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Koutalos AA, Koskiniotis A, Rountas C, Konstantinou E, Georgiadou S, Stefos A, Gatselis NK, Dalekos GN, Malizos KN. Osteonecrosis risk after steroids-related treatment of COVID-19 is not negligible: A cross sectional study. Eur J Intern Med 2024; 123:127-131. [PMID: 38281818 DOI: 10.1016/j.ejim.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND & AIMS During the pandemic, steroids use at various dosages and durations for the treatment of COVID-19 patients, especially in hospitalized patients, was a common and effective strategy. However, steroid administration is associated with osteonecrosis as an adverse event. The aim of the study was to examine the prevalence of skeleton osteonecrosis in COVID-19 patients treated with or without steroids. METHODS Eighty randomly selected hospitalized COVID-19 patients were analyzed, of which 40 were managed with a published protocol including steroids and 40 did not receive steroids. Demographics and laboratory measurements including white blood cells count, C-reactive protein and ferritin were retrieved from the medical records. All patients underwent magnetic resonance imaging of the hips, shoulders, and knees. Subsequently, all patients were clinically examined and Oxford hip score (OHS) and EuroQol- 5 Dimension (EQ-5D-5 L) were documented. RESULTS Three patients (3/40; 7.5 %) treated with steroids were diagnosed with femoral head osteonecrosis. None of the patients in the non-steroid-treated group developed osteonecrosis. There were no differences between the two groups regarding OHS and EQ-5D-5 L. Patients with osteonecrosis had higher ferritin levels, received higher doses of corticosteroids (median dose 2200 mg), and had longer hospitalization. CONCLUSIONS COVID-19-related therapy with steroids resulted in lower prevalence of osteonecrosis than that previously recorded in patients with severe acute respiratory syndrome caused by coronavirus-type-1. However, this risk seems not negligible and therefore, high clinical suspicion for early diagnosis is warranted, given the fact that a great proportion of hospitalized patients received steroids during the COVID-19 pandemic.
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Affiliation(s)
- Antonios A Koutalos
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, General University Hospital of Larissa, Greece
| | - Alexandros Koskiniotis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, General University Hospital of Larissa, Greece
| | - Christos Rountas
- Department of Radiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Efstathios Konstantinou
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, General University Hospital of Larissa, Greece
| | - Sarah Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Konstantinos N Malizos
- Department of Orthopaedic Surgery & Musculoskeletal Trauma, Faculty of Medicine, University of Thessaly, Larissa, Greece.
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Aljuhani O, Al Sulaiman K, Korayem GB, Altebainawi AF, Alsohimi S, Alqahtani R, Alfaifi S, Alharbi A, AlKhayrat A, Hattan A, Albassam M, Almohammed OA, Alkeraidees A, Alonazi DA, Alsalman WF, Aldamegh G, Alshahrani R, Vishwakarma R. The association between tocilizumab therapy and the development of thrombosis in critically ill patients with COVID-19: a multicenter, cohort study. Sci Rep 2024; 14:3037. [PMID: 38321099 PMCID: PMC10847412 DOI: 10.1038/s41598-024-53087-z] [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: 08/03/2023] [Accepted: 01/27/2024] [Indexed: 02/08/2024] Open
Abstract
The use of tocilizumab for the management of COVID-19 emerged since it modulates inflammatory markers by blocking interleukin 6 receptors. Concerns regarding higher thrombosis risk while using tocilizumab were raised in the literature. The aim of this study is to investigate the association between tocilizumab therapy and the development of thromboembolic events in critically ill COVID-19 patients. A propensity score-matched, multicenter cohort study for critically ill adult patients with COVID-19. Eligible patients admitted to ICU between March 2020 and July 2021 were categorized into two sub-cohorts based on tocilizumab use within 24 h of ICU admission. The primary endpoint was to assess the incidence of all thrombosis cases during ICU stay. The secondary endpoints were 30-day mortality, in-hospital mortality, and the highest coagulation parameters follow-up (i.e., D-dimer, Fibrinogen) during the stay. Propensity score matching (1:2 ratio) was based on nine matching covariates. Among a total of 867 eligible patients, 453 patients were matched (1:2 ratio) using propensity scores. The thrombosis events were not statistically different between the two groups in crude analysis (6.8% vs. 7.7%; p-value = 0.71) and regression analysis [OR 0.83, 95% CI (0.385, 1.786)]. Peak D-dimer levels did not change significantly when the patient received tocilizumab (beta coefficient (95% CI): 0.19 (- 0.08, 0.47)), while there was a significant reduction in fibrinogen levels during ICU stay (beta coefficient (95% CI): - 0.15 (- 0.28, - 0.02)). On the other hand, the 30-day and in-hospital mortality were significantly lower in tocilizumab-treated patients (HR 0.57, 95% CI (0.37, 0.87), [HR 0.67, 95% CI (0.46, 0.98), respectively). The use of tocilizumab in critically ill patients with COVID-19 was not associated with higher thrombosis events or peak D-dimer levels. On the other hand, fibrinogen levels, 30-day and in-hospital mortality were significantly lower in the tocilizumab group. Further randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- King Abdulaziz Medical City (KAMC)-Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia.
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ali F Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Hail, Saudi Arabia
| | - Samiah Alsohimi
- Pharmaceutical Care Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Saeedah Alfaifi
- Pharmaceutical Care Department, Dallah Hospital, Riydah, Saudi Arabia
| | - Aisha Alharbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Azzah AlKhayrat
- Pharmaceutical Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmed Hattan
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Meshal Albassam
- Department of Internal Medicine & Critical Care, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | | | - Atheer Alkeraidees
- Pharmaceutical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Dhay A Alonazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Weam F Alsalman
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghaliah Aldamegh
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rasha Alshahrani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- Norwich clinical trial unit, Norwich Medical School, University of East Anglia, Norwich, UK
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Mohamed Hussein AAR, Sayad R, Abdelshafi A, Hammam IA, Kedwany AM, Elkholy SAE, Ibrahim IH. A meta analysis on the utility of Anakinra in severe COVID-19 disease. Cytokine 2023; 169:156311. [PMID: 37536222 DOI: 10.1016/j.cyto.2023.156311] [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: 04/30/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND OBJECTIVE The most important presentation of COVID-19 is hyper inflammatory condition and cytokine storm that occurs due to excessive increase of the inflammatory mediators specially, pro-inflammatory interleukins such as IL-1β, IL-6 and tumor necrosis factor-α which have an important role in the cytokine storm pathway. Up till now there is not a definitive treatment for COVID-19 disease, but according to the pathophysiology of the disease, Anakinra (Interleukin- 1 inhibitor) is an adjuvant treatment option in patients with severe COVID-19 by blocking the effect of IL-1. So, we aimed to summarize the studies that evaluated the safety and efficacy of Anakinra in patients diagnosed with COVID-19. METHODS We performed a search in PubMed, Cochrane Library, Scopus, and Web of Science (WOS) databases from inception till 7 Jan 2022. Additionally, we searched randomized and non-randomized clinical trials, cohort, case series, case control, case report more than 3 patients which contain confirmed cases of COVID-19 who received Anakinra (Interleukin- 1 inhibitor) for the management of hyper-inflammatory condition associated with COVID-19 disease. A meta-analysis was conducted using review manager 5.4. RESULTS We included 44 articles in the systematic review. Ultimately, 23 studies were incorporated in the meta-analysis with a total number of 3179 patients. Our analysis showed statistically significant difference in the following outcomes: duration of ICU stays [MD = -0.65, 95% CI (-1.09, -0.03), p = 0.04], the number of patients who needed invasive mechanical ventilation [RR = 0.57, 95% CI (0.39, 0.84), p = 0.004], and number of deaths [RR = 0.80, 95% CI (0.66, 0.99), p = 0.04]. Our analysis showed no statistically significant difference in the following outcomes: length of hospital stays [MD = -0.16, 95% CI (-0.42, 0.11), p = 0.26], oxygen-free days [MD = -0.81, 95% CI (-3.81, 2.20), p = 0.60], and the number of patients who needed non-invasive mechanical ventilation [RR = 1.09, 95% CI (0.47, 2.52), p = 0.84]. CONCLUSION Anakinra showed some promising results in important outcomes related to COVID-19 as it significantly reduced the rate of mortality and the need of invasive mechanical ventilation. It should be used in severe cases more than mild and moderate cases to avoid possible immunosuppression complications. Anakinra use is safe in cases of COVID-19 at dose less than 100 mg. Another important outcome was significant reduction is the D-dimer level. Anakinra may be effective in the treatment of specific immunocompromised cases, but it should be used cautiously.
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Affiliation(s)
- Aliae A R Mohamed Hussein
- Pulmonology, Chest Department, Assiut Faculty of Medicine, Assiut, Egypt; Assiut Research Team (ART), Assiut 71515, Egypt.
| | - Reem Sayad
- Assiut Research Team (ART), Assiut 71515, Egypt; Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Abdelrahman Abdelshafi
- Assiut Research Team (ART), Assiut 71515, Egypt; Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Islam Abdelaal Hammam
- Assiut Research Team (ART), Assiut 71515, Egypt; Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Kedwany
- Assiut Research Team (ART), Assiut 71515, Egypt; Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Islam H Ibrahim
- Assiut Research Team (ART), Assiut 71515, Egypt; Faculty of Medicine, Assiut University, Assiut, Egypt
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Chen YC, Chen CY, Wang AY, Hou SK, Lai KSL, Chou CL, Lin YY, Lin YC, Huang CY. Thromboembolic Presentations among Patients Hospitalized to the Intensive Care Unit for Coronavirus Disease 2019 (COVID-19) - A Northern Taiwan Single Center Experience. ACTA CARDIOLOGICA SINICA 2023; 39:695-708. [PMID: 37720401 PMCID: PMC10499957 DOI: 10.6515/acs.202309_39(5).20230203a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/03/2023] [Indexed: 09/19/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) has been associated with a high thromboembolic risk among patients in intensive care units. Asian populations may share a similar thromboembolic risk, but with a higher prevalence of arterial thromboembolism than venous thromboembolism. To clarify this risk in Taiwan, this single-center retrospective study collected 27 consecutive intensive care unit patients with COVID-19 confirmed by polymerase chain reaction, with a median age of 67.6 years (male 81.5%). Twenty-three patients received prophylactic anticoagulation (85.2%), and there were four bleeding events (14.8%). Nine patients had thromboembolism (33.3%), including three with deep vein thrombosis, two with peripheral artery thromboembolism, and four with ischemic stroke. There were no significant clinical differences between the patients with or without thromboembolism. Initial serum ferritin [adjusted odds ratio (OR): 13.19, 95% confidence interval (CI): 1.01-172.07] and peak serum procalcitonin (adjusted OR: 18.93, 95% CI: 1.08-330.91) were associated with a higher risk of thromboembolism. Furthermore, prophylactic anticoagulation (adjusted OR: 0.01, 95% CI: < 0.001-0.55) was associated with a lower risk of thromboembolism. All cases of deep vein thrombosis and one peripheral artery thromboembolism occurred at intravascular catheter locations. No association between thromboembolism and survival was found (age-adjusted hazard ratio: 0.55, 95% CI: 0.10-2.95). In conclusion, the prevalence of COVID-19 thromboembolism among Taiwanese patients in intensive care units was high, even with prophylactic anticoagulation. Serum ferritin and procalcitonin may identify high-risk populations. Prophylactic anticoagulation may reduce the risk of thromboembolism with a manageable bleeding risk. Larger prospective studies are needed to clarify the risk of COVID-19 thromboembolism and its risk factors in the post-Omicron era.
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Affiliation(s)
- Yen-Chou Chen
- Taipei Heart Institute, Taipei Medical University
- Division of Cardiology and Cardiovascular Research Center
| | - Ching-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei
| | - An-Yi Wang
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | - Sen-Kuang Hou
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | - Kevin Shu Leung Lai
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | | | - Yun-Yi Lin
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital
- Institute of Health Policy and Management, College of Public Health, National Taiwan University
| | - Yi-Cheng Lin
- Department of Pharmacy, Taipei Medical University Hospital
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yao Huang
- Taipei Heart Institute, Taipei Medical University
- Division of Cardiology and Cardiovascular Research Center
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan
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Chen YC, Huang CP, Lin TM, Huang CY. Severe Digital Ischemia Associated with Upper Limb Arterial Thrombosis and Raynaud's Phenomenon in a Patient with Severe Acute Respiratory Syndrome Coronavirus 2 Infection. ACTA CARDIOLOGICA SINICA 2022; 38:650-652. [PMID: 36176367 PMCID: PMC9479058 DOI: 10.6515/acs.202209_38(5).20220330d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/30/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Yen-Chou Chen
- Taipei Heart Institute, Taipei Medical University;
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Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital
| | - Chien-Po Huang
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University
| | - Tzu-Min Lin
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital;
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Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chun-Yao Huang
- Taipei Heart Institute, Taipei Medical University;
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Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital;
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Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
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Theoharides TC. Could SARS-CoV-2 Spike Protein Be Responsible for Long-COVID Syndrome? Mol Neurobiol 2022; 59:1850-1861. [PMID: 35028901 PMCID: PMC8757925 DOI: 10.1007/s12035-021-02696-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023]
Abstract
SARS-CoV-2 infects cells via its spike protein binding to its surface receptor on target cells and results in acute symptoms involving especially the lungs known as COVID-19. However, increasing evidence indicates that many patients develop a chronic condition characterized by fatigue and neuropsychiatric symptoms, termed long-COVID. Most of the vaccines produced so far for COVID-19 direct mammalian cells via either mRNA or an adenovirus vector to express the spike protein, or administer recombinant spike protein, which is recognized by the immune system leading to the production of neutralizing antibodies. Recent publications provide new findings that may help decipher the pathogenesis of long-COVID. One paper reported perivascular inflammation in brains of deceased patients with COVID-19, while others showed that the spike protein could damage the endothelium in an animal model, that it could disrupt an in vitro model of the blood-brain barrier (BBB), and that it can cross the BBB resulting in perivascular inflammation. Moreover, the spike protein appears to share antigenic epitopes with human molecular chaperons resulting in autoimmunity and can activate toll-like receptors (TLRs), leading to release of inflammatory cytokines. Moreover, some antibodies produced against the spike protein may not be neutralizing, but may change its conformation rendering it more likely to bind to its receptor. As a result, one wonders whether the spike protein entering the brain or being expressed by brain cells could activate microglia, alone or together with inflammatory cytokines, since protective antibodies could not cross the BBB, leading to neuro-inflammation and contributing to long-COVID. Hence, there is urgent need to better understand the neurotoxic effects of the spike protein and to consider possible interventions to mitigate spike protein-related detrimental effects to the brain, possibly via use of small natural molecules, especially the flavonoids luteolin and quercetin.
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Affiliation(s)
- Theoharis C Theoharides
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, 136 Harrison Avenue, Suite 304, Boston, MA, 02111, USA.
- School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, 02111, USA.
- Departments of Internal Medicine and Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, 02111, USA.
- Institute of Neuro-Immune Medicine, Nova Southeastern University, Clearwater, FL, 33759, USA.
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