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2.
Front Med (Lausanne) ; 8: 698268, 2021.
Article in English | MEDLINE | ID: covidwho-1592355

ABSTRACT

This case report describes a 60 year-old Black-American male with a past medical history of human immunodeficiency virus (HIV) infection and hyperthyroidism, who suffered a bilateral spontaneous pneumothorax (SP) in the setting of coronavirus disease 2019 (COVID-19) pneumonia. SP is a well-established complication in HIV-positive patients and only recently has been associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. While HIV and COVID-19 infections have been independently linked with increased risk of SP development, it is unknown if both infections interact in a synergistic fashion to exacerbate SP risk. According to the Centers for Disease Control and Prevention (CDC), patients living with HIV have a higher risk of developing severe COVID-19 infection and the mechanism remains to be elucidated. To the best of our knowledge, this is the first report of a HIV-positive patient, who in the setting of SARS-CoV-2 infection, developed bilateral apical spontaneous pneumothorax and was later found to have a left lower lobe tension pneumothorax. This case highlights the importance of considering SP on the differential diagnosis when HIV-positive patients suddenly develop respiratory distress in the setting of SARS-CoV-2 infection.

3.
J Thromb Thrombolysis ; 52(4): 1032-1035, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1525576

ABSTRACT

There is a need to discriminate which COVID-19 inpatients are at higher risk for venous thromboembolism (VTE) to inform prophylaxis strategies. The IMPROVE-DD VTE risk assessment model (RAM) has previously demonstrated good discrimination in non-COVID populations. We aimed to externally validate the IMPROVE-DD VTE RAM in medical patients hospitalized with COVID-19. This retrospective cohort study evaluated the IMPROVE-DD VTE RAM in adult patients with COVID-19 admitted to one of thirteen Northwell Health hospitals in the New York metropolitan area between March 1, 2020 and April 27, 2020. VTE was defined as new-onset symptomatic deep venous thrombosis or pulmonary embolism. To assess the predictive value of the RAM, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Of 9407 patients who met study criteria, 274 patients developed VTE with a prevalence of 2.91%. The VTE rate was 0.41% for IMPROVE-DD score 0-1 (low risk), 1.21% for score 2-3 (moderate risk), and 5.30% for score ≥ 4 (high risk). Approximately 45.7% of patients were classified as high VTE risk, 33.3% moderate risk, and 21.0% low risk. Discrimination of low versus moderate-high VTE risk demonstrated sensitivity 0.971, specificity 0.215, PPV 0.036, and NPV 0.996. ROC AUC was 0.703. In this external validation study, the IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized COVID-19 patients at low, moderate, and high VTE risk.


Subject(s)
COVID-19 , Risk Assessment , Venous Thromboembolism , COVID-19/complications , Humans , Inpatients , New York City , Retrospective Studies , Risk Factors , Venous Thromboembolism/diagnosis , Venous Thromboembolism/epidemiology
4.
JAMA Intern Med ; 181(12): 1612-1620, 2021 12 01.
Article in English | MEDLINE | ID: covidwho-1453495

ABSTRACT

Importance: Hospitalized patients with COVID-19 are at risk for venous and arterial thromboembolism and death. Optimal thromboprophylaxis dosing in high-risk patients is unknown. Objective: To evaluate the effects of therapeutic-dose low-molecular-weight heparin (LMWH) vs institutional standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19. Design, Setting, and Participants: The HEP-COVID multicenter randomized clinical trial recruited hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater from May 8, 2020, through May 14, 2021, at 12 academic centers in the US. Interventions: Patients were randomized to institutional standard prophylactic or intermediate-dose LMWH or unfractionated heparin vs therapeutic-dose enoxaparin, 1 mg/kg subcutaneous, twice daily if creatinine clearance was 30 mL/min/1.73 m2 or greater (0.5 mg/kg twice daily if creatinine clearance was 15-29 mL/min/1.73 m2) throughout hospitalization. Patients were stratified at the time of randomization based on intensive care unit (ICU) or non-ICU status. Main Outcomes and Measures: The primary efficacy outcome was venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause, and the principal safety outcome was major bleeding at 30 ± 2 days. Data were collected and adjudicated locally by blinded investigators via imaging, laboratory, and health record data. Results: Of 257 patients randomized, 253 were included in the analysis (mean [SD] age, 66.7 [14.0] years; men, 136 [53.8%]; women, 117 [46.2%]); 249 patients (98.4%) met inclusion criteria based on D-dimer elevation and 83 patients (32.8%) were stratified as ICU-level care. There were 124 patients (49%) in the standard-dose vs 129 patients (51%) in the therapeutic-dose group. The primary efficacy outcome was met in 52 of 124 patients (41.9%) (28.2% VTE, 3.2% ATE, 25.0% death) with standard-dose heparins vs 37 of 129 patients (28.7%) (11.7% VTE, 3.2% ATE, 19.4% death) with therapeutic-dose LMWH (relative risk [RR], 0.68; 95% CI, 0.49-0.96; P = .03), including a reduction in thromboembolism (29.0% vs 10.9%; RR, 0.37; 95% CI, 0.21-0.66; P < .001). The incidence of major bleeding was 1.6% with standard-dose vs 4.7% with therapeutic-dose heparins (RR, 2.88; 95% CI, 0.59-14.02; P = .17). The primary efficacy outcome was reduced in non-ICU patients (36.1% vs 16.7%; RR, 0.46; 95% CI, 0.27-0.81; P = .004) but not ICU patients (55.3% vs 51.1%; RR, 0.92; 95% CI, 0.62-1.39; P = .71). Conclusions and Relevance: In this randomized clinical trial, therapeutic-dose LMWH reduced major thromboembolism and death compared with institutional standard heparin thromboprophylaxis among inpatients with COVID-19 with very elevated D-dimer levels. The treatment effect was not seen in ICU patients. Trial Registration: ClinicalTrials.gov Identifier: NCT04401293.


Subject(s)
Anticoagulants/administration & dosage , COVID-19/diagnosis , Enoxaparin/administration & dosage , Heparin, Low-Molecular-Weight/administration & dosage , Heparin/administration & dosage , Hospital Mortality , Inpatients , Venous Thromboembolism/prevention & control , Adult , Aged , COVID-19/blood , COVID-19/therapy , Female , Fibrin Fibrinogen Degradation Products/analysis , Hospitalization , Humans , Intensive Care Units , Male , SARS-CoV-2 , Treatment Outcome
5.
Blood ; 136(Supplement 1):33-34, 2020.
Article in English | PMC | ID: covidwho-1339052

ABSTRACT

IntroductionThromboembolic outcomes have emerged as an important issue in sick hospitalized patients with COVID-19. Multiple pathogenetic mechanisms for thrombosis have been implicated, including endothelial dysfunction, increased von Willebrand factor (vWF), interleukin-6 release, and activation of/interaction between macrophages, monocytes, endothelial cells, platelets and lymphocytes. The actual rate of arterial and venous thromboembolic events (ATE and VTE) in hospitalized patients with COVID-19, especially in the immediate post-hospital discharge period, has not been fully elucidated, with most of the data derived from retrospective studies with small sample sizes.MethodsAgainst this background, we have designed and implemented an ongoing prospective registry (CORE-19) consisting of 11,249 consecutive hospitalized patients with COVID-19 from March 1st 2020 through May 31st 2020 using data derived from the Northwell Health System and the COVID-19 Research Consortium to study through 90-days post-discharge the rate of VTE and ATE, major bleeding, all-cause mortality, and other complications. We are capturing data of interest including demographic characteristics, co-morbidities, relevant medications, hospital setting, in-hospital treatment, thromboprophylaxis usage, key laboratory parameters, and 90-day thromboembolic and other key outcomes. A unified data repository (datamart) of hospitalized COVID-19 patients across multiple datasets from electronic health records, health informatics exchange, a dedicated radiology database, and a standardized data collection tool in REDCap, that includes telephonic calls up to 90 days post-discharge, is being implemented. A common data model (CDM) is utilized to ensure semantic interoperability between data originating from disparate sources. Northwell Health protocols stipulate the use of post-discharge low-molecular weight heparin, direct oral anticoagulants, or baby aspirin in hospitalized COVID-19 patients with high thrombotic risk features.ResultsOur cohort as of August 7, 2020 consists of complete follow up in 4,100 patients with a mean age of 61.0 years (SD: 17.0) with 54.7% males (Table 1). Preliminary data show an all-cause mortality rate of 4.29%, an overall thromboembolic rate of 3.51% (2.41% VTE and 1.10% ATE), a major bleeding rate of 1.61%, and a rehospitalization rate of 12.85%. Of patients with either DVT or PE post-discharge, 13.43% (9/67) died. The full dataset, including risk factors, comorbidities, key in-hospital and post-discharge medications including anticoagulant and antiplatelet agents, will be available at the time of presentation to the ASH congress.ConclusionOur ongoing registry is a large prospective study evaluating the rate of overall thromboembolic complications and all-cause mortality in hospitalized COVID-19 patients through 90 days post discharge. Current rates of thromboembolic events signify the importance of post-discharge surveillance and, potentially, post-discharge extended thromboprophylaxis, in this acutely ill medical population.

6.
World J Radiol ; 13(6): 192-222, 2021 Jun 28.
Article in English | MEDLINE | ID: covidwho-1305868

ABSTRACT

The first year of the coronavirus disease 2019 (COVID-19) pandemic has been a year of unprecedented changes, scientific breakthroughs, and controversies. The radiology community has not been spared from the challenges imposed on global healthcare systems. Radiology has played a crucial part in tackling this pandemic, either by demonstrating the manifestations of the virus and guiding patient management, or by safely handling the patients and mitigating transmission within the hospital. Major modifications involving all aspects of daily radiology practice have occurred as a result of the pandemic, including workflow alterations, volume reductions, and strict infection control strategies. Despite the ongoing challenges, considerable knowledge has been gained that will guide future innovations. The aim of this review is to provide the latest evidence on the role of imaging in the diagnosis of the multifaceted manifestations of COVID-19, and to discuss the implications of the pandemic on radiology departments globally, including infection control strategies and delays in cancer screening. Lastly, the promising contribution of artificial intelligence in the COVID-19 pandemic is explored.

7.
Res Pract Thromb Haemost ; 5(5): e12547, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1287399
8.
Blood ; 137(20): 2838-2847, 2021 05 20.
Article in English | MEDLINE | ID: covidwho-1236540

ABSTRACT

Thromboembolic events, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), and mortality from subclinical thrombotic events occur frequently in coronavirus disease 2019 (COVID-19) inpatients. Whether the risk extends postdischarge has been controversial. Our prospective registry included consecutive patients with COVID-19 hospitalized within our multihospital system from 1 March to 31 May 2020. We captured demographics, comorbidities, laboratory parameters, medications, postdischarge thromboprophylaxis, and 90-day outcomes. Data from electronic health records, health informatics exchange, radiology database, and telephonic follow-up were merged. Primary outcome was a composite of adjudicated VTE, ATE, and all-cause mortality (ACM). Principal safety outcome was major bleeding (MB). Among 4906 patients (53.7% male), mean age was 61.7 years. Comorbidities included hypertension (38.6%), diabetes (25.1%), obesity (18.9%), and cancer history (13.1%). Postdischarge thromboprophylaxis was prescribed in 13.2%. VTE rate was 1.55%; ATE, 1.71%; ΑCM, 4.83%; and MB, 1.73%. Composite primary outcome rate was 7.13% and significantly associated with advanced age (odds ratio [OR], 3.66; 95% CI, 2.84-4.71), prior VTE (OR, 2.99; 95% CI, 2.00-4.47), intensive care unit (ICU) stay (OR, 2.22; 95% CI, 1.78-2.93), chronic kidney disease (CKD; OR, 2.10; 95% CI, 1.47-3.0), peripheral arterial disease (OR, 2.04; 95% CI, 1.10-3.80), carotid occlusive disease (OR, 2.02; 95% CI, 1.30-3.14), IMPROVE-DD VTE score ≥4 (OR, 1.51; 95% CI, 1.06-2.14), and coronary artery disease (OR, 1.50; 95% CI, 1.04-2.17). Postdischarge anticoagulation was significantly associated with reduction in primary outcome (OR, 0.54; 95% CI, 0.47-0.81). Postdischarge VTE, ATE, and ACM occurred frequently after COVID-19 hospitalization. Advanced age, cardiovascular risk factors, CKD, IMPROVE-DD VTE score ≥4, and ICU stay increased risk. Postdischarge anticoagulation reduced risk by 46%.


Subject(s)
COVID-19/complications , Thromboembolism/epidemiology , Thromboembolism/etiology , Aged , Anticoagulants/therapeutic use , Female , Humans , Male , Middle Aged , Patient Discharge , Registries , Risk Factors , SARS-CoV-2 , Thromboembolism/prevention & control
9.
Blood ; 137(20): 2838-2847, 2021 05 20.
Article in English | MEDLINE | ID: covidwho-1172063

ABSTRACT

Thromboembolic events, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), and mortality from subclinical thrombotic events occur frequently in coronavirus disease 2019 (COVID-19) inpatients. Whether the risk extends postdischarge has been controversial. Our prospective registry included consecutive patients with COVID-19 hospitalized within our multihospital system from 1 March to 31 May 2020. We captured demographics, comorbidities, laboratory parameters, medications, postdischarge thromboprophylaxis, and 90-day outcomes. Data from electronic health records, health informatics exchange, radiology database, and telephonic follow-up were merged. Primary outcome was a composite of adjudicated VTE, ATE, and all-cause mortality (ACM). Principal safety outcome was major bleeding (MB). Among 4906 patients (53.7% male), mean age was 61.7 years. Comorbidities included hypertension (38.6%), diabetes (25.1%), obesity (18.9%), and cancer history (13.1%). Postdischarge thromboprophylaxis was prescribed in 13.2%. VTE rate was 1.55%; ATE, 1.71%; ΑCM, 4.83%; and MB, 1.73%. Composite primary outcome rate was 7.13% and significantly associated with advanced age (odds ratio [OR], 3.66; 95% CI, 2.84-4.71), prior VTE (OR, 2.99; 95% CI, 2.00-4.47), intensive care unit (ICU) stay (OR, 2.22; 95% CI, 1.78-2.93), chronic kidney disease (CKD; OR, 2.10; 95% CI, 1.47-3.0), peripheral arterial disease (OR, 2.04; 95% CI, 1.10-3.80), carotid occlusive disease (OR, 2.02; 95% CI, 1.30-3.14), IMPROVE-DD VTE score ≥4 (OR, 1.51; 95% CI, 1.06-2.14), and coronary artery disease (OR, 1.50; 95% CI, 1.04-2.17). Postdischarge anticoagulation was significantly associated with reduction in primary outcome (OR, 0.54; 95% CI, 0.47-0.81). Postdischarge VTE, ATE, and ACM occurred frequently after COVID-19 hospitalization. Advanced age, cardiovascular risk factors, CKD, IMPROVE-DD VTE score ≥4, and ICU stay increased risk. Postdischarge anticoagulation reduced risk by 46%.


Subject(s)
COVID-19/complications , Thromboembolism/epidemiology , Thromboembolism/etiology , Aged , Anticoagulants/therapeutic use , Female , Humans , Male , Middle Aged , Patient Discharge , Registries , Risk Factors , SARS-CoV-2 , Thromboembolism/prevention & control
10.
Thromb Haemost ; 121(12): 1684-1695, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1171416

ABSTRACT

Coronavirus disease-2019 (COVID-19) has been associated with significant risk of venous thromboembolism (VTE), arterial thromboembolism (ATE), and mortality particularly among hospitalized patients with critical illness and elevated D-dimer (Dd) levels. Conflicting data have yet to elucidate optimal thromboprophylaxis dosing. HEP-COVID (NCT04401293) is a phase 3, multicenter, pragmatic, prospective, randomized, pseudo-blinded, active control trial to evaluate efficacy and safety of therapeutic-dose low-molecular-weight heparin (LMWH) versus prophylactic-/intermediate-dose LMWH or unfractionated heparin (UFH) for prevention of a primary efficacy composite outcome of VTE, ATE, and all-cause mortality 30 ± 2 days post-enrollment. Eligible patients have COVID-19 diagnosis by nasal swab or serologic testing, requirement for supplemental oxygen per investigator judgment, and Dd >4 × upper limit of normal (ULN) or sepsis-induced coagulopathy score ≥4. Subjects are randomized to enoxaparin 1 mg/kg subcutaneous (SQ)/two times a day (BID) (creatinine clearance [CrCl] ≥ 30 mL/min) or 0.5 mg/kg (CrCl 15-30 mL/min) versus local institutional prophylactic regimens including (1) UFH up to 22,500 IU (international unit) daily (divided BID or three times a day), (2) enoxaparin 30 and 40 mg SQ QD (once daily) or BID, or (3) dalteparin 2,500 IU or 5,000 IU QD. The principal safety outcome is major bleeding. Events are adjudicated locally. Based on expected 40% relative risk reduction with treatment-dose compared with prophylactic-dose prophylaxis, 308 subjects will be enrolled (assuming 20% drop-out) to achieve 80% power. Distinguishing design features include an enriched population for the composite endpoint anchored on Dd >4 × ULN, stratification by intensive care unit (ICU) versus non-ICU, and the ability to capture asymptomatic proximal deep venous thrombosis via screening ultrasonography prior to discharge.


Subject(s)
Anticoagulants/administration & dosage , COVID-19/drug therapy , Enoxaparin/administration & dosage , Thromboembolism/drug therapy , Anticoagulants/adverse effects , COVID-19/complications , COVID-19/diagnosis , Clinical Trials, Phase III as Topic , Enoxaparin/adverse effects , Humans , Pragmatic Clinical Trials as Topic , Prospective Studies , Risk Assessment , Risk Factors , Thromboembolism/diagnosis , Thromboembolism/etiology , Time Factors , Treatment Outcome , United States , Venous Thromboembolism/diagnosis , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control
11.
J Thromb Thrombolysis ; 51(4): 897-901, 2021 May.
Article in English | MEDLINE | ID: covidwho-1118256

ABSTRACT

Venous thromboembolism (VTE) has emerged as an important issue in patients with COVID-19. The purpose of this study is to identify the incidence of VTE and mortality in COVID-19 patients initially presenting to a large health system. Our retrospective study included adult patients (excluding patients presenting with obstetric/gynecologic conditions) across a multihospital health system in the New York Metropolitan Region from March 1-April 27, 2020. VTE and mortality rates within 8 h of assessment were described. In 10,871 adults with COVID-19, 118 patients (1.09%) were diagnosed with symptomatic VTE (101 pulmonary embolism, 17 deep vein thrombosis events) and 28 patients (0.26%) died during initial assessment. Among these 146 patients, 64.4% were males, 56.8% were 60 years or older, 15.1% had a BMI > 35, and 11.6% were admitted to the intensive care unit. Comorbidities included hypertension (46.6%), diabetes (24.7%), hyperlipidemia (14.4%), chronic lung disease (12.3%), coronary artery disease (11.0%), and prior VTE (7.5%). Key medications included corticosteroids (22.6%), statins (21.2%), antiplatelets (20.6%), and anticoagulants (20.6%). Highest D-Dimer was greater than six times the upper limit of normal in 51.4%. Statin and antiplatelet use were associated with decreased VTE or mortality (each p < 0.01). In COVID-19 patients who initially presented to a large multihospital health system, the overall symptomatic VTE and mortality rate was over 1.0%. Statin and antiplatelet use were associated with decreased VTE or mortality. The potential benefits of antithrombotics in high risk COVID-19 patients during the pre-hospitalization period deserves study.


Subject(s)
COVID-19/complications , Pulmonary Embolism , Venous Thrombosis , COVID-19/epidemiology , COVID-19/physiopathology , COVID-19/therapy , Female , Fibrin Fibrinogen Degradation Products/analysis , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Incidence , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Mortality , New York/epidemiology , Outcome and Process Assessment, Health Care , Platelet Aggregation Inhibitors/therapeutic use , Protective Factors , Pulmonary Embolism/blood , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/mortality , Retrospective Studies , Risk Factors , SARS-CoV-2/isolation & purification , Venous Thrombosis/blood , Venous Thrombosis/diagnosis , Venous Thrombosis/etiology , Venous Thrombosis/mortality
12.
Exp Clin Transplant ; 20(3): 237-245, 2022 03.
Article in English | MEDLINE | ID: covidwho-1110660

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic raised unprecedented concerns in the hematopoietic stem cell transplant community. The diagnosis of COVID-19 in these transplant recipients may require extensive laboratory testing and high clinical suspicion, as atypical clinical manifestations or other respiratory viral infections are common in this patient population. The underlying malignancies, immunosuppressed state, frequently observed coinfections, and advanced age in some patients may also predispose them to worse clinical outcomes. Similar outcomes have been previously described with other human coronaviruses, including the severe acute respiratory syndrome coronavirus and the Middle East respiratory syndrome coronavirus. Many hematopoietic stem cell transplant organizations have issued elaborative guidelines that aim to prevent transmission and hence adverse patient outcomes. All potential donors are thoroughly screened, and donated products are cryopreserved in advance. Potential hematopoietic stem cell transplant recipients are also screened, and most nonurgent transplant cases with low risk of progression and/or death are deferred. Current hematopoietic stem cell transplant recipients should adhere to precaution and isolation measures, while their transplant units should also follow strict safety protocols, similar to other infectious outbreaks. The prolonged susceptibility of hematopoietic stem cell transplant recipients to respiratory viral infections might necessitate extending these measures even after the peak of the outbreak until a gradually return to normality is possible.


Subject(s)
COVID-19 , Hematopoietic Stem Cell Transplantation , Hematopoietic Stem Cell Transplantation/adverse effects , Hematopoietic Stem Cell Transplantation/methods , Humans , Pandemics/prevention & control , Transplant Recipients , Treatment Outcome
13.
Res Pract Thromb Haemost ; 5(2): 296-300, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1100941

ABSTRACT

BACKGROUND: Antithrombotic guidance statements for hospitalized patients with coronavirus disease 2019 (COVID-19) suggest a universal thromboprophylactic strategy with potential to escalate doses in high-risk patients. To date, no clear approach exists to discriminate patients at high risk for venous thromboembolism (VTE). OBJECTIVES: The objective of this study is to externally validate the IMPROVE-DD risk assessment model (RAM) for VTE in a large cohort of hospitalized patients with COVID-19 within a multihospital health system. METHODS: This retrospective cohort study evaluated the IMPROVE-DD RAM on adult inpatients with COVID-19 hospitalized between March 1, 2020, and April 27, 2020. Diagnosis of VTE was defined by new acute deep venous thrombosis or pulmonary embolism by Radiology Department imaging or point-of-care ultrasound. The receiver operating characteristic (ROC) curve was plotted and area under the curve (AUC) calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using standard methods. RESULTS: A total of 9407 patients were included, with a VTE prevalence of 2.9%. The VTE rate was 0.4% for IMPROVE-DD score 0-1 (low risk), 1.3% for score 2-3 (moderate risk), and 5.3% for score ≥ 4 (high risk). Approximately 45% of the total population scored high VTE risk, while 21% scored low VTE risk. IMPROVE-DD discrimination of low versus medium/high risk showed sensitivity of 0.971, specificity of 0.218, PPV of 0.036, and NPV of 0.996. ROC AUC was 0.702. CONCLUSIONS: The IMPROVE-DD VTE RAM demonstrated very good discrimination to identify hospitalized patients with COVID-19 as low, moderate, and high VTE risk in this large external validation study with potential to individualize thromboprophylactic strategies.

14.
Exp Clin Transplant ; 19(11): 1117-1123, 2021 11.
Article in English | MEDLINE | ID: covidwho-1067949

ABSTRACT

The severe acute respiratory syndrome coronavirus 2 pandemic has dramatically changed medical practices worldwide. These changes have been aimed both to reallocate resources toward fighting the novel coronavirus and to prevent its transmission during nonurgent medical and surgical interventions. Heart and lung transplantation could not be an exception, as most transplant centers have either restricted their activity to only urgent, lifesaving procedures or stopped these surgical procedures for various periods of time depending on the local virus epidemiology. The effect of this infection on the immunosuppressed heart and lung transplant recipient is still questionable; however, there are limited reports suggesting that there is no increased risk of transmission or more severe disease course compared with that shown in the general population. Transplant organizations have disseminated early recommendations as a guidance in a yet evolving situation. Finally, data suggest that lung transplant could potentially serve as an ultimate, lifesaving procedure for COVID-19-related end-stage respiratory failure in carefully selected patients.


Subject(s)
COVID-19/transmission , Heart Transplantation , Lung Transplantation , COVID-19/immunology , COVID-19/mortality , COVID-19/surgery , Delivery of Health Care, Integrated , Health Services Needs and Demand , Heart Transplantation/adverse effects , Heart Transplantation/mortality , Humans , Immunocompromised Host , Immunosuppressive Agents/adverse effects , Lung Transplantation/adverse effects , Lung Transplantation/mortality , Needs Assessment , Patient Safety , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome
15.
Thromb Haemost ; 121(8): 1043-1053, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1038232

ABSTRACT

BACKGROUND: We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients. METHODS: A retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit [ICU]) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts. CONCLUSION: In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.


Subject(s)
COVID-19/complications , Venous Thromboembolism/etiology , Adult , Age Factors , Aged , Blood Coagulation , COVID-19/blood , COVID-19/diagnosis , COVID-19/mortality , Hospitalization , Humans , Male , Middle Aged , Prevalence , Prognosis , Retrospective Studies , Risk Factors , SARS-CoV-2/isolation & purification , Venous Thromboembolism/blood , Venous Thromboembolism/diagnosis , Venous Thromboembolism/mortality , Young Adult
16.
Exp Clin Transplant ; 2020 Nov 27.
Article in English | MEDLINE | ID: covidwho-961807
17.
World J Clin Pediatr ; 9(2): 7-16, 2020 Sep 19.
Article in English | MEDLINE | ID: covidwho-814785

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on pediatric surgery. The infection is often asymptomatic and atypical in children, while overlapping presentations with other infectious diseases generate additional diagnostic challenges. The high probability of missed pediatric cases and the invasive nature of surgery generate great concern for widespread transmission in this setting. Current guidelines suggest that triage of cases should be made on a case-by-case basis by a multidisciplinary team of experts. Decision-making can be assisted by classifying cases as elective, urgent, or an emergency according to the risks of delaying their surgical management. A workflow diagram should ideally guide the management of all cases from admission to discharge. When surgery is necessary, all staff should use appropriate personal protective equipment, and high-risk practices, such as aerosol-generating tools or procedures, should be avoided if possible. Furthermore, carefully designed organizational protocols should be established to minimize transmission while ensuring the uninterrupted operation of pediatric surgery units. For example, surgical teams can be divided into small weekly rotating groups, and healthcare workers should be continuously monitored for COVID-19 symptoms. Additionally, team protocols in the operating room can optimize communication and improve adherence to personal protective equipment use. Isolated operating rooms, pediatric intensive care units, and surgical wards should be specifically designed for suspected or confirmed COVID-19 cases. Finally, transportation of patients should be minimal and follow designated short routes. All these measures can help mitigate the effects of the COVID-19 pandemic on pediatric surgery units.

18.
Exp Clin Transplant ; 2020 Sep 17.
Article in English | MEDLINE | ID: covidwho-792124
20.
Front Med (Lausanne) ; 7: 287, 2020.
Article in English | MEDLINE | ID: covidwho-615504

ABSTRACT

As the coronavirus disease 2019 (COVID-19) outbreak has rapidly evolved into a global pandemic, abdominal organ transplantation programs are currently facing multiple challenges. Transplant candidates and recipients are considered high-risk populations for severe disease and death due to COVID-19 as a result of their numerous underlying comorbidities, advanced age and impaired immune function. Emerging reports of atypical and delayed clinical presentations in these patients generate further concerns for widespread disease transmission to medical personnel and the community. The striking similarities between COVID-19 and other outbreaks that took place over the past two decades, like Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome, highlight the severity of the situation and dictate that extra measures should be taken by the transplant programs to avoid adverse outcomes. Transplant organizations are currently calling for strict screening and isolation protocols to be established in all transplant programs, for both organ donors and recipients. As the situation escalates, more radical measures might be necessary, including a temporary hold on non-urgent transplantations, resulting in serious ethical dilemmas between the survival of these patients and the safety of the community. Further data about these special populations could result in more individualized guidelines for abdominal organ transplantation in the era of COVID-19.

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