Prophylactic versus therapeutic dose anticoagulation effects on survival among critically ill patients with COVID-19.

INTRODUCTION: Although patients with severe COVID-19 are known to be at high risk of developing thrombotic events, the effects of anticoagulation (AC) dose and duration on in-hospital mortality in critically ill patients remain poorly understood and controversial. The goal of this study was to investigate survival of critically ill COVID-19 patients who received prophylactic or therapeutic dose AC and analyze the mortality rate with respect to detailed demographic and clinical characteristics. MATERIALS AND METHODS: We conducted a retrospective, observational study of critically ill COVID-19 patients admitted to the ICU at Stony Brook University Hospital in New York who received either prophylactic (n = 158) or therapeutic dose AC (n = 153). Primary outcome was in-hospital death assessed by survival analysis and covariate-adjusted Cox proportional hazard model. RESULTS: For the first 3 weeks of ICU stay, we observed similar survival curves for prophylactic and therapeutic AC groups. However, after 3 or more weeks of ICU stay, the therapeutic AC group, characterized by high incidence of acute kidney injury (AKI), had markedly higher death incidence rates with 8.6 deaths (95% CI = 6.2-11.9 deaths) per 1,000 person-days and about 5 times higher risk of death (adj. HR = 4.89, 95% CI = 1.71-14.0, p = 0.003) than the prophylactic group (2.4 deaths [95% CI = 0.9-6.3 deaths] per 1,000 person-days). Among therapeutic AC users with prolonged ICU admission, non-survivors were characterized by older males with depressed lymphocyte counts and cardiovascular disease. CONCLUSIONS: Our findings raise the possibility that prolonged use of high dose AC, independent of thrombotic events or clinical background, might be associated with higher risk of in-hospital mortality. Moreover, AKI, age, lymphocyte count, and cardiovascular disease may represent important risk factors that could help identify at-risk patients who require long-term hospitalization with therapeutic dose AC treatment.

The Necessity of CT Hip Scans in the Investigation of Occult Hip Fractures and Their Effect on Patient Management.

The diagnostic challenge of negative plain radiography in the context of a previously ambulatory patient is increasing with the rise in geriatric trauma. These patients are often diagnosed with small undisplaced fractures of the pelvis and femur which may not alter management. This study aims to assess the frequency at which computed tomography (CT) hip scans altered patient management and whether two X-ray projections of the hip affected fracture detection rate. All CT hip scans performed over a three-year period were identified retrospectively. Only CT hips pertaining to the identification of occult fractures were included in the study. A total of 447 (63.6%) CT hips were performed to exclude an occult fracture, which was only detected in 108 (24.1%) of the scans requested. The majority were subcapital (n = 58, 53.7%) or intertrochanteric (n = 39, 36.1%). There was no significant difference between fracture detection rates when comparing one and two views of the pelvis. 82.4% (n = 89) of occult hip fractures were managed operatively. CT imaging led to a change in patient management in 20% of cases. The frequency at which CT scan detects and alters management in occult hip fractures confirms the justification for its use. Increasing the number of X-ray projection views does not decrease the reliance on CT. Pelvic ring fractures are common in nonambulatory patients following trauma, and if confirmed on initial imaging, subsequent imaging to exclude a concurrent occult hip is unnecessary. The focus of further research should be towards the development of investigation algorithms which decrease the reliance on CT and defining the optimal surgical criteria for occult hip fractures.

Characterizing non-critically ill COVID-19 survivors with and without in-hospital rehabilitation.

This study investigated pre-COVID-19 admission dependency, discharge assistive equipment, discharge medical follow-up recommendation, and functional status at hospital discharge of non-critically ill COVID-19 survivors, stratified by those with (N = 155) and without (N = 162) in-hospital rehabilitation. "Mental Status", intensive-care-unit (ICU) Mobility, and modified Barthel Index scores were assessed at hospital discharge. Relative to the non-rehabilitation patients, rehabilitation patients were older, had more comorbidities, worse pre-admission dependency, were discharged with more assistive equipment and supplemental oxygen, spent more days in the hospital, and had more hospital-acquired acute kidney injury, acute respiratory failure, and more follow-up referrals (p < 0.05 for all). Cardiology, vascular medicine, urology, and endocrinology were amongst the top referrals. Functional scores of many non-critically ill COVID-19 survivors were abnormal at discharge (p < 0.05) and were associated with pre-admission dependency (p < 0.05). Some functional scores were negatively correlated with age, hypertension, coronary artery disease, chronic kidney disease, psychiatric disease, anemia, and neurological disorders (p < 0.05). In-hospital rehabilitation providing restorative therapies and assisting discharge planning were challenging in COVID-19 circumstances. Knowledge of the functional status, discharge assistive equipment, and follow-up medical recommendations at discharge could enable appropriate and timely post-discharge care. Follow-up studies of COVID-19 survivors are warranted as many will likely have significant post-acute COVID-19 sequela.

Functional status of mechanically ventilated COVID-19 survivors at ICU and hospital discharge.

BACKGROUND: A significant number of COVID-19 patients have been treated using invasive mechanical ventilation (IMV). The ability to evaluate functional status of COVID-19 survivors early on at ICU and hospital discharge may enable identification of patients who may need medical and rehabilitation interventions. METHODS: The modified "Mental Status", ICU Mobility, and Barthel Index scores at ICU and hospital discharge were tabulated for 118 COVID-19 survivors treated with invasive mechanical ventilation (IMV). These functional scores were compared with pre-admission functional status, discharge durable medical equipment, discharge medical follow-up recommendation, duration on IMV, duration post-IMV, demographics, comorbidities, laboratory tests, and vital signs at ICU and hospital discharge. RESULTS: The majority of COVID-19 IMV patients were not functionally independent at hospital discharge (22% discharged with cane or rolling walker, 49% discharged with durable medical equipment, and 14% admitted to a rehabilitation facility), although 94% of these patients were functionally independent prior to COVID-19 illness. Half of the patients were discharged with supplemental oxygen equipment. The most prevalent medical follow-up recommendations were cardiology, vascular medicine, pulmonology, endocrinology, and neurology with many patients receiving multiple medical follow-up recommendations. Functional status improved from ICU discharge to hospital discharge (p < 0.001). Worse functional status at hospital discharge was associated with longer IMV duration, older age, male sex, higher number of comorbidities, and the presence of pre-existing comorbidities including hypertension, diabetes, chronic obstructive pulmonary disease, and immunosuppression (p < 0.05, ANOVA). CONCLUSIONS: The majority of IMV COVID-19 survivors were not functionally independent at discharge and required significant follow-up medical care. The COVID-19 circumstance has placed constraints on access to in-hospital rehabilitation. These findings underscore the need for prospective studies to ascertain the short- and long-term sequela in COVID-19 survivors.

Acoustic characteristics, early experience, and endocrine status interact to modulate female zebra finches' behavioral responses to songs.

Female songbirds use male songs as an important criterion for mate selection. Properties of male songs are thought to indicate the male's quality as a potential mate. Song preferences in female zebra finches are known to be influenced by two factors--early auditory experience and the acoustic characteristics of males' songs. Studies often investigate song preferences by priming females with estrogen. However, estrogenic influences on song preferences have not been studied. We investigated the relative influence of early auditory experience, acoustic features of songs, and estrogen availability on song responsiveness in female zebra finches. Juvenile female zebra finches were tutored for 10 days with 40 songs per day with one of three acoustically different song types--simple songs, long-bout songs or complex songs. A fourth group of females was untutored. Aside from this brief song exposure, females were raised and maintained without exposure to male songs. During adulthood, females' behavioral responses to the three song types were tested under three hormone conditions--untreated, estradiol-treated and 1,4,6-androstatriene-3,17-dione (ATD)-treated (to lower endogenous estrogen). Based on the results of our study, four conclusions can be drawn. First, song responsiveness in female zebra finches is strongly affected by minimal early acoustic experience. Second, inexperienced female zebra finches are inherently biased to respond more to complex songs over other song types Third, although female zebra finches are inherently biased to respond more to complex songs, early acoustic experience may either reinforce or weaken this inherent responsiveness to complex songs. Fourth, estrogen selectively accentuates song responsiveness in acoustically-experienced female zebra finches.