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Kowalski EN, Wang X, Patel NJ, Kawano Y, Cook CE, Vanni KMM, Qian G, Bade KJ, Srivatsan S, Williams ZK, Wallace ZS, Sparks JA. Risk factors and outcomes for repeat COVID-19 infection among patients with systemic autoimmune rheumatic diseases: A case-control study. Semin Arthritis Rheum 2023; 63:152286. [PMID: 37913612 PMCID: PMC10842150 DOI: 10.1016/j.semarthrit.2023.152286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/12/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To investigate risk factors and outcomes of repeat COVID-19 infections among patients with systemic autoimmune rheumatic diseases (SARDs). METHODS We performed a case-control study investigating repeat COVID-19 infection within the Mass General Brigham Health Care System. We systematically identified all SARD patients with confirmed COVID-19 (15/Mar/2020 to 17/Oct/2022). Cases had confirmed repeat COVID-19 infections >60 days apart (index date: repeat COVID-19 date). Controls were matched to cases (up to 3:1) by calendar date of first infection and duration between first COVID-19 infection and index dates. We collected demographics, lifestyle, comorbidities, SARD features, and COVID-19 characteristics at initial infection and index date by medical record review. We used conditional logistic regression to identify associations with repeat COVID-19 infection, adjusting for potential confounders. We described the severity of repeat COVID-19 infection among cases. RESULTS Among 2203 SARD patients with COVID-19, we identified 76 cases with repeat COVID-19 infection (80.3 % female) and matched to 207 matched controls (77.8 % female) with no repeat infection. At first infection, cases were younger (mean 49.5 vs. 60.3 years, p < 0.0001), less likely to have hypertension (32.9 % vs. 45.9 %, p = 0.050), and less likely to have been hospitalized for COVID-19 (13.2 % vs. 24.6 %, p = 0.037) than controls. At index date, cases were more likely than controls to be rituximab users (18.4 % vs. 6.3 %, p = 0.0021). In the multivariable model, younger age (OR 0.67 per 10 years, 95 %CI 0.54-0.82), rituximab use vs. non-use (OR 3.38, 95 %CI 1.26-9.08), and methotrexate use vs. non-use (OR 2.24, 95 %CI 1.08-4.61) were each associated with repeat COVID-19 infection. Among those with repeat COVID-19 infection, 5/76 (6.6 %) were hospitalized and there were no deaths. CONCLUSION Younger age, rituximab, and methotrexate were each associated with repeat COVID-19 infection risk among patients with SARDs. Reassuringly, there were no deaths, and the hospitalization rate was low among those with repeat COVID-19 infection.
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Affiliation(s)
- Emily N Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Xiaosong Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Harvard Medical School, Boston, MA, USA
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA; Harvard Medical School, Boston, MA, USA
| | - Claire E Cook
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Kathleen M M Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Katarina J Bade
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Shruthi Srivatsan
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Zachary K Williams
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Rheumatology Associates, 55 Fruit Street, Boston, MA, 02114, USA; Harvard Medical School, Boston, MA, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA, 02115, USA; Harvard Medical School, Boston, MA, USA.
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Nguyen KAN, Tandon P, Ghanavati S, Cheetirala SN, Timsina P, Freeman R, Reich D, Levin MA, Mazumdar M, Fayad ZA, Kia A. A Hybrid Decision Tree and Deep Learning Approach Combining Medical Imaging and Electronic Medical Records to Predict Intubation Among Hospitalized Patients With COVID-19: Algorithm Development and Validation. JMIR Form Res 2023; 7:e46905. [PMID: 37883177 PMCID: PMC10636624 DOI: 10.2196/46905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/18/2023] [Accepted: 06/27/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Early prediction of the need for invasive mechanical ventilation (IMV) in patients hospitalized with COVID-19 symptoms can help in the allocation of resources appropriately and improve patient outcomes by appropriately monitoring and treating patients at the greatest risk of respiratory failure. To help with the complexity of deciding whether a patient needs IMV, machine learning algorithms may help bring more prognostic value in a timely and systematic manner. Chest radiographs (CXRs) and electronic medical records (EMRs), typically obtained early in patients admitted with COVID-19, are the keys to deciding whether they need IMV. OBJECTIVE We aimed to evaluate the use of a machine learning model to predict the need for intubation within 24 hours by using a combination of CXR and EMR data in an end-to-end automated pipeline. We included historical data from 2481 hospitalizations at The Mount Sinai Hospital in New York City. METHODS CXRs were first resized, rescaled, and normalized. Then lungs were segmented from the CXRs by using a U-Net algorithm. After splitting them into a training and a test set, the training set images were augmented. The augmented images were used to train an image classifier to predict the probability of intubation with a prediction window of 24 hours by retraining a pretrained DenseNet model by using transfer learning, 10-fold cross-validation, and grid search. Then, in the final fusion model, we trained a random forest algorithm via 10-fold cross-validation by combining the probability score from the image classifier with 41 longitudinal variables in the EMR. Variables in the EMR included clinical and laboratory data routinely collected in the inpatient setting. The final fusion model gave a prediction likelihood for the need of intubation within 24 hours as well. RESULTS At a prediction probability threshold of 0.5, the fusion model provided 78.9% (95% CI 59%-96%) sensitivity, 83% (95% CI 76%-89%) specificity, 0.509 (95% CI 0.34-0.67) F1-score, 0.874 (95% CI 0.80-0.94) area under the receiver operating characteristic curve (AUROC), and 0.497 (95% CI 0.32-0.65) area under the precision recall curve (AUPRC) on the holdout set. Compared to the image classifier alone, which had an AUROC of 0.577 (95% CI 0.44-0.73) and an AUPRC of 0.206 (95% CI 0.08-0.38), the fusion model showed significant improvement (P<.001). The most important predictor variables were respiratory rate, C-reactive protein, oxygen saturation, and lactate dehydrogenase. The imaging probability score ranked 15th in overall feature importance. CONCLUSIONS We show that, when linked with EMR data, an automated deep learning image classifier improved performance in identifying hospitalized patients with severe COVID-19 at risk for intubation. With additional prospective and external validation, such a model may assist risk assessment and optimize clinical decision-making in choosing the best care plan during the critical stages of COVID-19.
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Affiliation(s)
- Kim-Anh-Nhi Nguyen
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Pranai Tandon
- Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sahar Ghanavati
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Satya Narayana Cheetirala
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Prem Timsina
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Robert Freeman
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - David Reich
- Hospital Administration, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Arash Kia
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Zaccardelli A, Wallace ZS, Sparks JA. Acute and postacute COVID-19 outcomes for patients with rheumatoid arthritis: lessons learned and emerging directions 3 years into the pandemic. Curr Opin Rheumatol 2023; 35:175-184. [PMID: 36752280 PMCID: PMC10065912 DOI: 10.1097/bor.0000000000000930] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
PURPOSE OF REVIEW To summarize the findings of studies investigating patients with rheumatoid arthritis (RA) and risk of acute and postacute COVID-19 outcomes 3 years into the pandemic. RECENT FINDINGS Most studies early in the pandemic included all patients with systemic autoimmune rheumatic diseases (SARDs), not only those with RA, due to limited sample size. Many of these studies found that patients with SARDs were at higher risk of COVID-19 infection and severe outcomes, including hospitalization, hyperinflammation, mechanical ventilation, and death. Studies performed later were able to focus on RA and found similar associations, while also identifying RA-specific factors such as immunosuppressive medications, disease activity/severity, and interstitial lung disease as risk factors for severe COVID-19. After COVID-19 vaccination, the risks for COVID-19 infection and severity were reduced for patients with RA, but a gap between the general population persisted, and some patients with RA are susceptible to breakthrough infection after vaccination. Preexposure prophylaxis, effective treatments, and changes in viral variants have also contributed to improved COVID-19 outcomes throughout the pandemic. Emerging data suggest that patients with RA may be at risk for postacute sequelae of COVID-19 (PASC). SUMMARY Although COVID-19 outcomes have improved over the pandemic for patients with RA, some experience poor acute and postacute outcomes after COVID-19. Clinicians and patients should remain vigilant about risk mitigation for infection and consider early treatment for RA patients with COVID-19. Future studies are needed to investigate clinical outcomes and mechanisms of PASC among patients with RA.
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Affiliation(s)
| | - Zachary S. Wallace
- Division of Rheumatology, Allergy, and Immunology
- Clinical Epidemiology Program, Mongan Institute, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Jeffrey A. Sparks
- Harvard Medical School
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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