Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. This process can be modified by lifestyle adjustments, pharmacological therapies, and invasive interventions designed to achieve disease stabilization or regression. The disease can have long, stable periods but can also become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion. However, the disease is chronic, most often progressive, and hence serious, even in clinically apparently silent periods. The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). The Guidelines presented here refer to the management of patients with CCS. The natural history of CCS is illustrated in Figure 1.

/pdf/2019-esc-guidelines-for-the-diagnosis-and-management-of-5b7mv2v506.pdf

2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.

European Resuscitation Council Guidelines for Resuscitation.

Hemophilia is a rare disorder that is complex to diagnose and to manage. These evidence-based guidelines offer practical recommendations on the diagnosis and general management of hemophilia, as well as the management of complications including musculoskeletal issues, inhibitors, and transfusion-transmitted infections. By compiling these guidelines, the World Federation of Hemophilia aims to assist healthcare providers seeking to initiate and/or maintain hemophilia care programs, encourage practice harmonization around the world and, where recommendations lack adequate evidence, stimulate appropriate studies.

/pdf/guidelines-for-the-management-of-hemophilia-1x6t2d999b.pdf

Guidelines for the management of hemophilia.

a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS2 index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS2 score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6. Conclusion The 2 existing classification schemes and especially a new stroke risk index, CHADS2, can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

Validation of clinical classification schemes for predicting stroke: results from the national registry of atrial fibrillation☆

We represent an update on diagnosing and treatment of vitamin B12 deficiency. Vitamin B12 deficiency should be suspected in all patients with unexplained anaemia and/or neurological symptoms,as well as in patients at risk of developing vitamin B12 deficiency such as the elderly and patients with intestinal diseases. Measurement of plasma cobalamins is suggested as the primary analysis followed by measurement of plasma methylmalonic acid in unsettled cases. Accumulating evidence indicates that the biologically active cobalamin,plasma holotranscobalamin (holoTC),may be superior to plasma cobalamins, and measurement of holoTC is currently introduced in the clinical setting. No consensus exists concerning evaluation of the cause for vitamin B12 deficiency,and pros and cons on the different tests mainly aiming at evaluation of the function of the gastric mucosa are presented. Once the diagnosis of vitamin B12 deficiency has been confirmed efficient treatment can be ensured either by injections every 2-3 month or by a daily dose of 1 mg vitamin B12.

Diagnosis and treatment of vitamin B12 deficiency--an update.

Platelets newly released from the bone marrow are RNA-containing and more haemostatically active than mature platelets. Immature platelets are reliably quantified by flow cytometry, and the immature platelet fraction (IPF) reflects platelet production and the rate of platelet turnover. It was the objective of this study to evaluate the presence of immature platelets in healthy subjects, patients with stable coronary artery disease (CAD) and patients with acute coronary syndromes. Flow cytometric determination of immature platelets was performed with an automated analyzer (Sysmex XE-2100) using RNA fluorescent dyes. IPF was determined in 420 individuals: 22 healthy subjects, 39 patients with stable CAD, 182 patients with unstable angina/non-ST-segment elevation myocardial infarction (non-STEMI) and 177 patients with acute STEMI. The geometric mean [95% confidence interval] of IPF was 2.51 [2.04-3.10] in healthy subjects, 2.87 [2.45-3.36] in CAD patients, 2.93 [2.72-3.15] in the non-STEMI/unstable angina group and 3.71 [3.45-3.99] in patients with STEMI (ANOVA: p < 0.0001). This difference remained significant after adjusting for baseline characteristics (p = 0.0003). In active smokers, IPF was 18% higher than in non-smoking individuals (p = 0.007), and IPF was 16% higher in diabetics compared with non-diabetics (p = 0.060). In conclusion, the fraction of immature platelets is increased in acute coronary syndromes, especially in the acute phase of STEMI. Immature platelets with an increased haemostatic potential may contribute to coronary thrombus formation.

Immature platelets in patients with acute coronary syndromes

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Objectives. The performance of holotranscobalamin (holoTC) was compared with the other markers of vitamin B12 deficiency, and the influence of age, renal function, and thyroid status was examined.



Design and interventions.  We examined 937 individuals not treated with vitamin B12 but in whom vitamin B12 deficiency was suspected because of a plasma methylmalonic acid (MMA) above 0.28 μmol L−1 within the past 4 years. Besides laboratory tests, a structured interview and a neurological examination were performed amongst 534 individuals. Amongst these, 140 individuals qualified for a randomized trial (MMA 0.40–2.00 μmol L−1). They were randomized to injections with vitamin B12 or placebo and re-examined after 3 months.



Setting.  One university hospital in Aarhus, Denmark.



Results.  The ROC curves indicate that holoTC (AUC: 0.90) compared favourable with plasma vitamin B12 (AUC: 0.85) for identifying individuals likely to have vitamin B12 deficiency (MMA ≥0.75 μmol L−1 and plasma total homocysteine (tHcy) ≥15 μmol L−1), and further that holoTC (AUC: 0.91) might replace combined testing with plasma vitamin B12 and the metabolites. No association was observed between the biochemical markers and symptoms and signs possibly related to vitamin B12 deficiency. HoloTC, TC saturation, plasma vitamin B12, MMA, and tHcy were significantly associated with plasma creatinine (all with P < 0.001). Only tHcy was significantly associated with thyroid stimulating hormone (P =0.02).



Conclusions.  HoloTC shows promise as first-line tests for diagnosing early vitamin B12 deficiency.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2796.2004.01437.x

Holotranscobalamin – a first choice assay for diagnosing early vitamin B12 deficiency?

Background: A low level of vitamin B6 might theoretically cause depression as vitamin B6 is a cofactor in the tryptophan-serotonin pathway. In the present stud

Vitamin B6 level is associated with symptoms of depression.

Individualised antiplatelet therapy and platelet function testing have attracted considerable clinical interest, but several aspects of test performance have not been thoroughly evaluated. We investigated repeatability and concordance of light transmission aggregometry (LTA) induced with arachidonic acid (AA) 1.0 mM, PFA-100 induced with collagen/epinephrine, multiple electrode aggregometry (MEA) induced with AA 0.5 or 0.75 mM and VerifyNow Aspirin. Patients with stable coronary artery disease (n=43) and healthy individuals (n=21) were included. All tests were performed in duplicate at baseline in healthy individuals and in duplicate for four days in all study participants during aspirin treatment. Serum and urinary thromboxane metabolites were measured several times to evaluate cyclooxygenase-1 inhibition by aspirin. MEA was most sensitive for aspirin as treatment induced a 12-fold difference in AA-induced platelet aggregation. Coefficients of variation for duplicate measurements at baseline (0.4-12%), during aspirin treatment (3-46%) and for day-to-day variability (3-37%) differed markedly between tests and were lowest for VerifyNow. The prevalence of aspirin low-responsiveness also differed between tests (0-9%) and the agreement was low: kappa<or=0.21 for all tests compared with AA-induced LTA (reference test), which correlated best with VerifyNow (r=0.43, p<0.001). Urinary thromboxane metabolites did not correlate with any platelet function test, whereas serum thromboxane correlated with VerifyNow Aspirin (r=0.41, p=0.001). Overall, repeatability was moderate and the correlation between tests was low. VerifyNow Aspirin proved most reproducible, and this was the only assay showing a significant positive correlation with serum thromboxane. This study demonstrated that conclusions based on platelet function testing strongly depend on the assay used.

A comparison of platelet function tests and thromboxane metabolites to evaluate aspirin response in healthy individuals and patients with coronary artery disease

Anne-Mette Hvas

Papers

Diagnosis and treatment of vitamin B12 deficiency--an update.

Immature platelets in patients with acute coronary syndromes

Holotranscobalamin – a first choice assay for diagnosing early vitamin B12 deficiency?

Vitamin B6 level is associated with symptoms of depression.

A comparison of platelet function tests and thromboxane metabolites to evaluate aspirin response in healthy individuals and patients with coronary artery disease