Hospitalised COVID-19 outcomes are predicted by hypoxaemia and pneumonia phenotype irrespective of the timing of their emergence.

Despite the known clinical importance of hypoxemia and pneumonia, there is a paucity of evidence for these variables with respect to risk of mortality and short-term outcomes among those hospitalised with COVID-19. OBJECTIVE: Describe the prevalence and clinical course of patients hospitalised with COVID-19 based on oxygenation and pneumonia status at presentation and determine the incidence of emergent hypoxaemia or radiographic pneumonia during admission. METHODS: A retrospective study was conducted using a Canadian regional registry. Patients were stratified according to hypoxaemia/pneumonia phenotype and prevalence. Clinical parameters were compared between phenotypes using χ2 and one-way Analysis of variance (ANOVA). Cox analysis estimated adjusted Hazard Ratios (HR) for associations between disease outcomes and phenotypes. RESULTS: At emergency department (ED) admission, the prevalence of pneumonia and hypoxaemia was 43% and 50%, respectively, and when stratified to phenotypes: 28.2% hypoxaemia+/pneumonia+, 22.2% hypoxaemia+/pneumonia-, 14.5% hypoxaemia-/pneumonia+ and 35.1% hypoxaemia-/pneumonia-. Mortality was 31.1% in the hypoxaemia+/pneumonia- group and 26.3% in the hypoxaemia+/pneumonia+ group. Hypoxaemia with pneumonia and without pneumonia predicted higher probability of death. Hypoxaemia either <24 hours or ≥24 hours after hospitalisation predicted higher mortality and need for home oxygen compared with those without hypoxaemia. Patients with early hypoxaemia had higher probability of Intensive care unit (ICU) admission compared with those with late hypoxaemia. CONCLUSION: Mortality in COVID-19 infection is predicted by hypoxaemia with or without pneumonia and was greatest in patients who initially presented with hypoxaemia. The emergence of hypoxaemia was predicted by radiographic pneumonia. Patients with early and emergent hypoxaemia had similar mortality but were less likely to be admitted to ICU. There may be delayed identification of hypoxaemia, which prevents timely escalation of care.

The Hospital at Home Model vs Routine Hospitalization for Acute Heart Failure: A Survey of Patients' Preferences.

Background: Patients with heart failure (HF) experience recurrent hospitalizations and may prefer a Hospital at Home (HaH) model over routine hospitalization. Methods: We administered a 9-item questionnaire on perceived effectiveness, safety, convenience, and acceptability of a HaH model among patients hospitalized for HF at 2 academic hospitals in Ontario. The primary outcome was HaH care acceptability, defined as a preference for or neutrality to HaH care over routine hospitalization. We used partial Spearman rank correlations (ρ) and multivariable logistic regression analyses to explore associations with outcomes. Results: Of 297 eligible patients, 269 (90.6%) completed the questionnaire. The mean age was 76.2 (standard deviation, 12.3) years; 48.3% were female; and 70.5% lived in their own home, commonly with a relative or caregiver (67.9%). As many as 211 patients (78.4%; 95% confidence interval [CI] 73.0%-83.2%) found HaH care acceptable, with 169 (62.8%; 95% CI, 56.8%-68.6%) preferring HaH care over routine hospitalization. Perceived convenience (ρ, 0.57; P < 0.001) and safety (ρ, 0.37; p < 0.001) were associated with HaH acceptability, whereas perceived effectiveness was not (ρ, 0.14; P = 0.021). A college (adjusted odds ratio [aOR], 5.96; 95% CI, 2.01-17.62; P = 0.001) or university (aOR, 3.58; 95% CI, 1.07-12.06; P = 0.039) education was associated with greater odds of HaH acceptability, whereas residing in a caregiver's home was associated with lower odds (aOR, 0.34; 95% CI 0.14-0.84; P = 0.019). Conclusions: A majority of patients with HF perceived HaH care to be an acceptable alternative to routine hospitalization, prioritizing perceived convenience and safety over effectiveness. Postsecondary education and living independently without caregiver support were associated with HaH acceptability.

Introduction: Puisque les patients atteints d'insuffisance cardiaque (IC) sont hospitalisés à répétition, ils peuvent préférer le modèle d'hospitalisation à domicile (HAD) à l'hospitalisation habituelle. Méthodes: Nous avons fait passer un questionnaire de neuf items sur l'efficacité, la sécurité, la commodité et l'acceptabilité perçues du modèle d'HAD aux patients hospitalisés atteints d'IC de deux hôpitaux universitaires de l'Ontario. Le critère de jugement principal était l'acceptabilité des soins en HAD, définie par la préférence ou la neutralité à l'égard des soins en HAD plutôt qu'à l'égard de l'hospitalisation habituelle. Nous avons utilisé les corrélations partielles sur les rangs de Spearman (ρ) et les analyses multivariées de régression logistique pour examiner les associations avec les résultats. Résultats: Au sein des 297 patients admissibles, 269 (90,6 %) ont rempli le questionnaire. L'âge moyen était de 76,2 (écart type, 12,3) ans; 48,3 % étaient des femmes et 70,5 % vivaient dans leur propre maison, généralement avec un parent ou un soignant (67,9 %). Jusqu'à 211 patients (78,4 %; intervalle de confiance [IC] à 95 %, 73,0 %-83,2 %) trouvaient les soins en HAD acceptables : 169 (62,8 %; IC à 95 %, 56,8 %-68,6 %) préféraient les soins en HAD à l'hospitalisation habituelle. La commodité (ρ, 0,57; P < 0,001) et la sécurité perçues (ρ, 0,37; p < 0,001) étaient associées à l'acceptabilité de l'HAD, tandis que l'efficacité perçue ne l'était pas (ρ, 0,14; P = 0,021). Une formation collégiale (ratio d'incidence ajusté [RIAa], 5,96; IC à 95 %, 2,01-17,62; P = 0,001) ou universitaire (RIAa, 3,58; IC à 95 %, 1,07-12,06; P = 0,039) était associée à une plus grande probabilité d'acceptabilité de l'HAD, tandis que le fait de vivre au domicile du soignant était associé à une plus faible probabilité (RIAa, 0,34; IC à 95 %, 0,14-0,84; P = 0,019). Conclusions: Une majorité de patients atteints d'IC considéraient que les soins en HAD étaient une alternative acceptable à l'hospitalisation habituelle, et accordaient la priorité à la commodité et à la sécurité perçues plutôt qu'à l'efficacité. La formation postsecondaire et le fait de vivre de façon indépendante sans l'aide d'un soignant étaient associés à l'acceptabilité de l'HAD.

External validation of the 4C mortality score among COVID-19 patients admitted to hospital in Ontario, Canada: a retrospective study.

Risk prediction scores are important tools to support clinical decision-making for patients with coronavirus disease (COVID-19). The objective of this paper was to validate the 4C mortality score, originally developed in the United Kingdom, for a Canadian population, and to examine its performance over time. We conducted an external validation study within a registry of COVID-19 positive hospital admissions in the Kitchener-Waterloo and Hamilton regions of southern Ontario between March 4, 2020 and June 13, 2021. We examined the validity of the 4C score to prognosticate in-hospital mortality using the area under the receiver operating characteristic curve (AUC) with 95% confidence intervals calculated via bootstrapping. The study included 959 individuals, of whom 224 (23.4%) died in-hospital. Median age was 72 years and 524 individuals (55%) were male. The AUC of the 4C score was 0.77, 95% confidence interval 0.79-0.87. Overall mortality rates across the pre-defined risk groups were 0% (Low), 8.0% (Intermediate), 27.2% (High), and 54.2% (Very High). Wave 1, 2 and 3 values of the AUC were 0.81 (0.76, 0.86), 0.74 (0.69, 0.80), and 0.76 (0.69, 0.83) respectively. The 4C score is a valid tool to prognosticate mortality from COVID-19 in Canadian hospitals and can be used to prioritize care and resources for patients at greatest risk of death.

Incidence and Outcomes of Acute Kidney Injury in Patients Admitted to Hospital With COVID-19: A Retrospective Cohort Study.

BACKGROUND: The incidence of acute kidney injury (AKI) in patients with COVID-19 and its association with mortality and disease severity is understudied in the Canadian population. OBJECTIVE: To determine the incidence of AKI in a cohort of patients with COVID-19 admitted to medicine and intensive care unit (ICU) wards, its association with in-hospital mortality, and disease severity. Our aim was to stratify these outcomes by out-of-hospital AKI and in-hospital AKI. DESIGN: Retrospective cohort study from a registry of patients with COVID-19. SETTING: Three community and 3 academic hospitals. PATIENTS: A total of 815 patients admitted to hospital with COVID-19 between March 4, 2020, and April 23, 2021. MEASUREMENTS: Stage of AKI, ICU admission, mechanical ventilation, and in-hospital mortality. METHODS: We classified AKI by comparing highest to lowest recorded serum creatinine in hospital and staged AKI based on the Kidney Disease: Improving Global Outcomes (KDIGO) system. We calculated the unadjusted and adjusted odds ratio for the stage of AKI and the outcomes of ICU admission, mechanical ventilation, and in-hospital mortality. RESULTS: Of the 815 patients registered, 439 (53.9%) developed AKI, 253 (57.6%) presented with AKI, and 186 (42.4%) developed AKI in-hospital. The odds of ICU admission, mechanical ventilation, and death increased as the AKI stage worsened. Stage 3 AKI that occurred during hospitalization increased the odds of death (odds ratio [OR] = 7.87 [4.35, 14.23]). Stage 3 AKI that occurred prior to hospitalization carried an increased odds of death (OR = 5.28 [2.60, 10.73]). LIMITATIONS: Observational study with small sample size limits precision of estimates. Lack of nonhospitalized patients with COVID-19 and hospitalized patients without COVID-19 as controls limits causal inferences. CONCLUSIONS: Acute kidney injury, whether it occurs prior to or after hospitalization, is associated with a high risk of poor outcomes in patients with COVID-19. Routine assessment of kidney function in patients with COVID-19 may improve risk stratification. TRIAL REGISTRATION: The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis.

Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78-22.77, I 2 = 0%; OR 2.39, 95% CI 0.63-9.11, I 2 = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31-5.96, I 2 = 0%; MD 3.38, 95% CI 0.44-6.31, I 2 = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02-2.09, I 2 = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.

Surgical versus conservative management of congenital pulmonary airway malformation in children: A systematic review and meta-analysis.

BACKGROUND: The ideal management of infants born with asymptomatic congenital pulmonary airway malformation (CPAM) is controversial. We performed a systematic review and meta-analysis comparing elective resection versus expectant management. METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and PubMed for studies describing the management of asymptomatic CPAM and reporting on postoperative morbidity, mortality, and length of hospital stay (LOS). We performed meta-analyses when possible and provide a narrative summary of results. RESULTS: One nonrandomized prospective and eight retrospective studies met our inclusion criteria. Out of 168 patients, 70 underwent surgery before symptoms developed with seven experiencing postoperative complications (10.0%); 63 developed symptoms while being managed expectantly and subsequently underwent surgery with 20 complications (31.8%). Thirty-five patients continued to be followed nonsurgically (three months to nine years of follow-up). Morbidity was higher with surgery after symptom development (6 studies; odds ratio 4.59, 95% confidence interval (CI) 1.40 to 15.11, P<0.01); there was no difference in LOS (3 studies; mean difference 4.96, 95% CI -1.75 to 11.67, P=0.15). There were no related deaths. CONCLUSIONS: Elective resection of asymptomatic CPAM lesions is safe and prevents the risk of symptom development, which may result in a more complicated surgery and recovery.