Risk Factor For Worse Outcomes Research Articles

SPARC scoring model

Background: A big concern for physicians during the coronavirus disease 2019 (COVID-19) pandemic has been its uncertain prognosis and sudden progression into critical illness. No objective measures have yet been in use to predict complications and plan a management accordingly. Aims: The objective of this study was to establish a predictive model of disease outcome to facilitate early and effective decision-making. Materials and Methods: A cluster of (COVID-19) patient data was assessed retrospectively to build a binary logistic regression-based model that predicts mortality based on clinical, laboratory and radiological parameters. The model performance was characterised based on the receiver operating characteristic (ROC) curve. Results: During the study period, over 2000 patients infected with severe acute respiratory syndrome coronavirus 2 infection, of whom 200 were admitted to the intensive care unit. Eleven patients were omitted as per the entry criteria. Five predictors (determined within 24 h of admission) were identified as independent risk factors for worse outcomes in COVID-19-infected patients: serum lactate dehydrogenase, PaO2/FiO2, age, respiratory rate and computed tomography severity. These were then used as a cluster and a nomogram- COVID-19, critical care, infectious disease, outcome prediction, SPARC score (SPARC) was made. Intended to be used at or within 24 h of admission, it is intended for better triage and management. Higher score correlates with a better prognosis. The performance of the overall score was 80% as assessed by ROC. Conclusion: The risk score SPARC, based on five factors, aids in the early prediction of disease outcome and hence facilitates triage, individualised and efficacious treatment and improved results.

The effect of sertraline on depression and associations with persistent depression in survivors of HIV-related cryptococcal meningitis

Background: Depression is a risk factor for worse outcomes in persons living with HIV/AIDS and has a prevalence more than three times as high as in the general population. Despite this, there are few randomized studies of antidepressants in HIV-infected Africans. Methods: We enrolled 460 HIV-infected Africans with cryptococcal meningitis into a randomized clinical trial of adjunctive sertraline vs placebo (2015-2017). We defined depression using depression using a Center for Epidemiologic Studies Depression Scale (CES-D) score of >15, and severe depression as >26 at one and three months after meningitis diagnosis and initiation of treatment.We evaluated the relationship between sertraline and depression, as well as associations with persistent depression, at three months. Results: At one- and three-months post meningitis diagnosis, 62% (108/174) and 44% (74/169) of all subjects had depression (CES>15), respectively. At three months, sertraline-treated subjects had consistent risk for depression as placebo-treated subjects but were significantly less likely to have severe depression (CES>26) (OR 0.335; 95%CI, 0.130-0.865). Of those with depression at one month, sertraline-treated subjects were less likely than placebo-treated subjects to be depressed at three months (p=0.05). Sertraline was the only factor we found significant in predicting persistent depression at three months among those who had depression at one month. Conclusions: Depression is highly prevalent in HIV-infected persons who have survived cryptococcal meningitis. We found that sertraline is associated with a modest reduction in depression in those with depression at baseline and a significant decrease in severe depression.

Predictive risk factors for worse outcomes in COVID-19 patients with different clinical features at baseline

IntroductionCOVID-19 is characterized by a wide range of clinical expression and by possible progression to critical illness and death. Therefore it is essential to identify risk factors predicting progression towards serious and fatal diseases. The aim of our study was to identify laboratory predictive markers of clinical progression in patients with moderate/severe disease and in those with acute respiratory distress syndrome (ARDS).Material and methodsUsing electronic medical records for all demographic, clinical and laboratory data, a retrospective study on all consecutive patients with COVID-19 admitted to the Infectious Disease Clinic of Perugia was performed. The PaO2/FiO2 ratio (P/F) assessment cut‑off of 200 mm Hg was used at baseline to categorize the patients into two clinical groups. The progression towards invasive ventilation and/or death was used to identify critical outcome. Statistical analysis was performed. Multivariate logistic regression analysis was adopted to identify risk factors of critical illness and mortality.ResultsIn multivariate logistic regression analysis neutrophil/lymphocyte ratio (NLR) was the only significant predictive factor of progression to a critical outcome (p = 0.03) and of in-hospital mortality (p = 0.03). In ARDS patients no factors were associated with critical progression. Serum ferritin > 1006 ng/ml was the only predictive value of critical outcome in COVID-19 subjects with moderate/severe disease (p = 0.02).ConclusionsNeutrophil/lymphocyte ratio and serum ferritin are the only biomarkers that can help to stratify the risk of severity and mortality in patients with COVID-19.

Initial Post-Operative Visit Absenteeism Is Associated With Worse Amputation-Free Survival After Tibial Angioplasty

Several studies have identified loss to follow-up (LTF) as a risk factor for worse outcomes in several vascular procedures. Specifically, tibial revascularization is often performed in the setting of critical limb ischemia and tissue loss thus requiring close patient monitoring in the early post-operative period for worsening gangrene and/or ischemia. Therefore, we evaluated the role of LTF and its risk factors against outcomes in patients undergoing tibial endovascular procedures.

Daytime Activity Is Associated With Discharge to Home in Older Adults Recovering From Critical Illness.

Hospitalized older adults recovering from critical illness after transition of care out of an intensive care unit (ICU) are often inactive, which may affect discharge disposition and hospital length of stay (LOS). The current study explored relationships between early post-ICU activity, discharge disposition, and LOS. Actigraphy measured post-ICU daytime and nighttime activity (mean activity counts/min). Prospective chart review provided discharge disposition and LOS (days). Independent samples t tests compared post-ICU daytime activity by discharge disposition. Multivariate regression examined associations between post-ICU activity and LOS. Post-ICU daytime activity was greater among those discharged home (54.42 [SD = 29.3 counts/min]) than those discharged to a facility (33.26 [SD = 24.26 counts/min]): t(26) = 2.054, p = 0.050). Lower post-ICU daytime activity was associated with longer LOS (β = -0.322, p = 0.041). Future research should investigate whether post-ICU daytime inactivity during hospitalization is a modifiable risk factor for worse outcomes among older adults discharged from the ICU. [Journal of Gerontological Nursing, 47(2), 13-19.].

Acute Kidney Injury in Hospitalized Patients Infected with COVID-19 from Wuhan, China: A Retrospective Study.

Background Since the first diagnosed case of infection with the novel coronavirus (SARS-CoV-2), there has been a rapid spread of the disease with an increasing number of cases confirmed every day, as well as a rising death toll. An association has been reported between acute kidney injury (AKI) and mortality in patients infected with SARS-CoV-2. Therefore, our study was conducted to explore possible risk factors of AKI as well as whether AKI was a risk factor for worse outcome, especially mortality among patients with coronavirus disease (COVID-19). Methods We included all hospital admissions with confirmed or clinically diagnosed COVID-19 from January 29 to February 25, 2020. We collected demographic and epidemiological information, past medical history, symptoms, laboratory tests, treatments, and outcome data from electronic medical records. A total of 492 patients with diagnosed or clinically diagnosed COVID-19 were included in this study. Results The prevalence rate of AKI was 7.32%. Among the factors associated with AKI, males versus females (aOR 2.73), chronic kidney disease (aOR 42.2), hypertension (aOR 2.82), increased leucocytes (aOR 6.08), and diuretic use (aOR 7.89) were identified as independent risk factors for AKI among patients infected by SARS-CoV-2. There was a significant difference in hospital fees and death in patients with and without AKI (p < 0.05). The mortality rate in patients with AKI was 63.9%. Conclusions AKI was widespread among patients with COVID-19. The risk factors of AKI in COVID-19 patients included sex, chronic kidney disease, hypertension, infection, and diuretic use. AKI may be associated with a worse outcome, especially mortality in COVID-19 patients.

COVID-19 Outcomes of Patients With Differentiated Thyroid Cancer: A Multicenter Los Angeles Cohort Study

ObjectiveCancer may be a risk factor for worse outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infections. However, there is a significant variability across cancer types in the extent of disease burden and modalities of cancer treatment that may impact morbidity and mortality from coronavirus disease-19 (COVID-19). Therefore, we evaluated COVID-19 outcomes in patients with a differentiated thyroid cancer (DTC) history. MethodsThis is a retrospective cohort study of patients with a history of DTC and SARS-CoV2 infection from 2 academic Los Angeles healthcare systems. Demographic, thyroid cancer, and treatment data were analyzed for associations with COVID-19 outcomes. ResultsOf 21 patients with DTC and COVID-19, 8 (38.1%) were hospitalized and 2 (9.5%) died from COVID-19. Thyroid cancer initial disease burden and extent, treatment, or current response to therapy (eg, excellent vs incomplete) were not associated with COVID-19 severity in DTC patients. However, older age and the presence of a comorbidity other than DTC were significantly associated with COVID-19 hospitalization (P = .047 and P = .024, respectively). COVID-19–attributed hospitalization and mortality in DTC patients was lower than that previously reported in cancer patients, although similar to patients with nonthyroid malignancies in these centers. ConclusionThese data suggest that among patients with DTC, advanced age and comorbid conditions are significant contributors to the risk of hospitalization from SARS-CoV2 infection, rather than factors associated with thyroid cancer diagnosis, treatment, or disease burden. This multicenter report of clinical outcomes provides additional data to providers to inform DTC patients regarding their risk of COVID-19.

Proximal Row Carpectomy in Young Patients

There continues to be controversy regarding the treatment of early-stage arthritis of the wrist, particularly in young patients, because of the large number of techniques, the poor long-term results for many of these techniques, and the overall paucity of high-level scientific data. Proximal row carpectomy (PRC) and 4-corner arthrodesis (4CA) have been established as the mainstay motion-sparing surgical treatment options in cases of early scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis. However, there is marked controversy surrounding the best treatment option for younger patients with greater physical demands because of the questionable outcomes associated with these motion-sparing options in such patients1-9. Traditionally, many surgeons prefer 4CA over PRC for young, high-demand patients, in part because studies have suggested that young age and work status as a laborer are important risk factors for worse outcomes following PRC1,8. However, the concern for symptomatic nonunion and potential for radiolunate arthritis in 4CA, as well as the lack of medium to long-term comparative studies in this subset, make this recommendation controversial10. The wrist is accessed via the dorsal approach, creating a retinacular flap and a radially based ligament-sparing capsulotomy. The scaphoid, lunate, and triquetrum are then excised en bloc. The radioscapholunate ligament is protected. The capsule and retinaculum and then repaired. Alternatives to PRC include nonoperative treatment, 4CA, capitolunate arthrodesis, posterior and anterior interosseous neurectomies, total wrist arthroplasty, and total wrist arthrodesis. A recent study by Wagner et al. compared patients <45 years old who underwent either PRC or 4CA11. Overall, PRC and 4CA had similar complication rates, postoperative pain levels, wrist function, and long-term outcomes free of conversion to arthrodesis. Patients who underwent PRC had improved motion and fewer complications, whereas patients who underwent 4CA had slightly lower rates of radiocarpal arthritis. Therefore, in this technique article, we describe PRC for wrist arthritis in patients <45 years old.

Multilevel Correlates of Immunosuppressive Nonadherence in Kidney Transplant Patients: The Multicenter ADHERE BRAZIL Study.

Immunosuppressive nonadherence is a risk factor for worse outcomes after kidney transplantation (KT). Brazil, having the world's largest public, fully covered transplantation system and the second-highest KT volume worldwide, provides a unique setting for studying multilevel correlates of nonadherence (patient, healthcare provider, transplant center, and healthcare system levels) independent of patients' financial burden. By applying a multistage sampling approach, we included 1105 patients from 20 KT centers. Nonadherence to immunosuppressives (implementation phase) was defined as any deviation in taking or timing adherence and dose reduction assessed by the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Based on Bronfenbrenner's ecological model, we assessed multilevel factors using established instruments and measures specifically developed for this study and analyzed their independent contribution to nonadherence by performing sequential logistic regression analysis. The nonadherence prevalence rate was 39.7%. The following factors were independently associated with nonadherence: Patient level-having a stable partner (odds ratio [OR]: 0.75; confidence interval [CI]: 0.58-0.97), nonadherence to appointments (OR: 2.98; CI: 2.03-4.39), and nonadherence to physical activity recommendations (OR: 1.84; CI: 1.38-2.46); and transplant center level-satisfaction with the waiting room structure (OR: 0.54; CI: 0.42-0.71), consultation >30 minutes (OR: 1.60; CI: 1.19-2.14), adequacy of the consultation frequency (OR: 0.62; CI: 0.43-0.90), and centers with >500 beds (OR: 0.58; CI: 0.46-0.73). As the first multicenter study assessing multilevel correlates of nonadherence in KT, our findings point to the need for multilevel interventions beyond the patient level, targeting transplant center practice patterns as an approach to tackle nonadherence.

Clostridium difficile infection in a Geriatric Care Unit: clinical characteristics and prognosis

Background &amp; aims. Clostridium difficile infection (CDI) is a leading cause of nosocomial diarrhoea in elderly people. This study aimed to describe the main clinical features and prognosis at 6 months of patients affected by CDI in a Geriatric Unit. Methods. Retrospective observational study based on clinical records conducted among elderly patients admitted to a Geriatric Care Unit. Inclusion criteria were: 1) patients discharged with diagnosis of CDI, confirmed by positive fast enzyme immunoassay for detection of C. Difficile toxin B on stool sample; 2) availability of Multidimensional Prognostic Index (MPI) score, assessed during the first 48 hours after admission. Secondary analysis was performed to investigate potential risk factors for worse outcomes during hospitalization, and on the incidence of recurrences and survival in a subgroup at 6 months of follow-up. Results. Thirty-three patients enrolled (23 F, 10 M), mean age 89 years. CDI was the reason for hospital admission in 39.6% of cases, while 60.4% developed the infection during hospitalization. All patients had undergone recent antibiotic treatment and 97% had recently been hospitalized or were nursing home residents. Ninety percent of subjects had more than two comorbidities and in 85% of cases, MPI predicted a high risk of mortality. In-hospital mortality was 21% and, in the subgroup of 16 patients who completed the 6-month follow-up, 31% had at least one recurrence and 75% died. Conclusions. CDI affects oldest-old and vary frail patients, with high comorbidity and high risk of mortality, and most of them have a poor prognosis, suggesting that CDI might be considered as a frailty marker itself.

Abstract 16566: Presentation and Outcome of Pediatric Multisystem Inflammatory Syndrome Temporally Associated With Sars-cov-2 Pandemic: An International Survey

Introduction: Following the SARS-CoV-2 pandemic peak, children suffering from a multiorgan inflammatory disease that often leads to shock have been reported. This condition shares features with Kawasaki disease, but its etiopathogenesis is unknown. Hypothesis: We aimed to describe presentation and hospital course for this pediatric inflammatory multisystemic syndrome associated with COVID-19 (PIMS-TS). Methods: Data were collected from a retrospective review of children from 33 participating European, Asian and American sites. Results: We included 183 patients (109 males, 59·6%) with PIMS-TS, at a mean age of 7·0 (±4·7) years. Fifty-six (30·6%) had black ethnicity and obesity was present in 48 (26·2%) cases. Overall, 114/183 (62·3%) had biological evidence of current or recent SARS-CoV-2 infection. At admission, all presented with fever, 117/183 (63·9%) with gastrointestinal symptoms and 79/183 (43·2%) with shock, that was associated with more frequent black ethnicity, higher inflammatory markers and more cardiac involvement. Twenty-seven patients (14·7%) fulfilled criteria for Kawasaki disease. They were younger with no shock, fewer gastrointestinal, cardio-respiratory and neurological symptoms. Among the remaining PIMS-TS patients, 77 (49·3%) had mainly fever and inflammation with less cardiac involvement. For the entire cohort of 183 patients, the mean duration of admission was 8·6 (±5·6) days. Inotropic support, mechanical ventilation and ECMO were indicated in 72 (39·3%), 43 (23·5%) and 4 (2·2%) patients, respectively. Three patients (1·6%) died. A shorter duration of symptoms before admission was a risk factor for worse outcome and for ECMO/death, with 63% increased risk per day reduction (95%CI 0·39-0·93, p=0·03) and with 51·4% increased risk per day reduction (95%CI 0·36-0·9, p=0·03), respectively. Conclusions: We describe the first largest international series of children with PIMS-TS. Life-threatening shock is a common presentation. A shorter duration of symptoms prior to admission characterizes the fulminant form of the disease with potentially worse outcome.

APOE4 genetic polymorphism results in impaired recovery in a repeated mild traumatic brain injury model and treatment with Bryostatin-1 improves outcomes

After traumatic brain injury (TBI), some people have worse recovery than others. Single nucleotide polymorphisms (SNPs) in Apolipoprotein E (APOE) are known to increase risk for developing Alzheimer’s disease, however there is controversy from human and rodent studies as to whether ApoE4 is a risk factor for worse outcomes after brain trauma. To resolve these conflicting studies we have explored the effect of the human APOE4 gene in a reproducible mouse model that mimics common human injuries. We have investigated cellular and behavioral outcomes in genetically engineered human APOE targeted replacement (TR) mice following repeated mild TBI (rmTBI) using a lateral fluid percussion injury model. Relative to injured APOE3 TR mice, injured APOE4 TR mice had more inflammation, neurodegeneration, apoptosis, p-tau, and activated microglia and less total brain-derived neurotrophic factor (BDNF) in the cortex and/or hippocampus at 1 and/or 21 days post-injury. We utilized a novel personalized approach to treating APOE4 susceptible mice by administering Bryostatin-1, which improved cellular as well as motor and cognitive behavior outcomes at 1 DPI in the APOE4 injured mice. This study demonstrates that APOE4 is a risk factor for poor outcomes after rmTBI and highlights how personalized therapeutics can be a powerful treatment option.

BIOM-15. SUBVENTRICULAR ZONE INVOLVEMENT IS ASSOCIATED WITH WORSE OUTCOME IN GLIOMA WHO GRADE II INDEPENDENT OF MOLECULAR MARKERS

Abstract BACKGROUND The subventricular zone represents a niche of adult neural stem cells. Involvement of the subventricular zone is associated with decreased survival in malignant glioma. We aimed to determine whether a similar association applies to low-grade gliomas. METHODS A retrospective institutional database search was performed for patients with glioma WHO grade II according to the 2016 classification. Demographic data, histology and molecular signature, imaging, and therapy were recorded and outcome was analysed for tumors with and without infiltration of the subventricular zone. RESULTS 182 patients with glioma WHO grade II were identified, including 97 oligodendrogliomas and 85 astrocytomas. 78 of 182 patients (43%) presented with subventricular zone involvement. Demographics, histopathology, and molecular signature did not differ between patients with and without subventricular zone involvement. First-line management included surgery, chemotherapy, radiotherapy, brachytherapy, and wait-and-scan approaches. Median follow-up was 43 months. Median time to malignant progression was 122 months; median overall survival was not reached. Subventricular zone involvement was a negative prognostic marker for time to malignant progression (p = 0.002) and overall survival (p = 0.023) in the entire cohort as well as in the subgroup of patients who were managed with wait-and-scan approaches. Among patients in which early therapy was provided, subventricular zone involvement was not prognostic for overall survival but for time to malignant progression. In multivariate analysis, subventricular zone involvement was associated with worse prognosis independent of molecular markers or treatment approaches including use of resection. CONCLUSION Subventricular zone involvement represents a key risk factor for worse outcome in glioma WHO grade II. Early first-line therapy may improve outcome in such patients.

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

Simple SummaryIt is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages.(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.

Letter by Tang et al regarding the article ‘Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”’

We read with great interest the article by Bandaru et al 1 in a recent issue of the Journal of NeuroInterventional Surgery in which they have identified that leukoaraiosis (LA)...

Frailty predicts worse outcomes after intracranial meningioma surgery irrespective of existing prognostic factors.

Frailty has been recognized as a predictor of adverse surgical outcomes across multiple surgical disciplines, but until now the relationship between frailty and intracranial meningioma surgery has not been studied. The goal of the present study was to determine the relationship between increasing frailty (determined using the modified Frailty Index [mFI]) and intracranial meningioma resection outcomes (including hospital length of stay [LOS], discharge location, and reoperation and readmission rates). This is a single-center retrospective cohort study of patients who underwent intracranial meningioma resection between August 2012 and May 2018. Seventy-six patients met the inclusion criteria. Frailty was associated with increased hospital LOS (p = 0.0218), increased reoperation rate (p = 0.029), and discharge to a higher level of care: an inpatient rehabilitation facility or a skilled nursing facility (p = 0.0002). After multivariable analysis, frailty was determined to be an independent risk factor for increased LOS, worse discharge disposition, and subsequent readmission. Frailty is an independent risk factor for worse outcomes following intracranial meningioma resection, including increased LOS, reoperations, and worse discharge disposition. Frailty may help stratify preoperative surgical risk, and thus may provide important clinical information to help neurosurgeons and elderly patients weigh the risks and benefits of resection.

Racial Disparities in Incidence and Outcomes Among Patients With COVID-19

Initial public health data show that Black race may be a risk factor for worse outcomes of coronavirus disease 2019 (COVID-19). To characterize the association of race with incidence and outcomes of COVID-19, while controlling for age, sex, socioeconomic status, and comorbidities. This cross-sectional study included 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020, at Froedtert Health and Medical College of Wisconsin (Milwaukee), the largest academic system in Wisconsin, with 879 inpatient beds (of which 128 are intensive care unit beds). Race (Black vs White, Native Hawaiian or Pacific Islander, Native American or Alaska Native, Asian, or unknown). Main outcomes included COVID-19 positivity, hospitalization, intensive care unit admission, mechanical ventilation, and death. Additional independent variables measured and tested included socioeconomic status, sex, and comorbidities. Reverse transcription polymerase chain reaction assay was used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A total of 2595 patients were included. The mean (SD) age was 53.8 (17.5) years, 978 (37.7%) were men, and 785 (30.2%) were African American patients. Of the 369 patients (14.2%) who tested positive for COVID-19, 170 (46.1%) were men, 148 (40.1%) were aged 60 years or older, and 218 (59.1%) were African American individuals. Positive tests were associated with Black race (odds ratio [OR], 5.37; 95% CI, 3.94-7.29; P = .001), male sex (OR, 1.55; 95% CI, 1.21-2.00; P = .001), and age 60 years or older (OR, 2.04; 95% CI, 1.53-2.73; P = .001). Zip code of residence explained 79% of the overall variance in COVID-19 positivity in the cohort (ρ = 0.79; 95% CI, 0.58-0.91). Adjusting for zip code of residence, Black race (OR, 1.85; 95% CI, 1.00-3.65; P = .04) and poverty (OR, 3.84; 95% CI, 1.20-12.30; P = .02) were associated with hospitalization. Poverty (OR, 3.58; 95% CI, 1.08-11.80; P = .04) but not Black race (OR, 1.52; 95% CI, 0.75-3.07; P = .24) was associated with intensive care unit admission. Overall, 20 (17.2%) deaths associated with COVID-19 were reported. Shortness of breath at presentation (OR, 10.67; 95% CI, 1.52-25.54; P = .02), higher body mass index (OR per unit of body mass index, 1.19; 95% CI, 1.05-1.35; P = .006), and age 60 years or older (OR, 22.79; 95% CI, 3.38-53.81; P = .001) were associated with an increased likelihood of death. In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. These findings can be helpful in targeting mitigation strategies for racial disparities in the incidence and outcomes of COVID-19.

Does nosocomial COVID-19 result in increased 30-day mortality? A multi-centre observational study to identify risk factors for worse outcomes in patients with COVID-19

This study aimed to determine whether nosocomial coronavirus disease 2019 (COVID-19) has a worse outcome compared with community-acquired COVID-19. This was a prospective cohort study of all hospitalized patients with confirmed COVID-19 in three acute hospitals on 9th April 2020. Patients were followed-up for at least 30 days. Nosocomial infection was defined as a positive swab after 7 days of admission. In total, one hundred and seventy-three patients were identified, and 19 (11.0%) had nosocomial infection. Thirty-two (18.5%) patients died within 30 days (all cause) of a positive swab test; there were no significant differences in 30-day all-cause mortality rates between the three groups (i.e. patients admitted with suspected COVID-19, patients with incidental COVID-19 and patients with nosocomial COVID-19): 21.1% vs 17.6% vs 21.6% (P=0.755). Nosocomial COVID-19 is not associated with increased mortality compared with community-acquired COVID-19.

Coronavirus Disease 2019 and Hypertension: The Role of Angiotensin-Converting Enzyme 2 and the Renin-Angiotensin System.

Hypertension emerged from early reports as a potential risk factor for worse outcomes for persons with coronavirus disease 2019 (COVID-19). Among the putative links between hypertension and COVID-19 is a key counter-regulatory component of the renin-angiotensin system (RAS): angiotensin-converting enzyme 2 (ACE2). ACE2 facilitates entry of severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19, into host cells. Because RAS inhibitors have been suggested to increase ACE2 expression, health-care providers and patients have grappled with the decision of whether to discontinue these medications during the COVID-19 pandemic. However, experimental models of analogous viral pneumonias suggest RAS inhibitors may exert protective effects against acute lung injury. We review how RAS and ACE2 biology may affect outcomes in COVID-19 through pulmonary and other systemic effects. In addition, we briefly detail the data for and against continuation of RAS inhibitors in persons with COVID-19 and summarize the current consensus recommendations from select specialty organizations.

What are the Risk Factors for Worse Outcomes of Meniscus Surgery in 23-39-Year-Old Patients Ligamentously Stable Knees?

Objectives:Meniscus tears are a common and significant source of knee dysfunction in active young adult patients, and no high-quality prospective cohort or RCTs studies exist evaluating patient-reported outcomes in patients in this age group with ligamentously stable knees. Our objective was to identify patient-reported outcomes and patient-specific risk factors from a prospective cohort with a minimum of one-year follow-up following meniscal repair or excision in patients with ligamentously stable knees. We hypothesized that both groups would have significant improvement in outcomes; patients undergoing meniscal repair would have a higher reoperation rate; and articular cartilage injuries, subsequent knee surgery, and certain demographic characteristics would be significant risk factors to inferior outcomes at one year.Methods:Between February 2015 and December 2017, ligamentously stable meniscal procedures were enrolled and prospectively followed using the outcomes management evaluation system (OME) at Cleveland Clinic. Patients aged 23-39 preoperatively completed a series of validated outcome measurements including the Knee Injury and Osteoarthritis Outcome Score for both Pain (KOOS Pain) and Quality of Life (KOOS QoL). At the time of surgery, physicians documented all intra-articular findings, treatment, and surgical techniques utilized. Patients were followed at minimum of 1-year postoperatively through the OME platform and asked to complete the same outcome instruments done at baseline as well as a question designed to evaluate the Patient Acceptable Symptom State (PASS). The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of outcomes.Results:A total of 371 patients aged 23-39 underwent meniscus excision or repair during the study period. One hundred ninety-four met inclusion criteria, and one-year follow-up was obtained on 72% (n = 139) of the cohort (67% male; median age 32). Both KOOS Pain and KOOS QoL improved significantly at one-year for the entire cohort. Fourteen percent of the cohort (9% on the ipsilateral knee, 5% on the contralateral knee) underwent subsequent surgery at a minimum of one-year postoperatively. The patient-specific risk factors for worse one-year outcomes included preoperative baseline mental capacity score (VR-12 MCS), lower baseline KOOS QoL score, and the intraoperative finding of any grade 3 or 4 chondral changes.Conclusion:Young adult patients with ligamentously stable knees undergoing meniscal surgery have significantly improved patient-reported outcomes regardless of excision or repair; however, 14% of patients underwent additional knee surgery at a minimum of one-year postoperatively. The risk factors for worse outcomes include lower baseline mental health score, lower baseline KOOS QoL score, and any grade 3 or 4 chondromalacia scene.