Association between mortality and age among mechanically ventilated COVID-19 patients: a Japanese nationwide COVID-19 database study

Impact of the COVID-19 pandemic on prehospital and in-hospital treatment and outcomes of patients after out-of-hospital cardiac arrest: a Japanese multicenter cohort study

BACKGROUND

In the chain of survival for Out-of-hospital cardiac arrest (OHCA), each component of care contributes to improve the prognosis of the patient with OHCA. The SARS-CoV-2 (COVID-19) pandemic potentially affected each part of care in the chain of survival. The aim of this study was to compare prehospital care, in-hospital treatment, and outcomes among OHCA patients before and after the COVID-19 pandemic.

METHODS

We analyzed data from a multicenter prospective study in Kanto area, Japan, named SOS-KANTO 2017. We enrolled patients who registered during the pre-pandemic period (September 2019 to December 2019) and the post-pandemic period (June 2020 to March 2021). The main outcome measures were 30-day mortality and the proportion of favorable outcomes at 1 month, and secondary outcome measures were changes in prehospital and in-hospital treatments between the pre- and post-pandemic periods.

RESULTS

There were 2015 patients in the pre-pandemic group, and 5023 in the post-pandemic group. The proportion of advanced airway management by emergency medical service (EMS) increased (p < 0.01), and EMS call-to-hospital time was prolonged (p < 0.01) in the post- versus pre-pandemic group. There were no differences between the groups in defibrillation, extracorporeal membrane oxygenation, or temperature control therapy (p = 0.43, p = 0.14, and p = 0.16, respectively). Survival rate at 1 month and favorable outcome rate at 1 month were lower (p = 0.01 and p < 0.01, respectively) in the post- versus pre-pandemic group.

CONCLUSION

Survival rate and favorable outcome rate 1 month after return of spontaneous circulation of OHCA worsened, EMS response time was prolonged, and advanced airway management by EMS increased in the post- versus pre-pandemic group; however, most prehospital and in-hospital management did not change between pre- and post-COVID-19 pandemic.

Risk factors for the need for advanced care among prescription and over-the-counter drug overdose patients

Aim

Prescription drug and over-the-counter (OTC) drug overdose is a major problem in emergency departments in Japan, and some need advanced care which is more than observation. We aimed to identify the prehospital risk factors for the need of advanced care among overdose patients.

Methods

This was a single-center retrospective cohort study. We included overdoses patients of prescription drugs or OTC drugs, who admitted to our hospital between 2016 and 2021. We grouped them into advanced care and non-advanced care. The main outcome was the need for advanced care. We performed a multiple logistic regression analysis, calculated the PAV score (Paracetamol use, Alcohol use, abnormal Vital signs on scene) and performed a receiver operating characteristic (ROC) analysis.

Results

There were 229 subjects. The logistic regression analysis revealed that alcohol, paracetamol, and the abnormal vital signs on scene were associated with advanced care (alcohol-odds ratio [OR]: 2.95; 95% confidence interval [CI]: 1.29-6.75; paracetamol-OR: 5.47; 95% CI: 2.18-13.71; abnormal vital signs-OR: 4.61, 95% CI: 2.07-10.27). The rate of advanced care in the high PAV score (2 and 3) group was statistically higher than that in the low PAV score (0-1) group (p = 0.04). Area under the ROC curve of the PAV score was 0.72 (95% CI, 0.65-0.80).

Conclusion

Alcohol, paracetamol use and abnormal vital signs on scene might be risk factors for advanced care among prescription drugs or OTC drugs overdose patients, and the PAV score may predict the need for advanced care.

Comparison of Azvudine and Nirmatrelvir/Ritonavir and Combined Use in Patients with COVID-19

Purpose

To compare the effectiveness of azvudine and nirmatrelvir/ritonavir for the treatment of coronavirus disease (COVID-19).

Patients and Methods

We conducted a retrospective analysis of data from 576 patients with COVID-19, comprising 195 patients without antiviral therapy, 226 patients treated with azvudine, 114 patients treated with nirmatrelvir/ritonavir, and 41 patients were treated with azvudine and nirmatrelvir/ritonavir concurrently. We compared their symptoms, mortality rates, and the length and cost of hospitalization.

Results

The incidence of symptoms was similar in patients treated with azvudine and in those treated with nirmatrelvir/ritonavir. However, among patients experiencing weakness, the duration of weakness was significantly shorter in the azvudine group than in the nirmatrelvir/ritonavir group (P=0.029). Mortality did not differ significantly between the azvudine group and the nirmatrelvir/ritonavir group (18.14% vs.10.53%, P=0.068). Among "severe patients", the mortality rate was markedly lower in patients treated with nirmatrelvir/ritonavir than in patients treated with azvudine (16.92% vs.32.17%, P=0.026). In patients with hepatic insufficiency, those treated with nirmatrelvir/ritonavir had substantially lower mortality than those treated with azvudine (15.09% vs.34.25%, P=0.016). In addition, patients treated with nirmatrelvir/ritonavir had longer hospital stays (P=0.002) and higher hospital costs (P<0.001) than those receiving azvudine. Compared with patients treated with nirmatrelvir/ritonavir or azvudine alone, patients taking nirmatrelvir/ritonavir and azvudine concurrently had no significant improvement in survival (P>0.05), length of stay (P>0.05), or hospital costs (P>0.05).

Conclusion

Azvudine is recommended for patients with non-severe COVID-19 with weakness. Nirmatrelvir/ritonavir is recommended for patients with severe COVID-19, to reduce mortality, and it could be the best choice for patients with hepatic insufficiency. The concurrent use of nirmatrelvir/ritonavir and azvudine in patients with COVID-19 could be not recommended.

The new combination of oxygen saturation with age shock index predicts the outcome of COVID-19 pneumonia

Introduction

Emergency departments around the world have been struggling to deal with patients with COVID-19 and presumed COVID-19. Triaging patients who need further medical support is the key matter to emergency physicians as the delay of proper treatment may worsen the results. The aim of this study was to validate the ability of age shock index and hypoxia-age-shock index at the time of presentation to the emergency department to predict case fatality in patients with COVID-19 pneumonia.

Methods

We only included patients who had COVID-19-associated pneumonia who needed in-hospital treatment. The vital signs and oxygen saturation used in the study were collected, especially from the triage sector, before patients were given supplemental oxygen.

Results

A total of 241 patients enrolled in the study. The case fatality rate was 27%. The median age of the study samples was 78 (66-86) years with 133 male and 108 female patients. Hypoxia-age-shock index showed the best performance in analysis (odds ratio 15.1, 95% confidence interval: 5.1-44.4; adjusted odds ratio 8.6, 95% confidence interval: 2.8-26.8).

Conclusion

The hypoxia-age-shock index was a strong predictor for in-hospital mortality of COVID-19 pneumonia. Furthermore, when it was compared with age shock index, hypoxia-age-shock index showed better performance in predicting fatality of the disease.

Efficacy of Early Rehabilitation for Severe Coronavirus Disease 2019 Pneumonia: Factor Analysis Using Machine Learning

Objectives

Patients with severe coronavirus disease 2019 (COVID-19) who develop pneumonia face the risk of ventilatory muscle disuse in the acute phase, which can result in persistent respiratory impairments in the subacute phase. Although rehabilitation during the acute phase is considered effective, there are limited reports on this topic. Therefore, this study aimed to investigate the effectiveness of acute-phase rehabilitation in patients with severe COVID-19.

Methods

The study included 57 patients (45 men and 12 women; mean age: 63.2±12.1 years) admitted between April and June 2021, all of whom required intubation for respiratory management. Among them, 34 patients underwent acute-phase rehabilitation interventions based on the early goal-directed mobilization protocol. The primary objectives were to assess the occurrence of medical accidents related to acute-phase rehabilitation and evaluate their impact on survival and mobility upon hospital discharge. Statistical techniques and machine learning algorithms were employed for data analysis.

Results

Remarkably, no medical accidents occurred during the acute-phase rehabilitation among the patients. Furthermore, our findings indicated that acute-phase rehabilitation did not influence survival outcomes. However, it did have a positive impact on the mobility of patients upon hospital discharge.

Conclusions

Acute-phase rehabilitation can be safely administered to patients with severe COVID-19 by following an early goal-directed mobilization protocol. This approach may also contribute to improved activities of daily living after discharge.

Physical function and mental health trajectories in COVID-19 patients following invasive mechanical ventilation: a prospective observational study

This prospective observational cohort study was performed to investigate the physical function and mental health trajectories of novel coronavirus disease 2019 (COVID-19) patients requiring invasive mechanical ventilation (IMV) after discharge from the intensive care unit (ICU). The study population consisted of 64 patients (median age, 60 years; 85.9% male; median IMV duration, 9 days). At ICU discharge, 28.1% of the patients had Medical Research Council (MRC) sum score < 48 points, and prolonged IMV was significantly associated with lower MRC sum score and handgrip strength. Symptoms were similar between groups at ICU discharge, and the symptoms most commonly reported as moderate-to-severe were impaired well-being (52%), anxiety (43%), tiredness (41%), and depression (35%). Although muscle strength and mobility status were significantly improved after ICU discharge, Edmonton Symptom Assessment System score did not improve significantly in the prolonged IMV group. EuroQol five-dimension five-level summary index was significantly lower in the prolonged than short IMV group at 6 months after ICU discharge. We found substantial negative physical function and mental health consequences in the majority of surviving COVID-19 patients requiring IMV, with prolonged period of IMV showing greater negative effects not only immediately but also at 6 months after discharge from the ICU.

Risk factors associated with mortality among elderly patients with COVID-19: Data from 55 intensive care units in Spain

INTRODUCTION AND OBJECTIVES

Critically-ill elderly ICU patients with COVID-19 have poor outcomes. We aimed to compare the rates of in-hospital mortality between non-elderly and elderly critically-ill COVID-19 ventilated patients, as well as to analyze the characteristics, secondary outcomes and independent risk factors associated with in-hospital mortality of elderly ventilated patients.

PATIENTS AND METHODS

We conducted a multicentre, observational cohort study including consecutive critically-ill patients admitted to 55 Spanish ICUs due to severe COVID-19 requiring mechanical ventilation (non-invasive respiratory support [NIRS; include non-invasive mechanical ventilation and high-flow nasal cannula] and invasive mechanical ventilation [IMV]) between February 2020 and October 2021.

RESULTS

Out of 5,090 critically-ill ventilated patients, 1,525 (27%) were aged ≥70 years (554 [36%] received NIRS and 971 [64%] received IMV. In the elderly group, median age was 74 years (interquartile range 72-77) and 68% were male. Overall in-hospital mortality was 31% (23% in patients <70 years and 50% in those ≥70 years; p<0.001). In-hospital mortality in the group ≥70 years significantly varied according to the modality of ventilation (40% in NIRS vs. 55% in IMV group; p<0.001). Factors independently associated with in-hospital mortality in elderly ventilated patients were age (sHR 1.07 [95%CI 1.05-1.10], p<0.001); previous admission within the last 30 days (sHR 1.40 [95%CI 1.04-1.89], p = 0.027); chronic heart disease (sHR 1.21 [95%CI 1.01-1.44], p = 0.041); chronic renal failure (sHR 1.43 [95%CI 1.12- 1.82], p = 0.005); platelet count (sHR 0.98 [95% CI 0.98-0.99], p<0.001); IMV at ICU admission (sHR 1.41 [95% CI 1.16- 1.73], p<0.001); and systemic steroids (sHR 0.61 [95%CI 0.48- 0.77], p<0.001).

CONCLUSIONS

Amongst critically-ill COVID-19 ventilated patients, those aged ≥70 years presented significantly higher rates of in-hospital mortality than younger patients. Increasing age, previous admission within the last 30 days, chronic heart disease, chronic renal failure, platelet count, IMV at ICU admission and systemic steroids (protective) all comprised independent factors for in-hospital mortality in elderly patients.

Risk Factors Associated with Mortality among Mechanically Ventilated Patients with Coronavirus Disease 2019 Pneumonia: A Multicenter Cohort Study in Japan (J-RECOVER Study)

Objective Mortality analyses of patients with coronavirus disease 2019 (COVID-19) requiring invasive mechanical ventilation in Japan are limited. The present study therefore determined the risk factors for mortality in patients with COVID-19 requiring invasive mechanical ventilation. Methods This retrospective cohort study used the dataset from the Japanese multicenter research of COVID-19 by assembling real-word data (J-RECOVER) study that was conducted between January 1 and September 31, 2020. Independent risk factors associated with in-hospital mortality were evaluated using a multivariate logistic regression analysis. Kaplan-Meier estimates of the survival were calculated for different age groups. A subgroup analysis was performed to assess differences in survival rates according to additional risk factors, including an older age and chronic pulmonary disease. Patients A total of 561 patients were eligible. The median age was 67 (interquartile range: 56-75) years old, 442 (78.8%) were men, and 151 (26.9%) died in the hospital. Results Age, chronic pulmonary disease, and renal disease were significantly associated with in-hospital mortality. Compared with patients 18-54 years old, the adjusted odds ratios of patients 55-64, 65-74, and 75-94 years old were 3.34 (95% CI, 1.34-8.31), 7.07 (95% CI, 3.05-16.40), and 18.43 (95% CI, 7.94-42.78), respectively. Conclusion Age, chronic pulmonary disease, and renal disease were independently associated with mortality in patients with COVID-19 requiring invasive mechanical ventilation, and age was the most decisive indicator of a poor prognosis. Our results may aid in formulating treatment strategies and allocating healthcare resources.

Impact of COVID-19 on the Surrounding Environment of Nursing Home Residents and Attitudes towards Infection Control and Oral Health Care among Nursing Home Staff in Japan

The environments of nursing home staff and residents have dramatically changed since the onset of the COVID-19 pandemic, with greater demand for infection control. This study aimed to clarify the changes and regional differences in the surrounding environment of nursing home residents as well as the working environment of staff, including oral health care, after the spread of SARS-CoV-2. A self-administered questionnaire survey was sent to nursing staff at about 40 nursing homes in different areas of Japan in September and October 2021. The questionnaire consisted of items centered around: (1) the surrounding environment of nursing home residents, (2) awareness and attitudes towards daily work among staff, and (3) attitudes to and procedures for oral health care among staff. A total of 929 respondents included 618 (66.5%) nursing care workers and 134 (14.4%) nurses. Regarding changes in resident daily life, 60% of staff perceived decreases in psychosocial and physical function after the start of the pandemic due to limited family communication and recreational activities, especially in urban areas. Concerning infection control, most respondents adopted routines of disinfecting hands before and after their duties. Oral health care was part of the regular duties of over 80% of respondents. Many participants answered that the frequency and time of oral health care only slightly changed after the onset of COVID-19, but many also reported disinfecting hands both before and after oral health care, particularly in rural areas. Our findings suggested that the COVID-19 pandemic decreased the daily living activities of residents, leading to psychosocial and physical decline, especially in urban areas. The results also indicated that the spread of SARS-CoV-2 triggered improvements in the awareness and attitudes towards infection control in daily work, including oral health care, among nursing care staff, notably in rural areas. Such an effect may contribute to a more positive perception of oral health care infection measures after the pandemic.

Comorbid Asthma Increased the Risk for COVID-19 Mortality in Asia: A Meta-Analysis

We aimed to explore the influence of comorbid asthma on the risk for mortality among patients with coronavirus disease 2019 (COVID-19) in Asia by using a meta-analysis. Electronic databases were systematically searched for eligible studies. The pooled odds ratio (OR) with 95% confidence interval (CI) was estimated by using a random-effect model. An inconsistency index (I2) was utilized to assess the statistical heterogeneity. A total of 103 eligible studies with 198,078 COVID-19 patients were enrolled in the meta-analysis; our results demonstrated that comorbid asthma was significantly related to an increased risk for COVID-19 mortality in Asia (pooled OR = 1.42, 95% CI: 1.20−1.68; I2 = 70%, p < 0.01). Subgroup analyses by the proportion of males, setting, and sample sizes generated consistent findings. Meta-regression indicated that male proportion might be the possible sources of heterogeneity. A sensitivity analysis exhibited the reliability and stability of the overall results. Both Begg’s analysis (p = 0.835) and Egger’s analysis (p = 0.847) revealed that publication bias might not exist. In conclusion, COVID-19 patients with comorbid asthma might bear a higher risk for mortality in Asia, at least among non-elderly individuals.

Patient-centered outcomes at hospital discharge in mechanically ventilated COVID-19 patients in Kobe, Japan: A single-center retrospective cohort study

BACKGROUND

Apart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.c METHODS: We conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors' outcomes with MV durations of >14 days and ≤14 days.

RESULTS

We included 85 patients with a median age of 69 years (interquartile range, 64-75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for >14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5-65] vs. 100 [85-100]), ICU mobility scale (8 [5-9] vs. 10 [10-10]), and functional oral intake scale (3 [1-7] vs. 7 [7-7]) (P < 0.0001).

CONCLUSION

Although four-fifths of the patients survived and >50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.

Significant Impact of Age on Mortality and Non-significant Impact of Age on Thrombosis and Major Bleeding in Patients with COVID-19: From the CLOT-COVID Study

AIM

There is scarce data on the impact of age on clinical outcomes in patients with coronavirus disease 2019 (COVID-19).

METHOD

The CLOT-COVID Study was a retrospective, multicenter cohort study enrolling 2894 consecutive hospitalized patients with COVID-19 among 16 centers in Japan from April 2021 to September 2021. We divided the entire cohort into five groups according to age strata; -19, 20-39, 40-59, 60-79, and 80- years.

RESULTS

Most patients under 19 had mild COVID-19 on admission (99%), while older patients had more severe COVID-19. The incidence rates of clinical outcomes during hospitalization in patients aged ≤ 19, 20-39, 40-59, 60-79, and 80 ≥ years were 0.0%, 0.5%, 2.2%, 2.7%, and 1.5% for thrombosis; 0.0%, 1.2%, 1.5%, 3.4%, and 2.0% for major bleeding; and 0.0%, 0.4%, 2.0%, 12.1%, and 16.8% for all-cause death, respectively. In the stratified analysis according to COVID-19 severity on admission, the incidences of thrombosis were generally higher among patients with more severe status, although those were not significantly different among age strata in all sub-types of COVID-19 severity. However, the incidences of all-cause death were significantly higher with increasing age in all sub-types of COVID-19 severity.

CONCLUSIONS

In the current large observational study of patients with COVID-19, the risk of mortality became markedly higher with increased age. However, the risks of thrombosis and major bleeding did not necessarily increase as age increases, which seemed to be consistent irrespective of COVID-19 severity on admission.

Japanese Multicenter Research of COVID-19 by Assembling Real-world Data: A Study Protocol

BACKGROUND

Data on the evaluation of the clinical course of coronavirus disease 2019 (COVID-19) and the efficacy of treatments after hospitalization in Japan are limited.

OBJECTIVE

This study aimed to construct a database of confirmed COVID-19 cases in Japan and promptly address unresolved research issues.

METHODS

This multicenter observational study included patients who had a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and were discharged from each participating institution between January 1 and September 31, 2020. We called for participating facilities and research proposals until the end of September 2020. The research steering committee members provided advice to co-investigators on refining their research proposals and analyses. After developing the research proposal, we collected clinical information, facility information, and laboratory data from each participating institution. Clinical information was also obtained from the Diagnosis Procedure Combination (DPC) data using a dedicated software called DPC hash application.

ANALYSIS

We planned to conduct an analysis based on the research proposal. Overall, 66 institutions from Japan announced their participation, and 102 research proposals were selected for the analyses. Research areas from the proposals included epidemiology, pathophysiology, therapeutic agents, ventilator settings, cost-benefit analyses, and prognosis prediction for COVID-19.

CONTRIBUTION AND SIGNIFICANCE TO THE FIELD

We have established an efficient data collection system and clinical research team for COVID-19 infection studies. The results of this study may be utilized in future response strategies for COVID-19.