Main Comorbidities Research Articles

Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19

BackgroundCoronavirus disease 2019 (COVID-19) infection can cause alterations in the coagulation mechanism conditioning thrombotic phenomena such as acute limb ischemia (ALI) as the only manifestation of the infection. The aim of the study was to describe clinical and surgical characteristics of a group of patients infected with severe acute respiratory syndrome coronavirus 2 who presented ALI in the context of the COVID-19 pandemic at Lima, Peru.MethodsA multicenter, observational, and retrospective study was performed in six general hospitals, from March to July 2020. The variables considered were the pathological history and associated habits, laboratory tests, the severity of COVID-19 infection and ALI, the anatomic location of the lesion, treatment, evolution, and discharge conditions.ResultsThirty patients with ALI infected with COVID-19 were evaluated. Their mean age was 60 ± 15 years, the condition being more frequent in men (76.6%). The main comorbidities were arterial hypertension (33.3%), obesity (33.3%), and diabetes mellitus 2 (26.6%). There were 23.3% asymptomatic patients, and their only manifestation was ALI. Rutherford IIA and IIB stage included 93.2% of patients. The most frequent location of the thrombosis was the lower limbs (73.3% vs. 26.6%). Thrombectomy was performed in 76.6% of the patients, and amputation (primary and secondary) was performed in 30% of the patients. The mortality rate was 23.3%, all of it because of acute respiratory distress syndrome.ConclusionsALI is a vascular pathology associated with embolic and thrombotic processes. COVID-19 infection can cause severe alterations in coagulation mechanisms, leading some patients to present severe acute arterial complications such as thrombosis, as the only associated manifestation. We report a younger cohort than those described in other studies and with a high frequency of amputations despite adequate surgical treatment.

The impact of comorbidities on diagnosis and treatment of pleural effusions of various origins

Relevance. The incidence comorbidities increases and and types of comorbidities change with the patient’s age. The severity can be assessed using multiple scales. The aim of this study was to identify the specifics of surgical intervention tactics to be used for treatment of pleural effusions of various etiologies, depending on comorbidities. Methods. Comorbid pathology was assessed in 424 patients with pleural effusions of various origins using three indices developed by Charlson, Karnovsky, and the European Joint Oncological Group (ECOG). Thoracentesis, drainage of the pleural cavity, and videothoracoscopy with pleural biopsy were used for diagnosis and treatment. Results. HIV, chronic hepatitis, and diseases of the gastrointestinal tract represented the most common comorbid pathologies in patients below the age of 49; cardiovascular diseases and diabetes mellitus were the most common comorbidities in patients after the age of 50. The Charlson's index was 2.6 ± 2.5 for patients younger than 39, 7.9 ± 2.7 for patients in the age range between 60 and 69, and 9.5 ± 2.5 for patients who were older than 70. 34 patients underwent pleural punctures as treatment of small and medium effusions with the Karnowski index less than 40 % and ECOG of 3 — 4 points; 33 resuscitated patients with more severe pathology underwent pleural cavity drainage due to large effusions without fragmentation. 355 patients underwent video thoracoscopy with pleural biopsy; 135 patients received intraoperative pleurodesis by insufflation of talcum powder, and 19 patients had trichloroacetic acid applied to the pleura. 17 (4%) patients died from worsening of the underlying disease and decompensation, including one case of myocardial infarction. Patients with fatal outcome had the Charlson's index of 9.4 ± 3.9, and survivors — 6.9 ± 3.1. Conclusion . Worsening of main pathology and comorbidities, age over 60, Charlson's comorbidity index higher than 8, and an unfavorable prognosis for pleural effusions of various origins serve as an indication for the most conservative diagnostic and treatment approach.

Link between Diabetes and corona virus disease – A review study

Diabetes is one of the main comorbidities related to the seriousness of every one in three known human pathogenic corona virus contaminations, including extreme intense respiratory disorder. Diabetic cases have expanded dangers in serious complexities involving Respiratory Distress Syndrome and MODS disappointment. Contingent upon worldwide district, twenty–half of cases in the Corona virus infection pandemic were diabetics. Given the significance of a connection linked corona virus disease and diabetes; we have shaped a global board of specialists amongst the branch of diabetes and endocrinology to give certain direction & functional suggestions in administration of diabetes during corona virus infection. We mean to quickly give understanding in likely robotic connections between the Corona virus illness & diabetes, current down to earth the board proposals, and expound on the various requirements of a few patient gatherings. Scant information exist with respect to glucose digestion and improvement of intense difficulties of diabetes example ketoacidosis in patients with COVID-19. Contamination of corona virus in those with diabetes potentially triggers higher pressure conditions, with more prominent arrival of hyperglycemic hormones, e.g., glucocorticoids and catecholamines, prompting expanded blood glucose levels and irregular glucose inconstancy. Then again, a review concentrate from Wuhan revealed that around 10% of the patients with type 2 diabetes mellitus and Corona virus illness endured in any event one scene of hypoglycemia less than 3.9 mmol/L. Hyperglycemia appeared to assemble favorable to fiery monocytes and increment platelet reactivity, adding to a higher cardiovascular mortality in patients with diabetes.

One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry

BackgroundWe report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study. MethodsKERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF. ResultsMean age at recruitment was 67.2 years (range 18–98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA2DS2-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%). ConclusionsDespite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry.

Características sociodemográficas, clínicas e cuidados com a saúde de pessoas com diabetes mellitus hospitalizadas

O objetivo deste estudo foi identificar característica sociodemográficas e clínicas relacionadas a cuidados com a saúde de pessoas com diabetes mellitus. Estudo de caráter quantitativo, do tipo observacional descritivorealizado com pessoas com diabetes mellitus, hospitalizadas em unidades de clínica cirúrgica e clínica médica, em um hospital escola do sul do Brasil. Coleta de dados por consulta de enfermagem à beira do leito e em prontuários, realizada entre agosto e dezembro de 2017. Os dados foram submetidos à estatística descritiva. Participaram da pesquisa 37 pessoas, a maioria, 33 (89,2%) com diabetes tipo 2, a média de idade de 60 anos e tempo médio de diagnóstico de 9,6 anos; 27 (72,9%) tiveram episódios de hiperglicemia na internação; seis (16,2%) eram insulinodependentes; 26 (70,2%) eram hipertensos. Em suma, o perfil evidenciado por este estudo converge para perfis regionais e globais de pessoas com diabetes e, especificamente, em situação de hospitalização. Destacaram-se as características relacionadas à faixa etária maior de 40 anos mais acometida pela doença, com baixa escolaridade e com comorbidades associadas, especialmente as doenças cardiovasculares e a obesidade. O conhecimento deste perfil é potencial para um cuidado de enfermagem contextualizado, sobretudo para estratégias de educação em saúde.

Impact of Adverse Drug Reactions in Patients with End Stage Renal Disease in Greece

Background: Patients with end-stage renal disease (ESRD) require specialized therapeutic interventions. The decreased renal function that modulates the physiology and presence of comorbidities is often associated with variations in the pharmacological response, thus increasing the risk of adverse drug events or reactions (ADE/ADRs) from co-administered drugs. Methods: A cross-sectional study to record comorbidities, drug–drug interactions (DDIs), ADE/ADRs in patients with chronic kidney disease of stage five in Greece. The study enrolled 60 patients of mean age 64.8 ± 12.9 years, undergoing hemodialysis three times a week. Demographic and social factors, comorbidities, laboratory test data, medication regimens, DDIs and the reporting of ADE/ADRs were analyzed. Results: Cardiovascular diseases and diabetes were the main comorbidities. In total, 50 different DDIs of various clinical significance were identified. CNS, GI-track, and musculoskeletal-system-related ADE/ADRs were most often reported by patients. ADE/ADRs as clinical outcome from DDIs were associated in 64% of the total identified DDIs. There was a positive trend between number of medications, ADE/ADRs report and DDIs. Conclusions: The impact of ADE/ADRs in ESRD patients should be always considered. Guidelines as well as continuous training in the context of evidence-based clinical practice by healthcare personnel on therapy administration and prevention of adverse events are important.

Análise da rede de multibormidades em idosos atendidos em um centro de referência: estudo transversal

INTRODUÇÃO: Idosos possuem múltiplos diagnósticos com padrões de similaridade que podem ser analisados pela teoria das redes complexas. Distúrbios crônicos com repercussões na capacidade funcional tendem aumentar em número e gravidade nesses indivíduos, sendo necessária análise integrada para compreender a relação entre envelhecimento e multimorbidades. OBJETIVO: Analisar os padrões de interação entre as doenças que acometem idosos de um centro de referência. MATERIAIS E MÉTODOS: Foram coletados dados clínicos e doenças diagnosticadas em 2973 prontuários de idosos cadastrados de um centro de referência de atenção à saúde do idoso. As doenças foram consideradas nós da rede e os idosos as arestas de modo não direcionada. O peso das arestas correspondiam à quantidade de idosos com duas doenças simultaneamente. Através do software Gephi (versão 0.9.2) foram analisados grau de conectividade entre as doenças (grau de entrada), interação das doenças em sugbrupos (Comunity), doenças mais influentes (Hubs) e doenças que atuam como pontes entre duas ou mais comunidades. RESULTADOS: Foram identificados 30 nós (doenças) e 433 arestas com pesos distintos de acordo com a quantidade de idosos, e 3 comunidades onde o grau de conectividade é maior entre si. A Hipertensão Arterial Sistêmica (HAS) apresentou-se como o Hub de maior influência na rede. CONCLUSÃO: A construção da rede complexa mapeou as doenças e a influência na assistência ao idoso. Informações relevantes para os gestores locais, na busca de intervenções efetivas no serviço que visem contribuir para prevenção das principais comorbidades e auxiliar na independência funcional dos pacientes.

Fungemia in the French department of Mayotte, Indian Ocean: A 10 years survey

ObjectiveThis study aimed at providing original data on fungemia in the Centre Hospitalier de Mayotte in terms of prevalence, epidemiological characteristics of infected patients, yeast species distribution and profile of in vitro antifungals susceptibility. MethodsA total of 223 positive blood cultures for yeasts were retrospectively reported during the period April 2010–April 2020. ResultsNinety-five episodes were identified corresponding to an incidence rate of 3.7 cases/100,000 inhabitants. The average age of patients was 33.5 years, and 63.3% patients were hospitalized in intensive care unit. The main co-morbidities were surgery in the 30 days prior to fungemia (27.8%), neoplasia (22.8%), parenteral nutrition (17.7%), diabetes (16.5%) and immunosuppressive medications (31.6%). Candida spp accounted for the majority of isolates (92.4%) with a predominance of non-albicans species (55.8% vs 33.7%), including C. albicans (33.7%), C. tropicalis (30.5%) and C. parapsilosis (20%). The antifungal susceptibility profiles did not differ from expected results for each species and did not change significantly over time. DiscussionFungemia remain frequent hospital infections associated with high mortality in Mayotte. The vast majority of fungemia was due to Candida spp. Non-albicansCandida species reach half of the Candida isolates with a high percentage of C. tropicalis. Surprisingly, no case of candidemia due to C. glabrata were identified. The management of candidemia remains satisfactory and the treatment was adapted according to the international recommendations. However, the high susceptibility of Candida spp. isolates to fluconazole may invite to reconsider the use of this molecule as empirical and first-line treatment of candidemia in Mayotte.

Severe Acute Respiratory Syndrome Coronavirus 2 Lethality Did not Change Over Time in Two Italian Provinces.

This retrospective cohort study included all the subjects diagnosed with severe acute respiratory syndrome coronavirus 2 infection (n = 2493) in 2 Italian provinces. Two hundred fifty-eight persons died, after a median of 14.0 ± 11.0 days. Adjusting for age, gender, and main comorbidities, the ≥28-day case-fatality rate did not decrease from March to April 2020 (adjusted hazard ratio, 0.93; P = .6).

CLINICAL CHARACTERISTICS OF PATIENTS UNDER ROUTINE SEDATION IN ENDOVASCULAR TREATMENT OF ISCHEMIC HEART DISEASE

In Ukraine, the number of emergency and elective coronary artery stenting operation is steadily growing from year to year, for instance, the number of the operations doubled for the period of 2014 – 2017. We carried out a retrospective study at the Heart Institute of the Ministry of Health of Ukraine in 2017 – 2018. The medical records of 73 patients (58 men and 15 women) aged 35 – 83 who underwent coronary angiography and emergency and elective coronary artery stenting were selected for the study. Surgical interventions were performed under routine sedation (sedation level II-III according to the Ramsay Sedation Score) with diazepam and / or fentanyl and / or morphine.
 The aim of the study was to characterize the main clinical characteristics of patients with different forms of coronary artery disease who underwent X-ray image-guided endovascular treatment under different modes of routine anesthesia. We have found out overweight men aged 59.93 ± 0.84 prevailed among the patients under the study. We selected patients with different clinical forms of coronary heart disease including acute coronary syndrome (myocardial infarction, unstable angina) and chronic coronary syndromes (angina pectoris of different functional classes, asymptomatic coronary artery atherosclerosis). 29 (39.73%) patients underwent coronary angiography and elective coronary artery stenting; 44 patients (60.27%) had diagnostic coronary angiography and emergence stenting operations. The main comorbidities on admission to the hospital were as follows: 64 patients were diagnosed as having hypertension of various stages and degrees (87.67%); nine patients (13.71%) had diabetes, including 1.37% of newly diagnosed diabetics. Atrial fibrillation was found in 12.33% of the patients. Hyperglycemia at the admission to the hospital was detected in 25 patients that made up a third of all patients (34.25%). Among the patients, who had elected operations, the overwhelming indication for stenting was exertional angina, FC III (21.92%); among the patients who underwent emergency operations, the key indications was myocardial infarction with ST segment elevation (38.36%). In the group of the patients who were admitted for emergency hospitalization, fentanyl was mainly used for intraoperative sedation, while fentanyl and diazepam were used for the patients, who had elective surgeries.

COVID-19 in Latin America: Symptoms, Morbidities, and Gastrointestinal Manifestations

COVID-19 in Latin America: Symptoms, Morbidities, and Gastrointestinal Manifestations

Cardiovascular rehabilitation after valvular heart surgery: predictive factors of major complications

Abstract Background The population of patients affected by valvular heart disease is growing and for many of them valvular surgery is still considered the gold standard treatment. Cardiovascular Rehabilitation (CR) following intervention is fundamental for the post-surgical functional recovery and for the monitoring and management of complications that may occur after surgery. Aim of the study We aimed at identifying predictors of major complications in patients who underwent valvular surgery and subsequently were involved in an in-patient CR program. Major complications were defined as those requiring an in-patient management: severe anemia needing transfusions, infection of the sternal surgical wound requiring an antibiotic treatment, a positive hemoculture in the presence of systemic signs of infection and pericardial effusion requiring surgical drainage. Methods and statistical analysis 1600 patients who have been hospitalized in our CR Unit after valvular surgery were enrolled (median age 64 years; 60% males). We examined the demographic data, the cardiovascular risk factors, the main comorbidities, the type of heart surgery (type of valvular surgery and the presence of concomitant other cardiac intervention), the complications developed in Cardiac Surgery Unit and in the CR Unit, the in-hospital length of stay, the 6 minutes-walking tests and principal blood tests. Results At multivariate analysis we found that chronic renal dysfunction [OR 1,902 (CI 1,103–3,280), p=0,021], complex cardiac intervention [OR 1,554 (CI 1,030–2,344), p=0,036], sternal re-synthesis [OR 4,671 (CI 1,659–13,152), p=0,004], early post-surgical transfusions [OR 1,670 (CI 1,083–2,573), p=0,020] are independent risk factors for major complications, while a higher hemoglobin value at CR admission [OR 0,677 (CI 0,566–0,810), p<0,001] resulted an independent protective factor. Conclusions We identified predictors of major complications during CR after valvular surgery. These factors may help in defining the patients at major risk tailoring the patient management, adopting an individualized clinical and instrumental monitoring. A tailored CR period gives the possibility to optimize the use of hospital economic resources and to achieve a better final outcome. Funding Acknowledgement Type of funding source: None

Clinical Presentation and Risk Factors for Poor Outcomes Among Adult Patients With Posterior Reversible Encephalopathy Syndrome: A Retrospective Cohort Study.

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition with unknown global incidence, variable clinical presentation, and prognosis. To describe a cohort of patients with PRES with a focus on brain magnetic resonance imaging (MRI) patterns and their relationship with short-term clinical outcomes. Retrospective cohort study. The authors included patients if they were older than 15 years and had a PRES diagnosis on the basis of a positive brain MRI at any time during the in-hospital stay. Forty-four patients were included in the present analysis. The median age was 57 years (interquartile range, 32.0-68.5) and 70.5% were women. Hypertension (59.1%), history of transplantation (27.3%), previous chemotherapy (27.3%), chronic renal failure (38.6%), and autoimmune disease (15%) were the main comorbid conditions present. The classic triad of seizures, headache, and visual impairment was present in 18.0% of the cases. Eighty-six percent of patients were admitted to the intensive care unit, with 36.0% needing invasive life support. Brain MRI showed a dominant parieto-occipital pattern in 26 patients, whereas cytotoxic edema and bleeding were present in 27.3% and 29.6%, respectively. In-hospital mortality was 11.4%. The median modified Rankin Scale at hospital discharge was 1 (0-2.5). Risk factors associated with low modified Rankin Scale scores were: headache, visual impairment, and parieto-occipital pattern. Decreased level of consciousness and mechanical ventilation requirement were associated with greater discharge disability. Characteristic symptoms and signs of PRES and classic MRI patterns are associated with better clinical outcomes.

P.666 Evolution over time of the main comorbidities associated with autism spectrum disorder in children and adolescents

P.666 Evolution over time of the main comorbidities associated with autism spectrum disorder in children and adolescents

Clinical characteristics of acute kidney injury in the first 13 critically ill patients infected with SARS-CoV-2 (COVID-19) at a Peruvian hospital; a preliminary report

Introduction: The high transmissibility and lethality of the novel coronavirus SARS-CoV-2 (COVID-19) have been catastrophic. Acute kidney injury (AKI) is one of the frequent complications in patients with respiratory insufficiency caused by the virus. The pathogenic mechanism is based on the binding of its S-proteins to the angiotensin-converting enzyme (ACE) receptors, which will trigger a cellular damage. A podocyte and tubular compromise are found in the kidneys which can lead to tubular necrosis and the consequent AKI. Objectives: The objective of this report is to identify the main risk factor to develop AKI in patients infected with SARS-CoV-2 with critical acute respiratory distress. Patients and Methods: We performed this report study, collecting data from 48 ICU patients. Data from 13 of them who developed AKI and needed renal replacement therapy (RRT)were analyzed. Clinical characteristics and laboratory findings were reported using STATA 10.0. Results: AKI was present in 27.08% of patients, mostly male (92.3%) with a mean age of 63.8 years old. Hypertension, diabetes and obesity were the main comorbidities in those patients. Additionally, the meantime between admission and AKI diagnosis was 2.69 days. All patients showed fibrinogen, D-dimer, ALT and values above normal range. Mortality was seen in 61.5% of patients. Conclusion: This report tries to show AKI as an important clinical manifestation in critically ill patients infected with SARS-CoV-2, with high mortality. Further studies are needed to demonstrate if there are independent risk factors.

Predicting Clinical Outcome with Phenotypic Clusters in COVID-19 Pneumonia: An Analysis of 12,066 Hospitalized Patients from the Spanish Registry SEMI-COVID-19.

(1) Background: Different clinical presentations in COVID-19 are described to date, from mild to severe cases. This study aims to identify different clinical phenotypes in COVID-19 pneumonia using cluster analysis and to assess the prognostic impact among identified clusters in such patients. (2) Methods: Cluster analysis including 11 phenotypic variables was performed in a large cohort of 12,066 COVID-19 patients, collected and followed-up from 1 March to 31 July 2020, from the nationwide Spanish Society of Internal Medicine (SEMI)-COVID-19 Registry. (3) Results: Of the total of 12,066 patients included in the study, most were males (7052, 58.5%) and Caucasian (10,635, 89.5%), with a mean age at diagnosis of 67 years (standard deviation (SD) 16). The main pre-admission comorbidities were arterial hypertension (6030, 50%), hyperlipidemia (4741, 39.4%) and diabetes mellitus (2309, 19.2%). The average number of days from COVID-19 symptom onset to hospital admission was 6.7 (SD 7). The triad of fever, cough, and dyspnea was present almost uniformly in all 4 clinical phenotypes identified by clustering. Cluster C1 (8737 patients, 72.4%) was the largest, and comprised patients with the triad alone. Cluster C2 (1196 patients, 9.9%) also presented with ageusia and anosmia; cluster C3 (880 patients, 7.3%) also had arthromyalgia, headache, and sore throat; and cluster C4 (1253 patients, 10.4%) also manifested with diarrhea, vomiting, and abdominal pain. Compared to each other, cluster C1 presented the highest in-hospital mortality (24.1% vs. 4.3% vs. 14.7% vs. 18.6%; p < 0.001). The multivariate study identified age, gender (male), body mass index (BMI), arterial hypertension, chronic obstructive pulmonary disease (COPD), ischemic cardiopathy, chronic heart failure, chronic hepatopathy, Charlson’s index, heart rate and respiratory rate upon admission >20 bpm, lower PaO2/FiO2 at admission, higher levels of C-reactive protein (CRP) and lactate dehydrogenase (LDH), and the phenotypic cluster as independent factors for in-hospital death. (4) Conclusions: The present study identified 4 phenotypic clusters in patients with COVID-19 pneumonia, which predicted the in-hospital prognosis of clinical outcomes.

The Role of COVID-19 in the Death of SARS-CoV-2-Positive Patients: A Study Based on Death Certificates.

Background: Death certificates are considered the most reliable source of information to compare cause-specific mortality across countries. The aim of the present study was to examine death certificates of persons who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to (a) quantify the number of deaths directly caused by coronavirus 2019 (COVID-19); (b) estimate the most common complications leading to death; and (c) identify the most common comorbidities. Methods: Death certificates of persons who tested positive for SARS-CoV-2 provided to the National Surveillance system were coded according to the 10th edition of the International Classification of Diseases. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Complications were defined as those conditions reported as originating from COVID-19, and comorbidities were conditions independent of COVID-19. Results: A total of 5311 death certificates of persons dying in March through May 2020 were analysed (16.7% of total deaths). COVID-19 was the underlying cause of death in 88% of cases. Pneumonia and respiratory failure were the most common complications, being identified in 78% and 54% of certificates, respectively. Other complications, including shock, respiratory distress and pulmonary oedema, and heart complications demonstrated a low prevalence, but they were more commonly observed in the 30–59 years age group. Comorbidities were reported in 72% of certificates, with little variation by age and gender. The most common comorbidities were hypertensive heart disease, diabetes, ischaemic heart disease, and neoplasms. Neoplasms and obesity were the main comorbidities among younger people. Discussion: In most persons dying after testing positive for SARS-CoV-2, COVID-19 was the cause directly leading to death. In a large proportion of death certificates, no comorbidities were reported, suggesting that this condition can be fatal in healthy persons. Respiratory complications were common, but non-respiratory complications were also observed.

The Role of COVID-19 in the Death of SARS-CoV-2–Positive Patients: A Study Based on Death Certificates

Background: Death certificates are considered the most reliable source of information to compare cause-specific mortality across countries. Aim of the present study was to examine death certificates of persons who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to a. quantify the number of deaths directly caused by coronavirus 2019 (COVID-19); b. estimate the most common complications leading to death; and c. identify the most common comorbidities.Methods: Death certificates of persons who tested positive for SARS-CoV-2 provided to the National Surveillance system were coded according to the 10th edition of the International Classification of Diseases. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Complications were defined as those conditions reported as originating from COVID-19, and comorbidities were conditions independent of COVID-19.Findings: A total of 5,311 death certificates of persons dying in March through May 2020 were analysed (16.7% of total deaths). COVID-19 was the underlying cause of death in 88% of cases. Pneumonia and respiratory failure were the most common complications, being identified in 78% and 54% of certificates, respectively. Other complications, including shock, respiratory distress and pulmonary oedema, and heart complications demonstrated a low prevalence, but they were more commonly observed in the 30–59 years age group. Comorbidities were reported in 72% of certificates, with little variation by age and gender. The most common comorbidities were hypertensive heart disease, diabetes, ischaemic heart disease, and neoplasms. Neoplasms and obesity were the main comorbidities among younger people.Interpretation: In most persons dying after testing positive for SARS-CoV-2, COVID-19 was the cause directly leading to death. In a large proportion of death certificates, no comorbidities were reported, suggesting that this condition can be fatal in healthy persons. Respiratory complications were common, but non-respiratory complications were also observed.Funding Statement: None.Declaration of Interests: No financial relationships with any organisation that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.Ethics Approval Statement: On February 27, 2020, the Italian Presidency of the Council of Ministers authorised the collection and scientific dissemination of data related to COVID-19 by the Italian Institute of Health.

Liver function test abnormalities are associated with a poorer prognosis in Covid-19 patients: Results of a French cohort

AimTo assess the impact of liver function test (LFT) abnormalities on the prognosis of patients with coronavirus disease 2019 (COVID-19) in a French cohort of hospitalized patients. Patients and methodFrom March 13 to April 22, 2020, we collected on a computerized and anonymized database, medical records, laboratory data and clinical outcomes of patients hospitalized for confirmed cases of COVID-19 infection (RT–PCR and/or CT-scan). Patients were followed up until April 22, 2020 or until death or discharge. We have considered for statistical analysis, LFT abnormalities with levels greater than two times the upper limit of normal. Composite endpoint included admission to ICU, mechanical ventilation, severe radiologic injury and death to define disease severity. ResultsAmong 281 patients (median age 60 years) with COVID-19, 102 (36.3%) had abnormal LFT. Hypertension (45.6%) and diabetes (29.5%) were the main comorbidities. 20.2% were taken liver-toxic drugs at the admission and 27.4% were given drugs known to induce hepatic cytolysis during hospitalization. Patients with elevated levels of ALT or AST were significantly more severe with a higher rate of admission to ICU (40.0% vs 6.0%, p< 0.0001), and global mortality (26.7% vs 12.1%, p= 0.03). In multivariate analysis, obesity and cytolytic profil were associated with the composite endpoint (respectively 2.37 [1.21; 4.64], p= 0.01 and OR 6.20, 95% confidence interval [1.84, 20.95], p-value 0.003) ConclusionMost of liver injuries are mild and transient during COVID-19. LFT abnormalities are associated with a poorer prognosis and could be a relevant biomarker for early detection of severe infection.

End of life management in Internal Medicine Wards: a single centre real life report

The burden of end of life in Internal Medicine wards is not neglegible. However, literature evidence about end of life care in Internal Medicine wards lacks. Therefore, the aim of this study was to report on end of life management in a Internal Medicine ward. We performed a retrospective study focusing on characteristics and management of patients consecutively died in an italian Internal Medicine ward between 2018, July-1 and 2019, June-30. Demographic, co-morbidity, pharmacological treatment at hospital admission and in the last 48- hours of life and procedures during hospital stay were collected. Study population was composed by 354 patients (190 females), corresponding to about ten percent of patients admitted in the ward, with mean age ± DS 83.5 ± 10.6 years. Eighty-four percent of deaths was exepected in the last 48 hours before exitus. The main co-morbidities were blood hypertension (66.3 %), solid or haematological malignancies (40.3%), arhythmias (34.7%), pressure ulcers (31.3%) and diabetes (27.4%). The main causes of hospitalization were infectious diseases (23.1%) and cardiac or respiratory failure (20.9%). In seven percent of patients palliative cares had been already activated before the hospital admission. No patient had written living wills or advance directives. In the last 48 hours of life, the main phramacological classes prescribed were opioids (63.2%), antibiotics (46.9%) and corticosteroids (46.3%). Compared with pharmacological classes prescribed at hospital admission, in the last 48 hours of life the prescription of antibiotics, corticosteroids, opioids and benzodiazepines was significantly increased, whereas the prescription of antihypertensive agents, proton pump inhibitors and antithrombotic drugs resulted significantly reduced. Written order to withdrawal of vital parameters relevation or active treatment were found in 30.7% and 31.9%, respectively. In the last 48 hours of life, 61% of patients underwent to at least one blood assay, 34% arterial blood gas analysis and about 35% at least one of radiography, computer tomography, magnetic resonance or endoscopy. During hospital stay 9% of patients underwent to blood transfusion. Of them 28.1% of patients received blood transfusion in the last 48 hours of life. Appropriate management of end of life represents a challenge in Internal Medicine wards.