A shorter symptom-onset to remdesivir treatment (SORT) interval is associated with a lower mortality in moderate-to-severe COVID-19: A real-world analysis

AbstractBackgroundRemdesivir is the current recommended anti-viral treatment in moderate-to-severe COVID-19. However, data on several aspects of its use such as impact of timing of therapy, efficacy, and safety in this severity category are limited. The current study aimed to evaluate the impact of timing of remdesivir initiation (symptom-onset to remdesivir treatment [SORT] interval) on in-hospital all-cause mortality in patients with moderate-to-severe COVID-19.MethodsThis retrospective study was conducted between June 25, 2020 and October 3, 2020, at a tertiary care dedicated COVID center in India. Consecutive patients with moderate-to-severe COVID-19 (moderate: SpO2 <94%; severe: SpO2 <90%) were included. Data were collected from the health records of the hospital. Remdesivir was administered along with other standard medications as per protocol. The main outcome was the impact of SORT interval on in-hospital all-cause mortality. Subgroups were formed based on SORT interval. Other measures analyzed included overall in-hospital mortality, length of hospital stay, and safety.ResultsOf 350 patients treated with remdesivir, 346 were included for the final analysis (males: 270 [78.0%]; median [range] age: 60 [24-94] years). Overall, 243 (70.2%) patients had ≥1 comorbidity; 109 (31.5%) patients had moderate disease, 237 (68.5%) had severe disease, and 50 (14.5%) patients required mechanical ventilation. Of the 346 patients, 76 (22.0%) patients died (moderate: 3 [2.8%], severe: 73 [30.8%]). In the subset of mechanically ventilated patients, 43 (86.0%) died. All-cause mortality was significantly lower in patients with SORT interval ≤9 days (n = 260) compared with those with SORT interval >9 days (n = 86; 18.1% vs 33.7%; P = .004). The odds of death were significantly lower in patients with SORT interval ≤9 days vs >9 days (odds ratio = 0.44; 95% CI, 0.25-0.76; P = .004). Adverse events (transaminitis ≥5 times upper limit of normal or estimated glomerular filtration rate <30ml/min) leading to drug discontinuation were seen in 4 (1.1%) patients.ConclusionIn this large series of moderate-to-severe COVID-19, initiation of remdesivir ≤9 days from symptom-onset was associated with a significant mortality benefit. These findings indicate a treatment window and reinforce the need for earlier remdesivir initiation in moderate-to-severe COVID-19 infection.

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Dermatology life quality index in psoriasis patients attending a tertiary care hospital: a study from North India

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20203677 ◽

2020 ◽

Vol 8 (9) ◽

pp. 3277

Author(s):

Faizan Younus Shah ◽

Ifrah Shafat Kitab ◽

Aaqib Aslam Shah ◽

Faisal Younis Shah ◽

Mohd Younus Shah ◽

...

Keyword(s):

Quality Of Life ◽

Severe Disease ◽

Life Quality ◽

Health Related Quality ◽

Disease Group ◽

Moderate Disease ◽

Related Quality ◽

Health Related ◽

The Impact

Background: Psoriasis affects nearly 1% of the world population. It can be a source of significant morbidity and psychological stress to the patient but is not lethal under ordinary circumstances. Patients suffering from the disease feel a lack of empathy on part of care-givers, family members, healthcare professionals as well as society in general. Dermatology life quality index (DLQI) is a questionnaire-based assessment of health related quality of life in patients suffering from skin disorders and has been seen to correlate well with the impact of the disease on a patient. This study was done to understand the impact of psoriasis on the overall well-being of patients using DLQI as the tool of assessment.Methods: The study included 40 cases of psoriasis that were assessed for the severity of the disease based on percentage body surface area involvement. The impact of disease severity and other factors on the quality of life of the patient was assessed using DLQI.Results: Out of 35 patients with BSA involvement <50% (mild and moderate disease), 28.6% (n=10/35) showed a very large or extremely large effect on the quality of life while no patient with a BSA involvement >50% (severe and very severe disease) reported the same. A small, moderate or no effect on the DLQI was seen in 71.4% (n=25/35) of cases from the mild and moderate disease group while 100% (n=5/5) of cases from severe and very severe disease group reported a similar effect. Thus, DLQI was not directly related to the extent of BSA involvement and was dependent on other factors as well.Conclusion: Age had a correlation with the effect of the disease on the quality of life of psoriasis cases. Patients who were younger were more likely to report stress and anxiety related to the recurrences seen with the disease. Patients with lesions on sites that are socially exposed like face, hands, scalp, etc. were more likely to feel embarrassed about their condition. Younger age, female gender, lesions on exposed sites and recently diagnosed patients (<12 months) were factors which had a significant impact on the health-related quality of life of patients. The severity of disease and extent of involvement were not always directly related to extent of impact on the quality of life.

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Beta-blockers Associated with a Mortality Benefit in Patients with Systolic Dysfunction and Elevated Serum Bilirubin

The Open Cardiovascular Medicine Journal ◽

10.2174/1874192401408010076 ◽

2014 ◽

Vol 8 (1) ◽

pp. 76-82

Author(s):

Christopher Labos ◽

Vivian Nguyen ◽

Nadia Giannetti ◽

Thao Huynh

Keyword(s):

Heart Failure ◽

Beta Blocker ◽

Beta Blockers ◽

Systolic Dysfunction ◽

Tertiary Care ◽

Elevated Serum ◽

Secondary Endpoint ◽

Cardiac Transplant ◽

All Cause Mortality ◽

The Impact

Background:Hyperbilirubinemia is associated with increased mortality in heart failure (HF) patients. We evaluated the impact of evidence-based medical therapy, in particular beta-blocker on the survival of patients with HF and hyperbilirubinemia.Methods and Results:We reviewed the charts of all patients followed at our tertiary care heart failure clinic. Hyperbilirubinemia was defined as total bilirubin >30 µmol/L (1.5 times the upper limit of our laboratory value). The primary endpoint was all-cause mortality. The secondary endpoint was a composite of death, cardiac transplant or ventricular assistance device implantation (VAD). Of 1035 HF patients, 121 patients (11.7%) had hyperbilirubinemia. Median follow-up was 556 days. Hyperbilirubinemia was associated with an eight-fold increase in all-cause mortality, hazard ratio (HR): 8.78[95% Confidence Intervals (CI): 5.89-13.06]. Beta-blocker use was associated with approximately 60% reduction in all-cause mortality (HR: 0.38, 95% CI:0.15-0.94) and 70% reduction in the composite secondary endpoint (HR:0.31, 95% CI:0.13-0.71) in patients with hyperbilirubinemia.Conclusion:HF patients with hyperbilirubinemia have increased early mortality, need for cardiac transplantation or VAD. Beta-blocker use was associated with early survival benefit in these patients. Bilirubin levels should be monitored in patients with HF and early initiation of beta-blockers in patients with hyperbilirubinemia should be considered.

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Tocilizumab shortens time on mechanical ventilation and length of hospital stay in patients with severe COVID-19: a retrospective cohort study.

10.1101/2020.07.29.20164160 ◽

2020 ◽

Author(s):

Johannes Eimer ◽

Jan Vesterbacka ◽

Anna-Karin Svensson ◽

Bertil Stojanovic ◽

Charlotta Wagrell ◽

...

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Propensity Score ◽

Ventilatory Support ◽

Length Of Hospital Stay ◽

Matched Cohort ◽

All Cause Mortality ◽

Secondary Endpoints ◽

The Impact

Background: Hyperinflammation is a key feature of the pathogenesis of COVID-19 with a central role of the interleukin-6 pathway. We aimed to study the impact of the IL-6 receptor antagonist tocilizumab on the outcome of patients admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) related to COVID-19. Methods: Eighty-seven patients with confirmed SARS-CoV-2 infection and moderate to severe ARDS were included (n tocilizumab = 29, n controls = 58). A matched cohort was created using a propensity score. The primary endpoint was 30-day all-cause mortality, secondary endpoints included ventilation-free days and length of stay. Results: No difference was found in 30-day all-cause mortality in patients treated with tocilizumab compared to controls (17.2% vs. 32.8%, p = 0.2; HR = 0.52 [0.19 - 1.39], p = 0.19). Ventilator-free days were 19.0 (IQR 12.5 - 20.0) versus 9 (IQR 0.0 - 18.5; p = 0.04), respectively. A higher rate of freedom from mechanical ventilation at 30 days was achieved in patients receiving tocilizumab (HR 2.83 [1.48 - 5.40], p < 0.002). Median length of stay in ICU and total length of stay were reduced by 8 and 9.5 days in patients treated with tocilizumab. Similar results were obtained in the analysis of the propensity score matched cohort. Conclusions: Treatment of critically ill patients with ARDS due to COVID-19 with tocilizumab was not associated with reduced 30-day all-cause mortality, but shorter duration on ventilatory support as well as shorter overall length of stay in hospital and in ICU.

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81. Children and COVID-19 in Colorado: The Children’s Hospital Colorado Experience

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.391 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S172-S173

Author(s):

Kelly E Graff ◽

Lori Silveira ◽

Jane Jarjour ◽

Shane Curran-Hays ◽

Lauren Carpenter ◽

...

Keyword(s):

Hospital Admission ◽

Wide Spectrum ◽

Severe Disease ◽

Tertiary Care ◽

Pediatric Intensive Care ◽

Respiratory Support ◽

Logistic Regression Models ◽

Children's Hospital ◽

Children’S Hospital ◽

The Impact

Abstract Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes coronavirus disease of 2019 (COVID-19) and has been reported in > 98,000 children in the U.S (5% of reported cases) as of early June 2020. Most published literature focuses on adults with COVID-19, but little is understood on the impact of SARS-CoV-2 in children. We created a database for children with COVID-19 at Children’s Hospital Colorado (CHCO), a large tertiary care pediatric hospital, to better understand the epidemiology and clinical outcomes of this disease in children. Methods We retrospectively reviewed the medical records of all pediatric and youth patients with positive SARS-CoV-2 PCR test results from March-May 2020. Univariate logistic regression models were used to identify predictors of hospital admission, need for critical care, and need for respiratory support among symptomatic patients, with p-values < 0.05 considered statistically significant. Results We identified 246 patients with SARS-CoV-2 (age range: 17 days-25 years). We noted a Hispanic predominance with 68% of all patients with SARS-CoV-2 identifying as Hispanic or Latino, compared to 29% among all CHCO visits in 2019 (Figure 1). The most common symptoms at presentation were fever, cough, or shortness of breath in 94% of symptomatic patients. Sixty-eight patients (28%) were admitted, of which 7 (10%) required admission to the pediatric intensive care unit (PICU) for symptomatic COVID-19 disease (Figure 2). Age 0–3 months, certain symptoms at presentation, and several types of underlying medical conditions were predictors for both hospital admission and need for respiratory support (Figure 3). Initial and peak C-reactive protein (CRP) values were predictors for PICU admission with median peaks of 24.8mg/dL vs. 2.0mg/dL among PICU vs. non-PICU patients (OR 1.27, p=0.004). Figure 3: Predictors for Admission and Respiratory Support Requirement in CHCO Patients with SARS-CoV-2 Conclusion There is a wide spectrum of illness in children with SARS-CoV-2, ranging from asymptomatic to critical illness. Hispanic ethnicity was disproportionately represented in our cohort, which requires further evaluation. We found that young age, comorbid conditions, and CRP appear to be risk factors for severe disease in children. Disclosures Kelly E. Graff, MD, BioFire Diagnostics, LLC (Grant/Research Support)

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Protocol-Based Intravenous Fluid Hydration for Newly Created Ileostomies Decreases Readmissions Secondary to Dehydration

The American Surgeon ◽

10.1177/0003134820971574 ◽

2020 ◽

pp. 000313482097157

Author(s):

Daniel J. Borsuk ◽

Adam Studniarek ◽

Slawomir J. Marecik ◽

John J. Park ◽

Kunal Kochar

Keyword(s):

Care Center ◽

Tertiary Care ◽

Length Of Hospital Stay ◽

Emergency Department Visits ◽

Sporadic Group ◽

Nursing Support ◽

Protocol Implementation ◽

Number Of Patients ◽

Intravenous Hydration ◽

The Impact

Background Newly created ileostomies often result in patient readmission due to dehydration secondary to high ostomy output. Implementation of a mandatory home intravenous hydration protocol can avoid this. We aim to evaluate the impact of mandatory home intravenous hydration for patients with newly created ileostomies. Materials and Methods All patients at a single, tertiary care center who underwent ileostomy creation during a period of sporadic home intravenous hydration (February 2011-December 2013) and mandatory protocol hydration (March 2016-December 2018) were reviewed for incidence of dehydration, readmissions, and emergency department visits. Results 241 patients were evaluated. 119 were in the “sporadic” group and 122 were in the “protocol” group. Operative approach differed among both groups, with hydration protocol patients undergoing 15% less open procedures and 4.9% more hand-assisted laparoscopic procedures ( P = .0017). Prior to protocol implementation, 23.5% of patients were sent home with intravenous hydration. Length of hospital stay after index ileostomy creation was shorter for “protocol” patients by 3.3 days ( P < .0001). 15.1% of “sporadic” patients experienced dehydration as compared to 7.4% of “protocol” patients ( P = .0283). Following protocol implementation, the number of patients readmitted due to dehydration increased from 13 to 14 ( P = .01). Discussion Standardized, mandatory at-home intravenous hydration following ileostomy creation leads to a significant reduction in postoperative incidence of dehydration and dehydration-associated readmissions. This protocol should be followed for all patients with newly created ileostomies, so long as adequate home health nursing support and active surveillance are available.

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Quality of life in patients with melasma in Turkish women

Dermatology Reports ◽

10.4081/dr.2017.7340 ◽

2017 ◽

Vol 9 (2) ◽

Cited By ~ 2

Author(s):

Hacer Uyanikoglu ◽

Mustafa Aksoy

Keyword(s):

Quality Of Life ◽

Severe Disease ◽

Life Quality ◽

Severity Index ◽

Older Individuals ◽

Turkish Women ◽

Moderate Disease ◽

Study Population ◽

The Impact

The aim of this study was to determine the impact of melasma on quality of life (QoL) using the dermatology life quality index (DLQI) questionnaire in a group of outpatients. This study is questionnairebased. A total of 101 Turkish women suffering from melasma, who themselves were able to understand and complete the Turkish version of the DLQI questionnaire, were enrolled. This questionnaire included 10 questions; each of each was scored on a scale of 0-3, with a maximum score of 30. The data were analyzed after the results had been collated and the higher the DLQI score, the poorer the QoL. The participants’ mean age was 29.53±6.87 years, and mean DLQI score was 6.02±4.94. When we divided the participants into two subgroups according to age, the DLQI scores for younger and older individuals were 7.44±4.99 and 4.33±4.36, respectively (P=0.001). When the melasma area and severity index (MASI) score was used, participants with mild and moderate disease had mean DLQI scores of 5.80±4.72 and 7.11±5.90, respectively. No patient had severe disease. Melasma might affect the participants’ QoL, especially that of the younger individuals, in our study population.

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Utilization of Fecal Occult Blood Testing and Its Impact on Endoscopic Procedures in Hospitalized Patients

10.21203/rs.3.rs-711548/v1 ◽

2021 ◽

Author(s):

Vinod Kumar ◽

Shobha Shahani ◽

FNU Jaydev ◽

Jaikumar Khatri ◽

Areeba Kara

Keyword(s):

Care Center ◽

Tertiary Care ◽

Final Analysis ◽

Occult Blood ◽

Fecal Occult Blood ◽

Gi Bleeding ◽

Endoscopic Evaluation ◽

Endoscopic Procedures ◽

Fecal Occult ◽

The Impact

Abstract Objective: To gain insights on the impact of fecal occult blood tests, we evaluated inpatients on whom these tests were performed.Patients and Methods: This single center, retrospective study was conducted at a large, academic, tertiary care center. Between Jan 1, 2016-Dec 31, 2017, inpatients who developed a drop in hemoglobin ≥2 grams/dL and had an FOBT were identified. Further data was extracted on a random selection of half of these patients. Patients were categorized as having an overt GI bleed (symptoms of melena, hematochezia, or hematemesis) or not.Results: Over the study period 6,310 patients developed a hemoglobin drop of ≥2 grams/dL. Of these 817 (12.9%) had an FOBT and we reviewed 407 (49.8%) randomly selected patients from this group. Those with missing FOBT results (n=13) were excluded, leaving 394 included in the final analysis. The mean age was 62.7 years with 211 females (53.7%). FOBTs were performed in 34.6% of patients despite the presence of overt GI bleeding. In patients without overt GI bleeding, the proportion of patients who underwent endoscopic procedures was higher in those with a positive FOBT than those with negative FOBT (40.4% vs 13.2%, p < .00001). There were no differences in rates of endoscopic evaluation in patients with overt GI bleeding based on FOBT results.Conclusions: FOBTs continue to be utilized in inpatient settings including in those presenting with overt GI bleeding. In the absence of overt GI bleeding, positive results may drive endoscopic evaluation.

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EP.FRI.752 Delay to Surgery in Acute Perforated and Ischaemic Gastrointestinal Pathology – A Systematic Review

British Journal of Surgery ◽

10.1093/bjs/znab312.114 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Victoria Murray ◽

Joshua Burke ◽

Michael Hughes ◽

Claire Schofield ◽

Alistair Young

Keyword(s):

Systematic Review ◽

Symptom Onset ◽

Final Analysis ◽

Mortality Prediction ◽

Emergency Laparotomy ◽

Management Framework ◽

Gastrointestinal Pathology ◽

National Mortality ◽

Increased Risk ◽

The Impact

Abstract Aims Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Methods A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results 17 studies were included in the final analysis. 15 unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

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Evaluating the Impact of Ventilator-Associated Parameters on Ventilation Free Days of non-ARDS Patients in ICU.

10.21203/rs.2.21795/v1 ◽

2020 ◽

Author(s):

Na Liu ◽

Jingxuan Ren ◽

Lina Yu ◽

Junran Xie

Keyword(s):

Mechanical Ventilation ◽

Primary Outcome ◽

Prognostic Significance ◽

Length Of Hospital Stay ◽

Multivariate Regression Analysis ◽

Parameter Setting ◽

Learning Models ◽

Mechanically Ventilated ◽

Ventilation Parameter ◽

The Impact

Abstract Background: Critically ill patients are not only mechanically ventilated because of ARDS, what kind of ventilation parameter setting is the optimal ventilation strategy for non-ARDS ICU patients?Methods: A retrospective cohort study for non-ARDS patients who received mechanical ventilation (MV), performed univariate, multivariate regression analysis, covariate balancing propensity score and inverse–probability–of–treatment weighting, and machines learning models to predict different outcomes. The included predicted factors are four parameters of mechanical ventilation (Driving pressure (DP) and its mediation of tidal volumes (VT) and positive end-expiratory pressure (PEEP), mechanical power (MP)), and the primary outcome was the ventilator-free days (VFD) at day 28.Results: The study included 2932 patients, low DP, low PEEP and low MP for non-ARDS patients could prolong VFD at day 28, reduce in-hospital mortality and length of hospital stay. However, the VT has no prognostic significance for the population. Among machine learning models with VFD, the randomforest had the best prediction.Conclusions: For non-ARDS patients who receive invasive ventilation for at least 48 hours, low DP, low PEEP and low MP are beneficial to the population. However, the effect of VT is inconclusive.

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Approaches to Antifungal Therapies and Their Effectiveness among Patients with Cryptococcosis

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.01800-12 ◽

2013 ◽

Vol 57 (6) ◽

pp. 2485-2495 ◽

Cited By ~ 24

Author(s):

Emily W. Bratton ◽

Nada El Husseini ◽

Cody A. Chastain ◽

Michael S. Lee ◽

Charles Poole ◽

...

Keyword(s):

Mortality Rate ◽

Best Practice ◽

Medical Center ◽

Severe Disease ◽

Tertiary Care ◽

Attributable Mortality ◽

Patient Death ◽

Adjusted Risk ◽

Tertiary Care Medical Center ◽

All Cause Mortality

ABSTRACTThe goal of this study was to determine the degree to which the persistence of cryptococcosis, overall 1-year mortality, and 1-year mortality due to cryptococcosis were influenced by initial antifungal treatment regimen in a cohort of adults with cryptococcosis treated at a tertiary care medical center. Risk factors, underlying conditions, treatment, and mortality information were obtained for 204 adults with cryptococcosis from Duke University Medical Center (DUMC) from 1996 to 2009. Adjusted risk ratios (RR) for persistence and hazard ratios (HR) for mortality were estimated for each exposure. The all-cause mortality rate among patients with nonsevere disease (20%) was similar to that in the group with disease (26%). However, the rate of cryptococcosis-attributable mortality with nonsevere disease (5%) was much lower than with severe disease (20%). Flucytosine exposure was associated with a lower overall mortality rate (HR, 0.4; 95% confidence interval [CI], 0.2 to 0.9) and attributable mortality rate (HR, 0.5; 95% CI, 0.2 to 1.2). Receiving a nonrecommended antifungal regimen was associated with a higher relative risk of persistent infection at 4 weeks (RR, 1.9; 95% CI, 0.9 to 4.3), and the rate of attributable mortality among those not receiving the recommended dose of initial therapy was higher than that of those receiving recommended dosing (HR, 2.3; 95% CI, 1.0 to 5.0). Thus, the 2010 Infectious Diseases Society of America (IDSA) guidelines are supported by this retrospective review as a best-practice protocol for cryptococcal management. Future investigations should consider highlighting the distinction between all-cause mortality and attributable mortality so as not to overestimate the true effect of cryptococcosis on patient death.

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