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El-Hady HA, Mahmoud Abd-Elwahab ES, Mostafa-Hedeab G, Shawky Elfarargy M. Portal vein thrombosis in patients with COVID-19: A systematic review. Asian J Surg 2022:S1015-9584(22)01547-0. [PMID: 36435627 PMCID: PMC9650574 DOI: 10.1016/j.asjsur.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/25/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022] Open
Abstract
Several studies have proven that COVID-19 is linked to a higher incidence of different thrombotic events. Thrombosis of the portal vein can result in portal hypertension and can extend to the mesenteric vein resulting in intestinal ischemia. A search of PubMed, Web of Science, and Scopus for relevant studies revealed an association between PVT and COVID-19. This review is structured according to PRISMA guidelines. Thirty-three studies met the inclusion criteria. Twenty-nine case studies/series and four cohort/cross-sectional studies were included. Age at diagnosis was lower when compared to PVT due to cirrhosis. In cohort/cross-sectional studies, males comprised 54.83% of subjects, whereas in case reports/series, males comprised 62.1%. Obesity, asthma, hypertension, and diabetes were the most common comorbidities identified. The majority of the thrombotic events occurred within two weeks. The treatment aimed to prevent thrombus progression and improve recanalization. According to the evidence, early intervention prevents the poor prognosis of intestinal ischemia and its propagation.
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Affiliation(s)
- Hany Abdelfatah El-Hady
- Department of Surgery, Faculty of Medicine, Jouf University, Saudi Arabia; Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Egypt.
| | | | - Gomaa Mostafa-Hedeab
- Pharmacology Department, Medical College, Jouf University, Sakaka, Saudi Arabia; Pharmacology Department, Faculty of Medicine, Beni-suef University, Egypt
| | - Mohamed Shawky Elfarargy
- Department of Pediatrics, College of Medicine, Jouf University, Saudi Arabia; Department of Pediatrics, Faculty of Medicine, Tanta University, Egypt
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Draxler DF, Brodard J, Zante B, Jakob SM, Wiegand J, Kremer Hovinga JA, Angelillo-Scherrer A, Rovo A. The potential impact of Covid-19 on the capacity of routine laboratory tests to detect heparin-induced thrombocytopenia. Thromb J 2022; 20:55. [PMID: 36163073 PMCID: PMC9510722 DOI: 10.1186/s12959-022-00411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022] Open
Abstract
In Covid-19, anticoagulation with heparin is often administered to prevent or treat thromboembolic events. Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin treatment, caused by heparin-dependent, platelet activating anti-platelet factor 4 (PF4)/heparin antibodies. Diagnosis of HIT is based on the combination of clinical parameters, allowing to determine the pretest probability, and laboratory testing for anti-PF4/heparin antibodies and confirmatory functional assays, such as the heparin-induced platelet activation (HIPA) test. We report the case of a patient with severe Covid-19 pneumonia requiring ECMO treatment, who developed recurrent clotting of the ECMO filter and a drop in platelet count under heparin treatment. He was therefore suspected to have HIT and the anticoagulation was switched to argatroban. Despite high clinical probability and high titres of anti-PF4/heparin antibodies, the functional HIPA test was negative. Nevertheless, argatroban was continued rather than to reinstate anticoagulation with heparin. Reevaluation 7 days later then demonstrated a strongly positive functional HIPA test and confirmed the diagnosis of HIT. Under anticoagulation with argatroban the patient gradually improved and was finally weaned off the ECMO. In conclusion, this case highlights the critical importance of clinical judgement, exploiting the 4 T score, given that Covid-19 patients may present a different pattern of routine laboratory test results in HIT diagnostics. The possibility of a false negative HIPA test has to be considered, particularly in early phases of presentation. In cases of a discrepancy with high clinical probability of HIT and/or high titre anti-PF4/heparin antibodies despite a negative HIPA test, a reevaluation within 3 to 5 days after the initial test should be considered in order to avoid precipitant reestablishment of unfractionated heparin, with potentially fatal consequences.
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Affiliation(s)
- Dominik F Draxler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Bern Center for Precision Medicine, Bern, Switzerland.
| | - Justine Brodard
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Björn Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Wiegand
- Department of Intensive Care Medicine, Lindenhofspital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Bern Center for Precision Medicine, Bern, Switzerland
| | - Alicia Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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The prevalence of vascular complications in SARS-CoV-2 infected outpatients. Wien Med Wochenschr 2022; 173:168-172. [PMID: 35939218 PMCID: PMC9358629 DOI: 10.1007/s10354-022-00954-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/12/2022] [Indexed: 11/23/2022]
Abstract
Background The risk of thromboembolic events is increased for coronavirus disease (COVID)-19 inpatients. For severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected outpatients, only few data are available so far. Methods In our prospective single-center study, 461 SARS-CoV-2-infected outpatients were screened for the presence of deep vein thrombosis. Results Two outpatients had suffered a deep vein thrombosis. An association with previously known risk factors, such as preexisting thrombosis in the medical history or cardiovascular risk factors, could not be proven. Conclusion General thromboprophylaxis in SARS-CoV-2-infected outpatients is still not recommended.
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Abstract
Introduction COVID-19 associated VTE is a new disease entity with high morbidity and mortality. The aim of this paper is to review contemporary emerging literature on the incidence, pathophysiology, predictive prognostic indicators, and management consensus for Covid-19 related thrombotic complications, in particular DVT and PE. Methods A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed. References of review articles were further screened according to the exclusion criteria. Results In total, 154 records were identified and 20 duplicates were removed. A final 68 articles were included in the qualitative analysis. COVID-19 related thrombosis can affect multiple organs of the body, presenting in the form of arterial or venous thrombosis such as ischemic stroke, myocardial infarction, mesenteric ischemia, limb ischemia, DVT, or PE. DVT and PE has an overall incidence of 6–26%, and severely ill COVID-19 patients have even higher incidence of thromboembolism. On the other hand, incidence of arterial thromboembolism is much lower with incidence of 0.7%–3.7%. D-dimer is found to be an independent risk factor, and IMPROVE score, Caprini score, and Padua score have all been used as predictors. International guidelines suggest the use of low molecular weight heparin (LMWH) or fondaparinux for prophylaxis of VTE, and therapeutic dosage of weight adjusted LMWH for treatment if confirmed diagnosis. Conclusions Contemporary rapidly evolving evidence shows that COVID-19 associated thrombosis was a novel clinical entity, especially in severely ill COVID-19 patients. There are multiple society-driven guidelines only, but without any level 1 evidence for management regimen. The ideal dose for prophylaxis is not established and may vary depending on balance of bleeding and thrombosis risk. The risk of bleeding may be increased in patients in intensive care unit.
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Affiliation(s)
- Nicole M Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong, China
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de Laat B, Traets MJM, De Laat-Kremers RWM, Verweij SP, Ninivaggi M, Jong E, Huskens D, Blok BA, Remme GCP, Miszta A, Nijhuis RHT, Herder GJM, Fijnheer R, Roest M, Fiolet ATL, Remijn JA. Haemostatic differences between SARS-CoV-2 PCR-positive and negative patients at the time of hospital admission. PLoS One 2022; 17:e0267605. [PMID: 35482749 PMCID: PMC9049327 DOI: 10.1371/journal.pone.0267605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/12/2022] [Indexed: 12/14/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with thrombosis. We conducted a cohort study of consecutive patients, suspected of SARS-CoV-2 infection presented to the emergency department. We investigated haemostatic differences between SARS-CoV-2 PCR positive and negative patients, with dedicated coagulation analysis. The 519 included patients had a median age of 66 years, and 52.5% of the patients were male. Twenty-six percent of the patients were PCR-positive for SARS-CoV-2.PCR positive patients had increased levels of fibrinogen and (active) von Willebrand Factor (VWF) and decreased levels of protein C and α2-macroglobulin compared to the PCR negative patients. In addition, we found acquired activated protein C resistance in PCR positive patients. Furthermore, we found that elevated levels of factor VIII and VWF and decreased levels of ADAMTS-13 were associated with an increased incidence of thrombosis in PCR positive patients. In conclusion, we found that PCR positive patients had a pronounced prothrombotic phenotype, mainly due to an increase of endothelial activation upon admission to the hospital. These findings show that coagulation tests may be considered useful to discriminate severe cases of COVID-19 at risk for thrombosis.
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Affiliation(s)
- B de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - M J M Traets
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | | | - S P Verweij
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - M Ninivaggi
- Synapse Research Institute, Maastricht, the Netherlands
| | - E Jong
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - D Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - B A Blok
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - G C P Remme
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - A Miszta
- Synapse Research Institute, Maastricht, the Netherlands
| | - R H T Nijhuis
- Department of Medical Microbiology and Medical Immunology, Meander Medical Center, Amersfoort, the Netherlands
| | - G J M Herder
- Department of Pulmonology, Meander Medical Center, Amersfoort, the Netherlands
| | - R Fijnheer
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - M Roest
- Synapse Research Institute, Maastricht, the Netherlands
| | - A T L Fiolet
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands
| | - J A Remijn
- Department of Clinical Chemistry, Meander Medical Center, Amersfoort, the Netherlands
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Poorna T A, J R L, Ek J, John B. Ludwig's angina in a COVID positive patient-An atypical case report. SPECIAL CARE IN DENTISTRY 2021; 42:99-102. [PMID: 34448220 PMCID: PMC8662242 DOI: 10.1111/scd.12643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 01/10/2023]
Abstract
The management of odontogenic infections is established and several guidelines have been proposed for its effective treatment. Outbreak of COVID‐19 has posed serious challenge in the management of odontogenic infections, further complicated by immunocompromised status of the patient, where adequate evaluation and prompt attention is mandatory to avoid untoward consequences. Ludwig's angina being a life threatening infection by itself, association or simultaneous presentation with COVID‐19 infection can add further complexity in the management for a maxillofacial surgeon. Here we present a case report of Ludwig's angina in a patient who tested positive for Coronavirus infection and how we treated her successfully.
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Affiliation(s)
- Anish Poorna T
- Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India
| | - Lokesh J R
- Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India
| | - Joshna Ek
- Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India
| | - Bobby John
- Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India
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Trabattoni D, Ravagnani PM, Merlino L, Montorsi P, Bartorelli AL. The bimodal "rise and fall" ACS curve overlapping COVID-19 pandemic peaks. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:295-299. [PMID: 34322300 PMCID: PMC8303045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/11/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The COVID-19 outbreak harmed acute coronary syndromes. During the national lockdown in Italy, the fear of post-admission contagion translated into significant delays in seeking medical help among STEMI (ST-elevation myocardial infarction) patients. OBJECTIVE AND METHODS Our analysis aimed to assess the ACS (Acute Coronary Syndromes) admissions during the pandemic, together with time to presentation and clinical outcomes compared to 2019 in a cardiovascular hub in Milan. Data of ACS patients admitted during the pandemic year 2020 were extracted by the hospital's database and compared to a historical cohort of patients admitted for the same clinical indications in 2019. RESULTS A total of 599 ACS cases were recorded in 2020 vs. 386 cases in 2019, with a net 55% increase, associated with late clinical presentations, a threefold increase in cardiogenic shock, and a more than two-fold higher mortality rate. CONCLUSIONS The ultimate goal of this analysis is to preserve the life-saving focus on universal and prompt STEMI diagnosis and treatment, even in a time of dynamic global crisis.
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Affiliation(s)
| | | | | | - Piero Montorsi
- Centro Cardiologico Monzino, IRCCSMilan, Italy
- Department of Clinical Sciences and Community Health, University of MilanItaly
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCSMilan, Italy
- Department of Biomedical and Clinical Sciences, “Luigi Sacco”, University of MilanMilan, Italy
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Gabbai-Armelin PR, de Oliveira AB, Ferrisse TM, Sales LS, Barbosa ERO, Miranda ML, Salomão KB, Brighenti FL. COVID-19 (SARS-CoV-2) infection and thrombotic conditions: A systematic review and meta-analysis. Eur J Clin Invest 2021; 51:e13559. [PMID: 33772772 PMCID: PMC8250119 DOI: 10.1111/eci.13559] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND COVID-19 is an infectious disease caused by SARS-CoV-2 associated with haematological manifestations (thrombolytic events). AIMS Considering the high prevalence of the thrombotic scenarios associated with COVID-19, the aim of this study was to perform a systematic review of the available literature, concerning the relation of COVID-19 and the thrombotic events, and identify prognostic factors for these events. MATERIALS & METHODS PubMed, Web of Science and Scopus databases were searched. Independent reviewers conducted all flow diagram steps. For qualitative analysis, Oxford level of evidence and Newcastle-Ottawa scale were used in the eligible articles. For the prognostic factors, a meta-analysis was conducted to age, number of neutrophils and platelets, and levels of ferritin, C-reactive protein, lactate dehydrogenase and D-dimer. Publication bias was accessed by funnel plot and by trim-and-fill test. Trim-and-fill test was also applied to evaluate meta-analysis bias. RESULTS Twenty articles were included in the qualitative analysis, and 6 articles were included in the meta-analysis. Case-control studies showed bias related to exposure, and the main bias in cohort studies were related to selection and outcome. All articles received score 4 for the level of evidence. Hypertension and diabetes were the comorbidities more frequently associated with thrombolytic events. Significant results were found regarding D-dimer (P < .0001) and age (P = .0202) for thrombotic events in patients diagnosed with COVID-19. CONCLUSION Patients older than 60 years, with hypertension, diabetes and D-Dimer values above 3.17 µg/mL, can be considered prognostic factors for developing thrombotic events due to COVID-19.
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9
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Aljamaan FS. Unusual Presentation of a Severe COVID-19 Case With Axillary Artery Thrombosis. Cureus 2021; 13:e15036. [PMID: 34150387 PMCID: PMC8200903 DOI: 10.7759/cureus.15036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has been evolving since early 2020 with high critical care mortality and morbidity. High mortality rates have been linked largely to respiratory failure. Hypercoagulability status induced by the massive inflammatory storm has led to a high rate of thrombotic events, whether arterial or venous, contributing to COVID-19 mortality especially in critically ill patients. Thrombotic events might be the presenting feature of the disease or might happen during hospitalization. In this case report, we describe a case of a 67-year-old male with severe COVID-19 pneumonia who was found on presentation to have left axillary artery thrombosis requiring embolectomy; the case was managed successfully. We reviewed the pathophysiology of hypercoagulability associated with COVID-19, clinical implications, and most recent treatment recommendations.
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Gonçalves FAR, Besen BAMP, de Lima CA, Corá AP, Pereira AJR, Perazzio SF, Gouvea CP, Fonseca LAM, Trindade EM, Sumita NM, Duarte AJDS, Lichtenstein A. Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study. Clinics (Sao Paulo) 2021; 76:e3547. [PMID: 34909913 PMCID: PMC8612302 DOI: 10.6061/clinics/2021/e3547] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/29/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.
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Affiliation(s)
- Fabio Augusto Rodrigues Gonçalves
- Laboratorio de Cirurgia Cardiovascular e Fisiopatologia da Circulacao (LIM11), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | | | - Clarice Antunes de Lima
- Departamento de Medicina Interna, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aline Pivetta Corá
- Divisao de Laboratorio Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Sandro Félix Perazzio
- Divisao de Laboratorio Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Christiane Pereira Gouvea
- Divisao de Laboratorio Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Augusto Marcondes Fonseca
- Servico de Imunologia Clinica e Alergia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Evelinda Marramon Trindade
- Nucleo de Avaliacao de Tecnologia em Saude, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Nairo Massakazu Sumita
- Divisao de Laboratorio Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alberto José da Silva Duarte
- Divisao de Laboratorio Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Dermatologia e Imunodeficiencias (LIM56), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Arnaldo Lichtenstein
- Departamento de Medicina Interna, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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