Predictors of Mortality in Hospitalized COVID-19 Patients Complicated With Hypotension and Hypoxemia: A Retrospective Cohort Study

Association Between Hypertension and Diabetes Control and COVID-19 Severity: National Patient-Centered Clinical Research Network, United States, March 2020 to February 2022

Background Hypertension and diabetes are associated with increased COVID-19 severity. The association between level of control of these conditions and COVID-19 severity is less well understood. Methods and Results This retrospective cohort study identified adults with COVID-19, March 2020 to February 2022, in 43 US health systems in the National Patient-Centered Clinical Research Network. Hypertension control was categorized as blood pressure (BP) <130/80, 130 to 139/80 to 89, 140 to 159/90 to 99, or ≥160/100 mm Hg, and diabetes control as glycated hemoglobin <7%, 7% to <9%, ≥9%. Adjusted, pooled logistic regression assessed associations between hypertension and diabetes control and severe COVID-19 outcomes. Among 1 494 837 adults with COVID-19, 43% had hypertension and 12% had diabetes. Among patients with hypertension, the highest baseline BP was associated with greater odds of hospitalization (adjusted odds ratio [aOR], 1.30 [95% CI, 1.23-1.37] for BP ≥160/100 versus BP <130/80), critical care (aOR, 1.30 [95% CI, 1.21-1.40]), and mechanical ventilation (aOR, 1.32 [95% CI, 1.17-1.50]) but not mortality (aOR, 1.08 [95% CI, 0.98-1.12]). Among patients with diabetes, the highest glycated hemoglobin was associated with greater odds of hospitalization (aOR, 1.61 [95% CI, 1.47-1.76] for glycated hemoglobin ≥9% versus <7%), critical care (aOR, 1.42 [95% CI, 1.31-1.54]), mechanical ventilation (aOR, 1.12 [95% CI, 1.02-1.23]), and mortality (aOR, 1.18 [95% CI, 1.09-1.27]). Black and Hispanic adults were more likely than White adults to experience severe COVID-19 outcomes, independent of comorbidity score and control of hypertension or diabetes. Conclusions Among 1.5 million patients with COVID-19, higher BP and glycated hemoglobin were associated with more severe COVID-19 outcomes. Findings suggest that adults with poorest control of hypertension or diabetes might benefit from efforts to prevent and initiate early treatment of COVID-19.

Decreased PRESET-Score corresponds with improved survival in COVID-19 veno-venous extracorporeal membrane oxygenation

INTRODUCTION

The PREdiction of Survival on ECMO Therapy Score (PRESET-Score) predicts mortality while on veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory distress syndrome. The aim of our study was to assess the association between PRESET-Score and survival in a large COVID-19 VV ECMO cohort.

METHODS

This was a single-center retrospective study of COVID-19 VV ECMO patients from 15 March 2020, to 30 November 2021. Univariable and Multivariable analyses were performed to assess patient survival and score differences.

RESULTS

A total of 105 patients were included in our analysis with a mean PRESET-Score of 6.74. Overall survival was 65.71%. The mean PRESET-Score was significantly lower in the survivor group (6.03 vs 8.11, p < 0.001). Patients with a PRESET-Score less than or equal to six had improved survival compared to those with a PRESET-Score greater than or equal to 8 (97.7% vs. 32.5%, p < 0.001). In a multivariable logistic regression, a lower PRESET-Score was also predictive of survival (OR 2.84, 95% CI 1.75, 4.63, p < 0.001).

CONCLUSION

We demonstrate that lower PRESET scores are associated with improved survival. The utilization of this validated, quantifiable, and objective scoring system to help identify COVID-19 patients with the greatest potential to benefit from VV-ECMO appears feasible. The incorporation of the PRESET-Score into institutional ECMO candidacy guidelines can help insure and improve access of this limited healthcare resource to all critically ill patients.

The importance of predictors for in-hospital COVID-19 mortality changes over one month

BACKGROUND

Risk stratification enables care providers to make the proper clinical decision for the management of patients with COVID-19 infection. We aimed to explore changes in the importance of predictors for inpatient mortality of COVID-19 over one month.

METHODS

This research was a secondary analysis of data from in-hospital patients with COVID-19 infection. Individuals were admitted to four hospitals, New York, USA. Based on the length of hospital stay, 4370 patients were categorized into three mutually exclusive interval groups, day 1, day 2-7, and day 8-28. We measured changes in the importance of twelve confirmed predictors for mortality over one month, using principal component analysis.

RESULTS

On the first day of admission, there was a higher risk for organ dysfunction, particularly in elderly patients. On day 1, serum aspartate aminotransferase and sodium were also associated with an increased risk of mortality, while normal troponin opposes in-hospital death. With time, the importance of high aspartate aminotransferase and sodium concentrations decreases, while the variable quality of high troponin levels increases. Our study suggested the importance of maintaining normal blood pressure early in the management of patients. High serum concentrations of creatinine and C-reactive protein remain poor prognostic factors throughout the 28 days. The association of age with mortality increases with the length of hospital stay.

CONCLUSION

The importance of some patients' characteristics changes with the length of hospital stay. This should be considered in developing and deploying predictive models and the management of patients with COVID-19 infection.

Mechanisms, Effects, and Management of Neurological Complications of Post-Acute Sequelae of COVID-19 (NC-PASC)

With a growing number of patients entering the recovery phase following infection with SARS-CoV-2, understanding the long-term neurological consequences of the disease is important to their care. The neurological complications of post-acute sequelae of SARS-CoV-2 infection (NC-PASC) represent a myriad of symptoms including headaches, brain fog, numbness/tingling, and other neurological symptoms that many people report long after their acute infection has resolved. Emerging reports are being published concerning COVID-19 and its chronic effects, yet limited knowledge of disease mechanisms has challenged therapeutic efforts. To address these issues, we review broadly the literature spanning 2020-2022 concerning the proposed mechanisms underlying NC-PASC, outline the long-term neurological sequelae associated with COVID-19, and discuss potential clinical interventions.

Zymosan Particle-Induced Hemodynamic, Cytokine and Blood Cell Changes in Pigs: An Innate Immune Stimulation Model with Relevance to Cytokine Storm Syndrome and Severe COVID-19

Hemodynamic disturbance, a rise in neutrophil-to-lymphocyte ratio (NLR) and release of inflammatory cytokines into blood, is a bad prognostic indicator in severe COVID-19 and other diseases involving cytokine storm syndrome (CSS). The purpose of this study was to explore if zymosan, a known stimulator of the innate immune system, could reproduce these changes in pigs. Pigs were instrumented for hemodynamic analysis and, after i.v. administration of zymosan, serial blood samples were taken to measure blood cell changes, cytokine gene transcription in PBMC and blood levels of inflammatory cytokines, using qPCR and ELISA. Zymosan bolus (0.1 mg/kg) elicited transient hemodynamic disturbance within minutes without detectable cytokine or blood cell changes. In contrast, infusion of 1 mg/kg zymosan triggered maximal pulmonary hypertension with tachycardia, lasting for 30 min. This was followed by a transient granulopenia and then, up to 6 h, major granulocytosis, resulting in a 3-4-fold increase in NLR. These changes were paralleled by massive transcription and/or rise in IL-6, TNF-alpha, CCL-2, CXCL-10, and IL-1RA in blood. There was significant correlation between lymphopenia and IL-6 gene expression. We conclude that the presented model may enable mechanistic studies on late-stage COVID-19 and CSS, as well as streamlined drug testing against these conditions.

Therapeutic target and clinical impact of day-to-day blood pressure variability in hypertensive patients with covid-19

Blood pressure variability (BPV) is essential in hypertensive patients and is frequently associated with organ damage. As of today, hypertension is still the most common comorbidity in COVID-19, but the impact of BPV and the therapeutic target of BPV on outcomes in COVID-19 patients with hypertension remain unclear. Therefore, this study investigated the relationship between BPV and severity of COVID-19, in-hospital mortality, hypertensive status, and efficacy of antihypertensives in suppressing hypertensive covid-19 patient BPV. This cohort retrospective study enrolled 351 patients hospitalized with COVID-19. Subjects were classified according to the severity of COVID-19, the presence of hypertension, and their BPV status. During hospitalization, mean arterial pressure (MAP) was measured at 6 a.m. and 6 p.m., and BPV was calculated as the coefficient of variation of MAP (MAPCV). MAPCV values above the median were defined as high BPV. In addition, we compared the hypertensive status, COVID-19 severity, in-hospital mortality, and antihypertensive agents between the BPV groups. The mean age was 53.85 ± 18.84 years old. Hypertension was significantly associated with high BPV with prevalence ratio (PR) = 1.38 (95% CI = 1.13-1.70; p = 0.003) or severe COVID-19 (PR = 1.39; 95% CI = 1.09-1.76; p = 0.005). In laboratory findings, high BPV group had lower Albumin, higher WBC, serum Cr, CRP, and creatinine to albumin ratio. High BPV status also significantly increased risk of mortality (HR = 2.30; 95% CI = 1.73-3.86; p < 0.001). Patients with a combination of severe COVID-19 status, hypertension, and high BPV status had the highest risk of in-hospital mortality (HR = 3.51; 95% CI = 2.32-4.97; p < 0.001) compared to other combination status groups. In COVID-19 patients with hypertension, combination therapy with calcium channel blockers (CCB) as well as CCB monotherapy significantly develop low BPV (PR = 2.002; 95 CI% = 1.33-3.07; p = 0.004) and low mortality (HR = 0.17; 95% CI = 0.05-0.56; p = 0.004). Hypertensive status and severe COVID-19 were significantly associated with high BPV, and these factors increased in-hospital mortality. CCBs might be antihypertensive agents that potentially effectively suppressing BPV and mortality in COVID-19 patients.