Risk Of Serious Adverse Outcomes Research Articles

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study

ObjectiveTo assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy.DesignObservational cohort study.SettingCommunity telephone triage provided...

Risk of adverse outcomes during gabapentinoid therapy and factors associated with increased risk in UK primary care using the clinical practice research datalink: a cohort study.

Growing evidence from pharmacovigilance data and postmortem toxicology reports highlights the misuse potential of gabapentinoids. This study aimed to investigate the risk of serious adverse outcomes (drug misuse, overdose, major trauma), and their risk factors, in primary care patients who are prescribed gabapentinoids. Using the UK Clinical Practice Research Datalink, a matched cohort study calculated adverse event rates separately for gabapentinoid-exposed and unexposed cohorts. In the exposed cohort, event rates for exposure to a range of potential risk factors were calculated. Event rates were compared using Cox proportional hazards models, adjusted for age, sex, deprivation, previous mental health diagnosis, and coprescribing with potentially interacting medicines. Substance misuse (gabapentin adjusted hazard ratio [95% CI]: 2.40 [2.25-2.55]), overdose (2.99 [2.56-3.49]), and major trauma (0-2.5 years: 1.35 [1.28-1.42]; 2.5 to 10 years: 1.73 [1.56-1.95]) were more common among patients prescribed gabapentinoids than matched individuals who were not. The association with overdose was stronger for pregabalin than gabapentin. All adverse outcomes were significantly associated with smoking, history of substance misuse, overdose, or a mental health condition and prescription of opioids, benzodiazepines, antidepressants, and Z-drug hypnotics (eg, gabapentin hazard ratios for association of concurrent opioid use: misuse 1.49 [1.47-1.51]; overdose 1.87 [1.78-1.96]; major trauma 1.28 [1.26-1.30]). Our findings highlight the importance of careful patient selection when prescribing gabapentinoids and the need to educate prescribers about the risks of these drugs, particularly in combination with other central nervous system depressants.

Design and implementation of an electronic opioid management plan to support consistent communication of opioid analgesia prescribing intentions to patients and general practitioners

AbstractOpioid prescribing requires careful planning to minimise the risk of serious adverse outcomes. However, documentation of discharge opioid plans for patients and their general practitioners (GPs) is inconsistent, particularly when opioids are commenced in the emergency department or after surgery. We describe an initiative to promote consistent discharge opioid plan communication by implementing an opioid management plan (OMP) in our hospital's electronic medical record. Completion of an electronic form by the prescriber generates an OMP note in the medical history, which is used by the pharmacist to provide tailored opioid patient education. The OMP also populates the discharge summary that is sent to the GP and the Australian national digital health record platform, My Health Record. Preliminary evaluation shows incorporating OMP documentation into routine workflows has assisted prescribers to consistently document the plan for supplied opioids, supporting continuity of care. Workflow optimisation is ongoing to further improve discharge summary documentation and provision of patient‐friendly written information. This study was conducted as a quality improvement project and audits conducted as part of the project were approved by Austin Health's Office for Research (Project No: LNR/18/Austin/155). Informed patient consent was not required by Austin Health.

Prevention of long COVID: progress and challenges

Prevention of long COVID: progress and challenges

The impact of COVID-19 on patients with chronic obstructive pulmonary disease

BACKGROUND: The aim of this study was to evaluate the risk of serious adverse outcomes in patients with chronic obstructive pulmonary disease (COPD) related to COVID-19 by stratifying the comorbidity status.METHODS: This is a prospective cohort study based on 1264 male and female patients, which were 25-75 years old. Nine hundred five (71.5%) patients gave consent to participate. The collected data included demographics, clinical, biochemistry, microbiology information, and the presence of disease. We performed descriptive and multivariate regression analyses to analyze the COVID-19 disease in the context of COPD.RESULTS: There was a significant difference between COPD versus control subjects with respect to age groups, BMI, smoking cigarette, comorbidity, infection, hypertension, stroke, coronary heart failure (CHF), diabetic and cerebral (P<0.001). The highly statistically significant differences were observed between COPD versus control subjects regarding, hemoglobin (P=0.022), HbA1C (P<0.001), glucose (P=0.040), vitamin D (P<0.001), vitamin B12 (P=0.020), triglyceride, uric acid (P<0.001), ferritin (P=0.002), Fe (P=0.004), and TSH (P=0.008), creatine-kinase (CK) (P=0.004), white blood cell (WBC) (P<0.001), hematocrit (P<0.001), monocytes (P<0.001), neutrophil (P<0.001), lymphocyte (P<0.001), platelet (P<0.001), aspartate transaminase-AST (P=0.018), alanine transaminase-ALT (P=0.008), respectively. The multivariate stepwise regression analysis indicated that monocyte (P<0.001), hematocrit (P<0.001), lymphocyte (P<0.001), smoking (yes) (P<0.001), vitamin D (P<0.001), uric acid (P<0.001), diastolic BP (P<0.001), ferritin (P=0.002), infection (yes) (P=0.002), creatine kinase (P=0.006), metabolic syndrome (IDF) (P=0.008) and BMI kg/m2 (P=0.009) can be considered as risk predictors of the COPD among COVID-19 patients after adjusting for age and gender.CONCLUSIONS: This study determined that COPD disease was the most prevalent comorbidity with CHF, hypertension and diabetes disease among COVID-19 patients. Interestingly, the current study revealed that 22.8% of COPD patients stated being smokers. The current study supports the evidence that COPD patients have worse outcomes from COVID-19 and explored the multiple factors responsible.

Lipoprotein(a) and calcific aortic valve disease initiation and progression: a systematic review and meta-analysis.

Although evidence indicates the association of lipoprotein(a) [Lp(a)] with atherosclerosis, the link with calcific aortic valve disease (CAVD) is unclear. This systematic review and meta-analysis explores the connection between Lp(a) and aortic valve calcification and stenosis (AVS). We included all relevant studies, indexed in eight databases, up to February 2023. A total of 44 studies (163 139 subjects) were included, with 16 of them being further meta-analysed. Despite considerable heterogeneity, most studies support the relationship between Lp(a) and CAVD, especially in younger populations, with evidence of early aortic valve micro-calcification in elevated-Lp(a) populations. The quantitative synthesis showed higher Lp(a) levels, by 22.63 nmol/L (95% CI: 9.98-35.27), for patients with AVS, while meta-regressing the data revealed smaller Lp(a) differences for older populations with a higher proportion of females. The meta-analysis of eight studies providing genetic data, revealed that the minor alleles of both rs10455872 and rs3798220 LPA gene loci were associated with higher risk for AVS (pooled odds ratio 1.42; 95% CI: 1.34-1.50 and 1.27; 95% CI: 1.09-1.48, respectively). Importantly, high-Lp(a) individuals displayed not only faster AVS progression, by a mean difference of 0.09 m/s/year (95% CI: 0.09-0.09), but also a higher risk of serious adverse outcomes, including death (pooled hazard ratio 1.39; 95% CI: 1.01-1.90). These summary findings highlight the effect of Lp(a) on CAVD initiation, progression and outcomes, and support the early onset of Lp(a)-related subclinical lesions before clinical evidence.

Colchicine Drug Interaction Errors and Misunderstandings: Recommendations for Improved Evidence-Based Management.

Colchicine is useful for the prevention and treatment of gout and a variety of other disorders. It is a substrate for CYP3A4 and P-glycoprotein (P-gp), and concomitant administration with CYP3A4/P-gp inhibitors can cause life-threatening drug-drug interactions (DDIs) such as pancytopenia, multiorgan failure, and cardiac arrhythmias. Colchicine can also cause myotoxicity, and coadministration with other myotoxic drugs may increase the risk of myopathy and rhabdomyolysis. Many sources of DDI information including journal publications, product labels, and online sources have errors or misleading statements regarding which drugs interact with colchicine, as well as suboptimal recommendations for managing the DDIs to minimize patient harm. Furthermore, assessment of the clinical importance of specific colchicine DDIs can vary dramatically from one source to another. In this paper we provide an evidence-based evaluation of which drugs can be expected to interact with colchicine, and which drugs have been stated to interact with colchicine but are unlikely to do so. Based on these evaluations we suggest management options for reducing the risk of potentially severe adverse outcomes from colchicine DDIs. The common recommendation to reduce the dose of colchicine when given with CYP3A4/P-gp inhibitors is likely to result in colchicine toxicity in some patients and therapeutic failure in others. A comprehensive evaluation of the almost 100 reported cases of colchicine DDIs is included in table form in the electronic supplementary material. Colchicine is a valuable drug, but improvements in the information about colchicine DDIs are needed in order to minimize the risk of serious adverse outcomes.

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: An observational cohort study linking NHS 111 telephone triage, primary and secondary healthcare and mortality records.

ObjectivesSettings in identifying need for emergency care amongst those with suspected COVID-19 infection and identify factors which affect triage accuracy. ApproachAn observational cohort study of adults who contacted the NHS 111 telephone triage service provided by Yorkshire Ambulance Service between March and June 2020 with symptoms indicating possible COVID-19 infection. Patient-level data encompassing triage call, primary care, hospital care and death registration records relating to 40,261 adults were linked. The accuracy of triage outcome (self-care/non-urgent assessment versus ambulance/urgent assessment) was assessed for death or organ support 30 days from first contact. Multivariable logistic regression was used to identify factors associated with risk of false negative or false positive triage. ResultsCallers had a 3% (1,200/40,261) risk of serious adverse outcomes. Telephone triage recommended self-care or non-urgent assessment for 60% (24,335/40,261), with a 1.3% (310/24,335) risk of adverse outcomes 30 days from first contact. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (61% to 62%) for the primary outcome. Analysis suggested respiratory comorbidities may be over-appreciated and diabetes under-appreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration. ConclusionPatients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

Development and Validation of a Nomogram for Adverse Outcomes of Geriatric Trauma Patients Based on Frailty Syndrome.

PurposeCurrently, assessing trauma severity alone in geriatric trauma patients (GTPs) cannot accurately predict the risk of serious adverse outcomes during hospitalization. As an emerging concept in recent years, frailty syndrome is closely related to the poor prognosis of many diseases in elderly patients, including trauma. A logistic model for predicting adverse outcomes in elderly trauma patients during hospitalization was constructed in elderly patients, and the predictive efficacy of the model was verified.Patients and MethodsTrauma patients aged ≥65 years between June 2020 and September 2021 were selected and randomly divided into a training set and validation set at a ratio of 3:1. Mid arm muscle circumference (MAMC) was measured to determine the degree of frailty. LASSO regression was used to screen appropriate variables for the construction of a prognostic model. The logistic regression model was established and presented in the form of a nomogram. Calibration curves and ROC curves were used to verify the performance of the model.ResultsA total of 209 patients were enrolled, including 143 (68.4%) males and 66 (31.6%) females, with an average age of 70.8 ± 4.8 years. Ageless Charlson comorbidity index, BT unit, ISS, GCS, MAMC, prealbumin and lactic acid levels were screened by LASSO regression to construct a prognostic model. The AUC of the ROC analysis prediction model was 0.89 (95% CI 0.80–0.97) in the validation set. The results of the Hosmer–Lemeshow test for the validation set were χ2 = 11.23, P = 0.189.ConclusionThe prognostic model of adverse outcomes in GTPs has good accuracy and differentiation, which can improve the prediction results of risk stratification of GTPs during hospitalization by medical staff and provide a new idea for prognostic prediction.

Compliance with clinical guidelines increases the safety of vacuum-assisted delivery.

Vacuum-assisted delivery (VAD) is a common and safe obstetric procedure. However, occasionally serious complications may occur. Clinical guidelines and College Statements have been developed to reduce the risk of serious adverse events. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) College Statement C-Obs 16 has not been evaluated to see if advice improves outcomes. The aim was to evaluate whether compliance with RANZCOG College Statement C-Obs 16 advice reduced the risk of serious adverse outcomes, specifically clinically significant subgaleal haemorrhage and major birth trauma. Retrospective audit of VADs in a level five hospital (NSW Maternity and Neonatal capability framework) from January 2020 to 2021. There were 1960 women who delivered in the study period, of whom 252 (12.8%) delivered by vacuum, and complete data were available from 241 cases. Statement compliance was observed in 81%. The main deviation from Statement compliance was pulls exceeding three. Statement compliance was associated with a significant reduction in the incidence of subgaleal haemorrhage (0% vs 11%, P= 0.0002), major birth trauma (3% vs 22%, P= 0.0001), requirement for neonatal resuscitation (14% vs 35%, P= 0.0026) and Apgar scores at oneminute less than six (5% vs 22% P= 0.0006). Statement compliance was associated with a significant reduction in maternal blood loss at delivery (388 mL vs 438 mL, P= 0.01). Noncompliance with Statement advice was observed significantly more often in pregnancy complicated by gestational diabetes (3% vs 15%, P= 0.02) and birth requiring instrument change (4% vs 13% P= 0.031). Compliance with a College Statement is associated with lower rates of subgaleal haemorrhage and major neonatal trauma. The main deviation from compliance was pulls in excess of three. Keyword: birth trauma, clinical guidelines, quality and safety in healthcare, subgaleal haemorrhage, vacuum delivery.

Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration.

Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.

The impact of COVID-19 on coronary heart failure patients and co-morbid diseases

Objective: The objective of this study was to evaluate the risk of serious adverse outcomes in patients with Chronic Coronary Heart Failure (CHF) related COVID-19 by stratifying the co-morbidity status.Subjects and Methods: This is a prospective cohort study based on 1,264 male and female aged 25-75 years old patients and 1,007 (74%) patients gave consent to participate. Demographics, clinical, biochemistry and microbiology information, the presence of disease. Results: There was a significant difference between CHF versus controls with respect to age groups (p

834. Characterization of Heavily Treatment Experienced HIV-1 Infected Clinical Trial Participants Infected with SARS-CoV-2 COVID 19: Fostemsavir BRIGHTE Phase 3 Clinical Trial

BackgroundBRIGHTE is an ongoing global study evaluating the gp120 attachment inhibitor fostemsavir (FTR) in heavily treatment-experienced (HTE) adults with multidrug resistant (MDR) HIV-1 unable to form a viable antiretroviral (ARV) regimen. An estimated 2 million people living with HIV-1 have been infected with SARS-CoV-2. Those with HIV viremia and/or low CD4+ counts are at increased risk of serious adverse outcome. We describe the reported COVID cases in a clinical trial population of people living with MDR HIV and immune suppression. MethodsAt the start of the COVID pandemic, all ongoing BRIGHTE subjects had achieved ≥ 192 weeks on FTR and optimized background ARVs; results through Week 96 were presented previously. Investigators used WHO guidelines for COVID diagnosis and reported exposure, testing results and symptom presence.Figure 1. BRIGHTE Study Design Results371 subjects [272 Randomized Cohort (RC), 99 Non-Randomized Cohort (NC)] were enrolled; 44% were ≥ 50 years of age and 86% had an AIDS history. Median CD4+ count at study start of was 80 cells/mm3 (IQR 11–202); 30% with ≤ 20 cells/mm3. 250 subjects remained in BRIGHTE at pandemic start. By April 2021, 17 subjects (14 RC, 3 NC) had confirmed COVID infection (positive PCR test). Severity was Grade 1-3, all cases resolved with no deaths. Six subjects were hospitalized (Table 1); most recent CD4+ count prior to COVID were 293-1641 cells/mm3 and 5/6 subjects were virologically suppressed. Treatments often included prophylactic anticoagulants and supplemental oxygen; no cART changes were made. The remaining 11/17 confirmed cases were managed outpatient. Five more subjects had suspect COVID not confirmed by PCR and 2 subjects had negative PCR tests.Table 1. Characterization of Participants with Serious AEs of Confirmed COVID-19 Infections – All Hospitalizations ConclusionA total of 22/250 COVID-19 cases (17 confirmed, 5 unconfirmed) have been reported in BRIGHTE. Outcomes were reassuring with no deaths or known persistent sequelae, despite having advanced HIV and comorbid diseases at baseline associated with poorer COVID outcomes. Outcomes may have benefitted from immunologic improvement during the trial. Disclosures Shiven Chabria, MD, Viiv Healthcare (Employee) Stephane De Wit, MD, Gilead (Grant/Research Support)Janssen (Grant/Research Support)Merck Sharpe & Dohme (Grant/Research Support)ViiV Healthcare (Grant/Research Support) Amy Pierce, BS, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Bronagh M. Shepherd, PhD, GlaxoSmithKline (Employee, Shareholder) Michael Warwick-Sanders, BM BSc DPM MFPM, GSK (Employee) Marcia Wang, PhD, GlaxoSmithKline (Employee, Shareholder) Andrew Clark, MD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Peter Ackerman, MD, GSK/ViiV Healthcare (Employee, Shareholder)

Association of Bariatric Surgery With Major Adverse Liver and Cardiovascular Outcomes in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis

No therapy has been shown to reduce the risk of serious adverse outcomes in patients with nonalcoholic steatohepatitis (NASH). To investigate the long-term relationship between bariatric surgery and incident major adverse liver outcomes and major adverse cardiovascular events (MACE) in patients with obesity and biopsy-proven fibrotic NASH without cirrhosis. In the SPLENDOR (Surgical Procedures and Long-term Effectiveness in NASH Disease and Obesity Risk) study, of 25 828 liver biopsies performed at a US health system between 2004 and 2016, 1158 adult patients with obesity were identified who fulfilled enrollment criteria, including confirmed histological diagnosis of NASH and presence of liver fibrosis (histological stages 1-3). Baseline clinical characteristics, histological disease activity, and fibrosis stage of patients who underwent simultaneous liver biopsy at the time of bariatric surgery were balanced with a nonsurgical control group using overlap weighting methods. Follow-up ended in March 2021. Bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy) vs nonsurgical care. The primary outcomes were the incidence of major adverse liver outcomes (progression to clinical or histological cirrhosis, development of hepatocellular carcinoma, liver transplantation, or liver-related mortality) and MACE (a composite of coronary artery events, cerebrovascular events, heart failure, or cardiovascular death), estimated using the Firth penalized method in a multivariable-adjusted Cox regression analysis framework. A total of 1158 patients (740 [63.9%] women; median age, 49.8 years [IQR, 40.9-57.9 years], median body mass index, 44.1 [IQR, 39.4-51.4]), including 650 patients who underwent bariatric surgery and 508 patients in the nonsurgical control group, with a median follow-up of 7 years (IQR, 4-10 years) were analyzed. Distribution of baseline covariates, including histological severity of liver injury, was well-balanced after overlap weighting. At the end of the study period in the unweighted data set, 5 patients in the bariatric surgery group and 40 patients in the nonsurgical control group experienced major adverse liver outcomes, and 39 patients in the bariatric surgery group and 60 patients in the nonsurgical group experienced MACE. Among the patients analyzed with overlap weighting methods, the cumulative incidence of major adverse liver outcomes at 10 years was 2.3% (95% CI, 0%-4.6%) in the bariatric surgery group and 9.6% (95% CI, 6.1%-12.9%) in the nonsurgical group (adjusted absolute risk difference, 12.4% [95% CI, 5.7%-19.7%]; adjusted hazard ratio, 0.12 [95% CI, 0.02-0.63]; P = .01). The cumulative incidence of MACE at 10 years was 8.5% (95% CI, 5.5%-11.4%) in the bariatric surgery group and 15.7% (95% CI, 11.3%-19.8%) in the nonsurgical group (adjusted absolute risk difference, 13.9% [95% CI, 5.9%-21.9%]; adjusted hazard ratio, 0.30 [95% CI, 0.12-0.72]; P = .007). Within the first year after bariatric surgery, 4 patients (0.6%) died from surgical complications, including gastrointestinal leak (n = 2) and respiratory failure (n = 2). Among patients with NASH and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and MACE.

Comorbidity and it,s Impact on COVID-19 Affected Patients in COVID-19 Dedicated Hospital of Bangladesh

The Wuhan City of China evidenced unknown aetiology pneumonia cases at the end of December 2019. On 7 January 2020, the causative agent was identified as a novel coronavirus (2019-nCoV), currently referred to as SARS-CoV-2, and coronavirus disease as COVID-19. Older adults and people of any age who have underlying medical conditions, such as hypertension and diabetes, have shown worse prognosis. The aim of this study to evaluate the risk of serious adverse outcomes in patients with COVID-19 by stratifying the comorbidity status. We conducted a retro-prospective study of 405 patients admitted into the Mugda Medical College and Hospital, Dhaka,Bangladesh. Among 405 cases, mean age was 46.33 years. About 216 (53.3%) patients were male. Almost 322 (79.5%) patients were managed inside Dhaka city. The most common symptom was fever on or after hospitalization (71.9%). Of the 405 cases the prevalence of specific comorbidities was: hypertension (n=141, 34.8%), other cardiovascular diseases (n=42, 10.4%) cerebrovascular diseases (n=7, 1.7%), diabetes (n=140, 34.6%), COPD (n=4, 1.0%), chronic kidney diseases (n=65, 16.0%), malignancy (n=4, 1.0%) and asthma (n=51,12.6%). Overall, 307 (75.8%) patients discharged alive during the time frame of this study. 98(24.2%) patients died, 63 (15.6%) were admitted to the ICU and 16 (4.0%) received invasive ventilation. Patients with comorbidities should take all necessary precautions to avoid getting infected with SARS CoV-2, as they usually have the worst prognosis. There is a need for a global public health campaign to raise awareness, on reducing the burden of these comorbidity illnesses causing deaths in COVID-19- infected patients.&#x0D; Bangladesh Med J. 2020 Jan; 49 (1): 19-25

Impact of comorbidities on patients with COVID-19: A large retrospective study in Zhejiang, China.

Coronavirus disease 2019 (COVID‐19) has become a serious public health problem worldwide. Here, we stratified COVID‐19 patients based on their comorbidities to assess their risk of serious adverse outcomes. We collected 856 hospitalized cases diagnosed with COVID‐19 from 17 January to 7 February 2020, in Zhejiang Province, and analyzed their comorbidities and composite endpoint (including admission to intensive care unit owing to disease progression, shock, invasive ventilation, and death) to determine the relationship between comorbidities and adverse outcomes. The median age of patients was 46 (36‐56) years; 439 (51.3%) were men, 242 (28.3%) had comorbidities, and 152 (17.8%) had two or more comorbidities. The most common comorbidity was hypertension (142 [16.6%]), followed by diabetes (64 [7.5%]). Of the 856 patients, there are 154 (18.0%) severe cases. Thirty‐two (3.7%) reached composite endpoints, of which 22 (9.1%) were from the comorbidity group and 10 (1.6%) from the non‐comorbidity group (P < .001). After adjusting for age and gender status, the risk of reaching the composite endpoint was higher in the group with comorbidity than in that without comorbidity (hazard ratio [HR] 3.04, 95% confidence interval [CI]: 1.40‐6.60). HR values for patients with one, two, and three or more comorbidities were 1.61 (95% CI: 0.44‐5.91), 3.44 (95% CI: 1.31‐9.08), and 6.90 (95% CI: 2.69‐17.69), respectively. COVID‐19 patients with comorbidities had worse clinical outcomes as compared with those without any comorbidity. The higher the number of comorbidities, the greater was the risk of serious adverse outcomes.

Which Patients Discharged to Home-Based Outpatient Parenteral Antimicrobial Therapy Are at High Risk of Adverse Outcomes?

BackgroundPatients increasingly receive home-based outpatient parenteral antimicrobial therapy (OPAT). Understanding which patients might be at higher risk of complications is critical in effectively triaging resources upon and after hospital discharge.MethodsA prospective cohort of patients discharged from 1 of 2 academic medical centers in Baltimore, Maryland, between March 2015 and December 2018 were consented and randomly divided into derivation and validation cohorts for development of a risk score for adverse OPAT outcomes. Data from the derivation cohort with the primary outcome of a serious adverse outcome (infection relapse, serious adverse drug event, serious catheter complication, readmission, or death) were analyzed to derive the risk score equation using logistic regression, which was then validated in the validation cohort for performance of predicting a serious adverse outcome.ResultsOf 664 patients in the total cohort, half (332) experienced a serious adverse outcome. The model predicting having a serious adverse outcome included type of catheter, time on OPAT, using a catheter for chemotherapy, using a catheter for home parenteral nutrition, being treated for septic arthritis, being on vancomycin, being treated for Enterococcus, being treated for a fungal infection, and being treated empirically. A score ≥2 on the serious adverse outcome score had a 94.0% and 90.9% sensitivity for having a serious adverse outcome in the derivation and validation cohorts, respectively.ConclusionsA risk score can be implemented to detect who may be at high risk of serious adverse outcomes, but all patients on OPAT may require monitoring to prevent or detect adverse events.

Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis.

BackgroundThe coronavirus disease 2019 (COVID-19) outbreak is evolving rapidly worldwide.ObjectiveTo evaluate the risk of serious adverse outcomes in patients with COVID-19 by stratifying the comorbidity status.MethodsWe analysed data from 1590 laboratory confirmed hospitalised patients from 575 hospitals in 31 provinces/autonomous regions/provincial municipalities across mainland China between 11 December 2019 and 31 January 2020. We analysed the composite end-points, which consisted of admission to an intensive care unit, invasive ventilation or death. The risk of reaching the composite end-points was compared according to the presence and number of comorbidities.ResultsThe mean age was 48.9 years and 686 (42.7%) patients were female. Severe cases accounted for 16.0% of the study population. 131 (8.2%) patients reached the composite end-points. 399 (25.1%) reported having at least one comorbidity. The most prevalent comorbidity was hypertension (16.9%), followed by diabetes (8.2%). 130 (8.2%) patients reported having two or more comorbidities. After adjusting for age and smoking status, COPD (HR (95% CI) 2.681 (1.424–5.048)), diabetes (1.59 (1.03–2.45)), hypertension (1.58 (1.07–2.32)) and malignancy (3.50 (1.60–7.64)) were risk factors of reaching the composite end-points. The hazard ratio (95% CI) was 1.79 (1.16–2.77) among patients with at least one comorbidity and 2.59 (1.61–4.17) among patients with two or more comorbidities.ConclusionAmong laboratory confirmed cases of COVID-19, patients with any comorbidity yielded poorer clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomes.

Contrast-Associated Acute Kidney Injury and Serious Adverse Outcomes Following Angiography

BackgroundContrast-associated acute kidney injury (CA-AKI) associates with an increased relative risk for serious adverse outcomes. However, the magnitude of this risk and the incidence of clinically significant CA-AKI derived from analyses of large cohorts with prospective assessment of CA-AKI and subsequent outcomes are unknown. ObjectivesThis study sought to characterize the relative risk for and incidence of serious adverse outcomes following the development of CA-AKI and to explore whether CA-AKI mediates the association of pre-angiography estimated glomerular filtration rate with adverse outcomes. MethodsAmong 4,418 participants in the PRESERVE (Prevention of Serious Adverse Outcomes Following Angiography) trial with comprehensive baseline and outcome data, we assessed whether CA-AKI was associated with the 90-day outcome comprising death, need for dialysis, or persistent impairment in kidney function. We calculated the incidence of clinically significant CA-AKI (i.e., proportion of patients who developed CA-AKI and the 90-day outcome) and examined whether CA-AKI was a mediator of the association of baseline kidney function with the 90-day outcome. ResultsCA-AKI was associated with an increased relative risk for 90-day death, need for dialysis, or persistent kidney impairment (odds ratio: 3.93; 95% confidence interval: 2.82 to 5.49; p < 0.0001). The incidence of clinically significant CA-AKI was 1.2% (53 of 4,418 patients). CA-AKI was not a mediator of the association of pre-angiography estimated glomerular filtration rate with the primary outcome. ConclusionsWhereas CA-AKI is associated with an increased relative risk of serious, adverse 90-day outcomes, the incidence of clinically significant CA-AKI is very low. CA-AKI does not mediate the association of the pre-angiography estimated glomerular filtration rate with these outcomes.

Environmental pollution and COVID-19: the molecular terms and predominant disease outcomes of their sweetheart agreement.

As the Coronavirus situation (COVID-19) continues to evolve, many questions concerning the factors relating to the diffusion and severity of the disease remain unanswered.Whilst opinions regarding the weight of evidence for these risk factors, and the studies published so far are often inconclusive or offer contrasting results, the role of comorbidities in the risk of serious adverse outcomes in patients affected with COVID-19 appears to be evident since the outset. Hypertension, diabetes, and obesity are under discussion as important factors affecting the severity of disease. Air pollution has been considered to play a role in the diffusion of the virus, in the propagation of the contagion, in the severity of symptoms, and in the poor prognosis. Accumulating evidence supports the hypothesis that environmental particulate matter (PM) can trigger inflammatory responses at molecular, cellular, and organ levels, sustaining respiratory, cardiovascular, and dysmetabolic diseases.To better understand the intricate relationships among pre-existing conditions, PM, and viral infection, we examined the response at the molecular level of T47D human breast adenocarcinoma cells exposed to different fractions of PM. T47D cells express several receptors, including the aryl hydrocarbon receptor (AhR), and ACE2, the main - but not the only - receptor for SARS-CoV-2 entry.PM samples were collected in an urban background site located in the Northern area of the City of Bologna (Emilia-Romagna Region, Northern Italy) during winter 2013. T47D cells were exposed to organic or aqueous (inorganic) extracts at the final concentration of 8 m3 for a 4-hour duration. Both the concentration and the exposure time were chosen to resemble an average outdoor exposure. RNA was extracted from cells, purified and hybridised on 66k microarray slides from Agilent.The lists of differentially expressed genes in PM organic extracts were evaluated by using Metacore, and an enrichment analysis was performed to identify pathways maps, process networks, and disease by biomarkers altered after T47D treatment.The analysis of the modulated genes gave evidence for the involvement of PM in dysmetabolic diseases, including diabetes and obesity, and hypertension through the activation of the aryl hydrocarbon receptor (AhR) canonical pathway.On the basis of current knowledge, existing data, and exploratory experimental evidence, we tease out the likely molecular interplay that can ultimately tip the disease outcome into severity. Looking beyond ACE2, several additional key markers are identified. Disruption of these targets worsens pre-existing conditions and/or exacerbates the adverse effects induced by SARS-CoV-2 infection. Whilst appropriately designed, epidemiological studies are very much needed to investigate these associations based on our hypothesis of investigation, by reviewing recent experimental and epidemiological evidence, here we speculate and provide new insights on the possible role of environmental pollution in the exacerbation of effects by SARS-CoV-2 and other respiratory viruses. This work is intended to assist in the development of appropriate investigative approaches to protect public health.