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Background: The clinical heterogeneity of COVID-19 suggests the existence of different phenotypes with prognostic implications. We aimed to analyze comorbidity patterns in critically ill COVID-19 patients and assess their impact on in-hospital outcomes, response to treatment and sequelae. Methods: Multicenter prospective/retrospective observational study in intensive care units of 55 Spanish hospitals. 5866 PCR-confirmed COVID-19 patients had comorbidities recorded at hospital admission; clinical and biological parameters, in-hospital procedures and complications throughout the stay; and, clinical complications, persistent symptoms and sequelae at 3 and 6 months. Findings: Latent class analysis identified 3 phenotypes using training and test subcohorts: low-morbidity (n=3385; 58%), younger and with few comorbidities; high-morbidity (n=2074; 35%), with high comorbid burden; and renal-morbidity (n=407; 7%), with chronic kidney disease (CKD), high comorbidity burden and the worst oxygenation profile. Renal-morbidity and high-morbidity had more in-hospital complications and higher mortality risk than low-morbidity (adjusted HR (95% CI): 1.57 (1.34-1.84) and 1.16 (1.05-1.28), respectively). Corticosteroids, but not tocilizumab, were associated with lower mortality risk (HR (95% CI) 0.76 (0.63-0.93)), especially in renal-morbidity and high-morbidity. Renal-morbidity and high-morbidity showed the worst lung function throughout the follow-up, with renal-morbidity having the highest risk of infectious complications (6%), emergency visits (29%) or hospital readmissions (14%) at 6 months (p<0.01). Interpretation: Comorbidity-based phenotypes were identified and associated with different expression of in-hospital complications, mortality, treatment response, and sequelae, with CKD playing a major role. This could help clinicians in day-to-day decision making including the management of post-discharge COVID-19 sequelae. Funding: ISCIII, UNESPA, CIBERES, FEDER, ESF.
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ABSTRACT Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.
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BACKGROUND: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. OBJECTIVES: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). METHODS: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. RESULTS: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom weredischarged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176 3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A totalof 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). CONCLUSION: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.
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COVID-19 , Pneumonia , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Pessoa de Meia-Idade , Alta do Paciente , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Clinical trials evaluating the management of acute exacerbations of COPD assess heterogeneous outcomes, often omitting those that are clinically relevant or more important to patients. We have developed a core outcome set, a consensus-based minimum set of important outcomes that we recommend are evaluated in all future clinical trials on exacerbations management, to improve their quality and comparability. COPD exacerbations outcomes were identified through methodological systematic reviews and qualitative interviews with 86 patients from 11 countries globally. The most critical outcomes were prioritised for inclusion in the core outcome set through a two-round Delphi survey completed by 1063 participants (256 patients, 488 health professionals and 319 clinical academics) from 88 countries in five continents. Two global, multi-stakeholder, virtual consensus meetings were conducted to 1) finalise the core outcome set and 2) prioritise a single measurement instrument to be used for evaluating each of the prioritised outcomes. Consensus was informed by rigorous methodological systematic reviews. The views of patients with COPD were accounted for at all stages of the project. Survival, treatment success, breathlessness, quality of life, activities of daily living, the need for a higher level of care, arterial blood gases, disease progression, future exacerbations and hospital admissions, treatment safety and adherence were all included in the core outcome set. Focused methodological research was recommended to further validate and optimise some of the selected measurement instruments. The panel did not consider the prioritised set of outcomes and associated measurement instruments to be burdensome for patients and health professionals to use.
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Doença Pulmonar Obstrutiva Crônica , Qualidade de Vida , Atividades Cotidianas , Técnica Delphi , Humanos , Doença Pulmonar Obstrutiva Crônica/terapia , Projetos de Pesquisa , Resultado do TratamentoRESUMO
La infl uenza A/H1N1 se diagnosticó por primera vez en México y Estados Unidos en abril de 2009. La rapidezde su diseminación mundial ha alertado a las autoridades sanitarias y a la comunidad científi ca internacional.Los síntomas clínicos habituales de esta enfermedad pueden no distinguirse de la infl uenza estacionale incluyen: tos, fi ebre, mal estado general, odinofagia y dolores musculares. Hasta el momento latasa de hospitalización es relativamente baja (menos de un 15%). De la población afectada, hay 2 gruposque presentan una mayor morbimortalidad: embarazadas y mayores de 65 años. El tratamiento es con losinhibidores de la neuraminidasa: oseltamivir, zanamivir y peramivir, que ayudarían a disminuir las complicacionesy el tiempo de duración de los síntomas. El diagnóstico defi nitivo se hace basándose en técnicasde rt-PCR. El resto del tratamiento consiste en las medidas universales de aislamiento, antitérmicos y reposo.La tasa de casos fatales (aunque en Latinoamérica parece ser más alta) se reporta globalmente comomenor del 1%. En este estudio se hace una recopilación de la información disponible acerca de las manifestaciones,criterios de diagnóstico y tratamiento/profi laxis de la enfermedad(AU)
Influenza A (H1N1) was fi rst diagnosed in Mexico and the United States in April 2009. The rapidity of itsworldwide spread has alerted the health authorities and international scientifi c community. The usualclinical symptoms of this disease cannot be distinguished from those of seasonal infl uenza and includecough, fever, poor general status, odynophagia and muscular aches. To date, the hospitalization rate hasbeen relatively low (less than 15%). Among the affected population, there are two groups with highmorbidity and mortality: pregnant women and persons aged more than 65 years. Treatment consists of theneuroaminidase inhibitors oseltamivir, zanamivir and peramivir, which can help to reduce complicationsand symptom duration. Defi nitive diagnosis is based on reverse-transcriptase polymerase chain reactiontechniques. The remaining treatment options consist of universal measures of isolation, antipyretics andrest. Mortality is less than 1% globally but seems to be higher in Latin America. The present study gathersthe available information on the manifestations, diagnostic criteria and treatment/prophylaxis of thedisease(AU)
