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1.
Intensive Care Med ; 48(12): 1726-1735, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2158015

ABSTRACT

PURPOSE: The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction. METHODS: Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs. RESULTS: In patients from the VIP2 study without limitations of life-sustaining treatment (n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort (n = 280). CONCLUSIONS: Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention.


Subject(s)
Frailty , Intensive Care Units , Humans , Organ Dysfunction Scores , Cohort Studies , Frailty/diagnosis , Cluster Analysis , Hospital Mortality
2.
Arch Iran Med ; 25(7): 443-449, 2022 Jul 01.
Article in English | MEDLINE | ID: covidwho-2067651

ABSTRACT

BACKGROUND: This study aimed to investigate CURB-65, quick COVID-19 Severity Index (qCSI) and quick Sepsis Related Organ Failure Assessment (qSOFA) scores in predicting mortality and risk factors for death in patients with COVID-19. METHODS: We retrospectively analyzed a total of 1919 cases for whom the rRT-PCR assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. For mortality risk factors, univariate and multivariate logistic regression analyses were used. Receiver operator characteristics (ROC) analysis and Kaplan-Meier survival analysis were performed for CURB-65, qCSI and qSOFA scores. RESULTS: The patients' average age was 45.7 (21.6) years. Male patients accounted for 51.7% (n=992). In univariate analysis, some clinical variables including age over 65 years and comorbid diseases such as hypertension, chronic kidney disease, malignancy, lymphopenia, troponin, lactate dehydrogenase (LDH) and fibrinogen elevation were associated with the mortality rate. In multivariate logistic regression analysis: Neutrophil lymphocyte ratio (NLR) 3.3 and above (OR, 9.1; 95% CI, 1.9-42), C-reactive protein (CRP)30 mg/L and above (OR, 4.1; 95% CI, 1.2-13.6), D-dimer 1000 ng/mL and above (OR, 4; 95% CI, 1.5-10.7) and age (OR, 1.11; 95% CI, 1.04-1.18-year increase) were identified as risk factors for mortality among COVID-19 patients. The CURB-65 and qCSI scores exhibited a high degree of discrimination in mortality prediction (AUC values were 0.928 and 0.865, respectively). Also, the qSOFA score had a moderate discriminant power (AUC value was 0.754). CONCLUSION: CURB-65 and qSCI scores had a high discriminatory power to predict mortality. Also, this study identified CURB-65, qCSI and qSOFA scores, NLR, CRP, D-dimer level, and annual age increase as important mortality risk factors.


Subject(s)
COVID-19 , Sepsis , Humans , Male , Middle Aged , Aged , Organ Dysfunction Scores , Retrospective Studies , ROC Curve , Prognosis , SARS-CoV-2 , Risk Factors
3.
BMJ Open Respir Res ; 9(1)2022 08.
Article in English | MEDLINE | ID: covidwho-2001863

ABSTRACT

BACKGROUND: The SARS-CoV-2 pandemic led to a steep increase in hospital and intensive care unit (ICU) admissions for acute respiratory failure worldwide. Early identification of patients at risk of clinical deterioration is crucial in terms of appropriate care delivery and resource allocation. We aimed to evaluate and compare the prognostic performance of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Confusion, Uraemia, Respiratory Rate, Blood Pressure and Age ≥65 (CURB-65), Respiratory Rate and Oxygenation (ROX) index and Coronavirus Clinical Characterisation Consortium (4C) score to predict death and ICU admission among patients admitted to the hospital for acute COVID-19 infection. METHODS AND ANALYSIS: Consecutive adult patients admitted to the Geneva University Hospitals during two successive COVID-19 flares in spring and autumn 2020 were included. Discriminative performance of these prediction rules, obtained during the first 24 hours of hospital admission, were computed to predict death or ICU admission. We further exluded patients with therapeutic limitations and reported areas under the curve (AUCs) for 30-day mortality and ICU admission in sensitivity analyses. RESULTS: A total of 2122 patients were included. 216 patients (10.2%) required ICU admission and 303 (14.3%) died within 30 days post admission. 4C score had the best discriminatory performance to predict 30-day mortality (AUC 0.82, 95% CI 0.80 to 0.85), compared with SOFA (AUC 0.75, 95% CI 0.72 to 0.78), qSOFA (AUC 0.59, 95% CI 0.56 to 0.62), CURB-65 (AUC 0.75, 95% CI 0.72 to 0.78) and ROX index (AUC 0.68, 95% CI 0.65 to 0.72). ROX index had the greatest discriminatory performance (AUC 0.79, 95% CI 0.76 to 0.83) to predict ICU admission compared with 4C score (AUC 0.62, 95% CI 0.59 to 0.66), CURB-65 (AUC 0.60, 95% CI 0.56 to 0.64), SOFA (AUC 0.74, 95% CI 0.71 to 0.77) and qSOFA (AUC 0.59, 95% CI 0.55 to 0.62). CONCLUSION: Scores including age and/or comorbidities (4C and CURB-65) have the best discriminatory performance to predict mortality among inpatients with COVID-19, while scores including quantitative assessment of hypoxaemia (SOFA and ROX index) perform best to predict ICU admission. Exclusion of patients with therapeutic limitations improved the discriminatory performance of prognostic scores relying on age and/or comorbidities to predict ICU admission.


Subject(s)
COVID-19 , Organ Dysfunction Scores , Adult , COVID-19/diagnosis , COVID-19/therapy , Cohort Studies , Humans , Inpatients , Prognosis , ROC Curve , Retrospective Studies , SARS-CoV-2
4.
Medicine (Baltimore) ; 101(28): e29206, 2022 Jul 15.
Article in English | MEDLINE | ID: covidwho-1948572

ABSTRACT

The Sequential Organ Failure Assessment (SOFA) could function as an effective risk stratification tool in the admission of critically ill patients with COVID-19 and would allow stratification based on a risk assessment. We aimed to examine whether the SOFA score is useful to define 2 severity profiles in COVID-19 patients admitted to ICU: mild with SOFA < 5, and severe with SOFA ≥ 5. A retrospective cohort, multicenter study was conducted from February 11 to May 11, 2020. We analyzed patients admitted to all ICUs of the 14 public hospitals of the Castilla-La Mancha Health Service at the beginning of the pandemic and with SARS-CoV-2 infection. Patients were divided in 2 groups according to the level of severity by SOFA at admission to the ICU. Cox regression was used to evaluate factors associated with survival and Kaplan-Meier test to examine survival probability. In total, 405 patients with a complete SOFA panel were recruited in the 14 participating ICUs. SOFA <5 group showed that age above 60 years and D-dimer above 1000 ng/mL were risk factors associated with lower survival. In SOFA ≥ 5 it was found that high blood pressure was a risk factor associated with shorter survival. Kaplan-Meier showed lower survival in SOFA ≥ 5 in combination with high blood pressure, time since viral symptom onset to admission in ICU < 7 days, D-dimer ≥1000 ng/mL and respiratory pathology. However, SOFA < 5 showed only higher age (≥60 years) associated with lower survival. Age over 60 years and D-dimer over 1000 ng/mL were risk factors reflecting lower survival in patients with SOFA < 5. Moreover, SOFA ≥ 5 patients within a week after COVID-19 onset and comorbidities such as high blood pressure and previous respiratory pathology showed lower survival.


Subject(s)
COVID-19 , Hypertension , Humans , Intensive Care Units , Middle Aged , Organ Dysfunction Scores , Prognosis , Retrospective Studies , SARS-CoV-2
5.
Braz J Med Biol Res ; 55: e11819, 2022.
Article in English | MEDLINE | ID: covidwho-1910753

ABSTRACT

Diabetes is associated with a worse prognosis and a high risk of morbidity and mortality in COVID-19 patients. We aimed to evaluate the main factors involved in the poor prognosis in diabetic patients. A total of 984 patients diagnosed with COVID-19 admitted to the hospital were included in this study. Patients were first divided into type-2 diabetic (DM+) and non-diabetic (DM-) groups. The participants were analyzed based on the National Early Warning Score (NEWS) and on the Quick-Sequential Organ Failure Assessment (qSOFA) to find the best prognostic risk score for our study. The DM+ and DM- groups were divided into non-severe and severe groups. Comparative and correlative analyses were used to identify the physiological parameters that could be employed for creating a potential risk indicator for DM+ COVID-19 patients. We found a poorer prognosis for the DM+ COVID-19 patients with a higher ICU admission rate, mechanical ventilation rate, vasopressor use, dialysis, and longer treatment times compared with the DM- group. DM+ COVID-19 patients had increased plasma glucose, lactate, age, urea, NEWS, and D-dimer levels, herein referred to as the GLAUND set, and worse prognosis and outcomes when compared with infected DM- patients. The NEWS score was a better indicator for assessing COVID-19 severity in diabetic patients than the q-SOFA score. In conclusion, diabetic COVID-19 patients should be assessed with the NEWS score and GLAUND set for determining their prognosis COVID-19 prognosis.


Subject(s)
COVID-19 , Diabetes Mellitus, Type 2 , Sepsis , COVID-19/complications , Diabetes Mellitus, Type 2/complications , Hospital Mortality , Humans , Intensive Care Units , Organ Dysfunction Scores , ROC Curve , Retrospective Studies , Sepsis/diagnosis
6.
BMC Infect Dis ; 22(1): 576, 2022 Jun 27.
Article in English | MEDLINE | ID: covidwho-1910276

ABSTRACT

BACKGROUND: Critically-ill Covid-19 patients require extensive resources which can overburden a healthcare system already under strain due to a pandemic. A good disease severity prediction score can help allocate resources to where they are needed most. OBJECTIVES: We developed a Covid-19 Severity Assessment Score (CoSAS) to predict those patients likely to suffer from mortalities within 28 days of hospital admission. We also compared this score to Quick Sequential Organ Failure Assessment (qSOFA) in adults. METHODS: CoSAS includes the following 10 components: Age, gender, Clinical Frailty Score, number of comorbidities, Ferritin level, D-dimer level, neutrophil/lymphocyte ratio, C-reactive Protein levels, systolic blood pressure and oxygen saturation. Our study was a single center study with data collected via chart review and phone calls. 309 patients were included in the study. RESULTS: CoSAS proved to be a good score to predict Covid-19 mortality with an Area under the Curve (AUC) of 0.78. It also proved better than qSOFA (AUC of 0.70). More studies are needed to externally validate CoSAS. CONCLUSION: CoSAS is an accurate score to predict Covid-19 mortality in the Pakistani population.


Subject(s)
COVID-19 , Sepsis , Adult , COVID-19/diagnosis , Emergency Service, Hospital , Hospital Mortality , Humans , Organ Dysfunction Scores , Prognosis , ROC Curve , Retrospective Studies
7.
PLoS One ; 17(5): e0267506, 2022.
Article in English | MEDLINE | ID: covidwho-1841151

ABSTRACT

BACKGROUND: In COVID-19 patients, lung ultrasound is superior to chest radiograph and has good agreement with computerized tomography to diagnose lung pathologies. Most lung ultrasound protocols published to date are complex and time-consuming. We describe a new illustrative Point-of-care ultrasound Lung Injury Score (PLIS) to help guide the care of patients with COVID-19 and assess if the PLIS would be able to predict COVID-19 patients' clinical course. METHODS: This retrospective study describing the novel PLIS was conducted in a large tertiary-level hospital. COVID-19 patients were included if they required any form of respiratory support and had at least one PLIS study during hospitalization. Data collected included PLIS on admission, demographics, Sequential Organ Failure Assessment (SOFA) scores, and patient outcomes. The primary outcome was the need for intensive care unit (ICU) admission. RESULTS: A total of 109 patients and 293 PLIS studies were included in our analysis. The mean age was 60.9, and overall mortality was 18.3%. Median PLIS score was 5.0 (3.0-6.0) vs. 2.0 (1.0-3.0) in ICU and non-ICU patients respectively (p<0.001). Total PLIS scores were directly associated with SOFA scores (inter-class correlation 0.63, p<0.001), and multivariate analysis showed that every increase in one PLIS point was associated with a higher risk for ICU admission (O.R 2.09, 95% C.I 1.59-2.75) and in-hospital mortality (O.R 1.54, 95% C.I 1.10-2.16). CONCLUSIONS: The PLIS for COVID-19 patients is simple and associated with SOFA score, ICU admission, and in-hospital mortality. Further studies are needed to demonstrate whether the PLIS can improve outcomes and become an integral part of the management of COVID-19 patients.


Subject(s)
COVID-19 , COVID-19/diagnostic imaging , Humans , Intensive Care Units , Lung/diagnostic imaging , Middle Aged , Organ Dysfunction Scores , Point-of-Care Systems , Prognosis , Retrospective Studies
8.
Clin Imaging ; 88: 4-8, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-1819456

ABSTRACT

BACKGROUND: COVID-19 is a disease with high mortality worldwide, and which parameters that affect mortality in intensive care are still being investigated. This study aimed to show the factors affecting mortality in COVID-19 intensive care patients and write a model that can predict mortality. METHODS: The data of 229 patients in the COVID-19 intensive care unit were scanned. Laboratory tests, APACHE, SOFA, and GCS values were recorded. CT scores were calculated with chest CTs. The effects of these data on mortality were examined. The effects of the variables were modeled using the stepwise regression method. RESULTS: While the mean age of female (30.14%) patients was 69.1 ± 12.2, the mean age of male (69.86%) patients was 66.9 ± 11.5. The mortality rate was 69.86%. Age, CRP, D-dimer, creatinine, procalcitonin, APACHE, SOFA, GCS, and CT score were significantly different in the deceased patients than the survival group. When we attempted to create a model using stepwise linear regression analysis, the appropriate model was achieved at the fourth step. Age, CRP, APACHE, and CT score were included in the model, which has the power to predict mortality with 89.9% accuracy. CONCLUSION: Although, when viewed individually, there is a significant difference in parameters such as creatinine, procalcitonin, D-dimer, GCS, and SOFA score, the probability of mortality can be estimated by knowing only the age, CRP, APACHE, and CT scores. These four simple parameters will help clinicians effectively use resources in treatment.


Subject(s)
COVID-19 , Sepsis , APACHE , Creatinine , Female , Humans , Intensive Care Units , Linear Models , Male , Organ Dysfunction Scores , Procalcitonin , Prognosis , ROC Curve , Regression Analysis , Retrospective Studies , Sepsis/therapy , Tomography, X-Ray Computed
9.
J Crit Care ; 70: 154045, 2022 08.
Article in English | MEDLINE | ID: covidwho-1814672

ABSTRACT

PURPOSE: Prolonged observation could avoid invasive mechanical ventilation (IMV) and related risks in patients with Covid-19 acute respiratory failure (ARF) compared to initiating early IMV. We aimed to determine the association between ARF management strategy and in-hospital mortality. MATERIALS AND METHODS: Patients in the Weill Cornell Covid-19 registry who developed ARF between March 5 - March 25, 2020 were exposed to an early IMV strategy; between March 26 - April 1, 2020 to an intermediate strategy; and after April 2 to prolonged observation. Cox proportional hazards regression was used to model in-hospital mortality and test an interaction between ARF management strategy and modified sequential organ failure assessment (mSOFA). RESULTS: Among 632 patients with ARF, 24% of patients in the early IMV strategy died versus 28% in prolonged observation. At lower mSOFA, prolonged observation was associated with lower mortality compared to early IMV (at mSOFA = 0, HR 0.16 [95% CI 0.04-0.57]). Mortality risk increased in the prolonged observation strategy group with each point increase in mSOFA score (HR 1.29 [95% CI 1.10-1.51], p = 0.002). CONCLUSION: In Covid-19 ARF, prolonged observation was associated with a mortality benefit at lower mSOFA scores, and increased mortality at higher mSOFA scores compared to early IMV.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Respiratory Insufficiency , COVID-19/therapy , Hospital Mortality , Humans , Organ Dysfunction Scores , Respiration, Artificial , Respiratory Insufficiency/therapy
10.
J Assoc Physicians India ; 70(4): 11-12, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1801779

ABSTRACT

The recent outbreak of COVID 19 is a great threat to public health. Because of limitation of resources, the number of patients that can be monitored and treated in Intensive Care Units is restricted. Hence identifying medical patients at risk of deterioration at the initial stage by means of simple protocols based on physiological parameters is crucial. The qSOFA score was introduced as a rapid bedside clinical score to identify patients with a suspected infection that are at greater risk for a poor outcome. The National Early Warning Score (NEWS) was developed to improve the detection of and response to clinical deterioration in patients with acute illness. There is paucity of literature regarding the use of these scores in patients with COVID 19 infection. This study aims at comparing the scoring systems qSOFA and NEWS in the setting of COVID-19 infection and its correlation with the final outcome of the illness. MATERIAL: It is a retrospective study in which patients presenting with COVID 19 infection(diagnosed by RT-PCR testing of nasopharyngeal and oral swab) between April 2021 to June 2021 were included. Scoring was done using both the scores at admission and the patients were followed up till the outcome. Outcome was defined as 5-day, 10-day and 15-day mortality after presentation. Predictive performance was expressed as discrimination (AUC). Subsequently, sensitivity and specificity were calculated. OBSERVATION: A total of 100 patients were included in the study, of whom 17 died within 5 days and 37 died within 10 days and 30 died within 15 days after presentation. q SOFA had the best performance, compared to NEWS (5 day auc : .668, .621, 10-day auc: .580, .569, 15-day auc: .625, .511) with q SOFA having sensitivity of 90.2% while that of news being 95.1% where as specificity of q SOFA is 40.7% and that of NEWS is 47.5%. CONCLUSION: qSOFA score is more accurate in predicting 5, 10 and 15-day mortality than NEWS score in COVID 19 patients. In resource limited settings, it is an inexpensive and simple tool for early identification of high risk COVID 19 patients.


Subject(s)
COVID-19 , Early Warning Score , Sepsis , COVID-19/diagnosis , Hospital Mortality , Humans , Intensive Care Units , Organ Dysfunction Scores , Prognosis , Retrospective Studies , Sepsis/diagnosis
11.
Can Respir J ; 2022: 5129314, 2022.
Article in English | MEDLINE | ID: covidwho-1770037

ABSTRACT

Background: COVID-19 pandemic has become a global dilemma since December 2019. Are the standard scores, such as acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) score, accurate for predicting the mortality rate of COVID-19 or the need for new scores? We aimed to evaluate the mortality predictive value of APACHE II and SOFA scores in critically ill COVID-19 patients. Methods: In a cohort study, we enrolled 204 confirmed COVID-19 patients admitted to the intensive care units at the Imam Khomeini hospital complex. APACHE II on the first day and daily SOFA scoring were performed. The primary outcome was the mortality rate in the nonsurvived and survived groups, and the secondary outcome was organ dysfunction. Two groups of survived and nonsurvived patients were compared by the chi-square test for categorical variables and an independent sample t-test for continuous variables. We used logistic regression models to estimate the mortality risk of high APACHE II and SOFA scores. Result: Among 204 severe COVID-19 patients, 114 patients (55.9%) expired and 169 patients (82.8%) had at least one comorbidity that 103 (60.9%) of them did not survive (P=0.002). Invasive mechanical ventilation and its duration were significantly different between survived and nonsurvived groups (P ≤ 0.001 and P=0.002, respectively). Mean APACHE II and mean SOFA scores were significantly higher in the nonsurvived than in the survived group (14.4 ± 5.7 vs. 9.5 ± 5.1, P ≤ 0.001, 7.3 ± 3.1 vs. 3.1 ± 1.1, P ≤ 0.001, respectively). The area under the curve was 89.5% for SOFA and 73% for the APACHE II score. Respiratory diseases and malignancy were risk factors for the mortality rate (P=0.004 and P=0.007, respectively) against diabetes and hypertension. Conclusion: The daily SOFA was a better mortality predictor than the APACHE II in critically ill COVID-19 patients. But they could not predict death with high accuracy. We need new scoring with consideration of the prognostic factors and daily evaluation of changes in clinical conditions.


Subject(s)
COVID-19 , Organ Dysfunction Scores , APACHE , Cohort Studies , Humans , Intensive Care Units , Pandemics
12.
Medicina (Kaunas) ; 58(3)2022 Mar 18.
Article in English | MEDLINE | ID: covidwho-1760770

ABSTRACT

Background and Objectives: Within a year, COVID-19 has advanced from an outbreak to a pandemic, spreading rapidly and globally with devastating impact. The pathophysiological link between COVID-19 and acute kidney injury (AKI) is currently being debated among scientists. While some studies have concluded that the mechanisms of AKI in COVID-19 patients are complex and not fully understood, others have claimed that AKI is a rare complication of COVID-19-related disorders. Considering this information gap and its possible influence on COVID-19-associated AKI management, our study aimed to explore the prevalence of AKI and to identify possible risk factors associated with AKI development among COVID-19 hospitalized patients. Materials and Methods: A retrospective cohort study included 83 laboratory-confirmed COVID-19 patients hospitalized at the isolation department in a tertiary hospital in Zagazig City, Egypt between June and August 2020. Patients younger than 18 years of age, those diagnosed with end-stage kidney disease, or those on nephrotoxic medications were excluded. All study participants had a complete blood count, liver and renal function tests, hemostasis parameters examined, inflammatory markers, serum electrolytes, routine urinalysis, arterial blood gas, and non-enhanced chest and abdominal computer tomography (CT) scans. Results: Of the 83 patients, AKI developed in 24 (28.9%) of them, of which 70.8% were in stage 1, 8.3% in stage 2, and 20.8% in stage 3. Patients with AKI were older than patients without AKI, with hypertension and diabetes being the most common comorbidities. Risk factors for AKI include increased age, hypertension, diabetes mellitus, and a higher sequential organ failure assessment (SOFA) score. Conclusions: AKI occurs in a considerable percentage of patients with COVID-19, especially in elderly males, those with hypertension, diabetes, and a higher sequential organ failure assessment (SOFA) score. Hence, the presence of AKI should be taken into account as an important index within the risk spectrum of disease severity for COVID-19 patients.


Subject(s)
Acute Kidney Injury , COVID-19 , Acute Kidney Injury/diagnosis , Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Aged , COVID-19/complications , Hospitalization , Humans , Male , Organ Dysfunction Scores , Retrospective Studies
13.
J Vet Emerg Crit Care (San Antonio) ; 32(2): 223-228, 2022 Mar.
Article in English | MEDLINE | ID: covidwho-1759260

ABSTRACT

OBJECTIVE: To evaluate the prognostic utility of quick Sepsis-related Organ Failure Assessment (qSOFA) for prediction of in-hospital mortality and length of hospitalization in dogs with pyometra. DESIGN: Retrospective cohort study from February 2013 to April 2019 SETTING: Tertiary referral hospital ANIMALS: Fifty-two dogs referred with confirmed diagnosis of pyometra INTERVENTIONS: None MEASUREMENTS AND PRINCIPAL OUTCOMES: Sixty-five percent of dogs survived to discharge. A cut-off score of ≥2 for qSOFA was associated with in-hospital mortality (odds ratio 6.51 [95% CI: 1.35 - 31.3]) P = 0.019. The area under the receiver operator characteristic curve for a qSOFA score ≥ 2 for mortality was 0.72 (95% CI: 0.59-0.85), with a sensitivity of 77.8% and a specificity of 66.7%. The mean ± SD number of organs with dysfunction was significantly higher in dogs with a qSOFA score ≥2 1.76 ± 0.83 compared to dogs with a qSOFA score < 2 1.08 ± 1.09, P = 0.015. The presence of a qSOFA score ≥ 2 was associated with a longer time of hospitalization in survivors with a median (interquartile range) length of stay in qSOFA < 2 (48 [33]) hours versus qSOFA score ≥ 2 (78 [52]) hours, P = 0.027. CONCLUSIONS: In dogs with pyometra, the qSOFA score was associated with mortality and length of hospitalization. This score might be useful to improve the risk stratification in dogs with pyometra. Further studies are necessary to evaluate the predictive capacity of qSOFA in other septic patient populations.


Subject(s)
Dog Diseases , Pyometra , Sepsis , Animals , Dog Diseases/diagnosis , Dogs , Hospitalization , Organ Dysfunction Scores , Prognosis , Pyometra/complications , Pyometra/veterinary , ROC Curve , Retrospective Studies , Sepsis/complications , Sepsis/veterinary
14.
Crit Care Med ; 50(7): 1051-1062, 2022 07 01.
Article in English | MEDLINE | ID: covidwho-1752195

ABSTRACT

OBJECTIVES: Prior research has hypothesized the Sequential Organ Failure Assessment (SOFA) score to be a poor predictor of mortality in mechanically ventilated patients with COVID-19. Yet, several U.S. states have proposed SOFA-based algorithms for ventilator triage during crisis standards of care. Using a large cohort of mechanically ventilated patients with COVID-19, we externally validated the predictive capacity of the preintubation SOFA score for mortality prediction with and without other commonly used algorithm elements. DESIGN: Multicenter, retrospective cohort study using electronic health record data. SETTING: Eighty-six U.S. health systems. PATIENTS: Patients with COVID-19 hospitalized between January 1, 2020, and February 14, 2021, and subsequently initiated on mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 15,122 mechanically ventilated patients with COVID-19, SOFA score alone demonstrated poor discriminant accuracy for inhospital mortality in mechanically ventilated patients using the validation cohort (area under the receiver operating characteristic curve [AUC], 0.66; 95% CI, 0.65-0.67). Discriminant accuracy was even poorer using SOFA score categories (AUC, 0.54; 95% CI, 0.54-0.55). Age alone demonstrated greater discriminant accuracy for inhospital mortality than SOFA score (AUC, 0.71; 95% CI, 0.69-0.72). Discriminant accuracy for mortality improved upon addition of age to the continuous SOFA score (AUC, 0.74; 95% CI, 0.73-0.76) and categorized SOFA score (AUC, 0.72; 95% CI, 0.71-0.73) models, respectively. The addition of comorbidities did not substantially increase model discrimination. Of 36 U.S. states with crisis standards of care guidelines containing ventilator triage algorithms, 31 (86%) feature the SOFA score. Of these, 25 (81%) rely heavily on the SOFA score (12 exclusively propose SOFA; 13 place highest weight on SOFA or propose SOFA with one other variable). CONCLUSIONS: In a U.S. cohort of over 15,000 ventilated patients with COVID-19, the SOFA score displayed poor predictive accuracy for short-term mortality. Our findings warrant reappraisal of the SOFA score's implementation and weightage in existing ventilator triage pathways in current U.S. crisis standards of care guidelines.


Subject(s)
COVID-19 , Organ Dysfunction Scores , Algorithms , Delivery of Health Care , Electronic Health Records , Hospital Mortality , Humans , Intensive Care Units , Prognosis , ROC Curve , Retrospective Studies , Triage , Ventilators, Mechanical
15.
JAMA Netw Open ; 5(3): e222735, 2022 03 01.
Article in English | MEDLINE | ID: covidwho-1748801

ABSTRACT

Importance: SARS-CoV-2 viral entry may disrupt angiotensin II (AII) homeostasis, contributing to COVID-19 induced lung injury. AII type 1 receptor blockade mitigates lung injury in preclinical models, although data in humans with COVID-19 remain mixed. Objective: To test the efficacy of losartan to reduce lung injury in hospitalized patients with COVID-19. Design, Setting, and Participants: This blinded, placebo-controlled randomized clinical trial was conducted in 13 hospitals in the United States from April 2020 to February 2021. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already using a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible for participation. Data were analyzed from April 19 to August 24, 2021. Interventions: Losartan 50 mg orally twice daily vs equivalent placebo for 10 days or until hospital discharge. Main Outcomes and Measures: The primary outcome was the imputed arterial partial pressure of oxygen to fraction of inspired oxygen (Pao2:Fio2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity; days without supplemental o2, ventilation, or vasopressors; and mortality. Losartan pharmacokinetics and RAAS components (AII, angiotensin-[1-7] and angiotensin-converting enzymes 1 and 2)] were measured in a subgroup of participants. Results: A total of 205 participants (mean [SD] age, 55.2 [15.7] years; 123 [60.0%] men) were randomized, with 101 participants assigned to losartan and 104 participants assigned to placebo. Compared with placebo, losartan did not significantly affect Pao2:Fio2 ratio at 7 days (difference, -24.8 [95%, -55.6 to 6.1]; P = .12). Compared with placebo, losartan did not improve any secondary clinical outcomes and led to fewer vasopressor-free days than placebo (median [IQR], 9.4 [9.1-9.8] vasopressor-free days vs 8.7 [8.2-9.3] vasopressor-free days). Conclusions and Relevance: This randomized clinical trial found that initiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury did not improve Pao2:Fio2 ratio at 7 days. These data may have implications for ongoing clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT04312009.


Subject(s)
Angiotensin II Type 1 Receptor Blockers/therapeutic use , COVID-19/complications , COVID-19/drug therapy , Losartan/therapeutic use , Lung Injury/prevention & control , Lung Injury/virology , Adult , Aged , COVID-19/diagnosis , Double-Blind Method , Female , Hospitalization , Humans , Lung Injury/diagnosis , Male , Middle Aged , Organ Dysfunction Scores , Respiratory Function Tests , United States
16.
JAMA Netw Open ; 5(3): e221744, 2022 03 01.
Article in English | MEDLINE | ID: covidwho-1739100

ABSTRACT

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.


Subject(s)
COVID-19/mortality , Health Care Rationing/statistics & numerical data , Residence Characteristics/statistics & numerical data , Standard of Care , Aged , Boston , COVID-19/diagnosis , COVID-19/therapy , Critical Care , Female , Health Priorities , Healthcare Disparities , Hospitalization , Humans , Male , Middle Aged , Organ Dysfunction Scores , Retrospective Studies , Severity of Illness Index , Vulnerable Populations/statistics & numerical data
17.
Anaesthesiol Intensive Ther ; 54(1): 3-11, 2022.
Article in English | MEDLINE | ID: covidwho-1737212

ABSTRACT

BACKGROUND: The Sequential Organ Failure Assessment (SOFA) score has been developed to score the severity of organ dysfunction in critically ill sepsis patients and has been proven to have a high predictive value for intensive care unit (ICU) mortality in severely ill patients. Our goal was to evaluate the prognostic value of the SOFA score as well as trends in SOFA score for ICU mortality in COVID-19 patients. METHODS: All consecutive patients with confirmed COVID-19 pneumonia admitted to the ICU between March 13th, 2020, and October 17th, 2020 were included in this retrospective cohort study. The worst SOFA score was evaluated daily. Multiple logistic regression models were used to evaluate the predictive value of SOFA in ICU mortality. RESULTS: 103 patients were included in this study. 30 patients (29%) died during their ICU stay and 73 (71%) patients were discharged alive. The ICU admission SOFA score was 5.2 ± 3.3 in ICU non-survivors vs. 4.3 ± 2.9 in ICU survivors (P = 0.15). The maximum SOFA score in ICU non-survivors was 11.7 ± 4.7 vs. 7.4 ± 4.3 in ICU survivors. SOFA scores increased the first week in both survivors and non-survivors, but the increase was less pronounced in survivors. In the multiple logistic regression models, neither admission SOFA score nor combination with delta SOFA in the first 48 hours was statistically significantly related to ICU mortality. Only the maximum SOFA score remained significant (OR = 1.23, 95% CI: 1.11-1.37, P < 0.001) in the multiple logistic models with an AUC of 0.91. CONCLUSIONS: Evaluation of SOFA scores in the first 48 hours after ICU admission is not a good prognostic indicator in COVID-19 patients. Only the maximum SOFA score was predictive for ICU mortality.


Subject(s)
COVID-19 , Organ Dysfunction Scores , Critical Illness , Humans , Intensive Care Units , Prognosis , ROC Curve , Retrospective Studies
18.
Crit Care Med ; 50(2): 212-223, 2022 02 01.
Article in English | MEDLINE | ID: covidwho-1735675

ABSTRACT

OBJECTIVES: Body temperature trajectories of infected patients are associated with specific immune profiles and survival. We determined the association between temperature trajectories and distinct manifestations of coronavirus disease 2019. DESIGN: Retrospective observational study. SETTING: Four hospitals within an academic healthcare system from March 2020 to February 2021. PATIENTS: All adult patients hospitalized with coronavirus disease 2019. INTERVENTIONS: Using a validated group-based trajectory model, we classified patients into four previously defined temperature trajectory subphenotypes using oral temperature measurements from the first 72 hours of hospitalization. Clinical characteristics, biomarkers, and outcomes were compared between subphenotypes. MEASUREMENTS AND MAIN RESULTS: The 5,903 hospitalized coronavirus disease 2019 patients were classified into four subphenotypes: hyperthermic slow resolvers (n = 1,452, 25%), hyperthermic fast resolvers (1,469, 25%), normothermics (2,126, 36%), and hypothermics (856, 15%). Hypothermics had abnormal coagulation markers, with the highest d-dimer and fibrin monomers (p < 0.001) and the highest prevalence of cerebrovascular accidents (10%, p = 0.001). The prevalence of venous thromboembolism was significantly different between subphenotypes (p = 0.005), with the highest rate in hypothermics (8.5%) and lowest in hyperthermic slow resolvers (5.1%). Hyperthermic slow resolvers had abnormal inflammatory markers, with the highest C-reactive protein, ferritin, and interleukin-6 (p < 0.001). Hyperthermic slow resolvers had increased odds of mechanical ventilation, vasopressors, and 30-day inpatient mortality (odds ratio, 1.58; 95% CI, 1.13-2.19) compared with hyperthermic fast resolvers. Over the course of the pandemic, we observed a drastic decrease in the prevalence of hyperthermic slow resolvers, from representing 53% of admissions in March 2020 to less than 15% by 2021. We found that dexamethasone use was associated with significant reduction in probability of hyperthermic slow resolvers membership (27% reduction; 95% CI, 23-31%; p < 0.001). CONCLUSIONS: Hypothermics had abnormal coagulation markers, suggesting a hypercoagulable subphenotype. Hyperthermic slow resolvers had elevated inflammatory markers and the highest odds of mortality, suggesting a hyperinflammatory subphenotype. Future work should investigate whether temperature subphenotypes benefit from targeted antithrombotic and anti-inflammatory strategies.


Subject(s)
Body Temperature , COVID-19/pathology , Hyperthermia/pathology , Hypothermia/pathology , Phenotype , Academic Medical Centers , Aged , Anti-Inflammatory Agents/therapeutic use , Biomarkers/blood , Blood Coagulation , Cohort Studies , Dexamethasone/therapeutic use , Female , Humans , Inflammation , Male , Middle Aged , Organ Dysfunction Scores , Retrospective Studies , SARS-CoV-2
19.
Crit Care ; 26(1): 26, 2022 01 25.
Article in English | MEDLINE | ID: covidwho-1701731

ABSTRACT

BACKGROUND: Intravenous vitamin C administration in septic shock may have a sparing effect on vasopressor requirements, and vitamin C's enzyme cofactor functions provide a mechanistic rationale. Our study aimed to determine the effect of intravenous vitamin C administration on vasopressor requirements and other outcomes in patients with septic shock. METHODS: This was a double-blind, randomised placebo-controlled trial in 40 patients with septic shock who were randomised (1:1) to receive intravenous vitamin C (at a dose of 25 mg/kg of body weight every 6 h) or placebo (intravenous 5% dextrose) for up to 96 h, or until death or discharge. The primary outcome was intravenous vasopressor requirements (dose and duration), and secondary outcomes included Sequential Organ Failure Assessment (SOFA) scores, intensive care unit (ICU) and hospital length of stay, and mortality. In addition, blood samples were collected to determine vitamin C kinetics and inflammatory marker concentrations. RESULTS: Median plasma vitamin C concentrations were deficient at baseline (9.2 [4.4, 12] µmol/L) and increased to 408 (227, 560) µmol/L following 72 h of intervention. The mean duration of intravenous vasopressor infusion in the vitamin C group was 48 (95% CI 35-62) hours and in the placebo group was 54 (95% CI 41-62) hours (p = 0.52). The dose of vasopressor delivered over time was comparable between the two groups, as were SOFA scores (p > 0.05). The median ICU length of stay in the intervention group was 3.8 (2.2, 9.8) days versus 7.1 (3.1, 20) days in the placebo group (p = 0.12). The median hospital length of stay for the vitamin C group was 18 (11, 35) days versus 22 (10, 52) days for the placebo group (p = 0.65). Mortality was comparable between the two groups (p > 0.05). Of the inflammatory markers, neutrophil counts were elevated in the vitamin C group relative to placebo by 72 h (p = 0.01). C-reactive protein and myeloperoxidase concentrations were elevated at baseline, however, the two groups were comparable over time (p > 0.05). CONCLUSIONS: Our pilot study indicated that intravenous vitamin C did not provide significant decreases in the mean dose or duration of vasopressor infusion. Further research that takes into account the potential impact of intervention timing, dose and duration, and location of trial, may provide more definitive evidence. TRIAL REGISTRATION: ACTRN12617001184369 (11/8/2017).


Subject(s)
Shock, Septic , Ascorbic Acid/therapeutic use , Double-Blind Method , Humans , Organ Dysfunction Scores , Pilot Projects , Shock, Septic/drug therapy , Vitamins
20.
Blood Purif ; 51(11): 879-888, 2022.
Article in English | MEDLINE | ID: covidwho-1685776

ABSTRACT

INTRODUCTION: Currently, the effect of hemoperfusion on outcome in severe COVID-19 patients is still unknown. Therefore, we aimed to investigate the effects of early HA-330 hemoperfusion in severe COVID-19 patients. METHODS: We conducted a single center, prospective cohort study on patients who were diagnosed with severe COVID-19 patients and admitted to ICU. Patients in hemoperfusion group (defined as patients who were treated with hemoperfusion therapy at least 3 sessions in combination with standard therapy) were compared with the control group (defined as patients who received standard treatment alone or received less than 3 sessions of hemoperfusion therapy). The primary outcome was daily sequential organ failure assessment (SOFA) scores. Secondary outcomes were all-cause mortality at 28 days, mechanical ventilator-free day, daily C-reactive protein (CRP), oxygenation (defined by PaO2/FiO2 ratio), and severity score of lung infiltration on the chest X-ray (CXR RALE score). All outcomes were adjusted by regression analysis to reduce the confounders due to some difference in baseline characteristics. RESULTS: A total number of 29 severe and critical COVID-19 confirmed patients were enrolled. Fifteen patients were defined as hemoperfusion group and 14 were control group. The median of CRP and SOFA score at the baseline (the day after severe pneumonia diagnosis or before hemoperfusion) in hemoperfusion and control groups were comparable, 96.79 mg/L and 87.3 mg/L, p = 0.53, 3.53 ± 0.99 versus 4.3 ± 1.89, p = 0.15, respectively. Clinical improvement associated with decreased SOFA score and improvement of CXR RALE score were found in hemoperfusion group compared to control group (p = 0.008 and p = 0.005, respectively). The 28-day mortality rate was significantly lower in hemoperfusion group compared to control group (6.67% vs. 85.71%, p < 0.001) and the adjusted hazard ratio of death was 0.017 (95% confidence interval = 0.008-0.351, p = 0.008). CONCLUSIONS: The addition of early HA-330 hemoperfusion to standard therapy improved severity of organ failure and might reduce the mortality rate. However, the results were affected by the baseline confounders and limited sample size.


Subject(s)
COVID-19 , Hemoperfusion , Humans , Hemoperfusion/methods , COVID-19/therapy , Prospective Studies , Respiratory Sounds , Organ Dysfunction Scores
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