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INTRODUCTION: Previous randomized trials suggest the benefit of inhaled budesonide for COVID-19 patients in outpatient settings. We evaluated available studies on the effect of the therapeutic use of inhaled corticosteroids (ICS) on mortality and pertinent clinical outcomes. METHOD(S): A comprehensive literature search was conducted across the WHO, LitCOVID, and EMBASE databases from inception until June 30th, 2022. The primary outcome was overall mortality and secondary outcomes included symptom-based clinical improvement rates at day 14, ER visits or hospitalization, and adverse events. Data analysis was performed using Review Manager Software, version 5.2, to evaluate the combined odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nine studies (7 RCTs (3 budesonide, 3 ciclesonide, 1 fluticasone RCTs), & 2 observational studies) were included in the mortality meta-analysis. Of the 3,934 patients included, 103 patients died (44 out of 1925 in the ICS group and 59 out of 2009 in the non-ICS group). The odds of mortality in the therapeutic ICS use group were lower compared to the non-ICS therapy group (OR 0.78, 95% CI 0.48-1.28, p-value=0.33, I2=0%). The result was statistically insignificant, possibly due to the low mortality rate. But therapeutic ICS showed statistically significant clinical improvement rates at day 14 (5 RCTs;3 Ciclesonide, 2 Budesonide) (OR 1.56, 95% CI 1.31-1.86, p < 0.0001, I2=0%). The number of ED visits/Hospitalization rate, and adverse events were not statistically significant between the groups (OR 0.73, 95% CI 0.32-1.70, p= 0.47 I2=75% and OR 1.10 95% CI 0.67-1.82, p=0.70, I2=28%). CONCLUSION(S): This meta-analysis shows that the therapeutic use of ICS in COVID-19 is associated with higher symptom-based clinical improvement rates. Although the reduction in mortality odds remained insignificant, as the overall mortality rates were low which increased the confidence interval overall. Early administration of ICS showed a trend towards the reduced likelihood of urgent care needs. Well-designed trials are needed to explore ICS efficacy in patients with a high risk of disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.
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INTRODUCTION: Studies of hospitalized patients with COVID-19 have found varying clinical outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. We performed a systematic review to summarize the effect of the pre-hospital use of inhaled corticosteroids on the clinical outcomes in patients with COVID-19. METHOD(S): A comprehensive literature accrual was conducted across the WHO, CDC, and LitCovid PubMed COVID-19 databases from inception until June 30th, 2022. The Overall mortality was the primary outcome, and the secondary outcomes were the need for intensive care unit (ICU) admission and the need for invasive mechanical ventilation (IMV). All included studies were observational and reported the desired outcomes with pre-hospital use of ICS in COVID-19 patients. Data analysis was performed using Review Manager Software, version 5.2 to evaluate the combined odds ratio (OR) with respective 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nineteen studies assessed mortality and were included in the meta-analysis. A total of 1,122,329 patients were included, of which 10,466 patients died (2,289 out of 824,005 in ICS arm patients and 8,177 out of 298,324 in the non-ICS arm), resulting in the unadjusted odds of death (OR 1.36, 95% CI 1.09-1.70, I2=82%). However, In the subgroups analyses of COPD patients (8 studies;598 out of 106,659 in the ICS arm and 353 out of 44,496 in the non-ICS arm) and Asthma patients (7 studies;705 out of 714,126 in the ICS arm and 179 out of 222,577 in the non-ICS arm), significantly increased risk of death was not shown (OR 1.20, 95% CI 0.93-1.57, I2=32%, OR 1.61, 95% CI 0.97-2.66, I2=82% respectively). There were no significantly increased odds in the assessed secondary outcomes;ICU admission (13 studies, OR 1.11, 95% CI 0.82-1.51, I2=84%), need for mechanical ventilation (7 studies, OR 1.21, 95% CI 1.00-1.45, I2=0%). CONCLUSION(S): Prehospital use of ICS in COVID-19 patients is associated with higher odds of overall mortality in unadjusted analysis. However, this was not shown in the subgroup of patients with a history of COPD or Asthma. Other clinical outcomes such as the need for ICU admission and mechanical ventilation show similar trends. Future research with well-designed clinical trials is needed to validate our findings.
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INTRODUCTION: The reduction of mortality in COVID-19 has been clinically established only for Dexamethasone and Tocilizumab to date, but the overall mortality in COVID-19 remains high. Baricitinib is a Janus Kinase 1/2 Inhibitor with known anti-inflammatory and anti-viral properties. The US FDA recently approved Baricitinib for the treatment of hospitalized adults with COVID-19 requiring either supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). We performed a meta-analysis of Randomized Controlled Trials (RCT) and observational studies assessing the effect of Baricitinib on mortality outcomes in hospitalized patients with COVID-19. METHOD(S): A systematic literature search was conducted on electronic databases including NIH LitCovid, WHO COVID-19 database, EMBASE, and Cochrane Central from inception until June 30th, 2022. Randomized Controlled Trials and observational studies evaluating the efficacy of Baricitinib in hospitalized patients with COVID-19 were screened for the assessment of all-cause mortality as the outcome. RESULT(S): Twenty-three studies (18 observational and 5 RCTs) were included in the mortality meta-analysis. Of the 16,390 patients (4,565 observational, 11,825 RCTs), 2,139 patients died (903 out of 7,610 in the Baricitinib arm and 1,236 out of 8,780 in the non-Baricitinib arm). Using the random-effects model, the odds of mortality in the therapeutic Baricitinib use showed a statistically significant reduction in all-cause mortality in hospitalized COVID-19 patients (OR 0.67, 95% CI 0.50-0.90;p=0.008, I2=79%). A similar trend of decreased mortality was observed in the subgroup analysis by study design (Observational OR 0.59, 95% CI 0.35-0.97, p=0.04, I2=83%;RCTs OR 0.72, 95% CI 0.56-0.93, p=0.01, I2=53%). CONCLUSION(S): Baricitinib used along with the standard of care treatments is associated with a reduction in mortality in hospitalized patients with COVID-19 disease.
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INTRODUCTION: There is published literature about COVID-19 disease associated coagulopathy in hospitalized patients. We aim to study association of early heparin use among adult patients with COVID-19 and sepsis and hospital outcomes. METHOD(S): Retrospective study utilizing the EMR (electronic medical record) data at a large tertiary care academic center with ICU patients admitted for COVID-19 and sepsis and received therapeutic heparin for anticoagulation. We reported nominal variables in (gender, exposure - yes/no, etc) as number and percentage. And reported continuous (age, length of stay, etc) as median (IQR). We used Chi Square test and t-test as appropriate for nominal and continuous data analysis. This study was IRB approved. RESULT(S): A total of 230 patients with age >=18 years were included in final analysis. Out of these, 183 (79.6%) patients received heparin within 48 hours of ICU admission and 47 (20.4%) after 48 hours. The median (IQR) age was 67.5 years (58-77) with majority being caucasian (73.9%) male (68%) patients. Overall, 59 (26%) patients had died, 86 (37%) had been discharged home without assistance, 12 (5%) discharged home, with home health from the hospitals. In univariable analysis, early (< 48 hours) administration of heparin was associated reduced utilization of invasive mechanical ventilation (IMV) (OR 0.23, p=< 0.01) and non-IMV (NIMV) (OR 0.49, p=0.03) and reduced ICU (MD -1.64, SE 0.58, p=< 0.01 and hospital length of stay (LOS) (MD-4.15, SE 0.93, p=< 0.01. This association remained significant when model was adjusted for age, gender, BMI, race, ethnicity, SOFA score on day 1, APACHE-III score on ICU admission: IMV utilization (aOR 0.12, p=< 0.01), NIMV utilization (aOR 0.47, p=0.35), ICU LOS (MD -1.65, SE 0.57, p=< 0.01) and hospital length of stay (MD -4.43, SE 0.95, p=< 0.01). The hospital mortality was observed to be not statistically significant (unadjusted OR 0.68, p=0.28 and adjusted OR 0.67, p=0.32) due to small sample size. CONCLUSION(S): Early administration of heparin in patients with moderate to severe COVID-19 sepsis was associated with reduced utilization of IMV and NIMV and reduced hospital LOS. Association with reduced hospital mortality did not reach the statistical significance.
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INTRODUCTION: Several state-based and single center studies have demonstrated evidence of higher COVID-19 exposure rates, infection rates, and worse morbidity and mortality outcomes among minorities. Furthermore, challenges with vaccine access, hesitancy, distrust of the medical system further influenced who was protected from COVID-19.This study combines databases to conduct a multisite study across diverse states during the pandemic. METHOD(S): We conducted an ancillary study using the VIRUS (Viral Infection and Respiratory illness Universal Study) registry data supplemented by electronic medical record data from Mayo Clinic enterprise to assess demographics and outcomes among hospitalized patients with severe COVID-19. We included hospitalized adult patients admitted in five participating sites between April 2020 and January 2022 including academic hospitals in MN, AZ, and FL and two community hospitals in MN and WI. Selfidentified race and ethnicity data was categorized as White, Black, Asian, and Other;Hispanic and non-Hispanic. Other baseline characteristics, disease severity, and vaccination status were included in the analyses. The primary outcome was hospital mortality, the secondary outcomes were length of stay and healthcare utilization. Multivariable regression models were developed to analyze the interactions of relevant variables to predict outcomes. RESULT(S): 6904 patients were included. 3398 (57.8%) were male and 86.9% White,3.6% Black,3.3% Asian,6.2% Other. The mean age of Whites was 64.9 years v.53.8, 58, 52.8 respectively (p< 0.0005). Whites had higher Charlson comorbidity scores-5.2 v.4.0,3.6,3.0 respectively (p< 0.005). Vaccination rates were low in cohort, but higher among Whites 11.2% v.5.4%,4.6%,5.0% respectively (p< 0.0005). Mortality outcomes between different racial groups did not differ (p=0.41). Non-Hispanics were older than Hispanics- mean age 64.5 years v.53 (p< 0.005) and had higher Charlson comorbidity scores-5.2 v.3.4 (p< 0.005) Vaccination rates among non-Hispanics were 10.7 v 3.4% (p< 0.005)). Mortality outcomes between ethnic groups did not differ(p=0.86). Mortality outcomes between vaccinated and unvaccinated patients did not differ (p=0.9). CONCLUSION(S): Despite differences in risk factors between demographic groups, outcomes did not differ significantly in this cohort.
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INTRODUCTION: During the COVID-19 pandemic, the burden on the healthcare system makes it critical to examine readmission patterns. In this study, we evaluated the readmission rates and risk factors associated with COVID-19 from the large SCCM Discovery VIRUS: COVID-19 Registry. METHOD(S): This was a retrospective, cohort study including hospitalized adult patients from 181 hospitals in 24 countries within the VIRUS: COVID-19 Registry. Demographic, clinical, and outcome data were extracted and divided into two groups: Patients with readmission with COVID-19 in 30 days from discharge and those who were not. A univariate analysis is done using chi-square and t-test as appropriate. Multivariable logistic regression was used to measure risk factor associations with 30-day readmission. RESULT(S): Among 20,283 patients, 1,195 (5.9%) were readmitted within 30 days from discharge. The median (IQR) age of readmitted patients was 66 (55-78) years and 45.2% were female, 60.2% were white, and 78.9% non-Hispanic. Higher odds of readmission were observed in patients aged >60 vs 18-40 years (OR 2.76;95% CI, 2.23-3.41), moderate COVID-19 disease (WHO Ordinal scale 4-5) vs Severe COVID-19 (WHO Ordinal scale 6-9) (OR 1.23;95% CI, 1.10-1.39), no ICU admission at index hospitalization (OR 1.70;95% CI, 1.32-1.80), and Hospital length of stay <=14 vs >14 days (OR 1.53;95% CI, 1.32-1.80) vs those not readmitted (p= < 0.001). Comorbidities including coronary artery disease (OR 2.14;95% CI 1.84-2.48), hypertension (OR 1.58;95% CI 1.40-1.78), congestive Heart Failure (OR 2.54;95% CI 2.16-2.98), chronic pulmonary disease (OR 2.26;95% CI 1.94-2.63), diabetes (OR 1.32;95% CI 1.17-1.49) or chronic kidney disease (CKD) (OR 2.41;95% CI 1.2.09-2.78) were associated with higher odds of readmission. In multivariate logistic regression adjusted for age group, hospital length of stay <=14 days and, highest WHO COVID-19 ordinal scale and index ICU admission coronary artery disease, congestive heart failure, chronic pulmonary disease, chronic kidney disease, hospital length of stay <=14 days and age >60 years remained independent risk factors for readmission within 30 days. CONCLUSION(S): Among hospitalized patients with COVID-19, those readmitted had a higher burden of comorbidities compared to those non-readmitted.