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Journal of the American Society of Nephrology ; 33:341, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2125223


Background: Acute Kidney Injury (AKI) is a known complication of COVID-19. Recent reports have suggested a decrease in AKI incidence with time. The objective of this study was to evaluate the incidence of AKI over time and determine whether changes in patients' characteristics could explain this decrease. Method(s): Data were selected from the Cerner Real-World DataTM, a cloud-based platform of de-identified electronic health records data from >100 health systems. Our study population was defined as hospitalized adults with COVID-19 in 2020-2021. We excluded patients with known end-stage kidney disease and those whose first interaction with the health system was the COVID-related hospitalization. AKI was defined as an increase in serum creatinine by >=0.3 mg/dl within 48 hours or >=1.5 times the baseline. We used logistic regression to estimate the association between time categorized in quarters and occurrence of AKI after adjusting for demographic variables and comorbidities identified from the Elixhauser ICD10-based algorithm. To determine whether the effect of demographic and comorbidities on the likelihood of AKI varied with time, we also ran separate logistic regression models for each quarter. Result(s): Our analytical dataset included 152,296 patients. Of those 49% were female, 12% black, 71% white, 29% Hispanic, mean age was 61+/-19, 32% had diabetes, 55% hypertension, 14% Kidney Disease, 20% coronary artery disease, 14% congestive heart failure, 24% COPD, 10% liver disease and 21% developed AKI while hospitalized. The incidence of AKI decreased from 28% in 2020 quarter one (2020Q1) to 19% in 2021Q4 (test of trend p<0.001). The odds of developing AKI for 2020Q2 to 2021Q4 compared to 2020Q1 were Odds Ratio=0.80, 95% CI 0.72-0.89, 0.73 (0.66-0.81), 0.72 (0.66-0.80), 0.72 (0.65-0.80), 0.58 (0.53-0.65), 0.67 (0.60-0.74), 0.61 (0.52-0.71) respectively. After adjusting for covariates, the effect of time although attenuated (highest 2020Q2 OR=0.79 (0.71-0.88), lowest 2021Q4 OR=0.67 (0.58-0.79) remained significant. Time did not modify the effect of the demographic variables and comorbidities on developing AKI. Conclusion(s): The decrease in AKI incidence with time is independent of the effect of demographic risk factors and comorbidities. This decrease is likely related to improvement in patients volume management, treatment with steroids, anticoagulation and early treatment of the virus.

Topics in Antiviral Medicine ; 30(1 SUPPL):250, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-1880741


Background: The World Health Organization (WHO) ordinal scale (OS) is used to evaluate participant outcomes in clinical trials. We modified the WHO OS to enable assessment of patient outcomes associated with various treatment agents using the National COVID Cohort Collaborative (N3C), a national database containing electronic Health Record (EHR) data from > 2.7 million persons with a COVID-19 diagnosis from > 55 U.S. sites. Methods: Modified OS severity scores (Table 1) were assigned in the first through fourth weeks following COVID-19 diagnosis for a sample of patients in N3C. To adjust for disease severity at patient hospitalization, we developed separate models to examine OS levels of 3, 5, 7, and 9. Elastic net penalized multinomial logistic regression was used to simultaneously identify risk factors and predict the probability of each level of the ordinal scale at week 4. We studied groups of anticoagulants (AC), steroids, antibiotics, antiviral agents (AA), monoclonal antibodies (MA), and a miscellaneous group that included all other treatments. Other factors considered were presence of comorbid conditions using the Charlson Comorbidity Index (CCI), ethnicity, age, gender, and time of diagnosis (by quarter). Results: We included 1,489,191 COVID-19 (161,385 outpatients were excluded) patients. Patient characteristics and treatment approaches applied to each OS level were analyzed (Table 1). For hospitalized patients with a Week 1 OS score of 3,5,7, or 9, we found that increased CCI values are associated with higher probabilities of a worsened OS score at Week 4. Given that MAs are a standard treatment for patients at OS levels 3 and 5, and that steroids are typically used at OS 7 and 9, we studied treatment combinations related to MA and steroids given during Week 1. Improved outcomes by Week 4 were demonstrated with AA+MA for OS 3 and for AC+MA for OS 5 (Table 1). Patients at OS 7 in Week 1 had improved Week 4 outcomes with steroids alone while OS 7 patients with CCI>10 had better outcomes with steroids+AC. OS 9 patients treated with steroids+MA had better outcomes compared with those not given that combination. Conclusion: Our analyses identify relationships between COVID-19 serverity, specific treatments and outcomes at 4 weeks after diagnosis. Use of MA at lower levels of severity, and steroids at higher severity levels were associated with survival to hospital discharge.

Open Forum Infectious Diseases ; 8(SUPPL 1):S324-S325, 2021.
Artigo em Inglês | EMBASE | ID: covidwho-1746549


Background. A major challenge to identifying effective treatments for COVID-19 has been the conflicting results offered by small, often underpowered clinical trials. The World Health Organization (WHO) Ordinal Scale (OS) has been used to measure clinical improvement among clinical trial participants and has the benefit of measuring effect across the spectrum of clinical illness. We modified the WHO OS to enable assessment of COVID-19 patient outcomes using electronic health record (EHR) data. Methods. Employing the National COVID Cohort Collaborative (N3C) database of EHR data from 50 sites in the United States, we assessed patient outcomes, April 1,2020 to March 31, 2021, among those with a SARS-CoV-2 diagnosis, using the following modification of the WHO OS: 1=Outpatient, 3=Hospitalized, 5=Required Oxygen (any), 7=Mechanical Ventilation, 9=Organ Support (pressors;ECMO), 11=Death. OS is defined over 4 weeks beginning at first diagnosis and recalculated each week using the patient's maximum OS value in the corresponding 7-day period. Modified OS distributions were compared across time using a Pearson Chi-Squared test. Results. The study sample included 1,446,831 patients, 54.7% women, 14.7% Black, 14.6% Hispanic/Latinx. Pearson Chi-Sq P< 0.0001 was obtained comparing the distribution of 2nd Quarter 2020 OS with the distribution of later time points for Week 4. The study sample included 1,446,831 patients, 54.7% women, 14.7% Black, 14.6% Hispanic/Latinx. Pearson Chi-Sq P< 0.0001 was obtained comparing the distribution of 2nd Quarter 2020 OS with the distribution of later time points for Week 4. Conclusion. All Week 4 OS distributions significantly improved from the initial period (April-June 2020) compared with subsequent months, suggesting improved management. Further work is needed to determine which elements of care are driving the improved outcomes. Time series analyses must be included when assessing impact of therapeutic modalities across the COVID pandemic time frame.

American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Artigo em Inglês | EMBASE | ID: covidwho-1277330


RATIONALE: Pneumothorax (PTX) incidence, risk factors and impact on outcomes in patients with COVID-19 are unknown. We hypothesized that PTX is associated with a higher rate of mortality and is more likely to occur in patients with severe COVID-19 requiring mechanical ventilation (MV) at higher maximal PEEP and with higher levels of markers of inflammation. METHODS: We conducted a retrospective, cohort study of all adult patients (>18 years) with confirmed diagnosed SARS-CoV-19 infection admitted to our medical intensive care units (ICU) between 3/11/2020 and 8/19/2020 at our 2 hospital healthcare system. Exclusion criteria were non-Covid illness resulting in ICU level of care and ICU stay less than 24 hours. Presence or absence of PTX was determined by retrospective review of chest imaging reports. The primary outcome was mortality at discharge. Secondary outcome measures assessed at the p=0.05 level included age, ethnicity, BMI, maximum PEEP on MV and laboratory inflammatory markers (CRP, D-dimer, LDH, Ferritin). RESULTS: 270 patients with COVID-19 were admitted to the ICU. 11 patients were excluded leaving 259 for analysis. PTX was identified in 16 (6.2%). In the entire group, 9 of 16 (56.2%) patients with PTX died in the hospital compared to 68 of 243 (28%) without PTX (p=0.017). There were no significant differences in age, BMI, highest PEEP, or mortality in the subgroup treated with MV. The rate of PTX was significantly lower in the Black population and higher in the Hispanic population (p=0.01). There were no significant differences in the levels of the inflammatory markers for those patients who developed PTX compared to those who did not (CRP p=0.71;D-dimer p=0.11;Ferritin p=0.36;LDH p=0.41). CONCLUSION: PTX occurred in about 6% of COVID-19 patients requiring ICU level of care with most on mechanical ventilation and was significantly associated with a higher rate of mortality for the entire population, but not in the subgroup of patients requiring mechanical ventilation. PTX frequency was significantly lower in the Black population and higher in the Hispanic population. PTX was not associated with higher PEEP values. The absence of an association with PEEP suggests that barotrauma may not be the etiology of pneumothorax in COVID-19. Age, BMI, and the levels of inflammatory markers were not significantly different in these groups.

Delaware Journal of Public Health ; 6(3), 2020.
Artigo em Inglês | Scopus | ID: covidwho-1257853