A new simple score to predict mortality of COVID-19 in the emergency department

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is one of the greatest challenges facing global medical research. The availability of a clinical score that can predict mortality risk at the time of diagnosis could be a valuable tool in the hands of emergency physicians to make clinical decisions. Our study is designed to evaluate clinical and laboratory endpoints associated with mortality and to determine a prognostic score based on clinical and laboratory variables. We retrospectively enrolled 367 patients diagnosed with coronavirus disease 19 (COVID-19) in our emergency department (ED). We evaluated their mortality 60 days after diagnosis. Symptoms, demographic data, concomitant diseases, and various laboratory parameters were obtained from all patients. Variables related to death were assessed using multiple logistic regression analysis. From these, we created a score called ANCOC (Age, blood urea Nitrogen, C-reactive protein, Oxygen saturation, Comorbidities). The area under the receiver operating characteristic (ROC) curve was calculated for the ANCOC and for the 4C score. The 4C score has been described and validated in previous works and can predict mortality in COVID-19 patients. We compared the 2 scores and analysed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for 60-day mortality for the ANCOC score. The ANCOC and 4C scores accurately predicted death from COVID-19. There were no differences in accuracy between the scores. An ANCOC score <-1 identified patients who will recover with a PPV and sensitivity of 100%, whereas a score >3 identified patients at high risk of death. The ANCOC score has very high diagnostic accuracy in predicting the risk of death in patients with COVID-19 diagnosed at ED. The ANCOC score has similar accuracy to the 4C score but is easier to calculate. If validated by external cohorts, this score could be an additional tool in the hands of ED physicians to identify COVID-19 patients at high risk of death.Copyright © 2023 The Author(s). Published by MRE Press.

How to handle occupational well-being of critical care workers. A lesson from the pandemic : Nicola Magnavita

Background The PSIC study (Prospective Study of Intensivists and COVID-19) monitored the intensivists working in one of the two COVID-19 hub hospitals in Central Italy over 2 years from April 2020. This study showed how mental health varies in relation to the stressors posed by the different pandemic phases. Methods In 4 surveys corresponding to the 4 pandemic waves, the intensivists were invited to indicate changes in work activity and measure their state of mental health using standardized questionnaires administered via SurveyMonkey. Results During the pandemic there was a change in occupational stressors that led to insomnia, anxiety, depression, burnout, job dissatisfaction, unhappiness and intention to quit. The predominant stressors in the first wave were fear of unprotected exposure, distrust of safety measures, and compassion fatigue from having to inform relatives of the adverse outcome of treatment. In the second and third waves the workload, the monotony due to always following only one type of patient, the isolation, and the lack of time to meditate were the more relevant factors. The fourth wave added the stress deriving from interacting with anti-vax patients Conclusions Specific prevention strategies have been developed and applied for each of the stress factors identified. Excessive workload and lack of time for meditation originated from lack of staff were remedied with extraordinary temporary hires. The management of compassion fatigue and relations with anti-vax people were addressed with specific policies and training. The monotony and isolation in COVID-19 wards can only be resolved through employee turnover in ordinary departments. Organizational and financial efforts are necessary to protect the health of intensivists during a pandemic. Key messages • Monitoring of critical care workers during the pandemic waves indicated the preventive measures necessary to ensure their mental health and quality of care. • Protecting healthcare workers is a priority.

A longitudinal study of frontline health care workers during the pandemic

Introduction: Occupational stressors have continuously varied throughout the COVID-19 pandemic. Only a prospective study can fully describe the phenomenon. Material and Methods: A one-year longitudinal study was performed in correspondence with the first three pandemic waves from April 2020 to June 2021 in the intensivists of a COVID-19 hub hospital. Changes in work activity due to the pandemic were measured together with the perception of organizational justice, occupational stress, sleep quality, anxiety, depression, burnout, job satisfaction, happiness, and intention to quit. The participation rate was over 60% in each of the three surveys. The Catholic University Ethics Committee had approved the study (ID 3292). Results: The various pandemic waves have placed different stressors and generated corresponding reactions in the workers. After the 3rd wave, 59.2% reported at least one unprotected exposure to COVID-19 patients and 19.2% had contracted the infection. Confidence in safety measures was low and occupational stressors (excessive workload, isolation, compassion fatigue, lack of time for meditation and physical activity) were present. Consequently, distress (73%), sleep problems (28%), anxiety (25%), and depression rate (64%) remained unacceptably high. Conclusions: Clearly, the situation illustrated in our study calls for preventive and supportive action. Preventive interventions are difficult to implement but cannot be postponed. Participatory involvement in safety procedures, increased intangible rewards, increased attention to meditation and sleep are recommended.

Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxemic respiratory failure (PRONELIFE)-protocol for a randomized clinical trial.

BACKGROUND: It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS: The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION: The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION: ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).

Household disinfectant exposure during the COVID-19 pandemic: a retrospective study of the data from an Italian poison control center.

OBJECTIVE: Since the beginning of the COVID-19 pandemic it has been recommended that chemical disinfectants are used to protect surfaces. This study aimed to determine whether the number of exposure calls related to household disinfectants (HD) received between January 30, 2020 to May 18, 2020 varied from the same time period in the previous year. MATERIALS AND METHODS: A retrospective review of the poison control center database from the Fondazione Universitario Policlinico Agostino Gemelli IRCCS, Rome, Italy, was conducted. Calls from Italian citizens, hospitals, and general practitioners received during the same time period in 2019 and 2020 were compared. RESULTS: The center received 1972 exposure calls during the study period. A 5% increase in calls regarding exposure to HDs was noted from 2019 to 2020 (9.8% to 15.2%, p<0.001). The majority of enquiries regarded bleach-containing products, hand sanitizers, ethanol, and hydrogen peroxide. Most calls were received from patients in their homes (n, 259; prevalence, 86%; increase, 107%) and concerned accidental exposure (n, 280; prevalence, 93%; increase, 76%), while cases of intentional exposure decreased (n, 14; prevalence, 5%; decrease, 33%). The main route of exposure was ingestion (n, 170; prevalence, 57%; increase, 45%), but the highest increase was observed in inhalation cases (n, 82; prevalence, 27%; increase, 122%). CONCLUSIONS: As the incidence of enquiries regarding products that can represent an important health hazard, when improperly used, increased in 2020 suggests that the COVID-19 public health messaging on the proper use of HDs should be improved.

Optimal symptom combinations to aid COVID-19 case identification: Analysis from a community-based, prospective, observational cohort.

OBJECTIVES: Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health. METHODS: UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity. FINDINGS: UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC. INTERPRETATION: We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.

Thromboelastography clot strength profiles and effect of systemic anticoagulation in COVID-19 acute respiratory distress syndrome: a prospective, observational study.

OBJECTIVE: Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection may yield a hypercoagulable state with fibrinolysis impairment. We conducted a single-center observational study with the aim of analyzing the coagulation patterns of intensive care unit (ICU) COVID-19 patients with both standard laboratory and viscoelastic tests. The presence of coagulopathy at the onset of the infection and after seven days of systemic anticoagulant therapy was investigated. PATIENTS AND METHODS: Forty consecutive SARS-CoV-2 patients, admitted to the ICU of a University hospital in Italy between 29th February and 30th March 2020 were enrolled in the study, providing they fulfilled the acute respiratory distress syndrome criteria. They received full-dose anticoagulation, including Enoxaparin 0.5 mg·kg-1 subcutaneously twice a day, unfractionated Heparin 7500 units subcutaneously three times daily, or low-intensity Heparin infusion. Thromboelastographic (TEG) and laboratory parameters were measured at admission and after seven days. RESULTS: At baseline, patients showed elevated fibrinogen activity [rTEG-Ang 80.5° (78.7 to 81.5); TEG-ACT 78.5 sec (69.2 to 87.9)] and an increase in the maximum amplitude of clot strength [FF-MA 42.2 mm (30.9 to 49.2)]. No alterations in time of the enzymatic phase of coagulation [CKH-K and CKH-R, 1.1 min (0.85 to 1.3) and 6.6 min (5.2 to 7.5), respectively] were observed. Absent lysis of the clot at 30 minutes (LY30) was observed in all the studied population. Standard coagulation parameters were within the physiological range: [INR 1.09 (1.01 to 1.20), aPTT 34.5 sec (29.7 to 42.2), antithrombin 97.5% (89.5 to 115)]. However, plasma fibrinogen [512.5 mg·dl-1 (303.5 to 605)], and D-dimer levels [1752.5 ng·ml-1 (698.5 to 4434.5)], were persistently increased above the reference range. After seven days of full-dose anticoagulation, average TEG parameters were not different from baseline (rTEG-Ang p = 0.13, TEG-ACT p = 0.58, FF-MA p = 0.24, CK-R p = 0.19, CKH-R p  = 0.35), and a persistent increase in white blood cell count, platelet count and D-dimer was observed (white blood cell count p < 0.01, neutrophil count p = 0.02, lymphocyte count p < 0.01, platelet count p = 0.13 < 0.01, D-dimer levels p= 0.02). CONCLUSIONS: SARS-CoV-2 patients with acute respiratory distress syndrome show elevated fibrinogen activity, high D-dimer levels and maximum amplitude of clot strength. Platelet count, fibrinogen, and standard coagulation tests do not indicate a disseminated intravascular coagulation. At seven days, thromboelastographic abnormalities persist despite full-dose anticoagulation.

Optimal symptom combinations to aid COVID-19 case identification: analysis from a community-based, prospective, observational cohort.

OBJECTIVES: Diagnostic work-up following any COVID-19 associated symptom will lead to extensive testing, potentially overwhelming laboratory capacity whilst primarily yielding negative results. We aimed to identify optimal symptom combinations to capture most cases using fewer tests with implications for COVID-19 vaccine developers across different resource settings and public health. METHODS: UK and US users of the COVID-19 Symptom Study app who reported new-onset symptoms and an RT-PCR test within seven days of symptom onset were included. Sensitivity, specificity, and number of RT-PCR tests needed to identify one case (test per case [TPC]) were calculated for different symptom combinations. A multi-objective evolutionary algorithm was applied to generate combinations with optimal trade-offs between sensitivity and specificity. FINDINGS: UK and US cohorts included 122,305 (1,202 positives) and 3,162 (79 positive) individuals. Within three days of symptom onset, the COVID-19 specific symptom combination (cough, dyspnoea, fever, anosmia/ageusia) identified 69% of cases requiring 47 TPC. The combination with highest sensitivity (fatigue, anosmia/ageusia, cough, diarrhoea, headache, sore throat) identified 96% cases requiring 96 TPC. INTERPRETATION: We confirmed the significance of COVID-19 specific symptoms for triggering RT-PCR and identified additional symptom combinations with optimal trade-offs between sensitivity and specificity that maximize case capture given different resource settings.