After surge in COVID-19 cases, Spain reinstates restrictions

Washington, Apr 28: After nearly three weeks in an intensive care unit in Los Angeles, doctors treating 41-year-old Broadway actor Nick Cordero for COVID-19 were forced to amputate his right leg.

The flow of blood had been impeded by a blood clot: yet another dangerous complication of the disease that has been bubbling up in frontline reports from China, Europe and the United States.

To be sure, so-called "thrombotic events" occur for a variety of reasons among intensive care patients, but the rates among COVID-19 patients are far higher than would be otherwise expected.

"I have had 40-year-olds in my ICU who have clots in their fingers that look like they'll lose the finger, but there's no other reason to lose the finger than the virus," Shari Brosnahan, a critical care doctor at NYU Langone said.

One of these patients is suffering from a lack of blood flow to both feet and both hands, and she predicts an amputation may be necessary, or the blood vessels may get so damaged that an extremity could drop off by itself.

Blood clots aren't just dangerous for our limbs, but can make their way to the lungs, heart or brain, where they may cause lethal pulmonary embolisms, heart attacks, and strokes.

A recent paper from the Netherlands in the journal Thrombosis Research found that 31 percent of 184 patients suffered thrombotic complications, a figure that the researchers called "remarkably high" -- even if extreme consequences like amputation are rare.

Behnood Bikdeli, a doctor at New York-Presbyterian Hospital, assembled an international consortium of experts to study the issue. Their findings were published in the Journal of The American College of Cardiology.

The experts found the risks were so great that COVID-19 patients "may need to receive blood thinners, preventively, prophylactically," even before imaging tests are ordered, said Bikdeli.

What exactly is causing it? The reasons aren't fully understood, but he offered several possible explanations.

People with severe forms of COVID-19 often have underlying medical conditions like heart or lung disease -- which are themselves linked to higher rates of clotting.

Next, being in intensive care makes a person likelier to develop a clot because they are staying still for so long. That's why for example people are encouraged to stretch and move around on long haul flights.

It's also now clear the COVID-19 illness is associated with an abnormal immune reaction called "cytokine storm" -- and some research has indicated this too is linked to higher rates of clotting.

There could also be something about the virus itself that is causing coagulation, which has some precedent in other viral illnesses.

A paper in the journal The Lancet last week showed that the virus can infect the inner cell layer of organs and of blood vessels, called the endothelium. This, in theory, could interfere with the clotting process.

According to Brosnahan, while thinners like Heparin are effective in some patients, they don't work for all patients because the clots are at times too small.

"There are too many microclots," she said. "We're not sure exactly where they are."

Autopsies have in fact shown some people's lungs filled with hundreds of microclots.

The arrival of a new mystery however helps solve a slightly older one.

Cecilia Mirant-Borde, an intensive care doctor at a military veterans hospital in Manhattan, told AFP that lungs filled with microclots helped explain why ventilators work poorly for patients with low blood oxygen.

Earlier in the pandemic doctors were treating these patients according to protocols developed for acute respiratory distress syndrome, sometimes known as "wet lung."

But in some cases, "it's not because the lungs are occupied with water" -- rather, it's that the microclotting is blocking circulation and blood is leaving the lungs with less oxygen than it should.

It has just been a little under five months since the virus emerged in Wuhan, China, and researchers are learning more about its impact every day.

"While we react surprised, we shouldn't be as surprised as we were. Viruses tend to do weird things," said Brosnahan.

While the dizzying array of complications may seem daunting, "it's possible there'll be one or a couple of unifying mechanisms that describe how this damage happens," she said.

"It's possible it's all the same thing, and that there'll be the same solution."

The Japan government on Monday decided to lift the state of emergency for COVID-19 in Tokyo and four other prefectures of the country, the only places where the measure implemented to curb the pandemic had remained in force.

The lifting of the alert was backed by the coronavirus advisory panel and will be formally approved by the government later day, the economic revitalization minister and head of the working group to coordinate Japan's fight against COVID-19, Yasutoshi Nishimura, said.

The Japanese authorities made the decision after taking into account the number of infections and the situation of the health system in Tokyo, the three neighbouring prefectures of Chiba, Kanagawa and Saitama and the northern Hokkaido, the only ones where the state of emergency declared more than a month ago to control the pandemic remained in effect, reports Efe news.

The health alert was initially declared in Tokyo and six other prefectures on April 17 and subsequently extended across the country.

It allowed local authorities to ban large-scale public events and close bars and restaurants at night, among other measures, while the government has launched a campaign to encourage teleworking and staying at home.

The government resorted to this measure for the first time in the country's recent history to contain the spread of the virus and is now withdrawing it after a sustained slowdown in infections throughout the archipelago, where around 16,600 confirmed COVID-19 cases and 839 deaths have been recorded, according to the latest data.

The group of experts advising the government appreciated the efforts made by citizens to comply with the recommendations to achieve the target of reducing interpersonal contact by 80 percent, top government spokesperson Yoshihide Suga said at a press conference on Monday.

The recommendation for citizens to avoid unnecessary trips outside and the request for non-essential businesses to close were not mandatory nor accompanied by fines or other penalties for non-compliance, unlike the stricter containment measures implemented in other countries.

The government plans to formally approve the lifting of the state of emergency on Monday after consulting with other political parties in parliament and another meeting with the advisory panel, following which Japanese Prime Minister Shinzo Abe will hold a press conference.

The government had already decided to lift the emergency in 39 prefectures on May 14 after they reported a marked decrease in the number of infections, leaving out the more populated regions such as Tokyo and Osaka.

To avoid new outbreaks of the virus, Abe has urged people to become accustomed to a "new lifestyle" that includes maintaining social distancing, the use of masks outside as well as a series of guidelines for the reopening of shops, restaurants and public facilities.