Thrombotic Events and Anticoagulation-Related Bleeding Complications in Critically Ill Patients with Coronavirus Disease 2019

Background: Thrombosis (T) is common in coronavirus disease 2019 (COVID-19) patients, and d-dimer concentrations correlate with outcomes. Controversy exists with regards to anticoagulation (AC) for patients. We implemented a full-heparinization AC protocol from the onset of the pandemic and hypothesized that a safety signal would be undetectable. Patients and Methods: Prospective evaluation of 111 patients with COVID-19 critical illness hospitalized from March to June 2020. All patients received therapeutic heparinoid-based AC from admission. Incidences of T, bleeding (B), or both (BT) were noted. The primary outcome was mortality. Kruskal-Wallis test and logistic regression were performed. Results are expressed as n (%), median (interquartile range) and odds ratios with 95% confidence intervals. Alpha was set at 0.05. Results: Thirty-two patients (28%) had T, 23 (20%) had B, and 14 (12%) had BT; 42 (40%) patients were unaffected. Two logistic regression models (outcome = mortality) evaluated BT as T, or BT as B. For BT as T, neither T, B, nor male gender predicted mortality; similarly, for BT as B, neither T, B, nor male gender predicted mortality. Factors associated with higher odds of death included higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.00-1.13; p = 0.0045), higher d-dimer concentration (OR, 1.00; 95% CI, 1.00-1.01; p = 0.043), and higher activated partial thromboplastin time (aPTT; OR, 1.09; 95% CI, 1.02-1.16; p = 0.010). Conclusions: Neither T nor B predicted mortality in this prospective cohort of anticoagulated patients with COVID-19 critical illness. These data support continued full-dose heparinoid prophylaxis.

Self-selection vs Randomized Assignment of Treatment for Appendicitis

Importance

For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ.

Objective

To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment.

Design, Setting, and Participants

The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy.

Interventions

Appendectomy vs antibiotics.

Main Outcomes and Measures

Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment.

Results

Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup.

Conclusions and Relevance

This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large.

Trial Registration

ClinicalTrials.gov Identifier: NCT02800785.

World trauma education: hemorrhage control training for healthcare providers in India

Background

Hemorrhage remains a major cause of death around the world. Eighty percent of trauma patients in India do not receive medical care within the first hour. The etiology of these poor outcomes is multifactorial. We describe findings from the first Stop the Bleed (StB) course recently offered to a group of medical providers in southern India.

Methods

A cross-sectional survey of 101 participants who attended StB trainings in India was performed. Pre-training and post-training questionnaires were collected from each participant. In total, 88 healthcare providers’ responses were analyzed. Three bleeding control skills were presented: wound compression, wound packing, and tourniquet application.

Results

Among participants, only 23.9% had received prior bleeding control training. Participants who reported feeling ‘extremely confident’ responding to an emergency medical situation rose from 68.2% prior to StB training to 94.3% post-training. Regarding hemorrhage control abilities, 37.5% felt extremely confident before the training, compared with 95.5% after the training. For wound packing and tourniquet application, 44.3% and 53.4%, respectively, felt extremely confident pre-training, followed by 97.7% for both skills post-training. Importantly, 90.9% of StB trainees felt comfortable teaching newly acquired hemorrhage control skills. A significant majority of participants said that confidence in their wound packing and tourniquet skills would improve with more realistic mannequins.

Conclusion

To our knowledge, this is the first StB training in India. Disparities in access to care, long transport times, and insufficient numbers of prehospital personnel contribute to its significant trauma burden. Dissemination of these critical life-saving skills into this region and the resulting civilian interventions will increase the number of trauma patients who survive long enough to reach a trauma center. Additionally, considerations should be given to translating the course into local languages to increase program reach.

Level of Evidence

Level IV.

Association Between Insurance Status and Hospital Length of Stay Following Trauma

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.

Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma

BACKGROUND

Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown.

STUDY DESIGN

This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities--home, home health, rehabilitation, or nursing facility--by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others.

RESULTS

There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts.

CONCLUSIONS

Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs

BACKGROUND

Pedestrian trauma is the most lethal blunt trauma mechanism, and the rate of mortality in African Americans and Hispanics is twice that compared with whites. Whether insurance status and differential survival contribute to this disparity is unknown.

METHODS

This study is a review of vehicle-struck pedestrians in the National Trauma Data Bank, v7.0. Patients <16 years and > or =65 years, as well as patients with Injury Severity Score (ISS) <9, were excluded. Patients were categorized as white, African American, or Hispanic, and as privately insured, government insured, or uninsured. With white and privately insured patients as reference, logistic regression was used to evaluate mortality by race and insurance status after adjusting for patient and injury characteristics.

RESULTS

In all, 26,404 patients met inclusion criteria. On logistic regression, African Americans had 22% greater odds of mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06-1.41) and Hispanics had 33% greater odds of mortality (OR, 1.33; 95% CI, 1.14-1.54) compared with whites. Uninsured patients had 77% greater odds of mortality (OR, 1.77; 95% CI, 1.52-2.06) compared with privately insured patients.

CONCLUSION

African American and Hispanic race, as well as uninsured status, increase the risk of mortality after pedestrian crashes. Given the greater incidence of pedestrian crashes in minorities, this compounded burden of injury mandates pedestrian trauma prevention efforts in inner cities to decrease health disparities.

Validating the Injury Severity Score (ISS) in different populations: ISS predicts mortality better among Hispanics and females

INTRODUCTION

The Injury Severity Score (ISS) is the most commonly used measure of injury severity. The score has been shown to have excellent predictive capability for trauma mortality and has been validated in multiple data sets. However, the score has never been tested to see if its discriminatory ability is affected by differences in race and gender.

OBJECTIVE

This study is aimed at validating the ISS in men and women and in three different race/ethnic groups using a nationwide database.

METHODS

Retrospective analysis of patients age 18-64 y in the National Trauma Data Bank 7.0 with blunt trauma was performed. ISS was categorized as mild (<9,) moderate (9-15), severe (16-25), and profound (>25). Logistic regression was done to measure the relative odds of mortality associated with a change in ISS categories. The discriminatory ability was compared using the receiver operating characteristics curves (ROC). A P value testing the equality of the ROC curves was calculated. Age stratified analyses were also conducted.

RESULTS

A total of 872,102 patients had complete data for the analysis on ethnicity, while 763,549 patients were included in the gender analysis. The overall mortality rate was 3.7%. ROC in Whites was 0.8617, in Blacks 0.8586, and in Hispanics 0.8869. Hispanics have a statistically significant higher ROC (P value < 0.001). Similar results were observed within each age category. ROC curves were also significantly higher in females than in males.

CONCLUSION

The ISS possesses excellent discriminatory ability in all populations as indicated by the high ROCs.

Frequency of CCR5 delta-32 mutation in human immunodeficiency virus (HIV)-seropositive and HIV-exposed seronegative individuals and in general population of Medellin, Colombia

Repeated exposure to human immunodeficiency virus (HIV) does not always result in seroconversion. Modifications in coreceptors for HIV entrance to target cells are one of the factors that block the infection. We studied the frequency of Delta-32 mutation in ccr5 gene in Medellin, Colombia. Two hundred and eighteen individuals distributed in three different groups were analyzed for Delta-32 mutation in ccr5 gene by polymerase chain reaction (PCR): 29 HIV seropositive (SP), 39 exposed seronegative (ESN) and 150 individuals as a general population sample (GPS). The frequency of the Delta-32 mutant allele was 3.8% for ESN, 2.7% for GPS and 1.7% for SP. Only one homozygous mutant genotype (Delta-32/Delta-32) was found among the ESN (2.6%). The heterozygous genotype (ccr5/Delta-32) was found in eight GPS (5.3%), in one SP (3.4%) and in one ESN (2.6%). The differences in the allelic and genotypic frequencies among the three groups were not statistically significant. A comparison between the expected and the observed genotypic frequencies showed that these frequencies were significantly different for the ESN group, which indirectly suggests a protective effect of the mutant genotype (Delta-32/Delta-32). Since this mutant genotype explained the resistance of infection in only one of our ESN persons, different mechanisms of protection must be playing a more important role in this population.

Myc-epitope tagged proteins detected with the 9E10 antibody in immunofluorescence and immunoprecipitation assays but not in western blot analysis

A human Myc epitope is frequently used to tag proteins for expression experiments in nonhuman cells. We used the monoclonal 9E10 antibody specific for this epitope to analyse the expression of four proteins carrying the Myc tag in cells transfected with expression vectors. While all four proteins can be detected by immunofluorescence and immunoprecipitation assays, surprisingly, only two proteins could be detected in Western blot analysis, indicating that epitope recognition by the monoclonal antibody can be blocked in some membrane-retained ectopic proteins. Other techniques such as immunofluorescence and immunoprecipitation assays can be successfully used with the 9E10 antibody to determine potential expression of Myc-tagged proteins.

The mammalian ribonucleotide reductase R2 component cooperates with a variety of oncogenes in mechanisms of cellular transformation

Ribonucleotide reductase, which is composed of the two protein components R1 and R2, is a highly regulated enzyme activity that is essential for DNA synthesis and repair. Recent studies have shown that elevated expression of the rate-limiting R2 component increases Raf-1 protein activation and mitogen-activated protein kinase activity and acts as a novel malignancy determinant in cooperation with H-ras and rac-1. We show that R2 cooperation in cellular transformation extends to a variety of oncogenes with different functions and cellular locations. Anchorage-independent growth of cells transformed with v-fms, v-src, A-raf, v-fes, c-myc, and ornithine decarboxylase was markedly enhanced when the R2 component of ribonucleotide reductase was overexpressed. In addition, we observed that elevated R2 expression conferred on c-myc-transformed NIH 3T3 cells an increased tumorigenic potential in immunoincompetent mice. Taken together, these observations demonstrate that the R2 protein is not only a rate-limiting component for ribonucleotide reduction but that it is also capable of acting in cooperation with a variety of oncogenes to determine transformation and tumorigenic potential.

The R1 component of mammalian ribonucleotide reductase has malignancy-suppressing activity as demonstrated by gene transfer experiments

Our recent studies have shown that deregulated expression of R2, the rate-limiting component of ribonucleotide reductase, enhances transformation and malignant potential by cooperating with activated oncogenes. We now demonstrate that the R1 component of ribonucleotide reductase has tumor-suppressing activity. Stable expression of a biologically active ectopic R1 in ras-transformed mouse fibroblast 10T(1/2) cell lines, with or without R2 overexpression, led to significantly reduced colony-forming efficiency in soft agar. The decreased anchorage independence was accompanied by markedly suppressed malignant potential in vivo. In three ras-transformed cell lines, R1 overexpression resulted in abrogation or marked suppression of tumorigenicity. In addition, the ability to form lung metastases by cells overexpressing R1 was reduced by >85%. Metastasis suppressing activity also was observed in the highly malignant mouse 10T(1/2) derived RMP-6 cell line, which was transformed by a combination of oncogenic ras, myc, and mutant p53. Furthermore, in support of the above observations with the R1 overexpressing cells, NIH 3T3 cells cotransfected with an R1 antisense sequence and oncogenic ras showed significantly increased anchorage independence as compared with control ras-transfected cells. Finally, characteristics of reduced malignant potential also were demonstrated with R1 overexpressing human colon carcinoma cells. Taken together, these results indicate that the two components of ribonucleotide reductase both are unique malignancy determinants playing opposing roles in its regulation, that there is a novel control point important in mechanisms of malignancy, which involves a balance in the levels of R1 and R2 expression, and that alterations in this balance can significantly modify transformation, tumorigenicity, and metastatic potential.

Ribonucleotide reductase R2 component is a novel malignancy determinant that cooperates with activated oncogenes to determine transformation and malignant potential

Ribonucleotide reductase is a highly regulated cell cycle-controlled activity that is essential for DNA synthesis and repair. A retroviral vector for the R2 component of mammalian ribonucleotide reductase, the rate-limiting protein for enzyme activity and DNA synthesis in proliferating cells, was constructed and introduced into mammalian cells. Expression of Myc epitope-tagged R2 protein in benign BALB/c 3T3 and NIH 3T3 cells leads to a greatly increased frequency of focus formation in cooperation with H-ras transformation. Four lines of H-ras-transformed mouse 10T1/2 fibroblasts showed increased growth efficiency in soft agar after infection with the recombinant R2 expression virus vector. Furthermore, cells with altered R2 expression also exhibited significantly reduced subcutaneous tumor latency and increased tumor growth rates in syngeneic mice, and showed markedly elevated metastatic potential in lung metastasis assays. The results indicate that altered R2 gene expression cooperates with ras in mechanisms of malignant progression. A major Ras pathway involves the Raf-1 protein, which is recruited to the plasma membrane for activation. We show that recombinant R2 expression leads to significant increases in membrane-associated Raf-1 protein and mitogenactivating protein kinase-2 activity suggesting a mechanism for the observed Ras/R2 synergism. In support of this finding, we observed that activated Rac-1, which operates parallel to Raf-1 and cooperates with Raf-1 in Ras activated pathways, also cooperates with R2 in cellular transformation. These studies demonstrate that the R2 protein can participate in other critical cellular functions in addition to ribonucleotide reduction, and that deregulated R2 is a novel tumor progressor determinant that cooperates in oncogene-mediated mechanisms, which control malignant potential.

Suppression of malignancy by the 3' untranslated regions of ribonucleotide reductase R1 and R2 messenger RNAs

Mammalian ribonucleotide reductase is rate limiting for the synthesis of DNA. The active enzyme is composed of two dissimilar components called R1 and R2, encoded by different genes. The 3' untranslated regions (3' UTRs) of R1 and R2 messages contain sequences that are important in regulating gene expression through changes in message stability. We have constructed expression plasmids containing the R1 or R2 mRNA 3' UTRs, and we show that transfection of these plasmids into highly malignant mouse 10 T1/2 cells significantly suppresses the tumorigenic properties of these cells in syngeneic mice when compared with cells transfected with the same plasmid lacking R1 or R2 3' UTR sequences or when compared with cells transfected with the same plasmid expressing a heterologous sequence as a control. Furthermore, cells expressing the R2 3' UTR exhibit significantly reduced potential to disseminate to the lungs of syngeneic animals in experimental metastasis assays. The tumor-suppressive effects of the mouse R1 and R2 3' UTRs were not confined to mouse cells, because human HeLa cells transfected with expression plasmids containing either RI or R2 3' UTRs were also significantly less tumorigenic in assays using BALB/c nu/nu mice. These studies demonstrate that the untranslated regions of ribonucleotide reductase mRNAs can function as modifiers of tumor cell development and for the more complex process of tumor dissemination. We propose that these malignancy-suppressive effects are mediated through RNA interactions with cellular components involved in growth regulation through mechanisms of posttranscriptional control of gene expression. In addition, these observations emphasize the enormous potential of untranslated RNA to act directly as modifiers of biological characteristics relevant to mechanisms of malignancy.

A link between ferritin gene expression and ribonucleotide reductase R2 protein, as demonstrated by retroviral vector mediated stable expression of R2 cDNA

We have constructed a retroviral expression vector for the mammalian ribonucleotide reductase R2 component. Stable infectants, which express a myc epitope tagged R2 protein from the vector cDNA were obtained and described for the first time. Cells containing the recombinant protein exhibited increased ribonucleotide reductase activity, and were resistant to the antitumour agent hydroxyurea, which targets the R2 component of ribonucleotide reductase. Furthermore, a direct link between ferritin gene expression and R2 protein was observed, since cells containing vector expressed recombinant R2 protein exhibited increased H-chain and L-chain ferritin gene expression.

Occupational allergic contact dermatitis in construction workers

We report the patch test results of 449 construction workers who came as patients to the Occupational Dermatology Service of the Instituto Nacional de Medicina y Seguridad del Trabajo in Madrid between 1989 and 1993. 90.8% of them were patch tested, because they had cutaneous lesions or a clinical history suggestive of occupational dermatitis. 65.5% (268) of those patch tested showed one or more reactions connected with their work. Chromate at 42.1% was the main allergen, followed by cobalt, 20.5%, nickel, 10%, and epoxy resin, 7.5%. 25.9% (106) of patients showed sensitization to rubber components, the majority at 23.7% to thiuram mix, with TETD being the main allergen.

Subcutaneous juvenile xanthogranuloma

A 1-month-old female infant was seen in consultation because of a congenital subcutaneous nodule, 2 x 3 cm in diameter, in the right retroauricular area. The nodule was surgically excised. Histologically, a large subcutaneous nodular mass was well delimited but not encapsulated. It consisted of a monomorphous sheet of foamy histiocytic cells with scattered eosinophils. Multinucleated giant cells were not found. The pure subcutaneous type of juvenile xanthogranuloma has been reported very rarely in the literature. The usual histological monomorphism of these cases, with only occasional eosinophils and lymphocytes and rare Touton giant cells, adds another diagnostic difficulty to their unusual clinical presentation.

Lichen planus with predominant plasma cell infiltrate

We herein report the case of a patient with lichenoid plaques on the lower extremities and anonychia of all toenails. Histologically, the eruption showed typical features of lichen planus, with the exceptional finding of a lichenoid infiltrate composed mostly of plasma cells. Only two other similar cases have been reported. The explanation for the numerous plasma cells remains unknown although such cases may represent a new histologic variant.