Predictors of pulmonary embolism in hospitalized patients with COVID-19.

BACKGROUND: High venous thromboembolism (VTE) rates have been described in critically ill patients with COVID-19. We hypothesized that specific clinical characteristics may help differentiate hypoxic COVID-19 patients with and without a diagnosed pulmonary embolism (PE). METHODS: We performed a retrospective observational case-control study of 158 consecutive patients hospitalized in one of four Mount Sinai Hospitals with COVID-19 between March 1 and May 8, 2020, who received a Chest CT Pulmonary Angiogram (CTA) to diagnose a PE. We analyzed demographic, clinical, laboratory, radiological, treatment characteristics, and outcomes in COVID-19 patients with and without PE. RESULTS: 92 patients were negative (CTA-), and 66 patients were positive for PE (CTA+). CTA + had a longer time from symptom onset to admission (7 days vs. 4 days, p = 0.05), higher admission biomarkers, notably D-dimer (6.87 vs. 1.59, p < 0.0001), troponin (0.015 vs. 0.01, p = 0.01), and peak D-dimer (9.26 vs. 3.8, p = 0.0008). Predictors of PE included time from symptom onset to admission (OR = 1.11, 95% CI 1.03-1.20, p = 0.008), and PESI score at the time of CTA (OR = 1.02, 95% CI 1.01-1.04, p = 0.008). Predictors of mortality included age (HR 1.13, 95% CI 1.04-1.22, p = 0.006), chronic anticoagulation (13.81, 95% CI 1.24-154, p = 0.03), and admission ferritin (1.001, 95% CI 1-1.001, p = 0.01). CONCLUSIONS: In 158 hospitalized COVID-19 patients with respiratory failure evaluated for suspected PE, 40.8% patients had a positive CTA. We identified clinical predictors of PE and mortality from PE, which may help with early identification and reduction of PE-related mortality in patients with COVID-19.

Palliative care in critically ill COVID-19 patients: the early New York City experience.

OBJECTIVES: The COVID-19 pandemic in the USA has been accompanied by high rates of mortality and an unprecedented need for palliative care delivery. Little is known about the use of palliative care services in intensive care unit (ICU) settings during the COVID-19 pandemic. METHODS: This is a retrospective cohort study of critically ill COVID-19 patients requiring ICU admission, between 7 March and 14 April 2020 to two academic teaching hospitals in New York City. Palliative care consultation included a one-time telemedicine consultation or continued telemedicine consultation and follow-up with multidisciplinary team involvement. Patient information was collected from the electronic health record and analyses were conducted with Stata V.15.1 (StataCorp) statistical software. RESULTS: A total of 151 critically ill patients with COVID-19 pneumonia requiring ICU admission were identified, of whom 59 (39.07%) received an inpatient palliative care consultation. More than half of patients died (n=85/151, 56.29%), with 57.65% (n=49/85) of these patients receiving palliative care services during their hospitalisation. Patients who received palliative care consultation were more likely to be older, sicker and receive mechanical ventilation than their counterparts. Patients who died and did not receive palliative care were younger and required non-invasive ventilation support. CONCLUSION: There is a lack of utilisation of palliative care in COVID-19 patients admitted to the ICU. Further research into predictors of poor outcomes in critically ill COVID-19 patients may help identify patients that would benefit from early palliative care involvement going forward.

Asthma and COVID-19: lessons learned and questions that remain.

INTRODUCTION: Asthma is one of the most common chronic diseases worldwide. As a disease of the respiratory tract, the site of entry for the SARS-CoV-2 virus, there may be an important interplay between asthma and COVID-19 disease. AREAS COVERED: We report asthma prevalence among hospitalized cohorts with COVID-19. Those with non-allergic and severe asthma may be at increased risk of a worsened clinical outcome from COVID-19 infection. We explore the epidemiology of asthma as a risk factor for the severity of COVID-19 infection. We then consider the role COVID-19 may play in leading to exacerbations of asthma. The impact of asthma endotype on outcome is discussed. Lastly, we address the safety of common asthma therapeutics. A literature search was performed with relevant terms for each of the sections of the review using PubMed, Google Scholar, and Medline. EXPERT OPINION: Asthma diagnosis may be a risk factor for severe COVID-19 especially for those with severe disease or nonallergic phenotypes. COVID-19 does not appear to provoke asthma exacerbations and asthma therapeutics should be continued for patients with exposure to COVID-19. Clearly much regarding this topic remains unknown and we identify some key questions that may be of interest for future researchers.[Figure: see text].

Impact of corticosteroids in hospitalised COVID-19 patients.

BACKGROUND: Corticosteroids are a potential therapeutic agent for patients with COVID-19 pneumonia. The RECOVERY (Randomised Trials in COVID-19 Therapy) trial provided data on the mortality benefits of corticosteroids. The study aimed to determine the association between corticosteroid use on mortality and infection rates and to define subgroups who may benefit from corticosteroids in a real-world setting. METHODS: Clinical data were extracted that included demographic, laboratory data and details of the therapy, including the administration of corticosteroids, azithromycin, hydroxychloroquine, tocilizumab and anticoagulation. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission and invasive mechanical ventilation. Outcomes were compared in patients who did and did not receive corticosteroids using the multivariate Cox regression model. RESULTS: 4313 patients were hospitalised with COVID-19 during the study period, of whom 1270 died (29.4%). When administered within the first 7 days after admission, corticosteroids were associated with reduced mortality (OR 0.73, 95% CI 0.55 to 0.97, p=0.03) and decreased transfers to the ICU (OR 0.72, 95% CI 0.47 to 1.11, p=0.02). This mortality benefit was particularly impressive in younger patients (<65 years of age), females and those with elevated inflammatory markers, defined as C reactive protein ≥150 mg/L (p≤0.05), interleukin-6 ≥20 pg/mL (p≤0.05) or D-dimer ≥2.0 µg/L (p≤0.05). Therapy was safe with similar rates of bacteraemia and fungaemia in corticosteroid-treated and non-corticosteroid-treated patients. CONCLUSION: In patients hospitalised with COVID-19 pneumonia, corticosteroid use within the first 7 days of admission decreased mortality and ICU admissions with no associated increase in bacteraemia or fungaemia.

The relationship between asthma, eosinophilia, and outcomes in coronavirus disease 2019 infection.

BACKGROUND: The impact of asthma diagnosis and asthma endotype on outcomes from coronavirus disease 2019 (COVID-19) infection remains unclear. OBJECTIVE: To describe the association between asthma diagnosis and endotype and clinical outcomes among patients diagnosed as having COVID-19 infection. METHODS: Retrospective multicenter cohort study of outpatients and inpatients presenting to 6 hospitals in the Mount Sinai Health System New York metropolitan region between March 7, 2020, and June 7, 2020, with COVID-19 infection, with and without a history of asthma. The primary outcome evaluated was in-hospital mortality. Secondary outcomes included hospitalization, intensive care unit admission, mechanical ventilation, and hospital length of stay. The outcomes were compared in patients with or without asthma using a multivariate Cox regression model. The outcomes stratified by blood eosinophilia count were also evaluated. RESULTS: Of 10,523 patients diagnosed as having COVID-19 infection, 4902 were hospitalized and 468 had a diagnosis of asthma (4.4%). When adjusted for COVID-19 disease severity, comorbidities, and concurrent therapies, patients with asthma had a lower mortality (adjusted odds ratio [OR], 0.64 (0.53-0.77); P < .001) and a lower rate of hospitalization and intensive care unit admission (OR, 0.43 (0.28-0.64); P < .001 and OR, 0.51 (0.41-0.64); P < .001, respectively). Those with blood eosinophils greater than or equal to 200 cells/µL, both with and without asthma, had lower mortality. CONCLUSION: Patients with asthma may be at a reduced risk of poor outcomes from COVID-19 infection. Eosinophilia, both in those with and without asthma, may be associated with reduced mortality risk.

Impact of Atrial Fibrillation on Acute Coronary Syndrome-Analysis of In-Hospital Outcomes and 30-Day Readmissions.

With an aging population and significant overlap of risk factors, the cohort of patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is a sizable and growing one, with implications on cardiac reserve, anticoagulation and antiplatelet therapies, and related complications. The present study uses a large national database to analyze the impact of AF on patients admitted with an ACS. We queried the 2012 to 2014 National Readmissions Database to identify patients admitted with an ACS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. These patients were then subcategorized based on the presence or absence of AF. Analysis of their initial hospitalization, 30-day readmissions and healthcare utilization and the economic burden was performed. Among 1,558,205 patients with ACS, 270,966 (17.4%) were noted to have concomitant AF. At baseline, these patients were older and more likely female, with a significantly higher burden of comorbidities. Patients with AF had longer and more complicated index hospitalizations with significantly higher mortality rates (8.6% vs 4.6%). Coronary artery bypass graft was the preferred method of revascularization in patients with AF as compared to percutaneous coronary intervention. The 30-day readmissions were higher in the AF group (15.6 vs 10.8%), largely driven by noncardiac causes. This was associated with higher healthcare utilization with longer hospitalizations during index admission. Patients admitted with ACS and concomitant AF is a high-risk population with increased in-hospital complications and mortality, as well as short term readmissions. Coronary artery bypass graft appears favored over percutaneous coronary intervention for revascularization in patients with AF.

Controversy over smoking in COVID-19-A real world experience in New York city.

Data are conflicting regarding the impact of tobacco smoking in people with pneumonia due to SARS-CoV-2 infection (COVID-19). We performed a retrospective multicentre cohort study of 9991 consecutive patients hospitalized in a major New York academic center between March 7th and June 5th, 2020 with laboratory-confirmed COVID-19. The clinical outcomes assessed included risk of hospitalization, in-hospital mortality, risk of intensive care unit (ICU) admission, and need for mechanical ventilation among smokers (current and former). Multivariable logistic regression and propensity score models were built to adjust for potential confounders. Among 9991 consecutive patients diagnosed with COVID-19, 2212 (22.1%) patients were self-reported smokers (406 current and 1806 former). Current smoking was not associated with an increased risk of hospitalization (propensity score [PS]-adjusted OR 0.91; p = .46), in-hospital mortality (PS-OR 0.77; p = .12), ICU admission (PS-OR 1.18; p = .37), or intubation (PS-OR 1.04; p = .85). Similarly, former smoking was not associated with an increased risk of hospitalization (PS-OR 0.88; p = .11), in-hospital mortality (PS-OR 1.03; p = .78), ICU admission (PS-OR 1.03; p = .95), or intubation (PS-OR 0.93; p = .57). Furthermore, smoking (current or former) was not associated with an increased risk of hospitalization (PS-OR 0.85; p = .05), in-hospital mortality (PS-OR 0.94; p = .49), ICU admission (PS-OR 0.86; p = .17), or intubation (PS-OR 0.79; p = .06). Smoking is a well-known risk factor associated with greater susceptibility and subsequent increased severity of respiratory infections. In the current COVID-19 pandemic, smokers may have increased risk and severe pneumonia. In the current COVID-19 pandemic, smokers are believed to have an increased risk of mortality as well as severe pneumonia. However, in our analysis of real-world clinical data, smoking was not associated with increased in-patient mortality in COVID-19 pneumonia, in accordance with prior reports.

Application of ultrasound accelerates the decalcification process of bone matrix without affecting histological and immunohistochemical analysis.

BACKGROUND/OBJECTIVES: Decalcification of bone specimens is necessary for routine paraffin embedding and sectioning. Ethylenediaminetetraacetic acid (EDTA), a chelating agent for decalcification, maintains bone tissue integrity and histological features but requires long decalcification period, especially for cortical bone with dense mineral matrix. We hypothesised that the application of a newly commercially available ultrasound (US) decalcifier would accelerate decalcification of thick cortical bone specimen in EDTA efficiently and that the working temperature at 30-45°C would not affect histological and immunohistochemical analysis. Comparison was made with traditional decalcification method with regards to quality of tissue morphology and antigenicity. METHODS: A fresh human cadaveric femoral shaft was sectioned into 5-mm-thick transverse sections. After fixation, the bone slices were divided into two groups: Ultrasound decalcification group (US DeCal), in which bone sections (n = 3) were placed in a US decalcifier (50 W at a frequency of 40kHz) with EDTA solution, and normal decalcification group (Normal DeCal), in which bone sections (n = 3) were decalcified in EDTA without US. The mineral content of the bone sections was measured with micro-computed tomography and dual-energy X-ray absorptiometry at different time points. Rate of calcium extraction was quantified by measuring the calcium concentration in EDTA solution using inductively coupled plasma optical emission spectrometry. After decalcification, the paraffin sections of the decalcified bone were stained with haematoxylin and eosin or immunohistochemical staining of sclerostin. RESULTS: Samples in US DeCal contained 2.9 ± 2.8% of the mineral content at Day 6 and were completely decalcified at Day 8. However, sections in Normal DeCal retained 36.3 ± 5.1% and 24.3 ± 4.8% at Day 6 and Day 8, respectively, and took six times longer to complete decalcification. The concentration of calcium in the EDTA solution of the US DeCal group was 70% higher than that of the Normal DeCal group (p < 0.05) in Day 1 and 2. No staining difference was observed in histological sections between the two groups. CONCLUSION: The application of US decalcification significantly shortened the decalcification time in EDTA without causing histological artefacts. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: This article shows that the application of ultrasound in sample decalcification would shorten the duration that decalcification required. This would accelerate the sample processing for routine bone histology in both basic and clinical research and assessments for diagnostic purposes.