Development and validation of a prediction model for estimating one-month mortality of adult COVID-19 patients presenting at emergency department with suspected pneumonia: a multicenter analysis.

There are only a few models developed for risk-stratifying COVID-19 patients with suspected pneumonia in the emergency department (ED). We aimed to develop and validate a model, the COVID-19 ED pneumonia mortality index (CoV-ED-PMI), for predicting mortality in this population. We retrospectively included adult COVID-19 patients who visited EDs of five study hospitals in Texas and who were diagnosed with suspected pneumonia between March and November 2020. The primary outcome was 1-month mortality after the index ED visit. In the derivation cohort, multivariable logistic regression was used to develop the CoV-ED-PMI model. In the chronologically split validation cohort, the discriminative performance of the CoV-ED-PMI was assessed by the area under the receiver operating characteristic curve (AUC) and compared with other existing models. A total of 1678 adult ED records were included for analysis. Of them, 180 patients sustained 1-month mortality. There were 1174 and 504 patients in the derivation and validation cohorts, respectively. Age, body mass index, chronic kidney disease, congestive heart failure, hepatitis, history of transplant, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and national early warning score were included in the CoV-ED-PMI. The model was validated with good discriminative performance (AUC: 0.83, 95% confidence interval [CI]: 0.79-0.87), which was significantly better than the CURB-65 (AUC: 0.74, 95% CI: 0.69-0.79, p-value: < 0.001). The CoV-ED-PMI had a good predictive performance for 1-month mortality in COVID-19 patients with suspected pneumonia presenting at ED. This free tool is accessible online, and could be useful for clinical decision-making in the ED.

Mortality Variations of COVID-19 from Different Hospital Settings During Different Pandemic Phases: A Multicenter Retrospective Study.

INTRODUCTION: Diverse coronavirus disease 2019 (COVID-19) mortalities have been reported but focused on identifying susceptible patients at risk of more severe disease or death. This study aims to investigate the mortality variations of COVID-19 from different hospital settings during different pandemic phases. METHODS: We retrospectively included adult (≥18 years) patients who visited emergency departments (ED) of five hospitals in the state of Texas and who were diagnosed with COVID-19 between March-November 2020. The included hospitals were dichotomized into urban and suburban based on their geographic location. The primary outcome was mortality that occurred either during hospital admission or within 30 days after the index ED visit. We used multivariable logistic regression to investigate the associations between independent variables and outcome. Generalized additive models were employed to explore the mortality variation during different pandemic phases. RESULTS: A total of 1,788 adult patients who tested positive for COVID-19 were included in the study. The median patient age was 54.6 years, and 897 (50%) patients were male. Urban hospitals saw approximately 59.5% of the total patients. A total of 197 patients died after the index ED visit. The analysis indicated visits to the urban hospitals (odds ratio [OR] 2.14, 95% confidence interval [CI], 1.41, 3.23), from March to April (OR 2.04, 95% CI, 1.08, 3.86), and from August to November (OR 2.15, 95% CI, 1.37, 3.38) were positively associated with mortality. CONCLUSION: Visits to the urban hospitals were associated with a higher risk of mortality in patients with COVID-19 when compared to visits to the suburban hospitals. The mortality risk rebounded and showed significant difference between urban and suburban hospitals since August 2020. Optimal allocation of medical resources may be necessary to bridge this gap in the foreseeable future.

Mortality association between obesity and pneumonia using a dual restricted cohort model.

BACKGROUND: An obesity survival paradox has been reported among obese patients with pneumonia. AIMS: To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia. METHODS: The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis. RESULTS: A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07). CONCLUSIONS: With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study.

PURPOSE: To determine the trends of infection sites and outcome of sepsis using a national population-based database. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality. RESULTS: During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%). CONCLUSIONS: The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.

Mortality association between obesity and pneumonia using a dual restricted cohort model.

BACKGROUND: An obesity survival paradox has been reported among obese patients with pneumonia. AIMS: To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia. METHODS: The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis. RESULTS: A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07). CONCLUSIONS: With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Standardized Patients to Teach Medical Students about Intimate Partner Violence.

OBJECTIVE: To use 360-degree evaluations within an Observed Structured Clinical Examination (OSCE) to assess medical student comfort level and communication skills with intimate partner violence (IPV) patients. METHODS: We assessed a cohort of fourth year medical students' performance using an IPV standardized patient (SP) encounter in an OSCE. Blinded pre- and post-tests determined the students' knowledge and comfort level with core IPV assessment. Students, SPs and investigators completed a 360-degree evaluation that focused on each student's communication and competency skills. We computed frequencies, means and correlations. RESULTS: Forty-one students participated in the SP exercise during three separate evaluation periods. Results noted insignificant increase in students' comfort level pre-test (2.7) and post-test (2.9). Although 88% of students screened for IPV and 98% asked about the injury, only 39% asked about verbal abuse, 17% asked if the patient had a safety plan, and 13% communicated to the patient that IPV is illegal. Using Likert scoring on the competency and overall evaluation (1, very poor and 5, very good), the mean score for each evaluator was 4.1 (competency) and 3.7 (overall). The correlations between trainee comfort level and the specific competencies of patient care, communication skill and professionalism were positive and significant (p<0.05). CONCLUSION: Students felt somewhat comfortable caring for patients with IPV. OSCEs with SPs can be used to assess student competencies in caring for patients with IPV.