Anticoagulant use before COVID-19 diagnosis prevent COVID-19 associated acute venous thromboembolism or not:A systematic review and meta-analysis

BACKGROUND Coagulopathy and thromboembolic events are associated with poor outcomes in coronavirus disease 2019(COVID-19)patients.There is conflicting evidence on the effects of chronic anticoagulation on mortality and severity of COVID-19 disease.AIM To summarize the body of evidence on the effects of pre-hospital anticoagulation on outcomes in COVID-19 patients.METHODS A Literature search was performed on LitCovid PubMed,WHO,and Scopus databases from inception(December 2019)till June 2023 for original studies reporting an association between prior use of anticoagulants and patient outcomes in adults with COVID-19.The primary outcome was the risk of thromboembolic events in COVID-19 patients taking anticoagulants.Secondary outcomes included COVID-19 disease severity,in terms of intensive care unit admission or invasive mechanical ventilation/intubation requirement in patients hospitalized with COVID-19 infection,and mortality.The random effects models were used to calculate crude and adjusted odds ratios(aORs)with 95%confidence intervals(95%CIs).RESULTS Forty-six observational studies met our inclusion criteria.The unadjusted analysis found no association between prior anticoagulation and thromboembolic event risk[n=43851,9 studies,odds ratio(OR)=0.67(0.22,2.07);P=0.49;I2=95%].The association between prior anticoagulation and disease severity was non-significant[n=186782;22 studies,OR=1.08(0.78,1.49);P=0.64;I2=89%].However,pre-hospital anticoagulation significantly increased all-cause mortality risk[n=207292;35 studies,OR=1.72(1.37,2.17);P<0.00001;I2=93%].Pooling adjusted estimates revealed a statistically non-significant association between pre-hospital anticoagulation and thromboembolic event risk[aOR=0.87(0.42,1.80);P=0.71],mortality[aOR=0.94(0.84,1.05);P=0.31],and disease severity[aOR=0.96(0.72,1.26);P=0.76].CONCLUSION Prehospital anticoagulation was not significantly associated with reduced risk of thromboembolic events,improved survival,and lower disease severity in COVID-19 patients.

Food poisoning associated methemoglobinemia: Time to wake up

Dear editor,With interest we read the recent article on methemoglobinemia by Chan et al.[1]Through this letter,we would like to add few additional comments regarding methemoglobinemia and its relevance in medicine practice with regards to food poisoning.While Chan et al[1]successfully managed their patient of methemoglobinemia and could pinpoint choy sum as the responsible agent,we wonder if there were any more cases of choy sum related to methemoglobinemia detected at the same time in the community?

Association between COVID-19 and anxiety during social isolation:A systematic review

BACKGROUND The uncertainties about coronavirus disease 2019(COVID-19),the change in routine,lifestyles and the reduction of physical contact can cause stress,anxiety,emotional overload,poor sleep and even physical health complications.AIM To evaluate the scientific publications available on the relationship between COVID-19 and anxiety experienced in the general population,during the period of social isolation,adopted by governmental organizations and public health policymakers as a measure to contain the spread of cases.METHODS A literature search was performed systematically exploring the PubMed and Medline databases using the following terms classified as MeSH descriptors:(“anxiety”AND“pandemic”AND“COVID-19”).For the search,in the Biblioteca Virtual em Saúde–BVS,Science.gov,Web of Science and National Library plat forms, the following keywords were used: ("anxiety" AND "coronavirus" AND"social isolation"). Thirty-seven peer-reviewed articles were found. PRISMA andthe Downs & Black checklist were used for qualitative evaluation.RESULTSAfter applying the inclusion criteria, seven (n = 7) original scientific articles wereselected. The collated evidence demonstrated increased levels of symptoms ofanxiety and depression during the period of social isolation. The populationbetween 21 to 40 years was most affected. The risk of severe depression was twiceas high at the epicenter of the pandemic. Sleep quality was significantly impaired.Questions about politics, religion, and consumption of products from China werefound to generate fear and anticipate probable changes in the pattern of postpandemicconsumption. Social isolation exacerbated feelings of extreme hopelessness,sadness, loneliness and suicidal ideation.CONCLUSIONWe conclude that there is a potential relationship between social isolation duringthe COVID-19 pandemic and symptoms of anxiety. It is important to note that thedirect and indirect costs of not identifying the detrimental effects of thisphenomenon and neglecting strategies for intervention could lead to a significantpsychological burden on society in several aspects after social isolation.

Heart failure in COVID-19 patients:Critical care experience

Patients with heart failure(HF)may be at a higher risk of coronavirus disease 2019(COVID-19)infection and may have a worse outcome due to their comorbid conditions and advanced age.In this narrative review,we aim to study the interaction between COVID-19 and HF from a critical care perspective.We performed a systematic search for studies that reported HF and critical carerelated outcomes in COVID-19 patients in the PubMed and Medline databases.From a total of 1050 papers,we identified 26 that satisfied the eligibility criteria for our review.Data such as patient demographics,HF,intensive care unit(ICU)admission,management,and outcome were extracted from these studies and analyzed.We reported outcomes in heart-transplant patients with COVID-19 separately.In hospitalized patients with COVID-19,the prevalence of HF varied between 4%and 21%.The requirement for ICU admission was between 8%and 33%.HF patients with COVID-19 had an overall mortality rate between 20%and 40%.We identified that HF is an independent predictor of mortality in hospitalized COVID-19 patients,and patients with HF were more likely to require ventilation,ICU admission and develop complications.Patients with HF with reduced ejection fraction did worse than those with HF with midrange ejection fraction,and HF with preserved ejection fraction.COVID-19 patients with HF should be identified early and managed aggressively in an attempt to improve outcomes in this cohort of patients.

Clinical considerations for critically ill COVID-19 cancer patients:A systematic review

BACKGROUND The World Health Organization(WHO)on March 11,2020,had declared the novel coronavirus disease 2019(COVID-19)outbreak a global pandemic.The COVID-19 infection continues to be a pandemic and is currently causing overwhelming challenges to healthcare across the nations.Cancer patients represent a unique population vulnerable to COVID-19 infection due to their advanced age,intrinsic frailty,medical comorbidities,immunosuppression,and frequent health care visits for their underlying disease.Robust analysis of COVID-19 infection among cancer patients is crucial to aid in the optimal management of these patients.AIM To identify contributors of worse outcomes in patients with malignancy and COVID-19 and to describe the role of critical care.METHODS In this review,we summarized the information from seminal articles on the presentation and management of patients with COVID-19 and malignancy that were published before December 10,2020.We searched the Pub Med and Medline database for“COVID-19”and“Cancer”,“Malignancy”.Studies published in English,including adults with malignancy and COVID-19 infection,were eligible to be included in this review.Studies on patients that provided details on malignancy,clinical presentation,management,and outcome were included.Various details of malignancy that were included are the site of cancer,histopathological type,stage,chemotherapy,and immunotherapy.Details of COVID-19 infection that were obtained are clinical presentation,the modality of testing,imaging,management,and outcome.Critical care details that were obtained were the type of the organ dysfunction and the requirement of organ support measures,requirement of noninvasive,invasive ventilation,management of vasopressor support,and outcome.Articles that did not have patient details,opinions,letters,and articles not published in English were excluded.All articles were reviewed by 2 independent clinicians.Articles were screened for the above terminologies by independent clinicians.RESULTS We identified two thousand one hundred eighty-six articles,among which fiftyfive were studies that had included patient details pertaining to COVID-19 and cancer(Figure 1).Among these,eighteen studies were eligible and were included in this review as shown in Table 1.A total of 5199 cancer patients were reported.The mean age of patients across all the studies was 64.3 years with male predominance was noted in 12 studies.The clinical presentation and diagnosis of these patients were similar to the general population.Most commonly reported malignancies with COVID-19 infection were hematological in 44%of patients,followed by thoracic malignancy in 11%of patients.The mean number of cancer patients with COVID-19 requiring critical care was 16%.The mean mortality reported was 27.4%.Among the studies that reported the presence of organ dysfunction,respiratory failure was reported in 52%of patients,of which 11.7%required mechanical ventilation.72%of COVID-19 cancer patients required hospitalization across all the studies.The factors which are associated with the worse outcome from COVID-19 infections among the cancer patients were male gender,age≥65 years,presence of higher comorbidity burden based on Charlson comorbidity index and cumulative illness reporting scale>6,and smoking history.CONCLUSION The majority of the cancer patients required intensive care due to respiratory failure and the need for mechanical ventilation.Appropriate contingency planning for these patients in terms of goals of care and judicious resource allocation in the resource-poor regions is the key.The factors associated with worse outcomes from COVID-19 infections were independent of oncological features such as tumor stage,disease status,or current provision of active anticancer therapy and it could be continued with caution.

Update on retroperitoneal hematoma in children

Dear editor,We read with great interest the recent article by Badheka et al[1]published in your esteemed journal.Hereby we would like to address few additional points related to childhood retroperitoneal hematoma(RPH).RPH can be broadly divided into two categories,trauma/procedure related or spontaneous bleeding.Similarly,there may be one or more predisposing factors contributing for RPH:chronic liver disease,chronic kidney disease,bleeding disorders,blood thinner,interventions and so on.

Artificial intelligence and computer simulation models in critical illness

Widespread implementation of electronic health records has led to the increased use of artificial intelligence(AI)and computer modeling in clinical medicine.The early recognition and treatment of critical illness are central to good outcomes but are made difficult by,among other things,the complexity of the environment and the often non-specific nature of the clinical presentation.Increasingly,AI applications are being proposed as decision supports for busy or distracted clinicians,to address this challenge.Data driven“associative”AI models are built from retrospective data registries with missing data and imprecise timing.Associative AI models lack transparency,often ignore causal mechanisms,and,while potentially useful in improved prognostication,have thus far had limited clinical applicability.To be clinically useful,AI tools need to provide bedside clinicians with actionable knowledge.Explicitly addressing causal mechanisms not only increases validity and replicability of the model,but also adds transparency and helps gain trust from the bedside clinicians for real world use of AI models in teaching and patient care.

Utility of cardiac bioenzymes in predicting cardiovascular outcomes in SARS-CoV-2

BACKGROUND Cardiovascular complications have been increasingly recognized in the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)associated coronavirus disease 2019(COVID-19).Cardiac biomarkers are released because of this ongoing cardiovascular injury and can act as surrogate markers to assess the disease severity.AIM To review the variation and utility of these biomarkers in COVID-19 to ascertain their role in diagnosis,prognosis and clinical outcomes of the disease.METHODS We performed a literature search in PubMed,Medline and the Reference Citation Analysis(RCA),using the search terms“COVID-19”and“cardiac bioenzymes”or“cardiac biomarkers”.Additionally,we also used the latest reference citation analysis tool to identify more articles.RESULTS Cardiac troponin has been consistently elevated in patients with COVID-19 associated myocarditis,and strongly correlated with adverse prognosis.Natriuretic peptides including brain natriuretic peptide(BNP)and pro-BNP is elevated in patients with COVID-19 associated cardiac injury,irrespective of their prior heart failure status,and independently correlated with worst outcomes.Alongside these traditional biomarkers,novel cardiac bioenzymes including presepsin,soluble ST2 and copeptin,are also increasingly recognized as markers of cardiovascular injury in COVID-19 and can be associated with poor outcomes.CONCLUSION Assessment of cardiac bioenzymes at admission and their serial monitoring can help assess the severity of disease and predict mortality in patients with SARS-CoV-2 infection.Future studies are needed to elude the critical importance of novel biomarkers.

Efficacy of remdesivir for hospitalized COVID-19 patients with end stage renal disease

BACKGROUND Since the beginning of corona virus disease 2019(COVID-19)pandemic,there has been a widespread use of remdesivir in adults and children.There is little known information about its outcomes in patients with end stage renal disease who are on dialysis.AIM To assess the clinical outcomes with use of remdesivir in adult patients with end stage kidney failure on hemodialysis.METHODS A retrospective,multicenter study was conducted on patients with end stage renal disease on hemodialysis that were discharged after treatment for COVID-19 between April 1,2020 and December 31,2020.Primary endpoints were oxygen requirements,time to mortality and escalation of care needing mechanical ventilation.RESULTS A total of 45 patients were included in the study.Twenty patients received remdesivir,and 25 patients did not receive remdesivir.Most patients were caucasian,females with diabetes mellitus and hypertension being the commonest comorbidities.There was a trend towards reduced oxygen requirement(beta=-25.93,X^(2)(1)=6.65,P=0.0099,probability of requiring mechanical ventilation(beta=-28.52,X^(2)(1)=22.98,P<0.0001)and mortality(beta=-5.03,X^(2)(1)=7.41,P=0.0065)in patients that received remdesivir compared to the control group.CONCLUSION Larger studies are justified to study the effects of remdesivir in this high-risk population with end stage kidney disease on dialysis.

Predictive modeling in neurocritical care using causal artificial intelligence

Artificial intelligence(AI)and digital twin models of various systems have long been used in industry to test products quickly and efficiently.Use of digital twins in clinical medicine caught attention with the development of Archimedes,an AI model of diabetes,in 2003.More recently,AI models have been applied to the fields of cardiology,endocrinology,and undergraduate medical education.The use of digital twins and AI thus far has focused mainly on chronic disease management,their application in the field of critical care medicine remains much less explored.In neurocritical care,current AI technology focuses on interpreting electroencephalography,monitoring intracranial pressure,and prognosticating outcomes.AI models have been developed to interpret electroencephalograms by helping to annotate the tracings,detecting seizures,and identifying brain activation in unresponsive patients.In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making.

Presentation and outcome of myocardial infarction with nonobstructive coronary arteries in coronavirus disease 2019

Among the cardiac complications of coronavirus disease 2019(COVID-19),one increasingly reported in the literature is myocardial infarction with nonobstructive coronaries(MINOCA).We reviewed all reported cases of MINOCA in COVID-19 patients to summarize its clinical features,evaluation,and treatment.We performed a literature search in Pubmed using the search terms‘COVID-19’and‘MINOCA’or‘non-obstructive coronaries’.Among the reported cases,the mean age was 61.5 years(SD±13.4),and 50%were men.Chest pain was the presenting symptom in five patients(62.5%),and hypertension was the most common comorbidity(62.5%).ST-elevation was seen in most patients(87.5%),and the overall mortality rate was 37.5%.MINOCA in COVID-19 is an entity with a broad differential diagnosis.Therefore,a uniform algorithm is needed in its evaluation to ensure timely diagnosis and management.

Cocaine-induced methemoglobinemia

Dear editor,We congratulate Chowdhury et al[1] for their excellentreport and successful management of a young ladysuffering from cocaine-induced methemoglobinemia.Through this letter, we aim to address some additionalconcerns, which would certainly be helpful for acomplete understanding of this topic.