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Katsoularis I, Fonseca-Rodríguez O, Farrington P, Jerndal H, Lundevaller EH, Sund M, Lindmark K, Fors Connolly AM. Risks of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19: nationwide self-controlled cases series and matched cohort study. BMJ 2022; 377:e069590. [PMID: 35387772 PMCID: PMC8984137 DOI: 10.1136/bmj-2021-069590] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To quantify the risk of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19. DESIGN Self-controlled case series and matched cohort study. SETTING National registries in Sweden. PARTICIPANTS 1 057 174 people who tested positive for SARS-CoV-2 between 1 February 2020 and 25 May 2021 in Sweden, matched on age, sex, and county of residence to 4 076 342 control participants. MAIN OUTCOMES MEASURES Self-controlled case series and conditional Poisson regression were used to determine the incidence rate ratio and risk ratio with corresponding 95% confidence intervals for a first deep vein thrombosis, pulmonary embolism, or bleeding event. In the self-controlled case series, the incidence rate ratios for first time outcomes after covid-19 were determined using set time intervals and the spline model. The risk ratios for first time and all events were determined during days 1-30 after covid-19 or index date using the matched cohort study, and adjusting for potential confounders (comorbidities, cancer, surgery, long term anticoagulation treatment, previous venous thromboembolism, or previous bleeding event). RESULTS Compared with the control period, incidence rate ratios were significantly increased 70 days after covid-19 for deep vein thrombosis, 110 days for pulmonary embolism, and 60 days for bleeding. In particular, incidence rate ratios for a first pulmonary embolism were 36.17 (95% confidence interval 31.55 to 41.47) during the first week after covid-19 and 46.40 (40.61 to 53.02) during the second week. Incidence rate ratios during days 1-30 after covid-19 were 5.90 (5.12 to 6.80) for deep vein thrombosis, 31.59 (27.99 to 35.63) for pulmonary embolism, and 2.48 (2.30 to 2.68) for bleeding. Similarly, the risk ratios during days 1-30 after covid-19 were 4.98 (4.96 to 5.01) for deep vein thrombosis, 33.05 (32.8 to 33.3) for pulmonary embolism, and 1.88 (1.71 to 2.07) for bleeding, after adjusting for the effect of potential confounders. The rate ratios were highest in patients with critical covid-19 and highest during the first pandemic wave in Sweden compared with the second and third waves. In the same period, the absolute risk among patients with covid-19 was 0.039% (401 events) for deep vein thrombosis, 0.17% (1761 events) for pulmonary embolism, and 0.101% (1002 events) for bleeding. CONCLUSIONS The findings of this study suggest that covid-19 is a risk factor for deep vein thrombosis, pulmonary embolism, and bleeding. These results could impact recommendations on diagnostic and prophylactic strategies against venous thromboembolism after covid-19.
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Affiliation(s)
- Ioannis Katsoularis
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Paddy Farrington
- School of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Hanna Jerndal
- Department of Clinical Microbiology, Umeå University, 90187 Umeå, Sweden
| | | | - Malin Sund
- Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Sund M, Fonseca-Rodríguez O, Josefsson A, Welen K, Fors Connolly AM. Association between pharmaceutical modulation of oestrogen in postmenopausal women in Sweden and death due to COVID-19: a cohort study. BMJ Open 2022; 12:e053032. [PMID: 35165090 PMCID: PMC8844968 DOI: 10.1136/bmjopen-2021-053032] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Determine whether augmentation of oestrogen in postmenopausal women decreases the risk of death following COVID-19. DESIGN Nationwide registry-based study in Sweden based on registries from the Swedish Public Health Agency (all individuals who tested positive for SARS-CoV-2); Statistics Sweden (socioeconomical variables) and the National Board of Health and Welfare (causes of death). PARTICIPANTS Postmenopausal women between 50 and 80 years of age with verified COVID-19. INTERVENTIONS Pharmaceutical modulation of oestrogen as defined by (1) women with previously diagnosed breast cancer and receiving endocrine therapy (decreased systemic oestrogen levels); (2) women receiving hormone replacement therapy (increased systemic oestrogen levels) and (3) a control group not fulfilling requirements for group 1 or 2 (postmenopausal oestrogen levels). Adjustments were made for potential confounders such as age, annual disposable income (richest group as the reference category), highest level of education (primary, secondary and tertiary (reference)) and the weighted Charlson Comorbidity Index (wCCI). PRIMARY OUTCOME MEASURE Death following COVID-19. RESULTS From a nationwide cohort consisting of 49 853 women diagnosed with COVID-19 between 4 February and 14 September 2020 in Sweden, 16 693 were between 50 and 80 years of age. We included 14 685 women in the study with 11 923 (81%) in the control group, 227 (2%) women in group 1 and 2535 (17%) women in group 2. The unadjusted ORs for death following COVID-19 were 2.35 (95% CI 1.51 to 3.65) for group 1 and 0.45 (0.34 to 0.6) for group 2. Only the adjusted OR for death remained significant for group 2 with OR 0.47 (0.34 to 0.63). Absolute risk of death was 4.6% for the control group vs 10.1% and 2.1%, for the decreased and increased oestrogen groups, respectively. The risk of death due to COVID-19 was significantly associated with: age, OR 1.15 (1.14 to 1.17); annual income, poorest 2.79 (1.96 to 3.97), poor 2.43 (91.71 to 3.46) and middle 1.64 (1.11 to 2.41); and education (primary 1.4 (1.07 to 1.81)) and wCCI 1.13 (1.1 to 1.16). CONCLUSIONS Oestrogen supplementation in postmenopausal women is associated with a decreased risk of dying from COVID-19 in this nationwide cohort study. These findings are limited by the retrospective and non-randomised design. Further randomised intervention trials are warranted.
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Affiliation(s)
- Malin Sund
- Department of Surgical and Perioperative Sciences, Umeå University Faculty of Medicine, Umeå, Sweden
- Department of Surgery, Univerisity of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Andreas Josefsson
- Department of Surgical and Perioperative Sciences, Umeå University Faculty of Medicine, Umeå, Sweden
- Department of Urology, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Karin Welen
- Department of Urology, University of Gothenburg, Gothenburg, Sweden
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Welén K, Rosendal E, Freyhult E, Oh WK, Gisslén M, Ahlm C, Connolly AMF, Överby AK, Josefsson A. Reply to Carlos G. Wambier and Gerard J. Nau’s Letter to the Editor re: Karin Welén, Ebba Rosendal, Magnus Gisslén, et al. A Phase 2 Trial of the Effect of Antiandrogen Therapy on COVID-19 Outcome: No Evidence of Benefit, Supported by Epidemiology and In Vitro Data. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2021.12.013. Positive Effects of Enzalutamide for Hospitalized COVID-19 Patients. Eur Urol 2022; 81:e143-e144. [PMID: 35248411 PMCID: PMC8864103 DOI: 10.1016/j.eururo.2022.02.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Karin Welén
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ebba Rosendal
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Eva Freyhult
- Department of Cell and Molecular Biology, National Bioinformatics Infrastructure Sweden, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - William K Oh
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Magnus Gisslén
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Anne-Marie Fors Connolly
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden; The Laboratory for Molecular Infection Medicine Sweden, Umeå, Sweden
| | - Anna K Överby
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden; The Laboratory for Molecular Infection Medicine Sweden, Umeå, Sweden
| | - Andreas Josefsson
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgical and Perioperative Sciences, Urology & Andrology, Umeå University, Umeå, Sweden; Wallenberg Center for Molecular Medicine, Umeå University, Umeå, Sweden.
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Welén K, Rosendal E, Gisslén M, Lenman A, Freyhult E, Fonseca-Rodríguez O, Bremell D, Stranne J, Balkhed ÅÖ, Niward K, Repo J, Robinsson D, Henningsson AJ, Styrke J, Angelin M, Lindquist E, Allard A, Becker M, Rudolfsson S, Buckland R, Carlsson CT, Bjartell A, Nilsson AC, Ahlm C, Connolly AMF, Överby AK, Josefsson A. A Phase 2 Trial of the Effect of Antiandrogen Therapy on COVID-19 Outcome: No Evidence of Benefit, Supported by Epidemiology and In Vitro Data. Eur Urol 2021; 81:285-293. [PMID: 34980495 PMCID: PMC8673828 DOI: 10.1016/j.eururo.2021.12.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [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: 09/07/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022]
Abstract
Background Men are more severely affected by COVID-19. Testosterone may influence SARS-CoV-2 infection and the immune response. Objective To clinically, epidemiologically, and experimentally evaluate the effect of antiandrogens on SARS-CoV-2 infection. Designs, settings, and participants A randomized phase 2 clinical trial (COVIDENZA) enrolled 42 hospitalized COVID-19 patients before safety evaluation. We also conducted a population-based retrospective study of 7894 SARS-CoV-2–positive prostate cancer patients and an experimental study using an air-liquid interface three-dimensional culture model of primary lung cells. Intervention In COVIDENZA, patients were randomized 2:1 to 5 d of enzalutamide or standard of care. Outcome measurements The primary outcomes in COVIDENZA were the time to mechanical ventilation or discharge from hospital. The population-based study investigated risk of hospitalization, intensive care, and death from COVID-19 after androgen inhibition. Results and limitations Enzalutamide-treated patients required longer hospitalization (hazard ratio [HR] for discharge from hospital 0.43, 95% confidence interval [CI] 0.20–0.93) and the trial was terminated early. In the epidemiological study, no preventive effects were observed. The frail population of patients treated with androgen deprivation therapy (ADT) in combination with abiraterone acetate or enzalutamide had a higher risk of dying from COVID-19 (HR 2.51, 95% CI 1.52–4.16). In vitro data showed no effect of enzalutamide on virus replication. The epidemiological study has limitations that include residual confounders. Conclusions The results do not support a therapeutic effect of enzalutamide or preventive effects of bicalutamide or ADT in COVID-19. Thus, these antiandrogens should not be used for hospitalized COVID-19 patients or as prevention for COVID-19. Further research on these therapeutics in this setting are not warranted. Patient summary We studied whether inhibition of testosterone could diminish COVID-19 symptoms. We found no evidence of an effect in a clinical study or in epidemiological or experimental investigations. We conclude that androgen inhibition should not be used for prevention or treatment of COVID-19.
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Affiliation(s)
- Karin Welén
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ebba Rosendal
- Department of Clinical Microbiology, Section of Virology, Umeå University, Umeå, Sweden; The Laboratory for Molecular Infection Medicine Sweden, Umeå, Sweden
| | - Magnus Gisslén
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annasara Lenman
- Department of Clinical Microbiology, Section of Virology, Umeå University, Umeå, Sweden
| | - Eva Freyhult
- Department of Medical Sciences, National Bioinformatics Infrastructure Sweden, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | | | - Daniel Bremell
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Stranne
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Åse Östholm Balkhed
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Katarina Niward
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johanna Repo
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - David Robinsson
- Department of Urology, Region of Jönköping, Jönköping, Sweden
| | - Anna J Henningsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Clinical Microbiology, Region Jönköping County, Jönköping, Sweden
| | - Johan Styrke
- Department of Surgical and Perioperative Sciences, Urology & Andrology, Umeå University, Umeå, Sweden
| | - Martin Angelin
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | | | - Annika Allard
- Department of Clinical Microbiology, Section of Virology, Umeå University, Umeå, Sweden
| | - Miriam Becker
- Department of Clinical Microbiology, Section of Virology, Umeå University, Umeå, Sweden
| | - Stina Rudolfsson
- Department of Surgical and Perioperative Sciences, Urology & Andrology, Umeå University, Umeå, Sweden
| | - Robert Buckland
- Department of Surgical and Perioperative Sciences, Urology & Andrology, Umeå University, Umeå, Sweden
| | | | - Anders Bjartell
- Division of Urological Cancers, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Anna C Nilsson
- Department of Translational Medicine, Infectious Diseases Research Unit, Lund University, Malmö, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Anne-Marie Fors Connolly
- The Laboratory for Molecular Infection Medicine Sweden, Umeå, Sweden; Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Anna K Överby
- The Laboratory for Molecular Infection Medicine Sweden, Umeå, Sweden; Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Andreas Josefsson
- Institute of Clinical Sciences, Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgical and Perioperative Sciences, Urology & Andrology, Umeå University, Umeå, Sweden; Wallenberg Center for Molecular Medicine (WCMM), Umeå University, Umeå, Sweden.
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Katsoularis I, Fonseca-Rodríguez O, Farrington P, Lindmark K, Connolly AMF. COVID-19 and myocardial infarction - Authors' reply. Lancet 2021; 398:1964. [PMID: 34838176 PMCID: PMC8616566 DOI: 10.1016/s0140-6736(21)02320-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Ioannis Katsoularis
- Department of Public Health and Clinical Medicine, Umeå University, Umeå 901 85, Sweden
| | | | - Paddy Farrington
- School of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, Umeå 901 85, Sweden
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Gustafsson PE, San Sebastian M, Fonseca-Rodriguez O, Fors Connolly AM. Inequitable impact of infection: social gradients in severe COVID-19 outcomes among all confirmed SARS-CoV-2 cases during the first pandemic wave in Sweden. J Epidemiol Community Health 2021; 76:261-267. [PMID: 34526373 PMCID: PMC8449839 DOI: 10.1136/jech-2021-216778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 09/06/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND The backdrop of the ubiquitous social inequalities has increasingly come into foreground in research on the COVID-19 pandemic, but the lack of high-quality population-based studies limits our understanding of the inequitable outcomes of the disease. The present study seeks to estimate social gradients in COVID-19 hospitalisations, intensive care admissions and death by education, income and country of birth, while taking into account disparities in comorbidities. METHODS We used a register-based retrospective open cohort design enrolling all 74 659 confirmed SARS-CoV-2-positive cases aged >25 years in Sweden during the first wave of the pandemic (until 14 September 2020). Information was retrieved from multiple registers and linked by the unique Swedish personal identity number concerning COVID-19 case identification; COVID-19 hospitalisations, intensive care admissions and death; comorbidities as measured by the Charlson Comorbidity Index; and sociodemographic information. Social gradients were estimated by the Relative Index of Inequality (RII) using Cox regression. RESULTS Adjusted analyses showed significant social gradients in COVID-19 hospitalisation, intensive care admission, across education, income and country of birth, which were unaffected by adjustment for comorbidities. Education and country of birth gradients were stronger for hospitalisation and intensive care admissions but small to non-existent for death. In contrast, income gradients were consistent across all three COVID-19 outcomes. CONCLUSION Social gradients in severe COVID-19 outcomes are widespread in Sweden, but appear to be unrelated to pre-existing health disparities. Inequitable outcomes of SARS-CoV-2 infection may therefore be at least partially avoidable and could rely on equitable management of confirmed COVID-19 cases.
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Affiliation(s)
- Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Katsoularis I, Fonseca-Rodríguez O, Farrington P, Lindmark K, Fors Connolly AM. Risk of acute myocardial infarction and ischaemic stroke following COVID-19 in Sweden: a self-controlled case series and matched cohort study. Lancet 2021; 398:599-607. [PMID: 34332652 PMCID: PMC8321431 DOI: 10.1016/s0140-6736(21)00896-5] [Citation(s) in RCA: 209] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND COVID-19 is a complex disease targeting many organs. Previous studies highlight COVID-19 as a probable risk factor for acute cardiovascular complications. We aimed to quantify the risk of acute myocardial infarction and ischaemic stroke associated with COVID-19 by analysing all COVID-19 cases in Sweden. METHODS This self-controlled case series (SCCS) and matched cohort study was done in Sweden. The personal identification numbers of all patients with COVID-19 in Sweden from Feb 1 to Sept 14, 2020, were identified and cross-linked with national inpatient, outpatient, cancer, and cause of death registers. The controls were matched on age, sex, and county of residence in Sweden. International Classification of Diseases codes for acute myocardial infarction or ischaemic stroke were identified in causes of hospital admission for all patients with COVID-19 in the SCCS and all patients with COVID-19 and the matched control individuals in the matched cohort study. The SCCS method was used to calculate the incidence rate ratio (IRR) for first acute myocardial infarction or ischaemic stroke following COVID-19 compared with a control period. The matched cohort study was used to determine the increased risk that COVID-19 confers compared with the background population of increased acute myocardial infarction or ischaemic stroke in the first 2 weeks following COVID-19. FINDINGS 86 742 patients with COVID-19 were included in the SCCS study, and 348 481 matched control individuals were also included in the matched cohort study. When day of exposure was excluded from the risk period in the SCCS, the IRR for acute myocardial infarction was 2·89 (95% CI 1·51-5·55) for the first week, 2·53 (1·29-4·94) for the second week, and 1·60 (0·84-3·04) in weeks 3 and 4 following COVID-19. When day of exposure was included in the risk period, IRR was 8·44 (5·45-13·08) for the first week, 2·56 (1·31-5·01) for the second week, and 1·62 (0·85-3·09) for weeks 3 and 4 following COVID-19. The corresponding IRRs for ischaemic stroke when day of exposure was excluded from the risk period were 2·97 (1·71-5·15) in the first week, 2·80 (1·60-4·88) in the second week, and 2·10 (1·33-3·32) in weeks 3 and 4 following COVID-19; when day of exposure was included in the risk period, the IRRs were 6·18 (4·06-9·42) for the first week, 2·85 (1·64-4·97) for the second week, and 2·14 (1·36-3·38) for weeks 3 and 4 following COVID-19. In the matched cohort analysis excluding day 0, the odds ratio (OR) for acute myocardial infarction was 3·41 (1·58-7·36) and for stroke was 3·63 (1·69-7·80) in the 2 weeks following COVID-19. When day 0 was included in the matched cohort study, the OR for acute myocardial infarction was 6·61 (3·56-12·20) and for ischaemic stroke was 6·74 (3·71-12·20) in the 2 weeks following COVID-19. INTERPRETATION Our findings suggest that COVID-19 is a risk factor for acute myocardial infarction and ischaemic stroke. This indicates that acute myocardial infarction and ischaemic stroke represent a part of the clinical picture of COVID-19, and highlights the need for vaccination against COVID-19. FUNDING Central ALF-funding and Base Unit ALF-Funding, Region Västerbotten, Sweden; Strategic funding during 2020 from the Department of Clinical Microbiology, Umeå University, Sweden; Stroke Research in Northern Sweden; The Laboratory for Molecular Infection Medicine Sweden.
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Affiliation(s)
- Ioannis Katsoularis
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Paddy Farrington
- School of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Fonseca-Rodríguez O, Gustafsson PE, San Sebastián M, Connolly AMF. Spatial clustering and contextual factors associated with hospitalisation and deaths due to COVID-19 in Sweden: a geospatial nationwide ecological study. BMJ Glob Health 2021; 6:bmjgh-2021-006247. [PMID: 34321234 PMCID: PMC8322019 DOI: 10.1136/bmjgh-2021-006247] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 05/08/2021] [Accepted: 07/15/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In Sweden, thousands of hospitalisations and deaths due to COVID-19 were reported since the pandemic started. Considering the uneven spatial distribution of those severe outcomes at the municipality level, the objective of this study was, first, to identify high-risk areas for COVID-19 hospitalisations and deaths, and second, to determine the associated contextual factors with the uneven spatial distribution of both study outcomes in Sweden. METHODS The existences of spatial autocorrelation of the standardised incidence (hospitalisations) ratio and standardised mortality ratio were investigated using Global Moran's I test. Furthermore, we applied the retrospective Poisson spatial scan statistics to identify high-risk spatial clusters. The association between the contextual demographic and socioeconomic factors and the number of hospitalisations and deaths was estimated using a quasi-Poisson generalised additive regression model. RESULTS Ten high-risk spatial clusters of hospitalisations and six high-risk clusters of mortality were identified in Sweden from February 2020 to October 2020. The hospitalisations and deaths were associated with three contextual variables in a multivariate model: population density (inhabitants/km2) and the proportion of immigrants (%) showed a positive association with both outcomes, while the proportion of the population aged 65+ years (%) showed a negative association. CONCLUSIONS Our study identified high-risk spatial clusters for hospitalisations and deaths due to COVID-19 and the association of population density, the proportion of immigrants and the proportion of people aged 65+ years with those severe outcomes. Results indicate where public health measures must be reinforced to improve sustained and future disease control and optimise the distribution of resources.
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Affiliation(s)
| | - Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Schmedes CM, Grover SP, Hisada YM, Goeijenbier M, Hultdin J, Nilsson S, Thunberg T, Ahlm C, Mackman N, Fors Connolly AM. Circulating Extracellular Vesicle Tissue Factor Activity During Orthohantavirus Infection Is Associated With Intravascular Coagulation. J Infect Dis 2020; 222:1392-1399. [PMID: 31722433 PMCID: PMC7488197 DOI: 10.1093/infdis/jiz597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/11/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Puumala orthohantavirus (PUUV) causes hemorrhagic fever with renal syndrome (HFRS). Patients with HFRS have an activated coagulation system with increased risk of disseminated intravascular coagulation (DIC) and venous thromboembolism (VTE). The aim of the study was to determine whether circulating extracellular vesicle tissue factor (EVTF) activity levels associates with DIC and VTE (grouped as intravascular coagulation) in HFRS patients. METHODS Longitudinal samples were collected from 88 HFRS patients. Patients were stratified into groups of those with intravascular coagulation (n = 27) and those who did not (n = 61). We measured levels of circulating EVTF activity, fibrinogen, activated partial prothrombin time, D-dimer, tissue plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), and platelets. RESULTS Plasma EVTF activity was transiently increased during HFRS. Levels of EVTF activity were significantly associated with plasma tPA and PAI-1, suggesting that endothelial cells could be a potential source. Patients with intravascular coagulation had significantly higher peak EVTF activity levels compared with those who did not, even after adjustment for sex and age. The peak EVTF activity value predicting intravascular coagulation was 0.51 ng/L with 63% sensitivity and 61% specificity with area under the curve = 0.63 (95% confidence interval, 0.51-0.76) and P = .046. CONCLUSIONS Plasma EVTF activity during HFRS is associated with intravascular coagulation.
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Affiliation(s)
- Clare M Schmedes
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carlina, USA
| | - Steven P Grover
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carlina, USA
| | - Yohei M Hisada
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carlina, USA
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johan Hultdin
- Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Sofie Nilsson
- Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Therese Thunberg
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Nigel Mackman
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carlina, USA
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Hansson M, Gustafsson R, Jacquet C, Chebaane N, Satchell S, Thunberg T, Ahlm C, Fors Connolly AM. Cystatin C and α-1-Microglobulin Predict Severe Acute Kidney Injury in Patients with Hemorrhagic Fever with Renal Syndrome. Pathogens 2020; 9:pathogens9080666. [PMID: 32824680 PMCID: PMC7460112 DOI: 10.3390/pathogens9080666] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/29/2022] Open
Abstract
Puumala orthohantavirus causes hemorrhagic fever with renal syndrome (HFRS) characterized by acute kidney injury (AKI), an abrupt decrease in renal function. Creatinine is routinely used to detect and quantify AKI; however, early AKI may not be reflected in increased creatinine levels. Therefore, kidney injury markers that can predict AKI are needed. The potential of the kidney injury markers urea, cystatin C, α1-microglobulin (A1M) and neutrophil gelatinase-associated lipocalin (NGAL) to detect early AKI during HFRS was studied by quantifying the levels of these markers in consecutively obtained plasma (P) and urine samples (U) for 44 HFRS patients. P-cystatin C and U-A1M levels were significantly increased during early HFRS compared to follow-up. In a receiver operating characteristic (ROC) curve analysis, P-cystatin C, U-A1M and P-urea predicted severe AKI with area under the curve 0.72, 0.73 and 0.71, respectively, whereas the traditional kidney injury biomarkers creatinine and U-albumin did not predict AKI. Nearly half of the HFRS patients (41%) fulfilled the criteria for shrunken pore syndrome, which was associated with the level of inflammation as measured by P-CRP. P-cystatin C and U-A1M are more sensitive and earlier markers compared to creatinine in predicting kidney injury during HFRS.
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Affiliation(s)
- Magnus Hansson
- Clinical Chemistry, Karolinska University Hospital, 17176 Stockholm, Sweden;
- Department of Laboratory Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Rasmus Gustafsson
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Chloé Jacquet
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
- Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187 Umeå, Sweden
| | - Nedia Chebaane
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Simon Satchell
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol BS1 3NY, UK;
| | - Therese Thunberg
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Anne-Marie Fors Connolly
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
- Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187 Umeå, Sweden
- Correspondence:
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Tatsumi K, Hisada Y, Connolly AMF, Buranda T, Mackman N. Patients with severe orthohantavirus cardiopulmonary syndrome due to Sin Nombre Virus infection have increased circulating extracellular vesicle tissue factor and an activated coagulation system. Thromb Res 2019; 179:31-33. [DOI: 10.1016/j.thromres.2019.04.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/25/2019] [Accepted: 04/30/2019] [Indexed: 12/22/2022]
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