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1.
Frontiers in Immunology ; 13:988125, 2022.
Article in English | MEDLINE | ID: covidwho-2039680

ABSTRACT

Double negative (DN) B cells (CD27-IgD-) comprise a heterogenous population of DN1, DN2, and the recently described DN3 and DN4 subsets. In autoimmune disease, DN2 cells are reported to be precursors to autoreactive antibody secreting cells and expansion of DN2 cells is linked to elevated interferon levels. Severe SARS-CoV-2 infection is characterized by elevated systemic levels of pro-inflammatory cytokines and serum autoantibodies and expansion of the DN2 subset in severe SARS-CoV-2 infection has been reported. However, the activation status, functional capacity and contribution to virally-induced autoantibody production by DN subsets is not established. Here, we validate the finding that severe SARS-CoV-2 infection is associated with a reduction in the frequency of DN1 cells coinciding with an increase in the frequency of DN2 and DN3 cells. We further demonstrate that with severe viral infection DN subsets are at a heightened level of activation, display changes in immunoglobulin class isotype frequency and have functional BCR signaling. Increases in overall systemic inflammation (CRP), as well as specific pro-inflammatory cytokines (TNFalpha, IL-6, IFNgamma, IL-1beta), significantly correlate with the skewing of DN1, DN2 and DN3 subsets during severe SARS-CoV-2 infection. Importantly, the reduction in DN1 cell frequency and expansion of the DN3 population during severe infection significantly correlates with increased levels of serum autoantibodies. Thus, systemic inflammation during SARS-CoV-2 infection drives changes in Double Negative subset frequency, likely impacting their contribution to generation of autoreactive antibodies.

3.
Annals of Clinical Psychiatry ; 34(3):19-20, 2022.
Article in English | EMBASE | ID: covidwho-2030704

ABSTRACT

BACKGROUND: Adjustment disorders are now primary diagnoses in the trauma and stressrelated disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Adjustment disorder with anxiety (AjDA) is the development of emotional or behavioral symptoms considered excessive in response to stressful events, significantly impairing a person's ability to function in social, occupational, and/ or other situations. Traumatic experiences related to the COVID-19 pandemic may have increased rates of adjustment disorders, especially among those whose life routines were disrupted by pandemic-associated stress and anxiety. PH94B (3b-hydroxy-androsta-4,16-dien-ol) has shown rapid-onset efficacy in the treatment of social anxiety disorder (Liebowitz et al. Am J Psychiatry. 2014). PH94B is a neuroactive steroid administered as a nasal spray that engages olfactory chemosensory neurons, activating subsets of olfactory bulb neurons that project directly to the limbic amygdala regulating fear and anxiety circuits. OBJECTIVE: To assess the efficacy, safety, and tolerability of PH94B in adults with AjDA. METHODS: This is an exploratory, phase 2A, randomized, double-blind, 4-week, placebo-controlled, 2-arm study in adults with AjDA. The primary outcome is change from baseline to week 4 in the Hamilton Anxiety Rating Scale (HAM-A) total score after intranasal administration of PH49B 4 times daily vs placebo. Patients with a DSM-5 diagnosis of AjDA confirmed by the Mini-International Neuropsychiatric Interview (MINI) with Adjustment Disorders Module and a clinician-rated HAM-A score of ≥20 at screening (Visit 1), with ≤15% decrease at baseline (Visit 2, randomization) are eligible for inclusion. Secondary outcomes include change from baseline to week 4 in the Adjustment Disorder New Module Scale (ADNM), the International Adjustment Disorder Questionnaire (IADQ), the Clinical Global Impression of Improvement (CGI-I), and the Patient Global Impression of Change (PGI-C). Change from baseline in the Hamilton Depression Rating Scale (HAM-D) was exploratory. RESULTS: A total of 40 patients will be randomized (1:1 drug to placebo). The study design features the use of the ADNM and IADQ, newly developed according to ICD-11 criteria for evaluation of AjDA. While both are validated, neither has been tested in placebo-controlled clinical trials. Both scales begin with a list of stressors (18 for ADNM and 9 for IADQ);a yes answer to any 1 stressor triggers a series of questions about the frequency and duration of a patient's reaction to the stressor (ADNM) or quantifies symptoms in response to the stressor (IADQ). CONCLUSIONS: Anxiety disorders are the most prevalent psychiatric disorders and a leading cause of disability. Anxiety and impaired functioning are increasing, particularly in response to the COVID-19 pandemic, and no pharmacologic treatment is currently approved by the FDA for AjDA. PH94B, an investigational pherine nasal spray, is also being studied for treatment of other anxiety-related disorders.

4.
Asian Bioethics Review ; : 1-17, 2022.
Article in English | MEDLINE | ID: covidwho-2027752

ABSTRACT

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

5.
Br J Nurs ; 31(16):854-860, 2022.
Article in English | PubMed | ID: covidwho-2025624

ABSTRACT

This article presents a holistic view of re-designing learner-centred nursing curricula in a post-coronavirus pandemic digital educational system while maintaining authentic service user and carer involvement. Higher education is facing turbulent times through ever-increasing recruitment targets and financial demands. This is coupled with increased requirements from health professional bodies to involve students and service users and carers in co-creating curricula. Reflecting on the authors' collective experiences pre-COVID-19, during COVID-19 and looking to the future, they present a service user-and-student-led proposal for the future of digitally enabled nursing education that involves people with lived experience in an authentic way.

6.
BMJ Military Health ; 2022.
Article in English | ProQuest Central | ID: covidwho-2020235

ABSTRACT

ObjectiveThe selection process to the British Army’s Brigade of Gurkhas is rigorous, demanding and competitive. The ethos of recruitment to the Gurkhas is grounded in an overarching tenant: that selection is free, fair and transparent. The aim of this study was to retrospectively review reasons for potential recruits (PRs) to be deemed medically unsuitable or deferred suitability on medical grounds for selection to the Brigade of Gurkhas.MethodsA retrospective review was conducted by extracted data from published post-exercise reports for the past four years to ascertain numbers of PRs deemed medically fit, medically unsuitable or deferred suitability on medical grounds. The International Classification of Disease version 11 (ICD-11) codes were retrospectively assigned to code medical reasons for non-progression. Rates of medical non-progression were compared by year.ResultsA total of 3154 PRs were analysed between 2018 and 2021. There was no significant difference between PRs deemed medically fit and those deemed medically suitable or deferred on medical grounds over the study period (p=0.351). There was a significant difference in the ratio of PRs deferred on medical grounds and those deemed medically unsuitable over the study period (p<0.05).ConclusionSelection to the Gurkhas is extremely competitive. These data demonstrate that, overall, reasons for medical deferral or unsuitability have remained constant despite the impact of a global pandemic. These data reinforce the central tenant of Gurkha selection;that it continues to be free, fair, and transparent.

7.
Innovation in Aging ; 5:842-842, 2021.
Article in English | Web of Science | ID: covidwho-2012885
8.
Journal of Cystic Fibrosis ; 21:S91-S92, 2022.
Article in English | EMBASE | ID: covidwho-1996781

ABSTRACT

Objectives: Accurate identification of airway pathogens with appropriate eradication and suppressive therapies is associated with improved health outcomes in cystic fibrosis (CF). From 2020, 2 key factors may have influenced the ability to carry out this monitoring effectively;1. the COVID- 19 pandemic accelerated a transition to ‘virtual’ clinic visits and 2. the introduction of ELX/TEZ/IVA. Methods:We retrospectively analysed out-patient clinic attendance in the month of November for the years 2017–2021 and microbiological samples received from adults with CF in the regional microbiology department. Results: The total number of microbiological samples reduced in 2020 and 2021 (Table 1). In 2017, 211 samples were generated from 261 clinic visits (80.8%). For subsequent years this was 80.0%, 71.0%, 51.2% and 72.2%, respectively. The proportion of cough swabs significantly increased in 2021, (p < 0.001). In 20216 postal sampleswere provided, indicating that yield of a sample from a virtual appointment was at most 8.3%. Table 1. Overview of microbiological samples and clinic visits November 2017–2021 (Table Presented)Conclusions: There has been a marked reduction in microbiological samples in the years 2020 and 2021 despite relative preservation of total clinic appointments. This appears to be partly due to an increase in virtual clinic attendance without adequate remote sampling. The disproportionate increase in cough swabs in 2021 can be attributed to ELX/TEZ/IVA availability resulting in decreased sputum burden. This work identifies challenges in monitoring patients established on highly effective modulator therapy in new clinic models

9.
ASAIO Journal ; 68(SUPPL 1):58, 2022.
Article in English | EMBASE | ID: covidwho-1912944

ABSTRACT

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the disease entity COVID- 19. Initially, reports showed children had generally mild disease, with few requiring hospitalization. However, as of December 2021 in Arkansas, USA, children and young adults aged 24 years and younger accounted for approximately 166,000 cases with over 1,800 hospitalizations and 27 deaths (3 deaths under age 17). Comparatively, there have been over 6 million cases nationally in children and young adults, with over 1,000 deaths. Bacterial, viral, and fungal co-infections are known complications of viral respiratory illnesses that can lead to increased mortality. There have been multiple reports in adults on the incidence and type of co-infections seen with COVID-19, but few in pediatric patients. Adult data shows that co-infections are present in approximately 13-45% of patients with COVID-19, most commonly with bacterial pathogens of Mycoplasma pneumoniae and Haemophilus influenzae. Methods: We describe four patients with acute SARS-CoV-2 infection, requiring intubation, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), all of whom had methicillin-sensitive Staphylococcus aureus(MSSA) infections discovered within 24 hours of escalating respiratory support. This case series was determined as exempt by the Institutional Review Board at our institution. Results: Our cohort includes 4 patients with a median age of 18 years (range 16-19 years), all of whom required ECMO for acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia. The median time from intubation to ECMO cannulation was 139 hours (range 3-319 hours). All patients received targeted COVID-19 therapy with dexamethasone, remdesivir, and either tociluzimab or baricitinib during their hospitalization. These patient also all had culture positive MSSA infections from blood and mini-BAL cultures. Three of the four patients had a positive culture within 24 hours of requiring ECMO and one patient had a positive culture within 24 hours of requiring intubation. All of the patients were initially placed on venovenous (V-V) ECMO and three (75%) later required transition to venoarterial venous (VA-V) ECMO for worsening hemodynamics. All were initially cannulated with dual site femoral-internal jugular configuration. Femoral arterial cannulas were used for the transition to VA-V. Complications encountered during ECMO for these patients included GI bleeding (n=1), atrial flutter requiring cardioversion (n=1), lower extremity compartment syndrome (n=1), and dislodgement of a venous ECMO cannula (n=1). One patient received a tracheostomy while on ECMO. The median ECMO duration was 19.35 days (range 11-48.5 days). All patients were successfully decannulated from ECMO and all were discharged from the hospital alive, except one who is still requiring inpatient rehabilitation services. Discussion: We describe 4 pediatric patients with acute SARS-CoV-2 respiratory infections who were found to have MSSA co-infection within 24 hours of escalating respiratory support, all of whom eventually required ECMO support. In a recently published study, Pickens, et al reported that 25% of recently intubated adult COVID-19 patients have a bacterial co-infection. Limited data is available in pediatric patients. Staphylococcus aureus infections are among the most common bacterial infections worldwide. They are responsible for over 100,000 infections in the United States each year and lead to increased morbidity and mortality. All of our patients received immunemodulating therapies with either tociluzimab or baricitinib, which carry the risk of secondary infections due to immunosuppressive effects. Clinicians should maintain a high index of suspicion and be aware of the possibility of secondary bacterial infections in COVID- 19 patients, especially in those treated with immune-modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with SARS-CoV-2, as seen in our cohort. More investigation s needed to further describe co-infections in patients with COVID- 19 and to identify risk factors for the development of co-infections.

10.
PLoS One ; 17(5): e0267261, 2022.
Article in English | MEDLINE | ID: covidwho-1910595

ABSTRACT

Even early in the COVID-19 pandemic, adherence to physical distancing measures was variable, exposing some communities to elevated risk. While cognitive factors from the Health Belief Model (HBM) and resilience correlate with compliance with physical distancing, external conditions may preclude full compliance with physical distancing guidelines. Our objective was to identify HBM and resilience constructs that could be used to improve adherence to physical distancing even when full compliance is not possible. We examined adherence as expressed through 7-day non-work, non-household contact rates in two cohorts: 1) adults in households with children from Minnesota and Iowa; and 2) adults ≥50 years-old from Minnesota, one-third of whom had Parkinson's disease. We identified multiple cognitive factors associated with physical distancing adherence, specifically perceived severity, benefits, self-efficacy, and barriers. However, the magnitude, and occasionally the direction, of these associations was population-dependent. In Cohort 1, perceived self-efficacy for remaining 6-feet from others was associated with a 29% lower contact rate (RR 0.71; 95% CI 0.65, 0.77). This finding was consistent across all race/ethnicity and income groups we examined. The barriers to adherence of having a child in childcare and having financial concerns had the largest effects among individuals from marginalized racial and ethnic groups and high-income households. In Cohort 2, self-efficacy to quarantine/isolate was associated with a 23% decrease in contacts (RR 0.77; 95% CI 0.66, 0.89), but upon stratification by education level, the association was only present for those with at least a Bachelor's degree. Education also modified the effect of the barrier to adherence leaving home for work, increasing contacts among those with a Bachelor's degree and reducing contacts among those without. Our findings suggest that public health messaging tailored to the identified cognitive factors has the potential to improve physical distancing adherence, but population-specific needs must be considered to maximize effectiveness.


Subject(s)
COVID-19 , Physical Distancing , Adult , COVID-19/epidemiology , COVID-19/prevention & control , Child , Cognition , Cross-Sectional Studies , Humans , Middle Aged , Pandemics/prevention & control , SARS-CoV-2
12.
Pediatric Blood and Cancer ; 69(SUPPL 2):S210, 2022.
Article in English | EMBASE | ID: covidwho-1885436

ABSTRACT

Background: Incidental diagnosis of malignancy during unrelated illness is challenging, both for diagnostic clarity and therapeutic decision-making. There are reported cases of incidental discovery of Wilms tumor (WT) in the setting of trauma, but there are none reported in the setting of acute inflammatory illness, such as Multisystem Inflammatory Syndrome in Children (MIS-C), and thus no guidance regarding timing of definitive therapy. Objectives: We describe a patient with MIS-C and incidentally diagnosed WT in order to inform the management of future patients with simultaneously diagnosed malignancy and acute inflammatory illness. Design/Method: Information was obtained by retrospective review of the electronic health record. Results: A healthy 5-year-old female presented with six days of fever, cervical lymphadenopathy, urinary symptoms, and rash. Labs showed acute kidney injury, prompting imaging that revealed a left-sided renal mass, most likely a WT. The constellation of signs and symptoms was initially suggestive of obstructive uropathy resulting in urinary tract infection. However, subsequent development of conjunctivitis and oral mucosal changes, positive SARS-CoV-2 nucleocapsid antibodies, rising inflammatory markers, and mild-moderate coronary artery dilation on echocardiogram, made MIS-C the most fitting diagnosis. The patient rapidly improved after initiation of aspirin, methylprednisolone, and intravenous immunoglobulin. Cross-sectional imaging showed no metastatic disease or local tumor invasion. A multidisciplinary team of pediatric subspecialists discussed appropriate timing for upfront resection and decided to defer surgery for at least two weeks while inflammation resolved. Unfortunately, the patient continued to have ongoing inflammation requiring a prolonged steroid course, and surgery was ultimately deferred until one month following diagnosis. Surgery was uncomplicated and pathology demonstrated stage II favorable histology WT. Chemotherapy began on post-operative day 9. Conclusion: The lack of published cases of malignancy incidentally discovered during acute illness, coupled with the rapidly rising rate of pediatric cases of COVID-19 and MIS-C, present a challenge for clinicians who must treat the concurrent conditions. This report highlights the complexities of managing a WT for which upfront resection is standard in the United States. Surgery is typically performed quickly due to the fast-growing nature and risk of rupture. Reports of paraneoplastic inflammatory syndromes (non-WT) suggest that tumor resection in the setting of acute inflammation is safe, but pediatric data remains scarce. This patient's multidisciplinary team chose to delay tumor resection given the potential morbidity of major surgery in the setting of a raging inflammatory state. The patient had a favorable clinical outcome both in terms of her MIS-C and WT.

13.
South Afr J Crit Care ; 38(1)2022.
Article in English | MEDLINE | ID: covidwho-1884656

ABSTRACT

Background: The COVID-19 pandemic has had a significant impact on healthcare systems globally as most countries were not equipped to deal with the outbreak. To avoid complete collapse of intensive care units (ICUs) and health systems as a whole, containment measures had to be instituted. In South Africa (SA), the biggest intervention was the government-regulated national lockdown instituted in March 2020. Objectives: To evaluate the effects of the implemented lockdown and institutional guidelines on the admission rate and profile of non-COVID-19 patients in a regional and tertiary level ICU in Pietermaritzburg, KwaZulu-Natal Province, SA. Methods: A retrospective analysis of all non-COVID-19 admissions to Harry Gwala and Greys hospitals was performed over an 8-month period (1 December 2019 - 31 July 2020), which included 4 months prior to lockdown implementation and 4 months post lockdown. Results: There were a total of 678 non-COVID-19 admissions over the 8-month period. The majority of the admissions were at Greys Hospital (52.4%; n=355) and the rest at Harry Gwala Hospital (47.6%; n=323). A change in spectrum of patients admitted was noted, with a significant decrease in trauma and burns admissions post lockdown implementation (from 34.2 - 24.6%; p=0.006). Conversely, there was a notable increase in non-COVID-19 medical admissions after lockdown regulations were implemented (20.1 - 31.3%; p<0.001). We hypothesised that this was due to the gap left by trauma patients in an already overburdened system. Conclusion: Despite the implementation of a national lockdown and multiple institutional directives, there was no significant decrease in the total number of non-COVID-19 admissions to ICUs. There was, however, a notable change in spectrum of patients admitted, which may reflect a bias towards trauma admissions in the pre COVID-19 era. Contributions of the study: We describe the impact of the COVID-19 pandemic on critical care services in a resource-limited setting. We also demonstrate the ongoing need for intensive care unit beds within the public sector.

14.
Fertility and Sterility ; 116(3 SUPPL):e298, 2021.
Article in English | EMBASE | ID: covidwho-1881045

ABSTRACT

OBJECTIVE: Social media is a popular way to disseminate new information and opinions, perhaps furthered by the COVID-19 pandemic and quarantine. Our objective was to analyze information and sentiments posted regarding the COVID-19 vaccine (VAX) on fertility-related social media. MATERIALS AND METHODS: The search function of Instagram (IG) and Twitter (TW) was used to identify the first fifty accounts with the following terms: fertility doctor, fertility, OBGYN, infertility, TTC, and IVF. Accounts not in English, private, no posts in >1 year, or content unrelated to search terms were excluded. Accounts were evaluated for author type and categorized as physician (PH), individual (ID), or fertility center/fertility-related organization (FCO). Account demographics including number of followers and prior baseline post activity (number of likes/number of followers) were recorded. The VAX was approved on 12/11/2020 and posts dated 12/1/2020 - 2/28/2021 were reviewed. Posts mentioningthe VAX were analyzed for content: sentiment (positive, negative, or neutral), mention of research studies (RS), national guidelines (NG), personal experience (PE), side effects (SE), reproductive related (RR) content and post activity. Statistical analysis included Chi-Squared and Fisher's exact tests, with significance set to <0.05 (∗). RESULTS: 536 accounts were identified and 276 were included (133 IG and 143 TW). There were 104 PH accounts (45 IG, 59 TW), 91 ID accounts (62 IG, 29 TW), and 81 FCO accounts (26 IG, 55 TW). PH accounts were most associated with mention of COVID (83.7%∗) and VAX (68.3%∗), followed by FCO (37% COVID∗, 30.9% VAX∗), and ID (8.8% COVID∗, 6.6% VAX∗). PH was most associated with >1 VAX posts compared to FCO or ID (51.0% v 11.1% v 1.0%∗). Sentiments toward the VAX were largely positive for all groups (PH 90.3%, ID 71.4%, FCO 70%), or neutral (PH 9.7%, ID 28.6%, FCO 30%), with no negative posts identified. Trends in mentions and sentiments were similar on both IG and TW platforms. PH cited NG (24.6%∗) and RS (17.5%) more than ID and FCO, with most cited guidelines from ACOG, ASRM, and SMFM. ID posts were mostly PE (87.5%∗) and SE (57.1%∗). RR posts were most associated with FCO accounts (80%∗) which included pregnancy, infertility, and breastfeeding. Sub-group analysis of IG accounts showed an increase in activity on VAX posts compared to baseline by likes (PH 4.86% v 3.76%, ID 7.5% v 6.37%, FCO 2.49% v 0.52%) as well as comments (PH 0.35% v 0.28%, ID 0.90% v 0.69%, FCO 0.10% v 0.02%). CONCLUSIONS: Overall, the majority of posts expressed positive sentiments toward the VAX with no negative posts identified. PH were most likely to post about COVID-19, the VAX and guidelines. Few ID accounts posted but when present were about personal experiences or side effects and remained positive. IMPACT STATEMENT: There is an active conversation regarding COVID-19 and VAX information on social media, with the majority of posts expressing positive sentiment. Physicians play a large role in circulating information regarding the VAX on social media platforms, and can be influential in discussions of VAX guidelines and dispelling fertility myth.

16.
American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1880830
17.
Journal of Reproductive and Infant Psychology ; 40(2):xv, 2022.
Article in English | EMBASE | ID: covidwho-1868118

ABSTRACT

Background Lack of access to mental health services during the perinatal period is a significant public health concern in the UK. Barriers to accessing services may occur at multiple points in the care pathway. However, no previous reviews have investigated multilevel system barriers or how they might interact to prevent women from accessing services. Aims and Objectives To explore: 1) the barriers affecting women's access to PMH care at different points in the care pathway, 2) how women's access to and experience of PMH care has been affected by the COVID-19 pandemic. Methods Findings from two studies will be presented: 1) A systematic review of women, their family members', and healthcare providers' perspectives of barriers to accessing PMH care in the UK;2) A qualitative study with women's (n = 18) experiences of accessing PMH services during the COVID-19 pandemic, in an ethnically diverse population in South East London. Results The systematic review identified several key barriers that affected help seeking and treatment during the perinatal period. Barriers were identified at four levels: Individual (e.g. stigma, poor awareness), organisational (e.g. resource inadequacies, service fragmentation), sociocultural (e.g. language, cultural barriers) and structural (e.g. unclear policy). Interviews with women highlighted that pandemic restrictions and social distancing created additional difficulties and disruptions to accessing PMH care, and increased feelings of anxiety and isolation. Women expressed mixed feelings about remote delivery of PMH. Interpretation/Discussion Complex interlinked barriers to accessing PMH care exist within the UK and services have been further disrupted by the COVID-19 pandemic. To improve access to mental healthcare for women during the perinatal period, multilevel strategies are recommended which address individual, organisational, sociocultural and structural-level barriers at different stages of the care pathway. Conclusions To address barriers and reduce inequity in access to care, multilevel national strategies combined with targeted approaches to identifying and responding to local population needs are required.

18.
British Journal of Haematology ; 197(SUPPL 1):214-215, 2022.
Article in English | EMBASE | ID: covidwho-1861246

ABSTRACT

The risk of venous thromboembolism (VTE) increases by 10% in pregnancy to around 1/1000 and is a leading cause of death in pregnant women. Low molecular weight heparins (LMWHs) are the anticoagulant of choice for treatment of acute VTE during pregnancy. The initial dose of LMWH is weight based but currently there is lack of evidence supporting routine Anti-Xa monitoring during pregnancy and LMWH dose adjustments based on Anti-Xa levels. We conducted a retrospective audit of pregnant patients receiving therapeutic dose LMWH between October 2020 and October 2021 in a tertiary referral centre. The aim of this audit was to review LMWH dosages required in pregnancy to achieve peak Anti-Xa levels relative to weight-based and report maternal thrombotic or bleeding outcomes based on dose adjustments. A total of 21 pregnant patients were included who required therapeutic LMWH (Tinzaparin) during pregnancy. Of these, 10 (48%) had an acute VTE in the index pregnancy;one (4%) had recurrence of DVT despite weight adjusted LMWH. Ten (48%) were on long-term anticoagulation for a prior VTE including two with antithrombin deficiency and one with JAK 2 positive myeloproliferative disorder. They were all changed to LMWH during pregnancy. The site of acute VTE in index pregnancy (11) included: five (45%) deep vein thrombosis (DVT), three (28%) pulmonary emboli (PE), two (18%) had thromboses at an unusual site, and one patient (9%) had a superficial thrombophlebitis with gestational age range 7-40 weeks. Majority of pregnant patients (18/21;86%) had at least one peak Anti-Xa measured, and 12 (67%) patients had dose of LMWH increased at least once to achieve a target peak Anti-Xa level of 0.5-0.7 IU/ml. Five required two dose adjustments, and one required three dose adjustments. Nineteen patients have delivered and two have ongoing pregnancy. Twelve patients had spontaneous vaginal delivery, three assisted vaginal delivery and four had caesarean section for obstetric reasons. No patients had a recurrent thrombosis while on therapeutic dose LMWH and with dose adjustments as per peak anti-Xa level. One patient who presented with an acute DVT at 40 weeks of gestational age (GA) was managed with twice daily therapeutic dose Tinzaparin and insertion of an inferior vena cava (IVC) filter for anticoagulation interruption around delivery. The last dose Tinzaparin was 12 h prior to emergency Caesarean Section. She had postpartum haemorrhage with an estimated blood loss of 1800 ml but did not require blood product support and there was no evidence of progression of her symptoms of VTE or bleeding postoperatively when anticoagulation was resumed. Of note, six patients (29%) had a BMI >30 with five (83%) needing at least one adjustment of LMWH dose based on Anti-Xa levels and two (33%) needing > 2 dose increments with LMWH based on Anti-Xa monitoring. One patient had recurrence of PE on weight based LMWH dose with no recurrence of symptoms when the LMWH dose was adjusted to peak Anti-Xa level. None of the patients developed SARS-CoV-2 infection in the reported cohort. Fourteen (67%) pf pregnant had received their COVID-19 vaccination during this period . None of the thrombotic episodes were associated with COVID-19 vaccination. Although this audit study has limitations due to small patient numbers there was no evidence of increase in bleeding or thrombotic risk with ongoing anticoagulation with Anti-Xa monitoring during pregnancy..

19.
Annals of Behavioral Medicine ; 56(SUPP 1):S569-S569, 2022.
Article in English | Web of Science | ID: covidwho-1849393
20.
Journal of Heart and Lung Transplantation ; 41(4):S482-S482, 2022.
Article in English | Web of Science | ID: covidwho-1849179
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