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Introduction COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. Metohds We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. Results Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (p = 0.819 and p = 0.265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3–18] and 12 [6–19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. Conclusion We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.
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INTRODUCTION: COVID-19 induces coagulopathy associated with an increase of thromboembolic events. Due to the lack of agreement on recommendations for thromboprophylactic management, the aim of this study was to study the dosages of LMWH used in critically ill COVID-19 patients assessing the effect on their outcome. METHODS: We evaluated data of the Reg-COVID19. According to LMWH dose two groups were analyzed: prophylaxis and treatment. Primary outcome was the relationship of LMWH dosage with mortality. Secondary outcomes included the incidence of thrombotic and bleeding events, length of ICU stay, invasive mechanical ventilation, and thrombotic and inflammatory parameters. RESULTS: Data of 720 patients were analyzed, 258 in the prophylaxis group and 462 in the treatment group. C Reactive Protein, invasive mechanical ventilation, tocilizumab and corticosteroid treatments were related with the choice of LMWH dose. Hemorrhagic events (66/720, 9.2%) and thrombotic complications (69/720, 9.6%) were similar in both groups (pâ¯=â¯.819 and pâ¯=â¯.265), as was the time course of the thrombotic events, earlier than hemorrhagic ones (9 [3-18] and 12 [6-19] days respectively). Mortality was lower in prophylaxis group (25.2% versus 35.1%), but once an inverse probability weighting model was applied, we found no effect of LMWH dose. CONCLUSION: We found no benefit or harm with the administration of therapeutic or prophylactic LMWH dose in COVID19 critically ill patients. With a similar rate of hemorrhagic or thrombotic events, the LMWH dose had no influence on mortality. More studies are needed to determine the optimal thromboprophylaxis protocol for critically ill patients.
Subject(s)
COVID-19 , Thrombosis , Venous Thromboembolism , Humans , Heparin, Low-Molecular-Weight/therapeutic use , Anticoagulants/therapeutic use , COVID-19/complications , Critical Illness , Prospective Studies , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control , Venous Thromboembolism/drug therapy , Thrombosis/etiology , Thrombosis/prevention & control , Hemorrhage/chemically induced , Hemorrhage/prevention & controlABSTRACT
Background: Vaccination during immunosuppression can result in impaired vaccine responses. In highly active patients requiring a rapid treatment initiation, vaccination can delay treatment onset. Natalizumab (NTZ) is a high-efficacy agent with potential low interference in vaccination responses, and could be a bridge therapy to achieve an adequate immunisation before starting another treatment. Objective(s): To assess the safety and immunogenicity of inactivated vaccines administered during NTZ treatment. Method(s): Self-controlled study based on an ongoing prospective cohort that included adult MS patients with complete immunisation schedules for hepatitis B vaccine (HBV), hepatitis A vaccine (HAV) and/or COVID-19 vaccine during NTZ treatment, between September 2016 and February 2022. Seroprotection rates were calculated for each vaccine. Demographic, clinical and radiological characteristics were collected the year before (pre-exposure period) and after vaccination (post-exposure period). Differences in annual relapse rate (ARR), contrast-enhancing lesions (CELs), new T2 lesions (NewT2) and changes in Expanded Disability Status Scale (EDSS) during pre and post exposure period were evaluated. Patients were also categorised according to time on NTZ exposure before vaccination (long-term exposure >1 year and short-exposure <=1 year) and according to JCV status. Result(s): From 248 patients treated with NTZ, 60 were vaccinated during NTZ exposure: 44 (73%) women, mean age 45 years, mean disease duration 17 (SD 8.7) years. Thirty (50%) patients bridged to anti-CD20 after immunisation, because of high titers of JC virus. Between the pre and post-exposure period, we observed a decrease in both the AAR (0.28 vs 0.01;p=0.004) and newT2 (0.8 vs 0.02;p=0.1) and no changes in disability accumulation (EDSS 3.5 vs 3.5 p=0.6). The global seroprotection rate was 93% (91.6% (IC95% 73-99) for HAV (n=24), 92.6% (IC95% 76- 99) for HBV (n=27), 100% (IC95% 84-100) for Covid-19 (n=23)). No differences were seen between short and long term NTZ exposure or between JCV positive or negative patients, in terms of safety and immunogenicity. Conclusion(s): Immunisation with inactivated vaccines during NTZ treatment is safe and effective, both for short and long term NTZ exposure. In highly active PwMS who need immunisation, NTZ could be a valuable strategy to avoid delays in the onset of high-efficacy DMD, even in JC virus positive in which it could be used as a bridge therapy strategy.
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Introduction: A series of restrictive health care measures emerged limiting actions that include the work of occupational therapists and proposing adaptations to provide care to people who require it. Objective: To identify the impact and adaptations in the care of Occupational Therapy clinical professionals due to the COVID-19 pandemic in Colombia. Methods: Cross-sectional study that applies an online questionnaire in January-February 2021 to Colombian occupational therapists in clinical/hospital settings. Sociodemographic variables, clinical professional practice, and the impact of COVID-19 in terms of job loss, modifications, and adaptations for the intervention were analyzed. Descriptive analyzes are performed by variable and a Chi-square test of independence is applied for associations between variables. Results: 382 Colombian occupational therapists participated. The average time of professional practice was 10.8 years. Of the total, 89% worked before the pandemic and continued their work, and at least 64% claimed that they lost their job due to COVID-19. Of those who continued to work, 20.5% did so virtually and 79.5% in a face-to-face clinic. On a virtual level, 89% did it due to a job requirement and at least 53% did it without training in telehealth. In face-to-face, 68% reported restrictions in the actions practiced and decreased referrals to therapy. Conclusions: The pandemic has resized the actions of the occupational therapist, has modified the means and forms of intervention, allowing the reinvention of their work. © 2022 Universidade Federal de Sao Carlos. All rights reserved.
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Background: Coronavirus (COVID-19) pandemic disease forced different countries to adopt quarantine measures. These actions could have an impact on mental health in the general population. The objective of this study was to analyze the differences in psychopathological symptoms shown by Spanish general population during the COVID-19 quarantine based on sociodemographic, occupational and environmental-contextual variables.
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The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.
ABSTRACT
The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.
Subject(s)
COVID-19 , Critical Illness/therapy , Humans , Intensive Care Units , Pandemics , SARS-CoV-2ABSTRACT
Introduction: Information about how SARS-CoV-2 specific humoral and cellular response is modified by disease-modifying therapies (DMTs) is scarce. Objective: To investigate humoral and cellular responses to SARS-CoV-2 and factors for presenting them in a Barcelona cohort of pwMS. Methods: Retrospective cohort study of adult unvaccinated PwMS with confirmed COVID-19 with at least one SARS-CoV-2 antibody (Ab) determination included from February 2020 to May 2021 and followed until May 2021. Demographic, clinical and laboratory data were obtained. Humoral SARS-CoV-2 response was measured with commercial chemiluminescence immunoassays targeting specific Ab against spike (IgG-S) and nucleocapsid proteins (Ig-N), as per clinical practice. SARS-CoV-2 specific T-cell response was studied in 42 selected pwMS according to DMT by a whole blood Interferon-Gamma (IFN-y) Release Immunoassay. Humoral and cellular response was assesed using a logistic regression model corrected for age, sex, comorbidities, MS form, expanded disability status scale, DMT, COVID-19 severity and PCR result. Results: 145 pwMS were enrolled (mean age 46.8 years;64.1% female;18.6% progressive forms, 20.7% untreated, 22.8% on anti-CD20s therapies and 56.6% on other DMTs). Humoral and cellular tests were performed from 0.3 to 13.1 months after COVID-19. 121(83.5%) presented positive Ab (57.6% anti-CD20 therapy, 90.2% other DMTs, 93.3% untreated). Untreated patients presented higher Ig-N titres (34.3[128.8]) compared to those with anti-CD20s (0.08[0.13], p<0.01), and other DMTs (19.55[42.92], p<0.01). Humoral response persisted over 6 months in 12/12 untreated, 9/22 with anti-CD20s and 22/28 with other DMTs (p=0.068). 31/42(73.8%) presented cellular response (81.0% anti- CD20, 62.5% other DMTs, 80.0% untreated), with similar levels of IFN-y levels among DMTs. 5/12(41.7%) anti-CD20-treated PwMS with negative Ab presented cellular response. In the multivariate analysis, humoral response decreased in anti-CD20 therapy (OR 0.08[95% CI,0.01-0.55]) and was associated with male sex (OR 3.59[1.02-12.68]). Cellular response was associated with seropositivity (OR13.0[1.29-130.4]), but can be present even in the absence of Ab. Conclusions: Humoral response is altered by DMTs, specially in anti-CD20-treated PwMS. Cellular response is associated with seropositivity but can be present in anti-CD20-treated PwMS even in the absence of Ab. Both can be detected up to 13.1 months after COVID-19.
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Background: Information about humoral and cellular responses to SARS-CoV-2 vaccination in patients with Multiple Sclerosis (PwMS) and other autoimmune diseases (AID) is scarce. Objective: To determine humoral and cellular responses after SARS-CoV-2 vaccination in PwMS and anti-CD20-treated patients with other AID. Methods: Ongoing prospective study performed in two Catalan MS centres from February 2021. Unvaccinated adult pwMS and other anti-CD20-treated AID were recruited. Demographic, clinical and laboratory data were obtained. Whole blood samples were obtained before and 30-90 days after vaccination. The humoral response to SARS-CoV-2 was qualitatively and quantitatively measured before and after vaccination with commercial chemiluminescence immunoassays targeting SARS-CoV-2 antibodies against spike (TrimericS, IgG anti-S) and nucleocasid proteins (Elecsys, Ig anti-N). In 150 selected patients according to diseasemodifying therapy (DMT), the SARS-CoV-2 specific T-cell response was assessed after vaccination by a whole blood Interferon-Gamma Release immuno Assay (IGRA) that uses two Qiagen proprietary mixes of SARS-CoV-2 S protein (Ag.1 and Ag.2) selected to activate both CD4 and CD8 T cells. Results: 457 patients have been enrolled in the study (anti-CD20 therapy n=164, S1P DMTs n=37, natalizumab n=32, cladribine n=29, alemtuzumab n=31, other DMTs n=129, no DMT n=35). Participants characteristics are: mean age 48.1 years (SD 12.0), 69% female, 422 pwMS (29.4% progressive forms) and 35 with other AID, disease duration 13.9 years (IQR 14.1), median EDSS 3.0 (IQR 3.0). 450 have been fully vaccinated (94.2% mRNA vaccine). Pre-vaccination samples were collected 0.33 days (SD 0.5) before the first vaccine dose of which 12 (3.35%) had positive anti S/N immunoglobulin (Ig). As of June 30th, 42 post-vaccination samples have been obtained (1.3 months [SD 0.42] after the 2nd vaccination dose). Positive IgG rates were 44.8% (n=13/29) for CD20s, 100% (8/8) for other DMTs and 100% (4/4) for no DMT. No anti-N Ig were detected. Media titres of anti-S IgG were lower in anti-CD20-treated patients (7.8 [IQR 50.1]) compared to untreated patients (800 [0], p<0.01) or other DMTs (755 [228], p<0.01). Conclusions: Initial results of the study suggest blunted anti-S/N Ig response under anti-CD20 therapy. Knowledge of the cellular response in these patients will be crucial. Data from the cellular study and the completed humoral study will be presented at the meeting.
Subject(s)
COVID-19 , Pulmonary Fibrosis , Humans , Lung/diagnostic imaging , Pulmonary Fibrosis/diagnostic imaging , Radiography , SARS-CoV-2ABSTRACT
Introduction: COVID-19 infection has been characterized by respiratory manifestations. After the experience of the current pandemic, it has been shown that the profile of manifestations of this infection is not limited exclusively to the respiratory system. Purpose: To analyze the hepatobiliopancreatic manifestations of COVID-19 infection in patients admitted to the ICU. Methods: We carried out a retrospective observational study in a polyvalent ICU of a second level hospital. We collected demographic variables, severity scales at admission, comorbidities, analytical data, treatment received and mortality. Statistical analysis was performed with IBM.SPSS Statistics 25. Results: 101 patients were admitted, 26 requiring transfer due to the absence of beds in our Unit, which have been excluded from the present study. Of the 75 patients in our sample, 67.6% were male with a mean age of 59.66 years. 80.3% were obese, 43.4% had a history of arterial hypertension, 22.4% were diabetic, 48.7% were dyslipidemic, and 29.9% were bronchopathic. The average score on the APACHE II was 16.83 and on the SOFA 6.8. All were admitted with the diagnosis of severe respiratory failure secondary to atypical pneumonia without any clear hepatobiliopancreatic manifestation. 67.6% had a cytolic pattern (elevation of GOT and / or GPT), 64.9% had a cholestatic pattern (elevation of alkaline phosphatase, GGT and / or bilirubin). 5.4% suffered from ischemic hepatitis. None of the patients admitted to the unit had cholecystitis or acute pancreatitis. The multivariate analysis shows a statistically significant relationship between obesity (BMI> 30) and elevation of enzymes with a cytolytic pattern (P 0.04). None of the treatments administered to patients with COVID-19 infection (Kaletra, Rezolsta, Tocilizumab, Interferon, Chloroquine) is statistically significantly associated with any hepatobiliopancreatic manifestations. Among all the variables analyzed, no significant relationship with liver ischemia was observed. Conclusion: Despite the fact that the reason for admission of our patients was pulmonary involvement due to SARS-CoV-2, throughout their admission they developed alterations in the hepatobiliary profile, probably related to viral infection. In our cohort, it is evidenced that obesity could be a risk factor for increased cytolysis in COVID-19 infection, regardless of the drugs used.
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The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.
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The covid-19 disease (coronavirus disease 2019) is a novel disease causing a world pandemic. Its presentation varies from an asymptomatic infection to a pneumonia with acute respiratory distress syndrome. We present a case presenting initially as a covid-19 pneumonia together with a disseminated intravascular coagulopathy consisting of arterial and venous thrombosis in different locations and a shock requiring admission in the intensive care unit. The abnormal coagulation test in covid-19 patients have been described since the first cases observed in Wuhan, China, as well as an increased incidence of venous thrombosis. On the contrary, a higher incidence of arterial thrombosis has not been described in these patients. The unusual case we present could be a manifestation of this altered tests. Resumen La enfermedad covid-19 (coronavirus disease 2019) es una infección de reciente aparición que está causando una pandemia a nivel mundial. La forma de presentación varía desde una infección asintomática hasta una neumonía con síndrome de distrés respiratorio. Presentamos el caso de un paciente que presentó una neumonía por covid-19 junto a una coagulación intravascular diseminada con trombosis arterial y venosa en múltiples localizaciones y un estado de choque que requirió ingreso en unidad de cuidados intensivos. La alteración de las pruebas de coagulación en pacientes afectos de covid-19 se ha descrito desde los primeros casos observados en Wuhan, China, así como una mayor incidencia de trombosis venosas. Al contrario, una mayor incidencia de trombosis arterial no ha sido descrita en estos pacientes. El caso inusual que presentamos podría representar una manifestación de estas alteraciones.
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The covid-19 disease (coronavirus disease 2019) is a novel disease causing a world pandemic. Its presentation varies from an asymptomatic infection to a pneumonia with acute respiratory distress syndrome. We present a case presenting initially as a covid-19 pneumonia together with a disseminated intravascular coagulopathy consisting of arterial and venous thrombosis in different locations and a shock requiring admission in the intensive care unit. The abnormal coagulation test in covid-19 patients have been described since the first cases observed in Wuhan, China, as well as an increased incidence of venous thrombosis. On the contrary, a higher incidence of arterial thrombosis has not been described in these patients. The unusual case we present could be a manifestation of this altered tests.
Subject(s)
COVID-19/complications , Disseminated Intravascular Coagulation/etiology , COVID-19/diagnosis , Humans , Male , Middle AgedABSTRACT
The clinical picture of SARS-CoV-2 infection (COVID-19) is characterized in its more severe form, by an acute respiratory failure which can worsen to pneumonia and acute respiratory distress syndrome (ARDS), and get complicated with thrombotic events and heart dysfunction. Therefore, admission to the Intensive Care Unit (ICU) is common. Ultrasound, which has become an everyday tool in the ICU, can be very useful during COVID-19 pandemic, since it provides the clinician with information which can be interpreted and integrated within a global assessment during the physical examination. A description of some of the potential applications of ultrasound is depicted in this document, in order to supply the physicians taking care of these patients with a adapted guide to the intensive care setting. Some of its applications since ICU admission include verification of the correct position of the endotracheal tube, contribution to safe cannulation of lines, and identification of complications and thrombotic events. Furthermore, pleural and lung ultrasound can be an alternative diagnostic test to assess the degree of involvement of the lung parenchyma by means of the evaluation of specific ultrasound patterns, identification of pleural effusions and barotrauma. Echocardiography provides information of heart involvement, detects cor pulmonale and shock states. Resumen La infección por SARS-CoV-2 (COVID-19) se caracteriza por producir en las formas graves, un cuadro de insuficiencia respiratoria que puede evolucionar hacia neumonía y síndrome de distrés respiratorio agudo (SDRA), presentar complicaciones como fenómenos trombóticos y disfunción cardiaca, lo que motiva el ingreso en la Unidad de Cuidados Intensivos (UCI). La ecografía, convertida en una herramienta de uso habitual en la UCI, puede ser muy útil durante la pandemia COVID-19 ya que la información obtenida por el clínico puede ser interpretada e integrada en la valoración global durante la exploración del paciente. Este documento describe algunas de sus aplicaciones con el objetivo de proporcionar una guía a los médicos responsables adaptado al paciente crítico con COVID-19. Alguna de sus aplicaciones desde el ingreso en la UCI incluyen confirmar la correcta posición del tubo endotraqueal, facilitar la inserción segura de las vías, e identificar complicaciones y fenómenos trombóticos. Además, la ecografía pleuropulmonar puede ser una alternativa diagnóstica válida que permite evaluar el grado de afectación pulmonar, mediante el análisis de patrones ecográficos específicos, identificación del derrame pleural y del barotrauma. La ecocardiografía proporciona información acerca de la afectación cardíaca, detección del cor pulmonale y estados de shock.
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BACKGROUD: COVID-19 coagulopathy linked to increased D-dimer levels has been associated with high mortality (Fei Z et al. in Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet (London, England) 395(10229):1054-62, 2020). While D-dimer is accepted as a disseminated intravascular coagulation marker, rotational thromboelastometry (ROTEM) also detects fibrinolysis (Wright FL et al. in Fibrinolysis shutdown correlates to thromboembolic events in severe COVID-19 infection. J Am Coll Surg (2020). Available from https://pubmed.ncbi.nlm.nih.gov/32422349/ [cited 14 Jun 2020]; Schmitt FCF et al. in Acute fibrinolysis shutdown occurs early in septic shock and is associated with increased morbidity and mortality: results of an observational pilot study. Ann Intensive Care 9(1):19, 2019). We describe the ROTEM profile in severely ill COVID-19 patients and compare it with the standard laboratory coagulation test. METHODS: Adult patients diagnosed with COVID-19 admitted to the ICU were prospectively enrolled after Ethics Committee approval (HCB/2020/0371). All patients received venous thromboembolism prophylaxis; those on therapeutic anticoagulation were excluded. The standard laboratory coagulation test and ROTEM were performed simultaneously at 24-48 h after ICU admission. Sequential organ failure assessment (SOFA), disseminated intravascular coagulation (DIC) and sepsis-induced coagulopathy (SIC) scores were calculated at sample collection. RESULTS: Nineteen patients were included with median SOFA-score of 4 (2-6), DIC-score of 1 (0-3) and SIC-score of 1.8 (0.9). Median fibrinogen, D-dimer levels and platelet count were 6.2 (4.8-7.6 g/L), 1000 (600-4200 ng/ml) and 236 (136-364 109/L), respectively. Clot firmness was above the normal range in the EXTEM and FIBTEM tests while clot lysis was decreased. There was no significant correlation between ROTEM or D-dimer parameters and the SOFA score. CONCLUSION: In COVID-19 patients, the ROTEM pattern was characterized by a hypercoagulable state with decreased fibrinolytic capacity despite a paradoxical increase in D-dimer levels. We suggest that, in COVID-19 patients, the lungs could be the main source of D-dimer, while a systemic hypofibrinolytic state coexists. This hypothesis should be confirmed by future studies.