Prognostic significance of CHADS2 and CHA2DS2-VASc scores to predict unfavorable outcomes in hospitalized patients with COVID-19.

Introduction: Owing to the imposed burden of the coronavirus disease 2019 (COVID-19),the need for stratifying the prognosis of patients has never been timelier. Hence, we aimed to ascertain the value of CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (one point for male instead of female) scores to predict unfavorable outcomes in COVID-19 patients. Methods: We enrolled consecutive patients above 18 years of age with confirmed COVID-19,who were admitted between February 16 and November 1, 2020. The primary endpoint of this study was three-month all-cause mortality. The secondary endpoints were considered four major in-hospital clinical features, including acute respiratory distress syndrome, cardiac injury,acute kidney injury, and mechanical ventilation. Results: A total of 1,406 hospitalized COVID-19 patients were studied, among which 301(21.40%) patients died during the follow-up period. Regarding the risk scores, CHADS 2≥1,CHA2DS2-VASc≥2, and CHA2DS2-VASc-M≥2 were significantly associated with mortality. The performance of all risk scores for predicting mortality was satisfactory (area under the curve:0.668, 0.668, and 0.681, respectively). Appraising secondary endpoints, we found that all three risk scores were associated with increased risk of acute respiratory distress syndrome, cardiac injury, acute kidney injury, and mechanical ventilation. Lastly, we revealed that all risk scores were significantly correlated with serum levels of laboratory biomarkers. Conclusion: Our analysis illustrated that the CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-Mscores could aid prognostication of unfavorable outcomes in COVID-19 patients. Therefore,these easily calculable methods could be integrated into the overall therapeutic strategy to guide the COVID-19 management more accurately.

Association of clinical characteristics, antidiabetic and cardiovascular agents with diabetes mellitus and COVID-19: a 7-month follow-up cohort study.

BACKGROUND: The prognostic factors of long-term outcomes in hospitalized patients with diabetes mellitus and COVID-19 are lacking. METHODS: In this retrospective cohort study, we evaluated patients aged ≥ 18-years-old with the COVID-19 diagnosis who were hospitalized between Feb 20 and Oct 29, 2020, in the Sina Hospital, Tehran, Iran. 1323 patients with COVID-19 entered in the final analysis, of whom 393 (29.7%) patients had diabetes. We followed up patients for incurring in-hospital death, severe COVID-19, in-hospital complications, and 7-month all-cause mortality. By doing univariate analysis, variables with unadjusted P-value < 0.1 in univariate analyses were regarded as the confounders to include in the logistic regression models. We made adjustments for possible clinical (model 1) and both clinical and laboratory (model 2) confounders. RESULTS: After multivariable regression, it was revealed that preadmission use of sulfonylureas was associated with a borderline increased risk of severity in both models [model 1, OR (95% CI):1.83 (0.91-3.71), P-value: 0.092; model 2, 2.05 (0.87-4.79), P-value: 0.099] and major adverse events (MAE: each of the severe COVID-19, multi-organ damage, or in-hospital mortality) in model 1 [OR (95% CI): 1.86 (0.90-3.87), P-value: 0.094]. Preadmission use of ACEIs/ARBs was associated with borderline increased risk of MAE in the only model 1 [OR (95% CI):1.83 (0.96-3.48), P-value: 0.066]. CONCLUSIONS: Preadmission use of sulfonylureas and ACEIs/ARBs were associated with borderline increased risk of in-hospital adverse outcomes. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40200-021-00901-4.

Association of clinical characteristics, antidiabetic and cardiovascular agents with diabetes mellitus and COVID-19: a 7-month follow-up cohort study

Background The prognostic factors of long-term outcomes in hospitalized patients with diabetes mellitus and COVID-19 are lacking. Methods In this retrospective cohort study, we evaluated patients aged ≥ 18-years-old with the COVID-19 diagnosis who were hospitalized between Feb 20 and Oct 29, 2020, in the Sina Hospital, Tehran, Iran. 1323 patients with COVID-19 entered in the final analysis, of whom 393 (29.7%) patients had diabetes. We followed up patients for incurring in-hospital death, severe COVID-19, in-hospital complications, and 7-month all-cause mortality. By doing univariate analysis, variables with unadjusted P-value < 0.1 in univariate analyses were regarded as the confounders to include in the logistic regression models. We made adjustments for possible clinical (model 1) and both clinical and laboratory (model 2) confounders. Results After multivariable regression, it was revealed that preadmission use of sulfonylureas was associated with a borderline increased risk of severity in both models [model 1, OR (95% CI):1.83 (0.91–3.71), P-value: 0.092;model 2, 2.05 (0.87–4.79), P-value: 0.099] and major adverse events (MAE: each of the severe COVID-19, multi-organ damage, or in-hospital mortality) in model 1 [OR (95% CI): 1.86 (0.90–3.87), P-value: 0.094]. Preadmission use of ACEIs/ARBs was associated with borderline increased risk of MAE in the only model 1 [OR (95% CI):1.83 (0.96–3.48), P-value: 0.066]. Conclusions Preadmission use of sulfonylureas and ACEIs/ARBs were associated with borderline increased risk of in-hospital adverse outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-021-00901-4.

The correlation between serum selenium, zinc, and COVID-19 severity: an observational study.

BACKGROUND: Without an adequate immune response, SARS-CoV2 virus can simply spread throughout the body of the host. Two of the well-known immunonutrients are selenium (Se) and zinc (Zn). Se and Zn deficiency might lead to inflammation, oxidative stress, and viral entry into the cells by decreasing ACE-2 expression; three factors that are proposed to be involved in COVID-19 pathogenesis. Thus, in the current study we aimed at evaluating the correlation between serum Se and Zn status and COVID-19 severity. METHODS: Eighty-four COVID-19 patients were enrolled in this observational study. Patients were diagnosed based on an infectious disease specialist diagnosis, using WHO interim guidance and the recommendations of the Iranian National Committee of Covid-19. The patients with acute respiratory tract infection symptoms were checked for compatibility of chest computed tomography (CT) scan results with that of Covid-19 and Real-time polymerase chain reaction (RT-PCR) for corona virus infection. The severity of Covid-19 was categorized into three groups (mild, moderate, and severe) using CDC criteria. Serum Zn and Se level of all subjects was measured. The severity of the disease was determined only once at the onset of disease. RESULTS: According to the results of linear regression test, there was a significant association between Zn and Se level and COVID-19 severity (ß = - 0.28, P-value = 0.01 for Se; ß = - 0.26, P-value = 0.02). However the significance disappeared after adjusting for confounding factors. Spearman correlation analysis showed a significant negative association between serum Zn, Se and CRP level (r = - 0.35, P-value = 0.001 for Se; r = - 0.41, P-value < 0.001 for Zn). CONCLUSION: Results suggest that increasing levels of Se and Zn were accompanied by a decrease in serum CRP level. However, the significant association between Se, Zn, and disease severity was lost after adjusting for confounding factors.

Influenza vaccination coverage and obstacles in healthcare workers (HCWs) and the follow up of side effects: a multicenter investigation in Iran.

INTRODUCTION: Seasonal influenza is an annual common occurrence in cold seasons; but the COVID-19 pandemic is also currently ongoing. These two diseases can't be distinguished from their symptoms alone; therefore, the importance of preventing influenza by vaccination is more than ever. Due to the high exposure of hospital personnel, widespread influenza vaccination of these high-risk groups seems to be a necessity. This Study conducted to determine vaccination coverage in the personnel of four tertiary referral collegiate hospitals in 2019 and to further investigate individual obstacles for Influenza vaccination. METHODS: In this cross-sectional descriptive study, 637 personnel were selected randomly from distinctive hospitals in a list-wised. Ones vaccinated filled the side effects questionnaire and who not vaccinated filled the vaccination obstacles questionnaire. The study was approved by the ethics committee of Tehran University of Medical Sciences with this reference number: IR.TUMS.IKHC.REC.1398.218. RESULTS: The mean vaccination coverage was 29.4% and the coverage difference among centers was not statistically significant (p = 0.192). The following items had the most impact on personnel decision: confidence about one's immune system (p < 0.05), the experience of side effects from previous vaccinations (p = 0.011), attitude about vaccination in colleagues (p = 0.021) and work experience (p < 0.05). About 23% of vaccinated individuals reported side effects following vaccination and the most common side effect was mild cold symptoms with 12.3% prevalence. CONCLUSION: The results of the current study revealed that influenza vaccination coverage among HCWs is not satisfactory in Iran. Hospital authorities and infection control units should plan to remove the obstacles of influenza vaccination.

The Risk Factors and Clinical Outcomes Associated with Acute Kidney Injury in Patients with COVID-19: Data from a Large Cohort in Iran.

INTRODUCTION: Kidney involvement, ranging from mild hematuria and proteinuria to acute kidney injury (AKI) in patients with coronavirus disease-2019 (COVID-19), is a recent finding with various incidence rates reported among hospitalized patients with COVID-19. Given the various AKI rates and their associated risk factors, lack of AKI recovery in the majority of patients hospitalized with COVID-19, and limited data regarding AKI in patients with COVID-19 in Iran, we aim to investigate the potential risk factors for AKI development and its incidence in patients hospitalized with COVID-19. METHODS: In this retrospective cohort study, we enrolled adult patients referred to the Sina Hospital, Iran, from February 20 to May 14, 2020, with either a positive PCR test or a highly susceptible chest computed tomography features consistent with COVID-19 diagnosis. AKI was defined according to the kidney disease improving global outcomes criteria, and patients were stratified based on their AKI staging. We evaluated the risk indicators associated with AKI during hospitalization besides in-hospital outcomes and recovery rate at the time of discharge. RESULTS: We evaluated 516 patients with a mean age of 57.6 ± 16.1 years and a male-to-female ratio of 1.69 who were admitted with the COVID-19 diagnosis. AKI development was observed among 194 (37.6%) patients, comprising 61.9% patients in stage 1, 18.0% in stage 2, and 20.1% in stage 3. Out of all patients, AKI occurred in 58 (11.2%) patients during the hospital course, and 136 (26.3%) patients arrived with AKI upon admission. AKI development was positively associated with all of the in-hospital outcomes, including intensive care unit admissions, need for invasive ventilation, acute respiratory distress syndrome (ARDS), acute cardiac injury, acute liver injury, multiorgan damage, and mortality. Patients with stage 3 AKI showed a significantly higher mortality rate, ARDS, and need for invasive ventilation than other stages. After multivariable analysis, male sex (odds ratio [OR]: 11.27), chronic kidney disease (CKD) (OR: 6.89), history of hypertension (OR: 1.69), disease severity (OR: 2.27), and high urea levels (OR: 1.04) on admission were independent risk indicators of AKI development. Among 117 (28.1%) patients who experienced AKI and survived, only 33 (28.2%) patients made a recovery from the AKI, and 84 (71.8%) patients did not exhibit full recovery at the time of discharge. DISCUSSION/CONCLUSION: We found that male sex, history of CKD, hypertension, disease severity, and high serum urea were independent risk factors associated with AKI in patients with COVID-19. Also, higher stages of AKI were associated with increased risk of mortality and in-hospital complications. Our results indicate a necessity for more precise care and monitoring for AKI during hospitalization in patients with COVID-19, and lack of AKI recovery at the time of discharge is a common complication in such patients.

Clinical significance of prognostic nutrition index in hospitalized patients with COVID-19: Results from single-center experience with systematic review and meta-analysis.

BACKGROUND: We aimed to ascertain risk indicators of in-hospital mortality and severity as well as to provide a comprehensive systematic review and meta-analysis to investigate the prognostic significance of the prognostic nutrition index (PNI) as a predictor of adverse outcomes in hospitalized coronavirus disease 2019 (COVID-19) patients. METHODS: In this cross-sectional study, we studied patients with COVID-19 who were referred to our hospital from February 16 to November 1, 2020. Patients with either a real-time reverse-transcriptase polymerase chain reaction test that was positive for COVID-19 or high clinical suspicion based on the World Health Organization (WHO) interim guidance were enrolled. A parallel systematic review/meta-analysis (in PubMed, Embase, and Web of Science) was performed. RESULTS: A total of 504 hospitalized COVID-19 patients were included in this study, among which 101 (20.04%) patients died during hospitalization, and 372 (73.81%) patients were categorized as severe cases. At a multivariable level, lower PNI, higher lactate dehydrogenase (LDH), and higher D-dimer levels were independent risk indicators of in-hospital mortality. Additionally, patients with a history of diabetes, lower PNI, and higher LDH levels had a higher tendency to develop severe disease. The meta-analysis indicated the PNI as an independent predictor of in-hospital mortality (odds ratio [OR] = 0.80; P < .001) and disease severity (OR = 0.78; P = .009). CONCLUSION: Our results emphasized the predictive value of the PNI in the prognosis of patients with COVID-19, necessitating the implementation of a risk stratification index based on PNI values in hospitalized patients with COVID-19.

Predicting Risk Score for Mechanical Ventilation in Hospitalized Adult Patients Suffering from COVID-19.

BACKGROUND: COVID-19 has become a pandemic since December 2019, causing millions of deaths worldwide. It has a wide spectrum of severity, ranging from mild infection to severe illness requiring mechanical ventilation. In the middle of a pandemic, when medical resources (including mechanical ventilators) are scarce, there should be a scoring system to provide the clinicians with the information needed for clinical decision-making and resource allocation. OBJECTIVES: This study aimed to develop a scoring system based on the data obtained on admission, to predict the need for mechanical ventilation in COVID-19 patients. METHODS: This study included COVID-19 patients admitted to Sina Hospital, Tehran University of Medical Sciences from February 20 to May 29, 2020. Patients' data on admission were retrospectively recruited from Sina Hospital COVID-19 Registry (SHCo-19R). Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were performed to identify the predictive factors for mechanical ventilation. RESULTS: A total of 681 patients were included in the study; 74 patients (10.9%) needed mechanical ventilation during hospitalization, while 607 (89.1%) did not. Multivariate logistic analysis revealed that age (OR,1.049; 95% CI:1.008-1.091), history of diabetes mellitus (OR,3.216; 95% CI:1.134-9.120), respiratory rate (OR,1.051; 95% CI:1.005-1.100), oxygen saturation (OR,0.928; 95% CI:0.872-0.989), CRP (OR,1.013; 95% CI:1.001-1.024) and bicarbonate level (OR,0.886; 95% CI:0.790-0.995) were risk factors for mechanical ventilation during hospitalization. CONCLUSIONS: A risk score has been developed based on the available data within the first hours of hospital admission to predict the need for mechanical ventilation. This risk score should be further validated to determine its applicability in other populations.

COVID-19-related refractory status epilepticus with the presence of SARS-CoV-2 (RNA) in the CSF: a case report.

Amongst the neurologic complications of COVID-19 disease, very few reports have shown the presence of the virus in the cerebrospinal fluid (CSF). Seizure and rarely status epilepticus can be associated with COVID-19 disease. Here we present a 73-year-old male with prior history of stroke who has never experienced seizure before. He had no systemic presentation of COVID-19 disease. The presenting symptoms were two consecutive generalized tonic-clonic seizures that after initial resolution turned into a nonconvulsive status epilepticus despite antiepileptic treatment (a presentation similar to NORSE (new-onset refractory status epilepticus)). There was no new lesion in the brain magnetic resonance imaging (MRI). The CSF analysis only showed an increased protein levels and positive reverse transcription polymerase chain reaction (RT-PCR) of 2019-nCoV. Patient recovered partially after anesthetic, IVIG, steroid, and remdesivir. To our knowledge, this is the first report of a refractory status epilepticus with the presence of SARS-CoV-2 ribonucleic acid (RNA) in the CSF.

Clinical Characteristics of COVID-19 Patients with Gastrointestinal Symptoms.

BACKGROUND: We aimed to assess the gastrointestinal (GI) manifestations of patients with severe acute respiratory syndrome coronavirus 2 infection and determine factors predicting disease prognosis and severity among patients with GI symptoms. METHODS: In this retrospective study, we evaluated laboratory confirmed (by real-time polymerase chain reaction) inpatient cases of coronavirus-associated disease 2019 (COVID-19), referred to Sina hospital, a tertiary educational hospital of Tehran University of Medical Sciences, from March 10 to May 20, 2020. Demographic and clinical characteristics, laboratory data, outcomes and treatment data were extracted and analyzed using SPSS version 20. RESULTS: A total of 611 patients (234 women and 377 men) were included with 155 patients having GI symptoms. The most prevalent reported GI symptom was nausea/vomiting in 115 (18.8%) of patients. A total of 20 patients (3.2%) only had GI symptoms (without respiratory symptoms). There was no statistically significant difference in the clinical outcomes, disease severity, intensive care unit (ICU) admission and mortality between patients with and without GI symptoms. Aspartate Aminotransferase level was associated with 446% increased risk of disease severity (adjusted odds ratio: 5.46, 95% CI: 2.01 to 14.81) (P=0.040) among patients with GI symptoms. Additionally, we found that treatment with antibiotics in addition to mechanical ventilation was associated with increased survival among patients with GI symptoms (Pearson Chi square: 6.22; P value: 0.013). CONCLUSION: More attention should be paid to patients with only GI symptoms for early patient detection and isolation. Moreover, patients with GI manifestations are not exposed to higher rates of disease severity or mortality.

Risk indicators associated with in-hospital mortality and severity in patients with diabetes mellitus and confirmed or clinically suspected COVID-19.

PURPOSE: This study aims to investigate risk indicators of in-hospital mortality and severity of coronavirus disease-2019 (COVID-19) in patients with diabetes mellitus (DM). METHODS: In this retrospective study, we studied patients with COVID-19 referred to Sina Hospital, Tehran, Iran, from February 20 to May 14, 2020. Patients with either a positive real-time reverse-transcriptase polymerase-chain-reaction test of swab specimens or high clinical suspicion according to the World Health Organization interim guidance were included. We accurately divided all patients into two groups based on diabetes affection and followed-up patients with DM based on incurring death, severe COVID-19, and in-hospital complications. RESULTS: We enrolled 574 patients with COVID-19 in the final analysis, of whom 176 (30.7%) patients had DM. In this study, 104 (18.1%) patients deceased, and 380 (66.2%) patients incurred severe COVID-19. We found that COVID-19 patients with DM had a significantly higher mortality rate (P value<0.001), severe disease (P value<0.001), and in-hospital complications (all P values<0.05). Besides that, in patients with DM, admission temperature (odds ratio (OR): 1.69, P value: 0.024), oxygen saturation (OR: 0.92, P value: 0.004), and urea (OR: 1.01, P value: 0.048) were independent risk indicators of in-hospital mortality. In addition, subgroup analysis of diabetic patients based on admission glucose level showed significant differences between these groups regarding acute cardiac injury (P value: 0.044) and acute liver injury (P value: 0.002). CONCLUSIONS: Patients with DM admitted with lower oxygen saturation, elevated temperature, and higher urea are more susceptible to progress to more severe COVID-19 and poor prognosis. This indicates a necessity for more precise care during hospitalization for these patients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40200-020-00701-2.

Vitamin D sufficiency, a serum 25-hydroxyvitamin D at least 30 ng/mL reduced risk for adverse clinical outcomes in patients with COVID-19 infection.

BACKGROUND: To investigate the association between serum 25-hydroxyvitamin D levels and its effect on adverse clinical outcomes, and parameters of immune function and mortality due to a SARS-CoV-2 infection. STUDY DESIGN: The hospital data of 235 patients infected with COVID-19 were analyzed. RESULTS: Based on CDC criteria, among our study patients, 74% had severe COVID-19 infection and 32.8% were vitamin D sufficient. After adjusting for confounding factors, there was a significant association between vitamin D sufficiency and reduction in clinical severity, inpatient mortality serum levels of C-reactive protein (CRP) and an increase in lymphocyte percentage. Only 9.7% of patients older than 40 years who were vitamin D sufficient succumbed to the infection compared to 20% who had a circulating level of 25(OH)D< 30 ng/ml. The significant reduction in serum CRP, an inflammatory marker, along with increased lymphocytes percentage suggest that vitamin D sufficiency also may help modulate the immune response possibly by reducing risk for cytokine storm in response to this viral infection. CONCLUSION: Therefore, it is recommended that improving vitamin D status in the general population and in particular hospitalized patients has a potential benefit in reducing the severity of morbidities and mortality associated with acquiring COVID-19.

Sofosbuvir and daclatasvir compared with standard of care in the treatment of patients admitted to hospital with moderate or severe coronavirus infection (COVID-19): a randomized controlled trial.

BACKGROUND: Currently no effective antiviral therapy has been found to treat COVID-19. The aim of this trial was to assess if the addition of sofosbuvir and daclatasvir improved clinical outcomes in patients with moderate or severe COVID-19. METHODS: This was an open-label, multicentre, randomized controlled clinical trial in adults with moderate or severe COVID-19 admitted to four university hospitals in Iran. Patients were randomized into a treatment arm receiving sofosbuvir and daclatasvir plus standard care, or a control arm receiving standard care alone. The primary endpoint was clinical recovery within 14 days of treatment. The study is registered with IRCT.ir under registration number IRCT20200128046294N2. RESULTS: Between 26 March and 26 April 2020, 66 patients were recruited and allocated to either the treatment arm (n = 33) or the control arm (n = 33). Clinical recovery within 14 days was achieved by 29/33 (88%) in the treatment arm and 22/33 (67%) in the control arm (P = 0.076). The treatment arm had a significantly shorter median duration of hospitalization [6 days (IQR 4-8)] than the control group [8 days (IQR 5-13)]; P = 0.029. Cumulative incidence of hospital discharge was significantly higher in the treatment arm versus the control (Gray's P = 0.041). Three patients died in the treatment arm and five in the control arm. No serious adverse events were reported. CONCLUSIONS: The addition of sofosbuvir and daclatasvir to standard care significantly reduced the duration of hospital stay compared with standard care alone. Although fewer deaths were observed in the treatment arm, this was not statistically significant. Conducting larger scale trials seems prudent.

The association between cardiac injury and outcomes in hospitalized patients with COVID-19.

In this study, we aimed to assess the association between development of cardiac injury and short-term mortality as well as poor in-hospital outcomes in hospitalized patients with COVID-19. In this prospective, single-center study, we enrolled hospitalized patients with laboratory-confirmed COVID-19 and highly suspicious patients with compatible chest computed tomography features. Cardiac injury was defined as a rise of serum high sensitivity cardiac Troponin-I level above 99th percentile (men: > 26 ng/mL, women: > 11 ng/mL). A total of 386 hospitalized patients with COVID-19 were included. Cardiac injury was present among 115 (29.8%) of the study population. The development of cardiac injury was significantly associated with a higher in-hospital mortality rate compared to those with normal troponin levels (40.9% vs 11.1%, p value < 0.001). It was shown that patients with cardiac injury had a significantly lower survival rate after a median follow-up of 18 days from symptom onset (p log-rank < 0.001). It was further demonstrated in the multivariable analysis that cardiac injury could possibly increase the risk of short-term mortality in hospitalized patients with COVID-19 (HR = 1.811, p-value = 0.023). Additionally, preexisting cardiovascular disease, malignancy, blood oxygen saturation < 90%, leukocytosis, and lymphopenia at presentation were independently associated with a greater risk of developing cardiac injury. Development of cardiac injury in hospitalized patients with COVID-19 was significantly associated with higher rates of in-hospital mortality and poor in-hospital outcomes. Additionally, it was shown that development of cardiac injury was associated with a lower short-term survival rate compared to patients without myocardial damage and could independently increase the risk of short-term mortality by nearly two-fold.