Fourteen-day survival among older adults with severe infection with severe acute respiratory syndrome coronavirus 2 treated with corticosteroid: a cohort study

Reporting of Observational Studies Explicitly Aiming to Emulate Randomized Trials: A Systematic Review

Importance

Observational (nonexperimental) studies that aim to emulate a randomized trial (ie, the target trial) are increasingly informing medical and policy decision-making, but it is unclear how these studies are reported in the literature. Consistent reporting is essential for quality appraisal, evidence synthesis, and translation of evidence to policy and practice.

Objective

To assess the reporting of observational studies that explicitly aimed to emulate a target trial.

Evidence Review

We searched Medline, Embase, PsycINFO, and Web of Science for observational studies published between March 2012 and October 2022 that explicitly aimed to emulate a target trial of a health or medical intervention. Two reviewers double-screened and -extracted data on study characteristics, key predefined components of the target trial protocol and its emulation (eligibility criteria, treatment strategies, treatment assignment, outcome[s], follow-up, causal contrast[s], and analysis plan), and other items related to the target trial emulation.

Findings

A total of 200 studies that explicitly aimed to emulate a target trial were included. These studies included 26 subfields of medicine, and 168 (84%) were published from January 2020 to October 2022. The aim to emulate a target trial was explicit in 70 study titles (35%). Forty-three studies (22%) reported use of a published reporting guideline (eg, Strengthening the Reporting of Observational Studies in Epidemiology). Eighty-five studies (43%) did not describe all key items of how the target trial was emulated and 113 (57%) did not describe the protocol of the target trial and its emulation.

Conclusion and Relevance

In this systematic review of 200 studies that explicitly aimed to emulate a target trial, reporting of how the target trial was emulated was inconsistent. A reporting guideline for studies explicitly aiming to emulate a target trial may improve the reporting of the target trial protocols and other aspects of these emulation attempts.

Effect of corticosteroid therapy on mortality in COVID-19 patients-A systematic review and meta-analysis

The effect of corticosteroid therapy is still controversial on prevention of mortality in coronavirus disease‐2019 (COVID‐19). The objective of this study is to investigate the effect of corticosteroids on mortality. This systematic review was performed as per preferred reporting items for systematic reviews and meta‐analyses guidelines. A systematic search was performed at different databases namely Medline/PubMed, Cochrane and Google scholar on 10 February 2022. A pooled estimate for effect of corticosteroid therapy on mortality was calculated as outcome of study. Risk bias analysis and Newcastle Ottawa Scale were used to assess the quality of randomized control trial (RCT) and cohort studies, respectively. Cochran's Q test and the I² statistic were conducted for heterogeneity and accordingly study model was applied. A total 43 studies were included, having sample size of 96,852 patients. Amongst them, 19,426 and 77,426 patients received corticosteroid therapy (intervention group) or standard treatment without corticosteroid (control group), respectively. Mortality observed in the intervention and control group was 14.2% (2749) and 7.1% (5459), respectively. The pooled estimate 2.173 (95% CI: 2.0690–2.2820) showed significantly increased mortality in intervention as compared to control. The pooled estimate of methyprednisolone 1.206 (95% CI: 1.0770–1.3500) showed significantly increased mortality while the pooled estimate of dexamethasone 1.040 (95% CI: 0.9459–1.1440) showed insignificantly increased mortality as compared to control. In conclusion, corticosteroid therapy produced a negative prognosis as depicted by increased mortality among COVID‐19 patients. The possible reasons might be delay in virus clearance and secondary infections due to corticosteroids initiated at high dose in the early stage of infection.

Efficacy and safety of corticosteroid regimens for the treatment of hospitalized COVID-19 patients: a meta-analysis

Aim

To evaluate the efficacy and safety of corticosteroids for treating hospitalized COVID-19 patients.

Materials & methods

Efficacy outcomes included time to negative SARS-CoV-2 tests, length of stay, duration and incidence of intensive unit care stay, incidence of mortality and duration and incidence of mechanical ventilation. Safety outcomes included the incidence of adverse events and severe adverse events, incidence of hyperglycemia and incidence of nosocomial infections.

Results

Ninety-five randomized controlled trials (RCTs) and observational studies (n = 42,205) were included. Corticosteroids were associated with increased length of stay (based on RCT only), increased time to negative tests, decreased length of mechanical ventilation and increased odds of hyperglycemia.

Conclusion

Corticosteroids should be considered in patients requiring mechanical ventilation, and glycemic monitoring may be needed when administering corticosteroids.

Caring for older adults during the COVID-19 pandemic

BACKGROUND

Elderly patients represent a high-risk group with increased risk of death from COVID-19. Despite the number of published studies, several unmet needs in care for older adults exist.

OBJECTIVES

To discuss unmet needs of COVID-19 in this special population.

SOURCES

A literature review for studies on COVID-19 in elderly patients published between December 2019 and November 2021 was performed. Clinical questions were formulated to guide the literature search. The search was conducted in the MEDLINE database, combining specific search terms. Two reviewers independently conducted the search and selected the studies according to the prespecified clinical questions.

CONTENT

Elderly patients with COVID-19 have peculiar characteristics. They may have atypical clinical presentation, with no fever and with delirium or neurological manifestations as the most common signs, with potential delayed diagnosis and increased risk of death. The reported fatality rates among elderly patients with COVID-19 are extremely high. Several factors, including comorbidities, atypical presentation, and exclusion from intensive care unit care, contribute to this excess of mortality. Age alone is frequently used as a key factor to exclude the elderly from intensive care, but there is evidence that frailty rather than age better predicts the risk of poor outcome in this category. Durability of vaccine efficacy in the elderly remains debated, and the need for a third booster dose is becoming increasingly evident. Finally, efforts to care for elderly patients who have survived after acute COVID-19 should be implemented, considering the high rates of long COVID sequelae and the risk of longitudinal functional and cognitive decline.

IMPLICATIONS

We highlight peculiar aspects of COVID-19 in elderly patients and factors contributing to high risk of poor outcome in this category. We also illuminated gaps in current evidence, suggesting future research directions and underlining the need for further studies on the optimal management of elderly patients with COVID-19.

Corticosteroid therapy in COVID-19 associated with in-hospital mortality in geriatric patients: a propensity matched cohort study

Background

Few data are available on the prognosis of older patients who received corticosteroids for COVID-19. We aimed to compare the in-hospital mortality of geriatric patients hospitalized for COVID-19 who received corticosteroids or not.

Methods

We conducted a multicentric retrospective cohort study in 15 acute COVID-19 geriatric wards in the Paris area from March to April 2020 and November 2020 to May 2021. We included all consecutive patients aged 70 years and older who were hospitalized with confirmed COVID-19 in these wards. Propensity score and multivariate analyses were used.

Results

Of the 1 579 patients included (535 received corticosteroids), the median age was 86 (interquartile range 81–91) years, 56% of patients were female, the median Charlson Comorbidity Index (CCI) was 2.6 (interquartile range 1–4), and 64% of patients were frail (Clinical Frailty Score 5–9). The propensity score analysis paired 984 patients (492 with and without corticosteroids). The in-hospital mortality was 32.3% in the matched cohort. On multivariate analysis, the probability of in-hospital mortality was increased with corticosteroid use (odds ratio [OR] = 2.61 [95% confidence interval (CI) 1.63–4.20]). Other factors associated with in-hospital mortality were age (OR = 1.04 [1.01–1.07], CCI (OR = 1.18 [1.07–1.29], activities of daily living (OR = 0.85 [0.75–0.95], oxygen saturation < 90% on room air (OR = 2.15 [1.45–3.17], C-reactive protein level (OR = 2.06 [1.69–2.51], and lowest lymphocyte count (OR = 0.49 [0.38–0.63]). Among the 535 patients who received corticosteroids, 68.3% had at least one corticosteroid side effect, including delirium (32.9%), secondary infections (32.7%), and decompensated diabetes (14.4%).

Conclusions

In this multicentric matched-cohort study of geriatric patients hospitalized for COVID-19, the use of corticosteroids was significantly associated with in-hospital mortality.

Premorbid aspirin use is not associated with lower mortality in older inpatients with SARS-CoV-2 pneumonia

Platelet aggregation has been associated with COVID-19 pathogenesis. In older patients hospitalized for SARS-CoV-2 pneumonia, we aimed to investigate the association between aspirin use before admission and the risk of in-hospital all-cause mortality. We performed a retrospective international cohort study in five COVID-19 geriatric units in France and Switzerland. Among 1,357 consecutive hospitalized patients aged 75 or older and testing positive for SARS-CoV-2, we included 1,072 with radiologically confirmed pneumonia. To adjust for confounders, a propensity score for treatment was created, and stabilized inverse probability of treatment weighting (SIPTW) was applied. To assess the association between aspirin use and in-hospital 30-day mortality, SIPTW-adjusted Kaplan–Meier and Cox proportional hazards regression analyses were performed. Of the 1047 patients with SARS-CoV-2 pneumonia and median age 86 years, 301 (28.7%) were taking aspirin treatment before admission. One hundred forty-seven (34.3%) patients who had taken aspirin died in hospital within 1 month vs 118 patients (30.7%) without aspirin. After SIPTW, aspirin treatment was not significantly associated with lower mortality (adjusted hazard ratio: 1.10 [0.81–1.49], P = .52). Moreover, patients on aspirin had a longer hospital stay and were more frequently transferred to the intensive care unit. In a large multicenter cohort of older inpatients with SARS-CoV-2 pneumonia, aspirin use before admission did not appear to be associated with an improved prognosis.

Clinical effectiveness of convalescent plasma in hospitalized patients with COVID-19: a systematic review and meta-analysis

AIMS

Given the variability of previously reported results, this systematic review aims to determine the clinical effectiveness of convalescent plasma employed in the treatment of hospitalized patients diagnosed with COVID-19.

METHODS

We conducted a systematic review of controlled clinical trials assessing treatment with convalescent plasma for hospitalized patients diagnosed with SARS-CoV-2 infection. The outcomes were mortality, clinical improvement, and ventilation requirement.

RESULTS

A total of 51 studies were retrieved from the databases. Five articles were finally included in the data extraction and qualitative and quantitative synthesis of results. The overall risk of bias in the reviewed articles was established at low-risk only in two trials. The meta-analysis suggests that there is no benefit of convalescent plasma compared with standard care or placebo in reducing the overall mortality and the ventilation requirement. However, there could be a benefit for the clinical improvement in patients treated with plasma.

CONCLUSION

Current results led to assume that the convalescent plasma transfusion cannot reduce the mortality or ventilation requirement in hospitalized patients diagnosed with SARS-CoV-2 infection. More controlled clinical trials conducted with methodologies that ensure a low risk of bias are still needed.The reviews of this paper are available via the supplemental material section.