COUNTERPOINT: Should Therapeutic Heparin Be Administered to Acutely Ill Hospitalized Patients With COVID-19? No

Jiménez, David; Rali, Parth; Doerschug, Kevin C.

doi:10.1016/j.chest.2022.01.037

Cited by 7 publications

(8 citation statements)

References 13 publications

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“…We agree with the point made by Jimenez et al 1 that consideration of bleeding risk is essential when evaluating administration of therapeutic anticoagulation. However, although well-intended, "first do not harm" is not an appropriate argument.…”

supporting

confidence: 90%

“…3 Some of the alleged limitations of RCTs evaluating therapeutic dose heparin in acutely ill patients with COVID-19 need to be addressed. 1 First, the fact that 20% of participants who were allocated to the therapeutic heparin arm in the multiplatform trial received less than therapeutic dose anticoagulation is not a reasonable concern. If anything, nonadherence to the study protocol would have diluted treatment effects and biased effect measures towards the null.…”

mentioning

confidence: 99%

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Rebuttal From Dr Tritschler et al

Tritschler

Gal

Brosnahan

et al. 2022

Chest

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supporting

confidence: 90%

mentioning

confidence: 99%

Rebuttal From Dr Tritschler et al

Tritschler

Gal

Brosnahan

et al. 2022

Chest

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“…However, among hospitalized patients not requiring ICU care, full dose anticoagulation has been reported to have benefits [38,39]. If and when to use higher dose anticoagulation remains controversial [40,41]. Our models suggest the possibility of benefit from the addition of anticoagulation to steroids.…”

Section: Plos Onementioning

confidence: 85%

Assessing the effects of therapeutic combinations on SARS-CoV-2 infected patient outcomes: A big data approach

Moradi¹,

Bunnell²,

Price³

et al. 2023

PLoS ONE

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Background The COVID-19 pandemic has demonstrated the need for efficient and comprehensive, simultaneous assessment of multiple combined novel therapies for viral infection across the range of illness severity. Randomized Controlled Trials (RCT) are the gold standard by which efficacy of therapeutic agents is demonstrated. However, they rarely are designed to assess treatment combinations across all relevant subgroups. A big data approach to analyzing real-world impacts of therapies may confirm or supplement RCT evidence to further assess effectiveness of therapeutic options for rapidly evolving diseases such as COVID-19. Methods Gradient Boosted Decision Tree, Deep and Convolutional Neural Network classifiers were implemented and trained on the National COVID Cohort Collaborative (N3C) data repository to predict the patients’ outcome of death or discharge. Models leveraged the patients’ characteristics, the severity of COVID-19 at diagnosis, and the calculated proportion of days on different treatment combinations after diagnosis as features to predict the outcome. Then, the most accurate model is utilized by eXplainable Artificial Intelligence (XAI) algorithms to provide insights about the learned treatment combination impacts on the model’s final outcome prediction. Results Gradient Boosted Decision Tree classifiers present the highest prediction accuracy in identifying patient outcomes with area under the receiver operator characteristic curve of 0.90 and accuracy of 0.81 for the outcomes of death or sufficient improvement to be discharged. The resulting model predicts the treatment combinations of anticoagulants and steroids are associated with the highest probability of improvement, followed by combined anticoagulants and targeted antivirals. In contrast, monotherapies of single drugs, including use of anticoagulants without steroid or antivirals are associated with poorer outcomes. Conclusions This machine learning model by accurately predicting the mortality provides insights about the treatment combinations associated with clinical improvement in COVID-19 patients. Analysis of the model’s components suggests benefit to treatment with combination of steroids, antivirals, and anticoagulant medication. The approach also provides a framework for simultaneously evaluating multiple real-world therapeutic combinations in future research studies.

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“…Many aspects of COVID-19 pathophysiology and treatment and prevention are possible causative factors. Among others, the difference in demographic and clinical characteristics of patients, changes in management strategies, including different anticoagulant regimens, and vaccination, and possibly the different impact of SARS-CoV-2 variants on coagulopathy, can play a significant role [20][21][22]. It is well known that SARS-CoV-2 through the binding to ACE2 receptor can trigger direct vascular injury, and may affect signaling pathways,…”

Section: Discussionmentioning

confidence: 99%

Incidence of lower limb deep vein thrombosis in patients with COVID-19 pneumonia through different waves of SARS-CoV-2 pandemic: A multicenter prospective study

et al. 2023

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Objective The aim of this study was to evaluate the incidence of deep vein thrombosis (DVT) of the lower limbs in patients hospitalized with COVID-19 pneumonia in a non-ICU setting according to the different waves of the SARS-CoV-2 pandemic. Methods Multicenter, prospective study of patients with COVID-19 pneumonia admitted to Internal Medicine units in Italy during the first (March-May 2020) and subsequent waves (November 2020 –April 2021) of the pandemic using a serial compression ultrasound (CUS) surveillance to detect DVT of the lower limbs. Results Three-hundred-sixty-three consecutive patients were enrolled. The pooled incidence of DVT was 8%: 13.5% in the first wave, and 4.2% in the subsequent waves (p = 0.002). The proportion of patients with early (< 4 days) detection of DVT was higher in patients during the first wave with respect to those of subsequent waves (8.1% vs 1.9%; p = 0.004). Patients enrolled in different waves had similar clinical characteristics, and thrombotic risk profile. Less patients during the first wave received intermediate/high dose anticoagulation with respect to those of the subsequent waves (40.5% vs 54.5%; p = 0.005); there was a significant difference in anticoagulant regimen and initiation of thromboprophylaxis at home (8.1% vs 25.1%; p<0.001). Conclusions In acutely ill patients with COVID-19 pneumonia, the incidence of DVT of the lower limbs showed a 3-fold decrease during the first with respect to the subsequent waves of the pandemic. A significant increase in thromboprophylaxis initiation prior to hospitalization, and the increase of the intensity of anticoagulation during hospitalization, likely, played a relevant role to explain this observation.

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COUNTERPOINT: Should Therapeutic Heparin Be Administered to Acutely Ill Hospitalized Patients With COVID-19? No

Cited by 7 publications

References 13 publications

Rebuttal From Dr Tritschler et al

Rebuttal From Dr Tritschler et al

Assessing the effects of therapeutic combinations on SARS-CoV-2 infected patient outcomes: A big data approach

Incidence of lower limb deep vein thrombosis in patients with COVID-19 pneumonia through different waves of SARS-CoV-2 pandemic: A multicenter prospective study

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