Evaluation of the occurrence of venous thromboembolic events in COVID-19 outpatients

Introduction

Thrombotic events are present at higher rates among COVID-19 patients. Prophylactic use of parenteral anticoagulants during hospitalisation is recommended to reduce the risk of complications. In this context, the Tunisian Anticoagulation Survey in COVID-19 patient General Practice experience (TASC-GP) was conducted.

Objective

The evaluation of the incidence of venous thromboembolic events (VTE) and bleedings in COVID-19 patients treated in ambulatory.

Method

The TASC-GP is an observational, multicenter study included 3,383 patients from July to October 2021. The following up of patients was done 35 days after inclusion date with investigation of VTE and bleeding events. The four main enrolment criteria were: 1) age ≥ 18 years; 2) confirmed COVID-19 infection; 3) treated as an outpatient; 4) initiation of Rivaroxaban 10 mg/d. Patients were excluded if any of the following criteria applied: 1) the use of anticoagulant or thrombolytic drugs other than Rivaroxaban on admission or within days of admission; 2) the use of any dosage other than that specified in the study protocol.

Results

The mean age of the population was 51.6 ± 15.5 years with a sex ratio of 0.67, 30.7% of the population had hypertension, 23.4% were diabetic and 34.9% were obese. At least one cardiovascular comorbidity was observed in 40% of cases and 9.5% had chronic respiratory disease. The mean IMPROVE and IMPROVE DDimer scores were 0.65 ± 0.9 and 1.4 ± 1.4, respectively. The mean Improve bleeding score was 1.4 ± 1.5. A VTE was reported during follow-up in 39 patients (1.15%). Diabetes and chronic respiratory disease were independent factors for the occurrence of VTE with an odd ratio of 2.2 [95% CI 1.1–4.2] (P = 0.017) and 3.2 [95% CI 1.5–6.4] (P = 0.002) respectively. IMPROVE and IMPROVE DDimer scores were comparable in patients with and without VTE. There was no statistically significant increase in the rate of major bleeding (0.001%). The IMPROVE Bleeding score was comparable in the bleeding and non-bleeding groups at follow-up. There were no predictive factors for bleeding.

Conclusion

Our study is in agreement with the literature concerning a decrease in the rate of thrombembolic complications when using prophylactic anticoagulation versus placebo. Other VTE estimation scores including chronic respiratory disease and diabetes can be proposed. The use of Rivaroxaban in this population was not associated with increased bleeding.

Ventricular stroke work indices to predict mortality after successful percutaneous edge-to-edge-repair for severe mitral valve regurgitation

Background

Several studies identified predictors of worse clinical outcome despite successful transcatheter mitral valve repair (TMVR). The capability of invasively measured left and right ventricular stroke work indices (LVSWi, RVSWi) to predict mortality after successful TMVR is unclear.

Purpose

To assess the impact of LVSWi and RVSWi on mortality in patients with chronic heart failure (CHF) and severe mitral regurgitation (MR) undergoing TMVR.

Methods

Consecutive patients (pts.) with CHF (LV ejection fraction ≤50% from any cause) and severe MR who underwent successful TMVR (MR≤2+ at discharge) were included and followed prospectively. Primary endpoint was defined as all-cause mortality during a median follow-up period of 16±9 months. LVSWi was calculated as: Stroke volume index × (mean arterial pressure − postcapillary wedge pressure) × 0.0136 = g/m–1/m2. RVSWi was calculated as: Stroke volume index × (mean pulmonary artery pressure − right atrial pressure) × 0.0136 = g/m–1/m2. Receiver operator characteristic (ROC) analysis was used to determine discriminative capacity of LVSWi and RVSWi. Kaplan-Meier estimate was used for survival analysis. A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for all-cause mortality.

Results

140 patients (median age 74±9.9 years, 67.9% male) at high operative risk (LogEuro-SCORE 34.6±14.1%) were enrolled. Mean LVSWi and RVSWi were 22.3±10.7 g/m–1/m2 and 8.9±4.1 g/m–1/m2, respectively. 46 pts. died (33.1%). Pts. who died presented higher LogEuro-SCORE (27.8±16.6% vs. 20.1±13.7%; p=0.001), higher levels of NT-proBNP (12121±10602 ng/l vs. 6745±10820 ng/l; p=0.001), higher levels of creatinine (1.8±0.8 mg/dl vs. 1.4±0.8 mg/dl; p<0.001), lower LVSWi (18.9±8.1 g/m–1/m2 vs. 24.0±11.4 g/m–1/m2; p=0.01) and RVSWi (7.8±3.2 g/m–1/m2 vs. 9.4±4.4 g/m–1/m2; p=0.037), respectively. ROC curve analysis revealed that optimal sensitivity and specificity were achieved using a threshold of 24.8 g/m–1/m2 for LVSWi (sensitivity 80.4%, specificity 40.2%, area under the curve (AUC) 0.71 [0.60–0.81]; p=0.001) and 8.3 g/m–1/m2 for RVSWi (sensitivity 67.4%, specificity 57.0%, AUC 0.67 [0.56–0.78]; p=0.006), respectively. At long-term follow-up, a significantly lower survival rate was observed in pts. with LVSWi ≤24.8 g/m–1/m2 (20.0% vs. 39.4%; log-rank p=0.038) and in pts. with RVSWi ≤8.3 g/m–1/m2 (22.1% vs. 43.7%; log-rank p=0.026), respectively. In Cox regression analysis a LVSWi of ≤24.8 g/m–1/m2 and a RVSWi of ≤8.3 g/m–1/m2 were independent predictors for all-cause mortality (hazard ratio (HR) 2.83; 95% confidence interval (CI) 1.1 to 7.6; p=0.04; HR 2.52; 95% CI 1.04 to 6.1; p=0.041).

Conclusions

LVSWi and RVSWi are associated with mortality among pts. with CHF undergoing successful TMVR for severe MR. A LVSWi cut-off value of >24g/m–1/m2 and a RVSWi cut-off value of <8g/m–1/m2 seem to predict mortality independent of other clinical and echocardiographic factors.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Hospital Links der Weser, Bremen, Germany

Apport de l’exploration cytogénétique et ultrastructurale dans le pronostic de fertilité des sujets globozoospermiques

La globozoospermie est une forme sévère de tératozoospermie caractérisée par des spermatozoïdes à tête ronde avec absence ou présence d’un acrosome rudimentaire. L’objectif de cette étude est d’analyser les spermatozoïdes de six patients présentant un syndrome de globozoospermie et de rendre compte de l’inefficacité de plusieurs tentatives de fécondation in vitro avec ICSI. L’exploration de ces sujets a été réalisée par l’étude du taux d’aneuploïdies spermatiques par hybridation in situ fluorescente (sperm-FISH) pour les chromosomes X, Y et 18, du taux de fragmentation d’ADN par la technique TUNEL ainsi que par l’étude ultrastructurale détaillée de la morphologie spermatique en utilisant la microscopie électronique à transmission (MET). Onze tentatives d’ICSI ont été réalisées chez ces patients, avec un taux de fécondation faible (9,37 %), et aucune grossesse n’a été obtenue. Cette étude a permis de confirmer la variabilité des phénotypes spermatiques observés dans ce syndrome et de faible taux de fécondation après FIV-ICSI, et ce, quel que soit le phénotype.

[Influence of open chest conditions on pulse pressure variations]

OBJECTIVES

Pulse pressure variations are used to assess fluid responsiveness in mechanically ventilated patients. The accuracy of this index in open chest conditions remained unclear. The aim of the study was to evaluate the effect of open chest conditions on pulse pressure variations.

STUDY DESIGN

Non-interventional prospective study.

METHODS AND PATIENTS

Twenty-eight mechanically ventilated patients scheduled for open-heart surgery were included. Pulse pressure variations, peak aortic velocity, and stroke volume were measured before and after thoracotomy with pericardotomy. Measurements were made at each step and compared.

RESULTS

Neither pulse pressure variation nor peak aortic velocity and nor stroke volume variation were modified by open chest conditions (median=5% [interquartile range=6] vs 4% [6], p=NS), (20% [11] vs 17% [12], p=NS and 11% [7] vs 10% [3], p=NS) respectively. Pulse pressure variations were correlated to stroke volume before thoracotomy (r'=-0.432; p=0.02) and after thorocatomy (r'=-0.433, p=0.02).

CONCLUSION

In these studied patients, preload dependancy indices were not modified by open chest conditions. Pulse pressure variations remained correlated to stroke volume even after thoracotomy.

[Intestinal and hepatic subcellular localization of aluminium and indium administered orally to rat]

Aluminium and indium are two elements used in industrial and medical fields. The purpose of this work was to study the subcellular localization of these elements, after their single and simultaneous oral administration to rats. 2h after the administration of these two elements, the small intestine and the liver were removed.Ultrastructural study showed the presence of electron dense deposits in the lysosomes of apical parts of duodenal enterocytes. When the minerals were administered simultaneously, deposits were observed in lysosomes of duodenal and jejunal enterocytes. No deposits were seen in the hepatic tissue of treated and control rats. Microanalysis identification showed that the deposits are constituted of aluminium, indium as well as phosphorus. Our results suggested that the elements are concentrated, in lysosomes, under the form of insoluble phosphate salts and it seemed that there are no specific lysosomes for the concentration of minerals since the two elements were concentrated in the same lysosome when they are administered simultaneously.

Celiac disease in adult patients with type 1 diabetes mellitus in Tunisia

OBJECTIVE

Type1 diabetes mellitus may be associated with celiac disease. The prevalence of celiac disease as determined by screening among adult patients with type 1 diabetes is high with rates of 1.07.8% in Europe and U.S.A. The aims of the study are to determine the prevalence of celiac disease in adults with type 1 diabetes in Tunisia.

METHODS

348 consecutive adult patients with type1 diabetes were investigated prospectively and screened for celiac disease. The mean age was 28.45+/-10.74 years old. There were 176 females and 172 males. For the screening of celiac disease, we used immunoglobulin A (IgA) anti-endomysium (EMA) antibodies determined by an indirect immunofluorescence method. Anti-transglutaminase (tTG) antibodies were determined by an ELISA method. Those patients with positive results for anti EMA and or tTG were proposed for duodenal biopsy.

RESULTS

14 patients were positive for anti EMA and had high or a weak positive level of tTG antibodies. One patient from this group was already known to have celiac disease. Only 8 patients consented to biopsy and morphological changes were consistent with celiac disease in all cases. Prevalence of biopsy-proven celiac disease was 2.3% (95% CI=1.0-4.5%).

CONCLUSION

The present study confirms that celiac disease of adults is prevalent in type 1 diabetic patients in Tunisia. Serological screening for celiac disease in type 1 diabetes is important because many patients are asymptomatic and most are detected by the screening.

[Giant retroperitoneal liposarcoma. One case report]

INTRODUCTION

Retroperitoneal Liposarcoma is a rare and primary malignancy developed from mesenchymal tissue. It's generally unique and shows an only one histologic component. We report a case of multicentric and synchronous liposarcoma (intraperitoneal and retroperitoneal) and with different histologic types.

EXEGESES

A 53-year old man presented with abdominal pain, increased abdominal girth and weight loss. Physical examination revealed two abdominal masses. Computed tomography scan showed a very large retroperitoneal mass displacing the left kidney, digestive loops and vessels. The patient underwent surgery. One enormous mass of the left renal lodge measuring 50 cm, a retroduodenal mass measuring 15 cm and a nodule of the coecum were removed. Histological examination of the mass of the left renal lodge revealed mixed type liposarcoma (dedifferentiated and myxoid). Histological examination of the retroduodenal mass and of the nodule of the coecum revealed well-differentiated liposarcoma.

CONCLUSION

Pathological, therapeutic and prognostic aspects of abdominal liposarcoma will be reviewed in this article.

Genotypes of hepatitis C virus circulating in Tunisia

Hepatitis C virus (HCV) isolates from 93 patients living in Tunisia, including 16 haemophiliacs, were genotyped by INNO LiPA and partial sequencing of the 5' untranslated region of the viral genome. In non-haemophiliacs, subtype 1b was largely predominant (79%), types 1a, 2a, 2b, 3a and 4a occurred much less frequently at 5, 7, 3, 3 and 1% of cases, respectively. In the group of haemophiliacs, a co-dominance between subtypes 1a and 1b was noticed (38%). Type distribution of HCV in Tunisia differs from that reported in other countries of the Mediterranean and Middle East regions. Genotyping results in respect of clinical status, age, and genotyping methods, are discussed.

[Behçet's disease associated with Crohn's disease]

INTRODUCTION

The association of Behçet's disease and of Crohn's disease is exceptional, and raises a nosological problem.

CASE REPORT

A 24 year-old female developed since 1996 chronic diarrhea, abdominal pain, recurrent oral and genital ulcer and polyarthralgia. Endoscopic colonoscopy examination showed a diffuse colitis. Histological examination revealed epitheloid granuloma without vasculitis compatible with a Crohn's disease. The patient was treated with oral prednisone (1mg/kg/day). In November 1998, she was admitted for diarrhea. Many pseudofolliculitis lesions, uveitis and positive pathergy test were noted. The HLA was B 51. The diagnosis of Crohn's disease associated with Behçet's disease was made. She was treated with high doses of prednisone (1mg/kg/day and 6 monthly intravenous pulses of cyclophosphamide). Skin lesions and diarrhea improved within few days, and cleared completely within five months. Presently, the patient remains clinically free of disease.

CONCLUSION

While being of different pathogenic origin, Behçet's disease and Crohn's disease may coexist within one and the same patient and cause diagnostic and therapeutic problems.

[Intestinal metaplasia at the gastroesophageal junction - epidemiologic and histologic aspects. Report of 164 cases]

Adenocarcinoma of the gastric cardia is increasing in incidence. The purpose of this study was to determine whether intestinal metaplasia of the esophagogastric and having a malignant potential junction can be considered as an ultra-short segment Barrett's esophagus. To study the epidemiologic and histological features of the intestinal metaplasia of esophagogastric junction two groups of patients were compared for the prevalence of this condition. Group 1 included 82 patients with gastroesophageal reflux symptoms et group 2 consisted of 82 healthy individuals. Both groups had two biopsy specimens taken from the esophagogastric junction. Histological evidence of intestinal metaplasia was defined as specialized columnar epithelium containing goblet cells staining with alcian blue at pH 2.5. Intestinal metaplasia of the esophagogastric junction was present in 12 patients in group 1 and 9 individuals in group 2. The global prevalence of this condition was 12.8% and there was not a statistically significant difference in the prevalence of this condition between the two groups. A significant difference could not be found when sex was considered. There was a significant association between this condition and older age (p = 0.01). Intestinal metaplasia of the esophagogastric junction and Barrett's esophagus do not have the same epidemiologic features. Therefore, we suggest that screening biopsy specimens of the esophagogastric junction be limited to study protocols at this time.

[Pregnancy-related liver diseases]

The liver diseases of pregnancy are specific liver disorders during the pregnancy. The principal hepatic anomaly during hyperemesis gravidarum is a reversible augmentation of liver enzymes under reanimation. Intrahepatic cholestasis of pregnancy occur during the last 2 trimesters of pregnancy, manifested usually by pruritus preceeding a jaundice. The liver enzymes and the serum biliary acids are augmented. The acute fatty liver of pregnancy occur during the last trimester of pregnancy leading to early interruption of pregnancy which would help to diminish the elevated level of maternal and fetal mortality. The HELLP syndrome usually observed during the toxemia of pregnancy, associate an hemolysis elevation of liver enzymes and low platelets.

High circulation of hepatitis B virus (HBV) precore mutants in Tunisia, North Africa

Hepatitis B Virus (HBV) e antigen (HBeAg), HBV DNA and precore mutations affecting HBeAg expression during active replication were studied in 72 Tunisian hepatitis B surface antigen (HBsAg) positive individuals: 30 asymptomatic carriers of the virus, 37 with chronic hepatitis and 5 with acute hepatitis. HBV DNA was detected in 44 patients, but only 20% of them expressed HBeAg. Precore mutant strains, with mutations at position 1896 or at positions 1896 and 1899, were detected by PCR-hybridization in 86 and 36% of patients, respectively. Wild-type strains were detected in 54% of patients. Precore mutants were found in chronically and in acutely infected individuals, in patients with severe and asymptomatic infections, in HBeAg positive as well as HBeAg negative individuals. These results show the high frequency of HBV precore mutants in Tunisia.

Gastric MALT lymphoma. A clinico-pathological study of 65 cases. Relationship to Helicobacter pylori

We report 65 cases of MALT gastric lymphomas. HP was looked for with Giemsa and Whartin Starry stains. Immunohistochemistry was done with PAP method. Anti-HP treatment was used in 9 cases. 38 were of low grade of malignancy, 23 were high grade, 4 were high grade with a low grade component. The mean age was 51.5 years, the sex ratio 1.5. Epigastric pain was the most frequent feature (87.7% of cases). Endoscopically, low grade lymphomas presented as unique or multiple ulcerations (55.3% of cases) with antral localisation (52.6% of cases). 60% of our patients were stage IE, of which 61% had low grade lymphoma, 18% were at stage II2E, 10% at stage III and 10% at stage IV. From 23 operated patients, 29% had early lymphoma which was low grade malignant in 71.5% of cases, and 71% had lymphomas which were widely spread beyond the submucosa. HP was found in 63% of cases. Histologic regression of two early lymphomas of low grade malignancy was achieved after HP eradication.

[Ménétrier disease associated with a gastric adenocarcinoma. Apropos of 2 cases]

Two new cases of Menetrier's disease with gastric adenocarcinoma in two men aged 62 and 81 years, respectively, are reported. In both cases, the diagnosis was established by histologic examination of the operative specimen. Emphasis is placed on diagnostic difficulties and on the risk of malignant transformation of Menetrier's disease, which should be viewed as a precancerous gastric lesion.

[Esophageal duplications: role of computed tomography. Apropos of 2 cases]

The authors present two cases of oesophageal duplication: tubular in one case and cystic in the other. This rare anomaly was identified in both cases by CT scan. A review of literature is proposed.

[Fibrous inflammatory polyp of the digestive tract. Apropos of 5 cases]

Inflammatory fibroid polyp is a rare benign tumor of the digestive tract. The authors report three cases: two intestinal and one gastric. These cases are of particular interest because of the association ill one case of an intestinal submucosal lipoma with the inflammatory fibroid polyp, and the existence in the gastric case of an inflammatory reaction caused by food debris. This offers, further evidence in support of the theory implicating a chronic inflammatory reaction.

[Malignant lymphoma on a gastric stump]

We report a case of lymphoplasmocytic and immunoblastic gastric remnant lymphoma occurring in a 51 year-old male. This patient had undergone subtotal gastrectomy for a gastric peptic ulcer at age 37. Histologic findings in the initial gastric specimen showed a dense lymphoid infiltrate surrounding the ulcer within the gastric mucosa. This proliferation was grouped into distinct follicles, and was compatible with pseudo-lymphoma. The progression of pseudo-lymphoma to malignant lymphoma is suggested.

[Study of malabsorption of lactose by the hydrogen breath test in a population of 70 Tunisian adults]

Lactose malabsorption was studied by the hydrogen breath-test in 23 adults suffering from irritable bowel syndrome (group A) and in 47 healthy subjects (group B). The concentration of hydrogen in end-expired alveolar samples was measured after ingestion of 25 g of lactose. Among the 70 subjects, 6 (8.5 p. 100) were not hydrogen producers and were excluded from the study. Lactose malabsorption was shown in 51 of the remaining 64 subjects (79.6 p. 100). Among these 51 patients, 36 were healthy and 15 had an irritable bowel syndrome. The frequency of lactose malabsorption among the 43 healthy hydrogen producers was 83 p. 100. This value is similar to those observed in other studies (greek and italian). Our results suggest that lactose malabsorption is frequent among the tunisian adult population.