Incidence of heparin resistance and heparin failure in patients receiving extracorporeal membrane oxygenation - an exploratory retrospective analysis

Objectives: Unfractionated heparin (UFH) remains the anticoagulation of choice at most centres for patients receiving extracorporeal membrane oxygenation (ECMO). One disadvantage of UFH relies on its individual dosing requirement to achieve target values. In this context heparin resistance has been described, defined as doses exceeding 35,000 IU UFH/d. However, the incidence of heparin resistance and its association with thromboembolic complications despite anticoagulation within target ranges remains unknown. Method(s): This retrospective study included adults receiving venovenous (VV) and venoarterial (VA) ECMO, or extracorporeal CO2-removal (ECCO2R) between 2010 and May 2022. The primary outcome was the incidence of heparin resistance (>35,000 IU of UFH/d). Secondary outcomes were heparin failure (thromboembolic complications despite anticoagulation within target ranges) and survival. A multivariable poisson regression model was fitted to analyse the effect of heparin resistance, COVID-19 and ECMO type on the incidence rate of thromboembolic events. Result(s): Of 197 included patients, 33 (16.8%) had heparin resistance. Patients with COVID-19 (n=51) had a higher rate of heparin resistance compared to nonCOVID-19 patients (37% vs. 9.6%, P<0.001). Thromboembolic complications occurred at a rate of 5.89/100 ECMO days. There was a significant effect of COVID-19 (incidence rate ratio (IRR) 2.12, 95% confidence interval (CI) 1.4 to 3.3, P<0.001) and ECMO type (VA ECMO: IRR 2.35;95% CI 1.43 to 3.87, P<0.001;ECCO2R: IRR 2.63, 95% CI 1.37 to 4.9, P=0.003;reference VV ECMO) on incidence rate of thromboembolic events, but not of heparin resistance (IRR 1.11, 95% CI 0.7 to 1.76, P=0.7). ECMO duration was longer (25d (IQR 11-33) vs. 8d (IQR 4-18), P<0.001) in patients with heparin resistance, but hospital survival did not differ (23 (70%) vs. 91 (57%), P=0.2). Conclusion(s): The study revealed a high incidence of heparin failure in ECMO patients, especially in those with COVID-19. Heparin resistance had no effect on the incidence rate of thromboembolic events, whereas our data suggest an increased risk in patients with COVID19, VA ECMO and ECCO2R.

Effect of Anticoagulant Administration in patients Hospitalized with COVID-19 - A study from Lahore, Pakistan

Background: The recognition of the relationship between thromboembolism in COVID-19 and poor clinical outcomes led to the use of anticoagulants in patients diagnosed with COVID-19. Aim(s): To determine the effects of anticoagulants in COVID-19 patients and to compare the effect of oral, subcutaneous, and combined anticoagulants on patient outcomes. Study design: Retrospective cohort study Place and duration: A private tertiary care hospital, in Lahore, from 1st April 2020 to 30 Sep 2020 Methodology: Data were collected from electronic and paper records of admitted patients with a confirmed diagnosis of COVID-19 on PCR or with a radiological diagnosis of COVID-19. A total of 179 patients were included in the study, 172 were given anticoagulation, out of these, 74 were given oral anticoagulation, 73 were given subcutaneous and 24 were given combination of oral and subcutaneous anticoagulants. Result(s): Among 172 patients on anticoagulants, 41(23.8%) expired while 131(76.2%) recovered. Among 7(100%) patients on no anticoagulation, 1(14.3%) patient expired while 6(85.7%) recovered. 19(11%) patients on anticoagulation progressed towards the need for invasive ventilation while 152(89%) patients did not need invasive ventilation. Among patients on subcutaneous anticoagulants, 27(37%) expired while 46(63%) recovered. 8(33.3%) patients on combined anticoagulants expired while 16(66.7%) recovered. 6(8.1%) patients on oral anticoagulants expired while 68(91.9%) recovered. Conclusion(s): Anticoagulation improves the outcome of COVID-19 patients and oral anticoagulation is better than subcutaneous and combined anticoagulation.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.

Research progress of ulinastatin in treatment of COVID-19.

Coronavirus disease 2019 (COVID-19) is still spreading worldwide. At present, no specific drug has been developed for the virus. Ulinastatin plays an important role in anti-inflammatory. Clinically, it is mainly used in acute pancreatitis, shock and disseminated intravascular coagulation. It also has the effects of antioxidant stress, anticoagulation and immune regulation, which may be of great significance to reduce the severity and mortality of COVID-19. Combined with the pharmacological effect of ulinastatin and its clinical application in the treatment of COVID-19 complications such as acute respiratory distress syndrome and sepsis lung injury, this paper discusses the feasibility of its application in COVID-19, so as to provide help for the clinical treatment and new drug research and development of this disease.Copyright © 2022 Tianjin Press of Chinese Herbal Medicines. All Rights Reserved.

ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

Prolonged oxygenator usage for VV ECMO for COVID ARDS: A clinical experience

Objectives: Its known that with the prolonged use of ECMO, because of the thrombogenic activations -minor/majorclot formations may ocur at the oxygenator and eventually it fails to function properly. Physicians take some precautions to prevent or postpone this process but usually exchange the circuit. In this study we share our follow up strategy and prolonged oxygenator use for the COVID-ARDS patients. Method(s): A total of 68 patients who were followed more than 7 days were included in this study. Sorin/LivaNova oxygenators and VV-ECMO circuit were used for all of the patients. Bivaluridin infusion was used for routine anticoagulation protocol. Result(s): Mean age of the patients was 44.1 +/-12.2 years. The patients were followed for a total of 2705 days with a total of 103 oxygenators [mean 26.2 +/-18.3(104-7) days for per oxygenator] Mean duration of ECMO support was 40.3 +/-24.4 days . The oxygenator use per patient was 1.5 +/-0.89. There was no major hypoxic period experience for the patients. Survival rate was 43.2 %. Conclusion(s): With using bivaluridin for anticoagulation, daily washing of oxygenators and close follow up methods we can protect the oxygenators and use them for longer periods safely like in our experience which can save us from serious additional costs and interventions.

Abdominal Aortic Occlusion in Setting of Covid-19

Introduction: The incidence of arterial thrombosis among critically ill patients with COVID-19 is 4.4%, acute aortic obstruction alone having a mortality rate of 31%. We present a review of the literature regarding isolated abdominal aortic thrombosis (IAAT) in the setting of COVID-19 infection, as well as a case presentation. Method(s): A literature review was performed using Pubmed with the keywords, aorta, aortic, thrombus, and Covid-19. Within these articles, the scope was narrowed to articles that related to IAAT in the setting of Covid-19 infection. Result(s): Our literature review found 9 articles detailing a total of 11 cases of IAAT in the setting of COVID-19 infection. IAAT had a mortality 22% (2 out of 9 patients). Approximately, 55% (6 out of 11) of the patients were treated with surgery and 27% (3 out of 11) received anticoagulation. 73%, (8 out of 11) of the patients in our literature review presented with symptoms of acute limb ischemia. Ages ranged from neonate to 85 years old, though 82% (9 out of 11) were over the age of 50. Conclusion(s): Our literature review suggests that IAAT is a serious complication of COVID-19 infection. IAAT is more common in males and people over the age of 50, which aligns with the 52 year- old male patient who presented to our clinic with lower extremity claudication and bilateral 1st & 5th toe cyanosis after COVID-19 infection. To prevent devastating limb ischemia, we emphasize early evaluation of claudication symptoms in patients with COVID-19 or recent COVID-19 infection.

Electrocardiographic Changes among Moderate and Severe COVID-19 Patients in a Tertiary Care Teaching Hospital at Shahdol, Madhya Pradesh, India: A Record-based Study

Introduction: Electrocardiographic (ECG) abnormalities in Coronavirus Disease 2019 (COVID-2019) patients are largely unknown. ECG changes in COVID-19 disease may guide to initiate therapeutic anticoagulation, more so in moderate and severe disease. Aims: To identify various ECG changes in moderate and severe COVID-19 patients and to ascertain the association between initial ECG changes and disease outcome. Materials and Methods: This was retrospective record-based study was conducted in the Department of Internal Medicine, Birsa Munda Medical College, Shahdol, Madhya Pradesh, India, on 216 patients with laboratory-confirmed COVID-19 in a tertiary care teaching hospital from March 2021 to June 2021. Demographic and clinical data including ECG were extracted from medical records of the patients and if needed, the patients were followed-up till outcome. COVID-19 disease severity was considered based on oxygen saturation at room air (moderate: 94%-90%;severe: <90%). Data were entered using the Epicollect5 mobile application to minimise errors. Results: A total of 216 patients were included (35 to 54 years), the majority were male. Mortality rate was 46.3%. Total 57.4% of ECG changes were classified as abnormal. Sinus tachycardia was the most common abnormality followed by ischaemic changes. Left axis deviation in ECG was more commonly seen than right axis deviation. Total 53.2% of patients with abnormal ECG findings and 36.9% with normal ECG findings died. Mortality was very high in patients with ischaemic changes. Conclusion: COVID-19 patients with ischaemic changes in ECG were significantly associated with increased mortality. Hence, early detection of these changes in COVID-19 patients is vital and will help primary care physicians to intervene early and help in deciding therapeutic anticoagulation requirements in patients with COVID-19. [ FROM AUTHOR] Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited 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.)

Membrane dysfunction in patients with severe COVID-19 treated with venovenous extracorporeal membrane oxygenation - analysis from a pooled data from a single centre

Objectives: It is well known that severe COVID-19 is associated with complex immunological and inflammatory dysregulation. Both these physiopathological events translate to a high risk of major thrombotic or hemorrhagic events. In patients treated with venovenous extracorporeal membrane oxygenation (VVECMO), membrane dysfunction might affect systemic oxygenation and limit its duration-expectancy. This study aimed to assess the possible causes of extracorporeal membrane failure in COVID-19 patients and its impact on outcome. Method(s): Retrospective, single-center, observational case-control study involving adult COVID-19 patients admitted to an ECMO referral centre in a tertiary university hospital. All patients required VVECMO for acute respiratory failure, including 48 cases who needed one or more extracorporeal membrane exchanges and 45 controls (no membrane exchange). These two groups were compared for demographic characteristics, severity of the disease using validated scores (SAPS II and SOFA), duration of ECMO run, coagulation assessment, cumulative anticoagulation dose, associated complications, and outcomes (ICU and hospital mortality). Result(s): Most patients were males (71.0%) and younger than 50 years (79.5%). Median ECMO run duration was significantly longer in the case group (35.0 vs 14.0 days, p <0.001), as well as ICU length-of-stay (45.5 vs 28 days, p <0.001). Membrane exchange tended to be associated with sepsis (56% vs 33%, p=0.037), major hemorrhage (58% vs 43%, p=0.022), heparin-induced thrombocytopenia (25% vs 9%, p=0.054), higher D-dimer title (17.36 ng/dL vs 7.5 ng/dL, p=0.07) and lower platelet counts (133.000/muL vs 154.000/muL). Median SAPS II (32.0 vs 33.0, p=0.20) and the mortality (27% vs 24%, p >0.99) were similar between these groups. Conclusion(s): In patients with SARS-CoV-2 pneumonia and severe hypoxemia treated with VVECMO support the emergence of infection, coagulopathy and inflammation were associated with high risk of membrane dysfunction. No impact on mortality could be confirmed from these data. Anticoagulation monitoring and dosing strategies should be reinforced to promote membrane protection.

Post-Covid Myocarditis Simulating Acute Coronary Syndrome

Background: Acute myocarditis corresponds to an acute inflammation of the myocardium whose origin is most often viral. Several viruses can be incriminated to note the parvovirus B19, the virus herpes of the group 6 and to a lesser degree the virus of the hepatitis C (VHC) [18,19]. Since 2019 and with the discovery of SARS COV2 some cases of myocarditis associated with covid have been noted, this last association is rare and is present in only 5% of cases [8]. The diagnosis of myocarditis is sometimes difficult and can lead to confusion with acute coronary syndrome, especially in cases of ST-segment elevation on the EKG, hence the interest of magnetic resonance imaging, which has made it possible in recent years to reduce the rate of unnecessary coronary angiography, especially in the case of young subjects with no cardiovascular risk factors. in this context we report the case of a 33 year old patient with no cardiovascular risk factors and no medical or surgical antecedents who was admitted to the emergency department for the management of acute chest pain related to acute post-covid myocarditis, the patient was initially admitted to the cardiology intensive care unit where he was put in condition and under analgesic treatment and under therapeutic protocal of covid 19 and under anticoagulation based on low molecular weight heparin at preventive dose with a good clinical evolution he was transferred thereafter to the clinical cardiology then declared outgoing under treatment of covid 19 with an appointment of control in 1 month.

Single centre, cross-sectional assessment of airway hemorrhage in a cohort of patients with COVID19-associated ARDS under Venovenous extracorporeal membrane oxygenation

Objectives: Airway hemorrhage (AH) frequently complicates extracorporeal membrane oxygenation (ECMO) treatment. Inflammation, coagulopathy and antithrombotic therapy are contributing factors. Patients with COVID-19- associated ARDS (CARDS) supported with ECMO present all these features. We aim to characterize the incidence and the clinical and prognostic impact of AH. Method(s): Review of a cohort of patients with CARDS treated with ECMO support at a single ECMO centre between March 2020-February 2022 (n=92). AH was defined as a clinically significant hemorrhage fit demanded interruption of anticoagulation, transfusional support or bronchoscopy. Univariate analysis was performed using GraphPadPrism. Result(s): One third (n= 31) of patients with CARDS treated with ECMO had clinically significant AH. Patients who developed AH had significantly longer ICU length-of-stay (LoS), ECMO run and invasive mechanical ventilation (IMV) duration. Significant differences in coagulation and inflammatory markers were detected between patients with early (<72h) versus late (>9 days) onset of AH (Table 1). Mortality at day 90, demographics, comorbidities, CT scan pattern and clinical severity indexes were similar between patients with and without AH (NAH). Conclusion(s): In patients with severe CARDS treated with ECMO support, the occurrence of airway hemorrhage leads to clinically important morbidity but does not increase mortality. Distinct pathways may be involved in the development of early v. late AH. (Table Presented).

Clinical evolution of patients with AF and diabetes mellitus in the COVID-19 pandemic. REFADI Registry

Introduction and objectives: To analyze the evolution of patients with atrial fibrillation (AF) and diabetes in the mid-term follow-up during the COVID-19 pandemic and to describe its impact on this population. Method(s): Multicenter and prospective registry that included patients with AF and diabetes attended in cardiology clinics. A multivariate analysis was performed to determine the variables associated with the occurrence of clinical events and mortality. Recruitment was performed in February-December 2019. Result(s): The evolution of 633 patients, 96,2% of those included in the REFADI registry with a median follow-up of 835 days was analyzed (mean age 73.8 +/- 8.5 years, 54.3% male, CHA2DS2-VASc 4,34 +/- 1,4, HAS-BLED 2,47 +/- 0,96) were analyzed. The proportion of anticoagulated patients remained constant (95.6% vs 94.5%;P = .24). There was a decrease in the prescription of vitamin K antagonists (from 31.4% to 19.7%;P < .01), and an increase in the use of direct anticoagulants (from 62.0% to 70.3%;P < .01). During the follow-up there was an increase in the prescription of SGLT2 inhibitors (from 20.0% to 25.5%;P < .01) and GLP1 agonists (from 4.2% to 9.1%;P < .01). During this period, 17.2% of patients died, the majority from cardiovascular causes, 6.4% from COVID-19, 2.8% from stroke, and 1.8% from hemorrhage. Older age, lower ejection fraction, lower hemoglobin levels, and especially lower direct anticoagulants prescription were associated with mortality. Conclusion(s): Patients with AF and diabetes have a high thromboembolic risk and a high risk of developing complications, especially of cardiovascular origin.Copyright © 2023 Sociedad Espanola de Cardiologia

Effect of weight-adjusted intermediate-dose versus fixed-dose prophylactic anticoagulation with low-molecular-weight heparin on venous thromboembolism among noncritically and critically ill patients with COVID-19: the COVI-DOSE trial, a multicenter, randomised, open-label, phase 4 trial.

Background: Venous thromboembolism is a major complication of coronavirus disease 2019 (COVID-19). We hypothesized that a weight-adjusted intermediate dose of anticoagulation may decrease the risk of venous thromboembolism COVID-19 patients. Methods: In this multicenter, randomised, open-label, phase 4, superiority trial with blinded adjudication of outcomes, we randomly assigned adult patients hospitalised in 20 French centers and presenting with acute respiratory SARS-CoV-2. Eligible patients were randomly assigned (1:1 ratio) to receive an intermediate weight-adjusted prophylactic dose or a fixed-dose of subcutaneous low-molecular-weight heparin during the hospital stay. The primary outcome corresponded to symptomatic deep-vein thrombosis (fatal) pulmonary embolism during hospitalization (COVI-DOSE ClinicalTrials.gov number: NCT04373707). Findings: Between May 2020, and April 2021, 1000 patients underwent randomisation in medical wards (noncritically ill) (80.1%) and intensive care units (critically ill) (19.9%); 502 patients were assigned to receive a weight-adjusted intermediate dose, and 498 received fixed-dose thromboprophylaxis. Symptomatic venous thromboembolism occurred in 6 of 502 patients (1.2%) in the weight-adjusted dose group and in 10 of 498 patients (2.1%) in the fixed-dose group (subdistribution hazard ratio, 0.59; 95% CI, 0.22-1.63; P = 0.31). There was a twofold increased risk of major or clinically relevant nonmajor bleeding: 5.9% in the weight-adjusted dose group and 3.1% in the fixed-dose group (P = 0.034). Interpretation: In the COVI-DOSE trial, the observed rate of thromboembolic events was lower than expected in patients hospitalized for COVID-19 infection, and the study was unable to show a significant difference in the risk of venous thromboembolism between the two low-molecular-weight-heparin regimens. Funding: French Ministry of Health, CAPNET, Grand-Est Region, Grand-Nancy Métropole.

Anti-factor Xa vs aPTT for heparin monitoring in extracorporeal membrane oxygenation.

PURPOSE: The goal of this study was to evaluate the correlation of anti-factor Xa (anti-Xa) and activated partial thromboplastin time (aPTT) measures with heparin dosing in adult patients on extracorporeal membrane oxygenation (ECMO) support. METHODS: This was a retrospective cohort study evaluating adult patients managed on ECMO for at least 24 hours who received unfractionated heparin for systemic anticoagulation and were monitored per protocol using anti-Xa and/or aPTT coagulation assays. The primary outcome was the correlation between aPTT and anti-Xa measures. The secondary outcomes included, but were not limited to, the number of hemorrhagic and thrombotic events. RESULTS: Twenty-seven patients were included in this study. In the 227 events where both laboratory values were collected, a weak correlation was found between anti-Xa and aPTT (Spearman's correlation coefficient = 0.4, P = 0). In the 12 hemorrhagic events that occurred, aPTT was collected for only 10 events. Fifty percent of those events were associated with supratherapeutic aPTT, while none of the hemorrhagic events were associated with a supratherapeutic anti-Xa level. Two thrombotic events occurred, one of which had subtherapeutic anti-Xa and aPTT and the other of which had neither an anti-Xa nor aPTT measure on the day the event occurred. CONCLUSION: In a population of patients on ECMO, many of whom had coronavirus disease 2019 (COVID-19), there was a weak association between aPTT and anti-Xa measures. Hemorrhagic evens were more common than thrombotic events; however, a relationship between these events and aPTT or anti-Xa levels was not determined. The applicability of these findings to an ECMO population without COVID-19 is unknown and will require further study.

Efficacy and Safety of Anticoagulant Therapy in COVID-19-Related Pulmonary Embolism with Different Extension.

Pulmonary embolism (PE) has been associated with SARS-CoV-2 infection, and its incidence is highly variable. The aim of our study was to describe the radiological and clinical presentations, as well as the therapeutic management, of PEs that occurred during SARS-CoV-2 infection in a cohort of hospitalized patients. In this observational study, we enrolled patients with moderate COVID-19 who developed PE during hospitalization. Clinical, laboratory, and radiological features were recorded. PE was diagnosed on clinical suspicion and/or CT angiography. According to CT angiography results, two groups of patients were further distinguished: those with proximal or central pulmonary embolism (cPE) and those with distal or micro-pulmonary embolism (mPE). A total of 56 patients with a mean age of 78 ± 15 years were included. Overall, PE occurred after a median of 2 days from hospitalization (range 0-47 days) and, interestingly, the majority of them (89%) within the first 10 days of hospitalization, without differences between the groups. Patients with cPE were younger (p = 0.02), with a lower creatinine clearance (p = 0.04), and tended to have a higher body weight (p = 0.059) and higher D-Dimer values (p = 0.059) than patients with mPE. In all patients, low-weight molecular heparin (LWMH) at anticoagulant dosage was promptly started as soon as PE was diagnosed. After a mean of 16 ± 9 days, 94% of patients with cPE were switched to oral anticoagulant (OAC) therapy, which was a direct oral anticoagulant (DOAC) in 86% of cases. In contrast, only in 68% of patients with mPE, the prosecution with OAC was indicated. The duration of treatment was at least 3 months from PE diagnosis in all patients who started OAC. At the 3-month follow-up, no persistence or recurrence of PE as well as no clinically relevant bleedings were found in both groups. In conclusion, pulmonary embolism in patients with SARS-CoV-2 may have different extensions. Used with clinical judgment, oral anticoagulant therapy with DOAC was effective and safe.

Outcomes in patients discharged with extended venous thromboembolism prophylaxis after hospitalization with COVID-19.

BACKGROUND: Venous thromboembolism (VTE) is a known complication of coronavirus disease (COVID-19) in patients requiring hospitalization and intensive care. We examined the association between extended pharmacological VTE prophylaxis and outcomes among patients hospitalized with COVID-19. METHODS: This was a retrospective cohort study of patients with an index positive SARS-CoV-2 polymerase chain reaction (PCR) test at the time of, or during hospitalization. Patients who were prescribed extended pharmacological VTE prophylaxis were compared against patients who were not. Multivariable logistic regression was used to produce odds ratio (OR) estimates and Cox proportional hazard models for hazard ratios (HR) with 95% CI to examine the association between pharmacological VTE prophylaxis and outcomes of interest. Primary outcomes were 30- and 90-day VTE events. Secondary outcomes included 30- and 90-day mortality, 30-day superficial venous thrombosis (SVT), acute myocardial infarction (MI), acute ischemic stroke, critical limb ischemia, clinically significant bleeding, and inpatient readmissions. RESULTS: A total of 1936 patients were included in the study. Among them, 731 (38%) were discharged on extended pharmacological VTE prophylaxis. No significant difference was found in 30- and 90-day VTE events among groups. Patients discharged on extended VTE prophylaxis showed improved survival at 30 (HR: 0.35; 95% CI: 0.21-0.59) and 90 days (HR: 0.36; 95% CI: 0.23-0.55) and reduced inpatient readmission at 30 days (OR: 0.12; 95% CI: 0.04-0.33) when compared to those without. CONCLUSION: Patients discharged on extended VTE prophylaxis after hospitalization due to COVID-19 had similar thrombotic events on follow-up. However, use of extended VTE prophylaxis was associated with improved 30- and 90-day survival and reduced risk of 30-day inpatient readmission.

National Trends in Anticoagulation Therapy for COVID-19 Hospitalized Adults in the United States: Analyses of the National COVID Cohort Collaborative.

BACKGROUND: Anticoagulation (AC) utilization patterns and their predictors among hospitalized coronavirus disease 2019 (COVID-19) patients have not been well-described. METHODS: Using the National COVID Cohort Collaborative, we conducted a retrospective cohort study (2020-2022) to assess AC use patterns and identify factors associated with therapeutic AC employing modified Poisson regression. RESULTS: Among 162,842 hospitalized COVID-19 patients, 64% received AC and 24% received therapeutic AC. Therapeutic AC use declined from 32% in 2020 to 12% in 2022, especially after December 2021. Therapeutic AC predictors included age (relative risk (RR), 1.02 [95% confidence interval (CI), 1.02-1.02] per year), male (RR, 1.29 [1.27-1.32]), Non-Hispanic Black (RR, 1.16 [1.13-1.18]), obesity (RR, 1.48 [1.43-1.52]), increased length of stay (RR, 1.01; [1.01-1.01] per day), and invasive ventilation (RR, 1.64 [1.59-1.69]). Vaccination (RR, 0.88 [0.84-0.92]) and higher Charlson Comorbidity Index (CCI) (RR, 0.98 [0.97-0.98]) were associated with lower therapeutic AC. CONCLUSIONS: Overall, two thirds of hospitalized COVID-19 patients received any AC and a quarter received therapeutic dosing. Therapeutic AC declined after the introduction of the Omicron variant. Predictors of therapeutic AC included demographics, obesity, LOS, invasive ventilation, CCI, and vaccination, suggesting AC decisions driven by clinical factors including COVID-19 severity, bleeding risks, and comorbidities.

Rectus Sheath Hematoma as a Complication in Patients With COVID-19: Clinical and Imaging Findings.

Objectives This study aims to investigate the frequency of rectus sheath hematoma (RSH), clinical findings, imaging findings, and prognosis in patients admitted to the hospital due to COVID-19. Methods In this retrospective study, the patient's demographic characteristics, known diseases, laboratory values, RSH-related symptoms, the treatment they received, imaging modality used to diagnose RSH, and side and size of RSH were recorded. In addition, the inpatient ward to which the patients were admitted, length of hospital stay, time from the beginning of anticoagulant use to the diagnosis of RSH, and prognosis were noted. Results A total of 9,876 patients were admitted to the hospital due to COVID-19 and started anticoagulant treatment. Of these patients, 12 (0.12%) were determined to have RSH (female/male ratio: 5). The prothrombin time, activated partial thromboplastin time, international normalized ratio, hemoglobin, and hematocrit values ​​of 11 patients were within the reference ranges. The mean length of hospital stay was 12 (4.25-22.5) days, and the duration of anticoagulant use was 5.5 (4-10.75) days. RSH was diagnosed using USG in 10 patients and CT in two patients. Conclusion There has been an increase in the use of anticoagulants due to COVID-19, and accordingly, RSH is now more frequently diagnosed and has a more fatal course. Female gender, advanced age, severe COVID-19 disease, and elevated d-dimer at the time of presentation can be considered risk factors for the development of RSH. All physicians who treat and follow up on patients with COVID-19 should consider the possibility of RSH in the differential diagnosis of patients with acute abdominal pain and palpable masses. USG should be undertaken as the first-line imaging modality for the diagnosis of patients, but CT may also be necessary to detect RSH in some cases.

Case report: Spontaneous hemothorax following anticoagulation for microthrombi in severe COVID pneumonia.

Background: Anticoagulant therapy has become a hallmark of treatment for critically ill COVID patients. Gastrointestinal and intracranial hemorrhage are known major complications of anticoagulation, but spontaneous hemothorax is a rare event, particularly in the absence of pre-existing structural lung disease, vascular malformations, or genetic bleeding diatheses. Herein is a case of spontaneous hemothorax following anticoagulation for microthrombi in a patient with acute hypoxic respiratory failure due to Covid pneumonia. Case presentation: A 49 year old male with hypertension, asthma, and obesity was admitted for acute hypoxic respiratory failure due to Covid pneumonia. He was treated with dexamethasone, baricitinib, and therapeutic enoxaparin as empiric therapy for severe COVID disease. He subsequently developed a massive right hemothorax with associated hemorrhagic shock, which required initiation of massive transfusion protocol, vasopressor support and mechanical ventilation. No clear etiology for the hemothorax was determined upon investigations. The patient eventually improved and was discharged to a skilled nursing facility on chronic oxygen therapy. Conclusions: Various mechanisms have been proposed for the development of non-traumatic hemothoraces, including tearing of adhesions and rupture of vascularized bullae. Such explanations find support in radiologic and pathologic studies of pleural changes in Covid pneumonia, and likely played a role in the hemorrhage experienced by our patient.

Case Report on a Rare Malignancy: Anorectal Melanoma

Introduction: Melanoma of the rectum is an extremely rare disease. The median survival rate is 2-5 years. Current treatment for this aggressive cancer is resection if possible and consider adjuvant or neoadjuvant radiotherapy;immunotherapy in nonresectable cases. Given the rapid spread of disease due to its submucosal growth and metastasis pattern, there is low success rates with treatments. Case Description/Methods: An 84-year-old male presented to the emergency department with an acute COVID-19 infection. The patient was also found to have gram-negative septicemia on blood cultures, so a CT abdomen/pelvis was performed (Figure 1a). The CT showed rectal wall thickening. A flexible sigmoidoscopy was planned for a future outpatient visit after recovering from his acute infection. The patient, however, developed an acute onset of dyspnea and had a high probability V/Q scan while in the hospital. He was started on anticoagulation, and shortly after starting therapy the patient developed bright red rectal bleeding. Due to the new onset of rectal bleeding it was decided to expedite the sigmoidoscopy. The sigmoidoscopy was performed in the hospital showing an ulcerated partially black pigmented non- obstructing medium-sized mass that was partially circumferential involving one-third of the lumen (Figure 1b). A biopsy of the lesion was taken using cold-forceps. The pathology stained positive for S100 consistent with melanoma. The diagnosis of anorectal melanoma was made, and colorectal surgery was consulted. The patient was deemed not to be a surgical candidate secondary to age and active COVID-19 infection. Oncology was consulted, and it was decided to start the patient on radiation and immunotherapy with a PD-1 inhibitor. Discussion(s): The symptoms of anorectal melanoma can be subtle and in this case report completely asymptomatic. Symptoms to be aware of are rectal bleeding and tenesmus. Diagnosing melanoma on sigmoidoscopy can be challenging as most tumors are not pigmented. Biopsies should be taken and sent for immunohistochemical staining for S100, if positive the patient should have a PET scan. Treatment choices for the tumor are based on staging. In a resectable tumor sphincter-saving local excision with radiotherapy to the site of the tumor and the pericolic and inguinal lymphatics is recommended. For unresectable tumors or tumors with distant metastasis, immunotherapy with PD-1 inhibitors (nivolumab and ipilimumab) is an emerging treatment choice.