1
|
Chatta P, Diep B, Kewcharoen J, Rossie D, Toomasian C, Parwani P, Abramov D. The diagnostic yield for computed tomography pulmonary angiography in patients with anticoagulation. World J Emerg Med 2024; 15:251-255. [PMID: 39050211 PMCID: PMC11265635 DOI: 10.5847/wjem.j.1920-8642.2024.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/09/2023] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Patients who present to the emergency department (ED) for suspected pulmonary embolism (PE) are often on active oral anticoagulation (AC). However, the diagnostic yield of computed tomography pulmonary angiography (CTPA) in screening for PE in patients who present on AC has not been well characterized. We aim to investigate the diagnostic yield of CTPA in diagnosing PE depending on AC status. METHODS We reviewed and analyzed the electronic medical records of patients who underwent CTPA for PE at a university hospital ED from June 1, 2019, to March 25, 2022. Primary outcome was the incidence of PE on CTPA depending on baseline AC status and indication for AC. RESULTS Of 2,846 patients, 242 were on AC for a history of venous thromboembolism (VTE), 210 were on AC for other indications, and 2,394 were not on AC. The incidence of PE on CTPA was significantly lower in patients on AC for other indications (5.7%) when compared to patients on AC for prior VTE (24.3%) and patients not on AC at presentation (9.8%) (P<0.001). In multivariable analysis among the whole cohort, AC was associated with a positive CTPA (odds ratio [OR] 0.26, 95% confidence interval [CI]: 0.15-0.45, P<0.001). CONCLUSION The incidence of PE among patients undergoing CTPA in the ED is lower in patients previously on AC for indications other than VTE when compared to those not on AC or those on AC for history of VTE. AC status and indication for AC may affect pre-test probability of a positive CTPA, and AC status therefore warrants consideration as part of future diagnostic algorithms among patients with suspected PE.
Collapse
Affiliation(s)
- Payush Chatta
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Brian Diep
- Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Jakrin Kewcharoen
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Daniel Rossie
- Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Cory Toomasian
- Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Purvi Parwani
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| | - Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA 92374, USA
| |
Collapse
|
2
|
Kasanga S, Khashan A, Salik A, Aboshehata AM, Casillas S, Islam M. Low Risk Meets High Stakes: Unraveling the Mystery of Low D-dimer Pulmonary Embolism. Cureus 2023; 15:e51045. [PMID: 38264382 PMCID: PMC10805402 DOI: 10.7759/cureus.51045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 01/25/2024] Open
Abstract
Pulmonary embolisms (PEs) are potentially life-threatening emergencies that carry significant morbidity and mortality. Advances in treatment options and the safety of existing procedures have effectively reduced the long-term and short-term effects of the condition. Therefore, it is important to make an early diagnosis so that treatment options can be thoroughly explored. The D-dimer is an important tool in the early diagnosis of PEs. It is especially useful in ruling out the diagnosis in patients with a low to moderate suspicion of the disease. We present a case of a 22-year-old male who presented with exertional dyspnea, congestion, and rhinorrhea for one day and was noted to have persistent hypoxia and tachycardia. The influenza test was positive, and he was started on oseltamivir. Due to persistent hypoxia, a CT pulmonary angiogram was ordered and revealed filling defects in the left lower lobe segmental vessels suggestive of PE, as well as multifocal multilobar bilateral ground-glass opacities. He was initially treated with a heparin drip and subsequently switched to eliquis. After a significant improvement in his hypoxia, he was discharged home for outpatient follow-up, including a hypercoagulable workup. This case demonstrates that despite the usefulness of the D-dimer as a diagnostic tool for PEs, it cannot solely or fully replace the full gamut of screening tools used to determine the risk of PE. Although rare, false-negative scores do occur; therefore, the tool should always be used in conjunction with other scoring systems, physician gestalt, and within the specific clinical context.
Collapse
Affiliation(s)
- Sadat Kasanga
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
| | | | - Ahsan Salik
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
| | | | | | - Mohammed Islam
- Internal Medicine, Raritan Bay Medical Center, Perth Amboy, USA
| |
Collapse
|
3
|
Artaud-Macari E, Le Bouar G, Maris J, Dantoing E, Vatignez T, Girault C. [Ventilatory management of SARS-CoV-2 acute respiratory failure]. Rev Mal Respir 2023; 40:751-767. [PMID: 37865564 DOI: 10.1016/j.rmr.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/19/2023] [Indexed: 10/23/2023]
Abstract
COVID-19 pneumonia presents several particularities in its clinical presentation (cytokine storm, silent hypoxemia, thrombo-embolic risk) and may lead to a number of acute respiratory distress syndrome (ARDS) phenotypes. While the optimal oxygenation strategy in cases of hypoxemic acute respiratory failure (ARF) is still under debate, ventilatory management of COVID-19-related ARF has confirmed the efficacy of high-flow oxygen therapy and restored interest in other ventilatory approaches such as continuous positive airway pressure (CPAP) and noninvasive ventilation involving a helmet, which due to patient overflow are sometimes implemented outside of critical care units. However, further studies are still needed to determine which patients should be given which oxygenation technique, and under which conditions they require invasive mechanical ventilation, given that delayed initiation potentially burdens prognosis. During invasive mechanical ventilation, ventral decubitus and extracorporeal membrane oxygenation have become increasingly prevalent. While innovative therapies such as awake prone position or lung transplantation have likewise been developed, their indications, modalities and efficacy remain to be determined.
Collapse
Affiliation(s)
- E Artaud-Macari
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France; UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France.
| | - G Le Bouar
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - J Maris
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - E Dantoing
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, 76000 Rouen, France
| | - T Vatignez
- Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| | - C Girault
- UNIROUEN, UR-3830, Normandie université, CHU de Rouen, 76000 Rouen, France; Service de médecine intensive et réanimation, CHU de Rouen, 76000 Rouen, France
| |
Collapse
|
4
|
Ortega-Paz L, Talasaz AH, Sadeghipour P, Potpara TS, Aronow HD, Jara-Palomares L, Sholzberg M, Angiolillo DJ, Lip GYH, Bikdeli B. COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:816-832. [PMID: 36223804 DOI: 10.1055/s-0042-1757634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non-COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.
Collapse
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Herbert D Aronow
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Luis Jara-Palomares
- Respiratory Unit, Hospital Universitario Virgen del Rocio, Sevilla, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| |
Collapse
|
5
|
Vielhauer J, Benesch C, Pernpruner A, Johlke AL, Hellmuth JC, Muenchhoff M, Scherer C, Fink N, Sabel B, Schulz C, Mayerle J, Mahajan UM, Stubbe HC. How to exclude pulmonary embolism in patients hospitalized with COVID-19: a comparison of predictive scores. Thromb J 2023; 21:51. [PMID: 37131204 PMCID: PMC10153021 DOI: 10.1186/s12959-023-00492-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 04/12/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is an important complication of Coronavirus disease 2019 (COVID-19). COVID-19 is associated with respiratory impairment and a pro-coagulative state, rendering PE more likely and difficult to recognize. Several decision algorithms relying on clinical features and D-dimer have been established. High prevalence of PE and elevated Ddimer in patients with COVID-19 might impair the performance of common decision algorithms. Here, we aimed to validate and compare five common decision algorithms implementing age adjusted Ddimer, the GENEVA, and Wells scores as well as the PEGeD- and YEARS-algorithms in patients hospitalized with COVID-19. METHODS In this single center study, we included patients who were admitted to our tertiary care hospital in the COVID-19 Registry of the LMU Munich. We retrospectively selected patients who received a computed tomography pulmonary angiogram (CTPA) or pulmonary ventilation/perfusion scintigraphy (V/Q) for suspected PE. The performances of five commonly used diagnostic algorithms (age-adjusted D-dimer, GENEVA score, PEGeD-algorithm, Wells score, and YEARS-algorithm) were compared. RESULTS We identified 413 patients with suspected PE who received a CTPA or V/Q confirming 62 PEs (15%). Among them, 358 patients with 48 PEs (13%) could be evaluated for performance of all algorithms. Patients with PE were older and their overall outcome was worse compared to patients without PE. Of the above five diagnostic algorithms, the PEGeD- and YEARS-algorithms performed best, reducing diagnostic imaging by 14% and 15% respectively with a sensitivity of 95.7% and 95.6%. The GENEVA score was able to reduce CTPA or V/Q by 32.2% but suffered from a low sensitivity (78.6%). Age-adjusted D-dimer and Wells score could not significantly reduce diagnostic imaging. CONCLUSION The PEGeD- and YEARS-algorithms outperformed other tested decision algorithms and worked well in patients admitted with COVID-19. These findings need independent validation in a prospective study.
Collapse
Affiliation(s)
- Jakob Vielhauer
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany.
- German Center for Infection Research, Partner Site Munich, Munich, Germany.
| | - Christopher Benesch
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany
- German Center for Infection Research, Partner Site Munich, Munich, Germany
| | - Anna Pernpruner
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany
- German Center for Infection Research, Partner Site Munich, Munich, Germany
| | - Anna-Lena Johlke
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany
- German Center for Infection Research, Partner Site Munich, Munich, Germany
| | - Johannes Christian Hellmuth
- Department of Medicine III, University Hospital LMU Munich, Munich, Germany
- COVID-19 Registry of the LMU Munich (CORKUM), University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Muenchhoff
- German Center for Infection Research, Partner Site Munich, Munich, Germany
- COVID-19 Registry of the LMU Munich (CORKUM), University Hospital, LMU Munich, Munich, Germany
- Max von Pettenkofer Institute and Gene Center, National Reference Center for Retroviruses, Ludwig Maximilian University (LMU) of Munich, Virology, Munich, Germany
| | - Clemens Scherer
- COVID-19 Registry of the LMU Munich (CORKUM), University Hospital, LMU Munich, Munich, Germany
- Department of Medicine I, University Hospital LMU Munich, Munich, Germany
| | - Nicola Fink
- Department of Radiology, Hospital of the LMU Munich, Munich, Germany
| | - Bastian Sabel
- Department of Radiology, Hospital of the LMU Munich, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany
- German Center for Infection Research, Partner Site Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany
| | | | - Hans Christian Stubbe
- Department of Medicine II, University Hospital LMU Munich, Munich, Germany.
- German Center for Infection Research, Partner Site Munich, Munich, Germany.
| |
Collapse
|
6
|
Lippi G, Favaloro EJ. Strength of Anticoagulation in Moderate to Severe COVID-19 Illness: In Medio Stat Virtus? Semin Thromb Hemost 2023; 49:81-84. [PMID: 36055257 DOI: 10.1055/s-0042-1756186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| |
Collapse
|
7
|
Meter M, Barcot O, Jelicic I, Gavran I, Skopljanac I, Parcina MZ, Dolic K, Ivelja MP. Revision of Clinical Pre-Test Probability Scores in Hospitalized Patients with Pulmonary Embolism and SARS-CoV-2 Infection. Rev Cardiovasc Med 2023; 24:18. [PMID: 39076868 PMCID: PMC11270401 DOI: 10.31083/j.rcm2401018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 07/31/2024] Open
Abstract
Background The need for computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) is based on clinical scores in association with D-dimer measurements. PE is a recognized complication in patients with SARS-CoV-2 infection due to a pro-thrombotic state which may reduce the usefulness of preexisting pre-test probability scores. Aim The purpose was to analyze new clinical and laboratory parameters while comparing existing and newly proposed scoring system for PE detection in hospitalized COVID-19 patients (HCP). Methods We conducted a retrospective study of 270 consecutive HCPs who underwent CTPA due to suspected PE. The Modified Wells, Revised Geneva, Simplified Geneva, YEARS, 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS), and PE rule-out criteria (PERC) scores were calculated and the area under the receiver operating characteristic curve (AuROC) was measured. Results Overall incidence of PE among our study group of HCPs was 28.1%. The group of patients with PE had a significantly longer COVID-19 duration upon admission, at 10 vs 8 days, p = 0.006; higher D-dimer levels of 10.2 vs 5.3 μ g/L, p < 0.001; and a larger proportion of underlying chronic kidney disease, at 16% vs 7%, p = 0.041. From already established scores, only 4PEPS and the modified Wells score reached statistical significance in detecting the difference between the HCP groups with or without PE. We proposed a new chronic kidney disease, D-dimers, 10 days of illness before admission (CDD-10) score consisting of the three aforementioned variables: C as chronic kidney disease (0.5 points if present), D as D-dimers (negative 1.5 points if normal, 2 points if over 10.0 μ g/L), and D-10 as day-10 of illness carrying 2 points if lasting more than 10 days before admission or 1 point if longer than 8 days. The CDD-10 score ranged from -1.5 to 4.5 and had an AuROC of 0.672, p < 0.001 at cutoff value at 0.5 while 4PEPS score had an AuROC of 0.638 and Modified Wells score 0.611. The clinical probability of PE was low (0%) when the CDD-10 value was negative, moderate (24%) for CDD-10 ranging 0-2.5 and high (43%) when over 2.5. Conclusions Better risk stratification is needed for HCPs who require CTPA for suspected PE. Our newly proposed CDD-10 score demonstrates the best accuracy in predicting PE in patients hospitalized for SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Mijo Meter
- Department of Cardiology, University Hospital of Split, 21000 Split, Croatia
| | - Ognjen Barcot
- Department of Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Irena Jelicic
- Department of Infectious Diseases, University Hospital of Split, 21000 Split, Croatia
| | - Ivana Gavran
- Department of Cardiology, University Hospital of Split, 21000 Split, Croatia
| | - Ivan Skopljanac
- Department of Pulmology, University Hospital of Split, 21000 Split, Croatia
| | | | - Kresimir Dolic
- Department of Radiology, University Hospital of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Mirela Pavicic Ivelja
- Department of Infectious Diseases, University Hospital of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia
| |
Collapse
|
8
|
Impact of clinical profile at admission on the outcomes in patients hospitalized for acute pulmonary embolism: data from the IPER Registry. J Thromb Thrombolysis 2023; 55:166-174. [PMID: 36350468 DOI: 10.1007/s11239-022-02726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
Acute pulmonary embolism (PE) is characterized by a large heterogeneity of clinical presentation and disease course. We investigate whether different symptom PE phenotypes in hemodynamically stable PE could be associated with 30-day mortality risk. Hemodynamically stable patients from the multicentre, prospective Italian Pulmonary Embolism Registry (IPER) (September 2006-August 2010) presenting the most common four clinical phenotypes (< 24 h onset dyspnoea, chest pain, pleuritic pain and phlebitis) at admission were included and compared to those who were asymptomatic at admission. Overall, 1365 (mean age 68.7 ± 15.3 years, 609 males) were evaluated. Recent onset dyspnoea (< 24 h), chest pain, pleuritic pain and phlebitis were observed in 28.4%, 19.7%, 12.9% and 25.2%, respectively while asymptomatic patients represented the remaining 13.6% of cases. PE presenting with recent dyspnoea onset and chest pain had a lower 30-day overall survival (log-rank p = 0.01 and p < 0.001, respectively). By contrast, there were no significant differences when comparing patients with pleuritic pain or phlebitis (log-rank p = 0.2). Similar findings were confirmed at the Cox multivariate regression analysis which indicated a higher mortality risk in patients with chest pain [HR 3.21, 95% CI 2.16-4.78, p < 0.001] or recent dyspnoea [HR 2.12, 95% CI 1.22-3.87, p = 0.002] independent of age, heart rate, presence of right ventricular dysfunction, positive cardiac troponin and administration of systemic thrombolysis. Hemodynamically stable PE patients presenting with chest pain or recent onset dyspnoea had a lower 30-day survival compared to those asymptomatic or presenting pleuritic or phlebitis pain.Trial registry ClinicalTrials.gov; No: NCT01604538).
Collapse
|
9
|
Garofalo E, Cammarota G, Neri G, Macheda S, Biamonte E, Pasqua P, Guzzo ML, Longhini F, Bruni A. Bivalirudin vs. Enoxaparin in Intubated COVID-19 Patients: A Pilot Multicenter Randomized Controlled Trial. J Clin Med 2022; 11:jcm11205992. [PMID: 36294312 PMCID: PMC9604898 DOI: 10.3390/jcm11205992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/15/2022] [Accepted: 10/08/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: In COVID-19 patients, the occurrence of thromboembolic complications contributes to disease progression and mortality. In patients at increased risk for thrombotic complications, therapeutic enoxaparin should be considered. However, critically ill COVID-19 patients could develop resistance to enoxaparin. Bivalirudin, a thrombin inhibitor, may be an alternative. This pilot multicenter randomized controlled trial aims to ascertain if bivalirudin may reduce the time spent under invasive mechanical ventilation, as compared to enoxaparin. (2) Methods: Intubated COVID-19 patients at risk for thrombo-embolic complications were randomized to receive therapeutic doses of enoxaparin or bivalirudin. We ascertained the time spent under invasive mechanical ventilation during the first 28 days from Intensive Care Unit (ICU) admission. A standardized weaning protocol was implemented in all centers. In addition, we assessed the occurrence of thromboembolic complications, the number of patients requiring percutaneous tracheostomy, the gas exchange, the reintubation rate, the ICU length of stay, the ICU and 28-days mortalities. (3) Results: We enrolled 58 consecutive patients. Bivalirudin did not reduce the time spent under invasive mechanical ventilation as compared to enoxaparin (12 [8; 13] vs. 13 [10; 15] days, respectively; p = 0.078). Thrombotic (p = 0.056) and embolic (p = 0.423) complications, need for tracheostomy (p = 0.423) or reintubation (p = 0.999), the ICU length of stay (p = 0.076) and mortality (p = 0.777) were also similar between treatments. Patients randomized to bivalirudin showed a higher oxygenation at day 7 and 15 after randomization, when compared to enoxaparin group. (4) Conclusions: In intubated COVID-19 patients at increased risk for thromboembolic complications, bivalirudin did not reduce the time spent under invasive mechanical ventilation, nor improved any other clinical outcomes.
Collapse
Affiliation(s)
- Eugenio Garofalo
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy
| | - Gianmaria Cammarota
- Department of Anesthesia and Intensive Care Medicine, University of Perugia, 06121 Perugia, Italy
| | - Giuseppe Neri
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy
| | - Sebastiano Macheda
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, 89121 Reggio Calabria, Italy
| | - Eugenio Biamonte
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy
| | - Pino Pasqua
- Anesthesia and Intensive Care Unit, Annunziata Hospital, 87100 Cosenza, Italy
| | - Maria Laura Guzzo
- Anesthesia and Intensive Care Unit, “Pugliese Ciaccio” Hospital, 88100 Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy
- Correspondence: ; Tel.: +39-34-7539-5967
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, “Magna Graecia” University, 88100 Catanzaro, Italy
| |
Collapse
|
10
|
da Silveira WC, Ramos LEF, Silva RT, de Paiva BBM, Pereira PD, Schwarzbold AV, Garbini AF, Barreira BSM, de Castro BM, Ramos CM, Gomes CD, Cimini CCR, Pereira EC, Roesch EW, Kroger EMS, Aranha FFMG, Anschau F, Botoni FA, Aranha FG, Crestani GP, Vietta GG, Bastos GAN, Costa JHSM, da Fonseca JRCS, Ruschel KB, de Oliveira LS, Pinheiro LS, Pacheco LS, Segala LB, Couto LSF, Kopittke L, Floriani MA, Silva MM, Carneiro M, Ferreira MAP, Martins MAP, de Faria MNZ, Nogueira MCA, Guimarães Júnior MH, Sampaio NDCS, de Oliveira NR, Pertile NDM, Andrade PGS, Assaf PL, Valacio RA, Menezes RM, Francisco SC, Guimarães SMM, Araújo SF, Rezende SM, Pereira SA, Kurtz T, Fereguetti TO, Polanczyk CA, Pires MC, Gonçalves MA, Marcolino MS. Predictors of venous thromboembolism in COVID-19 patients: results of the COVID-19 Brazilian Registry. Intern Emerg Med 2022; 17:1863-1878. [PMID: 35648280 PMCID: PMC9156830 DOI: 10.1007/s11739-022-03002-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/06/2022] [Indexed: 12/15/2022]
Abstract
Previous studies that assessed risk factors for venous thromboembolism (VTE) in COVID-19 patients have shown inconsistent results. Our aim was to investigate VTE predictors by both logistic regression (LR) and machine learning (ML) approaches, due to their potential complementarity. This cohort study of a large Brazilian COVID-19 Registry included 4120 COVID-19 adult patients from 16 hospitals. Symptomatic VTE was confirmed by objective imaging. LR analysis, tree-based boosting, and bagging were used to investigate the association of variables upon hospital presentation with VTE. Among 4,120 patients (55.5% men, 39.3% critical patients), VTE was confirmed in 6.7%. In multivariate LR analysis, obesity (OR 1.50, 95% CI 1.11-2.02); being an ex-smoker (OR 1.44, 95% CI 1.03-2.01); surgery ≤ 90 days (OR 2.20, 95% CI 1.14-4.23); axillary temperature (OR 1.41, 95% CI 1.22-1.63); D-dimer ≥ 4 times above the upper limit of reference value (OR 2.16, 95% CI 1.26-3.67), lactate (OR 1.10, 95% CI 1.02-1.19), C-reactive protein levels (CRP, OR 1.09, 95% CI 1.01-1.18); and neutrophil count (OR 1.04, 95% CI 1.005-1.075) were independent predictors of VTE. Atrial fibrillation, peripheral oxygen saturation/inspired oxygen fraction (SF) ratio and prophylactic use of anticoagulants were protective. Temperature at admission, SF ratio, neutrophil count, D-dimer, CRP and lactate levels were also identified as predictors by ML methods. By using ML and LR analyses, we showed that D-dimer, axillary temperature, neutrophil count, CRP and lactate levels are risk factors for VTE in COVID-19 patients.
Collapse
Affiliation(s)
- Warley Cezar da Silveira
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
- grid.8430.f0000 0001 2181 4888University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110, Santa Efigênia, Belo Horizonte, MG CEP 30130-100 Brazil
| | - Lucas Emanuel Ferreira Ramos
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Rafael Tavares Silva
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Bruno Barbosa Miranda de Paiva
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Polianna Delfino Pereira
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
- Institute for Health Technology Assessment (IATS/ CNPq), Rua Ramiro Barcelos, 2359, Prédio 21 | Sala 507, Porto Alegre, Brazil
| | - Alexandre Vargas Schwarzbold
- grid.488599.10000 0004 0481 6891Hospital Universitário de Santa Maria, Av. Roraima, 1000, prédio 22, Santa Maria, Brazil
| | - Andresa Fontoura Garbini
- grid.414914.dHospital Nossa Senhora da Conceição and Hospital Cristo Redentor, Av. Francisco Trein, 326, Porto Alegre, Brazil
| | | | - Bruno Mateus de Castro
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | | | - Caroline Danubia Gomes
- grid.414871.f0000 0004 0491 7596Hospital Mãe de Deus, Rua José de Alencar, 286, Porto Alegre, Brazil
| | - Christiane Corrêa Rodrigues Cimini
- grid.411287.90000 0004 0643 9823Mucuri Medical School – FAMMUC, Universidade Federal dos Vales do Jequitinhonha e Mucuri – UFVJM, Rua Cruzeiro, 01, Teófilo Otoni, Brazil
- Hospital Santa Rosalia, Rua do Cruzeiro, 01, Teófilo Otoni, Brazil
| | | | - Eliane Würdig Roesch
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | | | | | - Fernando Anschau
- grid.414914.dHospital Nossa Senhora da Conceição and Hospital Cristo Redentor, Av. Francisco Trein, 326, Porto Alegre, Brazil
| | | | | | - Gabriela Petry Crestani
- grid.414871.f0000 0004 0491 7596Hospital Mãe de Deus, Rua José de Alencar, 286, Porto Alegre, Brazil
| | | | - Gisele Alsina Nader Bastos
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Rua Ramiro Barcelos, 910, Porto Alegre, Brazil
| | | | | | - Karen Brasil Ruschel
- Institute for Health Technology Assessment (IATS/ CNPq), Rua Ramiro Barcelos, 2359, Prédio 21 | Sala 507, Porto Alegre, Brazil
- grid.414871.f0000 0004 0491 7596Hospital Mãe de Deus, Rua José de Alencar, 286, Porto Alegre, Brazil
| | | | | | - Liliane Souto Pacheco
- grid.488599.10000 0004 0481 6891Hospital Universitário de Santa Maria, Av. Roraima, 1000, prédio 22, Santa Maria, Brazil
| | - Luciana Borges Segala
- grid.488599.10000 0004 0481 6891Hospital Universitário de Santa Maria, Av. Roraima, 1000, prédio 22, Santa Maria, Brazil
| | - Luciana Siuves Ferreira Couto
- grid.411213.40000 0004 0488 4317Universidade Federal de Ouro Preto, Rua Diogo de Vasconcelos, 122, Ouro Preto, Brazil
| | - Luciane Kopittke
- grid.414914.dHospital Nossa Senhora da Conceição and Hospital Cristo Redentor, Av. Francisco Trein, 326, Porto Alegre, Brazil
| | - Maiara Anschau Floriani
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Rua Ramiro Barcelos, 910, Porto Alegre, Brazil
| | - Majlla Magalhães Silva
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Rua Ramiro Barcelos, 910, Porto Alegre, Brazil
| | - Marcelo Carneiro
- Hospital Santa Cruz, Rua Fernando Abott, 174, Santa Cruz do Sul, Brazil
| | - Maria Angélica Pires Ferreira
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, Brazil
| | | | | | - Matheus Carvalho Alves Nogueira
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
- Hospitais da Rede Mater Dei, Av. do Contorno, 9000, Belo Horizonte, Brazil
| | | | | | - Neimy Ramos de Oliveira
- grid.452464.50000 0000 9270 1314Hospital Eduardo de Menezes, Rua Dr. Cristiano Rezende, 2213, Belo Horizonte, Brazil
| | - Nicole de Moraes Pertile
- grid.414856.a0000 0004 0398 2134Hospital Moinhos de Vento, Rua Ramiro Barcelos, 910, Porto Alegre, Brazil
| | | | - Pedro Ledic Assaf
- Hospital Metropolitano Doutor Célio de Castro, Rua Dona Luiza, 311, Belo Horizonte, Brazil
| | | | | | | | | | | | - Suely Meireles Rezende
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Susany Anastácia Pereira
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Tatiana Kurtz
- Hospital Santa Cruz, Rua Fernando Abott, 174, Santa Cruz do Sul, Brazil
| | - Tatiani Oliveira Fereguetti
- grid.452464.50000 0000 9270 1314Hospital Eduardo de Menezes, Rua Dr. Cristiano Rezende, 2213, Belo Horizonte, Brazil
| | - Carísi Anne Polanczyk
- Institute for Health Technology Assessment (IATS/ CNPq), Rua Ramiro Barcelos, 2359, Prédio 21 | Sala 507, Porto Alegre, Brazil
| | - Magda Carvalho Pires
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
| | - Marcos André Gonçalves
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
- Institute for Health Technology Assessment (IATS/ CNPq), Rua Ramiro Barcelos, 2359, Prédio 21 | Sala 507, Porto Alegre, Brazil
| | - Milena Soriano Marcolino
- grid.8430.f0000 0001 2181 4888Universidade Federal de Minas Gerais, Av. Presidente Antônio Carlos, 6627, Belo Horizonte, Brazil
- Institute for Health Technology Assessment (IATS/ CNPq), Rua Ramiro Barcelos, 2359, Prédio 21 | Sala 507, Porto Alegre, Brazil
- grid.8430.f0000 0001 2181 4888Telehealth Center, University Hospital, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110, Belo Horizonte, Brazil
| |
Collapse
|
11
|
Suarez Castillejo C, Toledo-Pons N, Calvo N, Ramon-Clar L, Martínez J, Hermoso de Mendoza S, Morell-García D, Bauça JM, Berga F, Núñez B, Preda L, Sauleda J, Argente Castillo P, Ballesteros A, Martín L, Sala-Llinas E, Alonso-Fernández A. A Prospective Study Evaluating Cumulative Incidence and a Specific Prediction Rule in Pulmonary Embolism in COVID-19. Front Med (Lausanne) 2022; 9:936816. [PMID: 35847817 PMCID: PMC9283900 DOI: 10.3389/fmed.2022.936816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/25/2022] [Indexed: 01/08/2023] Open
Abstract
Rationale Abnormal values of hypercoagulability biomarkers, such as D-dimer, have been described in Coronavirus Disease 2019 (COVID-19), which has also been associated with disease severity and in-hospital mortality. COVID-19 patients with pneumonia are at greater risk of pulmonary embolism (PE). However, the real incidence of PE is not yet clear, since studies have been limited in size, mostly retrospective, and PE diagnostic procedures were only performed when PE was clinically suspected. Objectives (1) To determine the incidence, clinical, radiological, and biological characteristics, and clinical outcomes of PE among patients hospitalized for COVID-19 pneumonia with D-dimer > 1,000 ng/mL. (2) To develop a prognostic model to predict PE in these patients. Methods Single-center prospective cohort study. Consecutive confirmed cases of COVID-19 pneumonia with D-dimer > 1,000 ng/mL underwent computed tomography pulmonary angiography (CTPA). Demographic and laboratory data, comorbidities, CTPA scores, treatments administered, and clinical outcomes were analyzed and compared between patients with and without PE. A risk score was constructed from all these variables. Results Between 6 April 2020 and 2 February 2021, 179 consecutive patients were included. The overall incidence of PE was 39.7% (71 patients) (CI 95%, 32–47%). In patients with PE, emboli were located mainly in segmental/subsegmental arteries (67%). Patients with PE did not differ from the non-PE group in sex, age, or risk factors for thromboembolic disease. Higher urea, D-Dimer, D-dimer-to-ferritin and D-dimer-to-lactate dehydrogenase (LDH) ratios, platelet distribution width (PDW), and neutrophil-to-lymphocyte ratio (NLR) values were found in patients with PE when compared to patients with non-PE. Besides, lymphocyte counts turned out to be lower in patients with PE. A score for PE prediction was constructed with excellent overall performance [area under the ROC curve-receiver operating characteristic (AUC-ROC) 0.81 (95% CI: 0.73–0.89)]. The PATCOM score stands for Pulmonary Artery Thrombosis in COVID-19 Mallorca and includes platelet count, PDW, urea concentration, and D-dimer-to-ferritin ratio. Conclusion COVID-19 patients with pneumonia and D-dimer values > 1,000 ng/mL were presented with a very high incidence of PE, regardless of clinical suspicion. Significant differences in urea, D-dimer, PDW, NLR, and lymphocyte count were found between patients with PE and non-PE. The PATCOM score is presented in this study as a promising PE prediction rule, although validation in further studies is required.
Collapse
Affiliation(s)
- Carla Suarez Castillejo
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Nuria Toledo-Pons
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Néstor Calvo
- Servicio de Radiodiagnostico, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Luisa Ramon-Clar
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Joaquín Martínez
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | | | - Daniel Morell-García
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Josep Miquel Bauça
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Francisco Berga
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Belén Núñez
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Luminita Preda
- Servicio de Radiodiagnostico, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Jaume Sauleda
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
| | - Paula Argente Castillo
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Antonieta Ballesteros
- Servicio de Análisis Clínicos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Luisa Martín
- Servicio de Medicina Interna, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Ernest Sala-Llinas
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
| | - Alberto Alonso-Fernández
- Servicio de Neumología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
- Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
- CIBER Enfermedades Respiratorias, Palma de Mallorca, Spain
- *Correspondence: Alberto Alonso-Fernández,
| |
Collapse
|
12
|
Niculae CM, Anghel AMJ, Militaru ED, Tîrlescu LG, Lazar M, Hristea A. Acute Pulmonary Artery Thrombosis despite Anticoagulation in Patients with COVID-19 Pneumonia: A Single-Center Retrospective Cohort Study. J Clin Med 2022; 11:jcm11092633. [PMID: 35566758 PMCID: PMC9100155 DOI: 10.3390/jcm11092633] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 12/10/2022] Open
Abstract
(1) Background: We aimed to describe the clinical and imaging characteristics of patients diagnosed with pulmonary artery thrombosis (PAT) despite receiving anticoagulation with low-molecular-weight heparin (LMWH). (2) Methods: We retrospectively studied all hospitalized COVID-19 adult patients diagnosed with PAT between March 2020 and December 2021, who received LMWH for ≥72 h until the diagnosis of PAT. Acute PAT was confirmed by a CT pulmonary angiogram. (3) Results: We included 30 severe and critical COVID-19 patients. Median age was 62 (54–74) years, with 83.3% males, and comorbidities seen in 73.3%. PAT was diagnosed despite prophylactic (23.3%), intermediate (46.6%) or therapeutic (30%) doses of LMWH for a median time of 8 (4.7–12) days. According to their Wells score, 80% of patients had a low probability of pulmonary embolism diagnosis. PAT was localized in the lower lobes of the lungs in 76.6% of cases with 33.3% having bilateral involvement, with the distal, peripheral arteries being the most affected. At the PAT diagnosis we found a worsening of respiratory function, with seven patients progressing to mechanical ventilation (p = 0.006). The in-hospital mortality was 30%. (4) Conclusions: PAT should be considered in patients with severe and critical COVID-19, mainly in elderly male patients with comorbidities, irrespective of Wells score and LMWH anticoagulation.
Collapse
Affiliation(s)
- Cristian-Mihail Niculae
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, No. 37, Dionisie Lupu Street, Sector 2, 020021 Bucharest, Romania; (E.-D.M.); (M.L.); (A.H.)
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
- Correspondence: ; Tel.: +40-766298034
| | - Ana-Maria-Jennifer Anghel
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
| | - Eliza-Daniela Militaru
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, No. 37, Dionisie Lupu Street, Sector 2, 020021 Bucharest, Romania; (E.-D.M.); (M.L.); (A.H.)
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
| | - Laura-Georgiana Tîrlescu
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
| | - Mihai Lazar
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, No. 37, Dionisie Lupu Street, Sector 2, 020021 Bucharest, Romania; (E.-D.M.); (M.L.); (A.H.)
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
| | - Adriana Hristea
- Infectious Diseases Department, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, No. 37, Dionisie Lupu Street, Sector 2, 020021 Bucharest, Romania; (E.-D.M.); (M.L.); (A.H.)
- National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, No. 1, Calistrat Grozovici Street, Sector 2, 021105 Bucharest, Romania; (A.-M.-J.A.); (L.-G.T.)
| |
Collapse
|