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1.
J Clin Med ; 11(7)2022 Mar 29.
Article in English | MEDLINE | ID: covidwho-2216398

ABSTRACT

BACKGROUND: COVID-19 is caused by SARS-CoV-2 infection and has reached pandemic proportions. Since then, several clinical characteristics have been associated with poor outcomes. This study aimed to describe the morbidity profile of COVID-19 deaths in Portugal. METHODS: A study was performed including deaths certificated in Portugal with "COVID-19" (ICD-10: U07.1 or U07.2) coded as the underlying cause of death from the National e-Death Certificates Information System between 16 March and 31 December 2020. Comorbidities were derived from ICD-10 codes using the Charlson and Elixhauser indexes. The resident Portuguese population estimates for 2020 were used. RESULTS: The study included 6701 deaths (death rate: 65.1 deaths/100,000 inhabitants), predominantly males (72.1). The male-to-female mortality ratio was 1.1. The male-to-female mortality rate ratio was 1.2; however, within age groups, it varied 5.0-11.4-fold. COVID-19 deaths in Portugal during 2020 occurred mainly in individuals aged 80 years or older, predominantly in public healthcare institutions. Uncomplicated hypertension, uncomplicated diabetes mellitus, congestive heart failure, renal failure, cardiac arrhythmias, dementia, and cerebrovascular disease were observed among COVID-19 deceased patients, with prevalences higher than 10%. A high prevalence of zero morbidities was registered using both the Elixhauser and Charlson comorbidities lists (above 40.2%). Nevertheless, high multimorbidity was also identified at the time of COVID-19 death (about 36.5%). Higher multimorbidity levels were observed in men, increasing with age up to 80 years old. Zero-morbidity prevalence and high multimorbidity prevalences varied throughout the year 2020, seemingly more elevated in the mortality waves' peaks, suggesting variation according to the degree of disease incidence at a given period. CONCLUSIONS: This study provides detailed sociodemographic and clinical information on all certificated deaths from COVID-19 in Portugal during 2020, showing complex and extreme levels of morbidity (zero-morbidity vs. high multimorbidity) dynamics during the first year of the pandemic in Portugal.

2.
JACCP Journal of the American College of Clinical Pharmacy ; 5(12):1427-1428, 2022.
Article in English | EMBASE | ID: covidwho-2173044

ABSTRACT

Introduction: Infection with SARS-CoV-2 increases the risk of thrombosis and subsequently mortality. The impact of chronic anticoagulation prior to infection, however, is not well defined. Research Question or Hypothesis: Does the use of indicated chronic anticoagulation alter morbidity and mortality from thrombotic complications of COVID-19 in hospitalized patients? Study Design: Single-centered, retrospective chart review from March to December 2020. Method(s): Hospitalized adult patients with a positive COVID-19 test with or without chronic therapeutic anticoagulation were included. Exclusion criteria included pregnancy and hypercoagulable comorbidity not on anticoagulation. The primary endpoint was a combined incidence of venous thromboembolism, arterial thrombosis, myocardial infarction, ischemic stroke, and disseminated intravascular coagulation. Additional endpoints included ventilation or high-flow oxygen requirement, development of acute respiratory distress syndrome (ARDS) or respiratory failure, and bleeding. 152 patients per group would provide 80% power and a two-sided alpha of 0.05 for the primary outcome. Outcomes were analyzed with Chi-square or Fisher's exact tests using SPSS software. Result(s): 733 patients were included (453 not on anticoagulation (No- AC) and 280 on chronic anticoagulation (AC)). There were no differences in baseline characteristics between groups except for the Charlson Comorbidity Index score (No-AC: 4.8, AC: 5.8;p < 0.001). For the primary endpoint, events occurred in 133 patients (29.4%) in the No- AC group versus 27 patients (9.6%) in the AC group (p < 0.001). For the secondary endpoints, there were differences in need for ventilation [No-AC: 101 (22.3%), AC: 39 (13.9%);p = 0.005] and development of ARDS [No-AC: 252 (55.6%), AC: 124 (44.3%);p = 0.003], with no difference in bleed [No-AC: 5 (1.1%), AC: 7 (2.5%);p = 0.15]. Conclusion(s): Patients hospitalized with COVID-19 infection on chronic anticoagulation had lower incidence of thrombosis and mortality.

3.
Alzheimer's and Dementia ; 18(S8) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2172396

ABSTRACT

Background: Post Covid-19 syndrome is recognized as the maintenance of disease symptoms for weeks to months after the disease has healed. It is suspected that the involvement of the ACE enzyme and IL-6 may trigger an increased risk of dementia. Method(s): This is a cohort study that is evaluating over 12 months the functional status and cognition of elderly people after hospital discharge. One group is composed of elderly people admitted to the hospital for Covid-19 and the other group is composed of elderly people hospitalized for other clinical reasons. The groups are evaluated with The Mattis (DRS), AD8, IQCODE, ADCS-ADL, PCL-C, GDS-15, FIM, COPM, CFS, FSS, mMRC and SARC-calf. We will describe the preliminary results of the first 15 patients included in the COVID-19 group on functional status, cognition, mood and quality of life. Result(s): Fifteen patients with COVID-19 were evaluated three months after hospital discharge. One was excluded due to previous mental disorder and another due to a request to be excluded from the study. We found a mean age of 67.7 +/- 7.15 years, schooling 8.7 +/- 4.7 years, 61.5% female, Charlson Comorbidity Index 1.9 +/- 1.4, 69.2% with smoking history had incomplete vaccine protection for COVID-19. Considering cognition, 15.4% of the sample had no impairment, 53.9% had mild cognitive impairment (MCI) (30.8% amnestic MCI and 23.1% non-amnesic MCI) and 30.8% had dementia. 23.1% declared their health status and quality of life as fair or poor. Median CFS was 5 (3-5), mean GDS-15 was 4.7 +/- 2.9, FSS 32.9 +/- 18.9, PCL-c 32.6 +/- 12.5, SARC-calf 3.2 +/- 4.2. All had mMRC dyspnea classified between 2 and 4. Conclusion(s): There was a high prevalence of mild cognitive impairment and dementia among patients after three months of discharge, with a predominance of mild frailty due to CFS and the presence of fatigue. It is noteworthy that a quarter of the sample reported low quality of life. Copyright © 2022 the Alzheimer's Association.

4.
Aging Medicine. ; 2023.
Article in English | EMBASE | ID: covidwho-2172351

ABSTRACT

Objective: This study was intended to research the sensitivity of the Charlson Comorbidity Index (CCI), COVID-GRAM, and MuLBSTA risk scores for hospital length of stay (LOS) and mortality in older patients hospitalized with coronavirus disease 2019 (COVID-19). Method(s): A total of 217 patients (119 women) were included in the study. The first clinical signs, comorbidities, laboratory and radiology findings, and hospital LOS were recorded for each patient. The CCI, COVID-GRAM, and MuLBSTA risk scores were calculated, and their sensitivities for hospital LOS and mortality were evaluated using receiver operating characteristic (ROC) curve analysis. Result(s): Of the hospitalized patients, 59 (27.2%) were followed in the intensive care unit, and mortality developed in 44 (20.3%). The CCI positively correlated with COVID-GRAM and MuLBSTA scores (P < 0.001). COVID-GRAM and MuLBSTA results correlated with LOS and mortality (P < 0.001). According to the ROC curve analysis, the cutoff points for mortality were 5 for CCI, 169 for COVID-GRAM, and 9 for MuLBSTA. Conclusion(s): Older patients with comorbidities are the major risk group for severe COVID-19. COVID-GRAM and MuLBSTA scores appear to be sensitive and reliable mortality indicators for these patients. Copyright © 2023 The Authors. Aging Medicine published by Beijing Hospital and John Wiley & Sons Australia, Ltd.

5.
Turk Geriatri Dergisi ; 25(4):622-631, 2022.
Article in English | EMBASE | ID: covidwho-2205769

ABSTRACT

Introduction: We aimed to compare the COVID-19 outcomes in unvaccinated and CoronaVac vaccinated older adults. Material(s) and Method(s): In this single-center study, patients aged >=65 years who were hospitalized for COVID-19 were retrospectively analyzed in two groups: unvaccinated and vaccinated. Result(s): A total of 742 patients were included. The mean age was 76.6+/-7.6 years. Of these, 46.1% (n=342) were male, 76.0% (n=564) were vaccinated. Among patients who were transferred to the intensive care unit (n=217), 206 (27.8%) received invasive mechanical ventilation support and 194 (26.1%) were died. In the multivariate analysis, advanced age (OR=1.03, 95%CI=1.01-1.06, p<0.01) and a high Charlson Comorbidity Index (OR=1.24, 95%CI=1.12-1.38, p<0.01) were predictors of mortality, while being vaccinated (OR=0.75, 95%CI=0.62-0.91, p<0.01) was associated with survival. Vaccination reduced the need for intensive care by 26.5% and mortality by 24.9 %. When the vaccinated group was evaluated, high Charlson Comorbidity Index (OR=1.428, 95%CI=1.14-1.64, p<0.01) was an independent predictor for mortality. However, booster vaccination in the last 130 days was the only protective factor that reduced mortality (p=0.04, 95%CI=0.43-0.99, OR=0.66) in multivariate analysis. Booster dose vaccination in the last 130 days reduced mortality by 33.8%. Conclusion(s): CoronaVac vaccination improved survival in hospitalized older adult patients (>=65 years old) with COVID-19. However, delaying the booster dose for more than 130 days were significantly associated with decreased survival. Therefore, older adults who completed their primary vaccination series with CoronaVac should not delay their booster dose to reduce the risk of death. Copyright © 2022, Geriatrics Society. All rights reserved.

6.
JMIR public health and surveillance. ; 22, 2022.
Article in English | EMBASE | ID: covidwho-2198143

ABSTRACT

BACKGROUND: Since the outbreak of the COVID-19 pandemic, identifying the main risk factors has been imperative to properly manage the public health challenges that the pandemic exposes, such as organizing effective vaccination campaigns. In addition to gender and age, multimorbidity seems to be one of the predisposing factors coming out of many studies investigating the possible causes of increased susceptibility to SARS-CoV-2 infection and adverse outcomes. However, only a few studies conducted have used large samples. OBJECTIVE(S): The objective is to evaluate the association between multimorbidity, probability to be tested, susceptibility, and severity of SARS-CoV-2 infection in the Piedmont population (Northern Italy, about 4 million inhabitants). For this purpose, we considered five main outcomes: access to swab, positivity to SARS-CoV-2, hospitalization, ICU admission, and death within 30 days from the first positive swab. METHOD(S): Data were obtained from different Piedmont health-administrative databases. Subjects aged between 45 and 74 years and infections diagnosed between February and May 2020 were considered. Multimorbidity was defined both with the Charlson Comorbidity Index (CCI) and by identifying patients with previous comorbidities such as diabetes, and oncological, cardiovascular, and respiratory diseases. Multivariable logistic regression models (adjusted for age and month of infection and stratified by gender) were performed for each outcome. Analyses were also conducted by separating two age groups (45-59 and 60-74 years). RESULT(S): Out of 1,918,549 subjects, 85,348 performed at least one swab, 12,793 tested positive for SARS-CoV-2, 4,644 were hospitalized, 1,508 were admitted to the ICU, and 749 died within 30 days from the first positive swab. Individuals with a higher CCI had a higher probability of being swabbed but a lower probability of testing positive. We observed the same results when analyzing subjects with previous oncological and cardiovascular diseases. Moreover, especially in the youngest group, we identified a greater risk of being hospitalized and dying. Among comorbidities considered in the study, respiratory diseases seem to be the most likely to increase the risk of having a positive swab and worse disease outcomes. CONCLUSION(S): Our study shows that patients with multimorbidity, although swabbed more frequently, are less likely to result infected with SARS-CoV-2, probably due to greater attention on protective methods. Moreover, a history of respiratory diseases is a risk factor for a worse prognosis of COVID-19. Nonetheless, whatever comorbidities affect the patients, a strong dose-response effect was observed between an increased score of CCI and COVID-19 hospitalization, ICU admission, and death. These results are important in terms of public health because they help in identifying a group of subjects that are more prone to worse SARS-CoV-2 outcomes. This information is important for promoting targeted prevention and developing policies for the prioritization of public health interventions.

7.
Critical Care Medicine ; 51(1 Supplement):599, 2023.
Article in English | EMBASE | ID: covidwho-2190680

ABSTRACT

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.

8.
Critical Care Medicine ; 51(1 Supplement):585, 2023.
Article in English | EMBASE | ID: covidwho-2190677

ABSTRACT

INTRODUCTION: Prior data indicate that sepsis survivors face persistent health challenges and fail to receive adequate support after hospital discharge. Delivery of high-quality transition care may be exacerbated by the COVID-19 pandemic. We assessed patient reported satisfaction with transitional care and health outcome status for survivors of respiratory sepsis (due to COVID-19 and non-COVID-19 pneumonia) during the pandemic. METHOD(S): We enrolled patients (or surrogate caregivers) from both usual care and intervention arms of ENCOMPASS, an ongoing clinical trial evaluating the effectiveness of a multicomponent sepsis transition program. Individuals who consented to participate completed health related quality of life (HRQoL;EQ-5D-5L) and other outcomes measures (Mini-MOCA, IES-6, mMRC) 3 months after hospital discharge and responded to questions about post-discharge support. Interviews were conducted via telephone. Data were collected in REDCap (Research Electronic Data Capture) and analyzed with SAS. RESULT(S): Among 18 participants (14 patients, 4 caregivers [non-overlapping]), 56% were female, median patient age was 67 years, median Charlson index was 4, median SOFA was 4, and 2 patients were recovering from COVID-19. Most reported being satisfied/very satisfied with their transitional care (15, 83%) and were able to get all of the healthcare services needed during the pandemic (14, 78%). Many participants reported persistent problems at 3 months after discharge (mobility [17, 94%], self-care [17, 94%], usual activities [18, 100%], pain or discomfort [17, 94%], and anxiety or depression [15, 83%]), independent of coexisting chronic disease burden. The median EQ-5D visual analog scale was 65 (IQR=40-80). 12 (86%) patients reported persistent dyspnea, 2 (14%) had cognitive impairment by mini-MOCA, and 3 (21%) had symptoms of post-traumatic stress by IES-6. CONCLUSION(S): Sepsis survivors experience multidimensional HRQoL problems 3 months after discharge. Despite concerns about the provision of transitional support during the pandemic, most patients in this small study were satisfied with the transitional support received. Our findings reinforce the need for high-quality transitional support that addresses the new or worsening health problems experienced after sepsis.

9.
Critical Care Medicine ; 51(1 Supplement):471, 2023.
Article in English | EMBASE | ID: covidwho-2190646

ABSTRACT

INTRODUCTION: The appropriate use of empiric antibiotics for patients with severe COVID-19 presents a clinical challenge. Bacterial coinfection can be difficult to exclude, sometimes resulting in empiric antibiotic therapy. However, antibiotics alter the respiratory tract microbiome and these changes in the lung microbiome have been associated with prolonged ARDS in COVID-19. We hypothesized that early antibiotic use increase the risk of prolonged mechanical ventilation in patients hospitalized with COVID-19. METHOD(S): We used the National Covid Cohort Collaborative (N3C) to identify a retrospective cohort of patients admitted between March 2020 and May 2022 with a positive COVID-19 PCR or antigen test 15 days prior or within 48 hours of admission. We collected demographics, Charlson comorbidity index, month of hospitalization, antibiotics received, surgical procedures, details of mechanical ventilation, and diagnoses. We defined early empiric antibiotic use (EEAU) as administration of IV antibiotics for at least three calendar days before the sixth hospital day. Prolonged mechanical ventilation was defined as 14 consecutive days of mechanical ventilation. Our primary analysis used logistic regression after propensity score matching (PSM) with multiple imputation via chained equations for missing data. Sensitivity analyses included varying the required days of antibiotic exposure, using PSM with complete cases only, and using inverse probability of treatment weighting. RESULT(S): Our final cohort included 283,314 admissions. Prolonged mechanical ventilation and EEAU was observed in 1.4% and 13.9% of cases, respectively. In the unadjusted cohort, patients who received EEAU were more likely to be older, obese, and have more comorbidities. These patients were also more likely to have had mechanical ventilation, ECMO, major surgery, or a traumatic diagnosis during the first days of their hospitalization. After PSM, the standardized mean difference for all variables was less than 0.05. Early antibiotic use was associated with an increased risk of prolonged mechanical ventilation (OR 1.86, 95% CI 1.71 - 2.03). This finding was robust to all approaches in our sensitivity analysis. CONCLUSION(S): In our retrospective cohort, EEAU is independently associated with increased risk of prolonged mechanical ventilation.

10.
Critical Care Medicine ; 51(1 Supplement):438, 2023.
Article in English | EMBASE | ID: covidwho-2190618

ABSTRACT

INTRODUCTION: Many first wave COVID ARDS patients who were intubated spent a prolonged time on non-conventional ventilators (NCV) (e.g. transport devices, BiPAP machines) that are not intended for long-term use. The impact of prolonged NCV use on mortality is unknown. We hypothesized that time spent on NCV, compared to conventional ventilators (CV), is associated with higher mortality among COVID ARDS patients. METHOD(S): This is a retrospective multicenter study of our health system's COVID ARDS database from 03/01/20 - 04/30/20. We included intubated adults with COVID ARDS, mechanically ventilated on either NCV or CV. We excluded patients who switched between ventilator types, palliative extubations, and deaths within 24 hours of intubation. Baseline demographics and confounders were recorded. The primary outcome was 90 day mortality, and secondary outcomes were 3 and 28 day mortality. The effect of time spent on a NCV on 90 day mortality was modeled using logistic regression while controlling for confounders. The effect of time on NCV on 90 day mortality was quantified as an odds ratio (OR) and compared to the null using the Wald test. This was repeated for 3 and 28 day mortality. RESULT(S): Of 2094 patients who met inclusion criteria, we excluded 113 deaths within 24 hours, 500 ventilator switches, and 426 missing data points, for n=1055. Mean age was 65 years, 317 (30%) female, and 384 (36%) Caucasian. NCVs were used in 345 (33%) cases. Median time intubated was 9.8 days for NCV and 11 days for CV groups. Mean adjusted tidal volumes (ATV) were 6.8 for NCV and 6.6 ml/kg for CV. Overall unadjusted 90, 3 and 28 day mortality were 68%, 9% and 62%, respectively. Charlson Comorbidity Index (CCI), BMI, respiratory compliance (RC), ATV, P/F ratio, time averaged PEEP, time on vasopressors, and steroid use were controlled for. CCI and vasopressors correlated with higher mortality (p< 0.05). RC, P/F and PEEP correlated with lower mortality (p< 0.05). Time on NCV did not correlate with 90 day (OR=1.27, p=0.12) or 3 day mortality (OR=1.28, p=0.31) and correlated with increased 28 day mortality (OR = 1.5, p = 0.006). CONCLUSION(S): Among patients with COVID ARDS in early 2020, mechanical ventilation with NCVs was associated with increased adjusted mortality at 28 days but not at 3 and 90 days compared with CVs.

11.
Critical Care Medicine ; 51(1 Supplement):217, 2023.
Article in English | EMBASE | ID: covidwho-2190553

ABSTRACT

INTRODUCTION: The appropriate use of empiric antibiotics is a clinical challenge for patients with severe COVID-19. Early in the pandemic, there was concern that bacterial coinfection would influence morbidity and mortality. This concern often led to treating patients empirically with antibiotics. Fortunately, early data from the COVID-19 pandemic suggests bacterial coinfection is uncommon. However, there has been little published data on the antibiotic prescribing practices over the course of the pandemic. This study aims to investigate the inter-center variation and temporal trends of early antibiotic prescribing in patients hospitalized with COVID-19. METHOD(S): We performed a retrospective analysis using the National COVID Cohort Collaborative database. We identified patients admitted between March 2020 and December 2021 who had a positive COVID-19 PCR or antigen test 15 days prior or within 48 hours of admission. Age at time of COVID-19 diagnosis, gender, race/ethnicity, Charlson comorbidity index, the month of hospitalization, antibiotics received, labs at the time of hospital admission, and center identifier were collected. A chi-square test was used for categorical data and Wilcoxon rank-sum test for continuous data. Mixed effects logistic regression was used to evaluate predictors of early empiric antibiotic use. RESULT(S): Of 280,601 qualifying first hospitalizations, 30,469 patients received early empiric antibiotics. Antibiotic use declined across all centers over time from the first month (23%) to the last month in (8.1%) in the data collection period (p < 0.01). Antibiotic use decreased slightly by day 2 of hospitalization and was significantly reduced by day 5. Mechanical ventilation before day 2 (OR 2.25, 95% CI 2.14 - 2.36) and ECMO before day 2 (OR 1.60, 95% CI 1.25 - 2.05) but not region of residence was associated with early empiric antibiotic use. CONCLUSION(S): Although treatment of COVID-19 patients with empiric intravenous antibiotics has declined during the pandemic, the frequency of use remains higher than the reported incidence of bacterial superinfection. There is significant inter-center variation in antibiotic prescribing practices. Future research should focus on comparing outcomes and adverse events among COVID-19 patients treated with and without empiric antibiotics.

12.
Critical Care Medicine ; 51(1 Supplement):182, 2023.
Article in English | EMBASE | ID: covidwho-2190528

ABSTRACT

INTRODUCTION: SARS-CoV-2 (COVID-19) has continued to be a public health emergency, affecting almost 450 million people worldwide, with a disproportionate significant disease burden in the elderly community. Our objective is to provide population specific prognostic markers upon description of demographic factors, clinical characteristics, diagnostic variables, treatment characteristics and outcome variables in critically ill geriatric patients with acute hypoxic respiratory failure due to COVID-19 infection. METHOD(S): This is a retrospective chart review of 165 patients admitted to a single institution's medical and cardiovascular intensive care unit between the dates of March 01, 2020 and December 31, 2020. Inclusion criteria was patients age greater than or equal to 65 years, documented positive COVID-19 polymerase chain reaction test result and a diagnosis of acute hypoxic respiratory failure. Our primary end point evaluated the rate of mortality in relation to multiple variables during intensive care unit admission. RESULT(S): Of 165 patients, 45 patients were excluded. Of the remaining 120 patients, 41 were females and 79 were males. Four independent risk factors are significantly associated with higher odds of mortality for the concerned population: presence of solid tumor (AOR: 0.002, 95% CI: < 0.001, 0.31), maximum value of PaCO2 (AOR: 1.094, 95% CI: 1.029, 1.163), Charlson comorbidity index (AOR: 2.962, 95% CI: 1.59, 5.52), and use of diuretics (AOR: 0.015, 95% CI: < 0.001, 0.49). CONCLUSION(S): It was to our surprise that the mortality rate among those intubated was not statistically significant. However, it has been shown in prior research, which is in alignment with our results, that mechanical ventilation does not necessarily result in increased mortality. Certain factors were found to be poor prognostic markers during intensive care unit admission, which may predict a higher rate of mortality in those patient populations.

13.
Critical Care Medicine ; 51(1 Supplement):182, 2023.
Article in English | EMBASE | ID: covidwho-2190527

ABSTRACT

INTRODUCTION: As the world continues to experience waves of COVID-19 infections including new variants of the pathogen, it remains an important area of study to fully describe the etiology and associations of the severe disease. Recent studies have established correlations for Charlson Comorbidity Index (CCI) >3 with poor prognosis. Additionally, a previous study has shown that a high Ichikado CT score (ICTS) >172 predicts mortality. Here we further explore the validity of these prognostic tools when used together. METHOD(S): Single-center retrospective cohort data of patients with confirmed COVID pneumonia hospitalized between March 2020 and February 2022 was analyzed. Patients were included if, within 24 hours of admission, a CT Chest and full past medical history were obtained. ICTS was interpreted by 3 radiologists blinded to the outcomes. Thorough review of medical records provided information for CCI calculations. Primary outcomes measured were mortality and length of admission. Multivariate analysis performed using SPSS 28. RESULT(S): Data included eight hundred and seventythree patients (44.1% Female, mean age=55). Multivariate analysis for clinical outcomes of death comparing ICTS and CCI revealed a significant reduction in survival of patients with CCI>3 for ICTS>172 (log rank chi2=18.38, p< 0.001). Estimated survival time for these patients was 17.5 days (SE=0.996, 95%CI: 15.527-19.430) compared to CCI< 2 for ICTS>172 which estimated 26.4 days (SE=1.54, 95%CI: 23.405-29.441). For ICTS< 171, overall estimated survival was 33.5 days (SE=2.294, 95%CI: 28.972-37.966). ROC analysis using predicted survivability showed 75% sensitivity and 65% specificity (AUC=0.762, SE=0.021, p< 0.001, 95%CI: 0.720-0.804). CONCLUSION(S): As the number of confirmed COVID-19 cases continues to remain prevalent, practitioners may use these tools to guide the aggressiveness of their treatments and indications for tertiary care. ICTS and CCI are good predictors of COVID-19 prognosis especially when combined. Additionally, these tools can help firstline providers confidently assess and plan these seemingly complicated cases. Further research in this topic may lead to a prognostic tool specific to acute covid cases that is able to determine the prognosis for hospitalization, intubation, and mortality.

14.
Critical Care Medicine ; 51(1 Supplement):106, 2023.
Article in English | EMBASE | ID: covidwho-2190496

ABSTRACT

INTRODUCTION: Sedative medications are frequently utilized to relieve stress and anxiety, control agitation, and/or improve ventilator synchrony in patients requiring mechanical ventilation. However, many sedative agents have the potential to cause short- and long-term harm. Observational data have described associations between race and negative outcomes in patients with sepsis. It is unclear if race is associated with sedation administration practices. The purpose of this study was to investigate whether Black race is associated with differences in exposure to continuous infusion sedatives compared to White race. METHOD(S): A single-center, retrospective, cohort study was performed in adult patients admitted to the medical or surgical intensive care unit (ICU) with community-onset sepsis between June 1, 2018 and June 1, 2021. Data were collected from the electronic health record. The primary outcome was the cumulative dose of fentanyl received by continuous infusion between day 1-14 of ICU admission. The cumulative doses of other continuous infusion sedatives were described as secondary outcomes. A linear regression model assessed the association of race and the primary outcome while controlling for relevant confounding variables. RESULT(S): 772 patients were included. Black patients had a higher median modified APACHE II score (18 vs. 17, p< 0.001), Charlson Comorbidity Index (4 vs. 3, p=0.003), COVID-19 diagnosis incidence (18.5% vs. 7.1%, p< 0.001), and renal disease incidence (44.9% vs. 27.8%, p< 0.001) at baseline. No difference was observed in the amount of fentanyl received by continuous infusion between day 1-14 of ICU admission between Black and White patients (7085 mcg vs. 6426 mcg, p=0.37). Similarly, no association between Black race and the total amount of propofol (p=0.65), dexmedetomidine (p=0.67), or midazolam (p=0.08) via continuous infusion was observed. A linear regression model observed no significant association between race and the primary outcome. CONCLUSION(S): Black race was not associated with increased exposure to continuous infusion sedatives compared to White race. This is the first known study to investigate racial disparities in sedation strategies in mechanically ventilated adults in the ICU with sepsis.

15.
Critical Care Medicine ; 51(1 Supplement):103, 2023.
Article in English | EMBASE | ID: covidwho-2190493

ABSTRACT

INTRODUCTION: Several state-based and single center studies have demonstrated evidence of higher COVID-19 exposure rates, infection rates, and worse morbidity and mortality outcomes among minorities. Furthermore, challenges with vaccine access, hesitancy, distrust of the medical system further influenced who was protected from COVID-19.This study combines databases to conduct a multisite study across diverse states during the pandemic. METHOD(S): We conducted an ancillary study using the VIRUS (Viral Infection and Respiratory illness Universal Study) registry data supplemented by electronic medical record data from Mayo Clinic enterprise to assess demographics and outcomes among hospitalized patients with severe COVID-19. We included hospitalized adult patients admitted in five participating sites between April 2020 and January 2022 including academic hospitals in MN, AZ, and FL and two community hospitals in MN and WI. Selfidentified race and ethnicity data was categorized as White, Black, Asian, and Other;Hispanic and non-Hispanic. Other baseline characteristics, disease severity, and vaccination status were included in the analyses. The primary outcome was hospital mortality, the secondary outcomes were length of stay and healthcare utilization. Multivariable regression models were developed to analyze the interactions of relevant variables to predict outcomes. RESULT(S): 6904 patients were included. 3398 (57.8%) were male and 86.9% White,3.6% Black,3.3% Asian,6.2% Other. The mean age of Whites was 64.9 years v.53.8, 58, 52.8 respectively (p< 0.0005). Whites had higher Charlson comorbidity scores-5.2 v.4.0,3.6,3.0 respectively (p< 0.005). Vaccination rates were low in cohort, but higher among Whites 11.2% v.5.4%,4.6%,5.0% respectively (p< 0.0005). Mortality outcomes between different racial groups did not differ (p=0.41). Non-Hispanics were older than Hispanics- mean age 64.5 years v.53 (p< 0.005) and had higher Charlson comorbidity scores-5.2 v.3.4 (p< 0.005) Vaccination rates among non-Hispanics were 10.7 v 3.4% (p< 0.005)). Mortality outcomes between ethnic groups did not differ(p=0.86). Mortality outcomes between vaccinated and unvaccinated patients did not differ (p=0.9). CONCLUSION(S): Despite differences in risk factors between demographic groups, outcomes did not differ significantly in this cohort.

16.
Critical Care Medicine ; 51(1 Supplement):101, 2023.
Article in English | EMBASE | ID: covidwho-2190489

ABSTRACT

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.

17.
Open Forum Infectious Diseases ; 9(Supplement 2):S782-S783, 2022.
Article in English | EMBASE | ID: covidwho-2189979

ABSTRACT

Background. Major side effects after vaccination can be caused by a reactive immune system. We investigate statistical association between severity of self-reported reactions to immunisation with SARS-CoV-2 vaccines and immunological response (SARS-CoV-2 spike immunoglobulin [IgG]) using data from ENFORCE, an openlabel, non-randomised, parallel group, phase IV study that enrolled over 6500 Danish adult citizens prior to their first SARS-CoV-2 vaccination. Methods. Participants were included with assessments of self-reported reactions 1-2 weeks after vaccination and subsequent assessment of total serum levels of SARS-CoV-2 spike IgG at the next visit, before next vaccine dose. A severity score was defined based on 7 systemic reactions (muscle pain, joint pain, fatigue, fever, headache, nausea, chills) scored as moderate (+1) or severe (+2) with a maximum score of 14. Linear regression was used to test association between severity score and log-transformed spike IgG after first and second vaccinations, adjusted for time from vaccination to spike IgG assessment, age, sex, Charlson Comorbidity Index, vaccine type, evidence of prior SARS-CoV-2 infection. We also looked at the effect of adjusting for spike IgG level measured prior to each dose. Results. Of 6918 eligible ENFORCE participants, 6192 and 5937 were included for first and second vaccinations, respectively, with characteristics displayed in Table 1. Adjusted geometric mean ratios are presented in Table 2. Following first vaccination, no significant association was found between severity score and spike IgG (p=0.537). Following second vaccination, the association was highly significant (p< 0.001) with scores of 2 or more having up to 25% higher spike IgG level than a score of 0. When pre-dose spike IgG was subsequently adjusted for (Table 3), the association was no longer significant (p=0.530). assessment, age, sex, Charlson Comorbidity Index (CCI), vaccine type, and evidence of prior SARS-CoV-2 infection. Means and differences were back-transformed to present geometric means, ratios, and 95% confidence intervals. Conclusion. An average of 4 weeks after first vaccination, the SARS-CoV-2 spike IgG level was similar regardless of severity of reactions experienced. Around 9 weeks after second vaccination, those who had at least 2 moderate or 1 severe reaction had a significantly higher spike IgG level than those with no moderate/severe reactions. However, adjustment for pre-existing immunity attenuated the association and warrants further investigation.

18.
Open Forum Infectious Diseases ; 9(Supplement 2):S499, 2022.
Article in English | EMBASE | ID: covidwho-2189812

ABSTRACT

Background. Therapeutic vaccination following SARS-CoV-2 infection might stimulate anti-viral immunity and improve patient outcomes. We investigated, amongst previously unvaccinated patients, whether vaccination with the Pfizer, Moderna, or Johnson & Johnson vaccines within 14 days of a positive SARS-CoV-2 test affected 30-day patient outcomes. Methods. Using a deidentified national electronic health record dataset (Optum, Inc.), we identified previously unvaccinated patients who tested positive forCOVID-19 between 12/11/2020 and 12/19/2021. Among this cohort, 1,909 patients received a first vaccine dose within 14 days (vaccinated) while 446,309 did not receive a first dose of vaccine within 30 days of their first positive test (unvaccinated). We performed 1:1 propensity score matching based on age, gender, race, ethnicity, region, BMI, insurance, and comorbidities from the Charlson Comorbidity Index. Next, we compared odds of severe outcomes within 30 days between vaccinated and unvaccinated groups using a partial proportional odds model with the following ordinal severity outcome: no hospitalization, hospitalization, ICU stay, or death (Stata version 17.0, alpha = 0.05). Results. 1,909 vaccinated patients were propensity score-matched to 1,909 unvaccinated patients. The final matched cohort was statistically indistinguishable (p > 0.05) for all metrics used in propensity score calculation. This matched cohort (n = 3,818) was 58.6% female, 67.7% white, 12.6% Hispanic, and 56.4% commercially insured, with a mean age of 50.6 years and a similar comorbidity profile. A partial proportional odds model showed that unvaccinated patients were at increased risk for hospitalization and higher ordered outcomes (OR = 1.19, 95% CI: 1.02-1.39), ICU stay and higher ordered outcomes (OR 1.63, 95% CI: 1.21-2.20), and death (OR 4.57, 95% CI: 2.50-8.37). Conclusion. Among previously unvaccinated patients, those who received a first dose vaccine within 14 days of a positive COVID-19 test were less likely to experience hospitalization, ICU stay, or death compared to matched peers who did not receive a first dose in the acute phase of infection. The sample size of patients vaccinated during the acute phase is limited, so further studies are indicated to evaluate the safety and efficacy of this practice.

19.
Open Forum Infectious Diseases ; 9(Supplement 2):S440, 2022.
Article in English | EMBASE | ID: covidwho-2189700

ABSTRACT

Background. Several studies reported an increased rate of indeterminate QuantiFERON-TB Gold Plus (QFT-P) assay results in patients with severe Coronavirus Disease (COVID)-19. Methods. Aim of the study was to longitudinally evaluate QFT-P responses in patients who survived COVID-19, with a previous indeterminate result. Results. We observed 223 patients with an indeterminate QFT-P assay among 949 patients hospitalized because of COVID-19 (23,5%) during 2020 and 2021. 36 patients among those with an indeterminate QFT-P assay were enrolled for reassessing the test. In 12 patients peripheral blood lymphocyte subsets were also reassessed. Considering disease severity, 30 were classified as severe and 6 as non-severe. Median age was 57,5 (interquartile range [IQR]: 49,5-63,8), with a prevalence of male sex (M/F: 24/12);median Charlson Comorbidity Index was 2 (IQR: 1-3). The second QFT-P assay was performed after at least 1 month from the first assay (median time 7 months, IQR: 5-12 months). All QFT-P assays gave a determined result: 2 positive (5.5%) and 34 negatives (94,4%). A statistically significant difference was observed after comparing the laboratory parameters at the time of the first and the second QFT-P assay: the absolute counts of total lymphocyte, total CD3+, CD4+ and CD8+ T-lymphocytes were significantly increased (p< 0.001) while neutrophil absolute counts, neutrophil to lymphocyte (N/L) ratio, D-dimer,fibrinogen, ferritin, C-reactive protein (CRP) were significantly reduced (p< 0.0001). Concerning the QFT-P assay, interferon gamma (INF-gamma) production in the Mitogen-Nil, TB1-Nil and TB2-Nil conditions were significantly increased (p< 0.0001;p=0.0019;p=0.0205, respectively) (Table 1 and Figure 1). Conclusion. Once the acute phase of COVID-19 is resolved, inflammatory markers and peripheral blood leucocyte counts tend to normalize with an effective INF-gamma production after specific and nonspecific stimulation. All the 36 QFT-P showed a determinate result. Moreover, we observed 2 positive QFT-P assay, supporting the importance of retesting patients with indeterminate result to identify latent tuberculosis infection and monitor patients for possible reactivation because of the immunesuppression associated with COVID-19.

20.
Open Forum Infectious Diseases ; 9(Supplement 2):S270-S270, 2022.
Article in English | EMBASE | ID: covidwho-2189653

ABSTRACT

Background. COVID-19-associated pulmonary aspergillosis (CAPA) is a severe superinfection with the fungus Aspergillus frequently affecting critically ill COVID-19 patients. Pathophysiological insight, key to improve diagnostic and immunomodulatory therapeutic options, is lacking. Methods. We performed single-cell RNA sequencing (scRNA-seq) on 37 bronchoalveolar lavage (BAL) samples from 37 critically ill COVID-19 patients. Three groups were defined: patients who did not develop aspergillosis (COVID-19-only, n=22), CAPA patients with sampling < 5 days after CAPA diagnosis (early CAPA, n=6) and CAPA patients with sampling 5-11 days after CAPA diagnosis (late CAPA, n=9). All CAPA patients had probable/proven CAPA according to the 2020 ECMM/ISHAM consensus criteria. Additionally, we assessed neutrophil extracellular trap (NET) levels in a separate cohort of 33 biobanked COVID-19-only BAL samples and 24 early CAPA samples. Results. A total of 69008 cells passed quality filtering. CAPA patients had significantly lower BAL neutrophil proportions than COVID-19-only patients, particularly in early CAPA (Fig. 1A). Pseudotime inference revealed two neutrophil trajectories: a regular maturation trajectory, and a trajectory giving rise to "hybrid" neutrophils which express genes encoding proteins with antigen-presenting functions (Fig. 1B). The latter trajectory was dominant in CAPA patients (Fig. 1C). NETosis analyses revealed significantly higher levels of citrullinated histone H3 DNA complexes (H3Cit-DNA) in CAPA patients (Fig. 2A). This explains the low CAPA BAL neutrophil proportions, as neutrophils that underwent NETosis are no longer detected via scRNA-seq. CAPA patients with the lowest H3Cit-DNA levels had significantly decreased survival rates (Fig. 2B). Panel (A): BALF neutrophil proportions as analyzed by single-cell RNA sequencing using the Seurat R package are significantly lower in CAPA patients compared to COVID-19-only patients. Patients with early CAPA have significantly lower BALF neutrophil proportions than patients with late CAPA. Macrophage/monocyte and epithelial cell proportions are reciprocally increased in CAPA patients compared to COVID-19-only patients. P-values shown for differences between the pooled CAPA patients and the COVID-19-only patients. P-values were calculated using a generalized linear model correcting for age, Charlson Comorbidity Index at hospital admission, and administration of corticosteroids (prednisone equivalent dose 20 mg or higher) within 48 hours of BALF sampling. Panel (B): Two trajectories are defined using pseudotime inference calculated using the Slingshot R package: a trajectory dominant in COVID-19-only patients with regular maturation of progenitor neutrophils, and a trajectory dominant in CAPA patients with maturation towards a 'hybrid neutrophil' state, with neutrophils expression genes encoding proteins with functions in antigen presentation. Subsequently, the hybrid neutrophil proportion is significantly higher in CAPA patients compared to COVID-19-only patients, and is significantly higher in patients with early CAPA than those with late CAPA. The mature neutrophil proportion is reciprocally reduced in CAPA patients. P-values shown for differences between the pooled CAPA patients and the COVID-19-only patients. P-values were calculated using a generalized linear model correcting for age, Charlson Comorbidity Index at hospital admission, and administration of corticosteroids (prednisone equivalent dose 20 mg or higher) within 48 hours of BALF sampling. Panel (A): Myeloperoxidase (MPO) DNA levels were analyzed as measure for general NET-formation, while citrullinated histone H3 bound DNA (H3Cit-DNA) levels were analyzed as more specific PAD4-dependent NET-formation, in BALF samples from early CAPA and COVID-19-only patients. A trend towards higher MPO-DNA levels was found in early CAPA patients, while H3Cit-DNA levels were significantly higher in early CAPA compared to COVID-19-only patients. P-values calculated using Mann-Whitney U test. Panel (B): Kaplan-Meier analy is of patients with NETosis analyses, divided in early CAPA and COVID-19-only patients and subdivided according to H3Cit-DNA levels (cut-off at 20000 ng/mL for early CAPA and at 8000 ng/mL for COVID-19-only). Log-rank test was used to compare survival distributions. For the comparison early CAPA (low H3Cit-DNA) versus early CAPA (high H3Cit-DNA), the log-rank p-value was 0.033. Conclusion. CAPA patients display extremely high levels of released NETs in the lower respiratory tract, associated with a shift from the normal neutrophil maturation process towards "hybrid neutrophil" formation, probably upon encountering the fungus. In contrast to high NETosis contributing to mortality in severe COVID-19, CAPA patients likely require these NETs to survive aspergillosis. BAL NET levels hold promise as a tool to guide diagnosis, prognosis and treatment in these patients.

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