Low molecular weight heparin in COVID-19: benefits and concerns.

Since its emergence, the COVID-19 pandemic had a dramatic impact on the public health worldwide and it scarred the medical, economical, and social determinants of health. Even after the significant vaccination advances, the disease of SARS-CoV-2 can manifest in severe presentations with life-threatening thromboembolic and multi-organ complications leading to notable morbidity and mortality. Clinicians and researchers are on continuous pursuit of investigating different approaches in the attempt to prevent the infection and minimize its severity. Although the COVID-19's pathophysiology remains relatively unclear, it is well established now that coagulopathy, systemic thrombotic propensity, and a robust immunoinflammatory response are some of the most important determinants of its morbidity and mortality. Accordingly, research efforts have focused on addressing the inflammatory and hematological cascades using available agents to avoid thromboembolic events. Several studies and investigators have emphasized the importance of Low molecular weight heparin (LMWH), namely, Lovenox, in addressing these sequelae of the COVID-19 disease, either prophylactically or therapeutically. This review explores the benefits and concerns of employing LMWH, a widely used anticoagulant, in COVID-19 disease. It delves into Enoxaparin as a molecule, along with its pharmacology, mechanism of action, and clinical uses. It also reviews the current high-quality clinical evidence that highlight the role of enoxaparin in SARS-CoV-2 infection.

COVID-19 in Cyanotic Congenital Heart Disease.

Congenital heart disease (CHD) is the most prevalent congenital defect in newborn infants. Due to the various types of heart abnormalities, CHD can have a wide range of symptoms. Cardiac lesions comprise a range of different types and accordingly varying severities. It is highly helpful to classify CHD into cyanotic and acyanotic heart diseases. In this review, we are investigating the course of Coronavirus disease 2019 (COVID-19) in cyanotic CHD patients. The infection may directly or indirectly affect the heart by affecting the respiratory system and other organs. The effect on the heart that is pressure- or volume-overloaded in the context of CHD is theoretically more severe. Patients with CHD are at a higher risk of mortality from COVID-19 infection or suffering worse complications. While the anatomic complexity of CHD does not seem to predict the severity of infection, patients with worse physiological stages are more susceptible such as cyanosis and pulmonary hypertension. Patients with CHD exhibit continuous hypoxemia and have lower oxygen saturations because of a right-to-left shunt. Such individuals run the danger of rapidly deteriorating in the event of respiratory tract infections with inadequate oxygenation. Additionally, these patients have a higher risk of paradoxical embolism. Hence, critical care should be given to cyanotic heart disease patients with COVID-19 in comparison to acyanotic patients and this is through proper management, close observation, and adequate medical therapy.

Multisystem inflammatory syndrome in children (MIS-C) and "Near MIS-C": A continuum?

Introduction: Reports of multisystem inflammatory syndrome in children (MIS-C), following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, have been increasing worldwide, with an incidence varying significantly across studies based on the definition used for the diagnosis. At our tertiary medical center in Lebanon, we encountered several cases that presented a diagnostic challenge because they mimicked MIS-C but did not meet the US Centers for Disease Control and Prevention (CDC) definition. We decided to review these cases and describe their features in comparison with cases that met the CDC criteria of MIS-C and those that had an alternative diagnosis. Methods: This is a retrospective chart review of subjects aged <19 years old admitted to the American University of Beirut Medical Center (AUBMC) between March 1, 2020, and May 31, 2021, with suspected or confirmed MIS-C, following documented COVID-19 infection, with sufficient or insufficient criteria for diagnosis. Subjects were classified into 3 groups: "MIS-C", "Near MIS-C" and "Alternative Diagnosis". Results: A total number of 29 subjects were included in our cohort. Fever was present in all subjects. In the MIS-C group, evidence for cardiovascular system involvement was the most common feature followed by the mucocutaneous and gastrointestinal systems. In the "Near MIS-C" and "Alternative Diagnosis" group, gastrointestinal symptoms were the most common with only one patient with cardiac abnormalities and none with coagulopathy. Subjects with typical MIS-C presentation had higher inflammatory markers when compared to subjects in the other groups. Almost all the subjects had positive IgG for SARS-CoV-2. Of the 29 subjects, the Royal College of Paediatrics and Child Health (RCPCH) case definition would have identified all suspected cases without an alternative diagnosis as MIS-C, whereas the World Health Organization (WHO) and the CDC definitions would have excluded 6 and 10 subjects, respectively. Conclusion: MIS-C presents a diagnostic challenge due to the nonspecific symptoms, lack of pathognomonic findings, and potentially fatal complications. More research is needed to fully understand its pathogenesis, clinical presentation spectrum, and diagnostic criteria. Based on our experience, we favor the hypothesis that MIS-C has a continuum of severity that necessitates revisiting and unifying the current definitions.

Aspirin in COVID-19: Pros and Cons.

Since its emergence, the COVID-19 pandemic has been ravaging the medical and economic sectors even with the significant vaccination advances. In severe presentations, the disease of SARS-CoV-2 can manifest with life-threatening thromboembolic and multi-organ repercussions provoking notable morbidity and mortality. The pathogenesis of such burdensome forms has been under extensive investigation and is attributed to a state of immune dysfunction and hyperinflammation. In light of these extraordinary circumstances, research efforts have focused on investigating and repurposing previously available agents that target the inflammatory and hematological cascades. Aspirin, due to its well-known properties and multiple molecular targets, and ought to its extensive clinical use, has been perceived as a potential therapeutic agent for COVID-19. Aspirin acts at multiple cellular targets to achieve its anti-inflammatory and anti-platelet effects. Although initial promising clinical data describing aspirin role in COVID-19 has appeared, evidence supporting its use remains fragile and premature. This review explores the notion of repurposing aspirin in COVID-19 infection. It delves into aspirin as a molecule, along with its pharmacology and clinical applications. It also reviews the current high-quality clinical evidence highlighting the role of aspirin in SARS-CoV-2 infection.

Pre-operative assessment of pediatric congenital heart disease patients in the COVID-19 era: lessons learned.

BACKGROUND: Equal to COVID-19 patients, non-COVID-19 patients are affected by the medical and social drawbacks of the COVID-19 pandemic. A significant reduction in elective life-changing surgeries has been witnessed in almost all affected countries. This study discusses an applicable and effective pre-operative assessment protocol that can be applied during the COVID-19 era. METHODS: Our study is a descriptive retrospective observational study that involves children with CHD requiring open-heart surgeries at our tertiary care centre between March and November, 2020. We reviewed the charts of eligible patients aged 18 years and below. We identified the total numbers of scheduled, performed, and postponed surgeries, respectively. A thorough description of the clinical and physical presentation of the postponed cases, who tested positive for SARS-CoV-2, is provided. RESULTS: Sixty-eight open-heart surgeries were scheduled at our centre between March and November, 2020. Three surgeries (4%) were postponed due to COVID-19. The three patients were asymptomatic COVID-19 cases detected on routine SARS-CoV-2 polymerase chain reaction testing. No symptoms of cough, chest pain, dyspnea, rhinorrhea, diarrhea, abdominal pain, anosmia, and ageusia were reported by our patients. All patients were afebrile and hemodynamically stable. Owing to the pre-operative assessment protocol that was implemented after the first case was detected, only three healthcare workers were at risk of COVID-19 transmission and were imposed to infectious evaluation and home quarantine. CONCLUSIONS: Adopting our discussed preoperative COVID-19 assessment protocol for CHD patients is an effective method to detect COVID-19 infections, optimise patient care, and ensure healthcare workers' safety.

COVID-19: potential therapeutics for pediatric patients.

The global spread of COVID-19 has imparted significant economic, medical, and social burdens. Like adults, children are affected by this pandemic. However, milder clinical symptoms are often experienced by them. Only a minimal proportion of the affected patients may develop severe and complicated COVID-19. Supportive treatment is recommended in all patients. Antiviral and immunomodulatory medications are spared for hospitalized children with respiratory distress or severe to critical disease. Up till now, remdesivir is the only USFDA-approved anti-COVID-19 medication indicated in the majority of symptomatic patients with moderate to severe disease. Dexamethasone is solely recommended in patients with respiratory distress maintained on oxygen or ventilatory support. The use of these medications in pediatric patients is founded on evidence deriving from adult studies. No randomized controlled trials (RCTs) involving pediatric COVID-19 patients have assessed these medications' efficacy and safety, among others. Similarly, three novel monoclonal anti-SARS-CoV-2 spike protein antibodies, bamlanivimab, casirivimab and imdevimab, have been recently authorized by the USFDA. Nonetheless, their efficacy has not been demonstrated by multiple RCTs. In this review, we aim to dissect the various potential therapeutics used in children with COVID-19. We aspire to provide a comprehensive review of the available evidence and display the mechanisms of action and the pharmacokinetic properties of the studied therapeutics. Our review offers an efficient and practical guide for treating children with COVID-19.

Cardiac Manifestations in COVID-19 Patients: A Focus on the Pediatric Population.

BACKGROUND: SARS-CoV-2 is a new strain of the coronavirus family that emerged by the end of 2019 and led to the unpreceded COVID-19 pandemic. The virus affects multiple organs simultaneously and leads to a high rate of morbidity and mortality in all age groups. The cardiovascular system is one of the major affected organ systems. Various mechanisms including direct myocardial injury contribute to the cardiac manifestations of COVID-19 patients. METHODS: We performed a comprehensive and updated search on the cardiac manifestations of COVID-19. Our search included laboratory and imaging evaluations. In addition, we added a unique section on the effect of SARS-CoV-2 on the cardiovascular system in the pediatric population. RESULTS: COVID-19 might have an effect on the cardiovascular system at various levels leading to myocardial ischemia, arrhythmia, heart failure, myocarditis, and multisystem inflammatory syndrome in children. The incidence of cardiovascular complications varies among patients. This paper also provides a comprehensive summary of all the reported pediatric cases with cardiac manifestations. CONCLUSION: Multidisciplinary teams are crucial for adequate management of patients with COVID-19 regardless of age. Timely diagnosis is critical in reducing mortality.

COVID-19 in the MENA Region: Facts and Findings.

INTRODUCTION: Our study aims to assess the prevalence of COVID-19 in the Middle East and North Africa (MENA) region. It aims also to examine the various factors that have led to the unequal distribution of the confirmed cases among the different MENA countries. METHODOLOGY: Data was retrieved from the World Health Organization situation reports issued between January 29 and June 5, 2020. It included the numbers of cumulative cases, new cases, and cumulative deaths reported by MENA countries. Similarly, we searched for relevant articles in PubMed and Medline. RESULTS: A total of 481,347 cases and 11,851 deaths occurred in the MENA region, accounting for 7.37% and 3.06% of the global cases and deaths respectively. Iran had the highest number of cases and deaths accounting for 34.1% and 68.1% of the MENA cases and deaths respectively. Together the Gulf Cooperation Council (GCC) countries accounted for 52.2% and 10.6% of MENA cases and deaths respectively. Egypt had the highest number of confirmed cases and deaths among the African countries of the region. Syria, Libya and Yemen (countries at war) had the lowest numbers of reported cases. The MENA region overall case fatality rate (CFR) was estimated at 2.46%. The highest CFR (22.75%) occurred in Yemen, and the lowest (0.07%) in Qatar. CONCLUSIONS: The unequal distribution of wealth among the MENA countries, the lack of sociopolitical stability, and the high number of undetected and underreported cases in some of them have resulted in varied incidences of COVID-19 related morbidity and mortality.

COVID-19 in Pediatric Patients: A Focus on CHD Patients.

Coronavirus disease 2019 (COVID-19) is a global pandemic caused by SARS-CoV-2 virus. As of the 30th of September 2020, around 34,000,000 cases have been reported globally. Pediatrics with underlying congenital heart disease represent a small yet a critical proportion of these patients. In general, the majority of infected children experience mild to moderate disease with significant interindividual variability in laboratory and radiographic findings. Nevertheless, in healthy children with COVID-19, cardiac involvement has been documented and is attributed to various causes. Myocarditis, arrhythmias, cardiogenic shock, and serious multisystem inflammatory syndrome in children are all encountered. Since COVID-19 is a recent novel disease and based on previous experience with respiratory infections, children with underlying congenital heart disease should be given special attention. To date, little data is available about COVID-19 presentation, complications, and appropriate treatment in this population. However, variable and inconsistent disease presentation and severity have been observed. This paper discusses COVID-19 course of illness in pediatric population with a special emphasis on the cardiac manifestations of the disease in healthy population and also on the disease course in congenital heart disease patients in particular.

Hydroxychloroquine in COVID-19 Patients: Pros and Cons.

The pandemic of COVID-19, caused by SARS-CoV-2, has recently overwhelmed medical centers and paralyzed economies. The unparalleled public distress caused by this pandemic mandated an urgent quest for an effective approach to manage or treat this disease. Due to their well-established anti-infectious and anti-inflammatory properties, quinine derivatives have been sought as potential therapies for COVID-19. Indeed, these molecules were originally employed in the treatment and prophylaxis of malaria, and later in the management of various autoimmune rheumatic and dermatologic diseases. Initially, some promising results for the use of hydroxychloroquine (HCQ) in treating COVID-19 patients were reported by a few in vitro and in vivo studies. However, current evidence is not yet sufficiently solid to warrant its use as a therapy for this disease. Additionally, the therapeutic effects of HCQ are not without many side effects, which range from mild gastrointestinal effects to life-threatening cardiovascular and neurological effects. In this review, we explore the controversy associated with the repurposing of HCQ to manage or treat COVID-19, and we discuss the cellular and molecular mechanisms of action of HCQ.