Background The mainstay of control of the coronavirus disease 2019 (Covid-19) pandemic is vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Within a year, several vaccines have been developed and millions of doses delivered. Reporting of adverse events is a critical postmarketing activity. Methods We report findings in 23 patients who presented with thrombosis and thrombocytopenia 6 to 24 days after receiving the first dose of the ChAdOx1 nCoV-19 vaccine (AstraZeneca). On the basis of their clinical and laboratory features, we identify a novel underlying mechanism and address the therapeutic implications. Results In the absence of previous prothrombotic medical conditions, 22 patients presented with acute thrombocytopenia and thrombosis, primarily cerebral venous thrombosis, and 1 patient presented with isolated thrombocytopenia and a hemorrhagic phenotype. All the patients had low or normal fibrinogen levels and elevated d -dimer levels at presentation. No evidence of thrombophilia or causative precipitants was identified. Testing for antibodies to platelet factor 4 (PF4) was positive in 22 patients (with 1 equivocal result) and negative in 1 patient. On the basis of the pathophysiological features observed in these patients, we recommend that treatment with platelet transfusions be avoided because of the risk of progression in thrombotic symptoms and that the administration of a nonheparin anticoagulant agent and intravenous immune globulin be considered for the first occurrence of these symptoms. Conclusions Vaccination against SARS-CoV-2 remains critical for control of the Covid-19 pandemic. A pathogenic PF4-dependent syndrome, unrelated to the use of heparin therapy, can occur after the administration of the ChAdOx1 nCoV-19 vaccine. Rapid identification of this rare syndrome is important because of the therapeutic implications.

The ground-state energies of H2, LiH, Li2, and H2O are calculated by a fixed-node quantum Monte Carlo method, which is presented in detail. For each molecule, relatively simple trial wave functions ΨT are chosen. Each ΨT consists of a single Slater determinant of molecular orbitals multiplied by a product of pair-correlation (Jastrow) functions. These wave functions are used as importance functions in a stochastic approach that solves the Schrödinger equation by treating it as a diffusion equation. In this approach, ΨT serves as a ‘‘guiding function’’ for a random walk of the electrons through configuration space. In the fixed-node approximation used here, the diffusion process is confined to connected regions of space, bounded by the nodes (zeros) of ΨT. This approximation simplifies the treatment of Fermi statistics, since within each region an electronic probability amplitude is obtained which does not change sign. Within these approximate boundaries, however, the Fermi problem is solved exactly. The energy obtained by this procedure is shown to be an upper bound to the true energy. For the molecular systems treated, at least as much of the correlation energy is accounted for with the relatively simple ΨT’s used here as by the best configuration interaction calculations presently available.

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