Receiver operating characteristic (ROC) to determine cut-off points of clinical and biomolecular markers to discriminate mortality in severe COVID-19 living at high altitude (preprint)

Background In 2020, Ecuador had one of the highest death rates because of COVID-19. The role of clinical and biomolecular markers in COVID disease prognosis, is still not well supported by available data. In order for these markers to have practical application in clinical decision-making regarding patient treatment and prognosis, it is necessary to know an optimal cut-off point, taking into consideration ethnic differences and geographic conditions.  Aim: To determine the value of clinical and biomolecular markers, to predict mortality of patients with severe COVID-19 living at high altitude.  Methods: In this study, receiver operating characteristic (ROC) curves, area under the curve (AUC) of ROC, sensitivity, specificity and likelihood ratios were calculated to determine levels of clinical and biomolecular markers that best differentiate survivors versus non-survivors in severe COVID subjects that live at a high altitude setting.  Results: Selected cut-off values for ferritin (≥ 1225 ng/dl, p = 0.026), IL-6 (≥ 11 pg/ml, p = 0.005) and NLR (≥ 22, p = 0.008) at 24 hours, as well as PaFiO2 (≤ 164 mmHg, p = 0.015), NLR (≥ 16, p = p = 0.013) and SOFA (≥ 6, p = 0.031) at 72 hours, appear to have good discriminating power to differentiate survivors versus non-survivors. Additionally, odds ratios for ferritin (OR = 3.38); IL-6 (OR = 17.07); PaFiO2 (OR = 4.61); NLR 24h (OR = 4.95); NLR 72h (OR = 4.46), and SOFA (OR = 3.77) indicate increased risk of mortality when cut-off points were taken into consideration.  Conclusions: We proposed a straightforward and understandable method to identify dichotomized levels of clinical and biomolecular markers that can discriminate between survivors and non-survivors patients with severe COVID-19 living at high altitudes.

Predicting mortality in critically ill COVID-19 patients in a low-resources setting (preprint)

BackgroundSince its molecular isolation on January 7, 2020, the novel coronavirus SARS-CoV-2 has spread rapidly, taking governments worldwide off-guard. The virus arrived in low and middle-income countries violently, especially in Latin America. Ecuador received the worst outbreak in the world if we count excess mortality per capita. Although one study has reported the epidemiological impact of COVID-19 in Ecuador, there is no clinical course or outcome data among intensive care patients with COVID-19 in Ecuador. This study describes the clinical, epidemiological, and therapeutical features of 89 patients hospitalized in a secondary-level hospital in Quito, Ecuador.MethodsWe did a retrospective cohort study. We collected health records data from adult patients with severe COVID-19 admitted to the intensive care unit (ICU) in Quito, Ecuador, during the first five months of the SARS-CoV-2 outbreak in Ecuador. All patients had a confirmed SARS-CoV-2 RNA infection diagnostic, a positive real-time RT-PCR, and pulmonary imaging suggesting COVID-19. We used the Chi-square test or a Fisher's exact statistic to analyze risk and associations between survivors and non-survivors due to COVID-19. We used the ROC curve analysis to predict mortality, determining cut-off points for the parameters related to mechanical, analytical, and cytometry ventilation. At the multivariate level, we used the Wald test to evaluate model categorical predictors during the regression analysis.Results89 patients with COVID-19 were recruited during the study. The average age of the patients was 54.72 years. Man represented 68.54% (n = 61) and women 31,46% (n = 28). Significant differences were observed in terms of mortality (men 40.98% vs. women 17.76%). Serological parameters demonstrated that LDH and IL-6 at 24 hours were higher among non-survivors when compared with survivors. Persistent hypercapnia ( > > 45 mmHg), a PaFiO2 ratio of less than 140 mmHg, and a positive end-expiratory pressure (PEEP) titration greater than nine mmHg were also associated with higher mortality.ConclusionsIncreased levels of LDH at 24 hours, IL-6, the lymphocyte and platelet count at 48 hours, the neutrophil count at 48 hours, and the INL are factors associated with higher motility, increased risk of failed extubation and reintubation

Drug shortages in a state-owned academic hospital during the COVID-19 pandemic in Ecuador (preprint)

Background During a pandemic, medical supplies are at increased risk of being depleted rapidly. The COVID-19 sanitary emergency has generated global shortages in critical supplies, like personal protective equipment and medicines. This study aimed to describe the pharmaceutical procurement challenges to overcome medicine shortages in a state-owned academic hospital during the COVID-19 pandemic in Ecuador.Methods We conducted a cross-sectional study using secondary administrative data of documented public tenders for medicines and drug prescriptions for the critical care unit at Hospital Pablo Arturo Suárez in Quito, Ecuador. The occurrence of shortages, their frequency, and the procurement mechanisms used to overcome them were documented by the pharmacy service between January 1st and July 31th, 2020. The units purchased and unitary price of pharmaceuticals procured by the hospital was also documented and compared to data from 2019.Results From 38 medicines analyzed from 12 ATC groups, there were 84 shortages during the sanitary emergency period covered by the study, and 25 medicines had one or more shortages. Norepinephrine and midazolam shortages were most frequent. Retail or emergency direct purchase and loan-stock from other public hospitals were the main procurement methods to overcome the shortages. The purchase mechanism directly influenced the price. Drugs purchased in small tenders via retail or emergency direct purchase had the most significant price increase (up to 819%), while medicines acquired via the electronic catalog managed by the public procurement service experienced no price changes.Conclusion Monitoring and responding to drug shortages during a pandemic can be challenging, and governments must adapt quickly, providing specific guidance on how to deal with shortages.