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1.
Rev Inst Med Trop Sao Paulo ; 64: e13, 2022.
Article in English | MEDLINE | ID: covidwho-1709614

ABSTRACT

Clinical similarities among viral diseases become even more relevant considering the current scenario, especially in Brazil, where there is a high incidence of these diseases and overlapping seasonality. We report the case of a patient with acute clinical manifestations composed of predominant respiratory symptoms and alveolar hemorrhage in which three etiologies (dengue, influenza and COVID-19) were investigated concomitantly. Only the diagnosis of dengue was confirmed. Then, the patient's immunological profile in response to stimulation of mononuclear cells with dengue virus antigen was analyzed in an attempt to identify specific characteristics that could be associated with the clinical manifestation.


Subject(s)
COVID-19 , Dengue , Dengue/complications , Dengue/diagnosis , Diagnosis, Differential , Hemorrhage/diagnosis , Humans , SARS-CoV-2 , Syndrome
3.
BMJ ; 373: n1114, 2021 05 05.
Article in English | MEDLINE | ID: covidwho-1218221

ABSTRACT

OBJECTIVE: To assess rates of cardiovascular and haemostatic events in the first 28 days after vaccination with the Oxford-AstraZeneca vaccine ChAdOx1-S in Denmark and Norway and to compare them with rates observed in the general populations. DESIGN: Population based cohort study. SETTING: Nationwide healthcare registers in Denmark and Norway. PARTICIPANTS: All people aged 18-65 years who received a first vaccination with ChAdOx1-S from 9 February 2021 to 11 March 2021. The general populations of Denmark (2016-18) and Norway (2018-19) served as comparator cohorts. MAIN OUTCOME MEASURES: Observed 28 day rates of hospital contacts for incident arterial events, venous thromboembolism, thrombocytopenia/coagulation disorders, and bleeding among vaccinated people compared with expected rates, based on national age and sex specific background rates from the general populations of the two countries. RESULTS: The vaccinated cohorts comprised 148 792 people in Denmark (median age 45 years, 80% women) and 132 472 in Norway (median age 44 years, 78% women), who received their first dose of ChAdOx1-S. Among 281 264 people who received ChAdOx1-S, the standardised morbidity ratio for arterial events was 0.97 (95% confidence interval 0.77 to 1.20). 59 venous thromboembolic events were observed in the vaccinated cohort compared with 30 expected based on the incidence rates in the general population, corresponding to a standardised morbidity ratio of 1.97 (1.50 to 2.54) and 11 (5.6 to 17.0) excess events per 100 000 vaccinations. A higher than expected rate of cerebral venous thrombosis was observed: standardised morbidity ratio 20.25 (8.14 to 41.73); an excess of 2.5 (0.9 to 5.2) events per 100 000 vaccinations. The standardised morbidity ratio for any thrombocytopenia/coagulation disorders was 1.52 (0.97 to 2.25) and for any bleeding was 1.23 (0.97 to 1.55). 15 deaths were observed in the vaccine cohort compared with 44 expected. CONCLUSIONS: Among recipients of ChAdOx1-S, increased rates of venous thromboembolic events, including cerebral venous thrombosis, were observed. For the remaining safety outcomes, results were largely reassuring, with slightly higher rates of thrombocytopenia/coagulation disorders and bleeding, which could be influenced by increased surveillance of vaccine recipients. The absolute risks of venous thromboembolic events were, however, small, and the findings should be interpreted in the light of the proven beneficial effects of the vaccine, the context of the given country, and the limitations to the generalisability of the study findings.


Subject(s)
COVID-19 Vaccines/adverse effects , Cerebral Arterial Diseases/etiology , Hemorrhage/etiology , Thrombocytopenia/etiology , Venous Thromboembolism/etiology , Venous Thrombosis/etiology , Adolescent , Adult , Aged , Cerebral Arterial Diseases/diagnosis , Cerebral Arterial Diseases/epidemiology , Denmark/epidemiology , Female , Follow-Up Studies , Hemorrhage/diagnosis , Hemorrhage/epidemiology , Humans , Incidence , Male , Middle Aged , Norway/epidemiology , Registries , Thrombocytopenia/diagnosis , Thrombocytopenia/epidemiology , Venous Thromboembolism/diagnosis , Venous Thromboembolism/epidemiology , Venous Thrombosis/diagnosis , Venous Thrombosis/epidemiology , Young Adult
4.
J Thromb Thrombolysis ; 52(1): 338-344, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1204923

ABSTRACT

Coronavirus disease (COVID-19) initiates several life-threatening complications including coagulopathies with a unique characteristic that made this problem challenging. Here we presented 4 cases of RT-PCR positive patients that have experienced deadly intraperitoneal hemorrhage with fourth WHO Bleeding Grade after overcoming their respiratory phase. COVID-19 could induce several coagulopathies with different features that besides iatrogenic interventions increases its mortality and morbidity due to lack of clinical evidence based on well-designed randomized clinical trials on anticoagulation therapies (AT) and administration of varieties of newly approved and non-approved medicines. This report showed the urgent need for investigation on the pathophysiology of COVID-19-associated coagulopathy esp. in hemorrhagic events which are needed to make the best therapeutic decision.


Subject(s)
Blood Coagulation , COVID-19/complications , Disseminated Intravascular Coagulation/etiology , Hemorrhage/etiology , Aged , Aged, 80 and over , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Disseminated Intravascular Coagulation/blood , Disseminated Intravascular Coagulation/diagnosis , Disseminated Intravascular Coagulation/therapy , Fatal Outcome , Hemorrhage/blood , Hemorrhage/diagnosis , Hospital Mortality , Humans , Male , Middle Aged , Peritoneum
5.
Thorac Cardiovasc Surg ; 69(6): 526-536, 2021 09.
Article in English | MEDLINE | ID: covidwho-1189327

ABSTRACT

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a potential treatment option in critically ill COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) if mechanical ventilation (MV) is insufficient; however, thromboembolic and bleeding events (TEBE) during ECMO treatment still need to be investigated. METHODS: We conducted a retrospective, single-center study including COVID-19 patients treated with ECMO. Additionally, we performed a univariate analysis of 85 pre-ECMO variables to identify factors influencing incidences of thromboembolic events (TEE) and bleeding events (BE), respectively. RESULTS: Seventeen patients were included; the median age was 57 years (interquartile range [IQR]: 51.5-62), 11 patients were males (65%), median ECMO duration was 16 days (IQR: 10.5-22), and the overall survival was 53%. Twelve patients (71%) developed TEBE. We observed 7 patients (41%) who developed TEE and 10 patients (59%) with BE. Upper respiratory tract (URT) bleeding was the most frequent BE with eight cases (47%). Regarding TEE, pulmonary artery embolism (PAE) had the highest incidence with five cases (29%). The comparison of diverse pre-ECMO variables between patients with and without TEBE detected one statistically significant value. The platelet count was significantly lower in the BE group (n = 10) than in the non-BE group (n = 7) with 209 (IQR: 145-238) versus 452 G/L (IQR: 240-560), with p = 0.007. CONCLUSION: This study describes the incidences of TEE and BE in critically ill COVID-19 patients treated with ECMO. The most common adverse event during ECMO support was bleeding, which occurred at a comparable rate to non-COVID-19 patients treated with ECMO.


Subject(s)
COVID-19/therapy , Extracorporeal Membrane Oxygenation/adverse effects , Hemorrhage/epidemiology , Thromboembolism/epidemiology , Aged , COVID-19/diagnosis , COVID-19/epidemiology , Critical Illness , Female , Germany/epidemiology , Hemorrhage/diagnosis , Humans , Incidence , Male , Middle Aged , Retrospective Studies , Risk Assessment , Risk Factors , Thromboembolism/diagnosis , Treatment Outcome
6.
J Surg Res ; 264: 469-473, 2021 08.
Article in English | MEDLINE | ID: covidwho-1174400

ABSTRACT

BACKGROUND: The Stop the Bleed (STB) campaign was developed in part to educate the lay public about hemorrhage control techniques aimed at reducing preventable trauma deaths. Studies have shown this training increases bystanders' confidence and willingness to provide aid. One high-risk group might be better solicited to take the course: individuals who have been a victim of previous trauma, as high rates of recidivism after trauma are well-established. Given this group's risk for recurrent injury, we evaluated their attitudes toward STB concepts. METHODS: We surveyed trauma patients admitted to 3 urban trauma centers in Baltimore from January 8, 2020 to March 14, 2020. The survey was terminated prematurely due to the COVID-19 pandemic. Trauma patients hospitalized on any inpatient unit were invited to complete the survey via an electronic tablet. The survey asked about demographics, prior exposure to life-threatening hemorrhage and first aid training, and willingness to help a person with major bleeding. The Johns Hopkins IRB approved waiver of consent for this study. RESULTS: Fifty-six patients completed the survey. The majority of respondents had been hospitalized before (92.9%) and had witnessed severe bleeding (60.7%). The majority had never taken a first aid course (60.7%) nor heard of STB (83.9%). Most respondents would be willing to help someone with severe bleeding form a car crash (98.2%) or gunshot wound (94.6%). CONCLUSIONS: Most patients admitted for trauma had not heard about Stop the Bleed, but stated willingness to respond to someone injured with major bleeding. Focusing STB education on individuals at high-risk for trauma recidivism may be particularly effective in spreading the message and skills of STB.


Subject(s)
First Aid/methods , Health Education/methods , Hemorrhage/therapy , Hemostatic Techniques , Wounds and Injuries/therapy , Accidents, Traffic , Adolescent , Adult , Aged , Baltimore , Cohort Studies , Female , Firearms , Health Education/statistics & numerical data , Health Knowledge, Attitudes, Practice , Hemorrhage/diagnosis , Hemorrhage/etiology , Humans , Male , Middle Aged , Severity of Illness Index , Surveys and Questionnaires/statistics & numerical data , Wounds and Injuries/complications , Wounds and Injuries/diagnosis , Young Adult
7.
J Thromb Thrombolysis ; 52(1): 18-21, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1107856

ABSTRACT

As patients with COVID-19 pneumonia admitted to intensive care unit (ICU) have high rates of thrombosis, high doses of thromboprophylaxis have been proposed. The associated bleeding risk remains unknown. We investigated major bleeding complications in ICU COVID-19 patients and we examined their relationship with inflammation and thromboprophylaxis. Retrospective monocentric study of consecutive adult patients admitted in ICU for COVID-19 pneumonia requiring mechanical ventilation. Data collected included demographics, anticoagulation status, coagulation tests and outcomes including major bleeding and thrombotic events. Among 56 ICU COVID-19 patients, 10 (18%) patients had major bleeding and 16 (29%) thrombotic events. Major bleeding occurred later than thrombosis after ICU admission [17(14-23) days versus 9(3-11) days respectively (p = 0.005)]. Fibrinogen concentration always decreased several days [4(3-5) days] before bleeding; D-dimers followed the same trend. All bleeding patients were treated with anticoagulants and anticoagulation was overdosed for 6 (60%) patients on the day of bleeding or the day before. In the whole cohort, overdose was measured in 22 and 78% of patients receiving therapeutic anticoagulation during fibrinogen increase and decrease respectively (p < 0.05). Coagulation disorders had biphasic evolution during COVID-19: first thrombotic events during initial hyperinflammation, then bleeding events once inflammation reduced, as confirmed by fibrinogen and D-dimers decrease. Most bleeding events complicated heparin overdose, promoted by inflammation decrease, suggesting to carefully monitor heparin during COVID-19. Thromboprophylaxis may be adapted to this biphasic evolution, with initial high doses reduced to standard doses once the high thrombotic risk period ends and fibrinogen decreases, to prevent bleeding events.


Subject(s)
Anticoagulants/adverse effects , Blood Coagulation/drug effects , COVID-19/complications , Hemorrhage/chemically induced , Thrombosis/prevention & control , Aged , Anticoagulants/administration & dosage , Biomarkers/blood , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Critical Illness , Female , Fibrin Fibrinogen Degradation Products/metabolism , Fibrinogen/metabolism , Hemorrhage/diagnosis , Hemorrhage/prevention & control , Humans , Inflammation Mediators/blood , Male , Middle Aged , Respiration, Artificial , Retrospective Studies , Risk Assessment , Risk Factors , Thrombosis/blood , Thrombosis/diagnosis , Thrombosis/etiology , Time Factors , Treatment Outcome
8.
J Neurovirol ; 27(1): 35-51, 2021 02.
Article in English | MEDLINE | ID: covidwho-1061059

ABSTRACT

Since the outbreak of coronavirus disease 2019 (COVID-19) in 2019, it is gaining worldwide attention at the moment. Apart from respiratory manifestations, neurological dysfunction in COVID-19 patients, especially the occurrence of cerebrovascular diseases (CVD), has been intensively investigated. In this review, the effects of COVID-19 infection on CVD were summarized as follows: (I) angiotensin-converting enzyme 2 (ACE2) may be involved in the attack on vascular endothelial cells by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), leading to endothelial damage and increased subintimal inflammation, which are followed by hemorrhage or thrombosis; (II) SARS-CoV-2 could alter the expression/activity of ACE2, consequently resulting in the disruption of renin-angiotensin system which is associated with the occurrence and progression of atherosclerosis; (III) upregulation of neutrophil extracellular traps has been detected in COVID-19 patients, which is closely associated with immunothrombosis; (IV) the inflammatory cascade induced by SARS-CoV-2 often leads to hypercoagulability and promotes the formation and progress of atherosclerosis; (V) antiphospholipid antibodies are also detected in plasma of some severe cases, which aggravate the thrombosis through the formation of immune complexes; (VI) hyperglycemia in COVID-19 patients may trigger CVD by increasing oxidative stress and blood viscosity; (VII) the COVID-19 outbreak is a global emergency and causes psychological stress, which could be a potential risk factor of CVD as coagulation, and fibrinolysis may be affected. In this review, we aimed to further our understanding of CVD-associated COVID-19 infection, which could improve the therapeutic outcomes of patients. Personalized treatments should be offered to COVID-19 patients at greater risk for stroke in future clinical practice.


Subject(s)
Atherosclerosis/complications , COVID-19/complications , Disseminated Intravascular Coagulation/complications , Hemorrhage/complications , Hyperglycemia/complications , Stroke/complications , Thrombosis/complications , Anticoagulants/therapeutic use , Antiviral Agents/therapeutic use , Atherosclerosis/diagnosis , Atherosclerosis/drug therapy , Atherosclerosis/virology , COVID-19/diagnosis , COVID-19/drug therapy , COVID-19/virology , Cardiovascular Agents/therapeutic use , Disseminated Intravascular Coagulation/diagnosis , Disseminated Intravascular Coagulation/drug therapy , Disseminated Intravascular Coagulation/virology , Extracellular Traps/drug effects , Extracellular Traps/immunology , Hemorrhage/diagnosis , Hemorrhage/drug therapy , Hemorrhage/virology , Humans , Hyperglycemia/diagnosis , Hyperglycemia/drug therapy , Hyperglycemia/virology , Inflammation , Renin-Angiotensin System/drug effects , Renin-Angiotensin System/immunology , SARS-CoV-2/drug effects , SARS-CoV-2/pathogenicity , Stroke/diagnosis , Stroke/drug therapy , Stroke/virology , Thrombosis/diagnosis , Thrombosis/drug therapy , Thrombosis/virology
9.
BMJ Case Rep ; 13(11)2020 Nov 30.
Article in English | MEDLINE | ID: covidwho-949258

ABSTRACT

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months' time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.


Subject(s)
Adrenal Gland Diseases , Adrenal Glands/diagnostic imaging , COVID-19 , Computed Tomography Angiography/methods , Hemorrhage , Heparin/administration & dosage , Pulmonary Embolism , Pyrazoles/administration & dosage , Pyridones/administration & dosage , Adrenal Cortex Function Tests/methods , Adrenal Gland Diseases/diagnosis , Adrenal Gland Diseases/etiology , Adrenal Gland Neoplasms/diagnosis , Antithrombins/administration & dosage , COVID-19/complications , COVID-19/diagnosis , COVID-19/physiopathology , COVID-19/therapy , Clinical Deterioration , Diagnosis, Differential , Hemorrhage/diagnosis , Hemorrhage/etiology , Humans , Male , Middle Aged , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/physiopathology , Pulmonary Embolism/therapy , SARS-CoV-2/isolation & purification , SARS-CoV-2/pathogenicity , Treatment Outcome
10.
Am J Trop Med Hyg ; 103(3): 1156-1157, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-854401

ABSTRACT

A 70-year-old Dominican Republic man presented with lower back pain for 10 days. Fifteen days before pain onset, he had low-grade fever, chills, and asthenia, and 4 days before admission, he had constipation, malaise, generalized weakness, anorexia, nausea, and vomiting. On admission, the patient was afebrile and hypotensive, with a heart rate of 105 and an oxyhemoglobin saturation on room air of 95%. Hyponatremia, lymphopenia, elevated C-reactive protein, and ferritin were observed in complementary tests. Computed tomography (CT) scan showed findings consistent with COVID-19 bilateral bronchopneumonia, and an increase in size and blurring (loss of the Y shape) of both adrenals indicative of acute bilateral adrenal hemorrhage. The patient tested negative by reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal swab, yet positive for IgG and IgM by ELISA, suggesting COVID-19 diagnosis.


Subject(s)
Adrenal Gland Diseases/etiology , Betacoronavirus , Coronavirus Infections/complications , Hemorrhage/etiology , Pneumonia, Viral/complications , Adrenal Gland Diseases/diagnosis , Aged , COVID-19 , Hemorrhage/diagnosis , Humans , Male , Pandemics , SARS-CoV-2
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