Higher Risk Of Hospitalization Research Articles

Activity Monitoring for Early Detection and Management of Toxicity in Patients Undergoing Chemoradiation for Gastrointestinal Malignancy

<h3>Purpose/Objective(s)</h3> Higher levels of physical activity assessed by step count have been associated with lower risk of hospitalization during cancer treatment. We hypothesize that it is feasible to use activity data to identify patients undergoing concurrent chemoradiation for gastrointestinal (GI) malignancy who are at high risk for emergency department (ED) visits and hospitalizations, and to successfully trigger and execute triage visits for symptom management. <h3>Materials/Methods</h3> This prospective study randomized patients to activity monitoring versus observation. Each group was provided an activity monitor. If a patient in the intervention arm had 20% decreased activity or 20% increase in heart rate from their baseline, a triage visit was triggered to evaluate and treat symptoms. In the observation group, activity data was recorded but no triage visit was triggered. Baseline step count and heart rate were established during a one-week period between radiation simulation and treatment start. The primary endpoint was to demonstrate an increased rate of triage visits in the activity monitoring group compared to observation. Secondary outcomes included rates of ED visits and hospitalizations. Crude and adjusted odds ratios (OR) were computed using logistic regression modeling. <h3>Results</h3> A total of 40 patients were enrolled on the study: 22 in the intervention group and 18 in the observation group. Primary disease sites included anus (n = 4), gastric/esophagus (n = 14), hepatobiliary (n = 4), pancreas (n = 7), and rectum (n = 11). Median age was 60 years in the intervention arm and 62.5 years in the observation arm (<i>P</i> = 0.69). The median radiation dose and fractionation were similar among the two groups. Average baseline daily step counts were similar in the two groups (5,103 in intervention group vs. 5,668 in observation group, <i>P</i> = 0.43). Average daily step counts decreased from week 1 to week 5 in both groups (-960 steps in observation group and -1,164 steps in the intervention group). There was an increased rate of triage visits in the intervention arm compared to the observation arm (86.4% v 38.9%, OR 9.95, 95% CI 2.12-46.56, <i>P</i> = 0.015). Rates of ED visits and hospitalizations were numerically lower in the intervention group compared to the observation group (9.1% vs 22.2%, <i>P</i> = 0.31; 4.5% vs 16.7%, <i>P</i> = 0.31, respectively). Patients with anal (-1456 steps) cancer showed the largest decrease in mean daily step count over the treatment course. Medical intervention was more common in the intervention group compared to observation (<i>P</i> < 0.001). <h3>Conclusion</h3> This study supports the feasibility of actively monitoring patient's daily step and heart rate data to successfully trigger triage visits for patients at high risk for toxicity. Further studies are ongoing and may support the use of automated activity monitoring to decrease the rates of ED visits and hospitalizations.

Predicting Unplanned Hospitalization Among Patients Receiving Definitive Radiation

<h3>Purpose/Objective(s)</h3> A small fraction of cancer patients receiving definitive radiation experience unplanned hospitalizations related to treatment, which potentially leads to substantial morbidity or mortality. Identifying patients at high risk of unplanned hospitalizations could help with risk stratification, and potentially help inform future interventions aimed at improving patient outcomes. This study evaluated the predictive capacity of a machine learning prediction algorithm to identify unplanned hospitalizations and intensive care unit (ICU) visits among a large cohort of patients undergoing definitive radiation therapy. <h3>Materials/Methods</h3> We identified cancer patients undergoing definitive radiation therapy from the Veterans Health Administration (VHA) between 2000 and 2017. We used an extreme gradient boosting model to separately predict the risk of unplanned hospitalization and ICU admission within 30 days of completion of radiation treatment. Model covariates included patient demographics, cancer stage and subtype, and treatment information including previous chemotherapy and surgery. The data were split 75%/25% into training/testing datasets. We constructed the model with training data and evaluated performance within the test data using area under the curve (AUC), with an AUC of 1.0 indicating perfect prediction. <h3>Results</h3> We identified 60,804 cancer patients from 14 tumor subtypes receiving definitive radiation therapy, of which 936 (1.5%) experienced an unplanned hospitalization with 113 (0.19%) escalated to the ICU. Our final predictive model included 30 features, which contained 10 demographic variables and 20 tumor or treatment characteristics. The predictive models achieved an AUC of 0.82 and 0.79 for predicting unplanned hospitalization and ICU visit, respectively. Emergency department visits prior to radiation treatment was identified as the most important associated feature for predicting both unplanned hospitalizations and ICU visits. Other features including tumor subtype, Charlson comorbidity score, previous chemotherapy, and biologic effective dose were also important predictors in the final models. <h3>Conclusion</h3> This study demonstrates that a machine learning model can help provide a robust prediction of unplanned hospitalizations and ICU admission among cancer patients receiving definitive radiation. Machine learning prediction models show promise in helping to identify patients at risk of severe adverse outcomes, though additional validation is needed as well as research studying how to effectively implement these tools into practice.

The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients

The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001–2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984–0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09–1.17 and HR 1.11, 95% CI 1.06–1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10–1.12 and SHR 1.22, 95% CI 1.21–1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.

Are morbidity and mortality estimates from randomized controlled trials externally valid? A comparison of outcomes among infants enrolled into an RCT or a cohort study in Botswana

BackgroundThe external validity of the randomized controlled trial (RCT) refers to the extent to which the results of the RCT apply to the relevant, non-trial population and is impacted by its eligibility criteria, its organization, and its delivery of the intervention. Here, we compared the outcomes of mortality and hospitalization between an RCT and a cohort study that concurrently enrolled HIV-exposed uninfected (HEU) newborns in Botswana.MethodsThe Mpepu Study (the RCT) was a clinical trial which determined that co-trimoxazole (CTX) provided no survival benefit for HEUs, allowing both arms of the RCT to be used. The Maikaelelo study (the cohort study) was a prospective observational study that enrolled HEU newborns with telephone follow-up and no in-person visits. Rates of death and hospitalization in the pooled population, were modeled using cox-proportional hazards models for time to death or time to first hospitalization, with study setting (RCT vs. cohort study) as an independent variable. The causal effect of study setting on morbidity and mortality was obtained through a treatment effects approach.ResultsIn total, 4,010 infants were included; 1,306 were enrolled into the cohort study and 2,704 were enrolled into the RCT. No significant differences in mortality were observed between the two study settings (HR: 1.28, 95% CI: 0.76, 2.13), but RCT participants had a lower risk of hospitalization (HR: 0.72, 95% CI: 0.58, 0.89) that decreased with age. However, RCT participants had a higher risk of hospitalization within the first six months of life. The causal risk difference in hospitalizations attributable to the RCT setting was -0.03 (95% CI: -0.05, -0.01).ConclusionsChildren in an RCT with rigorous application of national standard of care guidelines experienced a significantly lower risk of hospitalization than children participating in a cohort study that did not alter clinical care. Future research is needed to further investigate outcome disparities when real-world results fail to mirror those achieved in a clinical trial.Trial registrationThe Mpepu Trial was funded by the U.S. National Institutes of Health (No. NCT01229761) and the Maikaelelo Study was funded primarily by the U.S. Centers for Disease Control and Prevention (32AI007433-21).

More evidence for worse COVID-19 outcomes in people with HIV

More evidence for worse COVID-19 outcomes in people with HIV

Correlation of peripheral pulse wave features and pulse rate variability parameters with hospitalization of COVID-19 patients – the scientific aspect of a tele-pulse oximetry project study design

Abstract Introduction The Operational Group, leading the fight against COVID-19 in Hungary, has approved a pilot program, in December 2020, to monitor high risk COVID-19 patients in 40 family practices. The main goal of this project is to connect family physicians to their COVID-19 patients through a telemedicine system, in order to ensure patients' security and support for personalized telemedical-care and on-time hospitalization of the patients. 200 special pulse-oximeters were distributed and are continuously rotated among patients with acute phase of infection. Every patient is required to install a smartphone application on their phones to capture and transfer the oxygen saturation (SpO2), heart rate and raw pulse wave data. The peripheral pulse wave is used for calculating more than 30, cardiovascular and autonomic nervous system parameters by a proprietary algorithm. Most of these parameters are well described in the medical literature but not used for decision support in this project. Research question Do remote pulse wave analysis parameters have a predictive value on hospitalization above SpO2 recordings in COVID-19 patients? Methods Retrospective observational cohort study. The data analysis will be performed on the pulsewave database collected during the above mentioned project and correlated with endpoints. The parameters are measured with a special pulse oximeter; transferred, stored, processed and calculated by a remote patient monitor platform. The information about primary and secondary endpoints will be collected from the primary care physician of the patient. Study population Patients with diagnosed SARS-CoV-2 infection who have been monitored with a certain remote patient monitor system between November 2020 and September 2021. Expected number of participants: 100–150 patients. Primary endpoint Hospitalization due to acute COVID-19 infection Secondary endpoints Death connected to SARS-CoV-2 infection, presence of long-COVID symptoms during the monitoring period- maximum one month after the start of the infection Expected outcome According to literature data pulse wave features show correlation with cardiovascular status of the patient, while pulse rate variability parameters can be descriptive of the autonomic nervous system status of the subject. These parameters are described to possibly alter during and after an acute SARS-CoV-2 infection. To our knowledge there was no similar telemedical pulsewave data collection and analysis relation to COVID-19 before. However this is an easy to use methodology to explore more details about the patient's status. In this research we aim to explore these parameter's clinical utility in COVID-19 patients. Results will help to determine if pulse wave analysis and pulse rate variability parameters can be used as indicators of higher risk of hospitalization in COVID-19 patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): E-Med4All Europe Kft., Budapest, Hungary

Risk of corticosteroid treatment and hospitalization after checkpoint inhibitor and radiation therapy in patients with cancer.

Immune checkpoint inhibitors (ICIs) are potent new cancer therapies but can cause serious immune-related adverse events. ICIs have contributed significantly to improved survival and thereby provide more opportunity for the development of local disease symptomatology requiring palliative radiation. Radiation therapy (RT) has also recently shown benefit in the oligometastatic setting. Data on the interaction and safety of concurrent ICIs and RT are limited. In this retrospective cohort study using a large medical claims database from 2010 to 2017, the need for corticosteroid therapy and the risk of hospitalization within 180 days of treatment with an ICI were determined for patients with a diagnosis of malignant melanoma or lung cancer. Patients were stratified by the use of RT within the 30 days before and after ICI therapy. In all, 2020 patients (218 with RT and 1802 without RT) met the inclusion criteria for prednisone analysis, whereas 3519 patients (361 with RT and 3158 without RT) met the inclusion criteria for all other analyses. In a univariable analysis, RT was not associated with the need for prednisone (relative risk [RR], 1.2; 95% confidence interval [CI], 0.8-1.9) or methylprednisolone (RR, 1.1; 95% CI, 0.7-2.0). When the end point was hospitalization, RT was significantly associated with hospitalization after ICI therapy for certain cancer/drug combinations (RR for lung cancer/programmed death 1 receptor inhibitors, 1.4; 95% CI, 1.2-1.6; P < .001; RR for melanoma/ipilimumab, 2.0; 95% CI, 1.0-3.5; P = .03). In patients treated with ICIs, receiving RT was not associated with a higher risk of requiring corticosteroid therapy in comparison with not receiving RT. However, RT was associated with a higher risk of hospitalization, although this finding may be a result of differences in the underlying patient illness severity or oncologic disease burden at the baseline. Data on the interaction of immunotherapy (immune checkpoint inhibitors) and radiation therapy and the safety of combining them are limited. Using a large database, this study has found that patients treated concurrently with immune checkpoint inhibitors and radiation therapy are not at increased risk for requiring corticosteroid therapy (which is used as a proxy for immune-related adverse events). However, concurrent therapy is associated with a higher risk of hospitalization, although this finding may be due to differences in the underlying patient illness severity (sicker patients may require both immunotherapy and radiation therapy).

Short term outcomes of COVID-19 in lupus: Propensity score matched analysis from a nationwide multi-centric research network

ObjectivesTo determine the severity and outcome of COVID-19 among individuals with lupus as compared to controls. The secondary objective was to identify the risk association of sex, race, presence of nephritis, and use of various immunomodulators with COVID-19 outcomes. MethodsRetrospective data of individuals with lupus with and without COVID-19 between January 2020 to May 2021 was retrieved from the TriNetX. A one-to-one matched COVID-19 positive control was selected using propensity score(PS) matching. We assessed several outcomes, including all-cause mortality, hospitalisation, intensive care unit (ICU) admission, mechanical ventilation, severe COVID, acute kidney injury (AKI), Haemodialysis, acute respiratory distress syndrome (ARDS), ischemic stroke, venous thromboembolism (VTE) and sepsis were assessed. ResultsWe identified 2140 SLE patients with COVID-19, 29,853 SLE without COVID-19 and 732,291controls. Mortality within 30 days of COVID-19 diagnosis was comparable among SLE and controls [RR-1.26; 95%CI-0.85,1.8]. SLE with COVID-19 had a higher risk of hospitalisation [RR-1.28; 95% CI 1.14–1.44], ICU admission [RR-1.35; 95% CI 1.01–1.83], mechanical ventilation [RR- 1.58 95% CI 1.07–2.33], stroke [RR-2.18; 95% CI 1.32,3.60], VTE [RR-2.22; 95% CI 1.57–03.12] and sepsis [RR-1.37; 95% CI 1.06–1.78].Individuals with SLE who contracted COVID-19 had higher mortality, hospitalisation, ICU admission, mechanical ventilation, AKI, VTE and sepsis (p < 0.001) compared to SLE without COVID-19. Males with SLE had a higher risk of AKI [RR-2.05; 95% CI 1.27–3.31] than females. Lupus nephritis was associated with higher risk of hospitalisation [RR-1.36; 95% CI 1.05–1.76], AKI [RR-2.32; 95% CI 1.50–3.59] and sepsis [RR-2.07; 95% CI-1.12–3.83]. ConclusionThe mortality of individuals with SLE due to COVID-19 is comparable to the general population but with higher risks of hospitalisation, ICU admission, mechanical ventilation, stroke, VTE and sepsis. The presence of nephritis increases the risk of AKI, thus probably increasing hospitalisation and sepsis

Impact of Tele-Coaching During the COVID-19 Pandemic on Risk-Reduction Behavior of Patients with Heart Failure.

Introduction: Our study assessed the effectiveness of tele-coaching over written information in educating patients with chronic heart failure (CHF) at high risk of hospitalization about corona virus disease 2019 (COVID-19). We analyzed the impact on number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and self-reported behavior change. Methods: In April 2020, a tele-coaching module and written summary about COVID-19, risk-reduction measures for prevention of COVID-19, and appropriate consultation of medical attention during the pandemic were integrated into an established tele-coaching program. Three hundred seventy-eight patients who had received both tele-coaching and written information 3 weeks earlier were interviewed using a structured questionnaire and compared with 1,748 patients who had only received written information at this point. Results: Tele-coaching had no short-term effect on numbers of SARS-CoV-2 infections. However, patients receiving tele-coaching reported significantly more behavioral changes, including increased room ventilation (88% vs. 78%, p < 0.0001), surface cleaning (80% vs. 70%, p = 0.0006), wearing of face masks (59% vs. 51%, p = 0.013), and reduced usage of public transport (77% vs. 68%, p = 0.0003), despite no observed difference in recall about risk-reduction measures. Moreover, tele-coaching improved patients' knowledge about how to seek medical help in an emergency (46% vs. 36%, p = 0.0006), with a significant reduction in self-reported doctors' appointments (304 vs. 413 per 1,000 patients, p = 0.002) and hospital visits (50 vs. 87 per 1,000, p = 0.033) during the first peak of the pandemic. Conclusion: In a population of patients with CHF at high risk of hospitalization, COVID-19-specific tele-coaching effectively supported behavioral changes and significantly reduced face-to-face medical contacts in a short-term follow-up period.

A Mediterranean Lifestyle and Frailty Incidence in Older Adults: The Seniors-ENRICA-1 Cohort.

Frailty is a geriatric syndrome that entails high risk of hospitalization, disability, and death. While adherence to Mediterranean diet has been associated with lower risk of frailty, the joint effect of diet and lifestyle is uncertain. This study examined the association between a Mediterranean lifestyle (diet, customs, and traditions) and frailty incidence in older adults. We analyzed data from 1 880 individuals aged ≥ 60 from the prospective Seniors-ENRICA-1 cohort. Adherence to the Mediterranean lifestyle was assessed at baseline with the 27-item MEDLIFE index (higher scores representing better adherence), divided into 3 blocks: (1) "Mediterranean food consumption," (2) "Mediterranean dietary habits" (practices around meals)," and (3) "Physical activity, rest, social habits and conviviality." Frailty was ascertained as the presence of ≥ 3 of the 5 Fried criteria: (a) Exhaustion; (b) Muscle weakness; (c) Low physical activity; (d) Slow walking speed; and (e) Unintentional weight loss. Main statistical analyses were performed using logistic regression models, adjusting for the main confounders. After a 3.3-year follow-up, 136 incident frailty cases were ascertained. Compared with participants in the lowest tertile of the MEDLIFE score, the OR (95% CI) for frailty was 0.88 (0.58-1.34) for the second tertile, and 0.38 (0.21-0.69) for the third tertile (p-trend = .003). Blocks 1 and 3 of the MEDLIFE score were independently associated with lower frailty risk. Most items within these blocks showed a tendency to reduced frailty. Higher adherence to a Mediterranean lifestyle was associated with lower risk of frailty.

Racial and ethnic differences in COVID-19 hospitalizations by metropolitan status among Medicare beneficiaries, 1 January-31 December 2020.

Risk for COVID-19 hospitalizations increases with increasing age and presence of underlying medical conditions. However, the burden has not been well-assessed in metropolitan and nonmetropolitan areas by race/ethnicity among Medicare population with chronic conditions. We used the 2020 Medicare data to estimate COVID-19 hospitalization rates by race/ethnicity among Medicare beneficiaries for COVID-19 by metropolitan status and to assess the association of hospitalizations from COVID-19 with each of selected 29 chronic conditions for patients by metropolitan status and by race/ethnicity. The COVID-19 hospitalization rate was higher among beneficiaries residing in nonmetropolitan counties than those residing in metropolitan counties in 2020. Approximately 1 in 2 AI/AN, 1 in 3 NHB, Hispanic and A/PI, and 1 in 4 NHW beneficiaries with COVID-19 residing in nonmetropolitan counties were hospitalized. Beneficiaries with COVID-19 and chronic conditions were more likely to be hospitalized compared with those without chronic conditions. Hospitalization rates among beneficiaries with COVID-19 and chronic conditions were not distributed equally by race/ethnicity and by metropolitan status. Researchers, policymakers and practitioners can use these findings to explore more effective ways of reducing racial/ethnic and geographic disparities among minorities disproportionately affected by COVID-19 and are at highest risk of hospitalization.

BAMLANIVIMAB-INDUCED GUILLAIN-BARRÉ SYNDROME

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Guillain-Barre syndrome (GBS) is an autoimmune post-infectious neuropathy resulting in acute ascending flaccid paralysis 1. To the best of our knowledge and review of literature, this is the first reported case of GBS after receiving bamlanivimab a monoclonal antibody immunotherapy, now authorized for use in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE PRESENTATION: A 61-year-old male presented with acute progressive ascending bilateral lower extremity weakness and fever. Previous medical history included Chronic obstructive pulmonary disease and a recent diagnosis of SARS-CoV-2 for which he received monoclonal antibody (Bamlanivimab) one week prior to admission. On admission, neurological exam was remarkable for decreased bilateral lower and upper extremity strength with poor hand grip strength. Patient was being monitored in the intensive care unit for respiratory failure using negative inspiratory force and vital capacity. Lumbar puncture results were remarkable for normal glucose (62 mg/dL), elevated protein (122.4 mg/dL) without an elevated white blood count. The patient was diagnosed with GBS and initially treated with Intravenous Immunoglobin (IVIG) for five days. However, he continued to be symptomatic and developed mild dysarthria and facial weakness. He was subsequently treated with plasmapheresis for five days. Neurological and respiratory function improved after plasmapheresis therapy. DISCUSSION: The case illustrates GBS presentation after treatment with monoclonal antibody therapy in the setting of SARS-CoV-2. Bamlanivimab is an IgG1κ monoclonal antibody that targets the spike protein of SARS-CoV-2 and prevents the attachment and entry of the virus into human cells. In mild-moderate cases, Bamlanivimab was authorized to treat mild-moderate SARS-CoV-2 in patients above 12 years old, weight more than 40 kg, and high risk of disease progression and/or hospitalization.2,3 In this case report, the patient developed GBS within a short time period after receiving Bamlanivimab. Other case studies have also reported subsequent development of GBS after treatment with monoclonal antibodies.4,5,6 Ipilimumab, an IgG1 monoclonal antibody that inhibits cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), was associated with GBS development after its use as an adjuvant therapy for patients with melanoma. 4,5 Adalimumab (a tumor necrosis factor alpha inhibitor) was also reported with GBS development when used as therapy for psoriasis and psoriatic arthritis. 6 These monoclonal antibodies have different mechanisms of action and were used in other disorders. CONCLUSIONS: This case report demonstrates that monoclonal antibodies may develop an autoimmune response. This case report is important in highlighting GBS as a potential side effect of Bamlanivimab given its potential for respiratory compromise and its current use in mild to moderate SARS-CoV-2.1,3 REFERENCE #1: Leonhard, S.E., Mandarakas, M.R., Gondim, F.A.A. et al. Diagnosis and management of Guillain–Barre syndrome in ten steps. Nat Rev Neurol 2019;15:671–683. REFERENCE #2: Chen, P., Nirula, A., Heller B. et al. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19. N Engl J Med 2021;384:229-237 REFERENCE #3: U.S. Food and Drug Administration. (2021, March 31). Coronavirus (COVID-19) Update: FDA Authorizes Monoclonal Antibody for Treatment of COVID-19. Retrieved from https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19 DISCLOSURES: no disclosure on file for Nia Jagroop;No relevant relationships by Visala Natarajan, source=Web Response No relevant relationships by Gladys Palaguachi, source=Web Response no disclosure on file for Benhoor Shamian;

Risk stratification for COVID-19 hospitalization: a multivariable model based on gradient-boosting decision trees.

Background:The COVID-19 pandemic has led to an increased demand for health care resources and, in some cases, shortage of medical equipment and staff. Our objective was to develop and validate a multivariable model to predict risk of hospitalization for patients infected with SARS-CoV-2.Methods:We used routinely collected health records in a patient cohort to develop and validate our prediction model. This cohort included adult patients (age ≥ 18 yr) from Ontario, Canada, who tested positive for SARS-CoV-2 ribonucleic acid by polymerase chain reaction between Feb. 2 and Oct. 5, 2020, and were followed up through Nov. 5, 2020. Patients living in long-term care facilities were excluded, as they were all assumed to be at high risk of hospitalization for COVID-19. Risk of hospitalization within 30 days of diagnosis of SARS-CoV-2 infection was estimated via gradient-boosting decision trees, and variable importance examined via Shapley values. We built a gradient-boosting model using the Extreme Gradient Boosting (XGBoost) algorithm and compared its performance against 4 empirical rules commonly used for risk stratifications based on age and number of comorbidities.Results:The cohort included 36 323 patients with 2583 hospitalizations (7.1%). Hospitalized patients had a higher median age (64 yr v. 43 yr), were more likely to be male (56.3% v. 47.3%) and had a higher median number of comorbidities (3, interquartile range [IQR] 2–6 v. 1, IQR 0–3) than nonhospitalized patients. Patients were split into development (n = 29 058, 80.0%) and held-out validation (n = 7265, 20.0%) cohorts. The gradient-boosting model achieved high discrimination (development cohort: area under the receiver operating characteristic curve across the 5 folds of 0.852; validation cohort: 0.8475) and strong calibration (slope = 1.01, intercept = −0.01). The patients who scored at the top 10% captured 47.4% of hospitalizations, and those who scored at the top 30% captured 80.6%.Interpretation:We developed and validated an accurate risk stratification model using routinely collected health administrative data. We envision that modelling such risk stratification based on routinely collected health data could support management of COVID-19 on a population health level.

Smoking and COVID-19 outcomes: an observational and Mendelian randomisation study using the UK Biobank cohort

BackgroundConflicting evidence has emerged regarding the relevance of smoking on risk of COVID-19 and its severity.MethodsWe undertook large-scale observational and Mendelian randomisation (MR) analyses using UK Biobank. Most recent smoking...

A Population-Based Cohort Study on Chronic Comorbidity Risk Factors for Adverse Dengue Outcomes.

ABSTRACT.The global burden of dengue is increasing against a background of rising global prevalence of chronic noncommunicable diseases (NCDs) and an epidemiological shift of dengue toward older age groups. The contribution of NCDs toward risk for adverse clinical and healthcare utilization outcomes was assessed in a national linked-database study. About 51,433 adult dengue cases between 2014 and 2015 were assessed for outpatient and inpatient claims data in Taiwan’s National Health Insurance Research Database for the 30 days after their dengue diagnosis. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of adverse dengue outcomes in patients with NCDs compared with dengue patients without underlying diseases. Rheumatoid arthritis and related disease were associated with the highest risk of hospitalization after dengue diagnosis (odds ratio: 1.78; 95% CI: 1.37–2.30), followed by stroke, chronic kidney disease (CKD), liver cirrhosis, asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, congestive heart failure, hypertension, and malignancy. Chronic kidney disease and diabetes were associated with higher risks of hospitalization, intensive care unit (ICU) use, and all-cause mortality. After adjusting for socioeconomic status and other variables, the number of coexisting chronic diseases was associated with increasing risk of adverse dengue outcomes. Specific NCDs were associated with longer hospitalizations, ICU admission, and higher healthcare costs. Quantifying the risks of adverse dengue outcomes and health expenditures among dengue patients with preexisting NCDs provides insights for improved clinical management and essential inputs for health economic analyses on the cost-benefit of risk-based routine or catch-up immunization programs.

Increased Risks of Death and Hospitalization in Influenza/Pneumonia and Sepsis for Individuals Affected by Psychotic Disorders, Bipolar Disorders, and Single Manic Episodes: A Retrospective Cross-Sectional Study.

Individuals with severe mental disorders (SMDs) such as psychotic disorders, bipolar disorders, and single manic episodes have increased mortality associated with COVID-19 infection. We set up a population-based study to examine whether individuals with SMD also had a higher risk of hospitalization and death from other infectious conditions. Anonymized and summarized data from multiple Swedish patient registers covering the entire Swedish population were supplied by the Swedish National Board of Health and Welfare. The frequencies of hospitalizations and deaths associated with influenza/pneumonia and sepsis in individuals with SMD were compared with the rest of the population during 2018–2019. Possible contributing comorbidities were also examined, of which diabetes, cardiovascular disease, chronic lung disease, and hypertension were chosen. A total of 7,780,727 individuals were included in the study; 97,034 (1.2%) cases with SMD and 7,683,693 (98.8%) controls. Individuals with SMD had increased risk of death associated with influenza/pneumonia (OR = 2.06, 95% CI [1.87–2.27]) and sepsis (OR = 1.61, 95% CI [1.38–1.89]). They also had an increased risk of hospitalization associated with influenza/pneumonia (OR = 2.12, 95% CI [2.03–2.20]) and sepsis (OR = 1.89, 95% CI [1.75–2.03]). Our results identify a need for further evaluation of whether these individuals should be included in prioritized risk groups for vaccination against infectious diseases other than COVID-19.

Summary of the National Advisory Committee on Immunization (NACI) Seasonal Influenza Vaccine Statement for 2021-2022.

Several influenza vaccines are authorized in Canada and the evidence on influenza immunization is continually evolving. The National Advisory Committee on Immunization (NACI) provides recommendations regarding the use of seasonal influenza vaccines annually to the Public Health Agency of Canada (PHAC). To summarize NACI recommendations regarding the use of seasonal influenza vaccines for 2021-2022 and to highlight new recommendations. Annual influenza vaccine recommendations are developed by NACI's Influenza Working Group for consideration and approval by NACI. The development of the recommendations is based on the NACI evidence-based process. The following new recommendations were made: 1) Influvac® Tetra may be considered as an option among the standard dose quadrivalent inactivated influenza vaccines (IIV4-SD) offered to adults and children three years of age and older; 2) Fluzone High Dose Quadrivalent (IIV4-HD) may be considered an option for individuals 65 years of age and older who are currently recommended to receive Fluzone® High Dose (trivalent); and 3) Flucelvax® Quad may be considered amongst the quadrivalent influenza vaccines offered to adults and children nine years of age and older for annual influenza immunization. Guidance for use of influenza immunizations during the coronavirus disease 2019 pandemic is also highlighted. NACI continues to recommend that an age-appropriate influenza vaccine should be offered annually to anyone six months of age and older who does not have contraindications to the vaccine. Vaccination should be offered as a priority to people at high risk of influenza-related complications or hospitalization, people capable of transmitting influenza to those at high risk of complications, and others as indicated.

Hospitalization and mortality from COVID-19 of patients with rheumatic inflammatory diseases in Andalusia

ObjectiveTo describe whether rheumatic inflammatory diseases (RID) are associated with a higher risk of hospitalization and/or mortality from COVID-19 and identify the factors associated with hospitalization and mortality in RID and COVID-19 in different Hospitals in Andalusia. MethodsDesign: Multicentre observational case-COntrol study. Patients: RID and COVID-19 from different centres in Andalusia. Controls: patients without RIS matched by sex, age and CRP-COVID.Protocol A list of patients with PCR for COVID-19 was requested from the microbiology service from March 14 to April 14, 2020. The patients who had RID were identified and then consecutively a paired control for each case.Variables The main outcome variable was hospital admission and mortality from COVID-19.Statistical analysis Bivariate followed by binary logistic regression models (DV: mortality/hospital admission). ResultsOne hundred and fifty-six patients were included, 78 with RID and COVID-19 and 78 without RID with COVID-19. The patients did not present characteristics of COVID-19 disease different from the general population, nor did they present higher hospital admission or mortality. The factor associated with mortality in patients with RID was advanced age (OR [95% CI], 1.1 [1.0–1.2]; P= .025), while the factors associated with hospitalization were advanced age (OR [95% CI], 1.1 [1.0–1.1]; P = .007) and hypertension (OR [95% CI], 3.9 [1.5–6.7]; P = .003). ConclusionMortality and hospital admission due to COVID-19 do not seem to increase in RID. Advanced age was associated with mortality in RID and, in addition, HTN was associated with hospital admission.

Association of renin-angiotensin system blockers with COVID-19 diagnosis and prognosis in patients with hypertension: a population-based study.

ABSTRACTBackgroundThe effect of renin–angiotensin system (RAS) blockade either by angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs) on coronavirus disease 2019 (COVID-19) susceptibility, mortality and severity is inadequately described. We examined the association between RAS blockade and COVID-19 diagnosis and prognosis in a large population-based cohort of patients with hypertension (HTN).MethodsThis is a cohort study using regional health records. We identified all individuals aged 18–95 years from 87 healthcare reference areas of the main health provider in Catalonia (Spain), with a history of HTN from primary care records. Data were linked to COVID-19 test results, hospital, pharmacy and mortality records from 1 March 2020 to 14 August 2020. We defined exposure to RAS blockers as the dispensation of ACEi/ARBs during the 3 months before COVID-19 diagnosis or 1 March 2020. Primary outcomes were: COVID-19 infection and severe progression in hospitalized patients with COVID-19 (the composite of need for invasive respiratory support or death). For both outcomes and for each exposure of interest (RAS blockade, ACEi or ARB) we estimated associations in age-, sex-, healthcare area- and propensity score-matched samples.ResultsFrom a cohort of 1 365 215 inhabitants we identified 305 972 patients with HTN history. Recent use of ACEi/ARBs in patients with HTN was associated with a lower 6-month cumulative incidence of COVID-19 diagnosis {3.78% [95% confidence interval (CI) 3.69–3.86%] versus 4.53% (95% CI 4.40–4.65%); P < 0.001}. In the 12 344 patients with COVID-19 infection, the use of ACEi/ARBs was not associated with a higher risk of hospitalization with need for invasive respiratory support or death [OR = 0.91 (0.71–1.15); P = 0.426].ConclusionsRAS blockade in patients with HTN is not associated with higher risk of COVID-19 infection or with a worse progression of the disease.

Population-based assessment of risks for severe COVID-19 disease outcomes.

Among approximately 4.6 million members of Kaiser Permanente Northern California, we examined associations of severe COVID‐19 with demographic factors and comorbidities. As of July 23, 2021, 16 182 had been hospitalized, 2416 admitted to an ICU, and 1525 died due to COVID‐19. Age was strongly associated with hospitalization, ICU admission, and death. Black persons and Hispanic ethnicity had higher risk of death compared with Whites. Among the comorbidities examined, Alzheimer's disease was associated with the highest risk for hospitalization (aHR 3.19, CI: 2.88–3.52) and death (aHR 4.04, CI: 3.32–4.91). Parkinson's disease had the second highest risk of death (aHR = 2.07, CI: 1.50–2.87).