Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis.

INTRODUCTION: We recently reported a high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 admitted to the intensive care units (ICUs) of three Dutch hospitals. In answering questions raised regarding our study, we updated our database and repeated all analyses. METHODS: We re-evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction and/or systemic arterial embolism in all COVID-19 patients admitted to the ICUs of 2 Dutch university hospitals and 1 Dutch teaching hospital from ICU admission to death, ICU discharge or April 22nd 2020, whichever came first. RESULTS: We studied the same 184 ICU patients as reported on previously, of whom a total of 41 died (22%) and 78 were discharged alive (43%). The median follow-up duration increased from 7 to 14 days. All patients received pharmacological thromboprophylaxis. The cumulative incidence of the composite outcome, adjusted for competing risk of death, was 49% (95% confidence interval [CI] 41-57%). The majority of thrombotic events were PE (65/75; 87%). In the competing risk model, chronic anticoagulation therapy at admission was associated with a lower risk of the composite outcome (Hazard Ratio [HR] 0.29, 95%CI 0.091-0.92). Patients diagnosed with thrombotic complications were at higher risk of all-cause death (HR 5.4; 95%CI 2.4-12). Use of therapeutic anticoagulation was not associated with all-cause death (HR 0.79, 95%CI 0.35-1.8). CONCLUSION: In this updated analysis, we confirm the very high cumulative incidence of thrombotic complications in critically ill patients with COVID-19 pneumonia.

Incidence of thrombotic complications in critically ill ICU patients with COVID-19.

INTRODUCTION: COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. METHODS: We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. RESULTS: We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. CONCLUSION: The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.

[Successful amantadine treatment of a patient with ECT-resistant catatonia]. / Succesvolle behandeling met amantadine bij een patiënt met ECT-resistente maligne katatonie.

Catatonia is a common neuropsychiatric syndrome. There is a life-threatening subtype of this disease known as malignant catatonia. One of the hypotheses regarding the pathogenesis is an imbalance of multiple neurotransmitters (gaba, glutamate and dopamine). The first step in treatment is to administer benzodiazepines; if the response is insufficient, the treatment can be replaced by electroconvulsive therapy (ect). So far, there is no consensus with regard to the tertiary treatment step. On the basis of a case report we describe the beneficial effects of administering an nmda receptor antagonist, amantadine, as the tertiary step for treating a patient with treatment-resistant malignant catatonia.

Quantitative biofouling diagnosis in full scale nanofiltration and reverse osmosis installations.

Biofilm accumulation in nanofiltration and reverse osmosis membrane elements results in a relative increase of normalised pressure drop (DeltaNPD). However, an increase in DeltaNPD is not exclusively linked to biofouling. In order to quantify biofouling, the biomass parameters adenosine triphosphate (ATP), total cell count and heterotrophic plate count in membrane elements were investigated during membrane autopsies and compared with DeltaNPD in test rigs and 15 full scale investigations with different types of feed water. The combination of biomass related parameters ATP and total cell count in membrane elements seem to be suitable parameters for diagnosis of biofouling, whereas plate counts were not appropriate to assess biofouling. The applied DeltaNPD measurement was too insensitive for early detection of fouling. Measurements of biological parameters in the water were shown to be not appropriate in quantifying biofouling. Evidently, there is a need for a practical tool, sensitive pressure drop data and systematic research.

The membrane fouling simulator: a suitable tool for prediction and characterisation of membrane fouling.

A new tool--the Membrane Fouling Simulator (MFS)--is developed to measure membrane fouling (pressure drop increase) in a small and simple system, representative for spiral wound membranes applied in water treatment. With the MFS, fouling development can be monitored systematically by (i) pressure drop, (ii) in situ and non-destructive (visual) observations using the sight glass and (iii) analysis of coupons sampled from the membrane sheet in the MFS. A comparison study of the MFS with spiral wound membrane elements (test rigs and a full scale installation) showed the same fouling. The MFS provided reproducible data. The small size and low water and chemical use of the MFS facilitate to perform systematic parallel studies. With the MFS, fouling of membranes applied in water treatment can be characterised.

[Intravascular lymphoma: a rare but curable cause of interstitial lung disease]. / Het intravasculair lymfoom; een zeldzame, maar curabele oorzaak van interstitiële longafwijkingen.

A 69-year-old man presented with dyspnoea, cough and diffuse interstitial changes and ground-glass effect on a CT-scan. After 5 months the patient was diagnosed with pulmonary intravascular lymphomatosis. A histologic diagnosis was made by a video-assisted thoracoscopic surgical biopsy. Treatment with combination chemotherapy, i.e. 8 cycles of cyclophosphamide-doxorubicin-vincristine-prednisone (CHOP), resulted in a complete remission and a disease-free survival of 5 years at the last follow-up. Intravascular lymphomatosis is a rare but curable cause of interstitial lung disease. Intravascular lymphomatosis is an uncommon type of non-Hodgkin's lymphoma, characterized by proliferation of neoplastic lymphoid cells within the lumen of small blood vessels, resulting in thrombotic and ischaemic complications in multiple organ systems. Primary pulmonary presentation is even more uncommon. It is important to consider intravascular lymphomatosis in the differential diagnosis of unexplained interstitial lung disease, since early diagnosis and treatment may lead to complete remission and long-term survival.