Incidence of heparin resistance and heparin failure in patients receiving extracorporeal membrane oxygenation - an exploratory retrospective analysis

Objectives: Unfractionated heparin (UFH) remains the anticoagulation of choice at most centres for patients receiving extracorporeal membrane oxygenation (ECMO). One disadvantage of UFH relies on its individual dosing requirement to achieve target values. In this context heparin resistance has been described, defined as doses exceeding 35,000 IU UFH/d. However, the incidence of heparin resistance and its association with thromboembolic complications despite anticoagulation within target ranges remains unknown. Method(s): This retrospective study included adults receiving venovenous (VV) and venoarterial (VA) ECMO, or extracorporeal CO2-removal (ECCO2R) between 2010 and May 2022. The primary outcome was the incidence of heparin resistance (>35,000 IU of UFH/d). Secondary outcomes were heparin failure (thromboembolic complications despite anticoagulation within target ranges) and survival. A multivariable poisson regression model was fitted to analyse the effect of heparin resistance, COVID-19 and ECMO type on the incidence rate of thromboembolic events. Result(s): Of 197 included patients, 33 (16.8%) had heparin resistance. Patients with COVID-19 (n=51) had a higher rate of heparin resistance compared to nonCOVID-19 patients (37% vs. 9.6%, P<0.001). Thromboembolic complications occurred at a rate of 5.89/100 ECMO days. There was a significant effect of COVID-19 (incidence rate ratio (IRR) 2.12, 95% confidence interval (CI) 1.4 to 3.3, P<0.001) and ECMO type (VA ECMO: IRR 2.35;95% CI 1.43 to 3.87, P<0.001;ECCO2R: IRR 2.63, 95% CI 1.37 to 4.9, P=0.003;reference VV ECMO) on incidence rate of thromboembolic events, but not of heparin resistance (IRR 1.11, 95% CI 0.7 to 1.76, P=0.7). ECMO duration was longer (25d (IQR 11-33) vs. 8d (IQR 4-18), P<0.001) in patients with heparin resistance, but hospital survival did not differ (23 (70%) vs. 91 (57%), P=0.2). Conclusion(s): The study revealed a high incidence of heparin failure in ECMO patients, especially in those with COVID-19. Heparin resistance had no effect on the incidence rate of thromboembolic events, whereas our data suggest an increased risk in patients with COVID19, VA ECMO and ECCO2R.

SAFETY INCIDENTS CLASSIFIED AS CLINICAL PROCESS/ PROCEDURE IN HOSPITALIZED PATIENTS DURING THE COVID-19 PANDEMIC

Objective: Compare reported patient safety incidents related to a clinical process/ procedure among patients with laboratory-confirmed COVID-19 diagnosis and with Severe Acute Respiratory Syndrome (SARS) caused by another infectious or undetermined agent and the other patients. Results and discussion: retrospective, documentary study approved by the ethics committee in a public teaching hospital in southern Brazil. In the study, 2,191 notifications and records of COVID-19 between March and September 2020 were used. The data were submitted to descriptive analysis with frequencies of the variables in the data set, Fisher's test to determine the associations between outcomes (classification/process/ problem) and calculation of relative risk to measure its strength. The incidence of pressure ulcers was almost 3.7 times higher in patients with SARS. In the others, various tube-related incidents and events associated to the surgical process predominated. Conclusion: Intensive nursing care for patients with SARS, risk management and strengthening of good practices for the safety of all patients were relevant. © 2023, Universidade Federal do Parana. All rights reserved.

Extracellular vesicles and citrullinated histone H3 in coronavirus disease 2019 (COVID-19) patients

Background : Pulmonary thrombus formation is a hallmark of COVID-19. A dysregulated immune response culminating in thromboinflammation has been described, but the pathomechanisms remain unclear. Aims : To evaluate the role of extracellular vesicles (EV) and citrullinated histone H3 (citH3) as markers of coagulopathy and inflammation. Methods : We studied 41 adult COVID-19 patients with a positive result on a reverse-transcriptase polymerase-chain-reaction assay and 37 sex-and age-matched healthy controls. Number and surface characteristics of EV and citH3 levels were determined in plasma upon admission by flowcytometry and immunoassay, respectively. Values are given as median (25 th , 75 th percentile) and differences by geometric mean ratios (GMR [95% CI]) or mean differences (ΔsMean [95% CI]). Results : 20 patients had severe and 21 mild disease. Patients exhibited significantly higher numbers of total EV, and of EV derived from platelets, endothelial cells, leukocytes, or neutrophils than controls (Table 1). EV from alveolar-macrophages and alveolar-epithelial-cells were detectable in plasma and were significantly higher in patients. ICAM-1 positive EV levels were higher in patients while no difference between TF-positive and ACE-positive EV was seen between the two groups. Levels of EV did not differ between patients with severe and mild COVID-19. citH3 levels were higher in patients than in controls [1.42 (0.6, 3.37) vs 0.31 (0.14, 0.6), GMR 4.44 (2.57, 7.66);P < 0.001], and were significantly lower in patients with mild disease compared to those with severe disease. Conclusions : EV and citH3 are associated with COVID-19. They provide information regarding pathophysiology and could be explored as markers of the disease.

The COVID-19 pandemic and the contributions of modern monetary theory

The present situation linked to the COVID-19 pandemic has fostered a general rethinking of how economic theories can inform an effective policy response. In such a context, perhaps no theory has been brought more to the test than modern monetary theory (MMT). As a matter of fact, MMT, by positing that governments can always create their currencies, seems particular apt for dealing with COVID-19. We will briefly address MMT, and focus on how MMT insights can be employed not only for today’s emergency but also for building a new sustainable economy. Some conclusions about economics education will follow. Copyright © 2021 Inderscience Enterprises Ltd.

On the meaning of meaning as shared meaning—leadership development in turbulent times

“In a crisis character proves itself” (Helmut Schmidt)—and so does the culture of an organization. Is it of support also in difficult times? Does pressure amplify its positive aspects or rather the dysfunctional ones? This case report addresses a nursing division within a university hospital, particularly its leadership culture that was recently “stress tested” by the COVID-19 pandemic. To the relief of those involved, the situation revealed a solid foundation and the positive force of a division-wide culture of shared leadership. Our contribution to this special issue of the journal Gruppe. Interaktion. Organisation. (GIO) reflects upon a leadership development process of five years, which supported the emergence of an adaptive and community-oriented leadership practice capable of constructively coping with complexity, permanent change and various tensions. Core elements of this process were regular large group workshops that provided spaces for resonance, reflection and experimentation and fostered the building of trust and connectedness. We first recapitulate significant steps and contents of this process and then examine impact factors and determinants of success by drawing on interviews with participating leaders. This is followed by an engagement with theoretical perspectives on questions of meaning in relation to leadership and a consideration and discussion of the case example against this background. In that we focus on such approaches that look at meaning phenomena as transsubjective and collective and our article advocates against considering meaning detached from the communities in which it emerges. We conclude with a résumé and outlook in view of a reorganization in the context of this case study. © 2020, The Author(s).