Plasma biomarkers associated with survival and thrombosis in hospitalized COVID-19 patients.

Severe coronavirus disease-19 (COVID-19) has been associated with fibrin-mediated hypercoagulability and thromboembolic complications. To evaluate potential biomarkers of coagulopathy and disease severity in COVID-19, we measured plasma levels of eight biomarkers potentially associated with coagulation, fibrinolysis, and platelet function in 43 controls and 63 COVID-19 patients, including 47 patients admitted to the intensive care unit (ICU) and 16 non-ICU patients. COVID-19 patients showed significantly elevated levels of fibrinogen, tissue plasminogen activator (t-PA), and its inhibitor plasminogen activation inhibitor 1 (PAI-1), as well as ST2 (the receptor for interleukin-33) and von Willebrand factor (vWF) compared to the control group. We found that higher levels of t-PA, ST2, and vWF at the time of admission were associated with lower survival rates, and that thrombotic events were more frequent in patients with initial higher levels of vWF. These results support a predictive role of specific biomarkers such as t-PA and vWF in the pathophysiology of COVID-19. The data provide support for the case that hypercoagulability in COVID-19 is fibrin-mediated, but also highlights the important role that vWF may play in the genesis of thromboses in the pathophysiology of COVID-19. Interventions designed to enhance fibrinolysis might prove to be useful adjuncts in the treatment of coagulopathy in a subset of COVID-19 patients.

Effectiveness of Nonoperative Management of Hip Microinstability

BACKGROUND: Hip microinstability has recently gained acceptance as a cause of hip pain. In this condition, the femoral head demonstrates increased motion relative to the acetabulum, which may lead to chondrolabral damage. Even though patients are initially prescribed a trial of nonoperative treatment, the success rates of rehabilitation are unknown. PURPOSE: To determine the success rate of nonoperative treatment of hip microinstability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: After institutional review board approval was obtained, a retrospective chart review was performed on patients at a university sports medicine practice between January 2013 and July 2016. All patients older than 18 years presenting with hip microinstability who were initially recommended for treatment with physical therapy were enrolled in this study. Formal physical therapy sessions focused on strengthening the hip and core muscles. These sessions took place twice a week for a minimum of 6 weeks in conjunction with a home exercise program. The number of patients who eventually underwent surgical treatment and the clinical scores for the cohort (modified Harris Hip Score [mHHS] and 33-item International Hip Outcome Tool) were recorded. RESULTS: A total of 64 patients (63 female, 1 male), with a mean ± SD age of 32.2 ± 10.5 years, were identified and studied. Onset of symptoms was insidious (n = 45; 70.3%), acute atraumatic (n = 12; 18.8%), and traumatic (n = 7; 10.9%). A total of 9 (14.1%) patients were high-level athletes. After a follow-up of 45.7 ± 14.6 months, 14 (29.8%) patients eventually underwent hip arthroscopy for persistent hip pain. Capsular plication was performed in all surgical cases. High-level athletes were not more likely to need surgery (50% vs 26.8%; P = .34). The mHHS was available in 24 patients who were treated nonoperatively, and it improved from 67.4 to 85.0 (P < .01). CONCLUSION: More than two-thirds of patients treated for hip microinstability were able to avoid surgery; they were successfully treated nonoperatively with physical therapy and a home exercise program and demonstrated improved clinical outcome scores.

Predicting Poor Outcome of COVID-19 Patients on the Day of Admission with the COVID-19 Score.

BACKGROUND: COVID-19 may result in multiorgan failure and death. Early detection of patients at risk may allow triage and more intense monitoring. The aim of this study was to develop a simple, objective admission score, based on laboratory tests, that identifies patients who are likely going to deteriorate. METHODS: This is a retrospective cohort study of all COVID-19 patients admitted to a tertiary academic medical center in New York City during the COVID-19 crisis in spring 2020. The primary combined endpoint included intubation, stage 3 acute kidney injury (AKI), or death. Laboratory tests available on admission in at least 70% of patients (and age) were included for univariate analysis. Tests that were statistically or clinically significant were then included in a multivariate binary logistic regression model using stepwise exclusion. 70% of all patients were used to train the model, and 30% were used as an internal validation cohort. The aim of this study was to develop and validate a model for COVID-19 severity based on biomarkers. RESULTS: Out of 2545 patients, 833 (32.7%) experienced the primary endpoint. 53 laboratory tests were analyzed, and of these, 47 tests (and age) were significantly different between patients with and without the endpoint. The final multivariate model included age, albumin, creatinine, C-reactive protein, and lactate dehydrogenase. The area under the ROC curve was 0.850 (CI [95%]: 0.813, 0.889), with a sensitivity of 0.800 and specificity of 0.761. The probability of experiencing the primary endpoint can be calculated as p=e (-2.4475+0.02492age - 0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH)/1+e (-2.4475+ 0.02492age - 0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH). CONCLUSIONS: Our study demonstrated that poor outcome in COVID-19 patients can be predicted with good sensitivity and specificity using a few laboratory tests. This is useful for identifying patients at risk during admission.

Mortality and renal outcomes of patients with severe COVID-19 treated in a provisional intensive care unit.

COVID-19 has created an enormous health crisis and this spring New York City had a severe outbreak that pushed health and critical care resources to the limit. A lack of adequate space for mechanically ventilated patients induced our hospital to convert operating rooms into critical care areas (OR-ICU). A large number of COVID-19 will develop acute kidney injury that requires renal replacement therapy (RRT). We included 116 patients with COVID-19 who required mechanical ventilation and were cared for in our OR-ICU. At 90 days and at discharge 35 patients died (30.2%). RRT was required by 45 of the 116 patients (38.8%) and 18 of these 45 patients (40%) compared to 17 with no RRT (23.9%, ns) died during hospitalization and after 90 days. Only two of the 27 patients who required RRT and survived required RRT at discharge and 90 days. When defining renal recovery as a discharge serum creatinine within 150% of baseline, 68 of 78 survivors showed renal recovery (87.2%). Survival was similar to previous reports of patients with severe COVID-19 for patients cared for in provisional ICUs compared to standard ICUs. Most patients with severe COVID-19 and AKI are likely to recover full renal function.