Identification of predictive patient characteristics for assessing the probability of COVID-19 in-hospital mortality (preprint)

As the world emerges from the COVID-19 pandemic, there is an urgent need to understand patient factors that may be used to predict the occurrence of severe cases and patient mortality. Approximately 20% of SARS-CoV-2 infections lead to acute respiratory distress syndrome caused by the harmful actions of inflammatory mediators. Patients with severe COVID-19 are often afflicted with neurologic symptoms, and individuals with pre-existing neurodegenerative disease have an increased risk of severe COVID-19. Although collectively, these observations point to a bidirectional relationship between severe COVID-19 and neurologic disorders, little is known about the underlying mechanisms. Here, we analyzed the electronic health records of 471 patients with severe COVID-19 to identify clinical characteristics most predictive of mortality. Feature discovery was conducted by training a regularized logistic regression classifier that serves as a machine-learning model with an embedded feature selection capability. SHAP analysis using the trained classifier revealed that a small ensemble of readily observable clinical features, including characteristics associated with cognitive impairment, could predict in-hospital mortality with an accuracy greater than 0.85 (expressed as the area under the ROC curve of the classifier). These findings have important implications for the prioritization of clinical measures used to identify patients with COVID-19 (and, potentially, other forms of acute respiratory distress syndrome) having an elevated risk of death.

Patient Satisfaction with Clinical Laboratory Services in Public Health Sector Hospitals of Azad Kashmir, Pakistan

Objectives: To determine patient satisfaction and factors affecting patient satisfaction with laboratory services in Azad Jammu & Kashmir (AJK). Study Design: Cross-sectional study. Place and Duration of Study: Seven District Headquarter Hospitals, DHQ Neelum, DHQ Hattian Bala, DHQ Pallandari, DHQ Bagh, DHQ Kotli, DHQ Bhimber and DHQ Mirpur, Kashmir Pakistan from Dec 2019 to Feb 2020. Methodology: The patients who were referred from the Outdoor Patient Department of the hospital for undergoing investigative tests were included, and patients of age less than 18 and critically ill patients were excluded. Results: The total number of respondents included in the study was 400, with the median score of patient satisfaction with laboratory services being 59 (19), ranging from 32 to 100. Statistically significant disparities in client satisfaction were observed in different DHQ hospitals (p-value=0.01) with Mirpur (63) and Pallandri (40) showing the extreme variation. Residential area, age, and education level were also identified as statistically significant determinants of patient satisfaction (p-value <0.05). Conclusion: patient satisfaction with laboratory services in public hospitals of AJK was very low, and targeted strategies are needed to improve the overall quality of these services. © 2022, Army Medical College. All rights reserved.

Labor Policy Implementation in Informal Sector during COVID-19

The informal economy is the set of diversified economic activities where workers have limited access to labor welfare services given by the state. The informal sector has a great capacity to resolve the increasing problem of unemployment, especially in developing countries. A persistent gap exists in the literature that arouses the interest of researchers to examine the policy implementation concerning important demographic variables of households. In this connection, the current research has been conducted to investigate the labor policy implementation in the informal sector of Pakistan using primary data taken from division Bahawalpur, Pakistan. The data was collected through face-to-face interviews of 240 individuals by using multi-stage random sampling, and the logit model was applied to analyze the data. Empirical results of the study showed positive and significant relationship among occupation of the respondent, age of respondent, number of adults in the household, relation with local governance, education of the respondent, the income of the household, male-female ratio, kind of house and average education of the household on labor policy implementation in the informal sector of Pakistan. However, there the two variables (age and loan) are statistically insignificant to labor policy implementation. In the light of empirical results, the current study suggested that the awareness and level of education help to proper implementation of labor policy in the informal sector which directly affects the well-being of the people. Furthermore, Government should provide interest-free loans at the micro level to enhance economic empowerment. This study will also be helpful to the policymaker to develop better policies for the implementation of labor policy in the informal sector of Pakistan, as the informal sector of Pakistan's economy represents the major share in the country's GDP. © 2021 IEEE.

CovidNet: A Light-Weight CNN for the Detection of COVID-19 Using Chest X-Ray Images

Corona virus more popularly known as COVID-19 is an extremely virulent strain from the Corona virus family of viruses and their origin is attributed to bats and civet cats. Currently, there is no cure for this virus nor are there any vaccines available to prevent this. Chest X-ray images are used for diagnosing the presence of this virus in the human body. Chest X-rays can be diagnosed only by expert radiotherapists for evaluation. Thus, the development of a system that would detect whether a person is infected by the Corona virus or not without any delay would be very helpful for people as well as doctors. In this research article, we proposed a novel deep learning model named CovidNet to detect the presence of Corona virus in a human body. We performed extensive experiments on the proposed model and pre-trained models, and the experiments show that the proposed model outperformed other pre-trained models. The proposed CovidNet model achieved best testing accuracy of 98.5%. © 2021, Springer Nature Singapore Pte Ltd.

Delirium Incidence, Duration, and Severity in Critically Ill Patients With Coronavirus Disease 2019.

OBJECTIVES: To determine delirium occurrence rate, duration, and severity in patients admitted to the ICU with coronavirus disease 2019. DESIGN: Retrospective data extraction study from March 1, 2020, to June 7, 2020. Delirium outcomes were assessed for up to the first 14 days in ICU. SETTING: Two large, academic centers serving the state of Indiana. PATIENTS: Consecutive patients admitted to the ICU with positive severe acute respiratory syndrome coronavirus 2 nasopharyngeal swab polymerase chain reaction test from March 1, 2020, to June 7, 2020, were included. Individuals younger than 18 years of age, without any delirium assessments, or without discharge disposition were excluded. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were delirium rates and duration, and the secondary outcome was delirium severity. Two-hundred sixty-eight consecutive patients were included in the analysis with a mean age of 58.4 years (sd, 15.6 yr), 40.3% were female, 44.4% African American, 20.7% Hispanic, and a median Acute Physiology and Chronic Health Evaluation II score of 18 (interquartile range, 13-25). Delirium without coma occurred in 29.1% of patients, delirium prior to coma in 27.9%, and delirium after coma in 23.1%. The first Confusion Assessment Method for the ICU assessment was positive for delirium in 61.9%. Hypoactive delirium was the most common subtype (87.4%). By day 14, the median number of delirium/coma-free were 5 days (interquartile range, 4-11 d), and median Confusion Assessment Method for the ICU-7 score was 6.5 (interquartile range, 5-7) indicating severe delirium. Benzodiazepines were ordered for 78.4% of patients in the cohort. Mechanical ventilation was associated with greater odds of developing delirium (odds ratio, 5.0; 95% CI, 1.1-22.2; p = 0.033) even after adjusting for sedative medications. There were no between-group differences in mortality. CONCLUSIONS: Delirium without coma occurred in 29.1% of patients admitted to the ICU. Delirium persisted for a median of 5 days and was severe. Mechanical ventilation was significantly associated with odds of delirium even after adjustment for sedatives. Clinical attention to manage delirium duration and severity, and deeper understanding of the virus' neurologic effects is needed for patients with coronavirus disease 2019.

Mortality Rates in a Diverse Cohort of Mechanically Ventilated Patients With Novel Coronavirus in the Urban Midwest.

OBJECTIVES: Differences in mortality rates previously reported in critically ill patients with coronavirus disease 2019 have increased the need for additional data on mortality and risk factors for death. We conducted this study to describe length of stay, mortality, and risk factors associated with in-hospital mortality in mechanically ventilated patients with coronavirus disease 2019. DESIGN: Observational study. SETTING: Two urban, academic referral hospitals in Indianapolis, Indiana. PATIENTS OR SUBJECTS: Participants were critically ill patients 18 years old and older, admitted with coronavirus disease 2019 between March 1, 2020, and April 27, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included in-hospital mortality, duration of mechanical ventilation, and length of stay. A total of 242 patients were included with mean age of 59.6 years (sd, 15.5 yr), 41.7% female and 45% African American. Mortality in the overall cohort was 19.8% and 20.5% in the mechanically ventilated subset. Patients who died were older compared with those that survived (deceased: mean age, 72.8 yr [sd, 10.6 yr] vs patients discharged alive: 54.3 yr [sd, 14.8 yr]; p < 0.001 vs still hospitalized: 59.5 yr [sd, 14.4 yr]; p < 0.001) and had more comorbidities compared with those that survived (deceased: 2 [0.5-3] vs survived: 1 [interquartile range, 0-1]; p = 0.001 vs still hospitalized: 1 [interquartile range, 0-2]; p = 0.015). Older age and end-stage renal disease were associated with increased hazard of in-hospital mortality: age 65-74 years (hazard ratio, 3.1 yr; 95% CI, 1.2-7.9 yr), age 75+ (hazard ratio, 4.1 yr; 95% CI, 1.6-10.5 yr), and end-stage renal disease (hazard ratio, 5.9 yr; 95% CI, 1.3-26.9 yr). The overall median duration of mechanical ventilation was 9.3 days (interquartile range, 5.7-13.7 d), and median ICU length of stay in those that died was 8.7 days (interquartile range, 4.0-14.9 d), compared with 9.2 days (interquartile range, 4.0-14.0 d) in those discharged alive, and 12.7 days (interquartile range, 7.2-20.3 d) in those still remaining hospitalized.Conclusions:: We found mortality rates in mechanically ventilated patients with coronavirus disease 2019 to be lower than some previously reported with longer lengths of stay.

Incidence of Venous Thromboembolism in Critically Ill Coronavirus Disease 2019 Patients Receiving Prophylactic Anticoagulation.

OBJECTIVES: One of the defining features of the novel coronavirus disease 2019 infection has been high rates of venous thromboses. The present study aimed to describe the prevalence of venous thromboembolism in critically ill patients receiving different regimens of prophylactic anticoagulation. DESIGN: Single-center retrospective review using data from patients with confirmed severe acute respiratory syndrome coronavirus 2 requiring intubation. SETTING: Tertiary-care center in Indianapolis, IN, United States. PATIENTS: Patients hospitalized at international units Health Methodist Hospital with severe acute respiratory syndrome coronavirus 2 requiring intubation between March 23, 2020, and April 8, 2020, who underwent ultrasound evaluation for venous thrombosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 45 patients were included. Nineteen of 45 patients (42.2%) were found to have deep venous thrombosis. Patients found to have deep venous thrombosis had no difference in time to intubation (p = 0.97) but underwent ultrasound earlier in their hospital course (p = 0.02). Sequential Organ Failure Assessment scores were similar between the groups on day of intubation and day of ultrasound (p = 0.44 and p = 0.07, respectively). D-dimers were markedly higher in patients with deep venous thrombosis, both for maximum value and value on day of ultrasound (p < 0.01 for both). Choice of prophylactic regimen was not related to presence of deep venous thrombosis (p = 0.35). Ultrasound evaluation is recommended if D-dimer is greater than 2,000 ng/mL (sensitivity 95%, specificity 46%) and empiric anticoagulation considered if D-dimer is greater than 5,500 ng/mL (sensitivity 53%, specificity 88%). CONCLUSIONS: Deep venous thrombosis is very common in critically ill patients with coronavirus disease 2019. There was no difference in incidence of deep venous thrombosis among different pharmacologic prophylaxis regimens, although our analysis is limited by small sample size. D-dimer values are elevated in the majority of these patients, but there may be thresholds at which screening ultrasound or even empiric systemic anticoagulation is indicated.

Delirium Incidence, Duration and Severity in Critically Ill Patients with COVID-19 (preprint)

BackgroundDelirium incidence, duration and severity in patients admitted to the intensive care unit (ICU) due to COVID-19 is not known. MethodsWe conducted an observational study at two large urban academic Level 1 trauma centers. Consecutive patients admitted to the ICU with a positive SARS-CoV-2 nasopharyngeal swab polymerase chain reaction test from March 1st, 2020 to April 27, 2020 were included. Individuals younger than 18 years of age, without any documented delirium assessments (CAM-ICU), or without a discharge disposition were excluded. The primary outcomes were delirium rates and delirium duration and the secondary outcome was delirium severity. Outcomes were assessed for up to the first 14 days of ICU stay. ResultsOf 243 consecutive patients with confirmed COVID-19 admitted to the ICU, 144 met eligibility criteria and were included in the analysis. Delirium occurred in 73.6% (106/144) and delirium or coma occurred in 76.4% (110/144). Sixty-three percent of patients were positive for delirium on the first CAM-ICU assessment. The median duration of delirium and coma was 7 days (IQR: 3-10), and the median delirium duration was 5 days (IQR: 2-7). The median CAM-ICU-7 score was 6 (IQR: 4-7) representing severe delirium. Mechanical ventilation was associated with greater odds of developing delirium (OR: 42.1, 95%CI: 13.0-137.1). Mortality was 26.4% in patients with delirium compared to 15.8% in patients without delirium. Conclusions73.6% of patients admitted to the ICU with COVID-19 experience delirium that persists for approximately 1 week. Invasive mechanical ventilation is significantly associated with odds of delirium. Clinical attention to prevent and manage delirium and reduce delirium duration and severity is urgently needed for patients with COVID-19.