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.
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.
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.
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.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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.
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.
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).
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.
Abstract
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.
We contribute to debate about causal inferences in educational research in two ways. First, we quantify how much bias there must be in an estimate to invalidate an inference. Second, we utilize ...Rubins causal model to interpret the bias necessary to invalidate an inference in terms of sample replacement. We apply our analysis to an inference of a positive effect of Open Court Curriculum on reading achievement from a randomized experiment, and an inference of a negative effect of kindergarten retention on reading achievement from an observational study. We consider details of our framework, and then discuss how our approach informs judgment of inference relative to study design. We conclude with implications for scientific discourse.
This study sought to identify the most important clinical variables that can be used to determine which COVID-19 patients hospitalized in the general floor will need escalated care early on using ...neural networks (NNs). Analysis was performed on hospitalized COVID-19 patients between 7 February 2020 and 4 May 2020 in Stony Brook Hospital. Demographics, comorbidities, laboratory tests, vital signs and blood gases were collected. We compared those data obtained at the time in emergency department and the time of intensive care unit (ICU) upgrade of: (i) COVID-19 patients admitted to the general floor (
= 1203) vs. those directly admitted to ICU (
= 104), and (ii) patients not upgraded to ICU (
= 979) vs. those upgraded to the ICU (
= 224) from the general floor. A NN algorithm was used to predict ICU admission, with 80% training and 20% testing. Prediction performance used area under the curve (AUC) of the receiver operating characteristic analysis (ROC). We found that C-reactive protein, lactate dehydrogenase, creatinine, white-blood cell count, D-dimer and lymphocyte count showed temporal divergence between COVID-19 patients hospitalized in the general floor that were upgraded to ICU compared to those that were not. The NN predictive model essentially ranked the same laboratory variables to be important predictors of needing ICU care. The AUC for predicting ICU admission was 0.782 ± 0.013 for the test dataset. Adding vital sign and blood-gas data improved AUC (0.822 ± 0.018). This work could help frontline physicians to anticipate downstream ICU need to more effectively allocate healthcare resources.
Introduction
Neurocognitive symptoms and dysfunction of various severities have become increasingly recognized as potential consequences of SARS-CoV-2 infection. Although there are numerous ...observational and subjective survey-reporting studies of neurological symptoms, by contrast, those studies describing imaging abnormalities are fewer in number.
Methods
This study conducted a metanalysis of 32 studies to determine the incidence of the common neurological abnormalities using magnetic resonance imaging (MRI) in patients with COVID-19.
Results
We also present the common clinical findings associated with MRI abnormalities. We report the incidence of any MRI abnormality to be 55% in COVID-19 patients with perfusion abnormalities (53%) and SWI abnormalities (44%) being the most commonly reported injuries. Cognitive impairment, ICU admission and/or mechanical ventilation status, older age, and hospitalization or longer length of hospital stay were the most common clinical findings associated with brain injury in COVID-19 patients.
Discussion
Overall, the presentation of brain injury in this study was diverse with no substantial pattern of injury emerging, yet most injuries appear to be of vascular origin. Moreover, analysis of the association between MRI abnormalities and clinical findings suggests that there are likely many mechanisms, both direct and indirect, by which brain injury occurs in COVID-19 patients.
Many COVID-19 survivors experience persistent COVID-19 related cardiac abnormalities weeks to months after recovery from acute SARS-CoV-2 infection. Non-invasive cardiac magnetic resonance (CMR) ...imaging is an important tool of choice for clinical diagnosis of cardiac dysfunctions. In this systematic review, we analyzed the CMR findings and biomarkers of COVID-19 related cardiac sequela after SARS-CoV-2 infection.BackgroundMany COVID-19 survivors experience persistent COVID-19 related cardiac abnormalities weeks to months after recovery from acute SARS-CoV-2 infection. Non-invasive cardiac magnetic resonance (CMR) imaging is an important tool of choice for clinical diagnosis of cardiac dysfunctions. In this systematic review, we analyzed the CMR findings and biomarkers of COVID-19 related cardiac sequela after SARS-CoV-2 infection.Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), we conducted a systematic review of studies that assessed COVID-19 related cardiac abnormalities using cardiovascular magnetic resonance imaging. A total of 21 cross-sectional, case-control, and cohort studies were included in the analyses.MethodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), we conducted a systematic review of studies that assessed COVID-19 related cardiac abnormalities using cardiovascular magnetic resonance imaging. A total of 21 cross-sectional, case-control, and cohort studies were included in the analyses.Ten studies reported CMR results < 3 months after SARS-CoV-2 infection and 11 studies > 3 months after SARS-CoV-2 infection. Abnormal T1, abnormal T2, elevated extracellular volume, late gadolinium enhancement and myocarditis was reported less frequently in the > 3-month studies. Eight studies reported an association between biomarkers and CMR findings. Elevated troponin was associated with CMR pathology in 5/6 studies, C-reactive protein in 3/5 studies, N-terminal pro-brain natriuretic peptide in 1/2 studies, and lactate dehydrogenase and D-dimer in a single study. The rate of myocarditis via CMR was 18% (154/868) across all studies. Most SARS-CoV-2 associated CMR abnormalities resolved over time.ResultsTen studies reported CMR results < 3 months after SARS-CoV-2 infection and 11 studies > 3 months after SARS-CoV-2 infection. Abnormal T1, abnormal T2, elevated extracellular volume, late gadolinium enhancement and myocarditis was reported less frequently in the > 3-month studies. Eight studies reported an association between biomarkers and CMR findings. Elevated troponin was associated with CMR pathology in 5/6 studies, C-reactive protein in 3/5 studies, N-terminal pro-brain natriuretic peptide in 1/2 studies, and lactate dehydrogenase and D-dimer in a single study. The rate of myocarditis via CMR was 18% (154/868) across all studies. Most SARS-CoV-2 associated CMR abnormalities resolved over time.There were CMR abnormalities associated with SARS-CoV-2 infection and most abnormalities resolved over time. A panel of cardiac injury and inflammatory biomarkers could be useful in identifying patients who are likely to present with abnormal CMR pathology after COVID-19. Multiple mechanisms are likely responsible for COVID-19 induced cardiac abnormalities.ConclusionsThere were CMR abnormalities associated with SARS-CoV-2 infection and most abnormalities resolved over time. A panel of cardiac injury and inflammatory biomarkers could be useful in identifying patients who are likely to present with abnormal CMR pathology after COVID-19. Multiple mechanisms are likely responsible for COVID-19 induced cardiac abnormalities.
Medical specialty usage of COVID-19 survivors after hospital discharge is poorly understood. This study investigated medical specialty usage at 1–12 and 13–24 months post-hospital discharge in ...critically ill and non-critically ill COVID-19 survivors. This retrospective study followed ICU (
N
= 89) and non-ICU (
N
= 205) COVID-19 survivors who returned for follow-up within the Stony Brook Health System post-hospital discharge. Follow-up data including survival, hospital readmission, ongoing symptoms, medical specialty care use, and ICU status were examined 1–12 and 13–24 months after COVID-19 discharge. “New” (not previously seen) medical specialty usage was also identified. Essentially all (98%) patients survived. Hospital readmission was 34%, but functional status scores at discharge were not associated with hospital readmission. Many patients reported ongoing neuromuscular (50%) respiratory (39%), chronic fatigue (35%), cardiovascular (30%), gastrointestinal (28%), neurocognitive (22%), genitourinary (22%), and mood-related (13%) symptoms at least once 1–24 months after discharge. Common specialty follow-ups included cardiology (25%), vascular medicine (17%), urology (17%), neurology (16%), and pulmonology (14%), with some associated with pre-existing comorbidities and with COVID-19. Common new specialty visits were vascular medicine (11%), pulmonology (11%), and neurology (9%). ICU patients had more symptoms and follow-ups compared to the non-ICU patients. This study reported high incidence of persistent symptoms and medical specialty care needs in hospitalized COVID-19 survivors 1–24 months post-discharge. Some specialty care needs were COVID-19 related or exacerbated by COVID-19 disease while others were associated with pre-existing medical conditions. Longer follow-up studies of COVID-19 survivor medical care needs are necessary.
To investigate the evolution of COVID-19 patient characteristics and multiorgan injury across the pandemic.
This retrospective cohort study consisted of 40,387 individuals tested positive for ...SARS-CoV-2 in the Montefiore Health System in Bronx, NY, between March 2020 and February 2022, of which 11,306 were hospitalized. Creatinine, troponin, and alanine aminotransferase were used to define acute kidney injury (AKI), acute cardiac injury (ACI) and acute liver injury, respectively. Demographics, comorbidities, emergency department visits, hospitalization, intensive care utilization, and mortality were analyzed across the pandemic.
COVID-19 positive cases, emergency department visits, hospitalization and mortality rate showed four distinct waves with a large first wave in April 2020, two small (Alpha and Delta) waves, and a large Omicron wave in December 2021. Omicron was more infectious but less lethal (p = 0.05). Among hospitalized COVID-19 patients, age decreased (p = 0.014), female percentage increased (p = 0.023), Hispanic (p = 0.028) and non-Hispanic Black (p = 0.05) percentages decreased, and patients with pre-existing diabetes (p = 0.002) and hypertension (p = 0.04) decreased across the pandemic. More than half (53.1%) of hospitalized patients had major organ injury. Patients with AKI, ACI and its combinations were older, more likely males, had more comorbidities, and consisted more of non-Hispanic Black and Hispanic patients (p = 0.005). Patients with AKI and its combinations had 4-9 times higher adjusted risk of mortality than those without.
There were shifts in demographics toward younger age and proportionally more females with COVID-19 across the pandemic. While the overall trend showed improved clinical outcomes, a substantial number of COVID-19 patients developed multi-organ injuries over time. These findings could bring awareness to at-risk patients for long-term organ injuries and help to better inform public policy and outreach initiatives.
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