Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection. All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients. 150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups. Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.

/pdf/high-risk-of-thrombosis-in-patients-with-severe-sars-cov-2-33bb5czu95.pdf

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study.

How mental health care should change as a consequence of the COVID-19 pandemic.

Neutrophil extracellular traps contribute to immunothrombosis in COVID-19 acute respiratory distress syndrome.

Summary Assessment of long-term outcomes is essential in brain surgery for epilepsy, which is an irreversible intervention for a chronic condition. Excellent short-term results of resective epilepsy surgery have been established, but less is known about long-term outcomes. We performed a systematic review and meta-analysis of the evidence on this topic. To provide evidence-based estimates of longterm results of various types of epilepsy surgery and to identify sources of variation in results of published studies, we searched Medline, Index Medicus, the Cochrane database, bibliographies of reviews, original articles and book chapters to identify articles published since 1991 that contained >20 patients of any age, undergoing resective or non-resective epilepsy surgery, and followed for a mean/median of >5 years. Two reviewers independently assessed study eligibility and extracted data, resolving disagreements through discussion. Seventy-six articles fulfilled our eligibility criteria, of which 71 reported on resective surgery (93%) and five (7%) on non-resective surgery. There were no randomized trials and only six studies had a control group. Some articles contributed more than one study, yielding 83 studies of which 78 dealt with resective surgery and five with non-resective surgery. Forty studies (51%) of resective surgery referred to temporal lobe surgery, 25 (32%) to grouped temporal and extratemporal surgery, seven (9%) to frontal surgery, two (3%) to grouped extratemporal surgery, two (3%) to hemispherectomy, and one (1%) each to parietal and occipital surgery. In the non-resective category, three studies reported outcomes after callosotomy and two after multiple subpial transections. The median proportion of long-term seizure-free patients was 66% with temporal lobe resections, 46% with occipital and parietal resections, and 27% with frontal lobe resections. In the long term, only 35% of patients with callosotomy were free of most disabling seizures, and 16% with multiple subpial transections remained free of all seizures. The year of operation, duration of follow-up and outcome classification system were most strongly associated with outcomes. Almost all long-term outcome studies describe patient cohorts without controls. Although there is substantial variation in outcome definition and methodology among the studies, consistent patterns of results emerge for various surgical interventions after adjusting for sources of heterogeneity. The long-term (>5 years) seizure free rate following temporal lobe resective surgery was similar to that reported in short-term controlled studies. On the other hand, long-term seizure freedom was consistently lower after extratemporal surgery and palliative procedures.

/pdf/long-term-seizure-outcomes-following-epilepsy-surgery-a-414k6s3xqj.pdf

Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis.

Summary Surgery is widely accepted as an effective therapy for selected individuals with medically refractory epilepsy. Numerous studies in the past 20 years have reported seizure freedom for at least 1 year in 53–84% of patients after anteromesial temporal lobe resections for mesial temporal lobe sclerosis, in 66–100% of patients with dual pathology, in 36–76% of patients with localised neocortical epilepsy, and in 43–79% of patients after hemispherectomies. Reported rates for non-resective surgery have been less impressive in terms of seizure freedom; however, the benefit is more apparent when reported in terms of significant seizure reductions. In this Review, we consider the outcomes of surgery in adults and children with epilepsy and review studies of neurological and cognitive sequelae, psychiatric and behavioural outcomes, and overall health-related quality of life.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(08)70109-1.pdf

Outcomes of epilepsy surgery in adults and children

Allocating Scarce Medical Resources for Covid-19 The Covid-19 pandemic has already stressed health care systems throughout the world, requiring rationing of medical equipment and care. The authors ...

https://www.nejm.org/doi/pdf/10.1056/NEJMsb2005114?articleTools=true

Fair Allocation of Scarce Medical Resources in the Time of Covid-19.

Violence against health care professionals in the workplace is underreported and understudied. Additional data are needed to understand steps that might be taken to reduce the risk.

Workplace Violence against Health Care Workers in the United States.

The present investigation, using various rosetting assays of cell suspensions prepared by mechanical disaggregation or collagenase digestion, demonstrated lymphoreticular cells in human normal brain (cerebral cortex and cerebellum) and in malignant brain tumours. The study revealed T and B lymphocytes and their subsets (bearing receptors for Fc(IgG) and C3) in 5/14 glioma suspensions, comprising less than 15% of the cell population. Between 20-60% of cells in tumour suspensions morphologically resembled macrophages and less than or equal to 75% of these cells formed strong rosettes. Lymphocytes were not found in cancer-free (putatively normal) brain. Macrophages and the smaller "microglial cells" (both phagocytic, staining with sudan black, and expressing Fc(IgG) and C3 receptors) were found in normal brain in numbers similar to those in tumour suspensions, but with less rosetting avidity. These cells may be part of an immunological defence mechanism.

Lymphoreticular cells in human brain tumours and in normal brain.

We report our series of twenty consecutive patients who underwent corpus callosotomy for medically intractable epilepsy. The follow-up is 6.7±0.5 years. Sixteen of 20 patients (80%) had a favourable outcome. Six patients have remained free of major generalized motor seizures, and ten further patients experienced significant sustained reduction in the severity and frequency of the seizures. The type of seizures associated with improved outcome were drop attacks, and generalized tonic-clonic seizures, in 11 of 13 (85%) and 14 of 18 (78%) of the patients, respectively. In order to establish the extent of necessary callosal resection to achieve seizure control, the outcome of patients was correlated with the extent of callosal sectioning on postoperative magnetic resonance imaging. This study confirms that an anterior callosal resection of two-thirds (or 65%) is sufficient to achieve significant improvement in seizure control with an acceptable morbidity in judiciously selected patients with medically intractable epilepsy. Results also suggest that the patient's history and clinical classification of the seizures have prognostic value as selection criteria for patients referred for this operation. In this series, no prognostic value was established for pre-operative electroencephalographic patterns, or neuroimaging findings.

Anterior callosotomy in the management of intractable epileptic seizures: significance of the extent of resection.

As a result of the extensive integration of technology into the healthcare system, cybersecurity incidents have become an increasing challenge for the healthcare industry Recent examples include WannaCry, a nontargeted ransomware attack on more than 150 countries worldwide that temporarily crippled parts of the National Health Service in the United Kingdom, and the 2016 ransomware attack on Los Angeles's Hollywood Presbyterian Medical Center The attacks cost millions of dollars in lost revenue and fines, as well as significant reputational damage Efforts are needed to devise tools that allow experts to more accurately quantify the actual impact of such events on both individual patients and healthcare systems as a whole While the United States has robust disaster preparedness and response systems integrated throughout the healthcare and government sectors, the rapidly evolving cybersecurity threat against healthcare entities is outpacing existing countermeasures and challenges in the "all-hazards" disaster preparedness paradigm Further epidemiologic research of clinical cybersecurity attacks and their effects on patient care and clinical outcomes is necessary to prevent and mitigate future attacks

James P. Phillips

Papers

Fair Allocation of Scarce Medical Resources in the Time of Covid-19.

Workplace Violence against Health Care Workers in the United States.

Lymphoreticular cells in human brain tumours and in normal brain.

Anterior callosotomy in the management of intractable epileptic seizures: significance of the extent of resection.

Healthcare Challenges in the Era of Cybersecurity.