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1.
Crit Care ; 25(1): 268, 2021 07 30.
Article in English | MEDLINE | ID: covidwho-1892224

ABSTRACT

BACKGROUND: Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS: We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS: Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS: During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.


Subject(s)
COVID-19/therapy , Noninvasive Ventilation , Respiratory Distress Syndrome/therapy , COVID-19/mortality , Continuous Positive Airway Pressure , Hospital Mortality , Humans , Intensive Care Units , Intubation/statistics & numerical data , Observational Studies as Topic , Randomized Controlled Trials as Topic , Respiration, Artificial , Respiratory Distress Syndrome/virology
2.
J Med Virol ; 94(1): 318-326, 2022 01.
Article in English | MEDLINE | ID: covidwho-1404586

ABSTRACT

When hospitals first encountered coronavirus disease 2019 (COVID-19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single-center studies began to report declining mortality of patients with COVID-19. To evaluate the effect of COVID-19 on hospital-based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID-19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all-cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID-19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.


Subject(s)
COVID-19/mortality , Hospital Mortality/trends , Respiratory Insufficiency/mortality , Hospitalization/statistics & numerical data , Humans , Inpatients/statistics & numerical data , Intubation/statistics & numerical data , Respiration, Artificial/mortality , SARS-CoV-2
5.
Crit Care ; 25(1): 268, 2021 07 30.
Article in English | MEDLINE | ID: covidwho-1330231

ABSTRACT

BACKGROUND: Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. METHODS: We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders. RESULTS: Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity. CONCLUSIONS: During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. REGISTRATION: PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.


Subject(s)
COVID-19/therapy , Noninvasive Ventilation , Respiratory Distress Syndrome/therapy , COVID-19/mortality , Continuous Positive Airway Pressure , Hospital Mortality , Humans , Intensive Care Units , Intubation/statistics & numerical data , Observational Studies as Topic , Randomized Controlled Trials as Topic , Respiration, Artificial , Respiratory Distress Syndrome/virology
6.
Nutrients ; 13(7)2021 Jun 26.
Article in English | MEDLINE | ID: covidwho-1288965

ABSTRACT

This study aimed to determine the relationships among hyperglycemia (HG), the presence of type 2 diabetes (T2D), and the outcomes of COVID-19. Demographic data, blood glucose levels (BG) measured on admission, and hospital outcomes of COVID-19 patients hospitalized at Boston University Medical Center from 1 March to 4 August 2020 were extracted from the hospital database. HG was defined as BG > 200 mg/dL. Patients with type 1 diabetes or BG < 70 mg/dL were excluded. A total of 458 patients with T2D and 976 patients without T2D were included in the study. The mean ± SD age was 56 ± 17 years and 642 (45%) were female. HG occurred in 193 (42%) and 42 (4%) of patients with and without T2D, respectively. Overall, the in-hospital mortality rate was 9%. Among patients without T2D, HG was statistically significantly associated with mortality, ICU admission, intubation, acute kidney injury, and severe sepsis/septic shock, after adjusting for potential confounders (p < 0.05). However, only ICU admission and acute kidney injury were associated with HG among patients with T2D (p < 0.05). Among the 235 patients with HG, the presence of T2D was associated with decreased odds of mortality, ICU admission, intubation, and severe sepsis/septic shock, after adjusting for potential confounders, including BG (p < 0.05). In conclusion, HG in the subset of patients without T2D could be a strong indicator of high inflammatory burden, leading to a higher risk of severe COVID-19.


Subject(s)
COVID-19/epidemiology , Diabetes Mellitus, Type 2/epidemiology , Hospitalization/statistics & numerical data , Hyperglycemia/epidemiology , Acute Kidney Injury/epidemiology , Adult , Aged , Blood Glucose , Boston/epidemiology , COVID-19/mortality , Cohort Studies , Female , Hospital Mortality , Humans , Intensive Care Units/statistics & numerical data , Intubation/statistics & numerical data , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Sepsis/epidemiology , Severity of Illness Index , Urban Population/statistics & numerical data
7.
J Coll Physicians Surg Pak ; 31(3): 258-261, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1156235

ABSTRACT

OBJECTIVE: To evaluate the temporal changes on serial chest radiographs (CXRs)of hospitalised COVID-19 positive patients till their outcome(discharge/death); to determine the severity of CXR score and its correlation with clinical outcome (hospital stay, chest intubation and mortality). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Shifa International Hospital (SIH), Islamabad from March to June 2020. METHODOLOGY: After IRB approval, 112 patients were consecutively enrolled, having laboratory-confirmed SARS-CoV-2 and hospitalised in SIH. Patients' demographics and clinical data were retrieved from Radiology Information System (RIS). Chest radiographs (CXR) were retrieved from picture archive and communication system (PACS). CXR severity scoring was determined by three radiologists, and results were analysed. RESULTS: Lung opacities (98.2%), involvement of both lungs (96.4%), both peripheral and central region involvement (62.5%) and upper/mid/lower zone distribution (61.6%) were the most frequent findings. Males affected more than females with a mean age of 58.9 ± 13.1 years. Zonal involvement, density and extent of opacities peaked on 10-13th day of illness. In the last CXR, opacities showed decrease in extent as well as density, reduction in zonal involvement, and few having mixed interstitial thickening/fibrosis. One hundred and five out of 112 (93.8%) patients had residual radiographic abnormalities on discharge. CONCLUSION: Serial chest radiography can be used to monitor disease progression and temporal changes after initial HRCT. Patients who have CXR severity score of 4 or more at the time of admission, is a red flag for prolonged hospital stay and possible intubation. Severity of CXR findings peaked at 10-13 days. It is recommended to repeat CXRs every 3-4th day during hospital stay. Majority of the patients has residual radiographic abnormality on discharge. Key Words: COVID-19, Radiography, Thoracic, Pandemic, Chest X-ray.


Subject(s)
COVID-19/diagnostic imaging , Pneumonia, Viral/diagnostic imaging , Radiography, Thoracic/methods , Adult , Aged , COVID-19/mortality , Disease Progression , Female , Humans , Intubation/statistics & numerical data , Length of Stay/statistics & numerical data , Male , Middle Aged , Pakistan/epidemiology , Pandemics , Pneumonia, Viral/mortality , Pneumonia, Viral/virology , SARS-CoV-2 , Severity of Illness Index , Time Factors
8.
N Engl J Med ; 383(24): 2333-2344, 2020 12 10.
Article in English | MEDLINE | ID: covidwho-1023985

ABSTRACT

BACKGROUND: The efficacy of interleukin-6 receptor blockade in hospitalized patients with coronavirus disease 2019 (Covid-19) who are not receiving mechanical ventilation is unclear. METHODS: We performed a randomized, double-blind, placebo-controlled trial involving patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hyperinflammatory states, and at least two of the following signs: fever (body temperature >38°C), pulmonary infiltrates, or the need for supplemental oxygen in order to maintain an oxygen saturation greater than 92%. Patients were randomly assigned in a 2:1 ratio to receive standard care plus a single dose of either tocilizumab (8 mg per kilogram of body weight) or placebo. The primary outcome was intubation or death, assessed in a time-to-event analysis. The secondary efficacy outcomes were clinical worsening and discontinuation of supplemental oxygen among patients who had been receiving it at baseline, both assessed in time-to-event analyses. RESULTS: We enrolled 243 patients; 141 (58%) were men, and 102 (42%) were women. The median age was 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino. The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64), and the hazard ratio for disease worsening was 1.11 (95% CI, 0.59 to 2.10; P = 0.73). At 14 days, 18.0% of the patients in the tocilizumab group and 14.9% of the patients in the placebo group had had worsening of disease. The median time to discontinuation of supplemental oxygen was 5.0 days (95% CI, 3.8 to 7.6) in the tocilizumab group and 4.9 days (95% CI, 3.8 to 7.8) in the placebo group (P = 0.69). At 14 days, 24.6% of the patients in the tocilizumab group and 21.2% of the patients in the placebo group were still receiving supplemental oxygen. Patients who received tocilizumab had fewer serious infections than patients who received placebo. CONCLUSIONS: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19. Some benefit or harm cannot be ruled out, however, because the confidence intervals for efficacy comparisons were wide. (Funded by Genentech; ClinicalTrials.gov number, NCT04356937.).


Subject(s)
Antibodies, Monoclonal, Humanized/therapeutic use , COVID-19/drug therapy , Receptors, Interleukin-6/antagonists & inhibitors , Adult , Aged , Aged, 80 and over , Boston , COVID-19/mortality , Disease Progression , Double-Blind Method , Female , Humans , Intubation/statistics & numerical data , Male , Middle Aged , Respiratory Therapy , Treatment Failure , Young Adult
10.
N Engl J Med ; 382(25): 2411-2418, 2020 06 18.
Article in English | MEDLINE | ID: covidwho-217993

ABSTRACT

BACKGROUND: Hydroxychloroquine has been widely administered to patients with Covid-19 without robust evidence supporting its use. METHODS: We examined the association between hydroxychloroquine use and intubation or death at a large medical center in New York City. Data were obtained regarding consecutive patients hospitalized with Covid-19, excluding those who were intubated, died, or discharged within 24 hours after presentation to the emergency department (study baseline). The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received hydroxychloroquine with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. RESULTS: Of 1446 consecutive patients, 70 patients were intubated, died, or discharged within 24 hours after presentation and were excluded from the analysis. Of the remaining 1376 patients, during a median follow-up of 22.5 days, 811 (58.9%) received hydroxychloroquine (600 mg twice on day 1, then 400 mg daily for a median of 5 days); 45.8% of the patients were treated within 24 hours after presentation to the emergency department, and 85.9% within 48 hours. Hydroxychloroquine-treated patients were more severely ill at baseline than those who did not receive hydroxychloroquine (median ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen, 223 vs. 360). Overall, 346 patients (25.1%) had a primary end-point event (180 patients were intubated, of whom 66 subsequently died, and 166 died without intubation). In the main analysis, there was no significant association between hydroxychloroquine use and intubation or death (hazard ratio, 1.04, 95% confidence interval, 0.82 to 1.32). Results were similar in multiple sensitivity analyses. CONCLUSIONS: In this observational study involving patients with Covid-19 who had been admitted to the hospital, hydroxychloroquine administration was not associated with either a greatly lowered or an increased risk of the composite end point of intubation or death. Randomized, controlled trials of hydroxychloroquine in patients with Covid-19 are needed. (Funded by the National Institutes of Health.).


Subject(s)
Coronavirus Infections/drug therapy , Hydroxychloroquine/therapeutic use , Intubation/statistics & numerical data , Pneumonia, Viral/drug therapy , Treatment Failure , Adult , Aged , Aged, 80 and over , Betacoronavirus , COVID-19 , Coronavirus Infections/mortality , Female , Hospitalization , Humans , Male , Middle Aged , New York City , Pandemics , Pneumonia, Viral/mortality , Propensity Score , SARS-CoV-2
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