ABSTRACT
Background: Due to the limited availability of rapid testing for SARS-CoV-2 infection, these tests are often reserved for those requiring urgent procedures or hospital admission and are often not available to emergency department (ED) patients. Complete blood count (CBC), C-reactive protein (CRP) and Ferritin levels can be easily obtained in the ED. Lymphopenia and high C-reactive protein and Ferritin levels are associated with poor outcome in COVID-19 illness. However, it is not known whether these biomarkers are useful for identifying persons with SARS-CoV-2 infection. Methods: We performed a cross-sectional study of patients 18 years or older who were evaluated at an academic ED for suspected SARS-CoV-2 infection from March to May 2020. CBC, CRP and Ferritin levels were ordered at clinician’s discretion in patients who were suspected to have SARS-CoV-2 infection. SARS-CoV-2 infection was diagnosed using a number of PCR-based tests including the Cepheid Xpert Xpress and the Diasorin Simplexa. The discriminative values of the candidate biomarkers were estimated using the area under the receiver operating characteristic curve (AUC). Results: We studied a total of 1082 patients who had a median age of 59.5 (IQR: 46.0 – 71.0) years. A total of 431 (39.8%) of the subjects had PCR confirmed SARS-CoV-2 infection. The median absolute lymphocyte count was 0.9 (IQR: 0.7 – 1.3) and 1.0 (0.7 – 1.6) in those with and those without SARS-CoV-2 infection respectively (p=0.0004). The median CRP level in mg/L was 8.9 (IQR: 4.6 – 17.3) and 6.1 (IQR: 1.6 – 14.0) in those with and those without SARS-CoV-2 infection respectively (p=0.0001). The median ferritin level in ng/mL was 782 (IQR: 299 – 1479) and 312 (IQR: 106 – 1015) in those with and those without SARS-CoV-2 infection respectively (p=0.0001). Lymphocyte count, CRP and Ferritin levels distinguished between those with and those without SARS-CoV-2 infection with AUCs of 0.56 (IQR: 0.53 – 0.60), 0.61 (IQR: 0.58 – 0.64) and 0.66 (IQR: 0.62 – 0.68). Conclusion: Although patients with SARS-CoV-2 infection have lymphopenia and elevated CRP and ferritin levels, the levels of these biomarkers are not useful for identifying persons under investigation who have SARS-CoV-2 infection.
ABSTRACT
Study Objectives: Emergency department (ED) revisits are associated with significant resource utilization. Accordingly, revisits serve as an important quality measure for emergency care. In recent times, EDs have been challenged by critical resource constraints in the setting of the COVID-19 pandemic. When appropriate, medically stable COVID-19 patients are discharged home rather than admitted for further care. However, the natural history of COVID-19 is not well understood and patients may quickly progress to requiring medical attention. To our knowledge, ED revisits have not been previously characterized in the setting of COVID-19. We aim to quantify the incidence of, as well as determine risk factors for, ED revisits for COVID-19 patients. Methods: We conducted retrospective study of 323 reverse-transcription polymerase chain reaction-confirmed COVID-19 patients who presented to a single academic tertiary-care institution from March 15 to April 15 of 2020. Demographic and clinical information was abstracted from the electronic medical record. Predictor variables (age, history of hypertension, diabetes, asthma, chronic obstructive pulmonary disease, current tobacco or marijuana use) were selected based on current knowledge of risk factors for severe COVID-19 illness. All return visits to the ED within 28 days of index ED presentation were classified as revisits. Multivariable logistic regression models were used to identify independent demographic and clinical risk factors for ED revisits. We also performed exploratory univariable analyses of a subset of 179 patients who had measured serum biomarkers (absolute neutrophil count (ANC), alanine aminotransferase (ALT), ferritin, C-reactive protein, D-dimer, lactate dehydrogenase (LDH)) in order to identify potential biochemical risk factors for ED revisits. Results: Of the 323 patients studied, 98 were discharged from the ED during their index visit and 225 were admitted to the hospital. Among those discharged, 25/98 (25.5%) returned within 28 days of index ED presentation. Median time to revisit was 3 days (interquartile range (IQR): 2 to 7). Among those admitted during their index visit (median hospital length of stay: 6 days), 26/225 (11.6%) returned within 28 days of index ED presentation. Median time to revisit for this group was 14.5 days (IQR: 5 to 22). Cumulative incidence of ED revisits was 15.8% (95% CI: 12.2 to 20.2). Patients with and without ED revisits were similar across demographic and clinical variables examined, with the exceptions of tobacco or marijuana use and history of COPD. Both tobacco or marijuana use (odds ratio (OR): 2.9, 95% CI: 1.1 to 7.6) and history of COPD (OR: 3.1, 95% CI: 1.1 to 8.8) were found to be independent risk factors for ED revisits. In our exploratory analysis of patients with biomarker data, ANC (OR: 0.808, 95% CI: 0.689 to 0.948), ALT (OR: 0.973, 95% CI: 0.953 to 0.993), and LDH (OR: 0.996, 95% CI: 0.992 to 0.999) were found to be associated with ED revisits. Conclusion: The incidence of ED revisits in our COVID-19 cohort was 15.8% (95% CI: 12.2 to 20.2). Risk factors for revisits included current tobacco or marijuana use and history of COPD. Preliminary study suggests the utility of serum biomarker data in helping to stratify revisit risk. In future analysis we will determine the reasons for ED revisits as well as develop a model for identifying those at risk for ED revisits.
ABSTRACT
Study Objectives: Concerns over the use of non-steroidal anti-inflammatory drugs (NSAIDs) for the management of fever and myalgia in COVID-19 patients were raised after four cases of critical illness in young, otherwise healthy patients who took NSAIDS were observed in France. France’s health minister subsequently made a recommendation to use acetaminophen in lieu of ibuprofen. However, the association between NSAID use and outcomes in COVID-19 illness has not been adequately studied. The objective of this study is to determine whether an association exists between prior NSAID use and COVID-19 illness severity. Methods: We performed a single-center retrospective cohort study of consecutive adult patients diagnosed in the emergency department (ED) with PCR confirmed SARS-Cov-2 infection. NSAID use was ascertained based on a review of the medication list found in patients’ electronic medical records. Our primary outcome was critical COVID-19 illness, defined as a composite of death, respiratory failure requiring intubation, and shock requiring vasopressors, occurring within 28 days of ED presentation. We modeled the association between NSAID use and our primary outcome using logistic regression, and adjusting for hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), other chronic lung disease, obstructive sleep apnea, immunocompromised status, angiotensin converting enzyme inhibitor (ACE-I) or aldosterone receptor blocker (ARB) use, anticoagulation use, and immunosuppressant use. Results: Among the 422 patients studied, 88 (21%) were on NSAIDS prior to acquiring COVID-19 and a total of 89 patients (21%) developed critical COVID-19 illness within 28 days of ED presentation. Among those using NSAIDs, 18 (20%) developed critical illness. Of the 11 predictor variables examined, hypertension (odds ratio = 1.04 (95% CI: 0.38 - 1.71)), diabetes (0.97 (95% CI: 0.42 - 1.52)), and chronic lung disease (1.20 (0.20 - 2.20)) were significantly associated with increased risk of critical COVID-19 illness (Table 1). NSAID use was not found to be an independent predictor of critical COVID-19 illness (odds ratio = 0.05 (95% CI;-0.57 - 0.73). Conclusion: To our knowledge, this is the first study of the association between NSAID use and critical COVID-19 illness. Our results demonstrate that NSAID use does not significantly increase the risk of critical COVID-19 illness. This study is limited by lack of prospective ascertainment of NSAID use. Prospective evaluation of evaluate outcomes among COVID-19 patients with NSAID use is warranted. [Formula presented]