Coagulation Abnormalities in Patients with COVID-19

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease. Bilateral pneumonia, acute respiratory failure, systemic inflammation, endothelial dysfunction, and coagulation activation have been described as key features of severe COVID-19. Fibrinogen and D-dimer are typically increased. Moreover, the risk for venous thromboembolism is markedly increased, especially in patients in the intensive care unit, often despite prophylactic-dose anticoagulation. Pulmonary microvascular thrombosis has also been described and the risk for arterial thrombotic diseases also appears to be increased. Bleeding is less common than thrombosis but can occur. Evaluation for venous thromboembolism may be challenging because symptoms of pulmonary embolism overlap with COVID-19, and imaging studies may not be feasible in all cases. All inpatients should receive thromboprophylaxis unless contraindicated. In hospitalized patients with COVID-19, prophylactic dosing rather than more intensive (intermediate or therapeutic) dosing are suggested. On the other hand, therapeutic dose of anticoagulation is always appropriate to treat deep venous thrombosis or pulmonary embolism, unless contraindicated. This article reviews evaluation and management of coagulation abnormalities in individuals with COVID-19. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

The incidence of deep vein thrombosis following COVID-19 vaccination in an Australian population

Introduction: After the COVID-19 vaccination roll out in March 2021 patients began presenting to a Victorian Emergency Department with lower limb pain following their vaccination. As a result, requests for ultrasound examinations, to exclude post vaccination deep vein thrombosis (DVT) began appearing. Method(s): A retrospective study of ultrasound examinations and their result over a 1-year period was undertaken. Patients were identified who had a clinical indication of having been referred following COVID-19 vaccination. Bivariate analysis was conducted, using logistic regression, to determine the strength of association between independent variables. Result(s): The study found 1689 patients had a lower limb DVT ultrasound examination. Ultrasound was positive for DVT in 244/1689 patients (14.4%). 104/1689 (6.1%) patients presented for ultrasound following COVID-19 vaccination. Six of these were found to have DVT detected. The association between post vaccination and DVT was an odds ratio (OR) of 0.347 (95% CI 0.150 to 0.799, p = 0.013). All patients had recently received AstraZeneca (AZ) vaccine. Four patients were diagnosed with superficial vein thrombosis (SVT) post vaccination. Nineteen patients were identified as COVID-19 positive. Three of these had DVT detected. Conclusion(s): This study found 6 patients out of 1689 (0.35%) of lower limb ultrasound examinations over a one-year period, were positive for DVT after COVID-19 vaccination. Take home message: The results showed post vaccination patients were less likely to be diagnosed with a DVT than the population referred who had not had recent vaccination.

Association between Type 2 Diabetes Mellitus and Covid-19 Severity: A Literature Review

We conducted a review and evaluated the already documents reports for the relationship among diabetes and COVID-19. The review outcome shows that the COVID-19 severity seems to be greater among patients with diabetes as comorbidity. So, strict glycemic control is imperative in patients infected with COVID-19. Thus, world-wide diabetes burden and COVID-19 pandemic must be deliberated as diabetes increases the COVID-19 severity. Established on this, it is precise significant to follow specific treatment protocols and clinical management in COVID-19 patients affected with diabetes to prevent morbidity and mortality.Copyright © 2023 The Authors.

The use of venovenous extracorporeal membrane oxygenation in COVID-19: An updated systematic review and meta-analysis of clinical outcomes

Objectives: The objective of this study is to assess the clinical benefits and potential risks of using venovenous extracorporeal membrane oxygenation (VV ECMO) as a treatment for COVID-19 patients with severe respiratory failure. Method(s): Relevant studies were identified through searches of electronic databases, including PubMed, EMBASE, and the Cochrane Library, from January 2020 to December 2022. We included observational studies on adult patients who received venovenous (VV) ECMO support for COVID-19-induced ARDS. The primary outcome was in-hospital mortality, 3-month mortality, and complications associated with VV ECMO. Statistical analysis was performed using R version 4.0.3 and the metafor and meta packages. Result(s): The final analysis included 39 studies comprising 10,702 patients. In-hospital mortality for adults receiving ECMO was 34.2% (95% CI: 28.5% - 40.3%;I2 = 93%), while the 3-month mortality rate was 50.2% (95% CI: 44.4% - 56.0%;I2 = 51%). Bleeding requiring transfusion occurred in 33.7% of patients (95% CI, 23.9 - 45.1;I2 = 96%). The pooled estimates for other complications were as follows: overall thromboembolic events 40.9% (95% CI, 24.8 - 59.3;I2 = 97%), stroke 8.7% (95% CI, 5.7 - 13.2;I2 = 72%), deep vein thrombosis 15.4% (95% CI, 9.7 - 23.6;I2 = 80%), pulmonary embolism 15.6% (95% CI, 9.3 - 25.1;I2 = 92%), gastrointestinal haemorrhage 8.1% (95% CI, 5.5 - 11.8;I2 = 56%), and the need for any renal replacement therapy in 38.0% of patients (95% CI, 31.6 - 44.8;I2 = 84%). Bacterial pneumonia occurred in 46.4% of patients (95% CI, 32.5 - 61.0;I2 = 96%). Conclusion(s): Venovenous extracorporeal membrane oxygenation (VV ECMO) may be an effective treatment option for COVID-19 patients with severe respiratory failure. The use of VV ECMO was associated with reduced in-hospital and 3-month mortality. However, bleeding is a common complication that should be closely monitored. Further research is needed to determine the optimal use of VV ECMO in this patient population and to identify factors that may predict a favourable response to treatment.

A review of venous thromboembolism in India.

Venous thromboembolism (VTE), which entails the formation of a thrombus (blood clot) in a vein, has a significant disease burden worldwide. While VTE has traditionally been considered to predominantly affect Caucasian populations, recent studies have indicated a gradual shift in the disease burden towards Asian populations, with added significance of it being a key driver of post-operative mortality. It is imperative to develop a sound understanding of the various factors that affect VTE in stratified local populations. However, there is a glaring paucity of quality data on VTE and its ramifications among Indians - both in terms of quality of life and cost of healthcare. This review aims to throw light on the disease burden, epidemiology, risk factors, environmental factors, food and nutrition that plays a key role in VTE. We also explored the association of VTE with coronavirus disease 2019 to grasp the interplay between the two most significant public health crises of our time. It is vital to place a special emphasis on future research on VTE in India to plug the gaps, which exist in our current knowledge of the disease, particularly with respect to Indian population.

Investigating the risk of deep vein thrombosis with JAK inhibitors: a disproportionality analysis using FDA Adverse Event Reporting System Database (FAERS).

BACKGROUND: Janus kinase (JAK) inhibitors are immune-modulating medications used to treat conditions including rheumatoid arthritis, COVID-19, ulcerative colitis, atopic dermatitis, myelofibrosis, and polycythemia Vera. However, these medications have been associated with higher incidence of deep vein thrombosis. The objective of this study was to investigate potential safety signals for DVT associated with JAK inhibitors using disproportionality analysis from the FDA Adverse Event Reporting System (FAERS) database. RESEARCH DESIGN AND METHODS: The authors retrospectively investigated case/non-case analysis using Openvigil 2.1-MedDRA-v24 (2004Q1 to 2022Q4). The preferred term used was 'deep vein thrombosis,' and the drugs included were baricitinib, tofacitinib, and upadacitinib. Reporting odds ratio, proportional reporting ratio, and information component were used to detect signals. RESULTS: Overall 114,005 AE reports related to JAK inhibitors were identified, of which 647 reports (baricitinib - 169, tofacitinib - 425, and upadacitinib - 53) associated with DVT were obtained from FAERS. On analysis, baricitinib and tofacitinib had greater signal strength for age group of 65-100 years and all three had the highest signal strength for male gender. CONCLUSIONS: Our study identified signals for DVT with baricitinib, tofacitinib, and upadacitinib. Further research using well-designed epidemiological data is needed to validate these results.

Fondaparinux Sodium: Recent Advances in the Management of Thrombosis.

Fondaparinux sodium is a chemically synthesized selective factor Xa inhibitor approved for the prevention and treatment of venous thromboembolic events, that is, deep vein thrombosis, pulmonary embolism, and superficial vein thrombosis, in acutely ill (including those affected by COVID-19 or cancer patients) and those undergoing surgeries. Since its approval in 2002, the efficacy and safety of fondaparinux is well demonstrated by many clinical studies, establishing the value of fondaparinux in clinical practice. Some of the advantages with fondaparinux are its chemical nature of synthesis, minimal risk of contamination, 100% absolute bioavailability subcutaneously, instant onset of action, a long half-life, direct renal excretion, fewer adverse reactions when compared with direct oral anticoagulants, and being an ideal alternative in conditions where oral anticoagulants are not approved for use or in patients intolerant to low molecular weight heparins (LMWH). In the last decade, the real-world use of fondaparinux has been explored in other conditions such as acute coronary syndromes, bariatric surgery, in patients developing vaccine-induced immune thrombotic thrombocytopenia (VITT) and in pregnant women with heparin-induced thrombocytopenia (HIT), or those intolerant to LMWH. The emerging data from these studies have culminated in recent updates in the guidelines that recommend the use of fondaparinux under various conditions. This paper aims to review the recent data and the subsequent updates in the recommendations of various guidelines on the use of fondaparinux sodium.

Coagulopathy in Covid-19 patients an observational institutional study at MGMMC, Indore

Introduction- Corona virus disease 2019 (COVID-19), first identified in Wuhan, China in December of 2019, has become a worldwide pandemic. It was declared by (WHO) World health organization as Public health emergency on 30th January 2020. Although respiratory compromise is the cardinal feature of the disease, early studies have suggested that elevated circulating D-dimer levels are associated with mortality, 1, 2 suggesting a distinct coagulation disorder associated with COVID-19 Materials And Methods- All patients aged ≥18 years with confirmed COVID-19 (defined as a positive SARS-CoV-2 reverse-transcriptase polymerase chain reaction test by nasopharyngeal/oropharyngeal swab or sputum specimen) were included in the study. The incidence of bleeding and thrombotic events in COVID-19 patients was assessed. Pulmonary embolism (PE) and deep vein thrombosis (DVT) were confirmed radiographically. Results of 6 routinely drawn coagulation-based laboratory parameters (PT, international normalized ratio [INR], activated partial thromboplastin time [aPTT], D-dimer, fibrinogen, and platelet count), 2 laboratory measures of inflammation (C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]), were evaluated and compared between patients with thrombotic complications (composite of venous thromboembolism, arterial thromboembolism, and clinically significant non-vessel thrombotic complications), patients with bleeding complications, and patients without bleeding or thrombotic complications. Result- In this study, we report the haemostatic manifestations and bleeding and thrombotic complications of 100 COVID-19 patients. In a population managed with standard doses of prophylactic anticoagulation, we found a radiographically confirmed venous thromboembolic rate of 4.8% (7.6% in critically ill patients) Conclusion- In conclusion, we observed that COVID-19 was associated with similar rates of thrombosis and bleeding as seen in hospitalized patients with similar degrees of critical illness. Elevated D-dimer levels at initial presentation predicted bleeding complications, thrombotic complications, critical illness, and death. Beyond D-dimer, thrombosis was primarily associated with inflammatory markers rather than coagulation parameters. We additionally found that elevations in D-dimer on admission predicted critical illness and death, as well as bleeding and thrombotic complications. Inflammatory markers, including CRP and ESR, were also associated with thrombosis. [ FROM AUTHOR] Copyright of Journal of Cardiovascular Disease Research (Journal of Cardiovascular Disease Research) is the property of Journal of Cardiovascular Disease Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Janus Kinase Inhibitors in Rheumatoid Arthritis Patients: Real-World Experience from a Regional Centre in Uk

Background/Aims Tofacitinib and baricitinib were the first orally available, targeted synthetic Janus kinase (JAK) inhibitors approved for the treatment of rheumatoid arthritis (RA) in the UK. Evidence suggests that JAK inhibitors are as efficacious as biological DMARDs in the treatment of RA. Their safety profile has been demonstrated in long term extension studies and RCTs. However, real-world, long-term data remains as important in bridging the gap between controlled studies and routine practice. We report our initial real-world experience of a cohort of RA patients commenced on JAKi before the SARS-CoV-2 pandemic within a regional centre in the UK. Methods All patients commenced on JAKi for the treatment of RA between February 2018 and March 2020 were identified from our in-house database. Data was retrospectively collected from clinical notes and electronic health records from February 2018 up until April 2022. This included patient demographics, disease duration, serological status, concurrent csDMARD usage, history of bDMARD exposure, duration of use and reason for discontinuation of the drug if appropriate. DAS- 28 scores were recorded at baseline and quarterly. SPSS (version 22.0) was used for data analysis. Results One hundred thirty patients were treated with JAK inhibitors (Tofacitinib 22%, Baricitinib 78%);80% female, mean (S.D.) age 61.5 (12.3) years. 92 (70.8%) patients were seropositive. 70 (53.8%) patients were on concurrent csDMARDs and 23 (17.7%) on concurrent steroids. The mean number of previous bDMARDs was 1.8 +/- 1.7;41 (31.5%) were bDMARD naive. The mean baseline DAS-28 ESR (S.D.) score was 5.96 (0.96). There were significant differences in mean DAS- 28 ESR scores (compared with baseline) of 1.54, 1.96, 2.41, 2.33 and 1.80 at 3, 6, 12, 18 and 24 months respectively (p<0.0001). Mean DAS-28 ESR scores were not statistically significant between bDMARD naive patients and those that had previously received bDMARDs. Overall JAKi retention rate was 66.9% with a mean follow up duration of 27.4+/-13.1 months. Persistence was 88.5%, 76.9%, 73.2% and 68.5% at 6, 12, 18, and 24 months, respectively. Of the 38 patients who stopped JAK inhibitors, 11 stopped due to inefficacy (6, primary inefficacy). 3 patients were lost to follow-up and 6 deceased. Cause of death was sepsis (2), venous thromboembolism (1) and unknown (3). 18 patients stopped because of adverse events (AEs). The most common AEs were recurrent infections (11), gastrointestinal side effects (9), lymphopenia (7), thromboembolic events (6) and herpes zoster (5). In total 6 (4.1%) patients had thromboembolic events which included pulmonary embolism (4) and deep vein thrombosis (1) and central retinal artery thrombosis (1). Conclusion JAK inhibitors in this real-world population of RA patients were effective in reducing disease activity and patients had high persistence rates. Recurrent infections, herpes zoster and thrombo-embolism remain adverse events of concern.

Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

The Impact of COVID-19 Infection on Diabetic Ketoacidosis Acidosis Hospitalization: A Nationwide Analysis

Objective: One of the potentially fatal consequences for diabetic patients is diabetic ketoacidosis acidosis (DKA), which is also linked to poor hospital outcomes. There is no much information in literature about COVID-19 and how it relates to other hospitalizations. The impact of COVID-19 on in-hospital mortality and other clinically relevant outcomes for DKA patients is being investigated for the first time in this study. Method(s): Patients admitted with a primary diagnosis of DKA with or without a subsequent diagnosis of COVID-19 Infection were found in the National Inpatient Sample (NIS) Database 2020. Patients were divided into two groups: those who have COVID-19 and those who don't. Univariate and multivariate logistic regression models were utilized to account for frequent confounders and assess the risk of mortality and in-hospital outcomes between the two groups. Result(s): The total of 110,130 DKA admissions were identified between Jan and Dec 2020. COVID-19 Infection was diagnosed in 2,504 patients (2.2%). The average age of the cohort sample was 35 years old, 51% were male, and 60% were white. The average length of stay (LOS) was 3 days, and the average total hospital charges were 33,132 US dollars. The total number of patients who died was 225 patients. When the two groups were compared, COVID-19 Infection was associated with an increased risk of in-hospital mortality among DKA patients (OR 5.3, 95% CI 1.7-15.9, p=0.003). COVID-19 patients had a higher risk of acute respiratory failure (OR 2.9, 95% CI 1.7-3.9, p< 0.001) and septic shock (OR 3.9, 95% CI 1.5-9.8, p=0.003). There was no significant difference between the COVID-19 and non-COVID-19 groups in the risk of acute coronary syndrome (OR 1.2, 95% CI 0.49-3, p=0.66), cardiac arrest (OR 2, 95% CI 0.5-7.9, p=0.31), hypokalemia (OR 1.14, 95% CI 0.92-1.4, p=0.214), deep vein thrombosis (OR 0.59, 95% CI 0.14-2.4, p=0.47), or pulmonary embolism (OR 3.6, 95% CI 0.84 - 15.4, p=0.083). COVID-19 patients had a longer mean LOS (4.2 vs 2.9 days, p< 0.001) and higher mean total hospital charges (41,216 vs 32,973 $, p=0.004). Discussion/Conclusion: Patients admitted with DKA and concomitant COVID-19 infection found to have a higher risk of in-hospital mortality and worse hospital outcomes, particularly acute respiratory failure and septic shock. In comparison to non-COVID patients, COVID-19 patients have a longer mean LOS and a higher mean of total hospital charges.Copyright © 2023

The Complexities of Managing Hypertriglyceridemia-Induced Pancreatitis in a Critically-Ill COVID-19 Patient

Introduction: Hypertriglyceridemia-induced pancreatitis (HTP) is a variant of pancreatitis requiring unique management. The complications of COVID-19 and its treatments can make HTP therapy more nuanced. This case describes a patient who presented in diabetic ketoacidosis (DKA) with HTP, and COVID-19. The patient developed renal and respiratory failure, necessitating hemodialysis (HD) and extracorporeal membrane oxygenation (ECMO), complicating an otherwise straightforward medical management plan. Case Description: A morbidly obese (BMI 38.9 kg/m2) 43-year-old male presented to an outside hospital with abdominal pain, and vomiting, and was found to have HTP with triglycerides (TG) >2000 mg/dL (<149 mg/dL) and presumed new-onset type 2 Diabetes (HbA1c 10.9%) with DKA. Treatment with fluids, intravenous (IV) insulin infusion and plasmapheresis were initiated. He developed hypoxia after receiving over 17 liters of fluids and was intubated, subsequently developing renal failure and was transferred to our tertiary center for HD and ECMO. On admission, he tested positive for COVID-19, rhabdomyolysis [creatinine kinase 5600 U/L (30-200 U/L)], HTP [TG 783 mg/dL (<149 mg/dL), lipase 461 U/l (7-60 U/L)], glucose 269 mg/dL (not in DKA), transaminitis [AST 184 U/L (4-40 U/L), ALT 61 U/L (4-41 U/L)] and renal failure (GFR 10 ml/min/1.73m2). IV insulin infusion was initiated for hyperglycemia worsened by COVID-19 dexamethasone treatment. Plasmapheresis was performed twice with minimal effect at maintaining a low TG. Fenofibrate was not initiated due to renal failure;Lovaza could not be given via oral gastric tube;Atorvastatin was attempted once rhabdomyolysis resolved, with subsequent worsening of liver function tests. Heparin infusion was initiated for deep vein thrombosis treatment and HTP but was stopped after development of heparin induced thrombocytopenia. The patient developed worsening hypoglycemia requiring cessation of IV insulin, hypotension requiring maximum pressor support, and worsening sepsis leading to his death. Discussion(s): This case illustrates the challenges of managing a patient with HTP and COVID-19. It demonstrates how a normally straightforward treatment algorithm can become increasingly complex when factoring the patient's comorbid conditions. The case highlights the importance of knowing both treatment indications and contraindications for HTP. In this case, HTP may have been the initial diagnosis, straightforward for most endocrinologists, but its treatments and comorbid conditions ultimately made the landscape more challenging, limiting effective management and ultimately leading to this patient's demise.Copyright © 2023

[Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism]. / Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía.

Introduction: Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. Methods: A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. Results: A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 - 2.05). Conclusions: In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.

Has Lockdown and COVID-19 Led to a Change in the Characteristics of Deep Vein Thrombosis and Patients Who Are Afflicted With It?

BACKGROUND: There is growing evidence identifying coronavirus disease 2019 (COVID-19) as a significant risk factor for thrombosis in inpatients. However, it remains uncertain if patients in the community have been influenced during the COVID-19 pandemic and national lockdown. This study, across four centres in the United Kingdom (UK), reviewed outpatients with deep vein thrombosis (DVT). AIM: This study aims to find out whether lockdown and COVID-19 led to a change in the characteristics of DVT and patients who are afflicted with it, alongside a review of DVT service. METHODS: Data was collected retrospectively from electronic patient records system for the following periods: April 1 to June 30, 2019, and April 1 to June 30, 2020. These were the key months during the first national lockdown in UK. Data were analysed for patient demographics, risk factors, characteristics of DVT, management, and DVT reoccurrence. Statistical analyses were performed using GraphPad Prism 8 (Dotmatics, Boston, Massachusetts, United States). RESULTS: During the study periods, 227 outpatients from the community sustained DVT in 2019 and 211 in 2020. Of these patients, 13 in 2020 were COVID-19 positive. There was a difference in gender distribution with 128 males and 99 females in 2019, and 93 males and 118 females in 2020 (p= 0.0128). No significant difference was noted in the incidence of thrombophilia with nine in 2019 and three in 2020 (p=0.1437). Fewer long-haul journeys were made in 2020 (only two), compared to 16 in 2019 (p=0.012). Fewer patients had immobility as a risk factor in 2020 (n=55) compared to 2019 (n=79) (p=0.0494). However, there were more patients using oral contraceptive pills, with one in 2019 and nine in 2020 (p=0.0086) . CONCLUSION: There is no significant difference in the characteristics, extent, and management of DVT prior to and during the COVID-19 lockdown. National lockdowns do not affect DVT in the community; however, it is important to highlight the surrounding inpatient numbers.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology.

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Supraventricular tachycardia and deep vein thrombosis following Moderna vaccination: A case series.

There have been reports of deep vein thrombosis and supraventricular tachycardia following the Moderna vaccination. The timing of SVT and DVT just after vaccination in our case series could suggest possible temporal relationships to the vaccination. But further studies are needed to establish such evidence.

COVID-19 disease is no longer alone: A case of severe COVID-19 pneumonia with pulmonary embolism and deep vein thrombosis

Almost eight million people were affected by the novel coronavirus (COVID-19) disease outbreak until now. The understanding of the disease has not fully emerged, but recent studies showed that thromboembolic events are frequently seen in this unique patient group as a contributor to mortality. A 65-year-old female was admitted to the emergency department (ED) with shortness of breath and fever for three days. Physical examination was notable with tachypnea and right lower extremity edema. The bedside ultrasound evaluation showed right-sided non-compressible common femoral vein with thrombus, and her laboratory was remarkable with a high D-dimer value (39.4 mug/dl). Finally, the patient was sent to the radiology unit for pulmonary computed tomography angiography, revealing filling defects at the pulmonary arteries and parenchymal findings that are consistent with COVID-19 pneumonia and pulmonary embolism (PE). Here, we presented a case of venous thromboembolism without any risk factor but COVID-19 pneumonia. To the best of our knowledge, this is one of the first cases reported in the literature diagnosed as COVID-19 pneumonia simultaneously with PE and deep vein thrombosis in the ED. Eventually, physicians should be vigilant about the occult pathologies associated with the novel coronavirus infection.Copyright © 2023, Kuwait Medical Association. All rights reserved.

Comorbidities Associated With Myocarditis In Hospitalized COVID-19 Patients

Introduction: While COVID-19 is predominantly a lung infection, it can cause systemic viremia in susceptible patients and lead to cardiac involvement and myocarditis (MC);an inflammation of the myocardium characterized by arrhythmias, cardiogenic shock, acute heart failure, and death. Although rare, there is evidence of a surge in MC-related admissions during the COVID-19 pandemic, implying a correlation. However, the risk factors associated with MC susceptibility in these patients remain unclear. This study aims to assess the comorbidities and demographic features associated with the development of MC in adult patients with COVID-19. Method(s): Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The database provides all-payers administrative claims data on the patient level. Using ICD-10-CM codes, a cohort of patients hospitalized with a primary diagnosis of COVID-19 was identified. The study included only patients admitted to the hospital between January and October 2020 to minimize bias associated with vaccine-related MC. Within this cohort, patients diagnosed with MC during and up to one month after admission were identified and their demographic features and comorbidities to were compared to those without MC. We calculated Risk Ratios with their respective 95% CI. A p-value <0.05 was deemed significant. Result(s): We found 627,465 admissions due to COVID-19 from January to October 2020, with 506 (0.08 %) diagnosis of MC. Patients with MC were more likely to be males (60%), younger (mean age 48, SD= 23 vs. 60, SD =17 - p<0.01), and they had more comorbidities (mean Elixhauser Comorbidity Index: 7.52, SD= 5 vs. 6.9, SD = 5 - p<0.001). The development of MC was significantly associated with a history of coagulopathies [0.55(0.46-0.66);p<0.0001], asthma [1.20 (1.06-1.23);p= 0.01], deep venous thrombosis [1.54(1.38-1.68);p<0.0001], renal disease[1.15 (1.02-1.27);p= 0.03], congestive heart failure [1.24 (1.12-1.34);p=0.006], ischemic heart disease [1.25 (1.14-1.35);p=0.0001], and arrhythmias [1.24 (1.14-1.32);p< 0.0001]. However, a history of diabetes [0.89 (0.67-0.99);p=0.02], hypertension [0.71 (0.62-0.80);<0.000.1], depression [0.71(0.52-0.88);p=0.0001], and hypothyroidism [0.42(0.08-0.69);p<0.0001] was associated with lower risk of MC-related hospitalization. Other preexistent conditions including, psychosis, rheumatoid arthritis, cerebrovascular disease, obesity, tobacco use, alcohol abuse, HIV, anemia, peripheral vascular disease, and non-metastatic solid tumor were not significantly correlated with MC. Discussion(s): MC is a rare yet serious complication of COVID-19. Therefore, a better knowledge of the pathophysiology of COVID-19 and the patient factors associated with development to MC is crucial for prognostication and providing risk-adjusted treatment. Conclusion(s): Patients with a history of cardiovascular disease, renal and pulmonary disease were more likely to develop MC as a result of COVID-19. However, hypertension and diabetes were associated with lower risk of MC, which warrants further investigation.Copyright © 2022

Protein S Deficiency with Favourable Foetomaternal Outcome: A Case Report

Protein S is a multifunctional plasma protein, whose deficiency, results in a rare congenital thrombophilia, inherited in an autosomal dominant pattern. It can aggravate the hypercoagulable state of pregnancy, when it presents in parallel with the condition, leading to adverse maternal outcomes and foetal loss. A 35-year-old female third gravida having previous 2 deliveries by Lower Segment Caesarean Section (LSCS) presented to emergency at 10 weeks pregnancy with chief complaints of pain and swelling in left thigh since 4-5 days. After thorough investigations and work-up, the patient was diagnosed with Protein S deficiency. She was managed conservatively and was delivered by elective LSCS with bilateral tubal ligation at 38 weeks of gestation with good foetal and maternal outcomes.The rarity of Protein S deficiency along with the successful outcome of the pregnancy makes this a unique case.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.