qSOFA score poorly predicts critical progression in COVID-19 patients

The Predictive Performance of Risk Scores for the Outcome of COVID-19 in a 2-Year Swiss Cohort

Various scoring systems are available for COVID-19 risk stratification. This study aimed to validate their performance in predicting severe COVID-19 course in a large, heterogeneous Swiss cohort. Scores like the National Early Warning Score (NEWS), CURB-65, 4C mortality score (4C), Spanish Society of Infectious Diseases and Clinical Microbiology score (COVID-SEIMC), and COVID Intubation Risk Score (COVID-IRS) were assessed in patients hospitalized for COVID-19 in 2020 and 2021. Predictive accuracy for severe course (defined as all-cause in-hospital death or invasive mechanical ventilation (IMV)) was evaluated using receiver operating characteristic curves and the area under the curve (AUC). The new 'COVID-COMBI' score, combining parameters from the top two scores, was also validated. This study included 1,051 patients (mean age 65 years, 60% male), with 162 (15%) experiencing severe course. Among the established scores, 4C had the best accuracy for predicting severe course (AUC 0.76), followed by COVID-IRS (AUC 0.72). COVID-COMBI showed significantly higher accuracy than all established scores (AUC 0.79, p = 0.001). For predicting in-hospital death, 4C performed best (AUC 0.83), and, for IMV, COVID-IRS performed best (AUC 0.78). The 4C and COVID-IRS scores were robust predictors of severe COVID-19 course, while the new COVID-COMBI showed significantly improved accuracy but requires further validation.

Time‑dependent ROC curve analysis to determine the predictive capacity of seven clinical scales for mortality in patients with COVID‑19: Study of a hospital cohort with very high mortality

Clinical data from hospital admissions are typically utilized to determine the prognostic capacity of Coronavirus disease 2019 (COVID-19) indices. However, as disease status and severity markers evolve over time, time-dependent receiver operating characteristic (ROC) curve analysis becomes more appropriate. The present analysis assessed predictive power for death at various time points throughout patient hospitalization. In a cohort study involving 515 hospitalized patients (General Hospital Number 1 of Mexican Social Security Institute, Colima, Mexico from February 2021 to December 2022) with COVID-19, seven severity indices [Pneumonia Severity Index (PSI) PaO2/FiO2 arterial oxygen pressure/fraction of inspired oxygen (Kirby index), the Critical Illness Risk Score (COVID-GRAM), the National Early Warning Score 2 (NEWS-2), the quick Sequential Organ Failure Assessment score (qSOFA), the Fibrosis-4 index (FIB-4) and the Viral Pneumonia Mortality Score (MuLBSTA were evaluated using time-dependent ROC curves. Clinical data were collected at admission and at 2, 4, 6 and 8 days into hospitalization. The study calculated the area under the curve (AUC), sensitivity, specificity, and predictive values for each index at these time points. Mortality was 43.9%. Throughout all time points, NEWS-2 demonstrated the highest predictive power for mortality, as indicated by its AUC values. PSI and COVID-GRAM followed, with predictive power increasing as hospitalization duration progressed. Additionally, NEWS-2 exhibited the highest sensitivity (>96% in all periods) but showed low specificity, which increased from 22.9% at admission to 58.1% by day 8. PSI displayed good predictive capacity from admission to day 6 and excellent predictive power at day 8 and its sensitivity remained >80% throughout all periods, with moderate specificity (70.6-77.3%). COVID-GRAM demonstrated good predictive capacity across all periods, with high sensitivity (84.2-87.3%) but low-to-moderate specificity (61.5-67.6%). The qSOFA index initially had poor predictive power upon admission but improved after 4 days. FIB-4 had a statistically significant predictive capacity in all periods (P=0.001), but with limited clinical value (AUC, 0.639-0.698), and with low sensitivity and specificity. MuLBSTA and IKIRBY exhibited low predictive power at admission and no power after 6 days. In conclusion, in COVID-19 patients with high mortality rates, NEWS-2 and PSI consistently exhibited predictive power for death during hospital stay, with PSI demonstrating the best balance between sensitivity and specificity.

Minimally invasive autopsies for the investigation of pulmonary pathology of COVID-19-experiences of a longitudinal series of 92 patients

Minimally invasive autopsies (MIAs) allow the collection of tissue samples for diagnostic and research purposes in special situations, e.g., when there is a high risk of infection which is the case in the context of COVID-19 or restrictions due to legal or personal reasons. We performed MIA to analyze lung tissue from 92 COVID-19 patients (mean age 78 years; range 48-98; 35 women, 57 men), representing 44% of all patients who died from the disease between October 2020 and April 2021. An intercostal approach was used with removal of a 5-cm rib section followed by manual collection of four lung tissue samples (5-8 cm in size). Diffuse alveolar damage (DAD) was found in 89 (97%) patients at various stages. Exudative DAD (eDAD) predominated in 18 (20%) patients, proliferative DAD (pDAD) in 43 (47%) patients, and mixed DAD (mDAD) in 31 (34%) patients. There were no significant differences in the predominant DAD pattern between tissue samples from the same patient. Additional purulent components were present in 46 (50%) cases. Fungi were detected in 11 (12%) patients. The pDAD pattern was associated with longer hospital stay including intensive care unit (p=0.026 and p<0.001) and younger age (p=0.019). Positive bronchoalveolar lavage and blood cultures were observed more frequently in pDAD patterns (p<0.001; p=0.018). In contrast, there was no significant association between intravital positive microbiological results and superimposed bronchopneumonia or fungal infection at autopsy. Having demonstrated the characteristic lung changes in a large longitudinal autopsy series, we conclude that the presented MIA approach can be considered a reliable and safe method for performing post mortem lung diagnostics in COVID-19 and other high-risk situations. The lack of correlation between histological changes indicative of bacterial or fungal superinfection and microbiology could have clinical implications for disease and treatment surveillance.

Comparison of different prognostic scores in estimating short- and long-term mortality in COVID-19 patients above 60 years old in a university hospital in Belgium

BACKGROUND AND OBJECTIVES

Multiple scoring systems were used for risk stratification in COVID-19 patients. The objective was to determine among 6 scores which performed the best in predicting short-and long-term mortality in hospitalized COVID-19 patients ≥ 60 years.

METHODS

An observational, retrospective cohort study conducted between 21/10/2020 and 20/01/2021. 6 scores were calculated (Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI), 4C Mortality Score (4CMS), NEWS score (NEWS), quick-SOFA score (qSOFA), and Quick COVID-19 Severity Index (qCSI)). We included unvaccinated hospitalized patients with COVID-19 ≥ 60 years old in Brugmann hospital, detected by PCR and/or suggestive CT thorax images. Old and nosocomial infections, and patients admitted immediately at the intensive care unit were excluded.

RESULTS

199 patients were included, mean age was 76.2 years (60-99). 47.2% were female. 56 patients (28%) died within 1 year after the first day of hospitalization. The 4CMS predicted the best intrahospital, 30 days and 6 months mortality, with area under the ROC curve (AUROC) 0.695 (0.58-0.81), 0.76 (0.65-0.86) and 0.72 (0.63-0.82) respectively. The CCI came right after with respectively AUROC of 0.69 (0.59-0.79), 0.74 (0.65-0.83) and 0.71 (0.64-0.8). To predict mortality at 12 months after hospitalization, the CCI had the highest AUROC with 0.77 (0.69-0.85), before the 4CMS with 0.69 (0.60-0.79).

DISCUSSION

Among 6 scores, the 4CMS was the best to predict intrahospital, 30-day and 6-month mortality. To predict mortality at 12 months, CCI had the best performance before 4CMS. This reflects the importance of considering comorbidities for short- and long-term mortality after COVID 19.

REGISTRATION

This study was approved by the ethical committee of Brugmann University Hospital (reference CE 2020/228).

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19

BACKGROUND

Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort.

OBJECTIVE

To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients.

DESIGNS, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021.

INTERVENTION

Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation.

MAIN OUTCOME AND MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated.

RESULTS

We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604).

CONCLUSIONS

Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage.

Comparison of prognostic scores for inpatients with COVID-19: a retrospective monocentric cohort study

Background

The SARS-CoV-2 pandemic led to a steep increase in hospital and intensive care unit (ICU) admissions for acute respiratory failure worldwide. Early identification of patients at risk of clinical deterioration is crucial in terms of appropriate care delivery and resource allocation. We aimed to evaluate and compare the prognostic performance of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Confusion, Uraemia, Respiratory Rate, Blood Pressure and Age ≥65 (CURB-65), Respiratory Rate and Oxygenation (ROX) index and Coronavirus Clinical Characterisation Consortium (4C) score to predict death and ICU admission among patients admitted to the hospital for acute COVID-19 infection.

Methods and analysis

Consecutive adult patients admitted to the Geneva University Hospitals during two successive COVID-19 flares in spring and autumn 2020 were included. Discriminative performance of these prediction rules, obtained during the first 24 hours of hospital admission, were computed to predict death or ICU admission. We further exluded patients with therapeutic limitations and reported areas under the curve (AUCs) for 30-day mortality and ICU admission in sensitivity analyses.

Results

A total of 2122 patients were included. 216 patients (10.2%) required ICU admission and 303 (14.3%) died within 30 days post admission. 4C score had the best discriminatory performance to predict 30-day mortality (AUC 0.82, 95% CI 0.80 to 0.85), compared with SOFA (AUC 0.75, 95% CI 0.72 to 0.78), qSOFA (AUC 0.59, 95% CI 0.56 to 0.62), CURB-65 (AUC 0.75, 95% CI 0.72 to 0.78) and ROX index (AUC 0.68, 95% CI 0.65 to 0.72). ROX index had the greatest discriminatory performance (AUC 0.79, 95% CI 0.76 to 0.83) to predict ICU admission compared with 4C score (AUC 0.62, 95% CI 0.59 to 0.66), CURB-65 (AUC 0.60, 95% CI 0.56 to 0.64), SOFA (AUC 0.74, 95% CI 0.71 to 0.77) and qSOFA (AUC 0.59, 95% CI 0.55 to 0.62).

Conclusion

Scores including age and/or comorbidities (4C and CURB-65) have the best discriminatory performance to predict mortality among inpatients with COVID-19, while scores including quantitative assessment of hypoxaemia (SOFA and ROX index) perform best to predict ICU admission. Exclusion of patients with therapeutic limitations improved the discriminatory performance of prognostic scores relying on age and/or comorbidities to predict ICU admission.

Brixia and qSOFA Scores, Coagulation Factors and Blood Values in Spring versus Autumn 2021 Infection in Pregnant Critical COVID-19 Patients: A Preliminary Study

(1) Background: From the recent variants of concern of the SARS-CoV-2 virus, in which the delta variant generated more negative outcomes than the alpha, we hypothesized that lung involvement, clinical condition deterioration and blood alterations were also more severe in autumn infection, when the delta variant dominated (compared with spring infections, when the alpha variant dominated), in severely infected pregnant patients. (2) Methods: In a prospective study, all pregnant patients admitted to the ICU of the Elena Doamna Obstetrics and Gynecology Hospital with a critical form of COVID-19 infection-spring group (n = 11) and autumn group (n = 7)-between 1 January 2021 and 1 December 2021 were included. Brixia scores were calculated for every patient: A score, upon admittance; H score, the highest score throughout hospitalization; and E score, at the end of hospitalization. For each day of Brixia A, H or E score, the qSOFA (quick sepsis-related organ failure assessment) score was calculated, and the blood values were also considered. (3) Results: Brixia E score, C-reactive protein, GGT and LDH were much higher, while neutrophil count was much lower in autumn compared with spring critical-form pregnant patients. (4) Conclusions: the autumn infection generated more dramatic alterations than the spring infection in pregnant patients with critical forms of COVID-19. Larger studies with more numerous participants are required to confirm these results.

CURB-65, qSOFA, and SIRS Criteria in Predicting In-Hospital Mortality of Critically Ill COVID-19 Patients; a Prognostic Accuracy Study

INTRODUCTION

Outcome prediction of intensive care unit (ICU)-admitted patients is one of the important issues for physicians. This study aimed to compare the accuracy of Quick Sequential Organ Failure Assessment (qSOFA), Confusion, Urea, Respiratory Rate, Blood Pressure and Age Above or Below 65 Years (CURB-65), and Systemic Inflammatory Response Syndrome (SIRS) scores in predicting the in-hospital mortality of COVID-19 patients.

METHODS

This prognostic accuracy study was performed on 225 ICU-admitted patients with a definitive diagnosis of COVID-19 from July to December 2021 in Tehran, Iran. The patients' clinical characteristics were evaluated at the time of ICU admission, and they were followed up until discharge from ICU. The screening performance characteristics of CURB-65, qSOFA, and SIRS in predicting their mortality was compared.

RESULTS

225 patients with the mean age of 63.27±14.89 years were studied (56.89% male). The in-hospital mortality rate of this series of patients was 39.10%. The area under the curve (AUC) of SIRS, CURB-65, and qSOFA were 0.62 (95% CI: 0.55 - 0.69), 0.66 (95% CI: 0.59 - 0.73), and 0.61(95% CI: 0.54 - 0.67), respectively (p = 0.508). In cut-off ≥1, the estimated sensitivity values of SIRS, CURB-65, and qSOFA were 85.23%, 96.59%, and 78.41%, respectively. The estimated specificity of scores were 34.31%, 6.57%, and 38.69%, respectively. In cut-off ≥2, the sensitivity values of SIRS, CURB-65, and qSOFA were evaluated as 39.77%, 87.50%, and 15.91%, respectively. Meanwhile, the specificity of scores were 72.99%, 34.31%, and 92.70%.

CONCLUSIONS

It seems that the performance of SIRS, CURB-65, and qSOFA is similar in predicting the ICU mortality of COVID-19 patients. However, the sensitivity of CURB-65 is higher than qSOFA and SIRS.