Impact of Body Mass Index on COVID-19-Related In-Hospital Outcomes and Mortality.

BACKGROUND: Given the high prevalence of obesity around the globe, patients with coronavirus disease 2019 (COVID-19) are at an increased risk of devastating complications. METHODS: A retrospective cohort study was performed to determine the association of basal metabolic index (body mass index (BMI)) with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively. RESULTS: A total of 176 consecutive patients with confirmed COVID-19 diagnosis were included. The mean age was 62.2 years, with 51% being male patients. The mean BMI for non-surviving patients was significantly higher compared to patients surviving on the seventh day of hospitalization (35 vs. 30 kg/m2, P = 0.022). Similarly, patients requiring IMV had a higher BMI (33 vs. 29, P = 0.002) compared to non-intubated patients. The unadjusted OR for patients with a higher BMI requiring IMV (56% vs. 28%, OR: 3.3, 95% CI: 1.6 - 7.0, P = 0.002) and upgrade to ICU (46% vs. 28%, OR; 2.2, 1.07 - 4.6, P = 0.04) were significantly higher compared to patients with a lower BMI. Similarly, patients with a higher BMI had higher in-hospital mortality (21% vs. 9%, OR: 3.2, 95% CI: 1.3 - 8.2, P = 0.01) compared to patients with a normal BMI. Despite a numerical advantage in the lower BMI group, there was no significant difference between the two groups in terms of the need for dialysis (5% vs. 13%, OR: 3.8, 13% vs. 4%, 1.1 - 14.1, P = 0.07). aORs controlled for baseline comorbidities and medications mirrored the overall results, except for the need to upgrade to ICU. CONCLUSIONS: In patients with confirmed COVID-19, morbid obesity serves as an independent risk factor of high in-hospital mortality and the need for IMV.

Anticoagulation in COVID-19: a single-center retrospective study.

Introduction: COVID-19 induces a pro-thrombotic state as evidenced by microvascular thrombi in the renal and pulmonary vasculature. Therapeutic anticoagulation in COVID-19 has been debated and data remain anecdotal. Hypothesis: We hypothesize that therapeutic anticoagulation is associated with a reduction in in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation, and acute renal failure necessitating dialysis by decreasing the over-all clot burden. Methods: A retrospective cohort study was done to determine the impact of therapeutic anticoagulation in hospitalized COVID-19 patients. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI) respectively. Results: A total of 176 hospitalized COVID-19 patients were divided into two groups, therapeutic anticoagulation and prophylactic anticoagulation. The mean age, baseline comorbidities and other medications used during hospitalization were similar in both groups. The aOR for in-hospital mortality (OR 3.05, 95% CI 1.15-8.10, p = 0.04), upgrade to intensive care (OR 3.08, 95% CI 1.43-6.64, p = 0.006) and invasive mechanical ventilation (OR 4.27, 95% CI 1.95-9.34, p = 0.00) were significantly lower while there was no statistically significant difference in the rate of developing acute renal failure (OR 1.87 95% CI 0.46-7.63, p = 0.64) between two groups. Conclusions: In patients with COVID-19, therapeutic anticoagulation offers a significant reduction in the rate of in-hospital mortality, upgrade to intensive medical care, and invasive mechanical ventilation. It should be preferred over prophylactic anticoagulation in COVID-19 patients unless randomized controlled trials prove otherwise.

Predictability of CRP and D-Dimer levels for in-hospital outcomes and mortality of COVID-19.

BACKGROUND: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the C-reactive protein (CRP) and D-Dimer levels for predicting in-hospital outcomes in COVID-19. METHODS: A retrospective cohort study was performed to determine the association of CRP and D-Dimer with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively. RESULTS: A total of 176 patients with confirmed COVID-19 diagnosis were included. On presentation, the unadjusted odds for the need of IMV (OR 2.5, 95% CI 1.3-4.8, p = 0.012) and upgrade to ICU (OR 3.2, 95% CI 1.6-6.5, p = 0.002) were significantly higher for patients with CRP (>101 mg/dl). Similarly, the unadjusted odds of in-hospital mortality were significantly higher in patients with high CRP (>101 mg/dl) and high D-Dimer (>501 ng/ml), compared to corresponding low CRP (<100 mg/dl) and low D-Dimer (<500 ng/ml) groups on day-7 (OR 3.5, 95% CI 1.2-10.5, p = 0.03 and OR 10.0, 95% CI 1.2-77.9, p = 0.02), respectively. Both high D-Dimer (>501 ng/ml) and high CRP (>101 mg/dl) were associated with increased need for upgrade to the ICU and higher requirement for IMV on day-7 of hospitalization. A multivariate regression model mirrored the overall unadjusted trends except that adjusted odds for IMV were high in the high CRP group on day 7 (aOR 2.5, 95% CI 1.05-6.0, p = 0.04). CONCLUSION: CRP value greater than 100 mg/dL and D-dimer levels higher than 500 ng/ml during hospitalization might predict higher odds of in-hospital mortality. Higher levels at presentation might indicate impending clinical deterioration and the need for IMV.

Incidence of Multidrug Resistant Infections in Emergency Department Patients with Suspected Sepsis.

BACKGROUND: Inappropriate antibiotic therapy in sepsis is associated with poor outcomes, clinicians often provide routine coverage for multidrug resistant (MDR) bacteria. However, these regimens may contribute to problems related to antibiotic overuse. To understand the incidence and related factors of multidrug resistant bacterial infections in ED patients with sepsis, we examined how often patients with sepsis in our emergency department had MDR infections. We also explored risk factors for, and outcomes from, MDR bacterial infections. METHODS: We reviewed records of patients presenting to our emergency department (ED) meeting criteria for severe sepsis or septic shock from March 2012 to July 2013. Patient demographics, comorbidities, preadmission location, and APACHE II scores were analyzed, as were clinical outcomes. RESULTS: A total of 191 episodes were examined. 108 (57%) cases were culture-positive, and of these, 23 (12.0%) had an MDR pathogen recovered. Among patients with positive cultures, MDR patients used mechanical ventilation more often 29% vs. 52% (P = 0.03) and had longer mean ICU and hospital length of stays: 4.0 vs 9.3 (P < 0.08) and 10.6 vs 20.8 (P = 0.01), respectively. We did not identify statistically significant predictors of MDR infection. CONCLUSIONS: The overall number of infections due to MDR bacteria was low, and MDR gram-negative infections were uncommon. The use of multiple empiric antibiotics for resistant gram-negative infections in the ED may be beneficial in only a small number of cases. Additionally, empiric coverage for vancomycin-resistant enterococci may need to be considered more often. Larger studies may help further elucidate the rates of MDR infections in ED patients, and identify specific risk factors to rationally guide empiric antibiotic treatment.

Hamman-Rich Syndrome: A Diagnosis of Exclusion in the COVID-19 Pandemic.

Hamman-Rich syndrome is a rapidly progressive interstitial lung disease with acute respiratory distress syndrome physiology. It carries a grave prognosis and a high early mortality rate. It is often distinguished from other similar pulmonary pathologies based on the clinical course, laboratory findings, bronchoalveolar lavage testing, and pathology report. We detail a 77-year-old lady with no prior pulmonary disease, smoking history, or occupational and environmental exposures present to the emergency department found to be in acute hypoxic respiratory failure with impressive progressive radiographic findings. The presumptive diagnosis of Hamman-Rich syndrome was made based on a combination of factors after ruling out other similar clinical entities, especially in the setting of an ongoing COVID-19 pandemic.

Lymphocyte-to-C-Reactive Protein Ratio: A Novel Predictor of Adverse Outcomes in COVID-19.

BACKGROUND: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the validity and clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric carcinoma prognostication, versus the neutrophil-to-lymphocyte ratio (NLR) for predicting in-hospital outcomes in COVID-19. METHODS: A retrospective cohort study was performed to determine the association of LCR and NLR with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively. RESULTS: The mean age for NLR patients was 63.6 versus 61.6, and for LCR groups, it was 62.6 versus 63.7 years, respectively. The baseline comorbidities across all groups were comparable except that the higher LCR group had female predominance. The mean NLR was significantly higher for patients who died during hospitalization (19 vs. 7, P ≤ 0.001) and those requiring IMV (12 vs. 7, P = 0.01). Compared to alive patients, a significantly lower mean LCR was observed in patients who did not survive hospitalization (1,011 vs. 632, P = 0.04). For patients with a higher NLR (> 10), the unadjusted odds of mortality (odds ratios (ORs) 11.0, 3.6 - 33.0, P < 0.0001) and need for IMV (OR 3.3, 95% CI 1.4 - 7.7, P = 0.008) were significantly higher compared to patients with lower NLR. By contrast, for patients with lower LCR (< 100), the odds of in-hospital all-cause mortality were significantly higher compared to patients with a higher LCR (OR 0.2, 0.06 - 0.47, P = 0.001). The aORs controlled for baseline comorbidities and medications mirrored the overall results, indicating a genuinely significant correlation between these biomarkers and outcomes. CONCLUSIONS: A high NLR and decreased LCR value predict higher odds of in-hospital mortality. A high LCR at presentation might indicate impending clinical deterioration and the need for IMV.

Neuroleptic Malignant Syndrome: A Case Aimed at Raising Clinical Awareness.

A 60-year-old man with a history of bipolar disorder on risperidone, bupropion, and escitalopram was admitted for community acquired streptococcal pneumonia. Four days later, he developed persistent hyperthermia, dysautonomia, rigidity, hyporeflexia, and marked elevation of serum creatine phosphokinase. He was diagnosed with neuroleptic malignant syndrome (NMS) and improved with dantrolene, bromocriptine, and supportive therapy. This case emphasizes the importance of considering a broad differential diagnosis for fever in the ICU, carefully reviewing the medication list for all patients, and considering NMS in patients with fever and rigidity.

Growth arrest-specific gene 6 (Gas6) levels are elevated in patients with chronic renal failure.

BACKGROUND: The TAM receptors (tyro3, axl and mer) and their ligands (vitamin K-dependent proteins-Gas6 and Protein S) are crucial modulators of inflammation, which may be relevant in chronic kidney disease (CKD). Gas6 and axl have multiple roles in mediating vascular atherosclerosis and injury, thrombosis and inflammation, yet nothing is known about the Gas6-axl pathway in humans with CKD. Given the prevalence of chronic inflammation and vascular disease in this population, we measured TAM ligands in patients with various levels of renal function. METHODS: Gas6 and protein S were quantified in the plasma by ELISA in three patient groups: end-stage renal disease on chronic hemodialysis (HD), CKD and normal controls. RESULTS: Significantly increased levels of Gas6 and protein S were found in CKD patients compared with normal controls (P < 0.01 and <0.001, respectively). In HD patients, Gas6 levels were elevated compared with controls (P < 0.001) and positively associated with low albumin (r = 0.33; P = 0.01), dialysis vintage (r = 0.36; P = 0.008) and IV iron administration (r = 0.33; P = 0.01). The levels of Gas6 rose with CKD stage and were inversely associated with estimated GFR (P < 0.0001). CONCLUSIONS: Dysregulation of circulating Gas6 is associated with renal disease and inversely proportional to renal function. Low albumin and higher IV iron administration were associated with higher Gas6 levels, suggesting a possible connection between inflammation and oxidative stress mediated by iron. Protein S levels were also elevated in CKD patients, but the relevance of this finding needs to be further investigated.