Four-month incidence of suicidal thoughts and behaviors among healthcare workers after the first wave of the Spain COVID-19 pandemic

Healthcare workers (HCW) are at high risk for suicide, yet little is known about the onset of suicidal thoughts and behaviors (STB) in this important segment of the population in conjunction with the COVID-19 pandemic. We conducted a multicenter, prospective cohort study of Spanish HCW active during the COVID-9 pandemic. A total of n = 4809 HCW participated at baseline (May-September 2020; i.e., just after the first wave of the pandemic) and at a four-month follow-up assessment (October-December 2020) using web-based surveys. Logistic regression assessed the individual- and population-level associations of separate proximal (pandemic) risk factors with four-month STB incidence (i.e., 30-day STB among HCW negative for 30-day STB at baseline), each time adjusting for distal (pre-pandemic) factors. STB incidence was estimated at 4.2% (SE = 0.5; n = 1 suicide attempt). Adjusted for distal factors, proximal risk factors most strongly associated with STB incidence were various sources of interpersonal stress (scaled 0-4; odds ratio [OR] range = 1.23-1.57) followed by personal health-related stress and stress related to the health of loved ones (scaled 0-4; OR range 1.30-1.32), and the perceived lack of healthcare center preparedness (scaled 0-4; OR = 1.34). Population-attributable risk proportions for these proximal risk factors were in the range 45.3-57.6%. Other significant risk factors were financial stressors (OR range 1.26-1.81), isolation/quarantine due to COVID-19 (OR = 1.53) and having changed to a specific COVID-19 related work location (OR = 1.72). Among other interventions, our findings call for healthcare systems to implement adequate conflict communication and resolution strategies and to improve family-work balance embedded in organizational justice strategies.

Thrombin Generation and Fibrinolysis in the Thrombotic Thrombocytopenic Purpura and the Hemolytic-Uremic Syndrome

Prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin complexes (TAT), as well as other coagulation and fibrinolysis parameters, were studied in a series of 13 patients affected by thrombotic thrombocytopenic purpura (TTP) or hemolytic-uremic syndrome (HUS). Fragment F1+2 was found to be increased in all patients at diagnosis (patients' range, 1.21-19.03 nmol/1; normal limits, 0.28-1.08 nmol/1), and remained also higher than normal after treatment with plasma exchange (patients' range, 1.5-4.01 nmol/1). Even though the analysis of fibrinolysis markers did not show a definite state of hypo or hyperfibrinolysis in the systemic circulation, enhanced circulating D-dimer levels (0.53-12.6 ug/ml, normal levels of 0.03-0.29 εg/ml) indicated that a certain grade of fibrin lysis was present at previously formed thrombi. Plasma PAI-1 activities either on admission (9.2-38.2 U/ml) and after plasma exchange therapy (2.6-38.6 U/ml) showed a behavior irrespective of t-PA: Ag changes, and post-plasmapheresis values remained high only in patients with fatal neurological outcome. Nevertheless, no correlations between clinical and laboratory data could be established useful for the TTP/HUS prognosis. We conclude that increased thrombin generation occurring in damaged areas is appropriately inhibited by antithrombin III in the systemic circulation, avoiding consumption coagulopathy to develop in uncomplicated patients. In addition, fibrinolysis data suggest that elevated PAI-1 may decisively favor the development of microvascular thrombi.

Donors older than 70 years in liver transplantation

INTRODUCTION

Expansion of donor criteria has become necessary with the increasing number of liver transplantation candidates, as aged donors who have been considered to yield marginal organs.

METHODS

Our database of 477 liver transplants (OLT) included 55 cases performed from donors at least 70 years old vs 422 with younger donors. We analyzed pretransplantation donor and recipient characteristics as well as evolution of the recipients.

RESULTS

The old donor group showed significantly lower ALT (23 +/- 17 vs 48.9 +/- 67; P = .0001) and LDH (444 +/- 285 vs 570 +/- 329; P = .01). There was a trend toward fewer hypotensive events in the aged donor group (27.2% vs 40.5%; P = .07). No steatosis (>10%) was accepted in the old donor group. Cold ischemia time was statistically shorter for the aged donors (297 +/- 90 minutes vs 346 +/- 139 minutes; P = .03). With these selected donors, the results were not different for primary nonfunction, arterial and biliary complications, hospitalization, acute reoperation or acute retransplantation, and hospital mortality when donors > or =70 years old were compared to younger donors. Functional cholestasis, neither related to rejection nor to biliary complications, was seen more frequently in old donor recipients (40% vs 22%; P = .03). No differences in 1, and 3 year survivals were observed between recipients of donors over 70 years old and these of younger organs: 93.8% and 90.6% vs 90.7% and 82.8%, respectively.

CONCLUSION

When using selected donors > or =70 years old the outcomes were comparable to those obtained with younger donors. Strict selection is necessary to achieve good long-term survival.

Prevention of thromboembolism with ticlopidine shortly after valve repair or replacement with a bioprosthesis

BACKGROUND AND AIMS OF THE STUDY

This study investigated the efficacy of postoperative ticlopidine as antiplatelet therapy in patients shortly after heart valve repair or replacement.

METHODS

Between 1990 and 1995, 235 consecutive patients underwent either valve repair (n = 67) or replacement with a bioprosthesis (n = 168). The bioprostheses used were Carpentier-Edwards porcine or pericardial (n = 158) valves, Prima stentless valves (n = 3) and cryopreserved homografts (n = 7). Types of repair were aortic (one), mitral annuloplasty with Carpentier ring (65) and tricuspid repair (one). Mean patient age was 67 (range: 16 to 83) years for valve replacement and 57 (range: 32 to 74) years for repair (p < 0.01). Atrial fibrillation occurred in 34% of patients. The hospital mortality rate was 11% (26 patients). Of the 209 survivors, 137 were assigned to antiplatelet treatment with ticlopidine for the first three months of follow up. The other 72 received either oral anticoagulation (coumadin; n = 40), aspirin (n = 14) or no medication (n = 18). In 15 patients, ticlopidine treatment was interrupted due to diarrhea (13 cases), mild allergic reaction (one) or anemia (one). The mean follow up was 3.2 years (range: 1 month to 6 years); cumulative follow up was 684 patient-years (pt-yr) and was complete in 96% of cases.

RESULTS

There were two episodes of thromboembolism in the ticlopidine group at 1 month and 6 months respectively, with a linearized incidence of 0.5% pt-yr. In the coumadin group there were four episodes of thromboembolism, three within the first three months of follow up. The linearized incidence was 3% pt-yr (p < 0.01). There were three episodes of hemorrhage in the ticlopidine group in the first three months of follow up and one in the coumadin group. The linearized incidence was 0.75% pt-yr.

CONCLUSIONS

Following heart valve repair or replacement with a bioprosthesis, the first three months is a high-risk period for thromboembolism. Ticlopidine seems to prevent this complication better than conventional therapy with oral anticoagulants. Nevertheless, hemorrhage continues to be a problem with ticlopidine therapy.

Prothrombin fragment 1 + 2 and thrombin-antithrombin complex measurements indicate continuous and progressive intraoperative thrombin generation in liver transplantation

Prothrombin fragment 1 + 2 (F1 + 2) and thrombin-antithrombin complex (TAT) have been measured in the different surgical phases in 40 patients undergoing 43 orthotopic liver transplantations (OLT), in order to study thrombin generation throughout the surgical procedure. F1 + 2 and TAT progressively rose from preoperative values (1.47 +/- 0.92 nmol/l and 22.41 +/- 19.15 ng/ml, respectively) to the end of anhepatic phase (5.97 +/- 2.20 nmol/l, 64.24 +/- 11.30 ng/ml), whereas changes in circulating antithrombin III (ATIII) were negligible in this period. Thrombin generation continued to slightly but significantly increase immediately after liver graft reperfusion (F1 + 2 6.87 +/- 1.65 nmol/l, TAT 89.32 +/- 7.54 ng/ml), and ATIII levels decreased from 70.61 +/- 12.28 to 57.16 +/- 9.57%. Higher preoperative values of F1 + 2 were associated with larger requirements of both packed red blood cells and fresh frozen plasma (FFP) in the host liver explantation phase, whereas the lowest basal levels of ATIII were related to a higher plasma expense in the whole OLT procedure. The activation of circulating prothrombin begins early in OLT, and adequate FFP infusion is capable of maintaining appropriate circulating thrombin-inhibitory activity.

Thrombin generation and fibrinolysis in the thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome

Prothrombin fragment 1 + 2 (F1 + 2) and thrombin-antithrombin complexes (TAT), as well as other coagulation and fibrinolysis parameters, were studied in a series of 13 patients affected by thrombotic thrombocytopenic purpura (TTP) or hemolytic-uremic syndrome (HUS). Fragment F1 + 2 was found to be increased in all patients at diagnosis (patients' range, 1.21-19.03 nmol/l; normal limits, 0.28-1.08 nmol/l), and remained also higher than normal after treatment with plasma exchange (patients' range, 1.5-4.01 nmol/l). Even though the analysis of fibrinolysis markers did not show a definite state of hypo or hyperfibrinolysis in the systemic circulation, enhanced circulating D-dimer levels (0.53-12.6 micrograms/ml, normal levels of 0.03-0.29 micrograms/ml) indicated that a certain grade of fibrin lysis was present at previously formed thrombi. Plasma PAI-1 activities either on admission (9.2-38.2 U/ml) and after plasma exchange therapy (2.6-38.6 U/ml) showed a behavior irrespective of t-PA:Ag changes, and post-plasmapheresis values remained high only in patients with fatal neurological outcome. Nevertheless, no correlations between clinical and laboratory data could be established useful for the TTP/HUS prognosis. We conclude that increased thrombin generation occurring in damaged areas is appropriately inhibited by antithrombin III in the systemic circulation, avoiding consumption coagulopathy to develop in uncomplicated patients. In addition, fibrinolysis data suggest that elevated PAI-1 may decisively favor the development of microvascular thrombi.