Characteristics and outcomes of cryptococcosis among patients with COVID-19 compared to non-COVID-19 controls

Background. It remains unclear if there is an association between COVID-19 and cryptococcosis. The purpose of this study was to compare demographic characteristics and outcomes of cryptococcosis between patients with COVID-19 to non-COVID-19 controls. Methods. Patients 18 years and older with cryptococcosis were identified from TriNetX, a global federated research network, and separated into two cohorts based on a diagnosis of COVID-19 within 3 months prior to the index diagnosis of cryptococcosis. The primary outcome was the percent mortality in each group. The secondary outcomes included the proportion of patients in each group who had underlying comorbidities, received immunosuppressive medications, or required hospitalization or ICU admission. Propensity score matching was performed to control for differences between groups based on demographics and comorbidities. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for outcomes, with p < 0.05 as the cut off for statistical significance. Results. A total of 6252 patients with cryptococcosis were included, of which 4.5% (n=283) had COVID-19 prior to diagnosis of cryptococcosis. Mortality was similar between patients with and without COVID-19 (13% vs 10%, p=0.075). Patients with cryptococcosis and previous COVID-19 were older (55.2 +/- 14.5 years vs 52 +/- 15.2 years, p=0.0005) and more likely to be non-Hispanic (73% vs 65%, p=0.0049). More patients with COVID-19 had a history of transplant (30% vs 13%, p < 0.0001), malignancy (37% vs 21%, p < 0.0001), and diabetes (35% vs 19%, p < 0.0001), but not HIV (29% vs 31%, p=0.5482). Prednisone and dexamethasone use were higher among patients with previous COVID-19 (32% vs 15%, p < 0.0001 and 17% vs 7%, p < 0.0001, respectively). Hospitalization rates were similar (54% vs 57%, p=0.278), but more patients with COVID-19 required ICU admission (19% vs 11%, p < 0.0001). In propensity score-matched analysis, patients with COVID-19 remained at higher odds of ICU admission (OR 1.85, 95% CI 1.15-2.97, p=0.010), but lower odds of hospitalization (OR 0.57, 95% CI 0.41-0.81, p=0.001). Conclusion. Patients with COVID-19 who developed cryptococcosis had higher rates of comorbidities, corticosteroid use, and ICU admission but did not experience higher mortality compared to non-COVID-19 controls.

Examining the Relationship between Excess Weight and In-Hospital Mortality in COVID-19 Patients in Southwest Georgia, U.S

Background. There are multiple mechanisms for the interconnection between obesity and adverse outcomes in COVID-19. Body mass index (BMI) has historically been used to delineate body fatness, but does not include age, which could influence the relationship between body fat and BMI. Ideal body weight (IBW) equations predict a single IBW, which could allow improved recognition of adults with excess weight at increased risk of death from COVID-19. The purpose of our study was to determine whether an association exists between excess weight and in-hospital mortality in COVID-19 patients. Methods. This was a multicenter, retrospective chart review of hospitalized patients with COVID-19. Patients were separated in two groups based on the difference between actual body weight (ABW) and IBW (ABW/IBW ≤ 120% and ABW/IBW > 120%) to compare rates of in-hospital mortality and length of stay (LOS). A subgroup analysis of patients with ABW/IBW > 120% was conducted to compare in-hospital mortality between patients with ABW/IBW 121-149%, ABW/IBW 150-199%, and ABW/IBW ≥ 200%. Results. A total of 445 patients were included of which 71% were in the ABW/ IBW > 120% group. Patients in the ABW/IBW ≤ 120% group had higher median age (71 [IQR 64-80.5] vs 60 [IQR 50-70] years) compared to those in the ABW/IBW > 120% group. Fewer African Americans and females were in the ABW/IBW ≤ 120% than in the ABW/IBW > 120% group (65% vs 86% and 35% vs 64%, respectively). There was no difference in the rate of in-hospital mortality between patients in the ABW/IBW ≤ 120% and ABW/IBW > 120% group (26% vs 20%, p=0.174). Average LOS was 10.5 days (SD 9.2) for patients in the ABW/IBW ≤ 120% and 9.3 days (SD 9.5) for those in the ABW/IBW > 120% group (p=0.227). Among those in the ABW/IBW > 120% group, in-hospital mortality was 14%, 23%, and 22% in patients with ABW/IBW 121-149%, ABW/IBW 150-199%, and ABW/IBW ≥ 200%, respectively (p=0.192). Conclusion. In-hospital mortality and LOS were not significantly higher among COVID-19 patients with excess weight, defined by ABW/IBW > 120%, when compared to those with ABW/IBW ≤ 120%. Further research is needed to compare COVID-19 outcomes when BMI and ABW/IBW are used to define excess weight.

Evaluating the Relationship between Comorbidity Treatment Status and In-hospital Mortality among COVID-19 Patients

Background. Chronic comorbidities increase the risk of poor outcomes in patients with COVID-19. However, there are insufficient data to determine whether control of chronic comorbidities influences outcomes. The purpose of this study was to determine whether pharmacologic treatment for common comorbidities influences in-hospital mortality. Methods. This multicenter, retrospective study included adult patients with diabetes, hypertension, and/or dyslipidemia who were hospitalized with COVID-19 in Southwest GA, U.S. Patients were divided into two groups based on treatment status, where treated was defined as documentation in the electronic medical record of outpatient pharmacologic therapy indicated for that specific comorbidity while untreated was defined as no record of pharmacologic therapy for one or more comorbidity. The primary outcome was to compare in-hospital mortality between treated and untreated COVID-19 patients. Secondary outcomes included comparing length of hospital stay, development of thrombotic events, requirement for vasopressors, mechanical ventilation, and transfer to the ICU between groups. Results. A total of 360 patients were included with a median age of 66 years (IQR 56-75). The majority were African American (83%) and female (61%) with a median Charlson Comorbidity Index of 4 (IQR 2-6). Hypertension, diabetes, and dyslipidemia were present in 91%, 55%, and 45% of patients, respectively, of which 76% (n=274) were treated. Mortality was similar between treated and untreated patients (25% vs 20%, p=0.304). Average length of stay was 9.5 days (SD 8.7) in treated patients compared to 10.6 days (SD 9.1) in untreated patients (p=0.302). No differences were observed in the rates of thrombosis (3% vs 4%, p=0.765), receipt of vasopressors (23% vs 21%, p=0.741), mechanical ventilation (31% vs 27%, p=0.450), or transfer to the ICU (27% vs 14%, p=0.112). Conclusion. Hospitalized COVID-19 patients being treated for hypertension, diabetes, and/or dyslipidemia have similar rates of complications and mortality compared to untreated patients. Further research is needed to determine whether degree of control of chronic comorbidities impacts COVID-19 outcomes.

Disproportionalities in COVID-19 Clinical Drug Trials in the United States: A Systematic Literature Review

Background. To combat higher rates of COVID-19 infection, hospitalization, and death among minorities, it is crucial to identify safe, efficacious, and generalizable treatments. Therefore, the purpose of this systematic literature review was to assess the demographic characteristics of COVID-19 clinical trial participants. Methods. A literature search was performed according to the PRISMA checklist using PubMed from December 1, 2019 to November 24, 2020 with the following search terms: 2019-nCoV, COVID-19, SARS-CoV-2, clinical trial, randomized controlled trial, observational study, and veterinary. To capture additional results, keyword searches were performed using various versions and plural endings with the title/ field tag. Randomized controlled trials evaluating a pharmacologic treatment for COVID-19 patients from one or more U.S site written in the English language were eligible for inclusion. Descriptive statistics were calculated to characterize age, gender, race, and ethnicity of patients enrolled in the included COVID-19 clinical trials, as well as for comparison with national COVID-19 data. Results. A total of 4472 records were identified, of which 16 were included. Most were placebo-controlled (69%) and included hospitalized patients with COVID-19 (69%). Demographic data were reported for each study arm in 81% of studies. Median number of participants was higher in studies of nonhospitalized patients (n=452 [range 20-1062] vs n=243 [range 152-2795]). Nine (56%) studies reported mean or median ages of 50 years or older amongst all study arms. Males comprised more than half of the study cohort in 50% of studies. Race and ethnicity were reported separately in five (31%) studies, reported in combination in four (25%), while six (38%) reported only race or ethnicity. White or Caucasian patients made up most participants across all arms in 75% of studies. Based on national COVID-19 data, hospitalizations were similar between White persons and African American persons, but higher than other race or ethnic groups, and evenly distributed among males and females. Conclusion. Lack of heterogeneously reporting demographic characteristics of COVID-19 clinical trial participants limits the ability to assess the generalizability of pharmacologic treatments for COVID-19.

Factors of Social Determinants of Health Associated with Length of Stay in COVID-19 Patients with Multimorbidity in Southwest Georgia, United States

Background. Previous studies have observed that multimorbidity, defined as two or more comorbidities, is associated with longer lengths of stay (LOS) and higher mortality in patients with COVID-19. In addition, inequality in social determinants of health (SDOH), dictated by economic stability, education access and quality, healthcare access and quality, neighborhoods and built environment, and social and community context have only added to disparities in morbidity and mortality associated with COVID-19. However, the relationship between SDOH and LOS in COVID-19 patients with multimorbidity is poorly characterized. Analyzing the effect SDOH have on LOS can help identify patients at high risk for prolonged hospitalization and allow prioritization of treatment and supportive measures to promote safe and expeditious discharge. Methods. This study was a multicenter, retrospective analysis of adult patients with multimorbidity who were hospitalized with COVID-19. The primary outcome was to determine the LOS in these patients. The secondary outcome was to evaluate the role that SDOH play in LOS. Poisson regression analyses were performed to examine associations between individual SDOH and LOS. Results. A total of 370 patients were included with a median age of 65 years (IQR 55-74), of which 57% were female and 77% were African American. Median Charlson Comorbidity Index was 4 (IQR 2-6) with hypertension (77%) and diabetes (51%) being the most common, while in-hospital mortality was 23%. Overall, median length of stay was 7 days (IQR 4-13). White race (-0.16, 95% CI -0.27 to -0.05, p=0.003) and residence in a single-family home (-0.28, 95% CI -0.38 to -0.17, p< 0.001) or nursing home/long term care facility (-0.36, 95% CI -0.51 to -0.21, p< 0.001) were associated with decreased LOS, while Medicare (0.24, 95% CI 0.10 to 0.38, p=0.001) and part-time (0.35, 95% CI 0.13 to 0.57, p=0.002) or full-time (0.25, 95% CI 0.12 to 0.38, p< 0.001) employment were associated with increased LOS. Conclusion. Based on our results, differences in SDOH, including economic stability, neighborhood and built environment, social and community context, as well as healthcare access and quality, have observable effects on COVID-19 patient LOS in the hospital.

Baseline characteristics, comorbidities, and outcomes of COVID-19 patients hospitalized in Southwest Georgia, u.s.-an interim analysis of an early hot spot

Background: Understanding the spectrum of disease severity and death are critical for identifying unrecognized risk factors associated with morbidity and mortality from coronavirus disease 19 (COVID-19). The purpose of this study was to describe the baseline characteristics, clinical presentation, and outcomes among patients hospitalized with COVID-19 in a major hotspot in the U.S. Southeast. Methods: This multicenter retrospective chart review included adult patients hospitalized with COVID-19, defined by laboratory-detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, in Southwest Georgia. The primary outcome was mortality, which was assessed through discharge or June 14, 2020, whichever occurred first. Secondary outcomes included comorbidities, laboratory and radiographic findings, as well as clinical course. Results: A total of 120 patients were included with a median age of 61 years (IQR 50-72). The majority were African American (73%) and female (56%). Comorbidities on admission were present in 88% of patients;most prevalent were hypertension (76%), diabetes mellitus (55%), and chronic pulmonary disease (27%). Median Charlson comorbidity index was 4 (IQR 2-6) and BMI was 32.8 kg/m2 (IQR 26.2-39.5). On presentation, patients most often complained of dyspnea (69%), fever (63%), and cough (53%), with a median SOFA score of 2 (IQR 2-4). Most patients were admitted to the general ward (71%), of which 17% were subsequently transferred to ICU. During hospitalization, 27% were mechanically ventilated for a median 11 days (IQR 5-13.5), 18% developed ARDS, and 43% developed AKI. Median length of stay was 9.5 days (IQR 3.75-14). Overall mortality was 20%, which was significantly higher among patients with comorbidities (p = 0.047), as well as those who developed ARDS (p < 0.001) or AKI (p = 0.027). Conclusion: Most reports of COVID-19 have focused on large urban settings. However, early during the pandemic, we identified a large cluster of cases with a high-case fatality rate in a semirural setting in Southwest Georgia in the U.S.

Impact of remote delivery on a pharmacists' patient care process capstone course on the development of patient work-up skills

Introduction: The coronavirus disease 2019 (COVID-19) pandemic caused colleges of pharmacy to abruptly change teaching strategies mid-semester in Spring 2020 due to campus closure and transition to remote learning. The objective of this study was to evaluate the effects of pandemic-induced remote learning on student skill acquisition in a third year pharmacy student (P3) Pharmacists' Patient Care Process (PPCP) capstone course. Methods: Student performance on weekly quizzes and mid-term and final practical examinations were evaluated before and after implementation of remote learning in 2020 and were compared with a previous class in 2019. Paired and anonymous student perceptions of their skill development were also compared within the same semester and between years. Independent sample and paired Student's t tests were used to compare means, the Pearson correlation was used to identify associations between continuous variables, and nonparametric tests were used to compare ordinal data. Results: In 2020, student performance was significantly higher on quizzes at the end of the semester after implementation of remote learning compared with pre-remote learning (8.2 ± 1.6 vs 7.7 ± 1.8 points, P <.05). Students performed significantly worse on the final examination compared with the mid-term examination (21.2 ± 5.4 vs 23.4 ± 5.3 points, P <.05) in 2020. Students also performed significantly worse on the final examination in 2020 compared with 2019 (21.3 ± 5.4 vs 23.1 ± 5.4, P <.01). In both 2019 and 2020, students rated their ability to meet course objectives higher at the end of the semester compared with the beginning of the semester (P <.05). Conclusion: The COVID-19 pandemic-related changes in course delivery, participation, and assessment had a mixed effect on development of a systematic process for patient work-up skills using the PPCP. Students progressed throughout the semester on early PPCP patient work-up skills, but performance decreased when higher level skills or later PPCP steps were assessed and was lower compared with a previous offering of the course.