COVID-19 outcomes in people living with HIV: peering through the waves (preprint)

Background: HIV infection remains a public health concern, especially in low- and middle-income countries. Data regarding exposure of COVID-19 in HIV infected patients remains scarce. We evaluated clinical characteristics and outcomes of COVID-19 patients infected with HIV, and compared with a paired sample without HIV infection. Methods: This is a substudy of a large Brazilian cohort that comprised two periods (2020 and 2021). Data was obtained through the retrospective review of medical records to collect variables of interest and primary outcomes: intensive care admission, mechanical ventilation and death. COVID-19 patients infected with HIV were compared to COVID-19 patients without concomitant diagnosis of HIV infection using the Chi-Square Test and Fisher's exact test for categorical variables and the Wilcoxon test for numerical variables. Both groups were matched for age, sex, number of comorbidities and hospital of origin using the technique of propensity score matching (up to 4:1).Results: Throughout the study, 17,101 COVID-19 patients were hospitalized, 130 (0.76%) of these infected with HIV. The median age was 54 (IQR: 43.0;64.0) years in 2020 and 53 (IQR: 46.0;63.5) years in 2021, with predominance of females in both periods. People living with HIV (PLHIV) and their controls showed similar prevalence for the admission in the ICU and mechanical ventilation requirement in the two periods, with no significant differences. In 2020, in-hospital mortality was higher in the PLHIV compared to the controls (27.9% vs 17.7%; p=0.049), but there was no difference in mortality between groups in 2021 (25.0% vs 25.1%; p>0.999). Conclusion: Our results reiterate that PLHIV were at higher risk of COVID-19 mortality in the early stages of the pandemic, however, this finding did not sustain in 2021, indicating that measures such as large-scale immunization programs have successfully contributed to reducing the excess mortality seen in PLHIV.

Mechanical Ventilation and Death During Pregnancy Complicated by COVID-19: A Prognostic Analysis from the Brazilian COVID-19 Registry Score (preprint)

Background: Assessing predictors of critical outcomes in COVID-19 may advise timely treatments and better prepare facilities to overcome extra adversities during pregnancy. However, many clinical parameters of existent scores are deeply modified by physiologic adaptations. Our aim was to assess the feasibility of a prognosis score developed for general hospitalized adults with COVID-19 in Brazil to predict clinical adverse outcomes in pregnant women upon hospital admission. Methods This is a multicenter retrospective substudy of the Brazilian COVID-19 Registry, a multicenter cohort analysis in Brazilian hospitals, which provided an accurate score to predict in-hospital death. The present analysis assessed the performance of this model, ABC 2 -SPH, based on data of 3978 patients, to assess poor clinical outcomes in data from 85 pregnant women admitted due to COVID-19 from March 1, 2020, to May 5, 2021, in 19 Brazilian hospitals. The primary outcomes were death and the composite mechanical ventilation or death, and secondary were pregnancy outcomes and severe/critical Covid-19. The overall discrimination of the model was presented as the area under the receiver operating characteristic curve (AUROC). Results Thirty-one (36.5%) pregnant women had critical or severe COVID-19. Most of them had no previous comorbidities (64.7%). The median gestational age was 31.0 (26.0, 36.2) weeks; 38 (44.7%) women gave birth during hospitalization by Covid-19, most of them by C-section (76.3%). The need for mechanical ventilation or death occurred in 14 (17.3%) pregnant women. Severe and critical COVID-19 in pregnant women was associated with diabetes, inflammatory markers, and abnormal vital signals observed at admission. The model was not able to identify adverse clinical outcomes. The AUROC of predicting severe/critical Covid-19 illness was 0.595 (95% CI: 0.424-0.754); AUROC of the inpatient death discrimination was 0.683 (95% CI: 0.293-0.945), as the AUROC of mechanical ventilation or death discrimination was 0.591 (95% CI: 0.434-0.75). Conclusions The model ABC 2 -SPH developed in Brazilian general patients was not able to identify adverse clinical outcomes in pregnant women with COVID-19. We warn against the use of general inpatients COVID-19 prognosis in pregnant women. A more useful model for clinical prognosis is necessary concerning the specificities of pregnancy affected by COVID-19.

Frequency and burden of neurological manifestations in hospitalized patients with COVID-19: findings from a large Brazilian cohort (preprint)

Background: Scientific data regarding the prevalence of COVID-19 neurological manifestations and prognosis in Latin America countries is still lacking. Therefore, the study aims to understand neurological manifestations of SARS-CoV 2 infection in the Brazilian population and its association with patient outcomes, such as in-hospital mortality. Methods This study is part of the Brazilian COVID-19 Registry, a multicentric COVID-19 cohort, including data from 37 Brazilian hospitals. For the analysis, patients were grouped according to the presence of self-reported vs. clinically-diagnosed neurological manifestations and matched with patients without neurological manifestations by age, sex, number of comorbidities, hospital, and whether or not patients ha neurological underlying disease. Results From 7,232 hospitalized patients with COVID-19, 27.8% presented self-reported neurological manifestations, 9.9% were diagnosed with a clinically-defined neurological syndrome and 1.2% did not show any neurological symptoms. In patients with self-reported symptoms, the most common ones were headache (19.3%), ageusia (10.4%) and anosmia (7.4%). Meanwhile, in the group with clinically-defined neurological syndromes, acute encephalopathy was the most common diagnosis (10.5%), followed by coma (0.6%1) and seizures (0.4%). Men and younger patients were more likely to self-report neurological symptoms, while women and older patients were more likely to develop a neurological syndrome. Patients with clinically-defined neurological syndromes presented a higher prevalence of comorbidities, as well as lower oxygen saturation and blood pressure at hospital admission. In the paired analysis, it was observed that patients with clinically-defined neurological syndromes were more likely to require ICU admission (46.9 vs. 37.9%), mechanical ventilation (33.4 vs. 28.2%), to develop acute heart failure (5.1 vs. 3.0%, p=0.037) and to die (40.7 vs. 32.3%, p<0.001) when compared to controls. Conclusion Neurological manifestations are an important cause of morbidity in COVID-19 patients. More specifically, patients with clinically defined neurological syndromes presented a poorer prognosis for the disease when compared to matched controls.

ABC2-SPH risk score for in-hospital mortality in COVID-19 patients: development, external validation and comparison with other available scores (preprint)

Objective: To develop and validate a rapid scoring system at hospital admission for predicting in-hospital mortality in patients hospitalized with coronavirus disease 19 (COVID-19), and to compare this score with other existing ones. Design: Cohort study Setting: The Brazilian COVID-19 Registry has been conducted in 36 Brazilian hospitals in 17 cities. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients that were admitted between March-July, 2020. The model was then validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients. Participants: Consecutive symptomatic patients ([≥]18 years old) with laboratory confirmed COVID-19 admitted to participating hospitals. Patients who were transferred between hospitals and in whom admission data from the first hospital or the last hospital were not available were excluded, as well those who were admitted for other reasons and developed COVID-19 symptoms during their stay. Main outcome measures: In-hospital mortality Results: Median (25th-75th percentile) age of the model-derivation cohort was 60 (48-72) years, 53.8% were men, in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. From 20 potential predictors, seven significant variables were included in the in-hospital mortality risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO2/FiO2 ratio, platelet count and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829 to 0.859), which was confirmed in the Brazilian (0.859) and Spanish (0.899) validation cohorts. Our ABC2-SPH score showed good calibration in both Brazilian cohorts, but, in the Spanish cohort, mortality was somewhat underestimated in patients with very high (>25%) risk. The ABC2-SPH score is implemented in a freely available online risk calculator (https://abc2sph.com/). Conclusions: We designed and validated an easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation, for early stratification for in-hospital mortality risk of patients with COVID-19.