Characteristics and outcomes of hospitalised adults with COVID-19 in a Global Health Research Network: a cohort study

Real-World Electronic Medical Records Data Identify Risk Factors for Myelofibrosis and Can Be Used to Validate Established Prognostic Scores

Myelofibrosis (MF) is a myeloproliferative neoplasia arising de novo as primary myelofibrosis (PMF) or secondary to polycythemia vera or essential thrombocythemia. Patients experience a high symptom burden and a marked reduction in life expectancy. Despite progress in molecular understanding and treatment, the clinical and prognostic heterogeneity of MF complicates treatment decisions. The International Prognostic Scoring System (IPSS) integrates clinical factors for risk stratification in MF. This study leverages the TriNetX database with more than 64,000 MF patients to assess the impact of accessible parameters on survival and complicating events, including AML transformation, cachexia, increased systemic inflammation, thrombosis and hemorrhage. Age over 65 years correlated with increased risks of death, AML transformation, thrombosis and hemorrhage. Anemia (Hb < 10 g/dL), leukocytosis (>25 × 103/µL) and thrombocytopenia (<150 × 103/µL) reduced survival and increased risks across all assessed events. Monocytosis is associated with decreased survival, whereas eosinophilia and basophilia were linked to improved survival. Further, as proof of concept for the applicability of TriNetX for clinical scores, we devised a simplified IPSS, and confirmed its value in predicting outcomes. This comprehensive study underscores the importance of age, anemia, leukocytosis and thrombocytopenia in predicting disease trajectory and contributes to refining prognostic models, addressing the challenges posed by the disease's heterogeneity.

A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm

BACKGROUND

Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure.

METHODS

Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure.

RESULTS

Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success.

CONCLUSION

In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.

Electrochemical degradation of key drugs to treat COVID-19: Experimental analysis of the toxic by-products formation (PCDD/Fs)

Drug consumption has grown exponentially in recent decades, particularly during the COVID-19 pandemic, leading to their presence in various water sources. In this way, degradation technologies for pollutants, such as electrochemical oxidation (ELOX), have become crucial to safeguard the quality of natural resources. This study has as its starting point a previous research, which demonstrated the efficacy of ELOX in the removal of COVID-19 related-drugs, such as dexamethasone (DEX), paracetamol (PAR), amoxicillin (AMX), and sertraline (STR), using the electrolytes NaCl and Na2SO4. The present research aims to study the potential risks associated with the generation of toxic by-products, during the ELOX of cited drugs, specifically focusing on the highly chlorinated persistent organic pollutants (POPs), such as polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs). Dioxins and furans can be formed potentially in electrochemical systems from precursor molecules or non-precursor molecules in chloride medium. First, the degradation of the parent compounds was found to be complete. At this point, a comprehensive investigation was conducted to identify and analyse the by-products formed during the degradation process; precursors of PCDD/Fs, such as chlorophenols or hydroquinones were identified. Additionally, in continuation of the previous study, PCDD/Fs congeners were investigated, revealing elevated concentrations; the highest concentration obtained was for the congener 1,2,3,4,6,7,8-HpCDF (234.6 pg L-1 in NaCl) during degradation of the AMX. Finally, an assessment of the toxicity based on TEQ values was conducted, with DEX exhibiting the highest concentration among all compounds: 30.1 pg L-1 for NaCl medium. Therefore, the formation of minor by-products should not be underestimated, as they can significantly enhance the toxicity of the final sample, so the selection of the appropriate remediation technology, as well as the optimization of experimental operating variables, is determining in the treatment of pharmaceutical-contaminated waters.

Use of high flow nasal cannula oxygen therapy for patients infected with SARS-CoV-2 outside intensive care setting

BACKGROUND

In early 2022, there was a sudden surge of patients infected by the Omicron variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Hong Kong (HK), resulting in 9,163 deaths as of 29 May 2022. Many of the local population had not been vaccinated before this wave. The number of patients who developed coronavirus disease 2019 (COVID-19) related respiratory failure outnumbered the capacity of intensive care unit (ICU) beds. Some of these patients had to be supported with high flow nasal cannula (HFNC) therapy outside ICU setting. HK was in crisis situation. The primary objective of this study is to assess the 28-day mortality of this group of patients. The secondary objective is to explore any predictors of non-survivors to help clinical decision-making in future crisis.

METHODS

This is a retrospective observational study of patients suffering from COVID-19 related respiratory failure who received HFNC therapy in general medical wards of two hospitals during the period of 17 Mar to 30 Apr 2022. Survival and risk factors were reviewed.

RESULTS

Forty-nine patients were recruited. Twenty-six patients (53%) survived at 28-day after initiation of HFNC support. Three clinical parameters were found to be significantly associated with mortality at 28-day: (I) SpO2/FiO2 (SF) ratio <160 at 48 hours; (II) SF ratio <191 at 72 hours; (III) serial SF ratio at 48 or 72 hours showing no improvement over that at the time of initiation of HFNC therapy.

CONCLUSIONS

Use of HFNC outside ICU setting showed benefit to patients suffering from COVID-19 related acute hypoxemic respiratory failure (AHRF). Serial SF ratio monitoring at 48 and 72 hours after therapy initiation might serve as predictors of outcome and thus guide clinical decision-making for medical resource allocation in outbreak situation.

Formation of polychlorinated dibenzo-p-dioxins and furans (PCDD/Fs) in the electrochemical oxidation of polluted waters with pharmaceuticals used against COVID-19

The COVID-19 pandemic has produced a huge impact on our lives, increasing the consumption of certain pharmaceuticals, and with this, contributing to the intensification of their presence in wastewater and in the environment. This situation demands the implementation of efficient remediation technologies, among them, electrochemical oxidation (ELOX) is one the most applied. This work studies the application of ELOX with the aim of eliminate pharmaceuticals used in the fight against COVID-19, assessing its degradation rate, as well as the risk of formation of toxic trace by-products, such as unintentional POPs like polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs). To this end, model solutions containing 10 mg L^-1 of dexamethasone (DEX), paracetamol (PAR), amoxicillin (AMX), and sertraline (STR) with two different electrolytes (NaCl and Na₂SO₄) have been evaluated. However, electrochemical systems that contain chloride ions in solution together with PCDD/Fs precursor molecules may lead to the formation of these highly toxic by-products. So, PCDD/Fs were quantified under conditions of complete degradation of the drugs. Furthermore, the presence of PCDD/Fs precursors such as chlorophenols was determined, as well as the role of Cl^-, Cl^• and SO 4 • - radicals in the formation of the by-products and PCDD/Fs. The maximum measured concentration of PCDD/Fs was around 2700 pg L^-1 for the amoxicillin case in NaCl medium. The obtained results emphasise the importance of not underestimating the potential formation of these highly toxic trace by-products, in addition to the correct selection of oxidation processes and operation variables, in order to avoid final higher toxicity in the medium.

Measuring SARS-CoV-2 aerosolization in rooms of hospitalized patients

Objective

Airborne spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains a significant risk for healthcare workers. Understanding transmission of SARS-CoV-2 in the hospital could help minimize nosocomial infection. The objective of this pilot study was to measure aerosolization of SARS-CoV-2 in the hospital rooms of COVID-19 patients.

Methods

Two air samplers (Inspirotec) were placed 1 and 4 m away from adults with SARS-CoV-2 infection hospitalized at an urban, academic tertiary care center from June to October 2020. Airborne SARS-CoV-2 concentration was measured by quantitative reverse transcription polymerase chain reaction and analyzed by clinical parameters and patient demographics.

Results

Thirteen patients with COVID-19 (eight females [61.5%], median age: 57 years old, range 25-82) presented with shortness of breath (100%), cough (38.5%) and fever (15.4%). Respiratory therapy during air sampling varied: mechanical ventilation via endotracheal tube (n = 3), high flow nasal cannula (n = 4), nasal cannula (n = 4), respiratory helmet (n = 1), and room air (n = 1). SARS-CoV-2 RNA was identified in rooms of three out of three intubated patients compared with one out of 10 of the non-intubated patients (p = .014). Airborne SARS-CoV-2 tended to decrease with distance (1 vs. 4 m) in rooms of intubated patients.

Conclusions

Hospital rooms of intubated patients had higher levels of aerosolized SARS-CoV-2, consistent with increased aerosolization of virus in patients with severe disease or treatment with positive pressure ventilation through an endotracheal tube. While preliminary, these data have safety implications for health care workers and design of protective measures in the hospital.

Level of Evidence

2.

Trends in characteristics and outcomes among US adults hospitalised with COVID-19 throughout 2020: an observational cohort study

OBJECTIVES

To examine the temporal patterns of patient characteristics, treatments used and outcomes associated with COVID-19 in patients who were hospitalised for the disease between January and 15 November 2020.

DESIGN

Observational cohort study.

SETTING

COVID-19 subset of the Optum deidentified electronic health records, including more than 1.8 million patients from across the USA.

PARTICIPANTS

There were 51 510 hospitalised patients who met the COVID-19 definition, with 37 617 in the laboratory positive cohort and 13 893 in the clinical cohort.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incident acute clinical outcomes, including in-hospital all-cause mortality.

RESULTS

Respectively, 48% and 49% of the laboratory positive and clinical cohorts were women. The 50- 65 age group was the median age group for both cohorts. The use of antivirals and dexamethasone increased over time, fivefold and twofold, respectively, while the use of hydroxychloroquine declined by 98%. Among adult patients in the laboratory positive cohort, absolute age/sex standardised incidence proportion for in-hospital death changed by -0.036 per month (95% CI -0.042 to -0.031) from March to June 2020, but remained fairly flat from June to November, 2020 (0.001 (95% CI -0.001 to 0.003), 17.5% (660 deaths /3986 persons) in March and 10.2% (580/5137) in October); in the clinical cohort, the corresponding changes were -0.024 (95% CI -0.032 to -0.015) and 0.011 (95% CI 0.007 0.014), respectively (14.8% (175/1252) in March, 15.3% (189/1203) in October). Declines in the cumulative incidence of most acute clinical outcomes were observed in the laboratory positive cohort, but not for the clinical cohort.

CONCLUSION

The incidence of adverse clinical outcomes remains high among COVID-19 patients with clinical diagnosis only. Patients with COVID-19 entering the hospital are at elevated risk of adverse outcomes.

Estradiol reduces ACE2 and TMPRSS2 mRNA levels in A549 human lung epithelial cells

Epidemiologic studies suggest slightly higher risk of severe Covid‐19 symptoms and fatalities following SARS‐CoV‐2 infection in men compared with women from similar age groups. This bias was suggested to reflect differences in the male and female immune system regulation, driven by different sex hormone levels in men and women, in particular, higher plasma estradiol in women. SARS‐CoV‐2 infects respiratory tract epithelial cells by binding to their cell membrane ACE2, followed by priming for cell entry by the host cell membrane serine protease TMPRSS2. The cell protease FURIN facilitates cell exit of mature SARS‐CoV‐2 virions. Our study examined the effects of in vitro treatment of A549 human lung epithelial cells with 17‐β‐estradiol on mRNA expression of genes coding for these proteins. Treatment of A549 human lung epithelial cells with 17‐β‐estradiol reduced the cellular mRNA levels of ACE2 and TMPRSS2 mRNA, while not affecting FURIN expression. Our findings suggest that 17‐β‐estradiol may reduce SARS‐CoV‐2 infection of lung epithelial cells, which may in part explain the reduced incidence of severe Covid‐19 and fatalities among women compared with men of similar age. Studies into the molecular pathways by which 17‐β‐estradiol reduces ACE2 and TMPRSS2 mRNA expression in lung epithelial cells are needed for assessing its potential protective value against severe Covid‐19.