Higher Risk Of Hospitalization Research Articles

Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care

Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022. Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner. Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015. Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]). Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

Viral clade is associated with severity of symptomatic genotype 3 hepatitis E virus infections in Belgium, 2010–2018

HEV genotype (gt) 3 infections are prevalent in high-income countries and display a wide spectrum of clinical presentations. Host - but not viral - factors are reported to be associated with worse clinical outcomes. Demographic, clinical, and biochemical data laboratory-confirmed HEV infections (by PCR and/or a combination of IgM and IgG serology) at the Belgian National Reference Centre between January 2010 and June 2018 were collected using standardised case report forms. Genotyping was based on HEV open reading frame 2 sequences. Serum CXCL10 levels were measured by a magnetic bead-based assay. H&E staining was performed on liver biopsies. A total of 274 HEV-infected individuals were included. Subtype assignment was possible for 179/218 viraemic cases, confirming gt3 as dominant with an almost equal representation of clades abchijklm and efg. An increased hospitalisation rate and higher peak serum levels of alanine aminotransferase, bilirubin, and alkaline phosphatase were found in clade efg-infected individuals in univariate analyses. In multivariable analyses, clade efg infections remained more strongly associated with severe disease presentation than any of the previously identified host risk factors, being associated with a 2.1-fold higher risk of hospitalisation (95% CI 1.1-4.4, p= 0.034) and a 68.2% higher peak of bilirubin levels (95% CI 13.3-149.9, p= 0.010), independently of other factors included in the model. In addition, acute clade efg infections were characterised by higher serum CXCL10 levels (p= 0.0005) and a more pronounced liver necro-inflammatory activity (p= 0.022). In symptomatic HEV gt3 infections, clade efg is associated with a more severe disease presentation, higher serum CXCL10 levels, and liver necro-inflammatory activity, irrespective of known host risk factors. The protocol was submitted to clinicaltrials.gov (NCT04670419). HEV genotype (gt) 3 infections display a wide spectrum of clinical presentations currently ascribed to host factors. Here we examined the role of viral factors on liver disease outcomes by combining viral phylogeny with clinical, biochemical, cytokine, and histological data from 274 Belgian adults infected with HEV presenting between 2010 and 2018. HEV gt 3 clade efg infections were associated with a more severe disease presentation, higher serum CXCL10 levels and liver necro-inflammatory activity, irrespective of known host risk factors. HEV gt3 clade-dependent clinical outcomes call for broad HEV gt3 subtyping in clinical practice and research to help identify those at higher risk for worse outcomes and to further unravel underlying virus-host interactions.

Intertwined Crises: California’s Public Universities’ Responses to COVID-19 and Anti-Asian Animus, January 2020 to June 2021

COVID-19 ravaged everyday life for individuals across the globe, but its impact was especially harmful to Asian Americans who suffered both a notably high risk of infection and hospitalization, as well as a sharp rise in anti-Asian racism. In this article, we take these intertwined issues—a synergistic interaction between a novel virus and the deeply rooted racism rendering Asian Americans as perennial foreigners—to interrogate whether and how organizations’ early responses to COVID-evidenced communicative strategies that acknowledged the crises that unraveled throughout 2020. Through the framings of Situational Crisis Communication Theory and Racialized Organizations, this study considers what repertoire of crisis communication strategies do public institutions employ to address COVID-19 and what do these responses reveal about racialized inequality in higher education? The findings draw from an original archive of 2,723 public community messages across 31 public institutions in the University of California and California State University systems and demonstrate a deprioritization of responsiveness to anti-Asian animus amid the multiple issues emergent from COVID-19; rather than taking the opportunity to foreground universities’ capacity to respond to this crisis, institutions often redirected their responsibility. Such evidence reveals that universities are racialized organizations that employ management strategies that remain ill-prepared to not only manage racialized inequality throughout the crises of the COVID-19 syndemic but also to interrupt racism’s durability.

Age as a Predictive Factor in Severity of Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

The growth in worldwide popularity of electric bikes (E-bikes) and powered scooters (P-scooters) has been accompanied by an increase in injuries associated with their use. The aim of this study was to evaluate the contribution of rider age to injury severity, represented by need for hospitalization. A retrospective review of the database of a tertiary medical center yielded 1234 patients (75.7% male) who attended the emergency department (ED) in 2014–2020 for injuries sustained while riding an E-bike or P-scooter. Mean age was 31.52 ± 14.77 years: 23% were aged <20 years; 33%, 21–30 years; 23%, 31–40 years; 10%, 41–50 years; 11%, >51 years. Ninety patients (7.3%) were hospitalized. Older age was significantly associated with the need for hospitalization on univariate analysis (p <.001), but significance was not maintained on binary logistic regression (OR = 1.02, 95%CI 0.99–1.06; p = 0.11). Patients who underwent imaging evaluation in the ED were at lower risk of hospitalization, and patients who had surgery or a relatively long operative procedure were at higher risk of hospitalization. The study shows that older age (>51 years) is not associated with a significantly increased probability of severe injury in E-bike and P-scooter riders. This finding has important implications for insurers and healthcare administrators.

Associations of Hearing Loss Severity and Hearing Aid Use With Hospitalization Among Older US Adults

Hearing loss is associated with higher hospitalization risk among older adults. However, evidence on whether hearing aid use is associated with fewer hospitalizations among individuals with hearing loss remains limited. To assess the association between audiometric hearing loss severity and hearing aid use and hospitalization. This population-based cross-sectional study used audiometric and health care utilization data for respondents aged 65 years or older from 4 cycles of the National Health and Nutrition Examination Survey from 2005 to 2016. Data were analyzed from February 23, 2021, to March 22, 2022. Audiometric hearing loss severity and participant-reported hearing aid use. The main outcome was respondent-reported hospitalization in the past 12 months. Multivariable logistic regression was performed to assess the association of hearing loss severity with hospitalization. To assess the association of hearing aid use with hospitalization, propensity score matching was performed with 2:1 nearest neighbor matching without replacement. Of 2060 respondents (mean [SD] age, 73.9 [5.9] years; 1045 [50.7%] male), 875 (42.5%) had normal hearing, 653 (31.7%) had mild hearing loss, 435 (21.1%) had moderate hearing loss, and 97 (4.7%) had severe to profound hearing loss. On multivariable analysis, moderate and severe hearing loss were associated with hospitalization (moderate hearing loss: odds ratio [OR], 1.50; 95% CI, 1.01-2.24; severe hearing loss: OR, 1.71; 95% CI, 1.03-2.84). Of 1185 respondents with at least mild hearing loss, 200 (16.9%) reported using a hearing aid. Propensity score-matched analysis showed that hearing aid use was not associated with hospitalization (OR, 1.17; 95% CI, 0.74-1.84), including among respondents with moderate or severe hearing loss (OR, 1.17; 95% CI, 0.71-1.92). In this cross-sectional study, hearing loss was associated with higher risk of hospitalization, but hearing aid use was not associated with a reduction in hospitalization risk in the population with hearing loss. The association of hearing aid use with hospitalization should be evaluated in larger prospective studies with reliable data on the frequency of hearing aid use.

Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure.

Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care. We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios. The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care. Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort

Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups. To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study. This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022. RYGB or SG. Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery. A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse. Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Chronic heart failure: a review of pharmacotherapy management

To evaluate, describe and compare the pharmacological treatments available for heart failure (HF). This is a literature review about the pharmacological treatment of HF based on articles selected from the PubMed database, as well as relevant guidelines, using pertinent keywords and application of inclusion and exclusion criteria. Chronic heart failure is a common condition that, if untreated, harms quality of life and is associated with a high risk of mortality, morbidity, and recurrent hospitalization. However, the prognosis of patients with this condition has been improved with knowledge of the pathophysiology of HF and, therefore, assertive application of both non-pharmacological and pharmacological treatment recommendations. Pharmacotherapy is based on neurohormoral inhibition of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system to improve the health status and survival of these patients. Currently, the recommendation for the treatment of HF with reduced ejection fraction (HFrEF) includes 4 drug classes: an angiotensin/neprilysin receptor inhibitor (ANRi), beta-blockers, mineralocorticoid receptor antagonists (MRA) and SGLT2 inhibitors (SGLT2ii). Mortality-reducing pharmacotherapy in HF currently includes ANRi, beta-blockers, MRA and SGLT2. Therefore, the challenge is to transform the results achieved in clinical studies into reality for the majority of patients with HF. This path must be promoted through multidisciplinary care with improved access to recommended drugs, close monitoring of patients, healthy habits, control of comorbidities and therapeutic adherence.

Reliability of predictive models to support early decision making in the emergency department for patients with confirmed diagnosis of COVID-19: the Pescara Covid Hospital score

BackgroundThe hospital management of patients diagnosed with COVID-19 can be hampered by heterogeneous characteristics at entry into the emergency department. We aimed to identify demographic, clinical and laboratory parameters associated with higher risks of hospitalisation, oxygen support, admission to intensive care and death, to build a risk score for clinical decision making at presentation to the emergency department.MethodsWe carried out a retrospective study using linked administrative data and laboratory parameters available in the initial phase of the pandemic at the emergency department of the regional reference hospital of Pescara, Abruzzo, Italy, March–June 2020. Logistic regression and Cox modelling were used to identify independent predictors for risk stratification. Validation was carried out collecting data from an extended timeframe covering other variants of concern, including Alpha (December 2020–January 2021) and Delta/Omicron (January–March 2022).ResultsSeveral clinical and laboratory parameters were significantly associated to the outcomes of interest, independently from age and gender. The strongest predictors were: for hospitalisation, monocyte distribution width ≥ 22 (4.09; 2.21–7.72) and diabetes (OR = 3.04; 1.09–9.84); for oxygen support: saturation < 95% (OR = 11.01; 3.75–41.14), lactate dehydrogenase≥237 U/L (OR = 5.93; 2.40–15.39) and lymphocytes< 1.2 × 103/μL (OR = 4.49; 1.84–11.53); for intensive care, end stage renal disease (OR = 59.42; 2.43–2230.60), lactate dehydrogenase≥334 U/L (OR = 5.59; 2.46–13.84), D-dimer≥2.37 mg/L (OR = 5.18; 1.14–26.36), monocyte distribution width ≥ 25 (OR = 3.32; 1.39–8.50); for death, procalcitonin≥0.2 ng/mL (HR = 2.86; 1.95–4.19) and saturation < 96% (HR = 2.74; 1.76–4.28). Risk scores derived from predictive models using optimal thresholds achieved values of the area under the curve between 81 and 91%. Validation of the scoring algorithm for the evolving virus achieved accuracy between 65 and 84%.ConclusionsA set of parameters that are normally available at emergency departments of any hospital can be used to stratify patients with COVID-19 at risk of severe conditions. The method shall be calibrated to support timely clinical decision during the first hours of admission with different variants of concern.

Impact of apixaban treatment discontinuation on the risk of hospitalization among patients with nonvalvular atrial fibrillation and COVID-19

Introduction This study evaluated the risk of hospitalization among nonvalvular atrial fibrillation (NVAF) patients with an outpatient COVID-19 diagnosis who discontinued vs continued apixaban treatment. Methods Adult patients with NVAF with an apixaban prescription prior to an outpatient COVID-19 diagnosis were identified from Optum Clinformatics claims database (1 April 2020–31 March 2021). Continuers were those who continued apixaban as of the index date (date of initial outpatient COVID-19 diagnosis) and discontinuers were those who had the last day of apixaban supply on or before index. Patients were followed from COVID-19 diagnosis to change of continuation/discontinuation status, switch, death, end of continuous coverage or study end, whichever occurred first. Inverse probability treatment weighting (IPTW) was performed to balance cohorts. Cox proportional hazard models were used to compare the risk of all-cause hospitalization and hospitalization for ischemic stroke (IS), venous thromboembolism (VTE), myocardial infarction (MI), bleeding and mortality. Results A total of 7869 apixaban patients with COVID-19 were included: 6676 continuers (84.8%) and 1193 discontinuers (15.2%). Compared with continuers, discontinuers had a higher risk of all-cause hospitalization (hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.08–1.40), IS (HR: 2.00; 95% CI: 1.03–3.87), VTE (HR: 2.37; 95% CI: 1.06–5.27) and mortality (HR: 2.28; 95% CI: 1.85–2.80). There were no significant differences in the risk of MI (HR: 1.01; 95% CI: 0.54–1.90) or bleeding-related hospitalization (HR: 1.13; 95% CI: 0.73–1.76). Conclusion NVAF patients with COVID-19 who discontinued apixaban had a higher risk of hospitalization and thrombotic events vs those who continued apixaban, with no significant difference in bleeding-related hospitalization.

High ambient temperature and risk of hospitalization for gastrointestinal infection in Brazil: A nationwide case-crossover study during 2000–2015

BackgroundThe burden of gastrointestinal infections related to hot ambient temperature remains largely unexplored in low-to-middle income countries which have most of the cases globally and are experiencing the greatest impact from climate change. The situation is particularly true in Brazil. ObjectivesUsing medical records covering over 78 % of population, we quantify the association between high temperature and risk of hospitalization for gastrointestinal infection in Brazil between 2000 and 2015. MethodsData on hospitalization for gastrointestinal infection and weather conditions were collected from 1814 Brazilian cities during the 2000–2015 hot seasons. A time-stratified case-crossover design was used to estimate the association. Stratified analyses were performed by region, sex, age-group, type of infection and early/late study period. ResultsFor every 5 °C increase in mean daily temperature, the cumulative odds ratio (OR) of hospitalization over 0–9 days was 1.22 [95 % confidence interval (CI): 1.21, 1.23] at the national level, reaching its maximum in the south and its minimum in the north. The strength of association tended to decline across successive age-groups, with infants < 1 year most susceptible. The effect estimates were similar for men and women. Waterborne and foodborne infections were more associated with high temperature than the ‘others’ and ‘idiopathic’ groups. There was no substantial change in the association over the 16-year study period. DiscussionOur findings indicate that exposure to high temperature is associated with increased risk of hospitalization for gastrointestinal infection in the hot season, with the strength varying by region, population subgroup and infection type. There was no evidence to indicate adaptation to heat over the study duration.

Impact of COVID-19 on gynecologic oncology patients: an SGO COVID-19 and Gynecologic Cancer Registry study (050)

Objectives: The COVID-19 pandemic has disrupted timely medical care, including receipt of anticancer therapy. Gynecologic oncology (GO) patients (pts), who are often comorbid and require a range of therapies, may have varied responses to COVID-19 infection. Our study aimed to describe outcomes for GO pts with concurrent COVID-19 infection in the United States.Methods: The Society of Gynecologic Oncology COVID-19 and Gynecologic Cancer Registry was developed as a web-based data entry platform to capture the clinical courses and cancer treatment-related effects in GO pts with confirmed COVID-19 infection. Demographics, clinical manifestations, outcomes, treatment type, and disease severity were analyzed.Results: Data were available for 312 GO pts across eight institutions. The median age was 63 years, and most pts were identified as White (70%), Black/African American (17%), or Asian (2%). GO diagnosis included low-grade endometrial (31%), high-grade ovarian (22%), cervical (14%), high-grade endometrial (13%), vulvar (3%), and other (16%). At the time of COVID-19 diagnosis, 37% of pts had active malignancy, with 25% receiving anticancer therapy. The most common anticancer treatments included chemotherapy (51%, n=39), targeted agents (25%, n = 27), and surgery (27%, n = 21), whereas 12 pts (16%) received multi-modal therapy. Delay or discontinuation of treatment due to COVID-19 infection occurred in 28% of patients (median 3-4 weeks delay). Chemotherapy was most frequently delayed (43%), followed by surgery (27%). In total, 19% of GO pts required supplemental oxygen, and 29% were hospitalized (5% in the intensive care setting). Ten pts (3%) required ventilator support, and 30% of pts receiving chemotherapy were hospitalized. Older age, having more than two comorbid conditions, and non-White race were associated (p<0.05) with a higher likelihood of being hospitalized or admitted to the intensive care unit. Patients who required hospitalization were disproportionately Black/African American, Asian, or other non-Whites (p = 0.003). On multivariable analysis, pts of non-White race (aOR: 2.86, 95% CI: 1.64-5.00; p<0.001) and advancing age (aOR: 1.28, 95% CI: 1.16-1.42; p<0.001) had a higher risk of hospitalization. In terms of mortality, 8% of hospitalized pts died of COVID-19 complications, and 4% of the entire cohort was not alive 30 days after COVID-19 diagnosis. Patients who died were more likely to be older (OR: 1.25 per 5-year increase, 95% CI: 1.01-1.55), had active malignancy (OR: 3.86, 95% CI: 1.16-12.85), or be of the non-White race (death rate of 3% White, 8% Black/African American, 25% Asian).Conclusions: GO pts diagnosed with COVID-19 are at high risk of hospitalization, delay of anticancer treatments, and death. Approximately one in 23 GO pts who contracted COVID-19 were not alive 30 days after diagnosis. Racial disparities exist in pt hospitalizations and mortality rates. Additional studies are needed to determine the long-term oncologic and mortality outcomes and the impact of race in this pt cohort.

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

Factors Associated With Severity of COVID-19 Disease in a Multicenter Cohort of People With HIV in the United States, March-December 2020.

Understanding the spectrum of COVID-19 in people with HIV (PWH) is critical to provide clinical guidance and risk reduction strategies. Centers for AIDS Research Network of Integrated Clinic System, a US multisite clinical cohort of PWH in care. We identified COVID-19 cases and severity (hospitalization, intensive care, and death) in a large, diverse HIV cohort during March 1, 2020-December 31, 2020. We determined predictors and relative risks of hospitalization among PWH with COVID-19, adjusted for disease risk scores. Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March and December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized, and 12 died. PWH with current CD4 count <350 cells/mm 3 [aRR 2.68; 95% confidence interval (CI): 1.93 to 3.71; P < 0.001] or lowest recorded CD4 count <200 cells/mm 3 (aRR 1.67; 95% CI: 1.18 to 2.36; P < 0.005) had greater risks of hospitalization. HIV viral load and antiretroviral therapy status were not associated with hospitalization, although most of the PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared with other racial/ethnic groups (aRR 1.51; 95% CI: 1.04 to 2.19; P = 0.03). Chronic kidney disease, chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher hospitalization risk. PWH who were older, not on antiretroviral therapy, and with current CD4 count <350 cells/mm 3 , diabetes, and chronic kidney disease were overrepresented among PWH who required intubation or died. PWH with CD4 count <350 cells/mm 3 , and a history of CD4 count <200 cells/mm 3 , have a clear excess risk of severe COVID-19, accounting for comorbidities associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination and early treatment and monitored closely for worsening illness.

Prescribing Pattern of Antibiotics in Respiratory Tract Infections in the Pediatric Indoor Patients at Manipal Teaching Hospital

Introduction: Respiratory tract infections are the most frequently occurring illness in childhood and antibiotics are the key drugs for its treatment which account for three-quarters of all antibiotics prescriptions. Injudicious use of antibiotics leads to the development of resistance, patients are at high risk for opportunistic infections or prolonged hospitalization. This study aimed to assess the prescribing pattern of antibiotics for respiratory tract infections in the pediatric indoor patients of Manipal Teaching Hospital.&#x0D; Methods: This study is a prospective cross-sectional study done in the paediatrics ward of Manipal Teaching Hospital Pokhara, conducted for six months. Patients aged range from 1 day to 14 years who meet the inclusion criteria were taken in this study. Data were collected from the inpatient ward and analysed using various statistical tools.&#x0D; Results: Among 170 patients, a maximum(43.3%) were in the age group of 1 day to 11 months with male predominance(74.1%). Bronchopneumonia was the most common respiratory tract infection (51.8%) followed by bronchiolitis (13%). Chest x-ray was done in all patients however blood culture was done only in 60.6% and an antibiotic sensitivity test (27.6%) before prescribing antibiotics. Cefotaxime was prescribed in maximum patients (62.4%) followed by ceftriaxone (17.1%). All the patients received at least one antibiotic by i.v route during the hospital stay.&#x0D; Conclusion: Since culture and sensitivity tests were not carried out on most of the patients before prescribing antibiotics in this study, which might lead to an increased chance of bacterial resistance and treatment failure in the future.

Impacts of androgen deprivation therapy on the risks and outcomes of SARS-CoV-2 infection in patients with prostate cancer.

Studies have investigated the effects of androgen deprivation therapy (ADT) use on the incidence and clinical outcomes of coronavirus disease 2019 (COVID-19); however, the results have been inconsistent. We searched the PubMed, Medline, Cochrane, Scopus, and Web of Science databases from inception to March 2022; 13 studies covering 84 003 prostate cancer (PCa) patients with or without ADT met the eligibility criteria and were included in the meta-analysis. We calculated the pooled risk ratios (RRs) with 95% confidence intervals (CIs) to explore the association between ADT use and the infection risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and severity of COVID-19. After synthesizing the evidence, the pooled RR in the SARS-CoV-2 positive group was equal to 1.17, and the SARS-CoV-2 positive risk in PCa patients using ADT was not significantly different from that in those not using ADT (P = 0.544). Moreover, no significant results concerning the beneficial effect of ADT on the rate of intensive care unit admission (RR = 1.04, P = 0.872) or death risk (RR = 1.23, P = 0.53) were found. However, PCa patients with a history of ADT use had a markedly higher COVID-19 hospitalization rate (RR = 1.31, P = 0.015) than those with no history of ADT use. These findings indicate that ADT use by PCa patients is associated with a high risk of hospitalization during infection with SARS-CoV-2. A large number of high quality studies are needed to confirm these results.

Why antidiabetic drugs are potentially neuroprotective during the Sars-CoV-2 pandemic: The focus on astroglial UPR and calcium-binding proteins.

We are living in a terrifying pandemic caused by Sars-CoV-2, in which patients with diabetes mellitus have, from the beginning, been identified as having a high risk of hospitalization and mortality. This viral disease is not limited to the respiratory system, but also affects, among other organs, the central nervous system. Furthermore, we already know that individuals with diabetes mellitus exhibit signs of astrocyte dysfunction and are more likely to develop cognitive deficits and even dementia. It is now being realized that COVID-19 incurs long-term effects and that those infected can develop several neurological and psychiatric manifestations. As this virus seriously compromises cell metabolism by triggering several mechanisms leading to the unfolded protein response (UPR), which involves endoplasmic reticulum Ca2+ depletion, we review here the basis involved in this response that are intimately associated with the development of neurodegenerative diseases. The discussion aims to highlight two aspects—the role of calcium-binding proteins and the role of astrocytes, glial cells that integrate energy metabolism with neurotransmission and with neuroinflammation. Among the proteins discussed are calpain, calcineurin, and sorcin. These proteins are emphasized as markers of the UPR and are potential therapeutic targets. Finally, we discuss the role of drugs widely prescribed to patients with diabetes mellitus, such as statins, metformin, and calcium channel blockers. The review assesses potential neuroprotection mechanisms, focusing on the UPR and the restoration of reticular Ca2+ homeostasis, based on both clinical and experimental data.

Assessment of unvaccinated and vaccinated patients with coronavirus disease 2019 (COVID-19) treated with monoclonal antibodies during the delta wave (July 1–August 20, 2021): a retrospective observational monocentric study

BackgroundMonoclonal antibodies (mAb) prevent COVID-19 progression when administered early. We compared mAb treatment outcomes among vaccinated and unvaccinated patients during Delta wave and assessed the feasibility of implementing stricter eligibility criteria in the event of mAb scarcity.MethodsWe conducted a retrospective observational study of casirivimab/imdevimab recipients with mild-to-moderate COVID-19 infection in an emergency department or outpatient infusion center (July 1–August 20, 2021). Primary outcome was all-cause hospital admission within 30 days post-treatment between vaccinated vs. unvaccinated patients during Delta surge in the Bronx, NY.ResultsA total of 250 patients received casirivimab/imdevimab (162 unvaccinated vs. 88 vaccinated). The median age was 39 years for unvaccinated patients, and 52 years for vaccinated patients (p < 0.0001). The median number of EUA criteria met was 1 for unvaccinated and 2 for vaccinated patients (p < 0.0001). Overall, 6% (15/250) of patients were admitted within 30 days post-treatment. Eleven unvaccinated patients (7%) were admitted within 30-days compared to 4 (5%) vaccinated patients (p = 0.48).ConclusionsAll-cause 30-day admission was not statistically different between vaccinated and unvaccinated patients. When federal allocation of therapies is limited, programs must prioritize patients at highest risk of hospitalization and death regardless of vaccination status.

Favipiravir and/or nitazoxanide: a randomized, double-blind, placebo-controlled trial of early therapy in COVID-19 in health workers, their household members, and patients treated at IMSS (FANTAZE)

BackgroundThe 2020 pandemic of SARS-CoV-2 causing COVID-19 disease is an unprecedented global emergency. COVID-19 appears to be a disease with an early phase where the virus replicates, coinciding with the first presentation of symptoms, followed by a later ‘inflammatory’ phase which results in severe disease in some individuals. It is known from other rapidly progressive infections such as sepsis and influenza that early treatment with antimicrobials is associated with a better outcome. The hypothesis is that this holds for COVID-19 and that early antiviral treatment may prevent progression to the later phase of the disease.MethodsTrial design: Phase IIA randomised, double-blind, 2 × 2 design, placebo-controlled, interventional trial.Randomisation: Participants will be randomised 1:1 by stratification, with the following factors: gender, obesity, symptomatic or asymptomatic, current smoking status presence or absence of comorbidity, and if the participant has or has not been vaccinated. Blinding: Participants and investigators will both be blinded to treatment allocation (double-blind).DiscussionWe propose to conduct a proof-of-principle placebo-controlled clinical trial of favipiravir plus or minus nitazoxanide in health workers, their household members and patients treated at the Mexican Social Security Institute (IMSS) facilities. Participants with or without symptomatic COVID-19 or who tested positive will be assigned to receive favipiravir plus nitazoxanide or favipiravir plus nitazoxanide placebo. The primary outcome will be the difference in the amount of virus (‘viral load’) in the upper respiratory tract after 5 days of therapy. Secondary outcomes will include hospitalization, major morbidity and mortality, pharmacokinetics, and impact of antiviral therapy on viral genetic mutation rate. If favipiravir with nitazoxanide demonstrates important antiviral effects without significant toxicity, there will be a strong case for a larger trial in people at high risk of hospitalization or intensive care admission, for example older patients and/or those with comorbidities and with early disease.Trial registrationClinicalTrials.govNCT04918927. Registered on June 9, 2021.

Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans.

Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.