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Objective: To determine public acceptance of COVID-19 booster dose, to know about perceptions and possible barriers regarding the vaccine. Study Design: Analytical cross-sectional study. Place and Duration of Study: Conducted regarding the acceptance and perception of the vaccine booster dose among the residents of Rawalpindi Pakistan, from Jun till Aug 2022 Methodology: The sample size was 320 and collected using convenient sampling technique. The study included residents of Rawalpindi between ages 18 and 65. Google forms based on Health Belief Model were used for data collection. Data analysis was done using SPSS version 28 and summary statistics were produced using frequencies, percentages and mean. Chi-square test was also used to determine associations between categorical variables. Results: The results revealed that 74% of the participants' primary reason for getting booster dose was their own safety while major barrier to booster dose vaccination was side effects related to vaccine-62%. 81.3% people were willing to get the booster dose and 87.9% people agreed to receive booster dose for free. Chi-square test indicated a significant association between acceptance and perceived susceptibility, benefits and severity. Conclusion: In conclusion, our findings reveal that majority of people were willing to get booster dose primarily for own safety. However, counselling is required to decrease the perceived barriers to vaccination regarding side effects of the vaccine. © 2022, Army Medical College. All rights reserved.
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INTRODUCTION: We set out to analyse the efficacy of Procalcitonin in identifying secondary infections in Covid-19 patients. METHOD(S): In this Retrospective Observational Study, inclusion criteria comprised patients admitted to the Grange University Hospital intensive care unit with SARS-CoV-2 infection throughout the second and third waves of the pandemic. Data collected included daily biomarkers of inflammation such as white blood cell (WBC) counts and C-Reactive Protein (CRP) values and the presence of microbiologically proven secondary infections, quantifying the clinical burden of co-infections in these patients and calculating the microorganism prevalence. Continuous variables are presented as median (interquartile ranges). Differences in continuous variables were analysed using independent Mann-Whitney-U tests and one-way Analysis of Variances (ANOVA). RESULT(S): 121 patients were analysed in Wave 2 and 118 in Wave 3. Of these patients, 69 (57%) tested positive for an infection in Wave 2 and 52 (44%) in Wave 3. The median Procalcitonin levels (ng/mL) on Day 0 were 0.21 (IQR 0.1-1.44) in the No infection Group, compared to 0.24 (0.1-0.44) in the Infection Group for Wave 2. For Wave 3, the Procalcitonin levels (ng/mL) on Day 0 were 0.23 (0.1-.5325) in the No infection Group, compared to 0.14 (0.09-0.44) in the Infection Group. There was no significant difference between the two cohorts over the 14 days period. Similarly, no significant difference was observed in Wave 3 between the Infection vs No infection group. WCB and CRP values were also almost identical in the groups in both waves. Length of ICU stay was higher in the Infection Group in both Wave 2 (median 15 [IQR 0-48]) and Wave 3 (12.05 [0-72.5]) compared to the No Infection Group (Wave 2: 5 [0.08-23.8], Wave 3: 4 [0.6-12.9]). The mean 1st day of infection was Day 6 (SD 3.9) in Wave 2 and Day 4 (SD 3) in Wave 3. The most common pathogen associated with a bloodstream infection was Escherichia Coli (ECOL) in Wave 2 (n=3) and Staphylococcus Aureus (SAUR) in Wave 3 (n=3). The most common pathogen found in sputum culture results was Candida Albicans (CALB) in both Wave 2 (n=32) and Wave 3 (n=19). CONCLUSION(S): Despite initial promise, absolute Procalcitonin values failed to indicate the emergence of critical care-acquired infection in COVID-19 Patients.
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INTRODUCTION: COVID-19 imposed a great amount of challenge and stress on global health care professionals. Critically ill patients were started on empirical antibiotics and antimicrobials at the beginning of the pandemic. However, studies have later shown that less than 10% of the patients with COVID-19 had a co-existing bacterial infection. METHOD(S): The aim of this study was to calculate the prevalence of antimicrobial use on patients with COVID-19 in both waves two and three. The prime objective was to audit the use of antibiotics in patients with COVID-19 using the UK NICE guidelines and to observe the initial antimicrobials started for the patients in both waves. Information on patient demographic, antibiotics, laboratory results, and patient outcome were collected. Microsoft Excel Version 16.62 and IBM SPSS Statistics Version 28.0.1.1 (14) were used for statistical analysis. RESULT(S): In total 57.02% of patients from wave 2 had a confirmed infection. However, 80.2% of the wave 2 cohort were prescribed antibiotics. The antibiotics density for wave 2 averaged 0.92. 44.07% of the patients admitted during wave 3 had a laboratory-confirmed infection and 52.1% of the cohort were prescribed antibiotics. The average antibiotic density for wave three patients was 0.71. A higher proportion of this cohort had less cumulative days on antibiotics. 90 patients had 0-1 density in wave 3 compared to 84 in wave 2. Tazocin (Tazobactam and Pipercillin) was used the most in both cohort. It was used much more in wave 2 than wave 3. Tazocin is recommended by NICE as the first-line antimicrobial if the patient has severe symptoms, signs of sepsis, or is at higher risk of resistance. The second most common combination of initial antimicrobial was Amoxicillin and Clarithromycin. CONCLUSION(S): Physicians have become increasingly confident in diagnosing and managing patients with COVID-19 however, identification of a biomarker that can aid in distinguishing between viral and bacterial infections is necessary. During times of intense pressure and high demand, an objective marker, infection control liaison, and early microbiological input, helps minimise unnecessary antibiotic use.
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Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.
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Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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Objective: To measure incidence of COVID-19 vaccine breakthrough infections among health care workers vaccinated with both doses of Sinopharm Vaccine. Study Design: Prospective cohort study. Place and Duration of Study: All Military Institutes of Pakistan, from Feb to Jun 2021. Methodology: Detailed surveillance mechanism was developed before the start of Health Care Workers vaccination in Pakistan Military to report any PCR positive COVID-19 infection post vaccination. Among 39512 health care workers vaccine-ted with both doses of COVID-19 vaccine;those who developed COVID-19 infection ≥14 days post 2nd dose were included in the study. Total 124 participants till 30 Jun 2021 fulfilled the criteria of COVID-19 vaccine breakthrough infection and were analyzed. Results: Mean age of the participants was 38.8 ± 11 years. Males were 69.4% while females were 30.6%. Median duration from 2nd dose to development of COVID-19 vaccine breakthrough infection was 36.5 days (IQR, 26-62). Asymptomatic/mild infections were reported among 94.4% and only 5.6% had moderate disease. No severe/critical disease requiring oxygen supplementation or ventilator support was observed. Recovery rate was 100% with no mortality. There was no significant statistical association of age, gender, job category with COVID-19 vaccine breakthrough infection (p>0.05). Conclusion: Vaccines remain an important weapon in the battle against COVID-19. No vaccine is 100% effective against all strains of COVID-19;however among the completely vaccinated health care workers less severe disease was observed. There was no mortality. © 2021, Army Medical College. All rights reserved.
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Tension pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that has increased in incidence with the novel coronavirus disease 2019 pandemic. Although traditionally managed with conservative measures, we present the indications and methods for the first operative management of tension pneumomediastinum with concomitant SARS-CoV-2 infection.
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One of the complications of the novel coronavirus disease 2019 (COVID-19) is hypercoagulability. For this reason, patients presenting with COVID-19 are often put on therapeutic or intermediate anticoagulation upon hospitalization. A common issue of this anticoagulation is the progression to hypocoagulability resulting in hemorrhage. Therefore, monitoring the hemostatic integrity of critically ill COVID-19 patients is of utmost importance. In this case series, we present the cases of three coagulopathic COVID-19 patients whose anticoagulation was guided by thromboelastography (TEG). In each case, TEG permitted the clinical team to simultaneously prevent thrombotic and hemorrhagic events, a difficult task for COVID-19 patients admitted to the intensive care unit. The first two cases illustrate the utility of TEG to guide anticoagulant dosing for COVID-19 patients when the activated partial thromboplastin time (aPTT) is inaccurate. The first case was a severely ill COVID-19 patient with end-stage renal disease and a falsely elevated aPTT secondary to hypertriglyceridemia. The second case was a severely ill COVID-19 patient with chronic pulmonary disease who demonstrated a falsely elevated aPTT due to polycythemia and hemoconcentration. In both cases, TEG was sensitive to the hypercoagulability caused by the metabolic derangements which enabled the goal-directed titration of anticoagulants. The last case depicts a severely ill COVID-19 patient with an inherited factor V Leiden mutation who required abnormally high dosing to achieve therapeutic anticoagulation, guided by TEG. Hypercoagulopathic COVID-19 patients are difficult to anticoagulate without development of hypocoagulopathy. Treatment of these patients demands goal-directed therapy by diligent laboratory monitoring. This can be accomplished by the use of TEG coupled with aPTT to guide anticoagulation. This case series illustrates the necessity for active hemostatic monitoring of critically ill COVID-19 patients.
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BACKGROUND: The treatment of COVID-19 patients with heparin is not always effective in preventing thrombotic complications, but can also be associated with bleeding complications, suggesting a balanced approach to anticoagulation is needed. A prior pilot study supported that thromboelastography and conventional coagulation tests could predict hemorrhage in COVID-19 in patients treated with unfractionated heparin or enoxaparin, but did not evaluate the risk of thrombosis. METHODS: This single-center, retrospective study included 79 severely ill COVID-19 patients anticoagulated with intermediate or therapeutic dose unfractionated heparin. Two stepwise logistic regression models were performed with bleeding or thrombosis as the dependent variable, and thromboelastography parameters and conventional coagulation tests as the independent variables. RESULTS: Among all 79 patients, 12 (15.2%) had bleeding events, and 20 (25.3%) had thrombosis. Multivariate logistic regression analysis identified a prediction model for bleeding (adjusted R2 = 0.787, p < 0.001) comprised of increased reaction time (p = 0.016), decreased fibrinogen (p = 0.006), decreased D-dimer (p = 0.063), and increased activated partial thromboplastin time (p = 0.084). Multivariate analysis of thrombosis identified a weak prediction model (adjusted R2 = 0.348, p < 0.001) comprised of increased D-dimer (p < 0.001), decreased reaction time (p = 0.002), increased maximum amplitude (p < 0.001), and decreased alpha angle (p = 0.014). Adjunctive thromboelastography decreased the use of packed red cells (p = 0.031) and fresh frozen plasma (p < 0.001). CONCLUSIONS: Significantly, this study demonstrates the need for a precision-based titration strategy of anticoagulation for hospitalized COVID-19 patients. Since severely ill COVID-19 patients may switch between thrombotic or hemorrhagic phenotypes or express both simultaneously, institutions may reduce these complications by developing their own titration strategy using daily conventional coagulation tests with adjunctive thromboelastography.
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BACKGROUND: The recognition, prevention and treatment of venous thromboembolism (VTE) remains a major challenge in the face of the recent COVID-19 pandemic which has been associated with significant cardiovascular, renal, respiratory and hematologic complications related to hypercoagulability. There has been little literature thus far on the utility of screening ultrasound and the role of the clinical pharmacist in treating these patients. METHODS: We present a prospective pilot program of thirty-one consecutive COVID-19 patients who were provided four extremity screening ultrasounds for VTE on admission. This was coordinated by a clinical pharmacist as part of a multidisciplinary approach. Quantitative and qualitative data were recorded with the goal of describing the utility of the clinical pharmacist in ultrasound screening. Data collected include demographics, information on clinical symptoms or signs at presentation, and laboratory and radiologic results during the hospitalization from each individual electronic medical record. RESULTS: Nine of the thirty-one patients presented with VTE. Of the nine patients, there were twenty-two total clotted vessels, all of which were asymptomatic. The clinical pharmacist, as the coordinator for a multidisciplinary COVID-19 associated coagulopathy management team, drafted a screening and treatment protocol for anticoagulation prophylaxis and therapy of VTE after ultrasound findings. CONCLUSION: VTE screening of hospitalized COVID-19 patients reveals a significant number of asymptomatic VTEs and justifies diagnostic, prophylactic, and treatment measures coordinated by a clinical pharmacist.
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Background: The recognition, prevention and treatment of venous thromboembolism (VTE) remains a major challenge in the face of the recent SARS-COV-2 pandemic which has been associated with significant cardiovascular, renal, respiratory and hematologic complications related to hypercoagulability. There has been little literature thus far on the utility of screening ultrasound and role of the clinical pharmacist in treating these patients.Methods: We present a prospective pilot program of thirty-one consecutive SARS-CoV-2 patients who were provided four extremity screening ultrasounds for VTE on admission. This was coordinated by a clinical pharmacist as part of a multidisciplinary approach. Quantitative and qualitative data were recorded with the goal of describing the utility of the clinical pharmacist in ultrasound screening. Data collected include: demographics, information on clinical symptoms or signs at presentation, and laboratory and radiologic results during the hospitalization from each individual electronic medical record.Results: Nine of the thirty-one patients presented with venous thrombosis. Of the nine patients, there were twenty-two total clotted vessels, all of which were asymptomatic. The clinical pharmacist, as the coordinator for a multidisciplinary COVID-19 associated coagulopathy management team, drafted a screening and treatment protocol for anticoagulation prophylaxis and therapy of VTE after ultrasound findings.Conclusion: VTE screening of hospitalized SARS-CoV-2 patients reveals a significant number of asymptomatic VTEs and justifies diagnostic, prophylactic, and treatment measures coordinated by a clinical pharmacist.
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Venous Thromboembolism , Thrombophilia , Blood Coagulation Disorders , COVID-19 , Venous ThrombosisABSTRACT
INTRODUCTION: The World Health Organization (WHO) declared COVID-19 outbreak as a world pandemic on 12th March 2020. Diagnosis of suspected cases is confirmed by nucleic acid assays with real-time PCR, using respiratory samples. Serology tests are comparatively easier to perform, but their utility may be limited by the performance and the fact that antibodies appear later during the disease course. We aimed to describe the performance data on serological assays for COVID-19. MATERIALS AND METHODS: A review of multiple reports and kit inserts on the diagnostic performance of rapid tests from various manufacturers that are commercially available were performed. Only preliminary data are available currently. RESULTS: From a total of nine rapid detection test (RDT) kits, three kits offer total antibody detection, while six kits offer combination SARS-CoV-2 IgM and IgG detection in two separate test lines. All kits are based on colloidal gold-labeled immunochromatography principle and one-step method with results obtained within 15 minutes, using whole blood, serum or plasma samples. The sensitivity for both IgM and IgG tests ranges between 72.7% and 100%, while specificity ranges between 98.7% to 100%. Two immunochromatography using nasopharyngeal or throat swab for detection of COVID-19 specific antigen are also reviewed. CONCLUSIONS: There is much to determine regarding the value of serological testing in COVID-19 diagnosis and monitoring. More comprehensive evaluations of their performance are rapidly underway. The use of serology methods requires appropriate interpretations of the results and understanding the strengths and limitations of such tests.