A Review of Pathophysiology, Clinical Features, and Management Options of COVID-19 Associated Coagulopathy

Two year comparative outcomes of drug coated balloons in long versus short femoropopliteal lesions

While the efficacy and safety of drug-coated balloons (DCBs) for treating short femoropopliteal lesions are well-established, evidence on long-term outcomes for long lesions remains limited. This study aims to compare the 2-year clinical outcomes of DCB angioplasty between long and short femoropopliteal lesions and identify risk factors for patency loss. This real-world and single-center cohort study included 234 patients with de novo stenosis or restenosis or occlusion of the femoropopliteal arteries (115 long lesions > 15 cm, 141 short lesions ≤ 15 cm) who underwent successful DCB treatment from January 2019 to December 2021 at Peking Union Medical College Hospital. The primary safety endpoint was defined as freedom from major adverse events (death, target limb amputation or thrombosis). The primary effectiveness endpoint was defined as 2-year primary patency, defined as freedom from both clinically driven target lesion revascularization (CD-TLR) and restenosis. Primary patency was significantly lower in long lesions (48.3% vs. 62.5%, p = 0.005), while freedom from CD-TLR rate showed no difference (83.6% vs. 87.4%, p = 0.25). Long lesions exhibited higher rates of occlusions (p < 0.001), in-stent restenosis (p = 0.025), and advanced ischemia (Rutherford Clinical Category (RCC) 4-6, p = 0.038). Multivariate analysis identified lesion length > 15 cm (p = 0.017) and RCC 4-6 (p = 0.026) as independent predictors of patency loss. Within the long lesion subgroup, only RCC 4-6 maintained prognostic significance (p = 0.027), and no significant predictors emerged in the short lesion group. Major adverse events occurred in 12.4% of patients, predominantly in long lesions with severe comorbidities. While DCB angioplasty achieved acceptable 2-year safety outcomes, long femoropopliteal lesions (> 15 cm) demonstrated significantly inferior primary patency compared to short lesions (48.3% vs. 62.5%, p = 0.005). Advanced ischemia (RCC 4-6) is a risk factor for patency loss.

Early Use of Liraglutide for the Treatment of Acute COVID-19 Infection: An Open-Label Single-Center Phase II Safety Study with Biomarker Profiling

BACKGROUND

Glucagon-like peptide-1 (GLP-1) agonists are an existing treatment option for patients with insulin-resistant states, which elicit further pleiotropic effects related to immune cell recruitment and vascular inflammation. GLP-1 agonists downregulate the cluster of differentiation 147 (CD147) receptor, one of several receptors for the SARS-CoV-2 spike protein that mediate viral infection of host cells.

METHODS

We conducted an open-label prospective safety and tolerability study including biomarker responses of the GLP-1 agonist Liraglutide, administered for 5 days as an add-on therapy to the standard of care within 48 h of presentation in a cohort of 13 patients hospitalized with COVID-19 pneumonia. Biomarker responses were compared in patients admitted to critical care and those not requiring critical care admission (non-critical group).

RESULTS

Liraglutide (0.6 mg, subcutaneously) was well tolerated by all patients and all patients were alive 30 days after diagnosis. Plasma soluble CD147 levels were reduced in the non-critical patient group at day 5 in contrast to critical care-treated patients, who demonstrated an increase in soluble CD147 levels between day 0 and day 5. Patients with milder COVID-19 pneumonia severity also demonstrated improvement in echocardiographic parameters of right and left ventricular function, reduction in plasma Troponin levels, increased CD147 expression on T lymphocytes, and reduction in plasma IL-8.

CONCLUSIONS

This first-in-disease use of the GLP-1 agonist Liraglutide demonstrates its safety and tolerability in an unselected cohort of patients hospitalized with COVID-19 pneumonia across a range of clinical severities.

Chronic thromboembolic pulmonary hypertension is an uncommon complication of COVID-19: UK national surveillance and observational screening cohort studies

BACKGROUND

Pulmonary embolism (PE) is a well-recognised complication of coronavirus disease 2019 (COVID-19) infection, and chronic thromboembolic pulmonary disease with and without pulmonary hypertension (CTEPD/CTEPH) are potential life-limiting consequences. At present the burden of CTEPD/CTEPH is unclear and optimal and cost-effective screening strategies yet to be established.

METHODS

We evaluated the CTEPD/CTEPH referral rate to the UK national multidisciplinary team (MDT) during the 2017-2022 period to establish the national incidence of CTEPD/CTEPH potentially attributable to COVID-19-associated PE with historical comparator years. All individual cases of suspected CTEPH were reviewed by the MDT for evidence of associated COVID-19. In a separate multicentre cohort, the risk of developing CTEPH following hospitalisation with COVID-19 was calculated using simple clinical parameters at a median of 5 months post-hospital discharge according to existing risk scores using symptoms, ECG and N-terminal pro-brain natriuretic peptide.

RESULTS

By the second year of the pandemic, CTEPH diagnoses had returned to the pre-pandemic baseline (23.1 versus 27.8 cases per month; p=0.252). Of 334 confirmed CTEPD/CTEPH cases, four (1.2%) patients were identified to have CTEPH potentially associated with COVID-19 PE, and a further three (0.9%) CTEPD without PH. Of 1094 patients (mean age 58 years, 60.4% male) hospitalised with COVID-19 screened across the UK, 11 (1.0%) were at high risk of CTEPH at follow-up, none of whom had a diagnosis of CTEPH made at the national MDT.

CONCLUSION

A priori risk of developing CTEPH following COVID-19-related hospitalisation is low. Simple risk scoring is a potentially effective way of screening patients for further investigation.

Energy-efficient trehalose-based polyester nanofiltration membranes for zero-discharge textile wastewater treatment

Recovery of water, salts, and hazardous dye from complex saline textile wastewater faces obstacles in separating dissolved ionic substances and recovering organic components during desalination. This study realized the simultaneous fractionation, desalination, and dye removal/recovery treatment of textile wastewater by using trehalose (Tre) as an aqueous monomer to prepare polyester loose nanofiltration (LNF) membrane with fine control microstructure via interfacial polymerization. Outperforming the NF270 commercial membrane, the Tre-1.05/TMC optimized membrane achieves zero-discharge textile wastewater treatment, cutting energy consumption by 295% and reducing water consumption by 42.8%. This efficiency surge results from remarkable water permeability (130.83 L m-2 h-1 bar-1) and impressive dye desalination (NaCl/ Direct Red 23 separation factor of 275) of the Tre-1.05/TMC membrane. For a deeper comprehension of filtration performance, the sieving mechanism of polyester LNF membranes was systematically elucidated. This strategic approach offers significant prospects for energy conservation, carbon emission mitigation, and enhanced feasibility of membrane-based wastewater treatment systems.

"When," "Where," and "How" of SARS-CoV-2 Infection Affects the Human Cardiovascular System: A Narrative Review

Coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory coronavirus-2 (SARS-CoV-2). Several explanations for the development of cardiovascular complications during and after acute COVID-19 infection have been hypothesized. The COVID-19 pandemic, caused by SARS-CoV-2, has emerged as one of the deadliest pandemics in modern history. The myocardial injury in COVID-19 patients has been associated with coronary spasm, microthrombi formation, plaque rupture, hypoxic injury, or cytokine storm, which have the same pathophysiology as the three clinical variants of Kounis syndrome. The angiotensin-converting enzyme 2 (ACE2), reninaldosterone system (RAAS), and kinin-kallikrein system are the main proposed mechanisms contributing to cardiovascular complications with the COVID-19 infection. ACE receptors can be found in the heart, blood vessels, endothelium, lungs, intestines, testes, neurons, and other human body parts. SARS-CoV-2 directly invades the endothelial cells with ACE2 receptors and constitutes the main pathway through which the virus enters the endothelial cells. This causes angiotensin II accumulation downregulation of the ACE2 receptors, resulting in prothrombotic effects, such as hemostatic imbalance via activation of the coagulation cascade, impaired fibrinolysis, thrombin generation, vasoconstriction, endothelial and platelet activation, and pro-inflammatory cytokine release. The KKS system typically causes vasodilation and regulates tissue repair, inflammation, cell proliferation, and platelet aggregation, but SARS-CoV-2 infection impairs such counterbalancing effects. This cascade results in cardiac arrhythmias, cardiac arrest, cardiomyopathy, cytokine storm, heart failure, ischemic myocardial injuries, microvascular disease, Kounis syndrome, prolonged COVID, myocardial fibrosis, myocarditis, new-onset hypertension, pericarditis, postural orthostatic tachycardia syndrome, pulmonary hypertension, stroke, Takotsubo syndrome, venous thromboembolism, and thrombocytopenia. In this narrative review, we describe and elucidate when, where, and how COVID-19 affects the human cardiovascular system in various parts of the human body that are vulnerable in every patient category, including children and athletes.

Therapeutic management of in-stent thrombosis after thoracic endovascular aortic repair for blunt thoracic aortic injury in a coronavirus disease 2019 patient

A 27-year-old man underwent thoracic endovascular aortic repair for blunt thoracic aortic injury. Fourteen months later, he presented with intermittent paraplegia, congestive heart failure, and a decline of kidney function as a result of high-grade aortic stenosis caused by in-stent thrombosis. He had a concurrent infection with coronavirus disease 2019. The patient was successfully treated using axillofemoral bypass, followed by stent relining 2 weeks later. The possible risk factors and the optimal therapeutic approach for in-stent thrombosis remain unknown, because only a limited number of cases describing this rare complication have been reported.

Pathophysiological Aspects of COVID-19-Associated Vasculopathic Diseases

Since the beginning of coronavirus disease 2019 (COVID-19) pandemic, numerous data reported potential effects on the cardiovascular system due to infection by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which may lead to COVID-19-associated vasculopathies during the acute phase and measurable vascular changes in the convalescent phase. Infection by SARS-CoV-2 seems to have specific direct and indirect effects on the endothelium, immune and coagulation systems thus promoting endothelial dysfunction, immunothrombosis, and formation of neutrophil extracellular traps although the exact mechanisms still need to be elucidated. This review represents a recent update of pathophysiological pathways of the respective three major mechanisms contributing to COVID-19 vasculopathies and vascular changes and includes clinical implications and significance of outcome data.

A Multi-Layered GRU Model for COVID-19 Patient Representation and Phenotyping from Large-Scale EHR Data

The unprecedented scale of the COVID-19 pandemic created an alarming shortage of healthcare resources. To enable a more efficient resource allocation and targeted treatment, in this manuscript, we conducted a data-driven study of COVID-19 patients to predict patient outcomes and identify patient phenotypes. Specifically, we developed a multi-layered gated recurrent units-based model, referred to as mGRU-CP, to learn patient embeddings and estimate patient survival probabilities by leveraging their electronic health record (EHR) data in the COVID-19 Research Data Commons. We empirically compared mGRU-CP against four state-of-the-art baseline methods on three sets of patient features. The experimental results demonstrate that mGRU-CP could achieve competitive or superior performance over the baseline methods in all the settings. Our analysis also shows that the learned patient embeddings in mGRU-CP could enable meaningful patient phenotyping to better understand patient mortalities. Our study is significant in understanding patients in the past COVID-19 pandemic, and provides computational tools to predict patient outcomes and inform associated healthcare resource allocation for the future pandemics proactively.

Dexamethasone Modulates the Cytokine Response but Not COVID-19-Induced Coagulopathy in Critically Ill

Severe forms of coronavirus 2019 (COVID-19) disease are caused by an exaggerated systemic inflammatory response and subsequent inflammation-related coagulopathy. Anti-inflammatory treatment with low dose dexamethasone has been shown to reduce mortality in COVID-19 patients requiring oxygen therapy. However, the mechanisms of action of corticosteroids have not been extensively studied in critically ill patients in the context of COVID-19. Plasma biomarkers of inflammatory and immune responses, endothelial and platelet activation, neutrophil extracellular trap formation, and coagulopathy were compared between patients treated or not by systemic dexamethasone for severe forms of COVID-19. Dexamethasone treatment significantly reduced the inflammatory and lymphoid immune response in critical COVID-19 patients but had little effect on the myeloid immune response and no effect on endothelial activation, platelet activation, neutrophil extracellular trap formation, and coagulopathy. The benefits of low dose dexamethasone on outcome in critical COVID-19 can be partially explained by a modulation of the inflammatory response but not by reduction of coagulopathy. Future studies should explore the impact of combining dexamethasone with other immunomodulatory or anticoagulant drugs in severe COVID-19.

Risk of Thrombosis during and after a SARS-CoV-2 Infection: Pathogenesis, Diagnostic Approach, and Management

Coronavirus disease 2019 (COVID-19) increases the risk of thromboembolic events, especially in patients with severe infections requiring intensive care and cardiorespiratory support. COVID-19 patients with thromboembolic complications have a higher risk of death, and if they survive, these complications are expected to negatively affect these patients’ quality of life. Moreover, recent data reported that the risk of thromboembolism remains high months after a COVID-19 infection. Therefore, understanding the pathogenesis of thrombosis in the setting of COVID-19 may facilitate the early prevention and treatment of COVID-19-associated thromboembolism to reduce concomitant morbidity, mortality, and disability. This review will first discuss the clinical characteristics of COVID-19 infections, particularly with regard to the underlying pathophysiology. Then, the pathogenesis of COVID-19-associated thrombosis at the molecular and cellular levels will be comprehensively reviewed. Next, the clinical manifestations of venous and arterial thromboembolism in COVID-19 as well as the potential benefits of several laboratory markers of thrombosis will be further discussed. Lastly, the preventive and therapeutic management of thromboembolism during and after COVID-19 will also be explained.

EVALUATION OF D-DIMER LEVEL AS A BIOMARKER OF DISEASE SEVERITY AND MORTALITY IN PATIENTS WITH COVID-19

OBJECTIVE

The aim: To examine risk factors and evaluate the use of D-dimer as a biomarker of disease severity and mortality in patients with COVID-19.

PATIENTS AND METHODS

Materials and methods: Data from a large NYU Langone Health system were analyzed to examine the prevalence of elevated D-dimer levels at first detection and the trend. A retrospective cohort study of 2,377 patients (NYU Langone Health) with severe COVID-19. Also we conducted a retrospective study based on the mortality database of 247 patients from COVID-19 at the Chernivtsi Regional Clinical Hospital.

RESULTS

Results: Patients with elevated baseline D-dimer were more likely to have critical illness than patients with normal D-dimer (43.9% vs. 18.5%). The frequency of adverse events increased with increasing D-dimer levels. Individuals with D-dimer >2000 ng/mL had the highest risk of critical illness (66.0%).

CONCLUSION

Conclusions: Thus, the level of D-dimer can be considered an important prognostic factor in COVID-19, as its level is elevated in the vast majority of patients with COVID-19 and correlates with a severe course and high mortality.

Recycling the High-Salinity Textile Wastewater by Quercetin-Based Nanofiltration Membranes with Minimal Water and Energy Consumption

Effective recovery of dyes and salts from textile wastewater by nanofiltration (NF) remains a serious challenge due to the high consumption of water and energy caused by the limited performance of the available membranes. Herein, a novel strategy is described to prepare loose polyester NF membranes by using renewable quercetin as the aqueous monomer for fractionation of high salinity textile wastewater with minimal water and energy consumption. Compared with NF270, taken as the reference membrane, the QE-0.2/TMC-0.2 membrane significantly improved the efficiency for dye/salt fractionation by 288%. The water consumption was also decreased by 42.9%. The efficiency is attributed to an ultrahigh water permeance of 198 ± 2.1 L^-1 m^-2 h^-1 bar^-1 with a high selectivity of 123 (extremely low NaCl rejection of 1.6% and high Congo red rejection of 99.2%). The optimal quercetin-based membrane had an ultrathin separation layer of about 39 ± 1.2 nm with good hydrophilicity and negative charge density. Moreover, this work includes a novel method of comparison with a theoretically ideal membrane, which shows that both the energy and water consumption are near their theoretical minimum. This strategy is expected to save energy and minimize carbon emissions for membrane-based wastewater treatment systems.

Pulmonary Embolism Severity Index Predicts Adverse Events in Hospitalized COVID-19 Patients: A Retrospective Observational Study

OBJECTIVES

Pulmonary embolism is one of the leading causes of death in patients with COVID-19. Autopsy findings showed that the incidence of thromboembolic events was higher than clinically suspected. In this study, the authors investigated the relationship between pulmonary embolism severity index (PESI) and simplified PESI (sPESI) on admission to the hospital, as well as adverse events in hospitalized COVID-19 patients without clinically documented venous and/or pulmonary embolism. The adverse events investigated were the development of acute respiratory distress syndrome, the need for intensive care unit admission, invasive or noninvasive mechanical ventilation, and in-hospital mortality.

DESIGN

A retrospective and observational study.

SETTING

Two large-volume tertiary hospitals in the same city.

PARTICIPANTS

A total of 720 hospitalized COVID-19 patients with a positive polymerase chain reaction were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the study population, 48.6% (350) were women, and the median age was 66 years (19-96). The overall in-hospital mortality rate was 20.5%. In the multivariate logistic regression analysis, a significant relationship was found between the whole adverse events considered and PESI, as well as sPESI (p < 0.001). According to the results, sPESI ≥2 predicts in-hospital mortality with a sensitivity of 61.4% and specificity of 83.3% (area under the curve = 0.817, 95% confidence interval 0.787-0.845, p < 0.001). Similarly, PESI classes IV and V also were found as independent risk factors for in-hospital mortality (for PESI class IV, odds ratio = 2.81, p < 0.017; for PESI class V, odds ratio = 3.94, p < 0.001).

CONCLUSIONS

PESI and sPESI scoring systems were both found to be associated with adverse events, and they can be used to predict in-hospital mortality in hospitalized COVID-19 patients without documented venous and/or pulmonary embolism.

Endocarditis in the intensive care unit: an update

PURPOSE OF REVIEW

The incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients with IE being admitted to intensive care units (ICU). Nearly half of patients with IE develop a complication during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE patients. This review discusses the contemporary perioperative and intensive care literature.

RECENT FINDINGS

IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of developing IE because they are often in a pro-inflammatory state and many also have several indwelling catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New developments in antibiotic treatment and adjunctive therapies are explored further in this review.

SUMMARY

The lack of evidence on ICU patients with IE highlights the critical importance of multidisciplinary decision-making and the need for further research.

Intraoperative pulmonary embolism in shoulder arthroscopy in a patient with previous SARS-CoV-2 infection: a case report

The objective of this article is to describe intraoperative pulmonary embolism during shoulder arthroscopy in a patient with previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Further, we describe how the pandemic has influenced the population by increasing the rate of embolisms. Awareness of such cases will help to increase knowledge regarding SARS-Cov-2 and to determine if such patients should receive routine antithrombotic prophylaxis.

Coagulation Profile and Outcomes of COVID-19 Patients at Wahidin Sudirohusodo Hospital, Makassar, Indonesia

Background: Coronavirus disease 2019 (COVID-19) is a viral pneumonia infection that spreads rapidly globally (with a number of cases > 15,000,000 worldwide and mortality of ±4%) until it is designated a pandemic by the World Health Organization (WHO). One of the complications of COVID-19 is the incidence of coagulopathy and thromboembolism. The coronavirus, SARS-CoV-2, activates inflammatory and thrombotic processes. Coagulopathy and abnormal coagulation parameters are indicated among the most significant biomarkers of poor prognosis in COVID-19 patients. COVID-19-associated coagulopathy is characterized by a decreased platelet count and the presence of a cytokine storm indicating an extreme hypercoagulable state. This study aims to determine the coagulation profile of moderate-severe patients and outcomes in COVID-19 patients Methods: The study was conducted in a hospital in Makassar: Infection Center RS. Wahidin Sudirohusodo. Medical Record Data for all inpatients who have been diagnosed with COVID-19 through the RT-PCR test taken from January 2021-August 2021.Statistical tests in the form of the Kolmogorov-Smirnov test to assess the Normality of the Data, Chi-Square test, and the calculation of the out ratio (OR) Mann-Whitney test, Independent T-Test. Multivariate analysis was carried out using a Multiple Logistic Regression-Backward Wald Method. The results of the statistical test were significant if the p-value <0.05.   Results: The research subjects were 231 patients with confirmed COVID-19. The mean PT, D-Dimer, and Fibrinogen were higher in severe COVID-19 than moderate COVID-19 and had significant results. While PLT did not have significant results against moderate-severe COVID-19. The relationship between groups of coagulation marker variables was found to have a significant relationship with moderate to severe COVID-19. 4.     All coagulation markers were significantly related to the outcome (p<0.05). The mean value of each variable was found to be greater in patients with outcomes who died   Conclusion: There was an increase in all coagulation markers in moderate to severe COVID-19 except for PLT which was not significant. All coagulation markers are significantly related to outcome

Implications of SARS-CoV-2 Infection in Systemic Juvenile Idiopathic Arthritis

Systemic juvenile idiopathic arthritis (sJIA) is a serious multifactorial autoinflammatory disease with a significant mortality rate due to macrophage activation syndrome (MAS). Recent research has deepened the knowledge about the pathophysiological mechanisms of sJIA-MAS, facilitating new targeted treatments, and biological disease-modifying antirheumatic drugs (bDMARDs), which significantly changed the course of the disease and prognosis. This review highlights that children are less likely to suffer severe COVID-19 infection, but at approximately 2-4 weeks, some cases of multisystem inflammatory syndrome in children (MIS-C) have been reported, with a fulminant course. Previous established treatments for cytokine storm syndrome (CSS) have guided COVID-19 therapeutics. sJIA-MAS is different from severe cases of COVID-19, a unique immune process in which a huge release of cytokines will especially flood the lungs. In this context, MIS-C should be reinterpreted as a special MAS, and long-term protection against SARS-CoV-2 infection can only be provided by the vaccine, but we do not yet have sufficient data. COVID-19 does not appear to have a substantial impact on rheumatic and musculoskeletal diseases (RMDs) activity in children treated with bDMARDs, but the clinical features, severity and outcome in these patients under various drugs are not yet easy to predict. Multicenter randomized controlled trials are still needed to determine when and by what means immunoregulatory products should be administered to patients with sJIA-MAS with a negative corticosteroid response or contraindications, to optimize their health and safety in the COVID era.

Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week

Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban. (FREEDOM COVID-19 Anticoagulation Strategy [FREEDOM COVID]; NCT04512079)

A case report of COVID-19-associated acute hand ischaemia in a young professional volleyball player

Background

Several coronavirus disease-19 (COVID-19)-associated complications are being increasingly reported, including arterial and venous thrombo-embolic events that may lead to amputation of the affected limbs. So far, acute upper limb ischaemia (ULI) has been reported only in critically ill patients.

Case summary

Herein, we aimed to present a case of a 29-year-old, otherwise healthy male volleyball player, with acute ischaemic signs in the upper extremity who was diagnosed with COVID-19 1 month before the ischaemic event. It has been shown that volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow that can lead to pain and cold digits, but never acute ULI.

Discussion

To our knowledge, this is the first case of such a hypercoagulable synergistic mechanism that leads to a high thrombus burden. Intra-arterial local thrombolysis and percutaneous transluminal angioplasty failed to succeed, and percutaneous large-bore embolectomy with the Indigo Aspiration System (Penumbra Inc., CA, USA) was deemed necessary.

Resolution of Acute Pulmonary Embolism using anticoagulation therapy alone in Coronavirus Disease 2019

Objective

Methods

Results

Conclusions

Biomarkers of thromboinflammation correlate to COVID-19 infection and admission status in emergency department patients

Background

COVID-19-associated coagulopathy is incompletely understood.

Objectives

To characterize thrombin generation, Von Willebrand Factor (VWF), neutrophil extracellular traps (NETs), and their role in COVID-19 risk stratification in the emergency department (ED).

Patients/methods

Plasma samples from 67 ED COVID-19 patients were compared to 38 healthy volunteers (HVs). Thrombin generation (calibrated automated thrombogram, CAT) was expressed as lag time (LT, min), peak height (PH, min), and time to peak (ttPeak, min). Citrullinated nucleosomes and histones were quantified with ELISA, VWF antigen and activity (IU/dL) through latex immunoassay, Factor VIII (IU/dL) through one-stage optical clot detection, and VWF multimers with Western blot densitometry. Wilcoxon testing and multivariable logistic regression were performed. Results presented as median [Q1, Q3]; p < 0.05 significant.

Results

COVID-19 patients had longer LT (4.00 [3.26, 4.67]; 2.95 [2.67, 3.10], p < 0.001) and ttPeak (7.33 [6.33, 8.04]; 6.45 [6.00, 7.50], p = 0.004), greater VWF antigen (212 [158, 275]; 110 [91, 128], p < 0.001) and Factor VIII levels (148 [106, 190]; 106 [86, 129], p < 0.001), with decreased high molecular weight multimers (Normalized multimer ratio 0.807 [0.759, 0.869]; 0.891 [0.858, 0.966], p < 0.001), than HVs. COVID-19 patients requiring admission from the ED had longer LT and ttPeak with greater VWF antigen and Factor VIII levels than those not admitted. Two and three variable models of CAT parameters and VWF correlated with COVID-19 and admission status (C-statistics 0.677 to 0.922).

Conclusions

Thrombin generation kinetics and VWF levels, independent of NETs, may have a role in predicting admission need for COVID-19 patients.

Impact of COVID-19 and lockdowns on pulmonary embolism in hospitalized patients in France: a nationwide study

BACKGROUND

This study assessed the impact of the COVID-19 epidemic on overall hospitalizations for pulmonary embolism (PE) in France in comparison with previous years, and by COVID-19 and non-COVID-19 status.

METHODS

Hospitalization data (2017-2020) were extracted from the French National Discharge database (all public and private hospitals). We included all patients older than 18 years hospitalized during the 3 years and extracted PE status and COVID-19 status (from March 2020). Age, sex and risk factors for PE (such as obesity, cancer) were identified. We also extracted transfer to an intensive care unit (ICU) and hospital death. The number of PE and the frequency of death in patients in 2019 and 2020 were described by month and by COVID-19 status. Logistic regressions were performed to identify the role of COVID-19 among other risk factors for PE in hospitalized patients.

RESULTS

The overall number of patients hospitalized with PE increased by about 16% in 2020 compared with 2019, and mortality also increased to 10.3% (+ 1.2%). These increases were mostly linked to COVID-19 waves, which were associated with PE hospitalization in COVID-19 patients (PE frequency was 3.7%; 2.8% in non-ICU and 8.8% in ICU). The final PE odds ratio for COVID-19 hospitalized patients was 4 compared with other hospitalized patients in 2020. The analyses of PE in non-COVID-19 patients showed a 2.7% increase in 2020 compared with the previous three years.

CONCLUSION

In 2020, the overall number of patients hospitalized with PE in France increased compared to the previous three years despite a considerable decrease in scheduled hospitalizations. Nevertheless, proactive public policy focused on the prevention of PE in all patients should be encouraged.

The Current Evidence Regarding COVID-19 and Pregnancy: Where Are We Now and Where Should We Head to Next?

Despite the volume of publications dedicated to unraveling the biological characteristics and clinical manifestations of SARS-CoV-2, available data on pregnant patients are limited. In the current review of literature, we present an overview on the developmental course, complications, and adverse effects of COVID-19 on pregnancy. A comprehensive review of the literature was performed in PubMed/Medline, Embase, and Cochrane Central databases up to June 2021. This article collectively presents what has been so far reported on the identified critical aspects, namely complications during pregnancy, delivery challenges, neonatal health care, potential routes of viral transmission, including vertical transmission or breastfeeding, along with the risks involved in the vaccination strategy during pregnancy. Despite the fact that we are still largely navigating uncharted territory, the observed publication explosion in the field is unprecedented. The overwhelming need for data is undoubtable, and this serves as the driver for the plethora of publications witnessed. Nonetheless, the quality of data sourced is variable. In the midst of the frenzy for reporting on SARS-CoV-2 data, monitoring this informational overload is where we should head to next, considering that poor quality research may in fact hamper our attempts to prevail against this unparalleled pandemic outbreak.

A multi-center retrospective cohort study defines the spectrum of kidney pathology in Coronavirus 2019 Disease (COVID-19)

Kidney failure is common in patients with Coronavirus Disease-19 (COVID-19) resulting in increased morbidity and mortality. In an international collaboration, 284 kidney biopsies were evaluated to improve understanding of kidney disease in COVID-19. Diagnoses were compared to five years of 63,575 native biopsies prior to the pandemic and 13,955 allograft biopsies to identify diseases increased in patients with COVID-19. Genotyping for APOL1 G1 and G2 alleles was performed in 107 African American and Hispanic patients. Immunohistochemistry for SARS-CoV-2 was utilized to assess direct viral infection in 273 cases along with clinical information at the time of biopsy. The leading indication for native biopsy was acute kidney injury (45.4%), followed by proteinuria with or without concurrent acute kidney injury (42.6%). There were more African American patients (44.6%) than patients of other ethnicities. The most common diagnosis in native biopsies was collapsing glomerulopathy (25.8%) which associated with high-risk APOL1 genotypes in 91.7% of cases. Compared to the five-year biopsy database, the frequency of myoglobin cast nephropathy and proliferative glomerulonephritis with monoclonal IgG deposits was also increased in patients with COVID-19 (3.3% and 1.7%, respectively), while there was a reduced frequency of chronic conditions (including diabetes mellitus, IgA nephropathy, and arterionephrosclerosis) as the primary diagnosis. In transplants, the leading indication was acute kidney injury (86.4%), for which rejection was the predominant diagnosis (61.4%). Direct SARS-CoV-2 viral infection was not identified. Thus, our multi-center large case series identified kidney diseases that disproportionately affect patients with COVID-19, demonstrated a high frequency of APOL1 high-risk genotypes within this group, with no evidence of direct viral infection within the kidney.

COVID-19 and cytokine storm syndrome: are there lessons from macrophage activation syndrome?

Although interest in "cytokine storms" has surged over the past decade, it was massively amplified in 2020 when it was suggested that a subset of patients with COVID-19 developed a form of cytokine storm. The concept of cytokine storm syndromes (CSS) encompasses diverse conditions or circumstances that coalesce around potentially lethal hyperinflammation with hemodynamic compromise and multiple organ dysfunction syndrome. Macrophage activation syndrome (MAS) is a prototypic form of CSS that develops in the context of rheumatic diseases, particularly systemic juvenile idiopathic arthritis. The treatment of MAS relies heavily upon corticosteroids and cytokine inhibitors, which have proven to be lifesaving therapies in MAS, as well as in other forms of CSS. Within months of the recognition of SARS-CoV2 as a human pathogen, descriptions of COVID-19 patients with hyperinflammation emerged. Physicians immediately grappled with identifying optimal therapeutic strategies for these patients, and despite clinical distinctions such as marked coagulopathy with endothelial injury associated with COVID-19, borrowed from the experiences with MAS and other CSS. Initial reports of patients treated with anti-cytokine agents in COVID-19 were promising, but recent large, better-controlled studies of these agents have had mixed results suggesting a more complex pathophysiology. Here, we discuss how the comparison of clinical features, immunologic parameters and therapeutic response data between MAS and hyperinflammation in COVID-19 can provide new insight into the pathophysiology of CSS.

The impact of the COVID-19 pandemic on cerebrovascular disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a systemic disease that affects nearly all organ systems through infection and subsequent dysregulation of the vascular endothelium. One of the most striking phenomena has been a coronavirus disease 2019 (COVID-19)–associated coagulopathy. Given these findings, questions naturally emerged about the prothrombotic impact of COVID-19 on cerebrovascular disease and whether ischemic stroke is a clinical feature specific to COVID-19 pathophysiology. Early reports from China and several sites in the northeastern United States seemed to confirm these suspicions. Since these initial reports, many cohort studies worldwide observed decreased rates of stroke since the start of the pandemic, raising concerns for a broader impact of the pandemic on stroke treatment. In this review, we provide a comprehensive assessment of how the pandemic has affected stroke presentation, epidemiology, treatment, and outcomes to better understand the impact of COVID-19 on cerebrovascular disease. Much evidence suggests that this decline in stroke admissions stems from the global response to the virus, which has made it more difficult for patients to get to the hospital once symptoms start. However, there does not appear to be a demonstrable impact on quality metrics once patients arrive at the hospital. Despite initial concerns, there is insufficient evidence to ascribe a causal relationship specific to the pathogenicity of SARS-CoV-2 on the cerebral vasculature. Nevertheless, when patients infected with SARS-CoV-2 present with stroke, their presentation is likely to be more severe, and they have a markedly higher rate of in-hospital mortality than patients with either acute ischemic stroke or COVID-19 alone.

Biosensing surfaces and therapeutic biomaterials for the central nervous system in COVID-19

COVID-19 can affect the central nervous system (CNS) indirectly by inflammatory mechanisms and even directly enter the CNS. Thereby, COVID-19 can evoke a range of neurosensory conditions belonging to infectious, inflammatory, demyelinating, and degenerative classes. A broad range of non-specific options, including anti-viral agents and anti-inflammatory protocols, is available with varying therapeutic. Due to the high mortality and morbidity in COVID-19-related brain damage, some changes to these general protocols, however, are necessary for ensuring the delivery of therapeutic(s) to the specific components of the CNS to meet their specific requirements. The biomaterials approach permits crossing the blood-brain barrier (BBB) and drug delivery in a more accurate and sustained manner. Beyond the BBB, drugs can protect neural cells, stimulate endogenous stem cells, and induce plasticity more effectively. Biomaterials for cell delivery exist, providing an efficient tool to improve cell retention, survival, differentiation, and integration. This paper will review the potentials of the biomaterials approach for the damaged CNS in COVID-19. It mainly includes biomaterials for promoting synaptic plasticity and modulation of inflammation in the post-stroke brain, extracellular vesicles, exosomes, and conductive biomaterials to facilitate neural regeneration, and artificial nerve conduits for treatment of neuropathies. Also, biosensing surfaces applicable to the first sensory interface between the host and the virus that encourage the generation of accelerated anti-viral immunity theoretically offer hope in solving COVID-19.