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Venous Thromboembolism Management in Patients With COVID-19

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The severe systemic inflammatory processes and hypercoagulability occurring with COVID-19 illness increase the risk for atherosclerotic plaque disruption and acute myocardial infarction (AMI). Patients with a previous history of coronary disease and/or other significant comorbidities are particularly predisposed to cardiovascular complications with COVID-19 infection.1 In this installment, we will discuss a patient with COVID-19 and venous thromboembolism.

Case Presentation

A 61-year-old woman presents to a rural emergency department with complaints of progressively worsening dyspnea over the past 24 hours and pleuritic chest pain. On initial presentation, the patient is hypoxic with an oxygen saturation of 92% on 5 L/min supplemental oxygen via nasal cannula and exhibits sinus tachycardia (130-140 beats per minute).

The patient’s COVID-19 polymerase chain reaction (PCR) test is positive. Blood work reveals D-dimer is 3 times higher than normal (<0.4 mcg/mL), initial troponin within normal limits (0-0.1 ng/mL), hemoglobin 10.7 g/dL, hematocrit 33.1%, and platelet count 172 ×10/µL.


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A massive saddle pulmonary emboli (PE) is present on spiral computed tomography (CT) arteriography with intravenous contrast of the pulmonary arteries. Echocardiogram demonstrates acute cor pulmonale with a right ventricular (RV) to left ventricular (LV) diameter ratio of 1.4. Venous ultrasound reveals a nonocclusive popliteal venous thromboembolism.

The patient is given full-dose enoxaparin and is transferred to an acute care cardiac specialty hospital for further treatment. Upon arrival at the specialty hospital, she is taken to the catheterization laboratory where a right and left pulmonary angiogram is performed with thrombectomy of the right and left pulmonary arteries.

Significant Medical History

The patient’s medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, hypothyroidism, and a 60-pack/year history of smoking.

Physical Examination

The patient is a middle-aged woman with obesity who is in acute respiratory distress. She has labored breathing and is tachypneic, with a respiratory rate in the mid-30s. Lung examination reveals mild expiratory wheezing bilaterally; a cardiac summation gallop is noted.

Electrocardiography (ECG) monitoring may indicate findings of cor pulmonale (right-sided heart failure) identified by a new incomplete or complete right bundle branch block, right axis deviation, or right ventricular ischemia with ST-segment depression in right pericardial leads. Monitoring with ECG also helps with evaluating for atrial arrhythmias such as atrial fibrillation commonly seen with PE.1

Spiral CT arteriography of the chest with contrast is ordered to rule out pulmonary embolus, which can be a contributing factor to respiratory symptoms, elevation in biomarkers, and a sequela of COVID-19 infection.3

Ultrasound of the lower extremities (bilaterally) is used to rule out deep vein thrombosis (DVT) in the lower extremities.

Diagnosis

The gold standard for confirmation of a PE is a spiral CT with arteriography. In this case, the test confirmed the presence of a massive saddle pulmonary embolus. Minimally invasive intervention is indicated if the patient is found to have right ventricular strain on echocardiogram (Table 1).

Coagulation: elevation in PT/INR, D-dimer, platelet count, fibrinogen
Cardiac biomarkers: troponin
Factor V Leiden mutation
Prothrombin gene mutation
Anticardiolipin antibodies (including lupus anticoagulant)
Hyperhomocysteinemia (usually due to folate deficiency)1,2
PT/INR, prothrombin time/international normalized radio

Radionuclide lung scan, commonly known as ventilation-perfusion (VQ) scan, may serve as a diagnostic tool for inpatients who have elevation in renal indices and are not able to undergo contrast studies. A VQ scan with a high clinical suspicion confirms the diagnosis of PE in 40% of cases.1

Echocardiogram is a useful tool for performing risk stratification. The presence of right ventricular wall akinesis or hypokinesis with sparing of the apex has a high specificity for acute PE. Also, in cases of PE, the ratio of the right ventricular end-diastolic area (RVEDA) to left ventricular end-diastolic area (LVEDA) exceeds the upper limit of normal, which is 0.6 mm.1

This article originally appeared on Clinical Advisor

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Source: https://www.medicalbag.com/home/medicine/venous-thromboembolism-management-patients-with-covid19/

Covid19

Impact of the COVID-19 Pandemic on Adolescent Mental Health

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Even before the COVID-19 pandemic began, concerning mental health trends and major treatment gaps were noted among adolescents in the United States. According to data from the National Survey on Drug Use and Health, an estimated 13.3% of US adolescents aged 12-17 experienced at least 1 episode of major depressive disorder in 2017, yet 60.1% of these individuals did not receive treatment for their illness.1

In addition, survey results from the Centers for Disease Control and Prevention demonstrated increasing rates of US high school students experiencing persistent sadness or hopelessness (from approximately 26% in 2009 to 37% in 2019), serious contemplation of suicide (from 14% to 19%), suicide planning (from 11% to 16%), and suicide attempts (from 6% to 9%). The highest risk levels were observed for White, female, and sexual minority students compared with non-White, male, and heterosexual students.2

Early findings indicate that these issues are being further exacerbated by the current crisis, with an especially high risk of worsening mental health among individuals with pre-existing psychological problems. These results have shown increased symptoms of depression, anxiety, and post-traumatic stress disorder among youth of various age groups.3,5 “The number, severity and duration of these symptoms are influenced by age, history of trauma, psychological status before the event, hours spent watching media coverage of the event, having a family member who died and the presence or absence of social and economic supports,” wrote Hertz and Barrios in a paper published in February 2021 in Injury Prevention.2


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They noted that school closures may reduce access to mental health screening and care for vulnerable students, considering the large number of adolescents — nearly 3.5 million in 2018 — receiving such services in educational settings.2 These settings represent the only source of mental health services for many adolescents, particularly those from low‐income households and racial and ethnic minority groups. The authors thus emphasized the heightened importance of collaboration between schools and community health professionals to address the growing mental health needs of students.

Adolescents and other youth are also affected by the impact of the pandemic on their caregivers, including unemployment, financial and emotional stress, and fear of infection, highlighting the need for adults to receive adequate care and support as well.6,7 Some youth have been forced to spend more time in abusive or otherwise dysfunctional homes due to quarantine requirements.

“Assessing the relative safety of a child at home is one of the major challenges posed to mental health professionals during a pandemic,” according to a November 2020 paper co-authored by Cécile Rousseau, MD, researcher, psychiatrist, and professor in the division of social and transcultural psychiatry at McGill University in Montreal, Canada.6 “Fueled by parental stress and in the absence of the benevolent gaze of the school or daycare, the risk of maltreatment is increasing as the rate of cases reported to youth protection is decreasing.”

Providers at hospitals across the US are reporting alarming increases in rates of attempted and completed suicides among youth — especially teenagers. One school district in Las Vegas has lost 19 children to suicide since the pandemic began. Regarding the increasing number of pediatric patients presenting to hospitals nationwide with suicidal ideation, clinicians have described them as having “worse mental states” compared to similar patients typically seen before the pandemic.8

Such trends underscore the vital importance of youth outreach and creative intervention and support during these times. Mental health providers “must continue to advocate to ensure that families and children get the mental health support that they need to support resilience, to decrease family conflict and child maltreatment, and to decrease risk-taking, unsafe, and dangerous behaviors,” as stated in the November 2020 article.6

We recently interviewed Dr Rousseau to further discuss these issues and potential solutions.

Cécile Rousseau, MD

What are believed to be the reasons for the generally low rates of mental health treatment among adolescents even pre-pandemic?

I believe there are 2 main reasons: First, MH services are overall difficult to access and often not very user-friendly for youth. Although some emerging models are addressing this, they are not generalized. Second, there is a widespread tendency to confound psychological distress and its expression — through sadness, anxiety, and anger — and mental disorder.

The first is associated with life being hurtful, which is very common, while the second is associated with more individual vulnerabilities. Of course, the 2 phenomena overlap, but in past times, distress was not medicalized or an object of treatment. Rather, it was addressed through interpersonal networks, spirituality, and so on. In the past decades there has been a shift in paradigm.

How has the pandemic affected and exacerbated mental health issues in this population?

The pandemic has generated first an acute stress response — which is normal, with fear and panic reactions, among others. To a certain extent, this has supported adherence to public health measures. As time passes, this becomes a chronic stress reaction with predominant avoidance symptoms such as denial and minimization of the pandemic risk. Frustration and anger regarding constraints have also increased, leading to scapegoating through conspiracy theories, and to legitimation of violence.

These are widespread reactions, which are not within the disorder range. For many people with vulnerabilities, however, the pandemic has exacerbated their symptoms, except for some cases of phobia — particularly school phobia — or cyberdependence, as these individuals may enjoy the confinement.

What are the relevant recommendations for clinicians about how to address these issues in practice and advocate for their adolescent patients?

Clinically, outreach to our patients to maintain continuity of care is crucial. In cases of frequent family conflict, virtual care should be used cautiously as it may not provide the needed confidentiality and safety and may aggravate the family conflict in some cases.

For new cases, management should include decreasing the impact of the collateral consequences of the pandemic — most commonly from social isolation and lack of stimulation — on adolescents’ development.

What are some of the broader, longer-term solutions that are also warranted?

Schools and colleges should be at the forefront of prevention. In Canada, pediatricians have advocated for the return of youth to school and the preservation of their social network (not partying, of course!). Youth need their peers to pursue their individuation-separation task, and this has been made impossible during confinement. We need to find a balance between the security of the elderly and the fulfillment of adolescent developmental needs.

References

  1. Major depression. National Institute of Mental Health. Updated February 2019. Accessed online February 7, 2021. https://www.nimh.nih.gov/health/statistics/major-depression.shtml
  2. Hertz MF, Barrios LC. Adolescent mental health, COVID-19, and the value of school-community partnerships. Inj Prev. 2021;27(1):85-86. doi:10.1136/injuryprev-2020-044050
  3. Rogers AA, Ha T, Ockey S. Adolescents’ perceived socio-emotional impact of COVID-19 and implications for mental health: results from a U.S.-based mixed-methods study. J Adolesc Health. 2021;68(1):43-52. doi:10.1016/j.jadohealth.2020.09.039
  4. Liang L, Ren H, Cao R, et al. The effect of COVID-19 on youth mental healthPsychiatr Q. 2020;91(3):841-852. doi:10.1007/s11126-020-09744-3
  5. Ma Z, Zhao J, Li Y, et al. Mental health problems and correlates among 746 217 college students during the coronavirus disease 2019 outbreak in China. Epidemiol Psychiatr Sci. 2020;29:e181. doi:10.1017/S2045796020000931
  6. Rousseau C, Miconi D. Protecting youth mental health during the COVID-19 pandemic: a challenging engagement and learning process. J Am Acad Child Adolesc Psychiatry. 2020;59(11):1203-1207. doi:10.1016/j.jaac.2020.08.007
  7. Chatterjee R. Make space, listen, offer hope: How to help a suicidal teen or child. NPR. Published online February 2, 2021. Accessed online February 7, 2021. https://www.npr.org/sections/health-shots/2021/02/02/962185779/make-space-listen-offer-hope-how-to-help-a-child-at-risk-of-suicide
  8. Chatterjee R. Child psychiatrists warn that the pandemic may be driving up kids’ suicide risk. NPR. Published online February 2, 2021. Accessed online February 7, 2021. https://www.npr.org/sections/health-shots/2021/02/02/962060105/child-psychiatrists-warn-that-the-pandemic-may-be-driving-up-kids-suicide-risk

This article originally appeared on Psychiatry Advisor

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Source: https://www.medicalbag.com/home/medicine/adolescent-mental-health-issues-are-further-exacerbated-by-the-covid-19-pandemic/

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Pfizer To Vaccinate Olympic Athletes As Japan Mulls Extending Pandemic Restrictions

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The last Olympic torch relay runner for the Osaka leg concludes the event in Suita, north of Osaka, western Japan, last month. Hiro Komae/AP hide caption

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Pfizer and its partner, Germany’s BioNTech, announced Thursday that they have agreed to donate vaccines to competitors and staff at the Tokyo Games, set to be held this summer despite ongoing concerns about the COVID-19 pandemic.

In a statement, the pharmaceutical companies said that they had signed a memorandum of understanding with the International Olympic Committee outlining the delivery of initial vaccine doses “expected to begin at the end of May where possible with the aim to ensure participating delegations receive second doses ahead of arrivals in Tokyo.”

In its own statement, the IOC said it would work with national Olympic committees to distribute the vaccines, but said many national governments were already vaccinating participants.

“It is expected that a significant proportion of Games participants will have been vaccinated before arriving in Japan,” the IOC said.

The announcement comes amid persistent concerns about proceeding with the Summer Olympics and Paralympics — already delayed a year due to the coronavirus. On Wednesday, officials in Tokyo, where the games are to be held, asked the central government to extend a coronavirus state of emergency there until May 31. A decision on Tokyo and three other prefectures — Osaka, Hyogo and Kyoto — is expected as early as Friday.

Japan had hoped that imposing what had been advertised as a “short and powerful” emergency would tamp down a fourth wave of infections in time for the games, which are set to begin July 23.

Instead, a surge in new cases apparently driven by a highly infectious N501Y coronavirus variant has added to skepticism about holding the games. Osaka, Japan’s third most populous city, has been especially hard hit, with hospitals overwhelmed by COVID-19 patients in recent days, according to Japan Times.

Just a week ago, on April 29, Japan recorded 7,914 new cases — its largest number of daily infections since the start of the pandemic.

Last month, organizers of the games said that competitors would be tested daily for coronavirus infection.

After weeks of hand-wringing as the scope and severity of the pandemic became increasingly clear, Japanese Olympics officials last year decided to postpone the 2020 Games until July 2021.

But now, a year later, many in Japan see the decision to go ahead as ill-advised. A poll taken by Japan’s NHK broadcaster in January showed that roughly 80% of those surveyed thought the games should be canceled or postponed.

As a sign of that concern, the world’s oldest woman according to Guinness World Records, 118-year-old Kane Tanaka, who had been scheduled to participate in the torch relay for the games – suddenly backed out.

Tanaka was going to take part in a wheelchair pushed by relatives in the May 11 leg of the torch relay in Shime, Fukuoka Prefecture.

But her relatives deemed it too risky due to the continuing spread of the coronavirus. They also did not want to subject Tanaka to the subsequent two week quarantine in the elderly care facility where she lives, Mainichi newspaper reported.

“It’s unfortunate, because I wanted people to feel hope in the sight of her cheerfully carrying the torch,” Tanaka’s great-granddaughter, 24-year-old Junko Tanaka, said.

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Source: https://www.npr.org/sections/coronavirus-live-updates/2021/05/06/994228843/pfizer-to-vaccinate-olympic-athletes-as-japan-mulls-extending-pandemic-restricti

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New Zealand Pauses ‘Travel Bubble’ With Australia Amid Coronavirus Outbreak In Sydney

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New Zealand Minister for COVID-19 Response Chris Hipkins looks on during a news conference at Parliament last month where he and Prime Minister Jacinda Ardern announced plans for a quarantine-free “travel bubble” between New Zealand and Australia. Hagen Hopkins/Getty Images hide caption

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Less than three weeks after launching a quarantine-free “travel bubble” between New Zealand and Australia, officials in Wellington, New Zealand’s capital, announced Thursday that flights from Sydney would be temporarily suspended after new coronavirus cases were detected there.

New Zealand’s COVID-19 Response Minister Chris Hipkins said that flights from the Australian state of New South Wales would be suspended for 48 hours from 11:59 p.m. Sydney time (9:59 a.m. ET) on Thursday.

Hipkins said health officials needed more time to evaluate the situation in Australia “and obviously we’ll make decisions where we need to.”

“We do acknowledge this has the potential to disrupt people’s travel,” he said, adding that the pause would be extended if necessary. “This isn’t a decision we take lightly.”

He said travel from New Zealand to Australia would still be allowed.

The news comes exactly a month after New Zealand Prime Minister Jacinda Ardern announced plans to create what she has described as a “Trans-Tasman bubble” to allow quarantine-free travel between the two countries. It was officially launched on April 19.

New Zealand and Australia have done better than most developed countries in controlling the spread of COVID-19 – closing their borders early in the pandemic and taking other measures to prevent the disease from gaining a foothold in their populations.

Although Australia imposed a prolonged lockdown in Melbourne, it has been largely successful at keeping COVID-19 at bay. New Zealand, a country of 5 million people, has also faced occasional, small outbreaks.

An overseas traveler from the U.S. who was quarantined at a hotel in central Sydney last month was found to be infected with the B.1.617 coronavirus variant. Subsequently, an Australian couple with no known links to the man or the hotel also tested positive for the virus, according to the Sydney Morning Herald.

Hipkins on Thursday said there didn’t appear to be any “obvious link” between the Australian cases. He characterized the pause in the travel bubble as precautionary and noted that the ability to turn on and turn off quarantine-free travel between the two countries had been built into the system when it was launched last month.

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Source: https://www.npr.org/sections/coronavirus-live-updates/2021/05/06/994179377/new-zealand-pauses-travel-bubble-with-australia-amid-coronavirus-outbreak-in-syd

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COVID-19 vaccines protect against variants, study suggests

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COVID-19 vaccine variants

A research group from the Johns Hopkins University School of Medicine has published a new study that suggests certain COVID-19 vaccines may protect against variant coronavirus strains.1 These include the variants first identified in the U.K. and South Africa.

The study analyzed the response of the SARS-CoV-2 virus and three other common cold coronaviruses after administration of an mRNA-based COVID-19 vaccine. Blood samples from 30 healthcare workers who had not tested positive for COVID-19 were analyzed before and after they received the Pfizer-BioNTech or Moderna COVID-19 vaccine.

The study model focused on the coronavirus surface proteins – spike proteins – which help viruses gain access to host cells and infect them. A type of immune cell called helper T cells or CD4+ T cells recognize these viral proteins on the coronavirus-infected cells and encourage cell destruction. The mRNA-based COVID-19 vaccines contain a code that allows healthy cells to produce these spike proteins. This promotes the build-up of a CD4+ T cell response specific to coronavirus spike proteins. The CD4+ T cell response was analyzed using blood samples before and after vaccination to indicate the effectiveness of the vaccine.

As the research group expected, the vaccinated participants showed a greater CD4+ T cell response to SARS-CoV-2 after vaccination. But other coronavirus variants were tested too with the hopes of understanding the effectiveness of the COVID-19 vaccine against variants.

Variants of the SARS-CoV-2 differ in some of the building blocks of their spike proteins. In testing the common cold coronaviruses HCoV-NL63, HCoV-229E, and HCoV-OC43, researchers measured the degree of immunity provided when exposed to the variants.

The research group observed that there was a broad T cell response to the SARS-CoV-2 virus, and they were able to identify 23 distinct viral proteins targeted by coronavirus-specific T cells.

Of these 23 peptides, four may be altered in the UK B.1.1.7 and South African B.1.351 variants. This suggests that the 19 other peptides (building blocks) are constant among coronaviruses and would be targeted by vaccine-induced CD4+ T cells when exposed to the SARS-CoV-2 virus and other emerging variants.

Results from another study by the Johns Hopkins School of Medicine reiterated the significance of the CD4+ T cell response to SARS-Cov-2 and common cold coronaviruses. They tested the T cell response to spike proteins in patients who had recovered from COVID-19 as well as unexposed individuals. In 65% of participants, memory CD4+ T cells recognized spike proteins from SARS-CoV-2 and at least one other common cold coronavirus.2

The cross-recognition observed by CD4+ T cells have led researchers to conclude that mRNA-based COVID-19 vaccines may protect against SARS-CoV-2 variants. The effectiveness of the COVID-19 vaccine against variants needs to be studied further to fully understand the level of protection.

References

  1. Woldemeskel, B. A. et al. (2021). SARS-CoV-2 mRNA vaccines induce broad CD4+ T cell responses that recognize SARS-CoV-2 variants and HCoV-NL63. The Journal of Clinical Investigation, In-Press Preview. Doi: 10.1172/JCI149335.
  2. Dykema, A. G. et al. (2021). Functional characterization of CD4+ T-cell receptors cross-reactive for SARS-CoV-2 and endemic coronaviruses. The Journal of Clinical Investigation, In-Press Preview. Doi: 10.1172/JCI146922.
  3. Image by mattthewafflecat from Pixabay 

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Source: https://medicalnewsbulletin.com/covid-19-vaccines-protect-against-variants-study-suggests/

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