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Introduction: During the COVID-19 pandemic, virtual interviews for resident and fellowship applicants became the standard. However, studies evaluating the experience of virtual interviews format are lacking. Accordingly, we sought to survey both gastroenterology fellowship applicants and interviewing faculty members about their experiences with the virtual interview process. Method(s): Interviewees and faculty at 13 different gastroenterology fellowship programs at academic medical centers across the United States completed a post-interview survey. The online survey was conducted during the 2020 ERAS fellowship interview season via Google Forms. The survey responses were anonymously collected and reported. Result(s): A total of 177 gastroenterology fellowship applicants and 83 faculty members completed the electronic surveys. Most participants reported a positive experience with 91% and 84% of applicants and faculty respectively, scoring at least 4 points on a 5-point scale. Eighty-8 percent and 85% of applicants and faculty respectively, reported that they had enough insight about the applicant or the fellowship program during the interview. Over 67% of applicants reported cost-savings of greater than $1,000 per interview. Thirty-6 percent of applicants reported that they missed the personal interaction with the current gastroenterology fellows in the respective programs and the experience of physically touring the facility. Twenty-7 percent and 25% of applicants and faculty experienced technical difficulties during the interview process, respectively. Thirty-one percent and 22% of applicants and faculty would like for the virtual interviews to be the standard of future fellowship interviews, while 35% and 42% of applicants and faculty would consider it in the future, respectively. Figure 1 shows the ranking process for both applicants and faculty. Conclusion(s): Virtual interviews were perceived as effective and cost-saving by both gastroenterology fellowship applicants and faculty members. The virtual experience was widely accepted by most applicants and faculty, with high potential to become the standard of fellowship interview process in the future. However, a substantial portion experienced technical difficulty. Further improvements in technology are needed to optimize the process and increase the acceptance of the virtual interview experience. (Figure Presented).
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Load balancing techniques are useful for efficient networking systems. In teleconferencing systems, it is not an easy job to balance the loads and obtain efficient performance. The current study tries to suggest a network-based approach for load balancing in teleconferencing systems. The aim is to make use of the concepts of graph theory in practicing and simulating teleconferencing systems. In the suggested approach, each computer in the network is considered as a vertex, an edge will be created between two vertices if they are accessible to each other. The weight of the edge between the two computers specifies the cost of access from one vertex to another. The task of transferring happens between the shortest ways of the two nodes taking into consideration the deadline time of the tasks. In terms of the number of the missed deadline tasks, the proposed approach reflected effectiveness in comparison with other approaches. Using the proposed, it is guarantee to obtain a smooth conferencing among users, which is beneficial for the teleconferencing and e-learning as well. Finally, this proposed method is useful for securing smooth conferencing during further lockdown situation (i.e., COVID situation).
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Background: Coronavirus disease 2019 (COVID-19) is currently spreading fast around the world. The rate of acute kidney damage (AKI) in patients hospitalized with Covid-19, as well as the outcomes related with it, are unknown. The goal of this study was to see if having acute kidney damage (AKI) increased the risk of severe infection and death in COVID-19 patients. It also described the symptoms, risk factors, and outcomes of AKI in Covid-19 patients. Material(s) and Method(s): We undertook a retrospective cohort from June 2020 and March 2021 to examine the connection between AKI and patient outcomes COVID-19. Result(s): The most common comorbid condition was hypertension and diabetes followed by chronic kidney disease and ischemic heart disease. Most of the patients who required low dose oxygen with nasal prongs, face masks, or rebreathing masks were in control groups (76.2% vs. 50.6%;p <.001). More patients in AKI group needed non-invasive ventilation and invasive mechanical ventilation compared to control group (33.8% vs. 19.9%;p .001, 15.6% vs. 3.9%;p <.001 respectively. Patients in the AKI group had higher levels of C-reactive protein, lactate dehydrogenase, D-dimer, and serum. Of 145 patients who developed AKI, 29 (20%) needed hemodialysis. Of 29 patients who needed hemodialysis, 18 (62%) expired. A higher number of patients in the control group were discharged than patients in the AKI group (82.1% vs. 56.9%;p <.001). One hundred five patients were expired, with higher mortality in the AKI group (41.7% vs. 12.4%;p <.001). Conclusion(s): COVID-19 patients admitted to the hospital, AKI is associated with a shockingly high fatality rate.Copyright © 2022 Lahore Medical And Dental College. All rights reserved.
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Objective: The objective of this study is to report the frequency and clinical characteristic of IFI in COVID-19 patients. Method(s): This observational study was conducted in Karachi, Pakistan from March 2020-April 2021. Patients with COVID-19 associated aspergillosis (CAPA) were diagnosed using ECMM/ISHAM criteria modified to include tracheal aspirate culture and/or Galactomannan Index (GMI) >4.5 in the possible CAPA category. COVID-19 associated candidemia (CAC) was defined by isolation of Candida species from blood cultures. COVID-19 associated mucormycosis (CAM) was defined as updated EORTC/MSG criteria with inclusion of COVID-19 as host factor. Pneumocystis jirovecii pneumonia (PJP) was defined by consistent clinical and radiological features and PCR positivity. Result(s): During the study period a total of 123 (3.3%) IFI in 3506 hospitalized COVID-19 patients were identified. This included 78 (2.2%) CAPA patients (42 probable;36 possible), 29 (0.8%) CAC (5 C. auris;24 non-C. auris), 10 (0.3%) CAM (7 pulmonary;3 rhinocerebral), 3 (0.08%) PJP and three (0.08%) cases of rare invasive fungal infections (2 C. neoformans;1 Trichosporon asahii). Outcome data was available on 117/123 patients. Of these 117 patients, 78 expired (66.7%). These include 52/74 (70%) CAPA patients, 17/27 (63%) CAC patients, 7/10 (70%) CAM patients and 2/3 (67%) PJP patients. Conclusion(s): We report a rate of 3.3% IFI amongst hospitalized COVID-19 patients at our center. We consider this rate to be an underestimate due to less bronchoscopic procedures and inclusion of only candidemia cases. We also report higher mortality rate with IFI in our patients than global data probably due to delayed diagnosis, co-infections and limited therapeutic options.
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Background: Early identification of COVID-19-associated pulmonary aspergillosis (CAPA) is particularly challenging in low- middle-income countries where diagnostic capabilities are limited, and risk factors for CAPA have not been identified. It is also essential to recognise CAPA patients who are likely to have a poorer outcome to decide on aggressive management approaches. Therefore, this study aimed to identify risk factors and outcomes for CAPA among admitted moderate to critical COVID-19 patients at our centre in Pakistan. Methods: An unmatched case–control study with ratio of 1:2 was conducted on hospitalised adult patients with COVID-19 from March 2020–July 2021. Cases were defined according to European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus criteria. Controls were defined as patients hospitalised with moderate, severe or critical COVID-19 without CAPA. Results: A total of 100 CAPA cases (27 probable CAPA;73 possible CAPA) were compared with 237 controls. Critical disease at presentation (aOR 5.04;95% CI 2.18–11.63), age ≥ 60 years (aOR 2.00;95% CI 1.20–3.35) and underlying co-morbid of chronic kidney disease (CKD) (aOR 3.78;95% CI 1.57–9.08) were identified as risk factors for CAPA. Patients with CAPA had a significantly greater proportion of complications and longer length of hospital stay (p-value <.001). Mortality was higher in patients with CAPA (48%) as compared to those without CAPA (13.5%) [OR = 6.36(95% CI 3.6–11)]. Conclusions: CAPA was significantly associated with advanced age, CKD and critical illness at presentation, along with a greater frequency of complications and higher mortality. © 2022 Wiley-VCH GmbH.
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The internet of things (IoT) is quickly evolving, allowing for the connecting of a wide range of smart devices in a variety of applications including industry, military, education, and health. Coronavirus has recently expanded fast across the world, and there are no particular therapies available at this moment. As a result, it is critical to avoid infection and watch signs like fever and shortness of breath. This research work proposes a smart and robust system that assists patients with influenza symptoms in determining whether or not they are infected with the coronavirus disease (COVID-19). In addition to the diagnostic capabilities of the system, the system aids these patients in obtaining medical care quickly by informing medical authorities via Blynk IoT. Moreover, the global positioning system (GPS) module is used to track patient mobility in order to locate contaminated regions and analyze suspected patient behaviors. Finally, this idea might be useful in medical institutions, quarantine units, airports, and other relevant fields. © 2023 Institute of Advanced Engineering and Science. All rights reserved.
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Aim: Colorectal cancer pathways were adversely affected as a result of the COVID-19 pandemic. This study aimed to assess this impact by comparing diagnoses and acute presentations of colorectal cancer before and during the first and second wave of the pandemic, in a UK hospital covering a population of 800,000. Method(s): Patients diagnosed with colorectal cancer over one year during the COVID-19 pandemic (April 2020 -March 2021), were compared to patients diagnosed in the previous year (April 2019 -March 2020). Groups were compared according to the route of referral, presenting symptoms, and tumour staging. Patients who presented with an emergency admission were further assessed to determine inpatient management and outcomes. Result(s): Colorectal cancer diagnoses fell during the COVID-19 period compared to the year before (261 v 338). Referrals to our cancer pathway fell from 5717 to 2438 (57%) and endoscopies performed from 4389 to 2309 (47%). Fewer patients were diagnosed from primary care, 105 v 174 (P = 0.0062). More patients were diagnosed following emergency admissions 49 v 43 (P = 0.042). At diagnosis, more patients presented with Stage 4 cancer during the pandemic, 65 vs 58 (25% v 17%, P = 0.020). Fewer patients presented with Stage 1, 26 v 63 (10% v 19%, P = 0.0031). Of patients who presented with an emergency admission, there were more cases of bowel obstruction 26 v 14 (P = 0.00046). 30-day mortality was higher in the COVID-19 group 15 v 3 (31% v 7%, P = 0.0044) and palliative care was the initial management in 18 v 7 (37% v 16%, P = 0.003). Conclusion(s): During the COVID-19 pandemic, fewer patients were diagnosed with colorectal cancer at our trust. A greater proportion of patients required emergency admission and presented with higher-stage colorectal cancer. Our results may be attributed to service disruption at our trust and reduced patient engagement with healthcare professionals. Further studies are required to assess the lasting impact of the disruption of colorectal cancer pathways on patient outcomes.
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INTRODUCTION: COVID-19-related organ dysfunction is increasingly recognized as sepsis, & sepsis has been reported as the most common proximate cause of death among COVD-19 patients in autopsy studies. Thus, the COVID-19 pandemic is expected to affect substantially the epidemiology of sepsis. However, the contribution of COVID-19 to sepsis-related mortality in the United States (US) is unknown. METHOD(S): We used the CDC WONDER Multiple Cause of Death database to identify decedents with a diagnosis of sepsis during 2015-2019 and with diagnoses of COVID-19, sepsis, or both during 2020. Sepsis was identified using previously reported ICD-10 code-based taxonomy. COVID-19 was identified by ICD-10 code U071. Negative binomial regression was used on the 2015-2019 data to forecast the number of sepsis-related deaths in 2020. We then compared the number of observed vs expected sepsis-related deaths in 2020. In addition, we examined the reporting of a diagnosis of COVID-19 among decedents with sepsis and the proportion of a diagnosis of sepsis among those with COVID-19. The latter analyses were then repeated across the Department of Health and Human Services (HHS) Regions. RESULT(S): In 2020, there were 242,630 sepsis-related deaths, 384,536 COVID-19-related deaths, & 35,057 deaths with both diagnoses. The expected number of sepsis-related deaths for 2020 was 207,175 (95% CI 205,929-208,429), with the ratio of observed to expected deaths 1.17 (95%CI 1.16-1.18). COVID-19-related deaths comprised 15.0% of all observed sepsis-related deaths, ranging from 8.1% (HHS Region 10) to 18.2% (HHS Region 2). A diagnosis of sepsis was reported in 9.1% of all COVID-19-related deaths, varying from 6.6% (HHS Region 2) to 12.5% (HHS Region 9). CONCLUSION(S): Sepsis-related mortality was reported in less than 1 in 10 COVID-19-related deaths in the US during 2020, with the frequency of sepsis diagnoses varying nearly 2-fold across HHS regions. Although the number of COVID-19-related deaths far exceeded sepsis-related mortality, the contribution of the former to the latter, based on death certificates, was relatively minor. Our findings suggest substantial underdocumentation and possibly underrecognition of sepsis among COVID-19 decedents, likely contributing to varying coding practices during the first year of the pandemic.
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INTRODUCTION: COVID-19-related organ dysfunction is increasingly recognized as sepsis of viral origin and is a common complication among those requiring hospitalization, with estimated prevalence of over 50% among the latter. However, the population-level association of COVID-19 with short-term mortality among septic patients is unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years with sepsis in Texas during April 1-December 31, 2020. Sepsis was defined by "explicit" and ICD-10 codes for severe sepsis (R65.20) and septic shock (R65.21) and COVID-19 by ICD-10 code U07.1. A hierarchical, mixed-effects model was fit to estimate the association of COVID-19 with short-term mortality (defined as in-hospital death or discharge to hospice) among sepsis hospitalizations. Sensitivity analyses of the sepsis hospitalization subsets with septic shock and ICU admission were performed using a similar modeling approach. RESULT(S): Among 55,145 sepsis hospitalizations, 13,149 (23.8%) had COVID-19. Compared to those without COVID-19, sepsis hospitalizations with COVID-19 were younger (aged >=65 years 53.6% vs 55.0%), more commonly male (59.5% vs 50.4%) and racial/ethnic minority (66.1% vs. 46.2%), with lower burden of chronic illness (mean [SD] Charlson comorbidity index 1.8 [1.9] vs 2.8 [2.6]), but with higher mean [SD] number of organ dysfunctions (3.1 [1.4] vs 2.7 [1.6]) [p < 0.0001 for all comparisons]. Short-term mortality among sepsis hospitalizations with and without COVID-19 was 52.7% vs 30.2%, respectively. On adjusted analysis, COVID-19 remained associated with higher risk of short-term mortality (adjusted odds ratio [aOR] 2.54 [95% 2.39-2.70]), with findings on sensitivity analyses consistent with the primary model among sepsis hospitalization subsets with septic shock ([aOR] 2.70 [95% 2.51-2.91]) and ICU admission ([aOR] 2.67 [95% 2.30-3.10]). CONCLUSION(S): COVID-19 infection was associated with over 250% higher odds of short-term mortality among septic patients. Additional studies are needed to determine the mechanisms underlying these observations in order to inform future efforts to reduce the observed outcome disparities.
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INTRODUCTION: Decreasing case fatality among septic patients has been documented in the United States (US). The strain on healthcare resources brought by the COVID-19 pandemic has been associated with a rise in adverse health outcomes in non-COVID patients. However, the populationlevel impact of the COVID-19 pandemic on the case fatality in sepsis among non-COVID patients is unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years in Texas during April 1-December 31, for each year of 2016-2020 (to align each year with the date of introduction of COVID-19-specific ICD-10 code [U071] in the US). Sepsis was defined by "explicit" ICD-10 codes for severe sepsis (R65.20) and septic shock (R65.21). COVID-19 hospitalizations were excluded. Hierarchical models were fit to estimate the changes in shortterm mortality (defined as in-hospital death or discharge to hospice) of sepsis hospitalizations using 2 approaches: 1) using the 2016-2019 data to forecast risk-adjusted shortterm mortality in 2020 and then comparing the predicted and observed 2020 mortality 2) using the 2019-2020 data to estimate the change in short-term mortality in 2020. RESULT(S): There were 207,953 sepsis hospitalizations without a diagnosis of COVID-19 during the study period (45,826 in 2019 and 41,996 in 2020). Short-term mortality has decreased between 2016 and 2019 from 29.7% to 26.6% (adjusted odds ratio [aOR]/year 0.93 [95% CI 0.92-0.94]). The predicted and observed short-term mortality among sepsis hospitalizations in 2020 was 25.8% (95% CI 25.6-26.0) vs 30.8%, respectively (p < 0.0001). Following adjustment for confounders, the risk of short-term mortality among sepsis hospitalizations was higher in 2020 than in 2019 (aOR 1.30 [95% CI 1.25-1.35]). CONCLUSION(S): The COVID-19 pandemic was associated with reversal of the progressive pre-pandemic downtrend in case fatality of septic patients, with 30% higher odds of short-term mortality in 2020 compared to the preceding year among sepsis hospitalizations without COVID-19. Further studies are needed to determine the patient-, health system-, and policy-related contributors to these findings in order to inform potential scalable strategies to reduce pandemicrelated adverse impact on outcomes of septic patients without COVID-19.
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INTRODUCTION: Indications for the use of central venous catheters (CL) outside the ICU are limited and prolonged use is associated with CL associated infections (CLABSI). This quality improvement study aimed to reduce the number of unnecessary CLs in the non-ICU setting. METHOD(S): A prospective interventional study was performed between April 4 and July 3, 2022, at a large tertiary care center. Daily chart audits were conducted on all non-ICU adult patients who had a non-tunneled CL to include peripherally inserted central catheters (PICC). Discharged patients, CLs removed prior to audit, duplicate documentation, or inaccurately labeled tunneled lines as nontunneled were excluded. Predetermined non-ICU indications for CL use were need for hemodialysis (HD), chemotherapy, total parenteral nutrition (TPN), long-term antibiotics (ABX), inotropes, and lack of IV access as a last resort. If the CL met indications, the chart was re-audited at one-week intervals to assess for ongoing need. Otherwise, the primary teams were advised to remove CLs. Descriptive statistics were used for analysis. RESULT(S): Of 1093 charts audited, 536 CLs were addressed (male: 60.1%;mean age: 60.7 +/-14.5). Locations of insertion were the floors (48.5%), the ICUs (24.6%) and the OR (16.6%). PICC lines constituted 62.1% of all CLs. Indications for CL placement were ABX (24.4%), vasopressors (20.9%), TPN (16.9%), inotropes (16.0%) and HD (12.1%). CL use in 9.9% of patients did not meet indications and were removed after prompting. Of 553 CLs placed in the ICU, 23.9% made it to the floor;18.9% of these did not meet indications. Our intervention rate decreased in time: 16.2% in the first two weeks vs 6.8% in the last week of the study period. There was no significant change in the number of CLABSIs in the study period (n=2) as compared to the three months prior (n=3) and a similar pre-COVID-19 time period (2019: n=2). All CLABSIs during the study period had appropriate indications for use. CONCLUSION(S): Approximately 10% of CLs outside the ICU did not have appropriate indications. A daily audit protocol on the floors reduced CL days. A significant proportion of CLs placed in the ICUs were inappropriately continued and should be removed when its use is no longer indicated. Continued education is essential to reduce inappropriate CL use.
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INTRODUCTION: Acute respiratory distress syndrome (ARDS) is the major manifestation of severe respiratory failure due to COVID-19 and is present in the majority of COVID-19-related deaths in autopsy studies. Thus, the COVID-19 pandemic is expected to change substantially the epidemiology of ARDS. However, the contribution of COVID-19 to ARDS-related mortality in the United States (US) is unknown. METHOD(S): We used the CDC WONDER Multiple Cause of Death Data set to identify decedents with a diagnosis of ARDS during 2015-2019, and with a diagnosis of COVID-19, ARDS, or both during 2020. ARDS and COVID-19 were identified by ICD-10 codes J80 and J071, respectively. Negative binomial regression was used on the 2015-2019 data to forecast the number of ARDS-related deaths in 2020. We then compared the number of observed vs expected ARDS-related deaths in 2020. In addition, we examined the reporting of a diagnosis of COVID-19 among decedents with ARDS and the proportion of a diagnosis of ARDS among those with COVID-19. The latter analyses were then repeated across the Department of Health and Human Services (HHS) Regions. RESULT(S): In 2020, there were 51,184 ARDS-related deaths, 384,536 COVID-19-related deaths, and 41,606 deaths with both in the US. The predicted number of ARDSrelated deaths for 2020 was 10,851 (95% CI 9,714-12,120). The ratio of the observed vs expected ARDS-related deaths was 4.71 (95% CI 4.62-4.82). A diagnosis of ARDS was reported in 10.8% of all COVID-19 related deaths, ranging from 8.2% (HHS Regions 1 & 7) to 16.1% (HHS Region 2). COVID-19-related deaths have contributed to 81.3% of observed ARDS-related deaths in 2020, varying from 68.8% (HHS Region 10) to 91.5% (HHS Region 2). CONCLUSION(S): The number of ARDS-related deaths in the US increased nearly 5-fold in 2020, due to the contribution of ARDS among COVID-19 decedents. However, ARDS was reported only in about 1 in 10 COVID-19-related deaths, with the frequency of ARDS diagnosis varying nearly 2-fold across HHS Regions. Our findings suggest that the major rise in ARDS-related deaths in the US in 2020 is nevertheless an underestimate of the actual toll of ARDS-related mortality that year, likely reflecting substantial underdocumentation and possibly underrecognition of ARDS among COVID-19 decedents.
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INTRODUCTION: Rural residence has been associated with increased risk of COVID-19-related mortality. However, the population-level prognostic implications of rural residence among critically ill patients with COVID-19 are lacking, and the impact of inter-hospital transfer and hospitals' location on the outcomes of these patients is unknown. METHOD(S): We used a statewide dataset to identify ICU admissions aged >=18 years with a diagnosis of COVID-19 in Texas during April 1-December 31, 2020. COVID-19 was defined by ICD-10 code U07.1. We used dichotomized (rural vs urban) ZIP Code-level Rural-Urban Commuting Area categories, linked to hospitalization data, to identify rural residence. Hierarchical, mixed-effects models were fit to estimate the association of rural residence with shortterm mortality (defined as in-hospital death or discharge to hospice) for the whole cohort and among hospitalizations with and without transfer from another hospital. Similar modeling was used to examine the association of care in rural hospitals among rural residents without transfer to another facility with short-term mortality. RESULT(S): Among 58,485 ICU admissions with COVID-19, 9,495 (16.2%) were rural residents. Among rural residents, 8,607 (90.6%) were managed in non-rural hospitals, and 1,827 (19.2%) were transferred from another hospital. The unadjusted short-term mortality among rural and urban residents was 25.9% vs 23.9%, respectively. Following adjustment for confounders, rural residence was associated with higher short-term mortality for the whole cohort (adjusted odds ratio [aOR] 1.093 [95% CI 1.003-1.191]) and among those transferred from another hospital (aOR 1.349 [95% CI 1.106-1.646]), but not among those without inter-hospital transfer (aOR 1.052 [95% CI 0.955-1.159]). Management of critically ill rural residents with COVID-19 in rural hospitals, without inter-hospital transfers was not associated with shortterm mortality on adjusted analyses (aOR 0.672 [95% CI 0.393-1.149]). CONCLUSION(S): The observed increased short-term mortality among critically ill patients with COVID-19 residing in rural areas is confounded by inter-hospital transfers and the geographic location of hospitals, with no adverse prognostic impact of rural residence in non-transferred patients and those managed in rural facilities.
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INTRODUCTION: Recent reports suggest very low to no hospital survival among COVID-19 patients with in-hospital cardiac arrest (IHCA). However, studies to date included generally very small number of IHCA events and were often single-centered. The population-level outcomes of IHCA among COVID-19 patients is unknown. METHOD(S): We used a statewide data set to identify hospitalizations aged >=18 years in acute care hospitals in Texas with a diagnosis of COVID-19 between April 1st and December 31st, 2020. COVID-19 infection was identified using ICD-10 code U071. Cardiopulmonary resuscitation was identified using ICD-10 code 5A12012. Hospitalizations with cardiac arrest as a primary diagnosis and those without a primary diagnosis of COVID-19 were excluded. Mixed-effects multivariable logistic regression modelling was used to identify predictors of hospital survival among those with IHCA. RESULT(S): Among 65,482 hospitalizations with COVID-19, 893 (1.4%) had IHCA. Among those with IHCA, 57.1% were aged >= 65 years, 64.2% male, 70.9% racial/ethnic minority, and 7.1% had shockable rhythm. IHCA occurred in 12.7% [95% CI 11.8-13.6] of terminal hospitalizations. Hospital survival was 7.3% [95%CI 5.6-9.3], ranging from 6.7% [95% CI 4.6-9.3] among those aged >=65 years to 10.7% [95% CI 4.6-21.0] among those aged < 45 years. On adjusted analyses, among examined patient and hospital characteristics, only shockable rhythm (adjusted odds ratio [aOR] 2.63 [95% CI 1.05-6.56]) and management in hospitals with 200-399 beds (aOR 0.14 [95% CI 0.03- 0.58]), but not demographics, comorbidities, or illness severity, were associated with hospital survival. Among hospital survivors, 23.1% were transferred to hospice and 35.4% were discharged home. CONCLUSION(S): Resuscitation of IHCA among COVID-19 patients occurred more selectively compared to the general population. Hospital survival was very low, and less than 3% of those with IHCA were discharged home. Once developing among patients with COVID-19, the short-term survival of IHCA was no longer affected by demographic characteristics, comorbidity burden, or illness severity. Further large studies, using granular data, are needed to better guide clinicians', patients', and surrogates' decision-making and to improve patients' outcomes.
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INTRODUCTION: The adverse impact of comorbid conditions on the development of severe illness and risk of death among hospitalized patients with COVID-19 has been well-documented. However, the population-level epidemiology and outcomes of previously healthy [PH] adults compared to those with prior comorbidities [PC] among COVID-19 patients requiring ICU admission are unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years with ICU admission and a diagnosis of COVID-19 in Texas during April 1-December 31, 2020. COVID-19 was defined by ICD-10 code U07.1. PH was defined as absence of the comorbidities included in the Charlson Comorbidity Index, and of obesity, malnutrition, mental disorders, and substance and alcohol use disorders. A hierarchical, mixed-effects model was fit to estimate the association of PH with short-term mortality (defined as in-hospital death or discharge to hospice) among ICU admissions. A similar approach was used to identify predictors of short-term mortality among the PH group. RESULT(S): Among 58,845 ICU admissions with COVID-19, 6,760 (11.6%) were PH. Compared to those with PC, those with PH were younger (aged >=65 years 36.1% vs 49.4%), more commonly racial/ethnic minority (63.8% vs 61.5%), and with lower mean [SD] number of organ dysfunctions (1.2 [1.1] vs 1.8 [1.4]) [p< 0.001 for all comparisons]. Short-term mortality was lower among PH than among PC (16.4% vs 25.0%). However, following adjustment for confounders, the risk of short-term mortality was higher among PH (adjusted odds ratio [aOR] 1.37 [95% CI 1.25-1.51]). Among PH ICU admissions, short-term mortality increased with age ([aOR] 35.20 [95% CI 22.09-56.09];>=65 vs 18-44 years) and management at facilities with >=50 ICU beds ([aOR] 4.43 [95% CI 1.07-18.32] vs < 10 ICU beds). CONCLUSION(S): PH was uncommon among critically ill adults with COVID-19 and PH patients had substantially lower short-term mortality than those with PC. However, once risk-adjusted, the odds of short-term mortality were, unexpectedly, 37% higher among PH, with the latter facing higher risk of death when managed at hospitals with higher number of ICU beds. Additional studies are needed to identify the patient-, care process-, and health system-related contributors to these findings.
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Introduction: Atypical hemolytic uremic syndrome (aHUS) is a form of thrombotic microangiopathy (TMA) characterized by dysregulated complement activation. Antibodies to factor H (anti-FH), a regulator of the alternative complement pathway, are a recognized cause of aHUS particularly in children. We present the case of an elderly patient who developed aHUS following COVID-19. Case Description: A 74-year-old male presented with weakness, petechial rash involving extremities and diarrhea for 2 weeks. Prior history included hepatitis C infection status-post treatment 2 years ago with associated cirrhosis. Three weeks ago, the patient had been diagnosed with COVID-19. His symptoms of sore throat, cough and fever had by now resolved. Initial investigations showed leukocytosis and AKI with an active urinary sediment and nephrotic range proteinuria (Fig 1). Hemoglobin and platelets were normal and a blood smear was negative for hemolysis. Imaging revealed small bowel enteritis suggestive of an infectious or vasculitic process. Infectious workup returned negative. Autoimmune serologies revealed a borderline positive ANA, low C3 and low-normal C4. Renal biopsy revealed diffuse endothelial injury with swollen endothelial cells, focal mesangiolysis and glomerular basement membrane duplication. Hence, pulse dose steroids were started and complement function panel sent. Soon after steroid initiation, the patient's renal function, leukocytosis and rash improved. Ultimately, complement testing returned positive for anti-FH. At follow-up, renal function had returned to baseline with continued steroid taper. Discussion(s): COVID-19 is associated with TMA likely due to endothelial toxicity or complement pathway dysregulation. Our patient had no prior history of renal or hematologic disease. Given the chronology of events, it is likely that COVID-19 triggered formation of anti-FH, in turn leading to development of aHUS in our patient.
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The coronavirus, one of the deadliest virus erupted in Wuhan, China in December and has claimed millions of lives worldwide and infected too. This virus has off-late demonstrated mutations thus making it difficult for the health professionals to adopt a uniform means of cure. Many people due to lack of support have confined themselves at home. The hospitals too are running short of equipment and support systems. Thus, computational connectivity between the patients at home and the hospitals needs to be established. The objective of this paper is to propose a framework/model that connects all the stakeholders so that either in regular monitoring or in emergency cases help can be provided to them. It has been well established through research and case studies that critical factors associated with this disease are oxygen level (SPO2), pulse rate, fever, chest infection, cough causing choking, and breathlessness. Data shall be collected, stored, and analyzed for the above symptoms and for this cloud storage and blockchain technology would be used. It has been established through various studies that non-clinical techniques like AI and machine learning prove to be effective for the prediction and diagnosis of COVID-19. Using this theory as the standard basis, machine learning models like SVM, Naive Bayes, and decision trees can be used for the analysis, diagnosis, and prediction. Using IoT and its variants, remote monitoring of patient, and consultation can be provided to the patient. Appropriate action would be taken. In addition, a mobile application would enable the patients to gather or read about experiences of other patients. Thus, it would be established through the proposed framework, that an integrated approach of technologies has a great potential in such applications and offers several advantages.
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BACKGROUND: Early identification of COVID-19 associated pulmonary aspergillosis (CAPA) is particularly challenging in low-middle income countries where diagnostic capabilities are limited and risk factors for CAPA have not been identified. It is also essential to recognise CAPA patients who are likely to have a poorer outcome to decide on aggressive management approaches. Therefore, this study aimed to identify risk factors and outcomes for CAPA amongst admitted moderate to critical COVID-19 patients at our center in Pakistan. METHODS: An unmatched case-control study with ratio of 1:2 was conducted on hospitalized adult patients with COVID-19 from March 2020-July 2021. Cases were defined according to European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) consensus criteria. Controls were defined as patients hospitalized with moderate, severe, or critical COVID-19 without CAPA. RESULTS: A total of 100 CAPA cases (27 probable CAPA;73 possible CAPA) were compared with 237 controls. Critical disease at presentation (aOR 5.04;95% CI 2.18-11.63), age greater than or equal to 60 years (aOR 2.00;95% CI 1.20-3.35), and underlying co-morbid of chronic kidney disease (CKD) (aOR 3.78;95% CI 1.57-9.08) were identified as risk factors for CAPA. Patients with CAPA had a significantly greater proportion of complications and longer length of hospital stay (p-value <0.001). Mortality was higher in patients with CAPA (48%) as compared to those without CAPA (13.5%) [OR=6.36(95%CI 3.6-11)]. CONCLUSIONS: CAPA was significantly associated with advanced age, chronic kidney disease, and critical illness at presentation, along with a greater frequency of complications and higher mortality.
ABSTRACT
Background: Systemic AL amyloidosis is an incurable relapsing plasma cell disorder. Despite therapeutic advances, there are no approved treatments for relapse disease. Treatment is often challenging due to underlying organ dysfunction. Belantamab mafodotin is an antibody-drug conjugate targeting B-cell maturation antigen with approval for relapsed refractory myeloma. In multiply pre-treated myeloma, the DREAMM-2 phase II trial showed an overall response rate of 32% for those with 2.5 mg/kg dose administered every three weeks with 2/3rd patients reporting keratopathy. A small case series of 6 patients with relapsed AL amyloidosis (Zhang et al , ASH 2021) was recently reported and a phase 2 trial is recruiting for patients with refractory amyloidosis (NCT04617925). Aims: We report our initial results using Belantamab monotherapy for the treatment of patients with AL amyloidosis with relapsed disease. Methods: Data for consecutive patients who were administered Belantamab at a specialist referral centre, National Amyloidosis Centre, University College London, was analysed. Results: Eleven patients were included 8 male, 3 female. Median age at Belantamab initiation was 65 (range 42-74) years. Eight patients had λ AL-type and three κ AL-type. At diagnosis, median involved free light-chain concentration was 534 (range 73-7181) mg/l. A median of two organs involved at baseline (range 1-3): 4 had cardiac involvement (half Mayo stage 2;half Mayo stage 3a) and 8 had renal involvement. The median prior lines of therapy was 3 (range 2-5) with all exposed to prior immunomodulatory drugs, proteasome inhibitors and 73% to anti-CD38 antibody treatments. Thirty-six percent had relapsed after melphalan-conditioned autologous stem cell transplantation. A median of 3 cycles of belantamab were delivered (range 1-8). The most frequent adverse event was ocular toxicity which was experienced in 8 patients (grade 1-3), necessitating dose modification of the three-weekly schedule. One patient developed transient grade 1 dyspnoea and liver dysfunction. No patients developed cytopenias, unlike previous reports (Zhang et al , 2021), nor infections beyond COVID (2 patients mild with no hospital admissions). The majority of the cohort required dose reduction either at initiation (patient 4, due to end stage renal failure;patient 11, post-renal transplant) or during therapy (n=5;three to 1.9mg/kg, two to 1.25mg/kg) due to ocular toxicity. Only one patient remained on the standard dose of 2.5mg/kg for >3 cycles. Ocular toxicity improved after treatment interruption (drug intervals 4-6 weeks) and no patients required complete treatment cessation. One patient is too early to assess response. Haematological responses (PR or better) were seen in 7 patients with 3 complete responses and two very good partial responses (VGPR) which are ongoing. Both renal patients (patients 4 and 11) commenced a dose of 1.25mg/kg and sustained a VGPR with no additional toxicity. Patient 3 had a 42% reduction in sFLC after two doses but then a prolonged gap due to keratopathy and has lost the response. There were no cardiac or renal toxicities observed. Summary/Conclusion: Belantamab mafodotin demonstrates significant activity in patients with heavily pre-treated AL amyloidosis with 70% achieving a ≥PR. Apart from keratopathy requiring dose modification, no other substantial toxicity was observed. Two patients with renal impairment (stage V CKD and ESRD) and one patient post-renal transplant tolerated treatment with no additional toxicity. Belantamab mafodotin shows promise in treatment of relapsed AL and needs further prospective trials.