Thrombosis of Chiari's network in the setting of non-bacterial thrombotic endocarditis occurring under non-vitamin K antagonist oral anticoagulation: a case report.

Background: Non-bacterial thrombotic endocarditis (NBTE) is a rare condition characterized by sterile thrombi on undamaged valves. We herein report a case of NBTE involving the Chiari's network and the mitral valve, related to a metastatic cancer, and occurring under non-vitamin K antagonist oral anticoagulant (NOAC). Case summary: A 74-year-old patient with metastatic pulmonary cancer was diagnosed with a right atrium mass during pre-treatment cardiovascular check-up. Transoesophageal echocardiography and cardiac magnetic resonance concluded that the mass was a Chiari's network. Two months later, the patient was admitted for a pulmonary embolism and started rivaroxaban. At 1-month follow-up, the patient underwent a new echocardiography, which showed an increased size of the right atrium mass and the presence of two new masses on the mitral valve. She suffered an ischaemic stroke. Infectious work-up was negative. Coagulation factor VIII was 419%. A NBTE with Chiari's network thrombosis and mitral valve involvement was suspected in the setting of a hypercoagulable state related to the active cancer, and intravenous heparin was started, bridged to vitamin K antagonist (VKA) after 3 weeks. All the lesions were fully resolved on follow-up echocardiography at 6 weeks. Discussion: This case highlights an atypical association of thrombosis on right and left heart chamber with systemic and pulmonary embolism, related to a hypercoagulable state. Chiari's network is an embryonic remnant with no clinical significance and is exceptionally thrombosed. Failure of treatment by NOAC highlights the complexity of cancer-related thrombosis, particularly in NBTE, and the necessity of heparin and VKA in our case.

Vertebral Artery Perforation as a Periprocedural Complication of Coronary Angiography.

Coronary angiography is a routinely performed intervention, with radial catheterization the recommended approach. We report a unique case of perforation of the right vertebral artery following coronary angiography that was successfully treated by endovascular management. (Level of Difficulty: Advanced.).

Exposure to SARS-CoV-2 in Hospital Environment: Working in a COVID-19 Ward Is a Risk Factor for Infection.

Aims. Health care workers (HCWs) are at risk of acquiring the Severe Acute Respiratory Syndrome Coronavirus 2 Infection (SARS-CoV-2). The aim of the study is to determine the SARS-CoV-2 positivity rates during the first epidemiologic peak among HCWs of a south Belgian hospital and to identify risks factors for infection. Methods. All hospital staff who worked during the first epidemiological peak were asked to answer a questionnaire regarding demographical data, function, type of working unit, type of contact with patients, eventual symptomatology, and the positivity of reverse transcription-polymerase chain reaction (RT-PCR) testing or immunoassay. Results. A total of 235 questionnaires were collected; 90 (38%) HCWs tested positive for SARS-CoV-2 from either RT-PCR or immunoassay testing. The positivity rate of HCWs between wards was statistically different (p = 0.004) and was higher in COVID-19 wards than Intensive Care Unit (ICU) and Emergency Department (ED). A total of 114 (49%) HCWs presented SARS-CoV-2-compatible symptomatology; 79 (88%) were positive on either RT-PCR or immunoassay testing; 74 (37%) HCWs were unable to work during the studied period; 5 were hospitalized. No deaths were reported. Multivariate logistic regression modeling showed that having symptoms was highly associated with test positivity (OR 23.3, CI 11.1, 53.1, p-value < 0.001). Working in a COVID-19 ward against working in ICU or ED was also predictive of positivity among HCWs (OR 3.25, CI 1.50, 7.28, p-value = 0.003). Discussion and Conclusions. This study shows a higher positivity rate compared to already reported positivity rates among HCWs. Reported differences in positivity rates depend on many factors, such as local crisis intensity, screening strategy, training in use of self-protective equipment, and study selection bias. HCWs working in COVID-19 wards, in comparison to ED and ICU, seemed at greater risk of being infected in this study. This could be explained by the disparity of HCWs' experience in handling self-protective equipment and knowledge in infection prevention. Hence, care should be taken in proper training for less-experienced HCWs during hospital epidemics. The latter could increase HCWs' protection and consequently decrease work absenteeism, ensuring enhanced continuity of patient care during hospital crisis. Rapid quarantine of symptomatic HCWs could reduce contamination rates, as having symptoms was highly associated with test positivity in this study.

Long-term outcome in ICU patients: what about quality of life?

OBJECTIVE: Analysis of mortality and quality of life (QOL) after intensive care unit (ICU) discharge. DESIGN: Prospective, observational study. SETTING: Mixed, 31-bed, medico-surgical ICU. PATIENTS: Consecutive adult ICU admissions between June 25 and September 10, 2000, except admissions for uncomplicated elective postoperative surveillance. INTERVENTIONS. None. MEASUREMENTS AND RESULTS: Age, past history, admission APACHE II, SOFA score (admission, maximum, discharge), ICU and hospital mortality were recorded. A telephone interview employing the EuroQol 5D system was conducted 18 months after discharge. Of 202 patients, 34 (16.8%) died in the ICU and 23 (11.4%) died in the hospital after ICU discharge. Of the 145 patients discharged alive from hospital, 22 could not be contacted and 27 (13.4%) had died after hospital discharge. Of the 96 patients (47.5%) who completed the questionnaire, 38% had a worse QOL than prior to ICU admission, but only 8.3% were severely incapacitated. Twenty-three patients (24%) had reduced mobility, 15 (15.6%) had limited autonomy, 24 (25%) had alteration in usual daily activities, 29 (30.2%) expressed more anxiety/depression, and 42 (44%) had more discomfort or pain. Twenty-eight (62.2% of those who worked previously) patients had returned to work 18 months after ICU discharge. CONCLUSIONS: Comparing QOL after discharge with that before admission, patients more frequently report worse QOL for the domains of pain/discomfort and anxiety/depression than for physical domains. Factors commonly associated with a change in QOL were previous problems in the affected domains, prolonged hospital length of stay (LOS), greater disease severity at admission and degree of organ dysfunction during ICU stay.