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1.
Lancet Respir Med ; 9(4): 407-418, 2021 04.
Artículo en Inglés | MEDLINE | ID: covidwho-1180128

RESUMEN

BACKGROUND: Most low-income and middle-income countries (LMICs) have little or no data integrated into a national surveillance system to identify characteristics or outcomes of COVID-19 hospital admissions and the impact of the COVID-19 pandemic on their national health systems. We aimed to analyse characteristics of patients admitted to hospital with COVID-19 in Brazil, and to examine the impact of COVID-19 on health-care resources and in-hospital mortality. METHODS: We did a retrospective analysis of all patients aged 20 years or older with quantitative RT-PCR (RT-qPCR)-confirmed COVID-19 who were admitted to hospital and registered in SIVEP-Gripe, a nationwide surveillance database in Brazil, between Feb 16 and Aug 15, 2020 (epidemiological weeks 8-33). We also examined the progression of the COVID-19 pandemic across three 4-week periods within this timeframe (epidemiological weeks 8-12, 19-22, and 27-30). The primary outcome was in-hospital mortality. We compared the regional burden of hospital admissions stratified by age, intensive care unit (ICU) admission, and respiratory support. We analysed data from the whole country and its five regions: North, Northeast, Central-West, Southeast, and South. FINDINGS: Between Feb 16 and Aug 15, 2020, 254 288 patients with RT-qPCR-confirmed COVID-19 were admitted to hospital and registered in SIVEP-Gripe. The mean age of patients was 60 (SD 17) years, 119 657 (47%) of 254 288 were aged younger than 60 years, 143 521 (56%) of 254 243 were male, and 14 979 (16%) of 90 829 had no comorbidities. Case numbers increased across the three 4-week periods studied: by epidemiological weeks 19-22, cases were concentrated in the North, Northeast, and Southeast; by weeks 27-30, cases had spread to the Central-West and South regions. 232 036 (91%) of 254 288 patients had a defined hospital outcome when the data were exported; in-hospital mortality was 38% (87 515 of 232 036 patients) overall, 59% (47 002 of 79 687) among patients admitted to the ICU, and 80% (36 046 of 45 205) among those who were mechanically ventilated. The overall burden of ICU admissions per ICU beds was more pronounced in the North, Southeast, and Northeast, than in the Central-West and South. In the Northeast, 1545 (16%) of 9960 patients received invasive mechanical ventilation outside the ICU compared with 431 (8%) of 5388 in the South. In-hospital mortality among patients younger than 60 years was 31% (4204 of 13 468) in the Northeast versus 15% (1694 of 11 196) in the South. INTERPRETATION: We observed a widespread distribution of COVID-19 across all regions in Brazil, resulting in a high overall disease burden. In-hospital mortality was high, even in patients younger than 60 years, and worsened by existing regional disparities within the health system. The COVID-19 pandemic highlights the need to improve access to high-quality care for critically ill patients admitted to hospital with COVID-19, particularly in LMICs. FUNDING: National Council for Scientific and Technological Development (CNPq), Coordinating Agency for Advanced Training of Graduate Personnel (CAPES), Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ), and Instituto de Salud Carlos III.


Asunto(s)
/epidemiología , Monitoreo Epidemiológico , Disparidades en Atención de Salud/estadística & datos numéricos , Mortalidad Hospitalaria/tendencias , Pandemias/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , /terapia , Comorbilidad , Femenino , Geografía , Accesibilidad a los Servicios de Salud/organización & administración , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Admisión del Paciente/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Estudios Retrospectivos , Adulto Joven
2.
Lancet Respir Med ; 9(4): 349-359, 2021 04.
Artículo en Inglés | MEDLINE | ID: covidwho-1180127

RESUMEN

BACKGROUND: Prognostic models to predict the risk of clinical deterioration in acute COVID-19 cases are urgently required to inform clinical management decisions. METHODS: We developed and validated a multivariable logistic regression model for in-hospital clinical deterioration (defined as any requirement of ventilatory support or critical care, or death) among consecutively hospitalised adults with highly suspected or confirmed COVID-19 who were prospectively recruited to the International Severe Acute Respiratory and Emerging Infections Consortium Coronavirus Clinical Characterisation Consortium (ISARIC4C) study across 260 hospitals in England, Scotland, and Wales. Candidate predictors that were specified a priori were considered for inclusion in the model on the basis of previous prognostic scores and emerging literature describing routinely measured biomarkers associated with COVID-19 prognosis. We used internal-external cross-validation to evaluate discrimination, calibration, and clinical utility across eight National Health Service (NHS) regions in the development cohort. We further validated the final model in held-out data from an additional NHS region (London). FINDINGS: 74 944 participants (recruited between Feb 6 and Aug 26, 2020) were included, of whom 31 924 (43·2%) of 73 948 with available outcomes met the composite clinical deterioration outcome. In internal-external cross-validation in the development cohort of 66 705 participants, the selected model (comprising 11 predictors routinely measured at the point of hospital admission) showed consistent discrimination, calibration, and clinical utility across all eight NHS regions. In held-out data from London (n=8239), the model showed a similarly consistent performance (C-statistic 0·77 [95% CI 0·76 to 0·78]; calibration-in-the-large 0·00 [-0·05 to 0·05]); calibration slope 0·96 [0·91 to 1·01]), and greater net benefit than any other reproducible prognostic model. INTERPRETATION: The 4C Deterioration model has strong potential for clinical utility and generalisability to predict clinical deterioration and inform decision making among adults hospitalised with COVID-19. FUNDING: National Institute for Health Research (NIHR), UK Medical Research Council, Wellcome Trust, Department for International Development, Bill & Melinda Gates Foundation, EU Platform for European Preparedness Against (Re-)emerging Epidemics, NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, NIHR HPRU in Respiratory Infections at Imperial College London.


Asunto(s)
/diagnóstico , Reglas de Decisión Clínica , Toma de Decisiones Clínicas/métodos , Deterioro Clínico , Anciano , Anciano de 80 o más Años , /terapia , Cuidados Críticos/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Admisión del Paciente/estadística & datos numéricos , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Respiración Artificial/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Reino Unido/epidemiología
3.
J Zhejiang Univ Sci B ; 22(4): 330-340, 2021 Apr 15.
Artículo en Inglés | MEDLINE | ID: covidwho-1175476

RESUMEN

Epidemiological evidence suggests that patients with hypertension infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at increased risk of acute lung injury. However, it is still not clear whether this increased risk is related to the usage of renin-angiotensin system (RAS) blockers. We collected medical records of coronavirus disease 2019 (COVID-19) patients from the First Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China), and evaluated the potential impact of an angiotensin II receptor blocker (ARB) on the clinical outcomes of COVID-19 patients with hypertension. A total of 30 hypertensive COVID-19 patients were enrolled, of which 17 were classified as non-ARB group and the remaining 13 as ARB group based on the antihypertensive therapies they received. Compared with the non-ARB group, patients in the ARB group had a lower proportion of severe cases and intensive care unit (ICU) admission as well as shortened length of hospital stay, and manifested favorable results in most of the laboratory testing. Viral loads in the ARB group were lower than those in the non-ARB group throughout the disease course. No significant difference in the time of seroconversion or antibody levels was observed between the two groups. The median levels of soluble angiotensin-converting enzyme 2 (sACE2) in serum and urine samples were similar in both groups, and there were no significant correlations between serum sACE2 and biomarkers of disease severity. Transcriptional analysis showed 125 differentially expressed genes which mainly were enriched in oxygen transport, bicarbonate transport, and blood coagulation. Our results suggest that ARB usage is not associated with aggravation of COVID-19. These findings support the maintenance of ARB treatment in hypertensive patients diagnosed with COVID-19.


Asunto(s)
Antagonistas de Receptores de Angiotensina/uso terapéutico , Anticuerpos Antivirales/sangre , Hipertensión/tratamiento farmacológico , Carga Viral , Anciano , Anciano de 80 o más Años , Antagonistas de Receptores de Angiotensina/efectos adversos , Antihipertensivos/efectos adversos , Antihipertensivos/uso terapéutico , Biomarcadores , China , Femenino , Humanos , Hipertensión/complicaciones , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Transcriptoma
4.
Nursing (Säo Paulo) ; 23(268): 4636-4645, set.2020.
Artículo en Portugués | LILACS (Américas) | ID: covidwho-1022450

RESUMEN

Objetivo: Evidenciar os fatores determinantes para adesão das medidas de biossegurança pela equipe de Enfermagem na Unidade de Terapia Intensiva. Método: Estudo de revisão sistemática, que usou o instrumento Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A busca foi realizada a partir de artigos publicados no período de 2004 a 2019, por dificuldade de encontrar publicações em menor período acerca da temática deste estudo. Resultados: O conhecimento e as ações de promoção e prevenção, como a lavagem de mãos e o uso de Equipamento de Proteção Individual, além de recursos físicos, são fatores determinantes para adesão às medidas de biossegurança na UTI. Conclusão: As medidas de biossegurança garantem a segurança do paciente, e, por isso, é importante que os profissionais sejam capacitados regularmente para prevenir dificuldades e falhas de adesão com as medidas de biossegurança o que pode colocar em risco o paciente e o profissional da enfermagem.(AU)


Objective: To highlight the determining factors for adherence to biosafety measures by the Nursing team in the Intensive Care Unit. Method: Systematic review study, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) instrument. The search was carried out from articles published from 2004 to 2019, due to the difficulty of finding publications in a shorter period on the theme of this study. Results: Knowledge and promotion and prevention actions, such as hand washing and the use of Personal Protective Equipment, in addition to physical resources, are determining factors for adherence to biosafety measures in the ICU. Conclusion: Biosafety measures guarantee patient safety, and, therefore, it is important that professionals are trained regularly to prevent difficulties and failures in adherence to biosafety measures, which can put the patient and the nursing professional at risk. (AU)


Objetivo: Resaltar los determinantes de la adherencia a las medidas de bioseguridad por parte del equipo de Enfermería de la Unidad de Cuidados Intensivos. Método: Estudio de revisión sistemática, utilizando el instrumento Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). La búsqueda se realizó a partir de artículos publicados de 2004 a 2019, debido a la dificultad de encontrar publicaciones en un período más corto sobre la temática de este estudio. Resultados: El conocimiento y las acciones de promoción y prevención, como el lavado de manos y el uso de Equipos de Protección Personal, además de los recursos físicos, son factores determinantes para el cumplimiento de las medidas de bioseguridad en la UCI. Conclusión: Las medidas de bioseguridad garantizan la seguridad del paciente, por lo que es importante que los profesionales se capaciten periódicamente para prevenir dificultades y fallas en la adherencia a las medidas de bioseguridad, que pueden poner en riesgo al paciente y al profesional de enfermería.(AU)


Asunto(s)
Humanos , Administración de la Seguridad/normas , Contención de Riesgos Biológicos/enfermería , Prevención de Enfermedades , Equipo de Protección Personal , Unidades de Cuidados Intensivos , Indicadores de Calidad de la Atención de Salud , Atención de Enfermería/normas
5.
Neurosciences (Riyadh) ; 26(2): 158-162, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: covidwho-1170592

RESUMEN

OBJECTIVES: To assess and quantify the impact COVID-19 has had thus far on ischemic stroke admission rate and severity (National Institutes of Health Stroke Scale (NIHSS) score) at a single tertiary center in Makkah, Saudi Arabia. METHODS: This is a retrospective analysis performed on admitted cases with definitive final diagnoses of transient ischemic attack (TIA) and ischemic stroke at King Abdullah Medical City in Makkah between January 1, 2020 and July 2020. RESULTS: Sixty-nine patients were included in our study, 41 of whom presented at our facility before the pandemic and 29 during the pandemic. No statistical significance was observed between rate of admission, stroke severity, and rate of thrombolysis before the COVID-19 pandemic and after the outbreak. We observed a reduction of mean arrival time after the pandemic began, as well as a reduction of hospital stay days. CONCLUSION: A 29% reduction of admission secondary to acute ischemic stroke was noted during the pandemic. However, COVID-19 did not affect acute stroke care at our institute. The study is limited because of its small sample size, as we assessed just one medical center.


Asunto(s)
Ataque Isquémico Transitorio/epidemiología , /epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Ataque Isquémico Transitorio/terapia , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Arabia Saudita/epidemiología , Índice de Severidad de la Enfermedad , Distribución por Sexo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Centros de Atención Terciaria , Terapia Trombolítica/estadística & datos numéricos , Tiempo de Tratamiento/estadística & datos numéricos , Adulto Joven
6.
Clin Appl Thromb Hemost ; 27: 10760296211008988, 2021.
Artículo en Inglés | MEDLINE | ID: covidwho-1169937

RESUMEN

Coagulation abnormalities have been reported in COVID-19 patients, which may lead to an increased risk of Pulmonary Embolism (PE). We aimed to describe the clinical characteristics and outcomes of COVID-19 patients diagnosed with PE during their hospital stay. We analyzed patients with PE and COVID-19 in a tertiary center in Mexico City from April to October of 2020. A total of 26 (100%) patients were diagnosed with Pulmonary Embolism and COVID-19. We observed that 14 (54%) patients were receiving either prophylactic or full anticoagulation therapy, before PE diagnosis. We found a significant difference in mortality between the group with less than 7 days (83%) and the group with more than 7 days (15%) in Intensive Care Unit (P = .004); as well as a mean of 8 days for the mortality group compared with 20 days of hospitalization in the survivor group (P = .003). In conclusion, there is an urgent need to review antithrombotic therapy in these patients in order to improve clinical outcomes and decrease hospital overload.


Asunto(s)
/mortalidad , Hospitalización , Unidades de Cuidados Intensivos , Embolia Pulmonar/mortalidad , Adulto , Anciano , Femenino , Humanos , Masculino , México/epidemiología , Persona de Mediana Edad , Embolia Pulmonar/terapia , Estudios Retrospectivos , Centros de Atención Terciaria , Factores de Tiempo
7.
JAMA ; 325(11): 1053-1060, 2021 03 16.
Artículo en Inglés | MEDLINE | ID: covidwho-1168753

RESUMEN

Importance: The efficacy of vitamin D3 supplementation in coronavirus disease 2019 (COVID-19) remains unclear. Objective: To investigate the effect of a single high dose of vitamin D3 on hospital length of stay in patients with COVID-19. Design, Setting, and Participants: This was a multicenter, double-blind, randomized, placebo-controlled trial conducted in 2 sites in Sao Paulo, Brazil. The study included 240 hospitalized patients with COVID-19 who were moderately to severely ill at the time of enrollment from June 2, 2020, to August 27, 2020. The final follow-up was on October 7, 2020. Interventions: Patients were randomly assigned to receive a single oral dose of 200 000 IU of vitamin D3 (n = 120) or placebo (n = 120). Main Outcomes and Measures: The primary outcome was length of stay, defined as the time from the date of randomization to hospital discharge. Prespecified secondary outcomes included mortality during hospitalization; the number of patients admitted to the intensive care unit; the number of patients who required mechanical ventilation and the duration of mechanical ventilation; and serum levels of 25-hydroxyvitamin D, total calcium, creatinine, and C-reactive protein. Results: Of 240 randomized patients, 237 were included in the primary analysis (mean [SD] age, 56.2 [14.4] years; 104 [43.9%] women; mean [SD] baseline 25-hydroxyvitamin D level, 20.9 [9.2] ng/mL). Median (interquartile range) length of stay was not significantly different between the vitamin D3 (7.0 [4.0-10.0] days) and placebo groups (7.0 [5.0-13.0] days) (log-rank P = .59; unadjusted hazard ratio for hospital discharge, 1.07 [95% CI, 0.82-1.39]; P = .62). The difference between the vitamin D3 group and the placebo group was not significant for in-hospital mortality (7.6% vs 5.1%; difference, 2.5% [95% CI, -4.1% to 9.2%]; P = .43), admission to the intensive care unit (16.0% vs 21.2%; difference, -5.2% [95% CI, -15.1% to 4.7%]; P = .30), or need for mechanical ventilation (7.6% vs 14.4%; difference, -6.8% [95% CI, -15.1% to 1.2%]; P = .09). Mean serum levels of 25-hydroxyvitamin D significantly increased after a single dose of vitamin D3 vs placebo (44.4 ng/mL vs 19.8 ng/mL; difference, 24.1 ng/mL [95% CI, 19.5-28.7]; P < .001). There were no adverse events, but an episode of vomiting was associated with the intervention. Conclusions and Relevance: Among hospitalized patients with COVID-19, a single high dose of vitamin D3, compared with placebo, did not significantly reduce hospital length of stay. The findings do not support the use of a high dose of vitamin D3 for treatment of moderate to severe COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04449718.


Asunto(s)
/tratamiento farmacológico , Colecalciferol/administración & dosificación , Tiempo de Internación , Vitaminas/administración & dosificación , Adulto , Brasil , /terapia , Método Doble Ciego , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Respiración Artificial , Insuficiencia del Tratamiento , Vitamina D/análogos & derivados , Vitamina D/sangre , Deficiencia de Vitamina D/tratamiento farmacológico
8.
Saudi Med J ; 42(4): 370-376, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: covidwho-1168262

RESUMEN

OBJECTIVES: To assess the neutrophil-to-lymphocyte ratio (NLR) diagnostic and prognostic value in the context of Coronavirus disease-2019 (COVID-19) infection in Saudi Arabia. METHODS: A case-control study in which 701 confirmed COVID-19 patients (of which 41 were intensive care unit [ICU]-admitted) and 250 control subjects were enrolled. The study was conducted retrospectively in October on patients admitted to 3 separate hospitals in Saudi Arabia namely: King Abdullah Bin Abdulaziz University Hospital (Riyadh), Ohud Hospital (Madinah), and Nojood Medical Center (Madinah) between May and September 2020. Neutrophil-to-lymphocyte ratio was calculated based on absolute neutrophil and lymphocyte count. Institutional ethical approval was obtained prior to the study. RESULTS: Patients (median age 35 years), of which 54.8% were females, were younger than the control cohort (median age 48 years). Patients had significantly higher NLR compared to the control group. Intensive care unit admitted patients had significantly higher platelet, WBC and neutrophil counts. The ICU patients' NLR was almost twice as of the non-intensive patients. The NLR value of 5.5 was found to be of high specificity (96.4%) and positive predictive value (91.4%) in diagnosing COVID-19. Furthermore, it had a very good sensitivity (86.4%) in predicting severe forms of disease, such as, ICU admission. CONCLUSION: Neutrophil-to-lymphocyte ratio is an important tool in determining the COVID-19 clinical status. This study further confirms the prognostic value of NLR in detecting severe infection, and those patients with high NLR should be closely monitored and managed.


Asunto(s)
/diagnóstico , Recuento de Linfocitos , Neutrófilos , Adulto , Recuento de Células Sanguíneas , Estudios de Casos y Controles , Femenino , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Arabia Saudita , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad
9.
Health Res Policy Syst ; 19(1): 47, 2021 Mar 31.
Artículo en Inglés | MEDLINE | ID: covidwho-1166913

RESUMEN

BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.


Asunto(s)
Cuidados Críticos , Enfermedad Crítica , Asignación de Recursos para la Atención de Salud , Accesibilidad a los Servicios de Salud , Pandemias , Guías de Práctica Clínica como Asunto , Toma de Decisiones , Revelación , Ética Médica , Recursos en Salud , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Pronóstico , Discriminación Social , Valores Sociales , Participación de los Interesados , Tailandia , Confianza
11.
Asia Pac J Clin Nutr ; 30(1): 15-21, 2021.
Artículo en Inglés | MEDLINE | ID: covidwho-1160056

RESUMEN

BACKGROUND AND OBJECTIVES: The novel coronavirus disease (COVID-19) epidemic is spreading all over the world. With the number of cases increasing rapidly, the epidemiological data on the nutritional practice is scarce. In this study, we aim to describe the clinical characteristics and nutritional practice in a cohort of critically ill COVID-19 patients. METHODS AND STUDY DESIGN: This is a multicenter, ambidirectional cohort study conducted at 11 hospitals in Hubei Province, China. All eligible critical COVID-19 patients in the study hospital intensive care units at 00:00, March 6th, 2020, were included. Data collection was performed via written case report forms. RESULTS: A total of 44 patients were identified and enrolled, of whom eight died during the 28-day outcome follow- up period. The median interval between hospital admission and the study day was 24 (interquartile range, 13- 26) days and 52.2% (23 of 44) of patients were on invasive mechanical ventilation. The median nutrition risk in critically ill (mNUTRIC) score was 3 (interquartile range, 2-5) on the study day. During the enrolment day, 68.2% (30 of 44) of patients received enteral nutrition (EN), while 6.8% (3 of 44) received parenteral nutrition (PN) alone. Nausea and aspiration were uncommon, with a prevalence of 11.4% (5 of 44) and 6.8% (3 of 44), respectively. As for energy delivery, 69.7% (23 of 33) of patients receiving EN and/or PN were achieving their prescribed targets. CONCLUSIONS: The study showed that EN was frequently applied in critical COVID-19 patients. Energy delivery may be suboptimal in this study requiring more attention.


Asunto(s)
/epidemiología , Enfermedad Crítica/epidemiología , Estado Nutricional , Apoyo Nutricional , Anciano , China/epidemiología , Estudios de Cohortes , Nutrición Enteral/estadística & datos numéricos , Femenino , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Nutrición Parenteral/estadística & datos numéricos
12.
Dis Markers ; 2021: 6658270, 2021.
Artículo en Inglés | MEDLINE | ID: covidwho-1159714

RESUMEN

Aim: Coronavirus disease (COVID-19) ranges from mild clinical phenotypes to life-threatening conditions like severe acute respiratory syndrome (SARS). It has been suggested that early liver injury in these patients could be a risk factor for poor outcome. We aimed to identify early biochemical predictive factors related to severe disease development with intensive care requirements in patients with COVID-19. Methods: Data from COVID-19 patients were collected at admission time to our hospital. Differential biochemical factors were identified between seriously ill patients requiring intensive care unit (ICU) admission (ICU patients) versus stable patients without the need for ICU admission (non-ICU patients). Multiple linear regression was applied, then a predictive model of severity called Age-AST-D dimer (AAD) was constructed (n = 166) and validated (n = 170). Results: Derivation cohort: from 166 patients included, there were 27 (16.3%) ICU patients that showed higher levels of liver injury markers (P < 0.01) compared with non-ICU patients: alanine aminotrasnferase (ALT) 225.4 ± 341.2 vs. 41.3 ± 41.1, aspartate aminotransferase (AST) 325.3 ± 382.4 vs. 52.8 ± 47.1, lactic dehydrogenase (LDH) 764.6 ± 401.9 vs. 461.0 ± 185.6, D-dimer (DD) 7765 ± 9109 vs. 1871 ± 4146, and age 58.6 ± 12.7 vs. 49.1 ± 12.8. With these finding, a model called Age-AST-DD (AAD), with a cut-point of <2.75 (sensitivity = 0.797 and specificity = 0.391, c - statistic = 0.74; 95%IC: 0.62-0.86, P < 0.001), to predict the risk of need admission to ICU (OR = 5.8; 95% CI: 2.2-15.4, P = 0.001), was constructed. Validation cohort: in 170 different patients, the AAD model < 2.75 (c - statistic = 0.80 (95% CI: 0.70-0.91, P < 0.001) adequately predicted the risk (OR = 8.8, 95% CI: 3.4-22.6, P < 0.001) to be admitted in the ICU (27 patients, 15.95%). Conclusions: The elevation of AST (a possible marker of early liver injury) along with DD and age efficiently predict early (at admission time) probability of ICU admission during the clinical course of COVID-19. The AAD model can improve the comprehensive management of COVID-19 patients, and it could be useful as a triage tool to early classify patients with a high risk of developing a severe clinical course of the disease.


Asunto(s)
Aspartato Aminotransferasas/química , /patología , Adulto , /virología , Estudios de Cohortes , Dimerización , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad
13.
Dtsch Med Wochenschr ; 146(7): 455-460, 2021 Apr.
Artículo en Alemán | MEDLINE | ID: covidwho-1155711

RESUMEN

Invasive fungal infections are gaining increasing importance in intensive care medicine. The aim of this article is to present an update on recent developments in the field of invasive fungal infection in critically ill patients. Particular emphasis is placed on the recently described invasive mold infections in patients with acute respiratory distress syndrome due to influenza or COVID-19. Detecting high-risk patients and the optimal diagnostic and therapeutic strategies play a decisive role to improve outcome.


Asunto(s)
/complicaciones , Gripe Humana/complicaciones , Infecciones Fúngicas Invasoras/epidemiología , /complicaciones , Biomarcadores , Candidiasis Invasiva/diagnóstico , Candidiasis Invasiva/epidemiología , Candidiasis Invasiva/terapia , Humanos , Incidencia , Gripe Humana/epidemiología , Unidades de Cuidados Intensivos , Infecciones Fúngicas Invasoras/diagnóstico , Infecciones Fúngicas Invasoras/terapia , Aspergilosis Pulmonar Invasiva/complicaciones , Aspergilosis Pulmonar Invasiva/diagnóstico , Aspergilosis Pulmonar Invasiva/epidemiología , Aspergilosis Pulmonar Invasiva/terapia , /etiología
14.
J Glob Health ; 11: 10001, 2021 Mar 01.
Artículo en Inglés | MEDLINE | ID: covidwho-1154786

RESUMEN

Background: Understanding the risk factors for poor outcomes among COVID-19 patients could help identify vulnerable populations who would need prioritisation in prevention and treatment for COVID-19. We aimed to critically appraise and synthesise published evidence on the risk factors for poor outcomes in hospitalised COVID-19 patients. Methods: We searched PubMed, medRxiv and the WHO COVID-19 literature database for studies that reported characteristics of COVID-19 patients who required hospitalisation. We included studies published between January and May 2020 that reported adjusted effect size of any demographic and/or clinical factors for any of the three poor outcomes: mortality, intensive care unit (ICU) admission, and invasive mechanical ventilation. We appraised the quality of the included studies using Joanna Briggs Institute appraisal tools and quantitatively synthesised the evidence through a series of random-effect meta-analyses. To aid data interpretation, we further developed an interpretation framework that indicated strength of the evidence, informed by both quantity and quality of the evidence. Results: We included a total of 40 studies in our review. Most of the included studies (29/40, 73%) were assessed as "good quality", with assessment scores of 80 or more. We found that male sex (pooled odds ratio (OR) = 1.32 (95% confidence interval (CI) = 1.18-1.48; 20 studies), older age (OR = 1.05, 95% CI = 1.04-1.07, per one year of age increase; 10 studies), obesity (OR = 1.59, 95% CI = 1.02-2.48; 4 studies), diabetes (OR = 1.25, 95% CI = 1.11-1.40; 11 studies) and chronic kidney diseases (6 studies; OR = 1.57, 95% CI = 1.27-1.93) were associated with increased risks for mortality with the greatest strength of evidence based on our interpretation framework. We did not find increased risk of mortality for several factors including chronic obstructive pulmonary diseases (5 studies), cancer (4 studies), or current smoker (5 studies); however, this does not indicate absence of risk due to limited data on each of these factors. Conclusion: Male sex, older age, obesity, diabetes and chronic kidney diseases are important risk factors of COVID-19 poor outcomes. Our review provides not only an appraisal and synthesis of evidence on the risk factors of COVID-19 poor outcomes, but also a data interpretation framework that could be adopted by relevant future research.


Asunto(s)
Hospitalización , Unidades de Cuidados Intensivos , Respiración Artificial , Índice de Severidad de la Enfermedad , Anciano , /mortalidad , Comorbilidad , Femenino , Humanos , Masculino , Factores de Riesgo
15.
Clin Nephrol ; 95(4): 171-181, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: covidwho-1154725

RESUMEN

The first documented case of SARS-CoV-2 infection was confirmed in South Africa (SA) in March 2020. The Western Cape (WC) province was the initial epicenter. The pandemic peaked in July 2020 when 76,851 cases were documented and 2,323 deaths reported. COVID-19 can have multisystem involvement. Acute kidney injury (AKI) is well-documented and associated with increased mortality. We report our experience as the pandemic evolved in the WC province, focusing on those patients with a SARS-CoV-2 positive test presenting with AKI. We also reviewed our chronic dialysis cohort and renal transplant recipients who tested positive to assess incidence and outcomes. All patients presenting to nephrology services at the four main public hospitals were included. Information regarding demographics, co-morbidities, medical care, laboratory data, and outcomes were recorded. There were 86 patients referred with AKI, 48 required dialysis, and 47 died. There were 52 patients admitted to the intensive care unit with AKI (37 received dialysis, 1 of whom survived). In those presenting with AKI, diabetes, obesity, hypertension, and HIV were the most common comorbidities. Of the 295 patients receiving chronic dialysis within our services, 31 tested positive for SARS-CoV-2, and 6 died. Of the 45 kidney transplant recipients who tested positive, 9 died. Only 3 required dialysis. In conclusion, we report a high rate of AKI and poor prognosis in those requiring kidney replacement therapy, a better prognosis than anticipated was found in our chronic dialysis cohort, and high numbers of admissions were required for renal transplant recipients.


Asunto(s)
Lesión Renal Aguda/terapia , Terapia de Reemplazo Renal , Lesión Renal Aguda/etiología , Lesión Renal Aguda/fisiopatología , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Riñón/fisiopatología , Pandemias , Pronóstico , Sudáfrica
16.
Int J Environ Res Public Health ; 18(7)2021 03 28.
Artículo en Inglés | MEDLINE | ID: covidwho-1154420

RESUMEN

Background: The COVID-19 pandemic has had global effects; cases have been counted in the tens of millions, and there have been over two million deaths throughout the world. Health systems have been stressed in trying to provide a response to the increasing demand for hospital beds during the different waves. This paper analyzes the dynamic response of the hospitals of the Community of Madrid (CoM) during the first wave of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in the period between 18 March and 31 May 2020. The aim was to model the response of the CoM's health system in terms of the number of available beds. Methods: A research design based on a case study of the CoM was developed. To model this response, we use two concepts: "bed margin" (available beds minus occupied beds, expressed as a percentage) and "flexibility" (which describes the ability to adapt to the growing demand for beds). The Linear Hinges Model allowed a robust estimation of the key performance indicators for capturing the flexibility of the available beds in hospitals. Three new flexibility indicators were defined: the Average Ramp Rate Until the Peak (ARRUP), the Ramp Duration Until the Peak (RDUP), and the Ramp Growth Until the Peak (RGUP). Results: The public and private hospitals of the CoM were able to increase the number of available beds from 18,692 on 18 March 2020 to 23,623 on 2 April 2020. At the peak of the wave, the number of available beds increased by 160 in 48 h, with an occupancy of 90.3%. Within that fifteen-day period, the number of COVID-19 inpatients increased by 200% in non-intensive care unit (non-ICU) wards and by 155% in intensive care unit (ICU) wards. The estimated ARRUP for non-ICU beds in the CoM hospital network during the first pandemic wave was 305.56 beds/day, the RDUP was 15 days, and the RGUP was 4598 beds. For the ICU beds, the ARRUP was 36.73 beds/day, the RDUP was 20 days, and the RGUP was 735 beds. This paper includes a further analysis of the response estimated for each hospital. Conclusions: This research provides insights not only for academia, but also for hospital management and practitioners. The results show that not all of the hospitals dealt with the sudden increase in bed demand in the same way, nor did they provide the same flexibility in order to increase their bed capabilities. The bed margin and the proposed indicators of flexibility summarize the dynamic response and can be included as part of a hospital's management dashboard for monitoring its behavior during pandemic waves or other health crises as a complement to other, more steady-state indicators.


Asunto(s)
Pandemias , Capacidad de Camas en Hospitales , Humanos , Unidades de Cuidados Intensivos
17.
Clin Med (Lond) ; 21(2): 101-106, 2021 03.
Artículo en Inglés | MEDLINE | ID: covidwho-1150980

RESUMEN

BACKGROUND: During the coronavirus pandemic, our intensive care units were faced with large numbers of patients with an unfamiliar disease. To support our colleagues and to assist with diagnosis and treatment, we developed a specialist team. METHODS: The acute respiratory disease support team reviewed 44 consecutive patients referred from the intensive care and coordinated therapies for pulmonary hypertension, pulmonary thrombosis, evolving lung fibrosis and large airway intervention. RESULTS: The mortality for this group was significantly lower (34%) than the total group admitted to critical care as a whole (51%) and for those not reviewed by the team (55%; p=0.012). Pulmonary hypertension was present in 84% of the patients and pulmonary thrombosis in 52%. Thirty-two patients received sildenafil therapy and this was associated with improvement in right heart function in survivors. Ten patients with evolving fibrosis and no evidence of sepsis received high-dose steroid therapy with excellent effect. Five patients developed airway complications requiring intervention. Short time on mechanical ventilation was associated with a poorer outcome (p<0.001). INTERPRETATION: A specialised cardiorespiratory team approach contributes significantly to successful management of severely unwell patients with COVID-19 and offers an important platform for continuity of patient care, education and staff well-being.


Asunto(s)
Infecciones por Coronavirus , Cuidados Críticos , Unidades de Cuidados Intensivos , /terapia , Humanos , Pandemias , Respiración Artificial
18.
PLoS One ; 16(3): e0249038, 2021.
Artículo en Inglés | MEDLINE | ID: covidwho-1150554

RESUMEN

BACKGROUND: Observational studies have consistently described poor clinical outcomes and increased ICU mortality in patients with severe coronavirus disease 2019 (COVID-19) who require mechanical ventilation (MV). Our study describes the clinical characteristics and outcomes of patients with severe COVID-19 admitted to ICU in the largest health care system in the state of Florida, United States. METHODS: Retrospective cohort study of patients admitted to ICU due to severe COVID-19 in AdventHealth health system in Orlando, Florida from March 11th until May 18th, 2020. Patients were characterized based on demographics, baseline comorbidities, severity of illness, medical management including experimental therapies, laboratory markers and ventilator parameters. Major clinical outcomes analyzed at the end of the study period were: hospital and ICU length of stay, MV-related mortality and overall hospital mortality of ICU patients. RESULTS: Out of total of 1283 patients with COVID-19, 131 (10.2%) met criteria for ICU admission (median age: 61 years [interquartile range (IQR), 49.5-71.5]; 35.1% female). Common comorbidities were hypertension (84; 64.1%), and diabetes (54; 41.2%). Of the 131 ICU patients, 109 (83.2%) required MV and 9 (6.9%) received ECMO. Lower positive end expiratory pressure (PEEP) were observed in survivors [9.2 (7.7-10.4)] vs non-survivors [10 (9.1-12.9] p = 0.004]. Compared to non-survivors, survivors had a longer MV length of stay (LOS) [14 (IQR 8-22) vs 8.5 (IQR 5-10.8) p< 0.001], Hospital LOS [21 (IQR 13-31) vs 10 (7-1) p< 0.001] and ICU LOS [14 (IQR 7-24) vs 9.5 (IQR 6-11), p < 0.001]. The overall hospital mortality and MV-related mortality were 19.8% and 23.8% respectively. After exclusion of hospitalized patients, the hospital and MV-related mortality rates were 21.6% and 26.5% respectively. CONCLUSIONS: Our study demonstrates an important improvement in mortality of patients with severe COVID-19 who required ICU admission and MV in comparison to previous observational reports and emphasizes the importance of standard of care measures in the management of COVID-19.


Asunto(s)
/patología , Prestación de Atención de Salud , Adolescente , Adulto , Anciano , /virología , Comorbilidad , Oxigenación por Membrana Extracorpórea , Femenino , Florida , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Respiración Artificial , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Adulto Joven
19.
JCI Insight ; 6(4)2021 02 22.
Artículo en Inglés | MEDLINE | ID: covidwho-1150281

RESUMEN

BackgroundMitochondrial DNA (MT-DNA) are intrinsically inflammatory nucleic acids released by damaged solid organs. Whether circulating cell-free MT-DNA quantitation could be used to predict the risk of poor COVID-19 outcomes remains undetermined.MethodsWe measured circulating MT-DNA levels in prospectively collected, cell-free plasma samples from 97 subjects with COVID-19 at hospital presentation. Our primary outcome was mortality. Intensive care unit (ICU) admission, intubation, vasopressor, and renal replacement therapy requirements were secondary outcomes. Multivariate regression analysis determined whether MT-DNA levels were independent of other reported COVID-19 risk factors. Receiver operating characteristic and area under the curve assessments were used to compare MT-DNA levels with established and emerging inflammatory markers of COVID-19.ResultsCirculating MT-DNA levels were highly elevated in patients who eventually died or required ICU admission, intubation, vasopressor use, or renal replacement therapy. Multivariate regression revealed that high circulating MT-DNA was an independent risk factor for these outcomes after adjusting for age, sex, and comorbidities. We also found that circulating MT-DNA levels had a similar or superior area under the curve when compared against clinically established measures of inflammation and emerging markers currently of interest as investigational targets for COVID-19 therapy.ConclusionThese results show that high circulating MT-DNA levels are a potential early indicator for poor COVID-19 outcomes.FundingWashington University Institute of Clinical Translational Sciences COVID-19 Research Program and Washington University Institute of Clinical Translational Sciences (ICTS) NIH grant UL1TR002345.


Asunto(s)
/diagnóstico , Ácidos Nucleicos Libres de Células/sangre , ADN Mitocondrial/sangre , Índice de Severidad de la Enfermedad , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , /terapia , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Curva ROC , Terapia de Reemplazo Renal/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Factores de Riesgo , Vasoconstrictores/uso terapéutico
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