (IQR) 19-42]. Abdominal surgery was the most common [n = 21 (43%)]. All patients had routine coagulation tests within the hemostatic range. FXIII deficiency was associated with a drop of more than 4 points in hematocrit [OR 59.69 (95% CI 4.71-755.30)], red blood transfused units >2 [OR 45.38 (95% CI 3.48-590.65)], and delayed bleeding >36 h after surgery [OR 100.90 (95% CI 3.78-2695.40)]. Plasma-derived FXIII concentrate was administered to eight patients with life-threatening bleeding with resolution within 24 h. Only one deficient patient died from bleeding. FXIII levels were measured 15 days after diagnosis or more in 20 out of 27 deficient patients, with normal results. Acquired FXIII deficiency may be a frequent underdiagnosed entity that should be considered when high-volume and delayed postoperative hemorrhage is present in patients with hemostatic routine coagulation test results.

Objective: To study some hematological parameters in patients with complicated severe malaria and their relations to clinical outcome. Materials and Methods: This was a cross sectional observational study, including 100 patients from a tertiary care centre in Ghaziabad patients who were diagnosed to have malaria by peripheral smear examination (both thick and thin smear) or Malaria Rapid Antigen. Blood sample for haematological and coagulation study were taken. Results: Out of 100 patients 62 patients had Hb % less than 10 gm percentage in which 14 patients had Hb of the total patients. Packed cell volume was decreased in about 86% of the patients. ESR increase was seen in 73% of the patient. Thrombocytopenia was observed in 63% of the patients and 25% of the patients with mixed infection had severe thrombocytopenia. PT and APTT was increased in 22% and 14% of the total cases. Bleeding time was increased in 5% of the total case and no any patients with vivax malaria had increased bleeding time. Mixed infection shows as falciparum malaria. Sever anemia, thrombocytopenia, increase BT, PT and APTT associated to severity and complication of malaria. Conclusion: This study concluded that hematological changes are common complications encountered in severe malaria, but they are not related to the clinical outcome. Keywords: Severe malaria, Thrombocytopenia, Prothrombin time, APTT.

The ongoing outbreak of Coronavirus Disease 2019 (COVID-19) is hitting the world hard, but the relationship between coagulation disorders and COVID-19 is still not clear. This study aimed to explore whether early coagulation tests can predict risk stratification and prognosis. PubMed, Web of Science, Cochrane Library, and Scopus were searched electronically for relevant research studies published up to March 24, 2020, producing 24 articles for the final inclusion. The pooled standard mean difference (SMD) of coagulation parameters at admission were calculated to determine severe and composite endpoint conditions (ICU or death) in COVID-19 patients. Meta-analyses revealed that platelet count was not statistically related to disease severity and composite endpoint; elevated D-dimer correlated positively with disease severity (SMD 0.787 (0.277-1.298), P= 0.003, I2= 96.7%) but had no significant statistical relationship with composite endpoints. Similarly, patients with prolonged prothrombin time (PT) had an increased risk of ICU and increased risk of death (SMD 1.338 (0.551-2.125), P = 0.001, I2 = 92.7%). Besides, increased fibrin degradation products (FDP) and decreased antithrombin might also mean the disease is worsening. Therefore, early coagulation tests followed by dynamic monitoring is useful for recognizing coagulation disorders accompanied by COVID-19 and guiding timely therapy to improve prognosis.

Assessing the viability and monitoring the function of liver graft in the early postoperative period are critical clinical tasks. One possible solution is to determine the changes in concentration of blood glucose, its metabolites and glycerol in the graft using interstitial microdialysis. Objective: to study the dynamics of interstitial glucose, lactate, pyruvate and glycerol in the early post-liver transplant period – depending on the initial graft function (IGF) – and to compare with the results of standard laboratory blood tests. Materials and methods. Four selected clinical observations of deceased donor liver transplantation are presented. Two of the observations showed normal IGF, one observation – early allograft dysfunction (EAD), complicated by hepatic artery thrombosis (HAT), while one observation demonstrated primary non-function (PNF). Collection of microdialysis samples began after arterial reperfusion of the liver graft and continued continuously for 7 days or until death. Standard blood biochemistry and coagulation tests were performed at least once a day. Results. With normal IGF and a smooth postoperative period, interstitial concentrations of glucose, lactate, pyruvate and glycerol remained stable throughout the observation period, ranging from 5 to 20 mmol/L, 1.1 to 7.5 mmol/L, 90 to 380 μmol/L, and 10–100 μmol/L, respectively. EAD was associated with initially higher levels of glucose, lactate, and pyruvate. With HAT development, there was a rapid (within 2–4 hours) five-fold increase in interstitial concentration of lactate with simultaneous decrease in glucose and pyruvate levels to 0.1 mmol/L and 11 μmol/L, respectively. In the case of PNF, there was an initially high concentration of interstitial lactate – 16.4 mmol/L, which increased further to 35.5 mmol/L. Glucose concentration was close to 0. Changes in interstitial glucose, its metabolites and glycerol concentrations chronologically preceded the corresponding changes in peripheral blood composition by 3–5 hours. Conclusion. Microdialysis measurement of interstitial glucose, lactate, pyruvate and glycerol concentrations facilitates real-time monitoring of liver graft viability and function. The high sensitivity of the method could help in accelerating diagnosis of vascular complications (HAT in particular), as well as graft dysfunction with other causes. Therefore, the method is feasible in clinical practice.

The outbreak of novel coronavirus disease 2019 (COVID-19) has now become a global pandemic. Coagulopathy has been reported widely in critically ill COVID-19 patients and was related to high mortality. However, the comprehensive coagulation profiles have not been examined and the underlying mechanism of the coagulopathy in COVID-19 patients is unclear. To study the coagulation profiles of routine hemostasis tests, natural anticoagulants, coagulant factors and antiphospholipid antibodies in critically ill COVID-19 patients. This single-center and cross-section study included 19 patients with COVID-19, who were admitted to intensive care unit (ICU) at Tongji hospital in Wuhan, China, from Feb 23 to Mar 3, 2020. Demographic data, laboratory parameters, treatments and clinical outcomes of the patients were collected and analyzed. The final date of follow-up was Mar 31, 2020. In this study, 12 thrombotic events occurred in 9 patients, including 4 cerebral infarctions, 7 acro-ischemia and 1 internal jugular vein thrombosis. The common abnormalities of routine coagulation tests included evelated D-Dimer level (100%), prolonged prothrombin time (73.7%) and hyperfibrinogenemia (73.7%). The median activities of natural anticoagulants including protein C, protein S and antithrombin were all below the normal range. Factor VIII activities were significantly above normal range (median value 307%, IQR 198–441) in all patients. Factor V and factor VII activities were significantly lower in near-terminal stage patients. Anti-phospholipid antibodies were present in 10 patients. Strikingly, 4 cerebral infarction events were in patients had anti-phospholipid antibodies of multiple isotypes. Sustained hypercoagulable status and thrombotic events were common in critically ill patients with COVID-19. The low activities of natural anticoagulants, elevated factor VIII level and the presence of antiphospholipid antibodies, together, may contribute to the etiopathology of coagulopathy in COVID-19 patients.

Lin Zhang,1,2,* Juan Ye,2– 4,* Qiuyun Luo,2 Miaohuan Kuang,1 Minjie Mao,1 Shuqin Dai,1 Xueping Wang1 1Department of Clinical Laboratory, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong 510060, People’s Republic of China; 2Department of Experimental Research, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People’s Republic of China; 3Department of Infectious Diseases, The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, People’s Republic of China; 4Department of Oncology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Xueping Wang; Shuqin Dai Tel/ Fax +86 20 8734 3438Email wangxuep@sysucc.org.cn; daishq@sysucc.org.cnBackground and Objective: Tools for the non-invasive assessment of colorectal cancer (CRC) prognosis have profound significance. Although plasma coagulation tests have been investigated in a variety of tumours, the prognostic value of the prothrombin time (PT) and activated partial thromboplastin time (APTT) in CRC has not been discussed. Our study objective was to explore the prognostic significance of preoperative PT and APTT in CRC patients.Patients and Methods: A retrospective analysis of preoperative coagulation indexes including PT, PTA, INR, APTT, FIB, TT, PLT, NLR and PLR in 250 patients with CRC was performed. Kaplan–Meier and multivariate Cox regression analysis were used to demonstrate the prognostic value of these preoperative coagulation indexes.Results: The overall survival (OS, p< 0.05) and disease-free survival (DFS, p< 0.05) of CRC patients with lower PT and APTT levels were significantly prolonged. Based on univariate analysis, PT levels (p< 0.001, p< 0.001), PTA levels (p=0.001, p=0.001), APTT levels (p=0.001, p< 0.001), INR levels (p< 0.001, p< 0.001), fibrinogen levels (p=0.032, p=0.036), tumour status (p=0.005, p=0.003), nodal status (p< 0.001, p< 0.001), metastasis status (p< 0.001, p< 0.001) and TNM stages (p< 0.001, p< 0.001) were remarkably associated with DFS and OS. Multivariate Cox regression analysis suggested that the levels of PT (HR: 2.699, p=0.006) and APTT (HR: 1.942, p=0.015), metastasis status (HR: 2.091, p= 0.015) and TNM stage (HR: 7.086, p=0.006) were independent predictors of survival in CRC. In the whole cohort, the enrolled patients were then divided into three groups according to their PT and APTT levels. The OS and DFS differed notably among the low-risk (PT< 11.85 sec and APTT< 25.85 sec), medium-risk (PT≥ 11.85 sec or APTT≥ 25.85 sec), and high-risk (PT≥ 11.85 sec and APTT≥ 25.85 sec) groups.Conclusion: Elevated levels of preoperative PT and APTT were predictors of poor outcomes in CRC patients. Moreover, the combination of preoperative PT and APTT can be a new prognostic stratification approach for more precise clinical staging of CRC.Keywords: PT, APTT, CRC, prognosis

Introduction: The liver is the cornerstone of the coagulation system. The physiology of blood coagulation is closely linked to liver function as it synthesizes most of the factors of coagulation cascade and fibrinolytic proteins. So it is responsible for regulation of haemostasis. Hepatic disorders are widely present in tropical countries and are responsible for morbidity and mortality. Aims and Objectives: The objective of this study was to evaluate coagulation abnormalities associated with chronic liver diseases using tests like prothrombin time (PT), and activated partial thromboplastin time (APTT). Materials and Methods: The study was conducted in the laboratory of Pathology department, during the period from October 2019 to June 2020. This study included 225 patients clinically diagnosed with liver disease who were divided into three categories: 1-cirrhosis, 2-other liver disease and 3-Hepatitis.The coagulation tests PT and APTT were performed and the results were evaluated in groups. 25 normal patients were taken as controls.Result: Out of 250 patients, 190(85%) were males and 60(24%) were females. A total of 13(6%) patients were of cirrhosis, 100 (44%) were of viral hepatitis and jaundice, and 112 (50%) were of other liver diseases and 25 normal patients (10%). Prothrombin time showed marked significant prolongation in all liver diseases. In cirrhosis: 90-100% bleeders showed elevation of Prothrombin time and non bleeders showed elevation in 50-55% cases. In viral hepatitis: 45% cases showed rise in PT. In Alcoholic liver diseases; 38.5% cases showed rise in PT.APTT is quite Significant in cirrhosis. In cirrhosis, Bleeders showed elevation of APTT in100% cases and non bleeders show 50% cases. In viral hepatitis, 25.3 % rise in APTT in Alcoholic liver diseases, 25.9%cases showed rise in APTT.Conclusion: In advancing liver diseases, damage to liver parenchyma resulting in reduced production of coagulation proteins so there is increase in PT and APTT which increase the risk of bleeding tendencies. Prolongation of PT and APTT in advancing liver cirrhosis indicates damage to the liver parenchyma resulting in decreased production of coagulation proteins with increased risk of bleeding tendencies, which can be detected before these ensue.

Context The thrombotic effects of estradiol therapy in transgender women are unclear. Global coagulation assays (GCA) may be better measures of hemostatic function compared with standard coagulation tests. Objective To assess the GCA profiles of transgender women in comparison to cisgender controls and to compare how GCA differ between routes of estradiol therapy in transgender women. Design Cross-sectional case-control study. Setting General community. Participants Transgender women, cisgender male and cisgender female controls. Main outcome measures Citrated blood samples were analyzed for (i) whole blood thromboelastography (TEG®5000), (ii) platelet-poor plasma thrombin generation (calibrated automated thrombogram); and (iii) platelet-poor plasma fibrin generation (overall hemostatic potential assay). Mean difference (95% confidence intervals) between groups are presented. Results Twenty-six transgender women (16 oral estradiol, 10 transdermal estradiol) were compared with 98 cisgender women and 55 cisgender men. There were no differences in serum estradiol concentration (P = 0.929) and duration of therapy (P = 0.496) between formulations. Transgender women demonstrated hypercoagulable parameters on both thromboelastography (maximum amplitude + 6.94 mm (3.55, 10.33); P Conclusion Transgender women on estradiol therapy demonstrated hypercoagulable GCA parameters compared with cisgender men with a shift towards cisgender female parameters. Route of estradiol delivery did not influence the GCA parameters.

Absztrakt: Bevezetés: Nemzetközi tapasztalatok alapján a COVID–19-fertőzött, kórházban kezelt betegek több mint 30%-ában vénás, artériás és microvascularis thrombosis, disszeminált intravascularis véralvadási zavar, illetve thromboembolia alakul ki. Ennek laboratóriumi jellemzői a magas D-dimer- és fibrinogénszint, valamint a megnyúlt prothrombinidő és aktivált parciális thromboplastinidő. Módszer: Az esetbemutatások során intenzív osztályon kezelt, COVID–19-fertőzött betegek (n = 3) ClotPro® trombolasztométeres (EX-test, IN-test, FIB-test, RVV-test és TPA-test) eredményeit értékeltük a klinikai állapottal összefüggésben. Eredmények: A ClotPro®-paraméterek procoagulatiót, hypercoagulatiót, fibrinolysist vagy annak „shut down” megnyilvánulását jelezték, és összhangban voltak a hagyományos alvadási tesztekkel, illetve a kompenzált disszeminált intravascularis coagulopathia meghatározásával. Következtetés: Eredményeink magyarázatot adhatnak a vénás thromboemboliás szövődményekre, támogatják a terápiás alvadásgátló kezelés és a thrombocytaaggregáció-gátlás fontosságát. A gyógyszer típusának, adagolási algoritmusának, optimális időtartamának meghatározásához intervenciós klinikai vizsgálatok szükségesek, ezek engedélyeztetése folyamatban van. Orv Hetil. 2020; 161(22): 899–907.

Background and objectives: Hemorrhage is the most common complication of tonsillectomy. However, the incidence of post-tonsillectomy hemorrhage may be affected by various factors including weight, age, medications, surgical technique, etc. This study was carried out to determine prevalence of post-tonsillectomy hemorrhage in patients undergoing tonsillectomy in a teaching hospital in Gorgan, Iran. Methods: This descriptive study was conducted on 1,043 cases of tonsillectomy who were admitted to a referral teaching hospital in Gorgan (Iran) between 2016 and 2017. Data were collected from medical records. Demographics characteristics, the applied surgical technique (e.g., tonsillectomy, adenoidectomy and adenotonsillectomy), the time of bleeding onset, the results of coagulation tests and the method of post-tonsillectomy hemorrhage management were recorded. Results: The frequency of tonsillectomy was 19.2, 50.8, 18.6, 4, 2.1 and 5.3% in subjects aged 0-5, 5-10, 10-15, 15-20, 20-25 and more than 25 year old, respectively. The overall prevalence of post-tonsillectomy hemorrhage was 2.1%. The frequency of post-tonsillectomy hemorrhage was highest (13.6%) in patients aged 20-25 years. The incidence of post-tonsillectomy hemorrhage was zero in those aged ≤5 years. The rate of post-tonsillectomy hemorrhage was 54.5, 31.8 and 13.6% for those undergoing tonsillectomy, adenoidectomy and adenotonsillectomy, respectively. Secondary post-tonsillectomy hemorrhage (after 24 hours) was more common (81.8%). Moreover, the rate of re-admission for controlling the bleeding was 63.4% (14 cases). Conclusion: The incidence of post-tonsillectomy hemorrhage, the methods for its management and the need for re-admission are quite different in different age groups.

Background Coagulopathy is common in multitrauma patients and repletion of procoagulant factor deficiency with fresh frozen plasma (FFP) improves hemostasis. Optimal kaolin-thromboelastography thresholds for FFP transfusion in trauma patients have not been well established. Study Design Adult trauma patients with an Injury Severity Score ≥15 were included in this retrospective observational cohort study. The primary end point was area under the receiver operating characteristic curve (AUROC) for reaction time (R-time) to detect procoagulant factor deficiency, as reflected by an elevated international normalized ratio (INR) or aPTT. Test characteristics for the optimal R-time threshold calculated in our study were compared against thresholds recommended by the American College of Surgeons for FFP transfusion. Results Six hundred and ninety-four pairs of thromboelastography and conventional coagulation tests were performed in 550 patients, with 144 patients having additional pairs of tests after the first hour. The R-time was able to detect procoagulant factor deficiency (INR ≥1.5 AUROC 0.80; 95% CI, 0.75 to 0.85; aPTT ≥40 seconds AUROC 0.85; 95% 0.80 to 0.89) and severe procoagulant factor deficiency (INR ≥2.0 AUROC 0.82; 95% CI, 0.73 to 0.99; aPTT ≥60 seconds AUROC 0.89; 95% CI, 0.81 to 0.98) with good accuracy. Optimal thresholds to maximize sensitivity and specificity were 3.9 minutes for detection of INR ≥1.5, 4.1 minutes for detection of aPTT ≥40 seconds, 4.3 minutes for detection of INR ≥2.0, and 4.3 for detection of aPTT ≥60 seconds. Currently recommended R-time thresholds for FFP transfusion had 100% specificity for detecting procoagulant factor deficiency, but low sensitivity (3% to 7%). Conclusions R-time can detect procoagulant factor deficiency in multitrauma patients with good accuracy, but currently recommended R-time thresholds are highly specific and not sensitive. Use of low-sensitivity thresholds might result in undertreatment of many patients with procoagulant factor deficiency.

Purpose of the study: to study the systemic immunity and hemostasis in women with infertility and pathological processes of glandular epithelium of genitals with atypical glandular cells not otherwise specified.Materials and methods. The study included 173 women with infertility and pathological processes of glandular epithelium of genitals with atypical glandular cells not otherwise specified (main group). The comparison group consisted of 100 women with infertility and without pathological processes of cervical epithelium. All patients underwent studies of the immune systems (population of lymphocytes, circulating immune complexes) and hemostasis (screening coagulation tests, number and aggregation function of platelets).Results. Analysis of the immune system revealed certain changes in the main group, more pronounced in women with endometrial pathology - inhibition of the cell link (evidenced by a decrease in absolute and relative CD3+ T cells value, absolute number of CD4+, CD16 and phagocytic number) against the background of humoral immunity activation (increase in the CD22+ level, circulating immune complexes, IgG and IgA). The study of the vascular-platelet hemostasis showed a decrease of platelets against the background of a tendency to an increase in platelet anisocytosis and an increase in platelet counts in women with endometrial pathology. An analysis of platelet aggregation function revealed a significant increase in platelet aggregation to adenosine diphosphate, adrenaline and collagen in patients with endometrial pathology, also a tendency to hypercoagulation.Conclusions. In women with infertility and pathological processes of glandular epithelium of genitals with atypical glandular cells there is suppression of the cellular immune system against the background of humoral immunity hyperactivation. Activation of the vascular–platelet hemostasis and a tendency to hypercoagulative state were revealed.