No abstract

Introduction The outcomes related to different anticoagulation doses in Coronavirus disease 2019 (COVID-19) patients are not well established. COVID-19 is associated with increased thrombotic events and early coagulopathy as reported by a large New York City health system. Initial studies on patients in Wuhan, China showed anticoagulant therapy mainly with low molecular weight heparin was reported to be associated with better prognosis in severe COVID-19 patients meeting sepsis-induced coagulopathy criteria or with markedly elevated D-dimer. These studies fueled the need for anticoagulation protocols to be institutionalized broadly. Here we report the outcomes of patients on prophylactic compared to treatment dose anticoagulation early in the COVID-19 pandemic. This data reflects results before broad institutionalization of anticoagulation protocols for this novel disease in a Brooklyn, New York population. Methods This is a retrospective chart review of all laboratory confirmed COVID-19 patients who were admitted to New York-Presbyterian Brooklyn Methodist Hospital between March and April, 2020. Patient clinical characteristics were manually extracted from electronic medical records. Patients were divided into 2 groups: patients on treatment dose anticoagulation and patients on prophylactic dose anticoagulation. Primary outcome of this study was inpatient mortality among the two groups. Secondary outcomes were thromboembolisms (both arterial and venous), myocardial infarction (MI), major bleeding, ICU admission, ICU length of stay, invasive mechanical ventilation and initiation of dialysis. Odds ratio and p-values were obtained using univariate analysis. Results We analyzed 580 hospitalized patients with confirmed nasopharyngeal COVID19 infection. Of these, 82 patients were on treatment dose anticoagulation 498 patients were on prophylactic dose. Median age was 70 years in treatment dose group and 66 years in prophylactic dose group. Percentage of males were similar between both groups (53%). African American race(56% vs 46%) was the predominant race in both groups. Median BMI was 28.1 in both groups. Percentage of smokers was higher in the treatment dose group (34% compared to 21%). Patients in the treatment dose group had a higher rate of all the comorbidities. Median D-Dimer (630 vs 590) was higher in the treatment dose group. Rates of ICU admission in treatment dose group and prophylactic dose group was 44% and 22% respectively. Patients requiring intubation (43% vs 24%) and transfusion (24% and 7%) were higher in the treatment dose group. There was an increased incidence of thromboembolic events in the treatment dose group as compared to prophylactic dose group with DVT (15.6% vs 1.6%) PE (3.7% vs 0.2%), arterial thrombosis (1.2% vs 0%) and MI (6.1% vs 1.6%). Incidence of major bleeding was higher in the treatment group (10% vs3.5%) Discussion Our study found increased inpatient mortality with treatment dose anticoagulation and increased risk of bleeding when compared with prophylactic dose anticoagulation. These findings may be due to higher rates of comorbidities, smoking and older age when compared to the prophylactic anticoagulation group. Higher rates of bleeding raises concern for the safety of treatment dose anticoagulation in these populations. Some limitations of this study include: uneven sample size between the two groups and data was collected from patients before anticoagulation dose recommendations were standardized and officially implemented. Further randomized control trials are needed to evaluate the dose- dependent relationship between anticoagulation and mortality. Our study suggests that the treatment dose anticoagulation may adversely affect the outcomes in COVID-19 patients who are older and have multiple comorbidities. Therefore, the anticoagulation dose must be chosen carefully given the overall clinical picture. Disclosures No relevant conflicts of interest to declare.

Hepatocellular carcinoma remains a leading cause of cancer-related deaths worldwide. Liver disease including cirrhosis and viral hepatitis remains among the leading causes of hepatocellular carcinoma and despite increased screening, many patients are diagnosed in the advanced stages precluding them from locoregional therapy. Therapeutic agents for advanced hepatocellular carcinoma were limited to Sorafenib for several years; however, with the emergence of molecular targeted therapies including tyrosine kinase inhibitors and vascular endothelial growth factor inhibitors, in addition to immunotherapies, the way hepatocellular carcinoma is treated has changed significantly. In this review, we summarize the key clinical trials that lead to the approval of these agents for systemic treatment of hepatocellular carcinoma and discuss the preferred sequence of treatment options as well as prospective studies for management of hepatocellular carcinoma.

Introduction: There is conflicting data on the association of blood type with COVID-19 infection. Recent studies have shown an association of blood type in acquisition of COVID-19 infection (Zhao et al., medRxiv 2020), but no association in terms of disease mortality (Latz, Ann Hematol 2020). Prior studies are limited due to lack of diversity. One of the largest studies conducted in China found blood type A conferred highest risk of acquiring COVID-19 infection (Zhao et al., medRxiv 2020). Similar results were found in which the odds of COVID-19 positive infection compared to negative test results were increased in blood group A and decreased in blood group O (Zietz et al., medRxiv 2020). There was no significant association between blood group and intubation or death. Neither of these studies addressed the association of blood groups with thromboembolism. This study aimed to evaluate the impact of blood types on outcomes of COVID-19 infection in a multiracial population. Methods: This is a retrospective electronic chart review of all patients admitted to New York-Presbyterian Brooklyn Methodist Hospital in Brooklyn, NY. All patients admitted from March 2020 to April 2020 who tested positive for SARS-CoV-2 nasopharyngeal swab were analyzed. Baseline patient characteristics and outcomes were entered manually by medical professionals via chart review using the electronic medical record (EMR). Baseline characteristics include blood group type, rhesus antigen status, age, gender, race, comorbid conditions, median initial and peak D-dimer. The primary endpoint was inpatient mortality. The secondary endpoints included thromboembolism (pulmonary embolism, deep venous thrombosis, arterial thrombosis), myocardial infarction, bleeding event, length of stay, intensive care unit admission, and intubation. Chi-square test for categorical variables was used to calculate statistical significance defined as p value ≤ .05 when comparing ABO blood group and rhesus antigen with mortality and development of thromboembolism. Results: Our study consisted of 249 patients that were COVID-19 positive with a documented blood group. Our population consisted of 51% of patients that identified as black, 35.7% that identified as white, and 17.7% that identified as Hispanic. Blood type B had the highest rate of patients that identified as black at 58.1% and blood type O had the highest rate that identified as Hispanic at 23.6%. When comparing blood groups A, AB, B and O to the rate of mortality the result was 46%, 44.4%, 41.9% and 50.9% respectively which was found to be not statistically significant (p=0.759). Rh positive patients had a 47.2% mortality rate while Rh negative patients had a 46.9% mortality rate however this was also found to be not statistically significant (p=0.954). Next, we compared development of thromboembolism during hospital stay in the A, AB, B, and O blood type groups and the rate was 8%, 11.1%, 9.3%, and 10.9% respectively with the results not being statistically significant when accounted for blood type (p=0.991). Rate of development of thromboembolism in Rh positive and negative patients was 9.3% and 9.4% respectively which was found to not be statistically significant as well (p=0.998). When looking at comorbidities, 70.2% of our patient population had hypertension and the second prevalent comorbidity was diabetes at 38.2% (Table 1). Discussion: In a diverse population, no association between ABO blood group, Rh status, and mortality was found which is similar to the conclusion found in prior studies done by Zhao et al. and Latz et al. in which the majority of the population was either Caucasian or Asian. Additionally, there is no association found between ABO blood group, Rh status and development of thromboembolism. Our patient population consisted mostly of minority groups. Prior studies have shown that blood type A has the highest risk of positive SARS-CoV-2 test whereas type O has the lowest risk of positive SARS-CoV-2 test. Our study further supplements this discovery by the conclusion that while blood type A conferred highest risk of acquiring COVID-19 infection, blood type had no significant association with mortality. Investigation on a larger scale is necessary to address the susceptibility of ABO blood group and COVID-19 infection severity in a multiracial population to address racial disparities. Disclosures No relevant conflicts of interest to declare.