Composite Poor Outcome Research Articles

Low-Density Lipoprotein Cholesterol to Triglyceride Ratio and Clinical Outcomes after Acute Ischaemic Stroke or Transient Ischaemic Attack.

Studies showed that low-density lipoprotein cholesterol (LDL-C) to triglyceride (TG) ratio could be used as a predictive parameter of low-density lipoprotein oxidation in vivo and the level of small dense LDL-C. However, whether LDL-C/TG ratio is associated with stroke prognosis remains unclear. We investigated the associations of LDL-C/TG ratio with outcomes in patients with acute ischaemic stroke (AIS) or transient ischaemic attacks (TIA) and explored whether it produced more predictive value than LDL-C and TG. Data were derived from the Third China National Stroke Registry (CNSR-III). Multivariable Cox regression for stroke recurrence, composite vascular events and all-cause death and logistic regression for the poor functional outcome (modified Rankin Scale score 3-6) were used. A total of 14123 patients were included. After adjusting for confounding factors, quartile 4 of LDL-C/TG ratio was associated with an increased risk of recurrent stroke (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.03-1.56), composite vascular events (HR,1.23; 95% CI, 1.00-1.52), death (HR,1.70; 95% CI, 1.13-2.54) and poor functional outcome (odds ratio, 1.34; 95% CI, 1.12-1.61) at 3 months follow-up compared with quartile 1. We also found that quartile 4 of LDL-C and TG was positively and negatively associated with poor functional outcome at 3 months, respectively. LDL-C/TG ratio performed better than LDL-C or TG in predicting clinical outcomes. LDL-C/TG ratio was associated with the risk of stroke recurrence, composite vascular events, death and poor functional outcome in patients with AIS or TIA.

Management of immunosuppression in lung transplant recipients and COVID-19 outcomes: an observational retrospective cohort-study

BackgroundThe aim of this study was to assess the impact of immunosuppression management on coronavirus disease 2019 (COVID-19) outcomes.MethodsWe performed a single-center retrospective study in a cohort of 358 lung transplant recipients (LTx) over the period from March 2020 to April 2022. All included symptomatic patients had at least one positive SARS-CoV-2 rt-PCR. We used a composite primary outcome for COVID-19 including increased need for oxygen since the hospital admission, ICU transfer, and in-hospital mortality. We assessed by univariate and multivariate analyses the risk factors for poor outcomes.ResultsOverall, we included 91 LTx who contracted COVID-19. The COVID-19 in-hospital mortality rate reached 4.4%. By hierarchical clustering, we found a strong and independent association between the composite poor outcome and the discontinuation of at least one immunosuppressive molecule among tacrolimus, cyclosporine, mycophenolate mofetil, and everolimus. Obesity (OR = 16, 95%CI (1.96; 167), p = 0.01) and chronic renal failure (OR = 4.6, 95%CI (1.4; 18), p = 0.01) were also independently associated with the composite poor outcome. Conversely, full vaccination was protective (OR = 0.23, 95%CI (0.046; 0.89), p = 0.047).ConclusionThe administration of immunosuppressive drugs such as tacrolimus, cyclocporine or everolimus can have a protective effect in LTx with COVID-19, probably related to their intrinsic antiviral capacity.

Cervical pessary to prevent preterm birth and poor neonatal outcome: An integrity meta-analysis of randomized controlled trials focusing on adherence to the European Medical Device Regulation.

Findings from randomized trials (RCTs) on cervical pessary treatment to prevent spontaneous preterm birth are inconsistent. Our hypothesis suggests that adhering to the European Medical Device Regulation (MDR) and following the instructions for use are essential prerequisites for successful therapy. Conversely, the non-adherence to these guidelines will probably contribute to its failure. Based on validated criteria from integrity assessments we performed a systematic review identifying 14 RCTs evaluating the effect of cervical pessaries. We analyzed the implications of 14 criteria each accounting for 0-2 points of a score reflecting the clinical evaluation plan (CEP) as proposed by the MDR to evaluate the risk-benefit ratio of medical devices. Seven RCTs in each singleton and twin pregnancies (5193 "cases") were included, detecting a high heterogeneity within control groups (I2 = 85% and 87%, respectively, P < 0.01). The CEP score varied from 11 to 26 points for all studies. The most common reasons for low scores and potential data compromise were poor recruitment rates, no (completed) power analysis, and no pre-registration, but mainly non-adherence to technical, biological, and clinical equivalence to the instructions for use as required by the MDR. All trials with score values greater than 20 had applied audit procedures. Within this group we found significantly reduced rates of spontaneous preterm birth at less than 34 weeks within the pessary group in singleton (odds ratio 0.28; 95% confidence interval 0.12-0.65) and twin pregnancies (odds ratio 0.30; 95% confidence interval 0.13-0.67). Similarly, there was a significant reduction in the composite poor neonatal outcome in singleton (odds ratio 0.25; 95% confidence interval 0.10-0.61) and twin pregnancies (odds ratio 0.54; 95% confidence interval 0.35-0.82) after a pessary as compared with controls. Non-audited RCTs and meta-analyses mixing studies of different clinical quality as pre-defined by a CEP and the MDR pose the risk for erroneous conclusions.

Impact of Antegrade Pulmonary Blood Flow as Patients Progress Through Single-Ventricle Palliations

BackgroundThe impact of antegrade pulmonary blood flow (APBF) during single-ventricle (SV) palliation continues to be debated. We sought to assess its impact on the hemodynamic profile and the short- and long-term outcomes of patients progressing through stages of SV palliation. MethodsA retrospective single-center study was conducted of SV patients who underwent surgery between January 2010 and December 2020. Patients with APBF were matched to those with no APBF by a propensity score based on body surface area, sex, and type of systemic ventricle. Analysis was performed using appropriate statistics with a significance level of P = .05. ResultsSixty-three patients with APBF were matched with 95 patients with no APBF. At the pre–stage 2 catheterization, APBF patients had a larger left pulmonary artery diameter (z score, 0.1 vs −0.8; P < .042). Patients with APBF had shorter cardiopulmonary bypass time (57.0 vs 79.0 minutes), shorter duration of mechanical ventilation (14.1 vs 17.4 hours), and shorter hospital length of stay (5.0 vs 7.0 days) at stage 2 palliation (P < .05). In the multivariable Cox regression analysis, patients with hypoplastic pulmonary arteries (z scores < −2; adjusted hazard ratio, 9.17) and patients with chromosomal abnormalities/genetic syndrome (adjusted hazard ratio, 4.03) were at increased risk for poor outcomes (P < .05). During the follow-up period, there was no significant difference in risk of the composite poor outcome and long-term survival between groups. ConclusionsSV patients with APBF had shorter cardiopulmonary bypass time, duration of mechanical ventilation, and hospital length of stay after stage 2 palliation. Patients with hypoplastic pulmonary arteries or chromosomal abnormalities/genetic syndromes had increased risk for poor outcomes. Maintaining APBF has better short-term outcomes, but there are no long-term hemodynamic or survival benefits.

A prospective cohort study on glucose variability and clinical outcomes in comatose children due to acute central nervous system infections admitted in the pediatric intensive care unit

Background: Pediatric acute central nervous system (CNS) infections are associated with severe neuromorbidity. This study aimed to study the effect of glucose variability on clinical outcomes in comatose children due to acute CNS infections admitted in pediatric intensive care unit (PICU). Subjects and Methods: A prospective cohort study enrolled comatose children aged 1 month to 12 years due to acute CNS infection. Within 6 h, continuous glucose monitoring was started (Freestyle Libre Pro, Abbott). The unit practice was targeting blood glucose (BG, mg/dL) of &lt;140–145. The hyperglycemic index was calculated to estimate the relative time spent above BG of &gt;126, &gt;140, &gt;180, &gt;200, and &lt;60. Glucose variability was defined as BG fluctuation, with both hypoglycemia (&lt;60) and hyperglycemia (&gt;126). The primary outcome was new-onset organ dysfunction. The secondary outcomes were organ support, length of mechanical ventilation, hospital (including PICU) stay, and 90-day composite poor outcome (mortality or severe neurodisability). Results: Total BG values measured were 27,792 from 66 patients (mean [standard deviation (SD)] 421.1 [212.6] values per patient). The mean (SD) BG was 103.2 (37.7) (minimum: 42.1; maximum: 228.8). The new-onset organ dysfunction has occurred in 83.3% (n = 55/66), and no difference was noted among normoglycemic and abnormal glycemic groups (84.4% vs. 80.9%; relative risk = 1.09, 95% confidence interval: 0.67–1.76). The median (interquartile range) PICU stay (days) was higher in the normoglycemic group (7, 5–14 vs. 4, 3.5–8.5; P = 0.014). No difference was noted in other outcomes. Conclusions: Glucose variability was not significantly associated with new-onset organ dysfunction and poor outcome in comatose children due to acute CNS infections.

Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit

Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT. We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed. 60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR=21.9, P=0.04) CONCLUSIONS: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.

Association of Vitamin D levels on the Clinical Outcomes of Patients Hospitalized for COVID-19 in a Tertiary Hospital.

This study aimed to compare the severity of COVID-19, inflammatory parameters and clinical outcomes among patients with normal and subnormal levels of Vitamin D. This is a retrospective cohort study of 135 patients admitted in a tertiary hospital for COVID-19. Patients were grouped according to their Vitamin D level. Primary outcome measure was the composite of all-cause mortality and morbidity. Other outcome measures determined were the comparison among the groups on the severity of COVID-19 infection, changes in inflammatory parameters, length of hospital stay and duration of respiratory support. There was a significant trend of higher ICU admission (p=0.024), mortality (p=0.006) and poor clinical outcome (p=0.009) among the Vitamin D deficient group. No significant difference was found for most of the inflammatory parameters, duration of hospital stay and respiratory support. Overall, patients with deficient, but not insufficient Vitamin D level had 6 times higher odds of composite poor outcome than those with normal Vitamin D (crude OR=5.18, p=0.003; adjusted OR=6.3, p=0.043). The inverse relationship between Vitamin D level and poor composite outcome observed in our study suggests that low Vitamin D may be a risk factor for poor prognosis among patients admitted for COVID-19.

Comprehensive evaluation of six interventions for hospitalized patients with COVID-19: A propensity score matching study

PurposeThe purpose of this study was to evaluate the effectiveness of either hydroxychloroquine, triple combination therapy (TCT), favipiravir, dexamethasone, remdesivir, or COVID-19 convalescent plasma (CCP) in comparison with standard-of-care for hospitalized patients with COVID-19 using real-world data from Saudi Arabia. Patients and methodsA secondary database analysis was conducted using the Saudi Ministry of Health database for patients with COVID-19. Adult (≥18 years) hospitalized patients with COVID-19 between March 2020 and January 2021 were included in the analysis. A propensity score matching technique was used to establish comparable groups for each therapeutic approach. Lastly, an independent t-test and chi-square test were used to compare the matching groups in the aspects of the duration of hospitalization, length of stay (LOS) in intensive care units (ICU), in-hospital mortality, and composite poor outcome. Multilevel logistic regression model was used to assess the association between the severity stage of COVID-19 and the outcomes while using the medication or intervention used as a grouping variable in the model. ResultsThe mean duration of hospitalization was significantly longer for patients who received TCT, favipiravir, dexamethasone, or CCP compared to patients who did not receive these therapies, with a mean difference ranging between 2.2 and 4.9 days for dexamethasone and CCP, respectively. Furthermore, the use of favipiravir or CCP was associated with a longer stay in ICU. Remdesivir was the only agent associated with in-hospital mortality benefit. A higher risk of mortality and poorer composite outcome were associated with the use of favipiravir or dexamethasone. However, the logistic regression model reveled that the difference between the two matched cohorts was due to the severity stage not the medication. Additionally, the use of hydroxychloroquine, TCT, or CCP had no impact on the incidence of in-hospital mortality or composite poor outcomes. ConclusionRemdesivir was the only agent associated with in-hospital mortality benefit. The observed worsened treatment outcomes associated with the use of dexamethasone or FPV shall be attributed to the severity stage rather than the medication use. In light of these varied results, additional studies are needed to continue evaluating the actual benefits of these therapies.

Mediation of Systemic Inflammation on Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke.

Insulin resistance is associated with stroke recurrence and poor functional outcomes of nondiabetic patients with ischemic stroke. The study aimed to investigate whether the association between insulin resistance and the prognosis of nondiabetic patients with ischemic stroke was mediated by systematic inflammation. Patients with ischemic stroke but without a history of diabetes who were enrolled in CNSR-III (Third China National Stroke Registry) were included in the study and followed up for 1 year after stroke onset. Insulin resistance was determined by using the homeostasis model assessment for insulin resistance (HOMA-IR) method. hs-CRP (high-sensitivity C-reactive protein) and Lp-PLA2 (lipoprotein-associated phospholipase A2) activity were measured at baseline. The primary outcome was stroke recurrence, and other outcomes included composite vascular events, mortality, and poor functional outcome (modified Rankin Scale score, 3-6). Multivariable Cox or logistic regression analyses were performed to estimate the association between HOMA-IR and the study outcomes. A mediation analysis was performed to examine the relationship between insulin resistance and the study outcomes mediated by systemic inflammation. Among a total of 3808 nondiabetic patients with ischemic stroke who were included in the study, the median HOMA-IR was 1.79 (interquartile range, 1.05-2.97). After adjustments for potential confounders, higher HOMA-IR quartiles were associated with higher risks of stroke recurrence, ischemic stroke, and composite vascular events, especially in the large artery atherosclerosis subtype. hs-CRP partially mediated the association between the HOMA-IR index and the prognosis of ischemic stroke (mediation proportion, 5.9% for stroke recurrence and 7.5% for composite vascular events). No evidence of Lp-PLA2 activity mediating the association of insulin resistance with stroke outcomes was observed. Our study found that insulin resistance was associated with poor clinical outcomes in nondiabetic patients with ischemic stroke, which was partially mediated by hs-CRP with a modest amount.

27: PRE-CARDIOPULMONARY BYPASS BIOMARKERS PREDICT POOR OUTCOMES IN NEONATAL CONGENITAL HEART DISEASE

Introduction: Neonates requiring cardiopulmonary bypass (CPB) for congenital heart disease have higher rates of postoperative mortality and morbidity than older children. However, identified risk factors for poor outcome to date have been limited to non-modifiable demographic or surgical factors. We aimed to identify novel biomarkers measured preoperatively that correlate with poor outcomes. Methods: Plasma samples were collected immediately prior to CPB in 65 consented subjects. Twenty-eight soluble analytes were measured via individual or multiplexed ELISA and tested for association with the validated “ICU-30” composite poor outcome, defined as (1) mortality within 30 days of CPB, (2) ICU stay >30 days, or (3) ICU readmission within 30 days. Differences in biomarker concentrations between subjects with and without ICU-30 were assessed using a Wilcoxon rank sum test. Associations of standardized biomarkers and ICU-30 was tested with logistic regression, adjusting for surgical complexity. Results: Samples for 63 patients were included for analysis (2 subjects did not undergo CPB after blood collection); 18 subjects (28%) had the ICU-30 outcome. Patients with ICU-30 were more likely to have a chromosomal abnormality, with no difference in gestational age or birth weight. There was no difference between age at CPB surgery and CPB time during operation. Seven biomarkers differed between those with and without ICU-30: angiopoietin 2, interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, growth differentiation factor-15, C-C motif ligand 2 (CCL2), and neutrophil gelatinase-associated lipocalin (NGAL) were higher in patients with ICU-30, and ADAMTS13 (A disintegrin and metalloproteinase with thrombospondin motifs 13) was lower in those with ICU-30. When controlling for STAT category, TNF-alpha (aOR 5.4, 95% CI 1.6-19.0), IL-6 (aOR 3.0, 95% CI 1.3-6.8), CCL2 (aOR 2.6, 95% CI 1.3-5.2), and NGAL (aOR 2.6, 95% CI 1.3-5.1) were associated with ICU-30. Conclusions: Four novel preoperative plasma biomarkers implicating innate immunity and renal function were associated with worse outcomes in neonates requiring CPB independent of STAT operation. Biomarkers have the potential to identify preoperative risk factors and mechanistic pathways for prognostication and targeted therapeutic interventions.

Eosinopenia as Predictor of Poor Outcome in Hospitalized COVID-19 Adult Patients from Waves 1 and 2 of 2020 Pandemic.

During SARS-CoV-2 infection, eosinopenia may reflect a hyperactive immune response. In this study of hospitalized COVID-19 patients, we aimed to better understand the prognostic value of severe eosinopenia (absolute eosinophil count = 0 G/L) and decipher its underlying mechanisms. We retrospectively analyzed the records of COVID-19 patients hospitalized from March to June 2020 in three university hospitals in Marseille, France. We assessed the association between severe eosinopenia and a composite poor outcome in these patients, including the need for oxygen supplementation at >6 L/min, ICU admission, and in-hospital death. Among the 551 COVID-19 patients included in this study, severe eosinopenia was found in 228 (51%) of them on admission to hospital and was associated with a composite poor outcome using multivariate analysis (OR = 2.58; CI95 [1.77−3.75]; p < 0.0001). We found a significant association between the presence of severe eosinopenia on admission and the elevation in C-reactive protein, ferritin, IP-10, and suPAR. The histological findings in a series of 37 autopsies from patients who died from severe COVID-19 and presented with severe eosinopenia showed no pulmonary eosinophil trapping. Severe eosinopenia can be a reliable biomarker associated with a composite poor outcome in hospitalized COVID-19 adult patients. It may reflect the magnitude of immune hyperactivation during severe-to-critical COVID-19.

Different treatment response to systemic corticosteroids according to white blood cell counts in severe COVID-19 patients

Background Limited data are available in COVID-19 patients on the prediction of treatment response to systemic corticosteroid therapy based on systemic inflammatory markers. There is a concern whether the response to systemic corticosteroid is different according to white blood cell (WBC) counts in COVID-19 patients. We aimed to assess whether WBC count is related with the clinical outcomes after treatment with systemic corticosteroids in severe COVID-19. Methods We conducted a retrospective cohort study and analysed the patients hospitalised for severe COVID-19 and received systemic corticosteroids between July 2020 and June 2021. The primary endpoint was to compare the composite poor outcome of mechanical ventilation, extracorporeal membrane oxygenation, and mortality among the patients with different WBC counts. Results Of the 585 COVID-19 patients who required oxygen supplementation and systemic corticosteroids, 145 (24.8%) belonged to the leukopoenia group, 375 (64.1%) belonged to the normal WBC group, and 65 (11.1%) belonged to the leukocytosis group. In Kaplan-Meier curve, the composite poor outcome was significantly reduced in leukopoenia group compared to leukocytosis group (log-rank p-value < 0.001). In the multivariable Cox regression analysis, leukopoenia group was significantly associated with a lower risk of the composite poor outcome compared to normal WBC group (adjusted hazard ratio [aHR] = 0.32, 95% CI 0.14–0.76, p-value = 0.009) and leukocytosis group (aHR = 0.30, 95% CI = 0.12–0.78, p-value = 0.013). There was no significant difference in aHR for composite poor outcome between leukocytosis and normal WBC group. Conclusion Leukopoenia may be related with a better response to systemic corticosteroid therapy in COVID-19 patients requiring oxygen supplementation. KEY MESSAGES In severe COVID-19 treated with systemic corticosteroids, patients with leukopoenia showed a lower hazard for composite poor outcome compared to patients with normal white blood cell counts or leukocytosis. Leukopoenia may be a potential biomarker for better response to systemic corticosteroid therapy in COVID-19 pneumonia.

The association between mean platelet volume and poor outcome in patients with COVID-19: Systematic review, meta-analysis, and meta-regression.

This study aims to assess the association between mean platelet volume (MPV) and poor outcome in patients with COVID-19. We performed a comprehensive literature search using the PubMed, Embase and Scopus databases with keywords "2019-nCoV" OR "SARS-CoV-2" OR "COVID-19" AND "mean platelet volume" OR "MPV" on 8 July 2021. The primary outcome was composite poor outcome, defined as severe COVID-19 or mortality. The pooled effect estimate was reported as mean differences in terms of MPV between the group with and without outcome. There were 17 studies which consist of 4549 patients with COVID-19 were included in this study. The incidence of poor outcome was 25% (20%-30%). Mean MPV was found to be higher in the poor outcome group in compare to no poor outcome group (10.3 ± 1.9 fL vs 9.9 ± 1.7 fL). The mean MPV difference between both group was 0.47 fL [95% CI 0.27, 0.67], p < 0.001; I2: 62.91%, p < 0.001). In the sub-group analysis, patients with severe COVID-19 had higher MPV (mean difference 0.54 fL [95% CI 0.28, 0.80], p < 0.001; I2: 54.84%, p = 0.014). Furthermore, MPV was also higher in the mortality group (mean difference 0.54 fL [95% CI 0.29, 0.80], p = 0.020; I2: 71.11%, p = 0.004). Meta-regression analysis showed that the association between MPV and poor outcome was not affected by age (p = 0.789), gender (p = 0.167), platelets (p = 0.056), white blood cells (p = 0.639), and lymphocytes (p = 0.733). This meta-analysis indicated that increased MPV was associated with severity and mortality in patients with COVID-19. Further research is needed to determine the optimum cut-off point.

Quantification of respiratory sounds by a continuous monitoring system can be used to predict complications after extubation: a pilot study.

To show that quantification of abnormal respiratory sounds by our developed device is useful for predicting respiratory failure and airway problems after extubation. A respiratory sound monitoring system was used to collect respiratory sounds in patients undergoing extubation. The recorded respiratory sounds were subsequently analyzed. We defined the composite poor outcome as requiring any of following medical interventions within 48h as defined below. This composite outcome includes reintubation, surgical airway management, insertion of airway devices, unscheduled use of noninvasive ventilation or high-flow nasal cannula, unscheduled use of inhaled medications, suctioning of sputum by bronchoscopy and unscheduled imaging studies. The quantitative values (QV) for each abnormal respiratory sound and inspiratory sound volume were compared between composite outcome groups and non-outcome groups. Fifty-seven patients were included in this study. The composite outcome occurred in 18 patients. For neck sounds, the QVs of stridor and rhonchi were significantly higher in the outcome group vs the non-outcome group. For anterior thoracic sounds, the QVs of wheezes, rhonchi, and coarse crackles were significantly higher in the outcome group vs the non-outcome group. For bilateral lateral thoracic sounds, the QV of fine crackles was significantly higher in the outcome group vs the non-outcome group. Cervical inspiratory sounds volume (average of five breaths) immediately after extubation was significantly louder in the outcome group vs non-outcome group (63.3dB vs 54.3dB, respectively; p < 0.001). Quantification of abnormal respiratory sounds and respiratory volume may predict respiratory failure and airway problems after extubation.

Predictors of Poor Outcome among Critically Ill COVID-19 Patients: A Nationally Representative Sample of the Saudi Arabian Population.

The outbreak and continuing impact of COVID-19 have significantly increased the rates of hospitalization and admissions to intensive care units (ICU). This study evaluates clinical outcomes in critically ill patients and investigates variables tied to poor prognosis. A secondary database analysis was conducted to investigate the predictors of poor outcome among critically ill COVID-19 patients in Saudi Arabia. Multivariable logistic regression analysis was used to assess the association between various demographic characteristics, comorbidities, and COVID-19 symptoms and patients’ poor prognosis, as a composite outcome. A total of 2257 critically ill patients were identified (male (71.8%), and elderly (37.3%)). The mortality rate was 50.0%, and the composite poor outcome was 68.4%. The predictors of poor outcome were being elderly (OR = 4.79, 95%CI 3.19–7.18), obesity (OR = 1.43, 95%CI 1.1–1.87), having a severe or critical case at admission (OR = 6.46, 95%CI 2.34–17.8; OR = 22.3, 95%CI 11.0–45, respectively), and some signs and symptoms of COVID-19 such as shortness of breath, feeling fatigued or headache, respiratory rate ≥ 30/min, PaO2/FiO2 ratio < 300, and altered consciousness. In conclusion, identifying high-risk populations that are expected to have a poor prognosis based on their criteria upon admission helps policymakers and practitioners better triage patients when faced with limited healthcare resources.

Differences in Outcomes in Obese (≥30), Morbidly Obese (≥40), and Super Morbidly Obese (≥50) Pregnancies

BackgroundObesity in pregnancy is an increasing problem in the United States. Obesity in pregnancy can result in dangerous complications such as premature birth, cesarean delivery, gestational diabetes, and preeclampsia. Little is currently known about outcomes in the morbidly (body mass index (BMI) ≥40 kg/m2) and super morbidly obese (BMI ≥50 kg/m2) in pregnant patients. Consequently, it is difficult to adequately counsel patients and plan for delivery care. Most current data groups outcomes for obese patients in general, however, some aspects such as reductions in hormone concentrations in pregnancy vary markedly with increasing weight. Obesity can alter hormone concentrations in pregnancy. For example, significantly lower beta human chorionic gonadotropin concentrations and progesterone are observed with increasing weight. Thus, we hypothesized that there are differences outcomes between obese, morbidly obese, and super morbidly obese pregnancies. The purpose of this study (IRB #202004178) is to analyze pregnancy outcomes of women with body mass index (BMI) ≥40 kg/m2 in comparison to obese women with a BMI of 30‐35 kg/m2 with a more rigorous BMI classification system than has been previously used. Our hypothesis is that morbidly obese and super morbidly obese pregnant women will have significant differences in adverse outcomes compared to obese women.MethodsA retrospective cohort study was performed comparing pregnancy outcomes of women with a BMI ≥ 30kg/m2 who delivered at the University of Iowa Hospitals and Clinics (UIHC) between 2009 and 2020. Data were extracted from the electronic health record (Epic) using the Intergenerational Health Knowledgebase, an enterprise data warehouse for research containing validated data from all pregnancies receiving care at UIHC. Additional data was extracted directly from the medical record. Women were included if they were ≥18 years old, had a singleton pregnancy and BMI ≥ 30 kg/m2, and delivered at UIHC (N=6445). Women were stratified into cohorts based on BMI (35‐39.9, 40‐49.9, 50‐59.9, 60‐69.9, 70‐79.9, ≥80 kg/m2) and compared to women with a BMI of 30‐35 kg/m2. Categorical variables were analyzed by chi square and continuous variables by t‐test. Regression models were created to control for confounding.ResultsStatistically significant increased incidences for gestational diabetes, preeclampsia, newborn hypoglycemia, number of days in the hospital post‐delivery, birthweight, and a composite poor neonatal outcome (P&lt;0.001 for each outcome) were associated with increasing BMI. Both the 1‐ and 5‐minute APGAR scores worsened with increasing BMI (P&lt; 0.001). However, there were decreased rates of caesarean section (P&lt;0.001) and pre‐term birth (P=0.02) associated with increasing BMI. There were no statistically significant differences in neonatal ICU admission, death, respiratory distress, and pulmonary hypoplasia.ConclusionBy identifying pregnancy outcomes using classifications with a smaller BMI range, it will be possible to develop more specific counseling and effective care plans for obese, morbidly obese, and super morbidly obese patients in the future.

Association of residual inflammatory risk with stroke recurrence in patients with acute ischaemic stroke or transient ischaemic attack.

The aim was to explore the association of residual inflammatory risk (RIR) with stroke recurrence after an index acute ischaemic stroke or transient ischaemic attack. This study was based on the Third China National Stroke Registry. A total of 5840 patients with two high sensitivity C-reactive protein (hsCRP) measurements at baseline and at 3 months were included in the analysis. High RIR was defined as an hsCRP ≥3mg/l. Patients were divided into four groups: persistent high RIR (first high then high hsCRP), attenuated RIR (first high then low hsCRP), increased RIR (first low then high hsCRP) and persistent low RIR (first low then low hsCRP). The primary outcome was new stroke onset during the 1-year follow-up. Secondary outcomes included composite vascular events, all-cause mortality and poor functional outcome (modified Rankin Scale score 3-6). During the 1-year follow-up, 523 (9.0%) patients had stroke recurrence. Patients with persistent high RIR had an increased risk of stroke recurrence (hazard ratio with 95% confidence interval 1.39, 1.08-1.78), compared with those with persistent low RIR. Similar results were found for the outcome of composite vascular events, mortality and poor functional outcome. An increased risk of stroke recurrence was further found in patients with persistent high RIR and intracranial artery stenosis or large-artery atherosclerosis stroke subtype. In patients with acute ischaemic stroke or transient ischaemic attack, persistent high RIR increased the risks of 1-year stroke recurrence, especially in those with intracranial artery stenosis or large-artery atherosclerosis subtype, composite vascular events, mortality and poor functional outcome.

Prognostic Value of Syndecan-1 in the Prediction of Sepsis-Related Complications and Mortality: A Meta-Analysis.

AimSyndecan-1 (SDC-1) has been shown to have a high predictive value for sepsis development, though uncertainty around these results exists. The aim of this meta-analysis was to assess the prognostic ability of SDC-1 in predicting sepsis-related complications and mortality.MethodsWe searched PubMed, EMBASE, Cochrane Library, and Google Scholar databases from January 01, 1990, to March 17, 2021, to identify eligible studies. The search terms used were “SDC-1,” “sepsis,” “severe sepsis,” and “septic shock,” and a meta-analysis was performed using the RevMan 5.4 software.ResultsEleven studies with a total of 2,318 enrolled patients were included. SDC-1 concentrations were significantly higher in the composite poor outcome group [standardized mean difference (SMD) = 0.55; 95% CI: 0.38–0.72; P < 0.001] as well as in deceased patients (SMD = 0.53; 95% CI: 0.40–0.67; P < 0.001), patients with septic shock (SMD = 0.81; 95% CI: 0.36–1.25; P < 0.001), and patients with acute kidney injury (SMD = 0.48; 95% CI: 0.33–0.62; P < 0.001). Statistical significance was also found in the subgroup analysis when stratified by different sepsis diagnostic criteria.ConclusionBaseline SDC-1 levels may be a useful predictor of sepsis-related complications and mortality.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021246344, PROSPERO, identifier: CRD42021246344.

Insulin Therapy and Outcome of Coronavirus Disease 2019 (COVID-19): A Systematic Review, Meta-Analysis, and Meta-Regression.

Currently, the relationship between insulin therapy and COVID-19 outcome is not yet established. Our study aims to evaluate the possible association between insulin and the composite poor outcome of COVID-19. We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until December 12th, 2020. All articles published on COVID-19 and insulin were retrieved. Statistical analysis was done using Review Manager 5.4 and Comprehensive Meta-Analysis version 3 software. Our pooled analysis showed that insulin use was associated with composite poor outcomes of COVID-19 [OR 2.06 (95% CI 1.70 - 2.48), p < 0.00001, I2 = 83%, random-effect modelling], and its subgroup which comprised of risk of COVID-19 [OR 1.70 (95% CI 1.40 - 2.08), p < 0.00001, I2 = 34%, random-effect modelling], severe COVID-19 [OR 2.30 (95% CI 1.60 - 3.30), p < 0.00001, I2 = 88%, random-effect modelling], and mortality [OR 2.14 (95% CI 1.47 - 3.10), p < 0.0001, I2 = 85%, random-effect modelling]. Meta-regression showed that the association was influenced by age (p = 0.008), but not by diabetes p = 0.423) and cardiovascular disease (p = 0.086). Physicians should be more aware and take extra precautions with diabetes patients who use insulin therapy.

The Use of Proton Pump Inhibitors and COVID-19: A Systematic Review and Meta-Analysis.

COVID-19 has proved to be a serious, and consequential disease that has affected millions of people globally. Previously, the adverse effects of proton pump inhibitors (PPI) have been observed with increasing the risk of pneumonia and COVID-19. This meta-analysis aims to address the relationship between the use of PPI and the severity of COVID-19 infection. We conducted a systemic literature search from PUBMED, Science Direct, and Cinahl from December 2019 to January 2022. Published and unpublished randomized control trials and cohort studies were included. Review Manager was used for all statistical analyses. In total, 14 studies were included in this systemic review and meta-analysis. Outcomes of interest include: (1) susceptibility of COVID-19 infection and (2) severity of COVID-19 (defined as the composite of poor outcomes: ICU admission, need for oxygen therapy, need for a ventilator, or death), and (3) mortality due to COVID-19. PPI use was marginally associated with a nominal but statistically significant increase in the risk of COVID-19 infection (OR 1.05 [1.01, 1.09]; I2 97%, p = 0.007). PPI use also increased the risk of the composite poor outcome (OR 1.84 [1.71, 1.99]; I2 98%, p < 0.00001) and mortality (OR 1.12 [1.00, 1.25]; I2 84%, p = 0.05) in patients with COVID-19.