ABSTRACT
Background Although dementia has emerged as an important risk factor for severe SARS-CoV-2 infection, results on COVID-19-related complications and mortality are not consistent. We examined the clinical presentations and outcomes of COVID-19 in a multicentre cohort of in-hospital patients, comparing those with and without dementia. Methods This retrospective observational study comprises COVID-19 laboratory-confirmed patients aged ≥60 years admitted to 38 hospitals from 19 cities in Brazil. Data were obtained from electronic hospital records. A propensity score analysis was used to match patients with and without dementia (up to 3:1) according to age, sex, comorbidities, year and hospital of admission. Our primary outcome was in-hospital mortality. We also assessed admission to the intensive care unit (ICU), invasive mechanical ventilation (IMV), kidney replacement therapy (KRT), sepsis, nosocomial infection, and thromboembolic events. Results Among 8,947 eligible patients, 405 (4.5%) had a diagnosis of dementia and were matched with 1,151 patients without dementia. Compared to a group of similar demographics and comorbidities, patients with dementia presented a lower duration of symptoms (5.0 vs. 7.0 days; p<0.001) and frequency of dyspnoea, cough, myalgia, headache, ageusia, and anosmia. Fever and delirium were more frequent in patients with dementia than the control group. Patients with dementia also received more palliative care than the control group. Dementia was associated with lower admission (32.7% vs. 47.1%, p<0.001) and length of stay (7 vs. 9 days, p<0.026) in the ICU, frequency of sepsis (17% vs. 24%, p=0.005), KRT (6.4% vs. 13%, p<0.001), and IVM (4.6% vs. 9.8%, p=0.002). We did not find differences in hospital mortality among those with and without dementia. Conclusion Clinical manifestations of COVID-19 differ in older patients with and without dementia in the hospital, with delirium being highly prevalent among those with dementia. Our findings indicate that dementia alone might not explain higher short-term mortality after severe COVID-19. Clinicians should include other risk factors such as acute morbidity severity and baseline frailty when evaluating the prognosis of COVID-19 in the hospital.
Subject(s)
COVID-19ABSTRACT
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.
Subject(s)
COVID-19ABSTRACT
Background: Acute kidney injury (AKI) is frequently associated with COVID-19 and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalized COVID-19 patients. Methods: This study is part of the multicentre cohort, the Brazilian COVID-19 Registry. A total of 5,212 adult COVID-19 patients were included between March/2020 and September/2020. We evaluated four categories of predictor variables: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) the need for mechanical ventilation at any time during hospitalization. Variable selection was performed using generalized additive models (GAM) and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. The accuracy was assessed using the area under the receiver operating characteristic curve (AUCROC). Risk groups were proposed based on predicted probabilities: non-high (up to 14.9%), high (15.0 to 49.9%), and very high risk ([≥] 50.0%). Results: The median age of the model-derivation cohort was 59 (IQR 47-70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalization. The validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in-hospital mortality. Thirty-two variables were tested and four important predictors of the need for KRT during hospitalization were identified using GAM: need for mechanical ventilation, male gender, higher creatinine at admission, and diabetes. The MMCD score had excellent discrimination in derivation (AUROC = 0.929; 95% CI 0.918-0.939) and validation (AUROC = 0.927; 95% CI 0.911-0.941) cohorts an good overall performance in both cohorts (Brier score: 0.057 and 0.056, respectively). The score is implemented in a freely available online risk calculator (https://www.mmcdscore.com/). Conclusion: The use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalized COVID-19 patients who may require more intensive monitoring, and can be useful for resource allocation.
Subject(s)
Diabetes Mellitus , Kidney Diseases , Acute Kidney Injury , COVID-19ABSTRACT
The majority prognostic scores proposed for early assessment of coronavirus disease 19 (COVID-19) patients are bounded by methodological flaws. Our group recently developed a new risk score - ABC 2 SPH - using traditional statistical methods (least absolute shrinkage and selection operator logistic regression - LASSO). In this article, we provide a thorough comparative study between modern machine learning (ML) methods and state-of-the-art statistical methods, represented by ABC 2 SPH, in the task of predicting in-hospital mortality in COVID-19 patients using data upon hospital admission. We overcome methodological and technological issues found in previous similar studies, while exploring a large sample (5,032 patients). Additionally, we take advantage of a large and diverse set of methods and investigate the effectiveness of applying meta-learning, more specifically Stacking, in order to combine the methods' strengths and overcome their limitations. In our experiments, our Stacking solutions improved over previous state-of-the-art by more than 26% in predicting death, achieving 87.1% of AUROC and MacroF1 of 73.9%. We also investigated issues related to the interpretability and reliability of the predictions produced by the most effective ML methods. Finally, we discuss the adequacy of AUROC as an evaluation metric for highly imbalanced and skewed datasets commonly found in health-related problems.
Subject(s)
COVID-19 , Coronavirus InfectionsABSTRACT
Chagas disease (CD) continues to be a major public health burden in Latina America. Information on the interplay between COVID-19 and CD is lacking. Our aim was to assess clinical characteristics and in-hospital outcomes of patients with CD and COVID-19, and to compare it to non-CD patients. Consecutive patients with confirmed COVID-19 were included from March to September 2020. Genetic matching for sex, age, hypertension, diabetes mellitus and hospital was performed in a 4:1 ratio. Of the 7,018 patients who had confirmed COVID-19, 31 patients with CD and 124 matched controls were included (median age 72 (64.-80) years-old, 44.5% were male). At baseline, heart failure (25.8% vs. 9.7%) and atrial fibrillation (29.0% vs. 5.6%) were more frequent in CD patients than in the controls (p
Subject(s)
Coinfection , Chagas Disease , Diabetes Mellitus , Hypertension , COVID-19ABSTRACT
Objective: Chagas disease (CD) continues to be a major public health burden in Latina America, where co-infection with SARS-CoV-2 can occur. However, information on the interplay between COVID-19 and Chagas disease is lacking. Our aim was to assess clinical characteristics and in-hospital outcomes of patients with CD and COVID-19, and to compare it to non-CD patients. Methods: Patients with COVID-19 diagnosis were selected from the Brazilian COVID-19 Registry, a prospective multicenter cohort, from March to September, 2020. CD diagnosis was based on hospital record at the time of admission. Study data were collected by trained hospital staff using Research Electronic Data Capture (REDCap) tools. Genetic matching for sex, age, hypertension, DM and hospital was performed in a 4:1 ratio. Results: Of the 7,018 patients who had confirmed infection with SARS-CoV-2 in the registry, 31 patients with CD and 124 matched controls were included. Overall, the median age was 72 (64.-80) years-old and 44.5% were male. At baseline, heart failure (25.8% vs. 9.7%) and atrial fibrillation (29.0% vs. 5.6%) were more frequent in CD patients than in the controls (p<0.05 for both). C-reactive protein levels were lower in CD patients compared with the controls (55.5 [35.7, 85.0] vs. 94.3 [50.7, 167.5] mg/dL). Seventy-two (46.5%) patients required admission to the intensive care unit. In-hospital management, outcomes and complications were similar between the groups. Conclusions: In this large Brazilian COVID-19 Registry, CD patients had a higher prevalence of atrial fibrillation and chronic heart failure compared with non-CD controls, with no differences in-hospital outcomes. The lower C-reactive protein levels in CD patients require further investigation.
Subject(s)
Coinfection , Heart Failure , Chagas Disease , Myotonic Dystrophy , Hypertension , COVID-19 , Atrial FibrillationABSTRACT
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.