COVID-19 and aging: Identifying measures of severity.

INTRODUCTION: We aimed to compare clinical features of older age group and young and middle-aged patients with COVID-19 and analyze mortality predictors. METHODS: Retrospective analysis of ongoing collection of prespecified data, on a single institution, including patients hospitalized consecutively due to COVID-19 infection, from March to June 2020. RESULTS: Of 195 patients, 56.9% were ⩾65 years (older age group). Older age group had multimorbidity (p < 0.001). At admission Early Warning Score-2 (p < 0.001), C-reactive protein, D-dimer, creatinine, anemia and lymphopenia were higher in older age group, as well as median time of hospitalization (14 vs 10 days, p = 0.004). Complications were more common in older age group, but there were no significant differences in admission to intensive care. There were 18 deaths, 16 in older age group. Modified Early Warning Score at admission (odds ratio = 1.60, 95% confidence interval = 1.07-1.37, p = 0.021) and C-reactive protein >5 mg/dL (odds ratio = 2.12, 95% confidence interval = 1.13-26.26, p = 0.034) were independent predictors of inhospital mortality in older age group but not in young and middle-aged. CONCLUSION: Older age group was at higher risk for complications and inhospital mortality. Identification of specific scores of severity for this population is essential to ensure that best care is provided.

A Reflection on the Use of Enoxaparin Based on Three Case Reports.

Enoxaparin is indicated for the treatment or prevention of many clinical disorders including deep vein thromboembolism, atrial fibrillation and mechanical valve thrombosis. It is one of the most commonly prescribed drugs in hospitals. However, haemorrhagic complications can occur, particularly in the elderly, patients with renal function impairment and patients with a very high or very low body weight. The authors describe the cases of three patients who had one or more risk factors for haemorrhagic complications, such as abdominal haematomas. The clinical presentation was similar in all three cases, with sudden-onset abdominal pain, an altered state of consciousness and hypotension. In all cases, investigation showed acute anaemia and large abdominal haematomas on imaging studies. A conservative approach was taken in the three patients, with suspension and reversal of anticoagulation, fluid resuscitation and red blood cell transfusion. Haemodynamic stability was achieved in two of the patients, but the third patient died. The authors consider it is important to present these case reports because of the widespread use of enoxaparin, and the need for rigorous dose adjustment for renal function variations and body weight. We hope this article raises awareness of haemorrhagic complications in high-risk groups and propose protocols are introduced for dose adjustment and monitoring the efficacy of enoxaparin. LEARNING POINTS: Clinicians should consider the possibility of enoxaparin-associated haemorrhagic complications in high-risk groups.Prompt identification and treatment of the haemorrhagic disorder can improve outcome.Correct dosing with anti-Xa in high-risk populations, such as the elderly, those with abnormal renal function and those with extremely high or low body weight, may be helpful in patients anticoagulated with enoxaparin.

Acute Anaemia: A Challenging Diagnosis.

Acute anaemia is characterized by a reduction in the number of red blood cells, haemoglobin levels or haematocrit. By far the most common aetiology is haemorrhage, but in its absence other less frequent causes should be considered. The authors present the case of a 42-year-old man with a diagnosis of glucose-6-phosphate deficiency and progressing gastric signet ring cell carcinoma, who was admitted to the internal medicine department for symptomatic back pain control. During his hospitalization, the patient developed acute anaemia with schistocytes on peripheral blood smear with no concurrent hyperbilirubinaemia or decreased haptoglobin. Bone metastatic disease was documented. The case was revised with the transfusion medicine department and malignancy-associated microangiopathic haemolytic anaemia (Ma-MAHA) was suggested. The patient was transferred to the oncology department and later discharged, dying at home shortly afterwards. LEARNING POINTS: The possibility of multiple aetiologies for anaemia in the same patient should be considered.Pathophysiological mechanisms are important in the differential diagnosis of anaemia.Malignancy-associated microangiopathic haemolytic anaemia can present as a paraneoplastic syndrome.