Thromboembolic and bleeding events in intensive care unit patients with COVID-19: results from a Brazilian tertiary hospital.

OBJECTIVES: To describe the incidence of thromboembolic events in adult patients with severe COVID-19 and identify clinical and laboratory factors associated with these events. DESIGN: Observational retrospective cohort study of 243 adult patients with severe COVID-19 admitted to an intensive care unit (ICU) at a Brazilian tertiary hospital. RESULTS: The incidence of all thromboembolic events was 14.8%, in which 3.8% developed deep vein thrombosis, 7.8% pulmonary embolism, 2.5% acute myocardial infarction, 1.2% stroke, and 1.2% peripheral artery occlusion. Risk factors identified were D-dimer at admission >3000 ng/mL (P=<0.0013) and major bleeding (P=0.001). The cumulative risk of developing thromboembolic events at day 28 after ICU admission was 16.0%. The rate of major bleeding was 4.1%. After receiver operating characteristic curve analysis, the D-dimer cut-off at admission correlating with thromboembolic events was 1140.5 ng/mL. CONCLUSIONS: The rate of thromboembolic events in our study was lower than previously described. High D-dimer level at admission was the leading risk factor; the optimal cut-off was 1140.5 ng/mL. The occurrence of thromboembolic events did not have an impact on the median overall survival rate. The optimal anticoagulant strategy in this context still needs to be established.

Methemoglobinemia and hemolytic anemia after COVID-19 infection without identifiable eliciting drug: A case-report.

We report a second case of methemoglobinemia and non-autoimmune hemolytic anemia after contracting the SARS-CoV-2 infection in the absence of an identifiable eliciting drug. A 35-year old male without previous known comorbidities was admitted after he was diagnosed with the COVID-19 infection and had large pulmonary involvement. Seven days later, he desaturated but was without any signs of respiratory distress. A check of arterial blood gas revealed normal partial pressure of oxygen and follow-up tests confirmed a methemoglobinemia diagnosis. Over the next few days, hemolysis was established after decreased levels of hemoglobin and increased levels of indirect bilirubin and lactate dehydrogenase. A hemolytic anemia investigation panel came back normal, including G6PD. A second G6PD test was ordered at the 5-month follow-up appointment and revealed decreased levels. Clinicians should thus be aware of possible false negative tests when testing for G6PD during hemolytic crisis. In addition, whether the COVID-19 infection alone would be responsible for this chain of events remains a challenging question.

The value of cellular components of blood in the setting of trimodal therapy for esophageal cancer.

BACKGROUND: Inflammation status plays an important role in the natural history of malignancy. Consequently, hematological markers of systemic inflammation may predict prognosis in neoplasms. This study evaluated the value of cellular blood components changes during neoadjuvant chemoradiotherapy followed by esophagectomy for cancer in predicting prognosis. METHODS: A cohort of 149 patients was analyzed. Cellular components of blood were assessed before neoadjuvant therapy (A); before surgery (B); and 3 to 5 months after surgery (C); for the following outcomes: pathological response, overall survival (OS), and disease-free survival (DFS). Univariate and multivariate Cox regression models were applied to evaluate the independent prognostic significance of blood count variables. RESULTS: Low hematocrit (Ht) (C) (HR, 0.85; 95% CI, 0.79-0.92) and high neutrophil-to-lymphocyte ratio (NLR) (C) (HR, 1.07; 95% CI, 1.07-1.10) were related to poor OS. Low Hb (C) (HR, 0.72; 95% CI, 0.58-0.88), red cell distribution width (RDW) (C-A) (HR, 1.16; 95% CI, 1.02-1.31), and NLR (C-A) (1.06; 95% CI, 1.03-1.09) were related to poor DFS. RDW (B-A) (HR, 1.15; 95% CI, 1.08-1.22), RDW (C) (HR, 1.12; 95% CI, 1.04-1.2), NLR (C) (HR, 1.12; 95% CI, 1.08-1.17) were related to systemic recurrence. CONCLUSION: Variables of routine blood count are easily assessable and their changes throughout trimodal therapy for esophageal carcinoma provide important information for cancer patient's prognosis.

LYMPHOCYTE COUNT AND PLATELET VOLUME PREDICTS POSTOPERATIVE COMPLICATIONS IN ESOPHAGECTOMY FOR CANCER: A COHORT STUDY.

BACKGROUND: Biomarkers from routine complete blood count are known predictive factors of long-term outcomes in cancer patients. The value of these biomarkers in the setting of trimodal therapy for esophageal cancer in predicting early postoperative outcomes is not studied. OBJECTIVE: The present study evaluated the value of cellular blood components changes during neoadjuvant chemoradiotherapy followed by curative intent esophagectomy for cancer in predicting postoperative mortality and morbidity. METHODS: A cohort of 149 consecutive patients that underwent chemoradiotherapy using platinum- and taxane-based regimens followed by esophagectomy was analyzed. Cellular components of blood collected before neoadjuvant therapy (period A) and before surgery (period B) were assessed for postoperative mortality and complications. Univariate and multivariate Cox regression models were applied to evaluate the independent prognostic significance of blood count variables. RESULTS: Postoperative morbidity was present in 46% of the patients. On multiple regression analysis platelet volume (B) (OR: 1.53; 95% CI: 1.2-2.33) was an independent predictor of general complications. Severe postoperative surgical complications were present in 17% of the patients. On multiple regression analysis, lymphocyte decrease between B-A periods (OR: 0.992; 95% CI: 0.990-0.997) was related to higher risk for severe complications. Cervical anastomotic leakage was present in 25.6% of the patients. On univariate analysis eosinophil count in A and B periods was related to cervical anastomotic leakage. For this outcome, multivariate joint model could not identify independent risk variables of cellular components of blood. The 30-day mortality rate was 7.4%. On univariate analysis, platelet count in period B was associated to higher risk for mortality. The multivariate joint model could not accurately predict mortality due to the few number of patients in the mortality group. CONCLUSION: This is the first study to assess the relationship between peripheral blood count variables changes during neoadjuvant chemoradiotherapy using a platinum- and taxane-based regimen followed by curative intent esophagectomy for cancer in predicting postoperative complications. The platelet volume prior to surgery is related to postoperative complications and the lymphocyte count change prior to surgery predicts severe postoperative complications in the setting of trimodal therapy for esophageal cancer.

Linfócitos e volume plaquetário estão associados a complicações pós-esofagectomia por câncer: um estudo de coorte / Lymphocyte count and platelet volume predicts postoperative complications in esophagectomy for cancer: a cohort study

ABSTRACT BACKGROUND: Biomarkers from routine complete blood count are known predictive factors of long-term outcomes in cancer patients. The value of these biomarkers in the setting of trimodal therapy for esophageal cancer in predicting early postoperative outcomes is not studied. OBJECTIVE: The present study evaluated the value of cellular blood components changes during neoadjuvant chemoradiotherapy followed by curative intent esophagectomy for cancer in predicting postoperative mortality and morbidity. METHODS: A cohort of 149 consecutive patients that underwent chemoradiotherapy using platinum- and taxane-based regimens followed by esophagectomy was analyzed. Cellular components of blood collected before neoadjuvant therapy (period A) and before surgery (period B) were assessed for postoperative mortality and complications. Univariate and multivariate Cox regression models were applied to evaluate the independent prognostic significance of blood count variables. RESULTS: Postoperative morbidity was present in 46% of the patients. On multiple regression analysis platelet volume (B) (OR: 1.53; 95% CI: 1.2-2.33) was an independent predictor of general complications. Severe postoperative surgical complications were present in 17% of the patients. On multiple regression analysis, lymphocyte decrease between B-A periods (OR: 0.992; 95% CI: 0.990-0.997) was related to higher risk for severe complications. Cervical anastomotic leakage was present in 25.6% of the patients. On univariate analysis eosinophil count in A and B periods was related to cervical anastomotic leakage. For this outcome, multivariate joint model could not identify independent risk variables of cellular components of blood. The 30-day mortality rate was 7.4%. On univariate analysis, platelet count in period B was associated to higher risk for mortality. The multivariate joint model could not accurately predict mortality due to the few number of patients in the mortality group. CONCLUSION: This is the first study to assess the relationship between peripheral blood count variables changes during neoadjuvant chemoradiotherapy using a platinum- and taxane-based regimen followed by curative intent esophagectomy for cancer in predicting postoperative complications. The platelet volume prior to surgery is related to postoperative complications and the lymphocyte count change prior to surgery predicts severe postoperative complications in the setting of trimodal therapy for esophageal cancer.

RESUMO CONTEXTO: Os biomarcadores obtidos do hemograma completo são fatores prognósticos a longo prazo em pacientes com câncer. No entanto, o valor desses biomarcadores no contexto da terapia trimodal para o câncer de esôfago na predição de resultados pós-operatórios precoces não é estudado. OBJETIVO: O presente estudo avaliou o papel dos componentes celulares do sangue na predição de mortalidade e morbidade pós-operatória. MÉTODOS: Uma coorte de 149 pacientes consecutivos submetidos à quimiorradioterapia usando esquemas baseados em platina e taxano seguidos por esofagectomia foi analisada. Os componentes celulares do sangue coletados antes da terapia neoadjuvante (período A) e antes da cirurgia (período B) foram avaliados quanto à mortalidade e complicações pós-operatórias. Modelos de regressão de Cox univariada e multivariada foram aplicados para avaliar a significância prognóstica independente das variáveis da contagem sanguínea. RESULTADOS: A morbidade pós-operatória esteve presente em 46% dos pacientes. Na análise de regressão múltipla, o volume plaquetário (B) (OR: 1,53; IC95%: 1,2-2,33) foi um preditor independente de complicações gerais. Complicações cirúrgicas pós-operatórias graves estavam presentes em 17% dos pacientes. Na análise de regressão múltipla, a diminuição de linfócitos entre os períodos B-A (OR: 0,992; 95% CI: 0,990-0,997) esteve relacionada ao maior risco de complicações graves. Fístula da anastomose cervical esteve presente em 25,6% dos pacientes. Na análise univariada, a contagem de eosinófilos nos períodos A e B relacionou-se com a fístula da anastomose cervical. Para este resultado, o modelo multivariado de articulação não conseguiu identificar variáveis de risco independentes entre os componentes celulares do sangue. A taxa de mortalidade em 30 dias foi de 7,4%. Na análise univariada, a contagem no período B foi associada a maior risco de mortalidade. O modelo multivariado de articulação não pôde predizer mortalidade devido ao pequeno número de pacientes no grupo de mortalidade. CONCLUSÃO: Este é o primeiro estudo a avaliar o papel das variáveis do hemograma durante a quimiorradioterapia neoadjuvante para câncer na predição de complicações pós-operatórias. Volume plaquetário e variação da contagem de linfócitos séricos antes da cirurgia podem ser utilizados como biomarcadores preditivos de complicações pós-operatórias nos pacientes com neoplasia de esôfago submetidos a terapia trimodal.

Chronic meningococcemia: a rare presentation of meningococcal disease: case report.

Chronic meningococcemia is a rare clinical presentation within the spectrum of infections due to Neisseria -en.jpg-en.jpgmeningitidis, which was first described in 1902. It is defined as a chronic and benign meningococcal bacteremia without meningeal signs or symptoms with at least one week's duration, characterized by intermittent or continuous fever, polymorphic cutaneous rash, and migratory arthropathy. The incidence is believed to be around 1:200,000 inhabitants. It affects predominantly young people and adults, and it is equally distributed between genders. Diagnosis may be challenging in the early stages of the disease because of the difficulty in isolating Neisseria -en.jpg-en.jpgmeningitidis (it reaches 74% of positivity in advanced stages). Recently, the use of PCR for detecting Neisseria -en.jpg-en.jpgsp antigen in skin biopsies specimens has been considered for those culture-negative cases. The authors report a case of a 54-year-old female patient who sought medical attention for a five-day fever followed by arthralgia and skin lesions predominantly in the lower limbs. The patient progressed to a toxemic clinical status that improved after the administration of antibiotic therapy, which consisted of oxacillin and ceftriaxone. The diagnosis of chronic meningococcemia was performed after the isolation of Neisseria meningitidis in two different blood sample cultures. This is, to our knowledge, the first case of chronic meningococcemia described in Brazil (up to the writing of this report).