Poor COVID-19 Outcomes Research Articles

Older Adults in the United States and COVID-19: A Qualitative Study of Perceptions, Finances, Coping, and Emotions.

Introduction: Older adults have the poorest coronavirus (COVID-19) prognosis with the highest risk of death due to complications, making their COVID-19 experiences particularly important. Guided by the stress-appraisal-coping theoretical model, we sought to understand COVID-related perceptions and behaviors of older adults residing in the United States.Materials and Methods: We used convenience sampling to recruit persons with the following inclusion criteria: Aged ≥ 65 years, English fluency, and U.S. residency. Semi structured in-depth interviews were conducted remotely and audio recorded between April 25, 2020 and May 7, 2020. Interviews were professionally transcribed with a final study sample of 43. A low-inference qualitative descriptive design was used to provide a situated understanding of participants' life experiences using their naturalistic expressions.Results: The mean age of participants was 72.4 ± 6.7. Slightly over half were female (55.8%), 90.6% were White, and 18.6% lived alone. The largest percentages of participants resided in a rural area (27.9%) or small city (25.6%). We identified four themes, including (1) risk perception, (2) financial impact, (3) coping, and (4) emotions. Most participants were aware of their greater risk for poor COVID-19 outcomes but many did not believe in their increased risk. Financial circumstances because of the pandemic varied with largely no financial impacts, while others reported negative impacts and a few reported positive impacts. Coping was problem- and emotion-focused. Problem-focused coping included precautionary efforts and emotion-focused coping included creating daily structure, pursuing new and/or creative activities, connecting with others in new ways, and minimizing news media exposure. Overall, emotional health was negatively affected by the pandemic although some participants reported positive emotional experiences.Conclusions: Perceiving themselves as high risk for COVID-19 complications, older adults used precautionary measures to protect themselves from contracting the virus. The precautionary measures included social isolation, which can negatively affect mental health. Older adults will need to be resourceful and draw on existing resources to cope, such as engaging in creative activities and new strategies to connect with others. Our findings underscore the importance of the preservation of mental health during extended periods of isolation by taking advantage of low-to-no-cost existing resources.

Systemic DPP4/CD26 is associated with natural HIV-1 control: Implications for COVID-19 susceptibility

The current intersection of the COVID-19 and HIV-1 pandemics, has raised concerns about the risk for poor COVID-19 outcomes particularly in regions like sub-Saharan Africa, disproportionally affected by HIV. DPP4/CD26 has been suggested to be a potential therapeutic target and a biomarker for risk in COVID-19 patients with high risk co-morbidities. We therefore evaluated soluble DPP4 (sDPP4) levels and activity in plasma of 131 HIV-infected and 20 HIV-uninfected South African individuals. Flow cytometry was performed to compare cell surface expression of DPP4/CD26 and activation markers on peripheral blood mononuclear cells of extreme clinical phenotypes. Progressors had lower specific DPP4 activity and lower frequency of CD3+ T-cells expressing CD26 than HIV-1 controllers, but more activated CD3+CD26+ T-cells. The frequency of CD26-expressing T-cells negatively correlated with HLA-DR+ and CD38+ T-cells. Divergent DPP4/CD26 expression between HIV-1 controllers and progressors may have implications for risk and treatment of COVID-19 in people living with HIV.

COVID-19 Severity and COVID-19-Associated Deaths Among Hospitalized Patients with HIV Infection - Zambia, March-December 2020.

The effect of HIV infection on COVID-19 outcomes is unclear. Studies in South Africa (1) and the United Kingdom (2) found an independent association between HIV infection and COVID-19 mortality; however, other studies have not found an association between poor COVID-19 outcomes and either HIV status among hospitalized patients (3-5) or HIV-associated factors such as CD4 count, viral load, or type of antiretroviral therapy (ART) (6). The effect of HIV infection on COVID-19 outcomes remains an urgent question in sub-Saharan Africa, where many countries are experiencing dual HIV and COVID-19 epidemics, and capacity to treat severe COVID-19 is limited. Using data from patients with probable or confirmed COVID-19 admitted to specialized treatment centers during March-December 2020 in Zambia, the Zambian Ministry of Health and CDC assessed the relationship between HIV infection and severe COVID-19 and COVID-19-associated death. Among 443 patients included in the study, 122 (28%) were HIV-positive, and of these, 91 (89%) were receiving ART at the time of hospitalization. HIV status alone was not significantly associated with severe COVID-19 at admission or during hospitalization or with COVID-19-associated death. However, among HIV-positive persons, those with severe HIV disease were more likely to develop severe COVID-19 and were at increased risk for COVID-19-associated death. Ensuring that persons maintain HIV disease control, including maintaining ART continuity and adherence, achieving viral suppression, and addressing and managing underlying medical conditions, could help reduce COVID-19-associated morbidity and mortality in sub-Saharan Africa.

Top 100 cited articles on diabetes mellitus and Covid-19: A bibliometric analysis

AimsThere is a lack of bibliometric analytical studies on Diabetes Mellitus in Covid-19. As diabetes mellitus is a common co-morbidity associated with poor outcomes in Covid-19, we undertook a bibliometric analysis of the top 100 publications relating to this subject. MethodsThe top 100 cited papers were searched on Pubmed. Information about authors, month and year of publication, name of the journal, country of the affiliating institute of the first author, affiliation, total citations, citation density, type of study, type of paper, nature of the study, collaborations, number of affiliations and erratum details were collected. ResultsThe top 100 papers were published in 57 journals and were cited 53,374 times. Though most of the top 100 papers were written by first authors affiliated to institutes in the United States, the publication from China were the most influential. Two institutions from the United States had the highest number of affiliations of the first author. The Lancet was the most productive journal with the highest number of total citations (24,221). ConclusionsThis study gives valuable information to academicians and researchers regarding trends in the publication of the most influential articles on diabetes mellitus and Covid-19 infection.

The emerging osteo-metabolic phenotype of COVID-19: clinical and pathophysiological aspects.

An emerging feature of COVID-19 is a clinically relevant osteo-metabolic phenotype characterized by widespread acute hypocalcaemia and chronic hypovitaminosis D with high prevalence of vertebral fractures. This phenotype might have negative effects on disease severity and its components could represent possible targets for prevention of SARS-CoV-2 infection and poor COVID-19 outcomes.

Outcomes of COVID-19 in solid organ transplant recipients: A matched cohort study.

Whether solid organ transplant (SOT) recipients are at increased risk of poor outcomes due to COVID‐19 in comparison to the general population remains uncertain. In this study, we compared outcomes of SOT recipients and non‐SOT patients hospitalized with COVID‐19 in a propensity score matched analysis based on age, race, ethnicity, BMI, diabetes, and hypertension. After propensity matching, 117 SOT recipients and 350 non‐SOT patients were evaluated. The median age of SOT recipients was 61 years, with a median time from transplant of 5.68 years. The most common transplanted organs were kidney (48%), followed by lung (21%), heart (19%), and liver (10%). Overall, SOT recipients were more likely to receive COVID‐19 specific therapies and to require ICU admission. However, mortality (23.08% in SOT recipients vs. 23.14% in controls, P = .21) and highest level of supplemental oxygen (P = .32) required during hospitalization did not significantly differ between groups. In this propensity matched cohort study, SOT recipients hospitalized with COVID‐19 had similar overall outcomes as non‐SOT recipients, suggesting that chronic immunosuppression may not be an independent risk factor for poor outcomes in COVID‐19.

MO365URINARY BIOMARKERS AND POOR OUTCOMES IN PATIENTS WITH COVID-19 ADMITTED TO A REFERENCE HOSPITAL IN NORTHEAST BRAZIL

Background and AimsKidney biomarkers improve early and specific AKI detection and also poor outcomes in different clinical contexts. Kidney disease is an important risk factor for poor outcomes in COVID-19. The aim of this study was to evaluate association of early levels of kidney biomarkers with poor outcomes in hospitalized patients with COVID-19.MethodThis is a prospective study conducted at the Instituto Dr. Jose Frota Hospital, an important public reference hospital for COVID-19 in northeast Brazil. Medical records with clinical, epidemiologic, laboratory and outcomes were collected. The urinary NGAL, KIM-1, MCP-1 and nephrin were the kidney biomarkers quantified at hospital admission. ELISA assays were used for analysis and biomarkers urinary concentrations were adjusted for urinary creatinine. Data were expressed as mean± standard deviation or median.ResultsA total of 69 patients collected urine and were included in this study. Male gender was predominant (65%) and mean age was 56±19 years. Regarding outcomes, the group had 62% of death, 92% of ICU admission and 65% of invasive respiratory support in ICU. Urinary NGAL and MCP-1 were significantly elevated in patients that needed invasive respiratory support in comparison with non-invasive support: uNGAL (median=104 [IQR=74-153] vs 71 [31-79] ng/mg-Cr, p=0.013), and uMCP-1 (3055 [1127-5008] vs 1315 [574-2127] pg/mg-Cr, p=0.027). Urinary nephrin and KIM-1 was also elevated, however with no statistical significance. Moreover, all urinary biomarkers were higher in ICU admission group and death group, but with p>0.05. In ROC curve analysis for prediction of invasive respiratory support, uNGAL had AUC=0.696 (0.565-0.827),p=0.012 and cut-off=78 ng/mg-Cr; uMCP-1 had AUC=0.676 (0.539-0.813), p=0.023 and cut-off=1354 pg/mg-Cr. In survival analysis, patients with uNGAL >78 ng/mg-Cr had worse prognosis and died more quickly (19 vs 48 days, log-rank test; p=0.01). In patients with uMCP-1 >1354 pg/mg-Cr, they also died more quickly, but with no significance (25 vs 48 days, log-rank test; p=0.08).ConclusionUrinary biomarkers NGAL and MCP-1 quantified at hospital admission were associated with poor outcomes, mostly with needed of invasive respiratory support in ICU. Prediction cut-off values for invasive respiratory support was useful to determine the survival prognosis.

Abstract #1042611: Impact of Diabetes and Glycemic Control on Poor Outcomes in Hospitalized Patients with Obesity and COVID-19 Infectionq2

Obesity and diabetes mellitus (DM) have emerged as significant risk factors for poor outcomes in COVID-19 (SARS-CoV-2) infection. In this study, we explored the impact of DM and glycemic control on mortality rates in patients with obesity admitted to the hospital with COVID-19 infection.

Defining COVID-19-associated hyperinflammatory syndrome in specific populations.

Defining COVID-19-associated hyperinflammatory syndrome in specific populations.

Laboratory trends, hyperinflammation, and clinical outcomes for patients with a systemic rheumatic disease admitted to hospital for COVID-19: a retrospective, comparative cohort study.

BackgroundCOVID-19 can induce a hyperinflammatory state, which might lead to poor clinical outcomes. We aimed to assess whether patients with a systemic rheumatic disease might be at increased risk for hyperinflammation and respiratory failure from COVID-19.MethodsWe did a retrospective, comparative cohort study of patients aged 18 years or older admitted to hospital with PCR-confirmed COVID-19 at Mass General Brigham (Boston, USA). We identified patients by a search of electronic health records and matched patients with a systemic rheumatic disease 1:5 to comparators. We compared individual laboratory results by case status and extracted laboratory results and COVID-19 outcomes for each participant. We calculated the COVID-19-associated hyperinflammation score (cHIS), a composite of six domains (a score of ≥2 indicating hyperinflammation) and used logistic regression to estimate odds ratios (ORs) for COVID-19 outcomes by hyperinflammation and case status.FindingsWe identified 57 patients with a systemic rheumatic disease and 232 matched comparators who were admitted to hospital with COVID-19 between Jan 30 and July 7, 2020; 38 (67%) patients with a rheumatic disease were female compared with 158 (68%) matched comparators. Patients with a systemic rheumatic disease had higher peak median neutrophil-to-lymphocyte ratio (9·6 [IQR 6·4–22·2] vs 7·8 [4·5–16·5]; p=0·021), lactate dehydrogenase concentration (421 U/L [297–528] vs 345 U/L [254–479]; p=0·044), creatinine concentration (1·2 mg/dL [0·9–2·0] vs 1·0 mg/dL [0·8–1·4], p=0·014), and blood urea nitrogen concentration (31 mg/dL [15–61] vs 23 mg/dL [13–37]; p=0·033) than comparators, but median C-reactive protein concentration (149·4 mg/L [76·4–275·3] vs 116·3 mg/L [58·8–225·9]; p=0·11) was not significantly different. Patients with a systemic rheumatic disease had higher peak median cHIS than comparators (3 [1–5] vs 2 [1–4]; p=0·013). All patients with a peak cHIS of 2 or more had higher odds of admission to intensive care (OR 3·45 [95% CI 1·98–5·99]), mechanical ventilation (66·20 [8·98–487·80]), and in-hospital mortality (16·37 [4·75–56·38]) than patients with a peak cHIS of less than 2. In adjusted analyses, patients with a rheumatic disease had higher odds of admission to intensive care (2·08 [1·09–3·96]) and mechanical ventilation (2·60 [1·32–5·12]) than comparators, but not in-hospital mortality (1.78 [0·79–4·02]). Among patients who were discharged from hospital, risk of rehospitalisation (1·08 [0·37–3·16]) and mortality within 60 days (1·20 [0·58–2·47]) was similar in patients and comparators.InterpretationPatients with a systemic rheumatic disease who were admitted to hospital for COVID-19 had increased risk for hyperinflammation, kidney injury, admission to intensive care, and mechanical ventilation compared with matched comparators. However, among patients who survived, post-discharge outcomes were not significantly different. The cHIS identified patients with hyperinflammation, which was strongly associated with poor COVID-19 outcomes in both patients with a rheumatic disease and comparators. Clinicians should be aware that patients with systemic rheumatic diseases and COVID-19 could be susceptible to hyperinflammation and poor hospital outcomes.FundingNone.

Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry

ObjectiveTo investigate baseline use of biologic or targeted synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) and COVID-19 outcomes in rheumatoid arthritis (RA).MethodsWe analysed the COVID-19 Global Rheumatology Alliance physician registry (from...

Learning from past respiratory failure patients to triage COVID-19 patient ventilator needs: A multi-institutional study

BackgroundUnlike well-established diseases that base clinical care on randomized trials, past experiences, and training, prognosis in COVID19 relies on a weaker foundation. Knowledge from other respiratory failure diseases may inform clinical decisions in this novel disease. The objective was to predict 48-hour invasive mechanical ventilation (IMV) within 48 h in patients hospitalized with COVID-19 using COVID-like diseases (CLD). MethodsThis retrospective multicenter study trained machine learning (ML) models on patients hospitalized with CLD to predict IMV within 48 h in COVID-19 patients. CLD patients were identified using diagnosis codes for bacterial pneumonia, viral pneumonia, influenza, unspecified pneumonia and acute respiratory distress syndrome (ARDS), 2008–2019. A total of 16 cohorts were constructed, including any combinations of the four diseases plus an exploratory ARDS cohort, to determine the most appropriate cohort to use. Candidate predictors included demographic and clinical parameters that were previously associated with poor COVID-19 outcomes. Model development included the implementation of logistic regression and three ensemble tree-based algorithms: decision tree, AdaBoost, and XGBoost. Models were validated in hospitalized COVID-19 patients at two healthcare systems, March 2020–July 2020. ML models were trained on CLD patients at Stanford Hospital Alliance (SHA). Models were validated on hospitalized COVID-19 patients at both SHA and Intermountain Healthcare. ResultsCLD training data were obtained from SHA (n = 14,030), and validation data included 444 adult COVID-19 hospitalized patients from SHA (n = 185) and Intermountain (n = 259). XGBoost was the top-performing ML model, and among the 16 CLD training cohorts, the best model achieved an area under curve (AUC) of 0.883 in the validation set. In COVID-19 patients, the prediction models exhibited moderate discrimination performance, with the best models achieving an AUC of 0.77 at SHA and 0.65 at Intermountain. The model trained on all pneumonia and influenza cohorts had the best overall performance (SHA: positive predictive value (PPV) 0.29, negative predictive value (NPV) 0.97, positive likelihood ratio (PLR) 10.7; Intermountain: PPV, 0.23, NPV 0.97, PLR 10.3). We identified important factors associated with IMV that are not traditionally considered for respiratory diseases. ConclusionsThe performance of prediction models derived from CLD for 48-hour IMV in patients hospitalized with COVID-19 demonstrate high specificity and can be used as a triage tool at point of care. Novel predictors of IMV identified in COVID-19 are often overlooked in clinical practice. Lessons learned from our approach may assist other research institutes seeking to build artificial intelligence technologies for novel or rare diseases with limited data for training and validation.

Association of systemic anticancer therapy with an increased risk of death in hospitalized COVID-19 positive oncology patients.

e18594 Background: Malignancy is thought to be an independent risk factor for increased COVID-19 morbidity and mortality. However, neoplastic diseases encompass a heterogenous group of pathologic processes, and further stratification of those patients prone to severe disease is necessary. We sought to identify predictors of poor COVID-19 outcomes among hospitalized patients with malignancy. Methods: We retrospectively reviewed all patients with a diagnosis of hematologic and solid tumor malignancy within the regional Scripps Health hospital system in San Diego County from March 1, 2020 to January 5, 2021 with a PCR confirmed diagnosis of COVID-19. Cancer diagnoses were confirmed via manual chart review; in situ non-melanoma skin cancers were excluded. Only hospitalizations greater than one day were included in the analysis and readmissions were excluded. Outcomes of interest included admission to the ICU, intubation during hospitalization, and death. Associations between outcomes of interest and tumor types, metastatic disease (with or without lung involvement) and those receiving active systemic anticancer therapy (treatment within 3 months of admission) were determined using univariable logistic regression analyses. The study was approved by the Scripps Health Institutional Review Board. Systemic anticancer therapy included cytotoxic chemotherapy, immunomodulators, immune checkpoint inhibitors, and other targeted therapies. Results: Among a total of 2,771 hospitalized patients, 204 (7.36%) met inclusion criteria. The average age was 72.7 years, 48.5% were male, 33.3% were Hispanic and the average BMI was 27.5. The majority of patients (82.8%) had solid tumors, with the most prevalent being breast carcinoma (17.6%) and prostate carcinoma (17.2%). Overall, 21.9% had metastatic disease and 16% had lung involvement. 17.2% had been receiving active cancer systemic treatment. On univariate analysis, patients who were actively receiving treatment had an increased rate of death (37.1% vs 18.9%, OR: 2.5 (1.1-5.5) p= .021). Among patients receiving systemic anticancer therapy, 48.6% received cytotoxic chemotherapy, 5.7% immune checkpoint inhibitors, 22.9% immunomodulators, 17.1% molecularly targeted agents and 2.7% other agents. Moreover, there was a trend towards increased mortality in those with lung involvement (33.3% vs 17.6%, OR: 2.3 (0.9-5.7) p= .067) and those with hematologic malignancy (31.4% vs 20.1%, OR: 0.5 (0.2-1.3) p = 0.146). Conclusions: Among patients hospitalized with a diagnosis of cancer, systemic anticancer therapy was associated with a significantly increased odds of death. Other factors potentially increasing risk of death include hematologic malignancy and solid tumors with lung involvement. Further validation of these findings in a larger sample could impact therapeutic decision making during the COVID-19 pandemic.

Exploring COVID-19 Case Fatality in Relation to the Prevalence of Chronic Conditions and Health Behaviors in Appalachian Kentucky.

BackgroundResearch has demonstrated that common chronic conditions, especially those related to cardiovascular health, are important risk factors for severe COVID-19 symptoms or hospitalization. Population prevalence rates of such conditions have not previously been examined in relation to COVID-19 case fatality rates in the Central Appalachian region.PurposeThis study examined prevalence rates of selected chronic conditions and COVID-19 case fatality rates to determine whether the relationship between them is consistent across Appalachian and non-Appalachian regions of Kentucky.MethodsData from Kentucky’s Behavioral Risk Factor Survey (KyBRFS) were used to calculate prevalence rates of asthma, diabetes, influenza vaccination, hypertension, obesity, having a personal doctor, physical inactivity, and cigarette smoking. Publicly available COVID-19 case and death counts by county were used to calculate incidence and case fatality rates. Units of analysis were 41 single- and multi-county areas developed to visualize KyBRFS prevalence rates. Analysis included t-tests to compare Appalachian and non-Appalachian regions, and correlations characterizing associations between COVID-19 case fatality and rates of chronic conditions and behaviors.ResultsIncidence and case fatality rates for COVID-19 were slightly lower in the Appalachian region, but not significantly. Significant correlations between COVID-19 case fatality and the prevalence of chronic conditions and behaviors were more common in the non-Appalachian region.ImplicationsCase fatality rates in Appalachia appear lower than expected, given the high prevalence of important chronic conditions and behaviors known to be associated with poor COVID-19 outcomes. This phenomenon merits further research and should be considered by public health researchers when examining COVID-19 outcomes in Kentucky and neighboring states.

Prolonged Intubation in Patients With Prior Cerebrovascular Disease and COVID-19.

Objectives: Patients with comorbidities are at increased risk for poor outcomes in COVID-19, yet data on patients with prior neurological disease remains limited. Our objective was to determine the odds of critical illness and duration of mechanical ventilation in patients with prior cerebrovascular disease and COVID-19.Methods: A observational study of 1,128 consecutive adult patients admitted to an academic center in Boston, Massachusetts, and diagnosed with laboratory-confirmed COVID-19. We tested the association between prior cerebrovascular disease and critical illness, defined as mechanical ventilation (MV) or death by day 28, using logistic regression with inverse probability weighting of the propensity score. Among intubated patients, we estimated the cumulative incidence of successful extubation without death over 45 days using competing risk analysis.Results: Of the 1,128 adults with COVID-19, 350 (36%) were critically ill by day 28. The median age of patients was 59 years (SD: 18 years) and 640 (57%) were men. As of June 2nd, 2020, 127 (11%) patients had died. A total of 177 patients (16%) had a prior cerebrovascular disease. Prior cerebrovascular disease was significantly associated with critical illness (OR = 1.54, 95% CI = 1.14–2.07), lower rate of successful extubation (cause-specific HR = 0.57, 95% CI = 0.33–0.98), and increased duration of intubation (restricted mean time difference = 4.02 days, 95% CI = 0.34–10.92) compared to patients without cerebrovascular disease.Interpretation: Prior cerebrovascular disease adversely affects COVID-19 outcomes in hospitalized patients. Further study is required to determine if this subpopulation requires closer monitoring for disease progression during COVID-19.

Sleep Apnea and Poor COVID-19 Outcomes: Beware of Causal Intermediates and Colliders

Sleep Apnea and Poor COVID-19 Outcomes: Beware of Causal Intermediates and Colliders

Insulin Use and Poor COVID-19 Outcomes among Diabetes Patients: Association Not Necessarily Causation

ABSTRACT Our study looked at the relationship between insulin use and clinical outcomes in COVID-19. A response to our article, written by Dr. Chia Sing Kow and Dr. Syed Shahzad Hasan raised a few questions. They mentioned our use of hemoglobin A1c may be inaccurate as the patients in our study had high rates of CKD or ESRD which could alter the hemoglobin A1c levels. However due to the limitations of our patient population and perhaps in a lot of other sample populations in the real-world setting, it was the most feasible way to represent glucose control.The writers also suggested that the use of metformin, a potential confounder, was also not adjusted for. This should be considered in future research but addition of too many variables in a regression model may lead to less reliability of results for our study.The letter writers also suggested that the results of our paper may lead to misinterpretation by readers and may influence providers to not use insulin therapy for their patients when necessary due to fear of worse outcomes in the setting of COVID-19. We reiterated that it is very important that the data not be misinterpreted, and that nowhere in our paper did we imply or suggest that patients who need insulin therapy to treat their diabetes should not receive proper therapy due to the association we delineated in our paper. Instead, more careful surveillance of patients with advanced diabetes is needed especially when admitted with COVID-19.

Which people with asthma are most likely to be hospitalized with COVID-19 in the United States?

Which people with asthma are most likely to be hospitalized with COVID-19 in the United States?

Length of Stay in ICU of Covid-19 Patients in England, March - May 2020

IntroductionLength of Stay (LoS) in Intensive Care Units (ICUs) is an important measure for planning beds capacity during the Covid-19 pandemic. However, as the pandemic progresses and we learn more about the disease, treatment and subsequent LoS in ICU may change.ObjectivesTo investigate the LoS in ICUs in England associated with Covid-19, correcting for censoring, and to evaluate the effect of known predictors of Covid-19 outcomes on ICU LoS.Data sourcesWe used retrospective data on Covid-19 patients, admitted to ICU between 6 March and 24 May, from the “Covid-19 Hospitalisation in England Surveillance System” (CHESS) database, collected daily from England’s National Health Service, and collated by Public Health England.MethodsWe used Accelerated Failure Time survival models with Weibull and log-normal distributional assumptions to investigate the effect of predictors, which are known to be associated with poor Covid-19 outcomes, on the LoS in ICU.ResultsPatients admitted before 25 March had significantly longer LoS in ICU (mean = 18.4 days, median = 12), controlling for age, sex, whether the patient received Extracorporeal Membrane Oxygenation, and a co-morbid risk factors score, compared with the period after 7 April (mean = 15.4, median = 10). The periods of admission reflected the changes in the ICU admission policy in England. Patients aged 50-65 had the longest LoS, while higher co-morbid risk factors score led to shorter LoS. Sex and ethnicity were not associated with ICU LoS.ConclusionsThe skew of the predicted LoS suggests that a mean LoS, as compared with median, might be better suited as a measure used to assess and plan ICU beds capacity. This is important for the ongoing second and any future waves of Covid-19 cases and potential pressure on the ICU resources. Also, changes in the ICU admission policy are likely to be confounded with improvements in clinical knowledge of Covid-19.

Is there a need to reconsider the use of metformin in COVID-19 patients with type 2 diabetes mellitus?

IntroductionDiabetes has been linked with poorer outcomes in coronavirus disease (COVID-19) patients. However, the question to whether continue or withdraw metformin therapy in COVID-19 patients with type 2 diabetes mellitus remains contentious. This study aims to investigate the association between metformin and poor COVID-19 outcomes.MethodsEligible studies published up to 21 October 2020 were included and appraised for validity, importance, and applicability. The included studies were further ranked according to the level of evidence (LOE).ResultsNine studies were included for further assessments, of which seven studies stated that metformin was not associated with poor COVID-19 outcomes (LOE II-V), while the other two with poorer designs stated otherwise (LOE V). Although metformin may increase the risk of developing acidosis and lactic acidosis (LOE IV), the observed risks were more accentuated in patients with severe COVID-19 disease or kidney impairment and in patients with > 2 daily metformin doses. Interestingly, one study revealed that metformin may even yield therapeutic role in reducing the risk of COVID-19 mortality (LOE II), although further studies are required to confirm these findings.ConclusionsOur findings indicated that metformin may be safely continued in COVID-19 patients. The benefit of metformin therapy with simultaneous continuous monitoring of COVID-19 severity and kidney function may outweigh the risks of lactic acidosis, of which incidence is relatively rare.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13410-021-00924-w.