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Neto NS, de Almeida MCV, de Oliveira Couto H, Miranda CH. Biomarkers of endothelial glycocalyx damage are associated with microvascular dysfunction in resuscitated septic shock patients. Microvasc Res 2024:104683. [PMID: 38522507 DOI: 10.1016/j.mvr.2024.104683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Microvascular dysfunction plays a central role in organ dysfunction during septic shock. Endothelial glycocalyx (eGC) damage could contribute to impaired microcirculation. The aim was to assess whether several eGC-damaged biomarkers are associated with microvascular dysfunction in resuscitated septic shock patients. METHODS This cross-sectional study included resuscitated septic shock patients (N = 31), and a group of healthy individuals (N = 20). The eGC damage biomarkers measured were syndecan-1 (SDC-1), soluble CD44 (CD44s), hyaluronic acid (HYAL) in blood sample; sulfated glycosaminoglycans (GAGs) in urine sample; and thrombomodulin (TBML) in blood sample as biomarker of endothelial cell damage. Microcirculation was assessed through sublingual videocapillaroscopy using the GlycoCheck™, which estimated the perfused vascular density (PVD); the perfused boundary region (PBR), an inverse parameter of the eGC thickness; and the microvascular health score (MVHS). We defined a low MVHS (<50th percentile in septic patients) as a surrogate for more impaired microvascular function. RESULTS The SDC-1, CD44s, TBML and GAGs levels were correlated with impaired microvascular parameters (PVD of vessels with diameter < 10 μm, MVHS and flow-adjusted PBR); p < 0.05 for all comparisons, except for GAGs and flow-adjusted PBR. The SDC-1 [78 ng/ml (interquartile range (IQR) 45-336) vs. 48 ng/ml (IQR 9-85); p = 0.052], CD44s [796ρg/ml (IQR 512-1995) vs. 526ρg/ml (IQR 287-750); p = 0.036], TBML [734ρg/ml (IQR 237-2396) vs. 95ρg/ml (IQR 63-475); p = 0.012] and GAGs levels [0.42 ρg/mg (IQR 0.04-1.40) vs. 0.07 ρg/mg (IQR 0.02-0.20); p = 0.024]; were higher in septic patients with more impaired sublingual microvascular function (low MVHS vs. high MVHS). CONCLUSION SDC-1, CD44s, TBML and GAGs levels were associated with impaired microvascular function in resuscitated septic shock patients.
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Affiliation(s)
- Nazir Soubine Neto
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University (USP), Ribeirão Preto, SP, Brazil
| | - Marcela Curci Vieira de Almeida
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University (USP), Ribeirão Preto, SP, Brazil
| | - Helton de Oliveira Couto
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University (USP), Ribeirão Preto, SP, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University (USP), Ribeirão Preto, SP, Brazil.
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Miranda CH. The Journey Towards Hypertension Control in Brazil. Arq Bras Cardiol 2023; 120:e20230533. [PMID: 37971049 PMCID: PMC10519250 DOI: 10.36660/abc.20230533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Carlos Henrique Miranda
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Clínica MédicaRibeirão PretoSPBrasilDepartamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP – Brasil
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Lourençato FM, Miranda CH, de Carvalho Borges M, Pazin-Filho A. Palliative care team in a Brazilian tertiary emergency department. Int J Emerg Med 2022; 15:53. [PMID: 36114470 PMCID: PMC9479313 DOI: 10.1186/s12245-022-00456-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
To describe the process of implementing a palliative care team (PCT) in a Brazilian public tertiary university hospital and compare this intervention as an active in-hospital search (strategy I) with the Emergency Department (strategy II).
Methods
We described the development of a complex Palliative Care Team (PCT). We evaluated the following primary outcomes: hospital discharge, death (in-hospital and follow-up mortality) or transfer, and performance outcomes-Perception Index (difference in days between hospitalization and the evaluation by the PTC), follow-up index (difference in days between the PTC evaluation and the primary outcome), and the in-hospital stay.
Results
We included 1203 patients—strategy I (587; 48.8%) and strategy II (616; 51.2%). In both strategies, male and elderly patients were prevalent. Most came from internal medicine I (39.3%) and II (57.9%), p < 0.01. General clinical conditions (40%) and Oncology I (27.7%) and II (32.4%) represented the majority of the population. Over 70% of all patients had PPS 10 and ECOG 4 above 85%. There was a reduction of patients identified in ICU from I (20.9%) to II (9.2%), p < 0.01, reduction in the ward from I (60.8%) to II (42.5%), p < 0.01 and a significant increase from I (18.2%) to II (48.2%) in the emergency department, p < 0.01. Regarding in-hospital mortality, 50% of patients remained alive within 35 days of hospitalization (strategy I), while for strategy II, 50% were alive within 20 days of hospitalization (p < 0.01). As for post-discharge mortality, in strategy II, 50% of patients died 10 days after hospital discharge, while in strategy I, this number was 40 days (p < 0.01). In the Cox multivariate regression model, adjusting for possible confounding factors, strategy II increased 30% the chance of death. The perception index decreased from 10.9 days to 9.1 days, there was no change in follow-up (12 days), and the duration of in-hospital stay dropped from 24.3 to 20.7 days, p < 0.01. The primary demand was the definition of prognosis (56.7%).
Conclusion
The present work showed that early intervention by an elaborate and complex PCT in the ED was associated with a faster perception of the need for palliative care and influenced a reduction in the length of hospital stay in a very dependent and compromised old population.
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Gadioli LP, Miranda CH, Marin-Neto JA, Volpe GJ, Filho ACLB, Filho AP, Pintya AO, de Figueiredo AB, Simões MV. Regional myocardial sympathetic denervation precedes the development of left ventricular systolic dysfunction in chronic Chagas' cardiomyopathy. J Nucl Cardiol 2022; 29:3166-3176. [PMID: 34981413 DOI: 10.1007/s12350-021-02869-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/20/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Regional myocardial sympathetic denervation is a conspicuous and early disorder in patients with chronic Chagas' cardiomyopathy (CCC), potentially associated to the progression of myocardial dysfunction OBJECTIVE: To evaluate in a longitudinal study the association between the presence and the progression of regional myocardial sympathetic denervation with the deterioration of global and segmental left ventricular dysfunction in CCC. METHODS 18 patients with CCC were submitted at initial evaluation and after 5.5 years to rest myocardial scintigraphy with 123Iodo-metaiodobenzylguanidine and 99mTc-sestamibi and to two-dimensional echocardiography to assess myocardial sympathetic denervation, extent of fibrosis, and the left ventricular ejection fraction (LVEF) and wall motion abnormalities. RESULTS In the follow-up evaluation, compared to the initial one, we observed a significant decrease in LVEF (56 ± 11 to 49% ± 12; P = .01) and increased summed defects scores in the myocardial innervation scintigraphy (15 ± 10 to 20 ± 9; P < .01). The presence of regional myocardial sympathetic denervation in ventricular regions of viable non-fibrotic myocardium presented an odds ratio of 4.25 for the development of new wall motion abnormalities (P = .001). CONCLUSION Regional and global myocardial sympathetic denervation is a progressive derangement in CCC. In addition, the regional denervation is topographically associated with areas of future development of regional systolic dysfunction in patients with CCC.
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Affiliation(s)
- Leonardo Pippa Gadioli
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Carlos Henrique Miranda
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - José Antonio Marin-Neto
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Gustavo Jardim Volpe
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Antonio Pazin Filho
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Antonio Osvaldo Pintya
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Marcus Vinicius Simões
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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Ribeiro ILA, Bellissimo-Rodrigues WT, Mussolin MG, Innocentini LMAR, Marangoni ATD, Macedo LD, Barbosa-Júnior F, de Souza HCC, Menegueti MG, Pereira APS, Gaspar GG, Schmidt A, Miranda CH, Lovato WJ, Puga ML, Auxiliadora-Martins M, Basile-Filho A, Bellissimo-Rodrigues F. Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: A quasi-experimental study. Am J Infect Control 2022; 50:1156-1161. [PMID: 35108582 DOI: 10.1016/j.ajic.2022.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND We aimed to evaluate the impact of providing dental care to critically ill patients on their risk of death and ventilator-associated pneumonia (VAP). METHODS A quasi-experimental study was conducted in 2 intensive care units (ICU) from 2016 to 2019. The intervention consisted of implementing routine dental care, focusing on oral hygiene and periodontal treatment, at least 3 times a week, for patients admitted to the study units. In the pre-intervention period, routine oral hygiene was provided by the ICU nursing staff. The primary and secondary study outcomes were mortality, evaluated at the end of the ICU stay, and VAP incidence density, respectively. Data were analyzed using the ARIMA (autoregressive integrated moving average) time series model in R software. RESULTS During the intervention period, 5,147 dental procedures were performed among 355 patients. The time series showed that ICU mortality was 36.11%, 32.71%, and 32.30% within the 3 years before the intervention, and 28.71% during the intervention period (P = .015). VAP incidence density did not significantly change during the study period (P = .716). CONCLUSION A dental care intervention focused on oral hygiene and periodontal treatment regularly provided by dentists to critically ill patients may decrease their risk of dying in the ICU. Randomized clinical trials should be performed to confirm these findings. TRIAL REGISTRATION WHO-affiliated Brazilian Clinical Trials Registry. RBR-4jmz36. Registered 7 October 2018, before first patient enrollment.
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Affiliation(s)
| | | | - Mariama Gentil Mussolin
- Graduate Program in Public Health/Clinical Oncology, Stem Cells and Cell Therapy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Adriano Tadeu Dias Marangoni
- Dentistry Service. University Hospital of the Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Leandro Dorigan Macedo
- Dentistry Service. University Hospital of the Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Barbosa-Júnior
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Gilberto Gambero Gaspar
- Infection Control and Prevention Service. University Hospital of the Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - André Schmidt
- Cardiology Division, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Carlos Henrique Miranda
- Cardiology Division, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Wilson José Lovato
- Intensive Care Unit, University Hospital of the Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Marcelo Lourencini Puga
- Intensive Care Medicine Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Maria Auxiliadora-Martins
- Intensive Care Medicine Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Anibal Basile-Filho
- Intensive Care Medicine Division, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Miranda CH. Pulmonary embolism: an underdiagnosed and underreported entity in Brazil. J Bras Pneumol 2022; 48:e20220207. [PMID: 36074410 PMCID: PMC9496265 DOI: 10.36416/1806-3756/e20220207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Carlos Henrique Miranda
- . Divisão de Medicina de Emergência, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP), Brasil
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Teixeira AB, Zancaner LF, Ribeiro FFDF, Pintyá JP, Schmidt A, Maciel BC, Marin JA, Miranda CH. Reperfusion Therapy Optimization in Acute Myocardial Infarction with ST-Segment Elevation using WhatsApp®-Based Telemedicine. Arq Bras Cardiol 2022; 118:556-564. [PMID: 35137785 PMCID: PMC8959040 DOI: 10.36660/abc.20201243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/22/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND About 40% of patients with ST-segment elevation myocardial infarction (STEMI) in Brazil do not receive reperfusion therapy. OBJECTIVE The use of a telemedicine network based on WhatsApp® could increase the percentage of patients receiving reperfusion therapy. METHODS A cross-sectional study analyzed outcomes before and after the organization of a telemedicine network to send the electrocardiogram via WhatsApp® of patients suspected of STEMI from 25 municipalities that are members of the Regional Health Department of Ribeirão Preto (DRS-XIII) to a tertiary hospital, which could authorize immediate patient transfer using the same system. The analyzed outcomes included the percentage of patients who received reperfusion therapy and the in-hospital mortality rate. A p value < 0.05 was considered statistically significant. RESULTS The study compared 82 patients before (February 1, 2016 to January 31, 2018) with 196 patients after this network implementation (February 1, 2018 to January 31, 2020). After implementing this network, there was a significant increase in the proportion of patients who received reperfusion therapy (60% vs. 92%), relative risk (RR): 1.594 [95% confidence interval (CI) 1.331 - 1.909], p < 0.0001 and decrease in the in-hospital mortality rate (13.4% vs. 5.6%), RR: 0.418 [95%CI 0.189 - 0.927], p = 0.028. CONCLUSION The use of WhatsApp®-based telemedicine has led to an increase in the percentage of patients with STEMI who received reperfusion therapy and a decrease in the in-hospital mortality rate.
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Affiliation(s)
- Alessandra Batista Teixeira
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDivisão de Medicina de Emergência do Departamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica,Ribeirão Preto, SP - Brasil
| | - Leonardo Fiaschi Zancaner
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDivisão de Medicina de Emergência do Departamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica,Ribeirão Preto, SP - Brasil
| | - Fernando Fonseca de França Ribeiro
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoCentro de CardiologiaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Centro de Cardiologia,Ribeirão Preto, SP - Brasil
| | - José Paulo Pintyá
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDivisão de Medicina de Emergência do Departamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica,Ribeirão Preto, SP - Brasil
| | - André Schmidt
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoCentro de CardiologiaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Centro de Cardiologia,Ribeirão Preto, SP - Brasil
| | - Benedito Carlos Maciel
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoCentro de CardiologiaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Centro de Cardiologia,Ribeirão Preto, SP - Brasil
| | - José Antônio Marin
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoCentro de CardiologiaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Centro de Cardiologia,Ribeirão Preto, SP - Brasil
| | - Carlos Henrique Miranda
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDivisão de Medicina de Emergência do Departamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica,Ribeirão Preto, SP - Brasil
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Lemos ACB, do Espírito Santo DA, Miranda CH. Therapeutic anticoagulation in COVID-19 patients. Thromb Res 2021; 203:72-73. [PMID: 33964522 PMCID: PMC8091734 DOI: 10.1016/j.thromres.2021.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Anna Cristina Bertoldi Lemos
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000 Ribeirão Preto, São Paulo, Brazil
| | - Douglas Alexandre do Espírito Santo
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000 Ribeirão Preto, São Paulo, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000 Ribeirão Preto, São Paulo, Brazil.
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Espinoza JAL, Júnior JE, Miranda CH. Atypical COVID-19 presentation with Budd-Chiari syndrome leading to an outbreak in the emergency department. Am J Emerg Med 2021; 46:800.e5-800.e7. [PMID: 33573853 PMCID: PMC7849468 DOI: 10.1016/j.ajem.2021.01.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
We described a case report of a 50 years-old-woman admitted to the emergency department with abdominal pain associated with febrile hepatosplenomegaly with the final diagnosis of suprahepatic vein thrombosis secondary to COVID-19. Initially, this patient stayed out of a private room because of this atypical presentation and caused a COVID-19 outbreak in the emergency department.
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Affiliation(s)
- Javier Alejandro Lecca Espinoza
- Division of Medical Imaging, Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Jorge Elias Júnior
- Division of Medical Imaging, Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil.
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Soriano L, Santos MK, Wada DT, Vilalva K, Castro TT, Weinheimer O, Muglia VF, Pazin Filho A, Miranda CH. Pulmonary Vascular Volume Estimated by Automated Software is a Mortality Predictor after Acute Pulmonary Embolism. Arq Bras Cardiol 2020; 115:809-818. [PMID: 33295442 PMCID: PMC8452195 DOI: 10.36660/abc.20190392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
Fundamento: A embolia pulmonar aguda (EPA) tem desfecho clínico variável. A angiotomografia computadorizada (angio-CT) é considerada o padrão-ouro para o diagnóstico. Objetivo: Avaliar se o volume vascular pulmonar (VVP) quantificado por software automatizado é um preditor de mortalidade após EPA. Métodos: Estudo de coorte retrospectivo no qual a imagem da angio-CT de 61 pacientes com EPA foi reanalisada. O VVP e o volume pulmonar (VP) foram estimados automaticamente pelo software Yacta. Calculamos o VVP ajustado pela razão: VVP(cm3)/VP(litros). Parâmetros prognósticos clássicos da angio-CT (carga embólica; razão do diâmetro do ventrículo direito/ventrículo esquerdo; razão do diâmetro da artéria pulmonar/aorta; desvio do septo interventricular; infarto pulmonar e refluxo de contraste na veia hepática) foram avaliados. A mortalidade em 1 mês foi o desfecho analisado. Consideramos um valor de p <0,05 como estatisticamente significativo. Resultados: Sete mortes (11%) ocorreram entre os 61 pacientes durante 1 mês de seguimento. O VVP ajustado <23cm3/L foi um preditor independente de mortalidade na análise univariada (odds ratio [OR]: 26; intervalo de confiança de 95% [IC95%]: 3-244; p=0,004) e na análise multivariada (OR ajustado: 19 [IC95%: 1,3-270]; p=0,03). Os parâmetros clássicos da angio-CT não foram associados à mortalidade em 1 mês nesta amostra. O VVP ajustado <23cm3/L apresentou sensibilidade de 86%, especificidade de 82%, valor preditivo negativo de 94% e valor preditivo positivo de 64% para identificação dos pacientes que morreram. Conclusão: VVP ajustado <23cm3/L foi um preditor independente de mortalidade após EPA. Esse parâmetro mostrou melhor desempenho prognóstico do que os outros achados clássicos da angio-CT. (Arq Bras Cardiol. 2020; 115(5):809-818)
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Affiliation(s)
- Leonardo Soriano
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brasil
| | - Marcel Koenigkam Santos
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Radiologia do Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Ribeirão Preto, SP - Brasil
| | - Danilo Tadeu Wada
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Radiologia do Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Ribeirão Preto, SP - Brasil
| | - Kelvin Vilalva
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brasil
| | - Talita Tavares Castro
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brasil
| | - Oliver Weinheimer
- University Hospital Heidelberg - Department of Diagnostic and Interventional Radiology and Translational Lung Research Centre Heidelberg (TLRC) - German Lung Research Centre (DZL), Heidelberg - Alemanha
| | - Valdair Francisco Muglia
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Radiologia do Departamento de Imagens Médicas, Hematologia e Oncologia Clínica, Ribeirão Preto, SP - Brasil
| | - Antonio Pazin Filho
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brasil
| | - Carlos Henrique Miranda
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brasil
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Veras FP, Pontelli MC, Silva CM, Toller-Kawahisa JE, de Lima M, Nascimento DC, Schneider AH, Caetité D, Tavares LA, Paiva IM, Rosales R, Colón D, Martins R, Castro IA, Almeida GM, Lopes MIF, Benatti MN, Bonjorno LP, Giannini MC, Luppino-Assad R, Almeida SL, Vilar F, Santana R, Bollela VR, Auxiliadora-Martins M, Borges M, Miranda CH, Pazin-Filho A, da Silva LLP, Cunha LD, Zamboni DS, Dal-Pizzol F, Leiria LO, Siyuan L, Batah S, Fabro A, Mauad T, Dolhnikoff M, Duarte-Neto A, Saldiva P, Cunha TM, Alves-Filho JC, Arruda E, Louzada-Junior P, Oliveira RD, Cunha FQ. SARS-CoV-2-triggered neutrophil extracellular traps mediate COVID-19 pathology. J Exp Med 2020. [PMID: 32926098 DOI: 10.1101/2020.06.08.20125823] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Severe COVID-19 patients develop acute respiratory distress syndrome that may progress to cytokine storm syndrome, organ dysfunction, and death. Considering that neutrophil extracellular traps (NETs) have been described as important mediators of tissue damage in inflammatory diseases, we investigated whether NETs would be involved in COVID-19 pathophysiology. A cohort of 32 hospitalized patients with a confirmed diagnosis of COVID-19 and healthy controls were enrolled. The concentration of NETs was augmented in plasma, tracheal aspirate, and lung autopsies tissues from COVID-19 patients, and their neutrophils released higher levels of NETs. Notably, we found that viable SARS-CoV-2 can directly induce the release of NETs by healthy neutrophils. Mechanistically, NETs triggered by SARS-CoV-2 depend on angiotensin-converting enzyme 2, serine protease, virus replication, and PAD-4. Finally, NETs released by SARS-CoV-2-activated neutrophils promote lung epithelial cell death in vitro. These results unravel a possible detrimental role of NETs in the pathophysiology of COVID-19. Therefore, the inhibition of NETs represents a potential therapeutic target for COVID-19.
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Affiliation(s)
- Flavio Protasio Veras
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marjorie Cornejo Pontelli
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Camila Meirelles Silva
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Juliana E Toller-Kawahisa
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Mikhael de Lima
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Daniele Carvalho Nascimento
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ayda Henriques Schneider
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Diego Caetité
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Lucas Alves Tavares
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Isadora M Paiva
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Roberta Rosales
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - David Colón
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ronaldo Martins
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Italo Araujo Castro
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Glaucia M Almeida
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maria Isabel Fernandes Lopes
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maíra Nilson Benatti
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Letícia Pastorelli Bonjorno
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcela Cavichioli Giannini
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Luppino-Assad
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sérgio Luna Almeida
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernando Vilar
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Santana
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Valdes R Bollela
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maria Auxiliadora-Martins
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcos Borges
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carlos Henrique Miranda
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Antônio Pazin-Filho
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luis Lamberti P da Silva
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Larissa Dias Cunha
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Dario S Zamboni
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, Santa Catarina, Brazil
| | - Luiz O Leiria
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Li Siyuan
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sabrina Batah
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alexandre Fabro
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thais Mauad
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marisa Dolhnikoff
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Amaro Duarte-Neto
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Paulo Saldiva
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Thiago Mattar Cunha
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - José Carlos Alves-Filho
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Eurico Arruda
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Paulo Louzada-Junior
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Renê Donizeti Oliveira
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernando Queiroz Cunha
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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12
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Lemos ACB, do Espírito Santo DA, Salvetti MC, Gilio RN, Agra LB, Pazin-Filho A, Miranda CH. Therapeutic versus prophylactic anticoagulation for severe COVID-19: A randomized phase II clinical trial (HESACOVID). Thromb Res 2020; 196:359-366. [PMID: 32977137 PMCID: PMC7503069 DOI: 10.1016/j.thromres.2020.09.026] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) causes a hypercoagulable state. Several autopsy studies have found microthrombi in pulmonary circulation. METHODS In this randomized, open-label, phase II study, we randomized COVID-19 patients requiring mechanical ventilation to receive either therapeutic enoxaparin or the standard anticoagulant thromboprophylaxis. We evaluated the gas exchange over time through the ratio of partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FiO2) at baseline, 7, and 14 days after randomization, the time until successful liberation from mechanical ventilation, and the ventilator-free days. RESULTS Ten patients were assigned to the therapeutic enoxaparin and ten patients to prophylactic anticoagulation. There was a statistically significant increase in the PaO2/FiO2 ratio over time in the therapeutic group (163 [95% confidence interval - CI 133-193] at baseline, 209 [95% CI 171-247] after 7 days, and 261 [95% CI 230-293] after 14 days), p = 0.0004. In contrast, we did not observe this improvement over time in the prophylactic group (184 [95% CI 146-222] at baseline, 168 [95% CI 142-195] after 7 days, and 195 [95% CI 128-262] after 14 days), p = 0.487. Patients of the therapeutic group had a higher ratio of successful liberation from mechanical ventilation (hazard ratio: 4.0 [95% CI 1.035-15.053]), p = 0.031 and more ventilator-free days (15 days [interquartile range IQR 6-16] versus 0 days [IQR 0-11]), p = 0.028 when compared to the prophylactic group. CONCLUSION Therapeutic enoxaparin improves gas exchange and decreases the need for mechanical ventilation in severe COVID-19. TRIAL REGISTRATION REBEC RBR-949z6v.
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Affiliation(s)
- Anna Cristina Bertoldi Lemos
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Douglas Alexandre do Espírito Santo
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Maísa Cabetti Salvetti
- Hospital Estadual de Américo Brasiliense, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Renato Noffs Gilio
- Hospital Estadual de Américo Brasiliense, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Lucas Barbosa Agra
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Antonio Pazin-Filho
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, SP, Brazil.
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13
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Tritschler T, Mathieu ME, Skeith L, Rodger M, Middeldorp S, Brighton T, Sandset PM, Kahn SR, Angus DC, Blondon M, Bonten MJ, Cattaneo M, Cushman M, Derde LPG, DeSancho MT, Diehl JL, Goligher E, Jilma B, Jüni P, Lawler PR, Marietta M, Marshall JC, McArthur C, Miranda CH, Mirault T, Morici N, Perepu U, Schörgenhofer C, Sholzberg M, Spyropoulos AC, Webb SA, Zarychanski R, Zuily S, Le Gal G. Anticoagulant interventions in hospitalized patients with COVID-19: A scoping review of randomized controlled trials and call for international collaboration. J Thromb Haemost 2020; 18:2958-2967. [PMID: 32888372 PMCID: PMC9906402 DOI: 10.1111/jth.15094] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/06/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Coronavirus disease (COVID-19) is associated with a high incidence of thrombosis and mortality despite standard anticoagulant thromboprophylaxis. There is equipoise regarding the optimal dose of anticoagulant intervention in hospitalized patients with COVID-19 and consequently, immediate answers from high-quality randomized trials are needed. METHODS The World Health Organization's International Clinical Trials Registry Platform was searched on June 17, 2020 for randomized controlled trials comparing increased dose to standard dose anticoagulant interventions in hospitalized COVID-19 patients. Two authors independently screened the full records for eligibility and extracted data in duplicate. RESULTS A total of 20 trials were included in the review. All trials are open label, 5 trials use an adaptive design, 1 trial uses a factorial design, 2 trials combine multi-arm parallel group and factorial designs in flexible platform trials, and at least 15 trials have multiple study sites. With individual target sample sizes ranging from 30 to 3000 participants, the pooled sample size of all included trials is 12 568 participants. Two trials include only intensive care unit patients, and 10 trials base patient eligibility on elevated D-dimer levels. Therapeutic intensity anticoagulation is evaluated in 14 trials. All-cause mortality is part of the primary outcome in 14 trials. DISCUSSION Several trials evaluate different dose regimens of anticoagulant interventions in hospitalized patients with COVID-19. Because these trials compete for sites and study participants, a collaborative effort is needed to complete trials faster, conduct pooled analyses and bring effective interventions to patients more quickly.
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Affiliation(s)
- Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie-Eve Mathieu
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marc Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Timothy Brighton
- Department of Haematology, New South Wales Health Pathology Randwick, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Divisions of Internal Medicine and Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Derek C Angus
- University of Pittsburgh and UPMC Health System, Pittsburgh, PA, USA
| | - Marc Blondon
- Division of Angiology and Haemostasis, Faculty of Medicine and Geneva University Hospitals, Geneva, Switzerland
| | - Marc J Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marco Cattaneo
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Mary Cushman
- Departments of Medicine and Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jean-Luc Diehl
- Service de Médecine Intensive - Réanimation, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, Paris, France
| | - Ewan Goligher
- Interdivisional Department of Critical Care, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Ted Rogers Centre for Heart Research, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marco Marietta
- Dipartimento Oncologia ed Ematologia, Azienda Ospedaliero-Universitaria di Modena, Ospedale Policlinico, Modena, Italy
| | - John C Marshall
- Department of Critical Care Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Colin McArthur
- Auckland City Hospital, Intensive Care, Auckland, New Zealand
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, Brazil
| | - Tristan Mirault
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, Paris University, Paris, France
- PARCC, INSERM U970, Paris, France
- Hôpital Européen Georges-Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Usha Perepu
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Michelle Sholzberg
- St. Michael's Hospital and Departments of Medicine, and Laboratory Medicine and Pathobiology, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - Alex C Spyropoulos
- Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA
| | - Steve A Webb
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Zarychanski
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Cancer Care Manitoba, Research Institute of Oncology and Haematology, Winnipeg, MB, Canada
| | - Stéphane Zuily
- Vascular Medicine Division and Regional Competence Center for Marfan Syndrome, Inserm, DCAC and CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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14
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Veras FP, Pontelli MC, Silva CM, Toller-Kawahisa JE, de Lima M, Nascimento DC, Schneider AH, Caetité D, Tavares LA, Paiva IM, Rosales R, Colón D, Martins R, Castro IA, Almeida GM, Lopes MIF, Benatti MN, Bonjorno LP, Giannini MC, Luppino-Assad R, Almeida SL, Vilar F, Santana R, Bollela VR, Auxiliadora-Martins M, Borges M, Miranda CH, Pazin-Filho A, da Silva LLP, Cunha LD, Zamboni DS, Dal-Pizzol F, Leiria LO, Siyuan L, Batah S, Fabro A, Mauad T, Dolhnikoff M, Duarte-Neto A, Saldiva P, Cunha TM, Alves-Filho JC, Arruda E, Louzada-Junior P, Oliveira RD, Cunha FQ. SARS-CoV-2-triggered neutrophil extracellular traps mediate COVID-19 pathology. J Exp Med 2020; 217:152086. [PMID: 32926098 PMCID: PMC7488868 DOI: 10.1084/jem.20201129] [Citation(s) in RCA: 569] [Impact Index Per Article: 142.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/11/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
Severe COVID-19 patients develop acute respiratory distress syndrome that may progress to cytokine storm syndrome, organ dysfunction, and death. Considering that neutrophil extracellular traps (NETs) have been described as important mediators of tissue damage in inflammatory diseases, we investigated whether NETs would be involved in COVID-19 pathophysiology. A cohort of 32 hospitalized patients with a confirmed diagnosis of COVID-19 and healthy controls were enrolled. The concentration of NETs was augmented in plasma, tracheal aspirate, and lung autopsies tissues from COVID-19 patients, and their neutrophils released higher levels of NETs. Notably, we found that viable SARS-CoV-2 can directly induce the release of NETs by healthy neutrophils. Mechanistically, NETs triggered by SARS-CoV-2 depend on angiotensin-converting enzyme 2, serine protease, virus replication, and PAD-4. Finally, NETs released by SARS-CoV-2–activated neutrophils promote lung epithelial cell death in vitro. These results unravel a possible detrimental role of NETs in the pathophysiology of COVID-19. Therefore, the inhibition of NETs represents a potential therapeutic target for COVID-19.
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Affiliation(s)
- Flavio Protasio Veras
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marjorie Cornejo Pontelli
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Camila Meirelles Silva
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Juliana E Toller-Kawahisa
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Mikhael de Lima
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Daniele Carvalho Nascimento
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ayda Henriques Schneider
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Diego Caetité
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Lucas Alves Tavares
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Isadora M Paiva
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Roberta Rosales
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - David Colón
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ronaldo Martins
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Italo Araujo Castro
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Glaucia M Almeida
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maria Isabel Fernandes Lopes
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maíra Nilson Benatti
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Letícia Pastorelli Bonjorno
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcela Cavichioli Giannini
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Luppino-Assad
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sérgio Luna Almeida
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernando Vilar
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Santana
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Valdes R Bollela
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maria Auxiliadora-Martins
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcos Borges
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Carlos Henrique Miranda
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Antônio Pazin-Filho
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Luis Lamberti P da Silva
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Larissa Dias Cunha
- Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Dario S Zamboni
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciúma, Santa Catarina, Brazil
| | - Luiz O Leiria
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Li Siyuan
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sabrina Batah
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Alexandre Fabro
- Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thais Mauad
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marisa Dolhnikoff
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Amaro Duarte-Neto
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Paulo Saldiva
- Department Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Thiago Mattar Cunha
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - José Carlos Alves-Filho
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Eurico Arruda
- Virology Research Center, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Cell and Molecular Biology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Paulo Louzada-Junior
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Renê Donizeti Oliveira
- Divisions of Clinical Immunology, Emergency, Infectious Diseases and Intensive Care Unit, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fernando Queiroz Cunha
- Center of Research in Inflammatory Diseases, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Benatti MN, Fabro AT, Miranda CH. Endothelial glycocalyx shedding in the acute respiratory distress syndrome after flu syndrome. J Intensive Care 2020; 8:72. [PMID: 32974033 PMCID: PMC7503444 DOI: 10.1186/s40560-020-00488-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Scientific evidence indicates that endothelial glycocalyx (EG) shedding contributes to the pathophysiological installation of acute respiratory distress syndrome (ARDS) after bacterial sepsis. The aim was to evaluate the EG shedding in ARDS installation after flu syndrome. Methods This cross-sectional study included patients with flu syndrome during the influenza outbreak divided into two groups: patients with and without ARDS. Healthy subjects without flu syndrome were included in a control group. We measured EG damage biomarkers (hyaluronan, syndecan-1) and endothelial cell injury biomarker (soluble thrombomodulin) during the first medical evaluation. Histological assessment of the perimeter of the hyaline membrane and the number of neutrophils infiltrated in the alveolar septum was performed in patients who died. Results ARDS group had 30 patients (44 ± 16 years old, 57% men), the non-ARDS group had 36 patients (39 ± 17 years old, 42% men), and the control group had 35 individuals (44 ± 9 years old, 51% men). Hyaluronan levels were significantly higher in the ARDS group than the two groups [31 ng/ml (interquartile range-IQR 12–56) vs. 5 ng/ml (IQR 3–10) vs. 5 ng/ml (IQR 2–8); p < 0.0001]. Hyaluronan levels above 19 ng/ml in patients with flu syndrome were associated with a significant increase in 28-day mortality rate: relative risk (RR): 6.95; (95% confidence interval 1.88–25.67); p = 0.0017. A positive correlation was observed between hyaline membrane perimeter and soluble thrombomodulin levels (r = 0.89; p = 0.05) as well as between the number of neutrophils in the alveolar septum and hyaluronan levels (r = 0.89; p = 0.05). Conclusions Evidence of EG shedding was found in ARDS established after flu syndrome.
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Affiliation(s)
- Maira Nilson Benatti
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, São Paulo, 14020-670 Brazil
| | - Alexandre Todorovic Fabro
- Department of Pathology and Legal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Ribeirão Preto, São Paulo, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, São Paulo, 14020-670 Brazil
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Abstract
Several autopsy studies showed microthrombi in pulmonary circulation of severe COVID-19 patients. The major limitation of these investigations is that the autopsy provided static information. Some of these alterations could be secondary to the disseminated intravascular coagulation (DIC) observed as the final standard route to the multisystem organ failure exhibited in critically ill patients. We report preliminary results of an in vivo evaluation of sublingual microcirculation in thirteen patients with severe COVID-19 requiring mechanical ventilation. We observed multiple filling defects moving within the microvessels indicative of thrombi in most of the cases 11/13 (85%). This is the first imaging documentation of microvascular thrombosis in living severe COVID-19 patients since the beginning of the hospitalization. The clinical relevance of microvascular thrombosis in this disease requires further research.
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Affiliation(s)
- Douglas Alexandre do Espírito Santo
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil
| | - Anna Cristina Bertoldi Lemos
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil
| | - Carlos Henrique Miranda
- Division of Emergency Medicine, Department of Internal Medicine, Ribeirão Preto School of Medicine, São Paulo University, Rua Bernardino de Campos, 1000, Ribeirão Preto, SP, 14020-670, Brazil.
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Aimoli US, Miranda CH. Clinical Competence in ST-segment Elevation Myocardial Infarction Management by Recently Graduated Physicians Applying for a Medical Residency Program. Arq Bras Cardiol 2020; 114:35-44. [PMID: 32049168 PMCID: PMC7025295 DOI: 10.36660/abc.20180309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/20/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A significant reduction in the morbidity and mortality related to ST-segment elevation myocardial infarction (STEMI) has been achieved with the development of reperfusion therapies. Early diagnosis and correct initial management are important to ensure this benefit. In Brazil, recent graduates in medicine are responsible for a large part of the initial care provided for these patients. OBJECTIVE To assess the clinical competence in the diagnosis and initial treatment of STEMI by newly graduated physicians applying for a medical residency program. METHODS We assessed the performance of 771 applicants for the direct entry selection process of the FMRP-USP Clinical Hospital Medicine Residency Program, performed in a simulated setting of STEMI, with professional actors and medical evaluators, using a standardized checklist following the recommendations of the Brazilian Guidelines for the management of this disease. RESULTS The general performance score presented a median of 7 and an interquartile range of 5.5-8.0. In relation to the items assessed: 83% required ECG monitoring, 57% requested the insertion of a peripheral venous access catheter, 95% administered acetylsalicylic acid, 80% administered a second antiplatelet agent (p2y12 inhibitor), 66% administered nitrate, 71% administered morphine, 69% recognized the diagnosis of STEMI, 71% assessed the pain duration, 63% recognized the need for immediate transfer, 34% showed adequate communication skills and only 25% insisted on the transfer even in case of non-availability of beds. CONCLUSIONS The initial diagnosis and management of STEMI need to be improved in medical undergraduate courses and inserted into the reality of the hierarchical network structure of the Brazilian Unified Health System (SUS).
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Affiliation(s)
- Ugo Stocco Aimoli
- Universidade de São Paulo - Campus de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brazil
| | - Carlos Henrique Miranda
- Universidade de São Paulo - Campus de Ribeirão Preto - Divisão de Medicina de Emergência do Departamento de Clínica Médica, Ribeirão Preto, SP - Brazil
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Montenegro SMSL, Miranda CH. Evaluation of the performance of the modified early warning score in a Brazilian public hospital. Rev Bras Enferm 2019; 72:1428-1434. [DOI: 10.1590/0034-7167-2017-0537] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/22/2017] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To evaluate the performance of the modified early warning score (Mews) in a nursing ward for patients in clinical deterioration. Method: This is an analytical, quantitative and predictive study. Mews’ parameters (systolic blood pressure, heart rate, respiratory rate, temperature and level of consciousness) were evaluated every six hours. The following events were reported: death, cardiopulmonary arrest and transfer to intensive care. The evaluations were performed in a hospital of reference in the state of São Paulo, Brazil. Results: A total of 300 patients were included (57 ± 18 years old, males: 65%). There number of combined events was observed to be greater the higher the score’s value (00%; 00%; 01; 09%; 19%; 28%; 89%, respectively, for Mews 0; 1; 2; 3; 4; 5 and 6; p < 0.0001). Mews ≥ 4 was the most appropriate cut-off point for prediction of these events (sensitivity: 87%, specificity: 85% and accuracy: 0.86). Conclusion: Mews properly measured the occurrence of severe events in hospitalized patients of a Brazilian public hospital’s nursing ward. Mews ≥ 4 seems to be the most appropriate cut-off point for prediction of these events.
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Soriano LDA, Castro TT, Vilalva K, Borges MDC, Pazin-Filho A, Miranda CH. Validation of the Pulmonary Embolism Severity Index for risk stratification after acute pulmonary embolism in a cohort of patients in Brazil. J Bras Pneumol 2019; 45:e20170251. [PMID: 30810642 PMCID: PMC6534413 DOI: 10.1590/1806-3713/e20170251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/12/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. METHODS This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. RESULTS We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). CONCLUSIONS The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.
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Affiliation(s)
- Leonardo de Araujo Soriano
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Talita Tavares Castro
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Kelvin Vilalva
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcos de Carvalho Borges
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Antonio Pazin-Filho
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Carlos Henrique Miranda
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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Miranda CH. Use of thrombolytic agents in the treatment of acute pulmonary thromboembolism: things are not as simple as you might thinkReflections on the use of thrombolytic agents in acute pulmonary embolismReperfusion in acute pulmonary thromboembolismFibrinolysis for patients with intermediate-risk pulmonary embolismImpact of Thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism. ACTA ACUST UNITED AC 2019; 45:e20180297. [PMID: 30758431 PMCID: PMC6534414 DOI: 10.1590/1806-3713/e20180297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Carlos Henrique Miranda
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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Magalhães PKR, Miranda CH, Vilar FC, Schmidt A, Bittar RR, Paixão GACDC, Martinez EZ, Maciel LMZ. Effects of drying and storage conditions on the stability of TSH in blood spots. Arch Endocrinol Metab 2018; 62:201-204. [PMID: 29641739 PMCID: PMC10118981 DOI: 10.20945/2359-3997000000026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/25/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the influence of sample drying and storage temperature on TSH stability in neonatal screening. SUBJECTS AND METHODS Blood samples from 29 adult volunteers as a surrogate for neonatal blood (10 with normal TSH, 9 with overt hypothyroid and 10 with subclinical hypothyroidism) were spotted on filter paper and dried at 22°C or 35°C for 3 hours. The samples were then stored at 22°C, -4°C, or -20°C, and TSH measurements were performed at day 0 (D0), D7, D30, D60, D180, and D360 of storage. RESULTS The drying temperature did not interfere with TSH measurement on D0. TSH values remained stable up to D30 when stored at 22°C and were stable up to D60 when stored in a refrigerator or freezer. Samples stored at 22°C had a greater decrease in TSH values than samples stored in a refrigerator or a freezer. CONCLUSIONS Freezer storage is not advantageous compared to storage in the refrigerator. At the end of one year, if confirmation of the initial result is required, a reduction of TSH concentrations should be taken into account.
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Affiliation(s)
- Patrícia Künzle Ribeiro Magalhães
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - Carlos Henrique Miranda
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - Fernando Crivelenti Vilar
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - André Schmidt
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - Roberta Rodrigues Bittar
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | | | - Edson Zangiacomi Martinez
- Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - Léa Maria Zanini Maciel
- Divisão de Endocrinologia, Departamento de Medicina Interna, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
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Gadioli LP, Miranda CH, Pintya AO, de Figueiredo AB, Schmidt A, Maciel BC, Marin-Neto JA, Simões MV. The severity of ventricular arrhythmia correlates with the extent of myocardial sympathetic denervation, but not with myocardial fibrosis extent in chronic Chagas cardiomyopathy : Chagas disease, denervation and arrhythmia. J Nucl Cardiol 2018; 25:75-83. [PMID: 27381340 DOI: 10.1007/s12350-016-0556-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/28/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND To investigate the correlation between the extent of myocardial sympathetic denervation and fibrosis and the presence of degrees of severity of ventricular arrhythmias in chronic Chagas cardiomyopathy (CCC). METHODS Forty-three CCC patients with left ventricular ejection fraction (LVEF) ≥ 35% were divided into three groups: SVT group-presenting Sustained Ventricular Tachycardia (SVT) (n = 15), NSVT group-exhibiting episodes of non-SVT (NSVT) on 24-h Holter monitoring (n = 11), and Control group-exhibiting neither SVT nor episodes of NSVT (n = 17). The patients underwent SPECT imaging for myocardial sympathetic innervation with 123Iodine-MIBG (MIBG) and myocardial perfusion with 99mTc-Sestamibi (MIBI) for the evaluation of regional myocardial fibrosis. RESULTS The summed rest perfusion scores were similar in the three groups. The summed difference score between MIBG and MPI images, which evaluated the extent of denervated but viable myocardium, was significantly higher in SVT group (20.0 ± 8.0) as compared with the control group (2.0 ± 5.0, P < .0001) and with the NSVT group (11.0 ± 8.0, P < .05). CONCLUSIONS The occurrence of ventricular arrhythmias of different degrees of severity correlates quantitatively with the extent of cardiac sympathetic denervation, but not with the extent of fibrosis, suggesting that myocardial sympathetic denervation plays a major role in triggering ventricular arrhythmia in CCC.
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Affiliation(s)
- Leonardo Pippa Gadioli
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Carlos Henrique Miranda
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Antonio Osvaldo Pintya
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - André Schmidt
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Benedito Carlos Maciel
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - José Antonio Marin-Neto
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Marcus Vinicius Simões
- Division of Cardiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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Miranda CH, de Carvalho Borges M, Schmidt A, Marin-Neto JA, Pazin-Filho A. Evaluation of the endothelial glycocalyx damage in patients with acute coronary syndrome. Atherosclerosis 2016; 247:184-8. [DOI: 10.1016/j.atherosclerosis.2016.02.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 02/12/2016] [Accepted: 02/17/2016] [Indexed: 11/16/2022]
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CR Franchi AC, Filho AP, Bottura C, Miranda CH, Ferreira FB, de C Borges M, de C Santana R, Okino VT. Could saline instillation displace bacteria from the endotracheal tube biofilm to lower airways during suctioning procedure? Crit Care 2015. [PMCID: PMC4601785 DOI: 10.1186/cc14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Miranda CH, Braggion-Santos MF, Schmidt A, Filho AP, Cupo P. Evolution of the electrocardiogram QRS complexes voltage in scorpion envenomation–induced Takotsubo syndrome. Am J Emerg Med 2015; 33:837-8. [DOI: 10.1016/j.ajem.2015.02.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/21/2015] [Indexed: 01/14/2023] Open
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Miranda CH, Gerolim GP, Gali AMS, Pazin-Filho A. Diagnostic Accuracy of the P Wave in the Lewis and Gallop Leads for Atrial Enlargement Detection. International Journal of Cardiovascular Sciences 2015. [DOI: 10.5935/2359-4802.20150061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gonzalez MM, Timerman S, Gianotto-Oliveira R, Polastri TF, Canesin MF, Schimidt A, Siqueira AW, Pispico A, Longo A, Pieri A, Reis A, Tanaka ACS, Santos AM, Quilici AP, Ribeiro ACL, Barreto ACP, Pazin-Filho A, Timerman A, Machado CA, Franchin Neto C, Miranda CH, Medeiros CR, Malaque CMS, Bernoche C, Gonçalves DM, Sant'Ana DG, Osawa EA, Peixoto E, Arfelli E, Evaristo EF, Azeka E, Gomes EP, Wen FH, Ferreira FG, Lima FG, Mattos FR, Galas FG, Marques FRB, Tarasoutchi F, Mancuso FJN, Freitas GR, Feitosa-Filho GS, Barbosa GC, Giovanini GR, Miotto HC, Guimarães HP, Andrade JP, Oliveira-Filho J, Fernandes JG, Moraes Junior JBMX, Carvalho JJF, Ramires JAF, Cavalini JF, Teles JMM, Lopes JL, Lopes LNGD, Piegas LS, Hajjar LA, Brunório L, Dallan LAP, Cardoso LF, Rabelo MMN, Almeida MFB, Souza MFS, Favarato MH, Pavão MLRC, Shimoda MS, Oliveira Junior MT, Miura N, Filgueiras Filho NM, Pontes-Neto OM, Pinheiro PAPC, Farsky OS, Lopes RD, Silva RCG, Kalil Filho R, Gonçalves RM, Gagliardi RJ, Guinsburg R, Lisak S, Araújo S, Martins SCO, Lage SG, Franchi SM, Shimoda T, Accorsi TD, Barral TCN, Machado TAO, Scudeler TL, Lima VC, Guimarães VA, Sallai VS, Xavier WS, Nazima W, Sako YK. [First guidelines of the Brazilian Society of Cardiology on Cardiopulmonary Resuscitation and Cardiovascular Emergency Care]. Arq Bras Cardiol 2014; 101:1-221. [PMID: 24030145 DOI: 10.5935/abc.2013s006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Miranda CH, Borges MDC, Schmidt A, Pazin-Filho A, Rossi MA, Ramos SG, Lopes da Fonseca BA. A case presentation of a fatal dengue myocarditis showing evidence for dengue virus-induced lesion. Eur Heart J Acute Cardiovasc Care 2014; 2:127-30. [PMID: 24222821 DOI: 10.1177/2048872613475889] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 01/06/2013] [Indexed: 12/19/2022]
Abstract
Dengue is a prevalent arthropod-borne viral disease in tropical and subtropical areas of the globe. Dengue clinical manifestations include asymptomatic infections; undifferentiated fever; dengue fever, which is characterized by fever, headache, retroorbital pain, myalgia, and arthralgia; and a severe form of the disease denominated dengue haemorrhagic fever/dengue shock syndrome, characterized by haemoconcentration, thrombocytopenia, and bleeding tendency. However, atypical manifestations, such as liver, central nervous system, and cardiac involvement, have been increasingly reported. We report an atypical and rare presentation of dengue disease marked by a dramatic and fatal cardiogenic shock due to acute myocarditis. Histopathological analysis of heart tissue showed several multifocal areas of muscle necrosis and intense interstitial oedema associated with clusters of virus particles inside the cardiomyocytes and in the interstitial space, providing evidence of a possible direct action of dengue virus on myocardium.
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Miranda CH, Borges MDC, Matsuno AK, Vilar FC, Gali LG, Volpe GJ, Schmidt A, Pazin-Filho A, Silva FMFD, Castro-Jorge LAD, Oliveira MFD, Saggioro F, Martines RB, Fonseca BALD. Evaluation of cardiac involvement during dengue viral infection. Clin Infect Dis 2013; 57:812-9. [PMID: 23784923 DOI: 10.1093/cid/cit403] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Dengue is a disease whose clinical manifestations range from asymptomatic infections to a severe disease. There have been some previous reports of myocardial involvement in dengue, but this association has not been completely established. METHODS From January to July of 2011, patients hospitalized with dengue, confirmed through dengue nonstructural protein 1 and/or immunoglobulin M detection, were included in this study and troponin I and N terminal fragment of B-type natriuretic peptide levels were determined. Patients with abnormal biomarkers underwent echocardiography and when any abnormality was detected, they underwent cardiac magnetic resonance imaging. RESULTS Eighty-one patients were evaluated and 12 patients (15%) presented with elevated biomarker levels. Compared to controls, they had higher leukocyte (P < .001) and platelet counts (P = .005); higher C-reactive protein (P = .02), and a lower viral load (P = .03). There was no difference according to clinical dengue classification; dengue hemorrhagic fever/dengue shock syndrome severity; duration of symptoms; or prevalence of secondary infection between the 2 groups. Two patients died secondary to cardiogenic shock before imaging studies. Necroscopic findings were compatible to myocarditis in both, and immunohistochemistry for dengue virus showed increased staining on mononuclear cells located in the myocardial tissue. Of the 10 patients who underwent echocardiography, depressed left ventricular ejection fraction (LVEF) was identified in 1, left ventricular segmental abnormalities with preserved LVEF in 2, and an important pericardial effusion with tamponade in another. Cardiac involvement was confirmed by CMR in these 4 patients. CONCLUSIONS Dengue viruses were shown to cause cardiac disease with clinical manifestations ranging from mild elevation of biomarkers to myocarditis and/or pericarditis.
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Affiliation(s)
- Carlos Henrique Miranda
- Department of Internal Medicine, University of São Paulo Medical School at Ribeirão Preto, São Paulo, Brazil
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Miranda CH, Gali LG, Marin-Neto JA, Louzada-Júnior P, Pazin-Filho A. Coronary thrombosis as the first complication of antiphospholipid syndrome. Arq Bras Cardiol 2012; 98:e66-9. [PMID: 22735914 DOI: 10.1590/s0066-782x2012000400014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Accepted: 07/04/2011] [Indexed: 11/22/2022] Open
Abstract
The antiphospholipid syndrome (APS) is an autoimmune thrombophilia, characterized by the presence of plasma antibodies against phospholipids, associated with recurrent episodes of venous and/or arterial thrombosis and gestational morbidity (especially recurrent miscarriage). We report the case of a young female patient diagnosed with systemic lupus erythematosus (SLE) associated with the presence of antiphospholipid antibodies for a long time, presenting with acute myocardial infarction (AMI) due to proximal thrombosis of the anterior descending artery as the first clinical complication of APS.
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Affiliation(s)
- Carlos Henrique Miranda
- Unidade Coronariana da Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
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Miranda CH, Xavier L, Fiorante F, Misiara GP, Guimarães EG, Galli AM, Pazin-Filho A, de Carvalho Borges M. Cardiac Rhythm Disturbances Associated with Amlodipine Acute Intoxication. Cardiovasc Toxicol 2012; 12:359-62. [DOI: 10.1007/s12012-012-9176-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ribeiro KB, Miranda CH, Andrade JM, Galli LG, Tiezzi DG, Oliveira HF, Zola FE, Volpe G, Pazin-Filho A, Peria FM. Trastuzumab-induced myocardiotoxicity mimicking acute coronary syndrome. Case Rep Oncol 2012; 5:125-33. [PMID: 22666200 PMCID: PMC3364043 DOI: 10.1159/000337576] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Trastuzumab is an important biological agent in the treatment of HER2-positive breast cancer, with effects on response rates, progression-free survival, overall survival and quality of life. Although this drug is well tolerated in terms of adverse effects, trastuzumab-associated myocardiotoxicity has been described to have an incidence of 0.6–4.5% and in rare cases, the drug can trigger severe congestive heart failure with progression to death or even mimic acute coronary syndrome with complete left bundle branch blockade. In this paper is reported a case of trastuzumab-associated myocardiotoxicity manifesting as acute coronary syndrome in a 69-year-old female. The patient is currently undergoing a conservative clinical treatment that restricts overexertion. The majority of clinical studies report trastuzumab-induced cardiotoxicity as a rare event, and, when present, characterized by mild to moderate clinical signs, the ease of reversibility with pharmacological measures and the temporary discontinuation of the medication. Conversely, it is vital for the oncologist/cardiologist to consider the possibility that trastuzumab-induced cardiotoxicity may manifest itself as a severe clinical case, mimicking acute coronary syndrome, justifying careful risk stratification and adequate cardiac monitoring, especially in high-risk patients.
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Affiliation(s)
- K B Ribeiro
- Clinical Oncology Division, University of São Paulo - FMRP-USP, São Paulo, Brazil
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Mott AR, Fraser CD, McKenzie ED, Bezold LI, Andropoulos DB, Reul GJ, Miranda CH, Bedford SL, Feltes TF. Perioperative care of the adult with congenital heart disease in a free-standing tertiary pediatric facility. Pediatr Cardiol 2002; 23:624-30. [PMID: 12530496 DOI: 10.1007/s00246-002-0236-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adult patients with congenital heart disease are presenting more frequently for cardiac surgery. Frequently, pediatric congenital heart surgeons perform these procedures at pediatric hospitals. Between July 1995 and June 2000, a retrospective review of adult patients (> or = 18 years old) who had undergone cardiothoracic operations was performed. A total of 112 operations were performed and divided into two groups--81 cardiac operations in 79 patients and 31 noncardiac operations in 23 patients. One patient had a cardiac and noncardiac operation performed. The overall early operative mortality was 6% (6/101). There were 3 late deaths. New-onset cardiac arrhythmias requiring treatment were diagnosed after 5/81 (6%) cardiac operations. Six of 79 (7%) patients were diagnosed with postoperative clinical depression. An acceptable mortality can be achieved when adult patients undergo cardiothoracic operations at a pediatric facility. New-onset arrhythmias necessitating treatment are relatively common, and postoperative clinical depression should be anticipated.
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Affiliation(s)
- A R Mott
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
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Venzor J, Hua Q, Bressler RB, Miranda CH, Huston DP. Behçet's-like syndrome associated with idiopathic CD4+ T-lymphocytopenia, opportunistic infections, and a large population of TCR alpha beta+ CD4- CD8- T cells. Am J Med Sci 1997; 313:236-8. [PMID: 9099154 DOI: 10.1097/00000441-199704000-00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Herein we report a patient with Behçet's like syndrome, idiopathic CD4+ T-lymphocytopenia, opportunistic infections, and a large polyclonal population of TCR alpha beta + CD4- CD8- T cells. Microfluorimetric analysis of peripheral blood mononuclear cells revealed CD4+ T-cell counts of 10 +/- 5/mm3. The CD3+ T cells were 99% TCR alpha beta +, of which 74 +/- 5% were CD4- CD8-. No clonal populations were detected by southern analysis for T-cell receptor V beta gene rearrangements. No evidence of human immunodeficiency virus infection was present, although nocardia, candida, pneumocystis, cytomegalovirus, and herpes infections were documented. The concomitant presence of opportunistic infections and a large population of TCR alpha beta + CD4- CD8- T cells suggests a pathogenic association and an intense immune response to microbial lipid or lipoglycan antigens presented in the context of CD1 molecules. This case demonstrates the potential for idiopathic CD4+ T-lymphocytopenia to occur in Behçet's-like syndrome with lethal consequences.
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Affiliation(s)
- J Venzor
- Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
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