Abstract
Background
We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients.
Methods
A ...retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit ICU) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts.
Conclusion
In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.
IMPORTANCE: There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). OBJECTIVE: To ...describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. DESIGN, SETTING, AND PARTICIPANTS: Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. EXPOSURES: Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. MAIN OUTCOMES AND MEASURES: Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. RESULTS: A total of 5700 patients were included (median age, 63 years interquartile range {IQR}, 52-75; range, 0-107 years; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years IQR, 56-78; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years IQR, 54-75), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). CONCLUSIONS AND RELEVANCE: This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.
COVID‐19 in kidney transplant recipients Nair, Vinay; Jandovitz, Nicholas; Hirsch, Jamie S. ...
American journal of transplantation,
July 2020, Volume:
20, Issue:
7
Journal Article
Peer reviewed
Open access
There is minimal information on coronavirus disease 2019 (COVID‐19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients ...tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range IQR 47‐67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID‐19 testing was 2822 days (IQR 1272‐4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X‐ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID‐19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.
In this series of 10 kidney transplant recipients with COVID‐19, most patients presented with symptoms similar to those of the nontransplant population, 9 required hospitalization and were treated with reduction of immunosuppression, and there was a 50% incidence of acute kidney injury and a 30% mortality.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced ...nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting.
This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department.
A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons.
Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields.
We propose an algorithmic approach to the interpretation of diffuse lung disease on high-resolution CT. Following an initial review of pertinent lung anatomy, the following steps are included. Step ...1: a preliminary review of available chest radiographs, including the "scanogram" obtained at the time of the CT examination. Step 2: a review of optimal methods of data acquisition and reconstruction, emphasizing the need for contiguous high-resolution images throughout the entire thorax. Step 3: initial uninterrupted scrolling of contiguous high-resolution images throughout the chest to establish the quality of examination as well as an overview of the presence and extent of disease. Step 4: determination of one of three predominant categories - primarily reticular disease, nodular disease, or diseases associated with diffuse alteration in lung density. Based on this determination, one of the three following Steps are followed: Step 5: evaluation of cases primarily involving diffuse lung reticulation; Step 6: evaluation of cases primarily resulting in diffuse lung nodules; and Step 7: evaluation of cases with diffuse alterations in lung density including those with diffusely diminished lung density vs those with heterogenous or diffusely increased lung density, respectively. It is anticipated that this algorithmic approach will substantially enhance initial interpretations of a wide range of pulmonary disease.
Clinical prognostic models can assist patient care decisions. However, their performance can drift over time and location, necessitating model monitoring and updating. Despite rapid and significant ...changes during the pandemic, prognostic models for COVID-19 patients do not currently account for these drifts. We develop a framework for continuously monitoring and updating prognostic models and apply it to predict 28-day survival in COVID-19 patients. We use demographic, laboratory, and clinical data from electronic health records of 34912 hospitalized COVID-19 patients from March 2020 until May 2022 and compare three modeling methods. Model calibration performance drift is immediately detected with minor fluctuations in discrimination. The overall calibration on the prospective validation cohort is significantly improved when comparing the dynamically updated models against their static counterparts. Our findings suggest that, using this framework, models remain accurate and well-calibrated across various waves, variants, race and sex and yield positive net-benefits.
•We developed and tested an NLP algorithm to identify and extract Lung-RADS scores from radiology reports.•We compared the NLP algorithm to prior methods of Lung-RADS score identification, including ...manual entry by radiologists and LCS specialists.•The NLP algorithm identified more Lung-RADS scores, was faster, and was similarly accurate to the manual entry methods.
Radiology scoring systems are critical to the success of lung cancer screening (LCS) programs, impacting patient care, adherence to follow-up, data management and reporting, and program evaluation. LungCT ScreeningReporting and Data System (Lung-RADS) is a structured radiology scoring system that provides recommendations for LCS follow-up that are utilized (a) in clinical care and (b) by LCS programs monitoring rates of adherence to follow-up. Thus, accurate reporting and reliable collection of Lung-RADS scores are fundamental components of LCS program evaluation and improvement. Unfortunately, due to variability in radiology reports, extraction of Lung-RADS scores is non-trivial, and best practices do not exist. The purpose of this project is to compare mechanisms to extract Lung-RADS scores from free-text radiology reports.
We retrospectively analyzed reports of LCS low-dose computed tomography (LDCT) examinations performed at a multihospital integrated healthcare network in New York State between January 2016 and July 2023. We compared three methods of Lung-RADS score extraction: manual physician entry at time of report creation, manual LCS specialist entry after report creation, and an internally developed, rule-based natural language processing (NLP) algorithm. Accuracy, recall, precision, and completeness (i.e., the proportion of LCS exams to which a Lung-RADS score has been assigned) were compared between the three methods.
The dataset includes 24,060 LCS examinations on 14,243 unique patients. The mean patient age was 65 years, and most patients were male (54 %) and white (75 %). Completeness rate was 65 %, 68 %, and 99 % for radiologists’ manual entry, LCS specialists’ entry, and NLP algorithm, respectively. Accuracy, recall, and precision were high across all extraction methods (>94 %), though the NLP-based approach was consistently higher than both manual entries in all metrics.
An NLP-based method of LCS score determination is an efficient and more accurate means of extracting Lung-RADS scores than manual review and data entry. NLP-based methods should be considered best practice for extracting structured Lung-RADS scores from free-text radiology reports.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Organizing pneumonia (OP), characterized histopathologically by patchy filling of alveoli and bronchioles by loose plugs of connective tissue, may be seen in a variety of conditions. These include ...but are not limited to after an infection, drug reactions, radiation therapy, and collagen vascular diseases. When a specific cause is responsible for this entity, it is referred to as "secondary OP." When an extensive search fails to reveal a cause, it is referred to as "cryptogenic OP" (previously called "bronchiolitis obliterans with OP"), which is a clinical, radiologic, and pathologic entity classified as an interstitial lung disease. The clinical presentation of OP often mimics that of other disorders, such as infection and cancer, which can result in a delay in diagnosis and inappropriate management of the underlying disease. The radiographic presentation of OP is polymorphous but often has subpleural consolidations with air bronchograms or solitary or multiple nodules, which can wax and wane. Diagnosis of OP sometimes requires histopathologic confirmation and exclusion of other possible causes. Treatment usually requires a prolonged steroid course, and disease relapse is common. The aim of this article is to summarize the clinical, radiographic, and histologic presentations of this disease and to provide a practical diagnostic algorithmic approach incorporating clinical history and characteristic imaging patterns.
Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not ...been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p < 0.001, 95% CI 2.01, 4.59) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC > 100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical ...measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations.
Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded.
A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%.
Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.
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