Efficacy of Hydroxychloroquine and Tocilizumab in Patients With COVID-19: Single-Center Retrospective Chart Review

Background During the initial phases of the COVID-19 pandemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ) and tocilizumab (TCZ); however, evidence on their efficacy and safety have been controversial. Objective The purpose of this study is to evaluate the overall clinical effectiveness of HCQ and TCZ in patients with COVID-19. We hypothesize that HCQ and TCZ use in these patients will be associated with a reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. Methods A retrospective cohort study was performed to determine the impact of HCQ and TCZ use on hard clinical outcomes during hospitalization. A total of 176 hospitalized patients with a confirmed COVID-19 diagnosis was included. Patients were divided into two comparison groups: (1) HCQ (n=144) vs no-HCQ (n=32) and (2) TCZ (n=32) vs no-TCZ (n=144). The mean age, baseline comorbidities, and other medications used during hospitalization were uniformly distributed among all the groups. Independent t tests and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios with 95% CIs, respectively. Results The unadjusted odds ratio for patients upgraded to a higher level of care (ie, intensive care unit) (OR 2.6, 95% CI 1.19-5.69; P=.003) and reductions in C-reactive protein (CRP) level on day 7 of hospitalization (21% vs 56%, OR 0.21, 95% CI 0.08-0.55; P=.002) were significantly higher in the TCZ group compared to the control group. There was no significant difference in the odds of in-hospital mortality, upgrade to intensive medical care, need for invasive mechanical ventilation, acute kidney failure necessitating dialysis, or discharge from the hospital after recovery in both the HCQ and TCZ groups compared to their respective control groups. Adjusted odds ratios controlled for baseline comorbidities and medications closely followed the unadjusted estimates. Conclusions In this cohort of patients with COVID-19, neither HCQ nor TCZ offered a significant reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. These results are similar to the recently published preliminary results of the HCQ arm of the Recovery trial, which showed no clinical benefit from the use of HCQ in hospitalized patients with COVID-19 (the TCZ arm is ongoing). Double-blinded randomized controlled trials are needed to further evaluate the impact of these drugs in larger patient samples so that data-driven guidelines can be deduced to combat this global pandemic.

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Efficacy of Hydroxychloroquine and Tocilizumab in Patients With COVID-19: Single-Center Retrospective Chart Review (Preprint)

10.2196/preprints.21758 ◽

2020 ◽

Author(s):

Sohaib Roomi ◽

Waqas Ullah ◽

Faizan Ahmed ◽

Soban Farooq ◽

Usama Sadiq ◽

...

Keyword(s):

Mechanical Ventilation ◽

Renal Failure ◽

Acute Renal Failure ◽

Hospital Mortality ◽

Medical Care ◽

Invasive Mechanical Ventilation ◽

Hospitalized Patients ◽

Odds Ratios ◽

Significant Difference ◽

The Impact

BACKGROUND During the initial phases of the COVID-19 pandemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ) and tocilizumab (TCZ); however, evidence on their efficacy and safety have been controversial. OBJECTIVE The purpose of this study is to evaluate the overall clinical effectiveness of HCQ and TCZ in patients with COVID-19. We hypothesize that HCQ and TCZ use in these patients will be associated with a reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. METHODS A retrospective cohort study was performed to determine the impact of HCQ and TCZ use on hard clinical outcomes during hospitalization. A total of 176 hospitalized patients with a confirmed COVID-19 diagnosis was included. Patients were divided into two comparison groups: (1) HCQ (n=144) vs no-HCQ (n=32) and (2) TCZ (n=32) vs no-TCZ (n=144). The mean age, baseline comorbidities, and other medications used during hospitalization were uniformly distributed among all the groups. Independent t tests and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios with 95% CIs, respectively. RESULTS The unadjusted odds ratio for patients upgraded to a higher level of care (ie, intensive care unit) (OR 2.6, 95% CI 1.19-5.69; P=.003) and reductions in C-reactive protein (CRP) level on day 7 of hospitalization (21% vs 56%, OR 0.21, 95% CI 0.08-0.55; P=.002) were significantly higher in the TCZ group compared to the control group. There was no significant difference in the odds of in-hospital mortality, upgrade to intensive medical care, need for invasive mechanical ventilation, acute kidney failure necessitating dialysis, or discharge from the hospital after recovery in both the HCQ and TCZ groups compared to their respective control groups. Adjusted odds ratios controlled for baseline comorbidities and medications closely followed the unadjusted estimates. CONCLUSIONS In this cohort of patients with COVID-19, neither HCQ nor TCZ offered a significant reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. These results are similar to the recently published preliminary results of the HCQ arm of the Recovery trial, which showed no clinical benefit from the use of HCQ in hospitalized patients with COVID-19 (the TCZ arm is ongoing). Double-blinded randomized controlled trials are needed to further evaluate the impact of these drugs in larger patient samples so that data-driven guidelines can be deduced to combat this global pandemic.

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Abstract 17292: Does Morbid Obesity Worsens Outcomes in COVID-19?

Circulation ◽

10.1161/circ.142.suppl_3.17292 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sohaib Roomi ◽

Waqas Ullah ◽

Nayab Nadeem ◽

Rehan Saeed ◽

Donald Haas ◽

...

Keyword(s):

Morbid Obesity ◽

Mechanical Ventilation ◽

Hospital Mortality ◽

Invasive Mechanical Ventilation ◽

Multivariate Logistic Regression Analysis ◽

Odds Ratios ◽

Increased Risk ◽

Significant Difference ◽

The Mean ◽

Mean Differences

Introduction: Given the high prevalence of obesity around the globe, patients with coronavirus disease 2019 (COVID-19) are at an increased risk of devastating complications. Hypothesis: We hypothesize that morbid obesity is independently associated with increased risk of in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation(IVM), and acute renal failure necessitating dialysis. Methods: A retrospective cohort study was performed to determine the association of basal metabolic index (BMI) with the above-mentioned outcomes. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively. Results: A total of 176 patients with confirmed COVID-19 diagnosis were included. The mean age was 62.2 years, with 51% of male patients. The mean BMI for non-surviving patients was significantly higher compared to patients surviving on the 7th day of hospitalization (35 vs. 30 kg/m2, p=0.022) and patients with a higher BMI had higher in-hospital mortality (21% vs. 9%, OR 3.2, 95% CI 1.3-8.2, p=0.01) compared to patients with a normal BMI. Similarly, patients requiring IMV had a higher BMI (33 vs. 29, p=0.002) compared to non-intubated patients. aOR of patients needing IMV (56% vs. 28%, OR 3.3, 95% CI 1.6-7.0, p=0.002) and upgrade to ICU (46% vs. 28%, OR 2.2, 1.07-4.6, p=0.04) were significantly higher compared to patients with a lower BMI. There was no significant difference between the two groups in terms of the need for dialysis (5% vs. 13%, OR 3.8, 13% vs. 4%, 1.1-14.1, p=0.07). Adjusted odds ratios controlled for baseline comorbidities and medications mirrored the overall results, except for the need to upgrade to ICU. Conclusions: In patients with confirmed COVID-19, morbid obesity serves as an independent risk factor of high in-hospital mortality and the need for invasive mechanical ventilation.

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Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

Biomarker Research ◽

10.1186/s40364-021-00283-y ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Clinical outcomes of concomitant use of enteral and intravenous sedatives and analgesics in mechanically ventilated patients with COVID-19

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab385 ◽

2021 ◽

Author(s):

Nayoung Kang ◽

Mohammed A Alrashed ◽

Eric M Place ◽

Phuongthao T Nguyen ◽

Stephen J Perona ◽

...

Keyword(s):

Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Institutional Review Board ◽

Chain Reaction ◽

Mechanically Ventilated ◽

Ventilation Time ◽

Institutional Review ◽

Significant Difference ◽

Polymerase Chain ◽

The Impact

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To evaluate potential differences in days on mechanical ventilation for patients with coronavirus disease 2019 (COVID-19) based on route of administration of analgesic and sedative medications: intravenous (IV) alone vs IV + enteral (EN). Summary This institutional review board–approved study evaluated ventilation time and fentanyl or midazolam requirements with or without concurrent EN hydromorphone and lorazepam. Patients were included in the study if they were 18 to 89 years old and were admitted to the intensive care unit with a positive severe acute respiratory syndrome coronavirus 2 reverse transcription and polymerase chain reaction or antigen test and respiratory failure requiring invasive mechanical ventilation for more than 72 hours. In total, 100 patients were evaluated, 60 in the IV-only group and 40 in the IV + EN group. There was not a significant difference in ventilation time between the groups (mean [SD], 19.6 [12.8] days for IV + EN vs 15.6 [11.2] days for IV only; P = 0.104). However, fentanyl (2,064 [847] μg vs 2,443 [779] μg; P < 0.001) and midazolam (137 [72] mg vs 158 [70] mg; P = 0.004) requirements on day 3 were significantly higher in the IV-only group, and the increase in fentanyl requirements from day 1 to day 3 was greater in the IV-only group than in the IV + EN group (378 [625] μg vs 34 [971] μg; P = 0.033). Conclusion Addition of EN analgesic and sedative medications to those administered by the IV route did not change the duration of mechanical ventilation in patients with COVID-19, but the combination may reduce IV opioid requirements, decreasing the impact of IV medication shortages.

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The Epidemiology and Clinical Associations of Stroke in Patients with Acute Myeloid Leukemia: A Review of 10,972 Admissions from the 2012 National Inpatient Sample

Blood ◽

10.1182/blood.v126.23.1314.1314 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1314-1314

Author(s):

Taeha Kim ◽

Joseph Shatzel ◽

Harley Friedman ◽

Frederick Lansigan

Keyword(s):

Mechanical Ventilation ◽

Renal Failure ◽

Acute Renal Failure ◽

Length Of Stay ◽

Myeloid Leukemia ◽

Hospitalized Patients ◽

National Database ◽

National Inpatient Sample ◽

Inpatient Mortality ◽

Clinical Associations

Abstract Background: Patients withacute myeloid leukemia (AML) are at increased risk for both hemorrhage and thrombosis, including in the central nervous system. There is limited data on the incidence, clinical association and mortality associated with cerebrovascular accident (CVA) in hospitalized patients with active AML. The aim of this study is to evaluate the epidemiology and mortality of hospitalized patients with AML who suffered concurrent stroke from a large national database. Methods: Using the 2012 National Inpatient Sample (NIS), admissions with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes for AML without remission and AML in relapse (205.00 and 205.02, respectively) were extracted, and correlated with age, gender, length of stay and mortality. All CVA (ICD-9-CM 434.91) data were extracted as well for comparison of mortality, length of stay (LOS). Results: Of the 7,296,968 unweighted admissions in the 2012 NIS, 9384 involved AML patients who had not yet achieved remission, and 1600 involved relapsed AML (Prevalence of 0.12% and 0.021% respectively). Of the combined group of admitted patients with active AML (N=10,984), 65 patients (0.59%) had a concomitant CVA (either hemorrhagic or ischemic, of whom 56 (0.51%) had active disease and 9 (0.08%) had relapsed disease). Compared to all other active AML patients, those who developed stroke were older (Mean age 66 y/o vs 58 y/o P=0.003), had longer LOS (20 days vs 12 days P= 0.53), were predominantly female (55% vs 45%; p=0.078) and had significantly higher inpatient mortality rates (36.9% vs 10.5%; OR 3.5; 95%CI 2.2, 5.5; P<0.0001). AML patients with CVA had significantly higher inpatient mortality then all admitted patients with stroke (36.9% vs 6.7%; OR 5.5; 95%CI 3.5, 8.8; P<0.0001). Multivariate logistic regression attempting to find significant clinical associations in AML patients who develop stroke, after controlling for confounding variables, found that acute renal failure with tubular necrosis(OR 4.47; 95%CI 1.8, 11.2; P=0.0013), hypernatremia (OR 3.85; 95%CI 1.6, 9.1; P=0.002), urinary tract infection (OR 3.28; CI95% 1.8, 6.1; P=0.0002) and secondary thrombocytopenia (OR 2.92; 95%CI 1.5, 5.7; P=0.0018) were all significantly predictive, as were mechanical ventilation >96 hours (OR 4.92; CI95% 1.02, 23.6; P=0.047) and continuous positive airway pressure ventilation (OR 3.03; CI95% 1.11, 8.26; P=0.031). Disseminated intravascular coagulation (DIC) and leukocytosis were more prevalent in AML patients with CVA compare to all AML patients, but the difference did not reach statistical significance. Conclusions: CVA in patients with active AML was strongly associated with older age and higher mortality, and appeared to be a relatively rare event, occurring in only 0.59% of patients. There was no statistically significant difference in LOS or gender distribution between those who developed CVA and those who did not amont active AML patients. As compared to all CVA patients, active AML patients with CVA had 5-fold higher risk of mortality. Significant acute renal failure, hypernatremia and thrombocytopenia appear to portend a higher risk of stroke in patients with active AML. It is unclear if UTI, and the need for mechanical ventilation is a predictor of stroke, as much as they may be a ramification of it. While more common in AML patients with CVA vs AML patients without CVA, we did not find DIC or hyperleukocytosis to be significantly predictive. Disclosures No relevant conflicts of interest to declare.

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The Impact of Hyperoxia on Outcome of Patients Treated with Noninvasive Respiratory Support

Canadian Respiratory Journal ◽

10.1155/2020/3953280 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Seyhan Pala Cifci ◽

Yasemin Urcan Tapan ◽

Bengu Turemis Erkul ◽

Yusuf Savran ◽

Bilgin Comert

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Oxygen Therapy ◽

Invasive Mechanical Ventilation ◽

Respiratory Support ◽

High Flow Oxygen ◽

The Impact

Objective. Oxygen therapy is one of the most common treatment modalities for hypoxemic patients, but target goals for normoxemia are not clearly defined. Therefore, iatrogenic hyperoxia is a very common situation. The results from the recent clinical researches about hyperoxia indicate that hyperoxia can be related to worse outcomes than expected in some critically ill patients. According to our literature knowledge, there are not any reports researching the effect of hyperoxia on clinical course of patients who are not treated with invasive mechanical ventilation. In this study, we aimed to determine the effect of hyperoxia on mortality, and length of stay and also possible side effects of hyperoxia on the patients who are treated with oxygen by noninvasive devices. Materials and Methods. One hundred and eighty-seven patients who met inclusion criteria, treated in Dokuz Eylul University Medical Intensive Care Unit between January 1, 2016, and October 31, 2018, were examined retrospectively. These patients’ demographic data, oxygen saturation (SpO2) values for the first 24 hours, APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, whether they needed intubation, if they did how many days they got ventilated, length of stay in intensive care unit and hospital, maximum PaO2 values of the first day, oxygen treatment method of the first 24 hours, and the rates of mortality were recorded. Results. Hyperoxemia was determined in 62 of 187 patients who were not treated with invasive mechanic ventilation in the first 24 hours of admission. Upon further investigation of the relation between comorbid situations and hyperoxia, hyperoxia frequency in patients with COPD was detected to be statistically low (16% vs. 35%, p<0.008). Hospital mortality was significantly high (51.6% vs. 35.2%, p<0.04) in patients with hyperoxia. When the types of oxygen support therapies were investigated, hyperoxia frequency was found higher in patients treated with supplemental oxygen (nasal cannula, oronasal mask, high flow oxygen therapy) than patients treated with NIMV (44.2% vs. 25.5%, p<0.008). After exclusion of 56 patients who were intubated and treated with invasive mechanical ventilation after the first 24 hours, hyperoxemia was determined in 46 of 131 patients. Mortality in patients with hyperoxemia who were not treated with invasive mechanical ventilation during hospital stay was statistically higher when compared to normoxemic patients (41.3% vs 15.3%, p<0.001). Conclusion. We report that hyperoxemia increases the hospital mortality in patients treated with noninvasive respiratory support. At the same time, we determined that hyperoxemia frequency was lower in COPD patients and the ones treated with NIMV. Conservative oxygen therapy strategy can be suggested to decrease the hyperoxia prevalence and mortality rates.

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Patient–ventilator asynchrony, impact on clinical outcomes and effectiveness of interventions: a systematic review and meta-analysis

Journal of Intensive Care ◽

10.1186/s40560-021-00565-5 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Michihito Kyo ◽

Tatsutoshi Shimatani ◽

Koji Hosokawa ◽

Shunsuke Taito ◽

Yuki Kataoka ◽

...

Keyword(s):

Systematic Review ◽

Mechanical Ventilation ◽

Hospital Mortality ◽

Clinical Outcomes ◽

Closed Loop ◽

Meta Analysis ◽

Invasive Mechanical Ventilation ◽

Cochrane Central Register ◽

Icu Mortality ◽

The Impact

Abstract Background Patient–ventilator asynchrony (PVA) is a common problem in patients undergoing invasive mechanical ventilation (MV) in the intensive care unit (ICU), and may accelerate lung injury and diaphragm mis-contraction. The impact of PVA on clinical outcomes has not been systematically evaluated. Effective interventions (except for closed-loop ventilation) for reducing PVA are not well established. Methods We performed a systematic review and meta-analysis to investigate the impact of PVA on clinical outcomes in patients undergoing MV (Part A) and the effectiveness of interventions for patients undergoing MV except for closed-loop ventilation (Part B). We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ClinicalTrials.gov, and WHO-ICTRP until August 2020. In Part A, we defined asynchrony index (AI) ≥ 10 or ineffective triggering index (ITI) ≥ 10 as high PVA. We compared patients having high PVA with those having low PVA. Results Eight studies in Part A and eight trials in Part B fulfilled the eligibility criteria. In Part A, five studies were related to the AI and three studies were related to the ITI. High PVA may be associated with longer duration of mechanical ventilation (mean difference, 5.16 days; 95% confidence interval [CI], 2.38 to 7.94; n = 8; certainty of evidence [CoE], low), higher ICU mortality (odds ratio [OR], 2.73; 95% CI 1.76 to 4.24; n = 6; CoE, low), and higher hospital mortality (OR, 1.94; 95% CI 1.14 to 3.30; n = 5; CoE, low). In Part B, interventions involving MV mode, tidal volume, and pressure-support level were associated with reduced PVA. Sedation protocol, sedation depth, and sedation with dexmedetomidine rather than propofol were also associated with reduced PVA. Conclusions PVA may be associated with longer MV duration, higher ICU mortality, and higher hospital mortality. Physicians may consider monitoring PVA and adjusting ventilator settings and sedatives to reduce PVA. Further studies with adjustment for confounding factors are warranted to determine the impact of PVA on clinical outcomes. Trial registration protocols.io (URL: https://www.protocols.io/view/the-impact-of-patient-ventilator-asynchrony-in-adu-bsqtndwn, 08/27/2020).

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Empiric use of Anticoagulation in Hospitalized Patients with COVID-19: A Propensity Score-Matched Study of Risks and Benefits

10.21203/rs.3.rs-242205/v1 ◽

2021 ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background: Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods: We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 15 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results: The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345-0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110-1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114-3.729, p = 0.016). Conclusion: Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Impact of coexisting pneumonia in the patients admitted with Clostridium difficile infection: a retrospective study from a national inpatient database

Journal of Investigative Medicine ◽

10.1136/jim-2021-001820 ◽

2021 ◽

pp. jim-2021-001820

Author(s):

Asim Kichloo ◽

Zain El-Amir ◽

Dushyant Singh Dahiya ◽

Jagmeet Singh ◽

Dhanshree Solanki ◽

...

Keyword(s):

Septic Shock ◽

Renal Failure ◽

Acute Renal Failure ◽

Clostridium Difficile ◽

Hospital Mortality ◽

Antibiotic Use ◽

Hospital Charges ◽

Inpatient Setting ◽

Antibiotic Administration ◽

The Impact

Clostridium difficile is a gram-positive anaerobic spore forming bacillus that can cause infection in a setting of antibiotic use. Pneumonia is a major cause of morbidity and mortality in an inpatient setting and is frequently associated with significant antibiotic administration. This study aims to compare the outcomes of C. difficile infection (CDI) with and without pneumonia to determine the impact of pneumonia in hospitalized patients with CDI. This population-based retrospective observational propensity matched analysis study uses data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcomes were in-hospital mortality, total hospital charges, and mean length of stay. Secondary outcomes were the rates of sepsis, septic shock, non-ST elevation myocardial infarction (NSTEMI), acute renal failure, deep vein thrombosis, and pulmonary embolism. In-hospital mortality was noted to be higher in patients with pneumonia than those without (6.5% vs 1.2%, adjusted OR (aOR) 3.85; 95% CI 2.90 to 5.11, p<0.001). The following outcomes were more prevalent in patients with pneumonia compared with those without pneumonia: sepsis (9.8% vs 1.8%, aOR 4.69, 95% CI 3.73 to 5.87, p<0.001), septic shock (4.0% vs 0.5%, aOR 6.32, 95% CI 4.43 to 9.03, p<0.001), NSTEMI (1.9% vs 0.5%, aOR 2.95, 95% CI 1.85 to 4.71, p<0.001), and acute renal failure (31.5% vs 23.1%, aOR 1.23, 95% CI 1.07 to 1.40, p=0.003). In conclusion, patients with pneumonia were associated with significantly higher rates of system-based complications and higher in-hospital mortality rates.

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Low Free T3 Is Associated With Worse Outcomes in Patients in the ICU Requiring Invasive Mechanical Ventilation

Journal of Intensive Care Medicine ◽

10.1177/0885066619890822 ◽

2019 ◽

pp. 088506661989082 ◽

Cited By ~ 1

Author(s):

Gary D. Rothberger ◽

Paul K. Valestra ◽

Khalilah Knight ◽

Anish K. Desai ◽

Rose Calixte ◽

...

Keyword(s):

Mechanical Ventilation ◽

Hospital Mortality ◽

Invasive Mechanical Ventilation ◽

Free Triiodothyronine ◽

Nonthyroidal Illness ◽

Serum Free ◽

Entire Cohort ◽

The Mean ◽

Poor Outcomes ◽

The Impact

Objective: Critical illness causes a decrease in serum free triiodothyronine (T3) levels. This condition, known as nonthyroidal illness syndrome (NTIS), is associated with poor outcomes. The association of NTIS and outcomes in patients in the intensive care unit (ICU) requiring mechanical ventilation has not been well studied. This study aimed to determine the impact of NTIS on the outcomes of these patients. Methods: This prospective study included 162 patients in the ICU who underwent mechanical ventilation. Serum free T3 levels were tested on the day of initiation of mechanical ventilation. The rates of in-hospital mortality and ventilator-free days (VFDs) at day 28 after the initiation of mechanical ventilation were compared between patients with low (<2.3 pg/mL) and normal (≥2.3 pg/mL) free T3 levels. Patients who died while on mechanical ventilation were assigned a VFD of 0. Results: Low T3 was present in 60% of study patients. The in-hospital mortality rate of the entire cohort was 39%, and the mean and median VFDs at day 28 were 13.5 and 21 days, respectively. Compared to patients with normal free T3, patients with low free T3 had higher in-hospital mortality (52% vs 19%, P < .001) and less mean and median VFDs at day 28 (10.7 vs 18 and 0 vs 23, respectively. P < .001 for both mean and median VFDs). Conclusions: The presence of low T3 due to NTIS in patients in the ICU requiring mechanical ventilation is associated with poor outcomes.

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