Comparison of the characteristics, morbidity and mortality of COVID-19 between first and second/third wave in a hospital setting in Lombardy: a retrospective cohort study

Evolution of in-hospital patient characteristics and predictors of death in the COVID-19 pandemic across four waves: are they moving targets with implications for patient care?

Objectives

The aim of this work was to study characteristics, outcomes and predictors of all-cause death in inpatients with SARS-CoV-2 infection across the pandemic waves in one large teaching hospital in Italy to optimize disease management.

Methods

All patients with SARS-CoV-2 infection admitted to our center from March 2020 to June 2022 were included in this retrospective observational cohort study. Both descriptive and regression tree analyses were applied to identify factors influencing all-cause mortality.

Results

527 patients were included in the study (65.3% with moderate and 34.7% with severe COVID-19). Significant evolutions of patient characteristics were found, and mortality increased in the last wave with respect to the third wave notwithstanding vaccination. Regression tree analysis showed that in-patients with severe COVID-19 had the greatest mortality across all waves, especially the older adults, while prognosis depended on the pandemic waves in patients with moderate COVID-19: during the first wave, dyspnea was the main predictor, while chronic kidney disease emerged as determinant factor afterwards.

Conclusion

Patients with severe COVID-19, especially the older adults during all waves, as well as those with moderate COVID-19 and concomitant chronic kidney disease during the most recent waves require more attention for monitoring and care. Therefore, our study drives attention towards the importance of co-morbidities and their clinical impact in patients with COVID-19 admitted to hospital, indicating that the healthcare system should adapt to the evolving features of the epidemic.

A global analysis of implants and replacements of pacemakers and cardioverter-defibrillators before, during, and after the COVID-19 pandemic in Italy

At the beginning of the COVID-19 emergency, non-urgent surgical procedures had to be deferred, but also emergencies were reduced. To assess the global trend of pacemaker (PM) and implantable cardiac-defibrillator (ICD) procedures performed in Italy before, during, and after the first COVID-19 emergency, all the Italian hospital discharge records related to PM/ICD procedures performed between 2012 and 2021, sent to the National Institute of Health, were reviewed. Compared to 2019, in 2020, there was a reduction of first PM implants (52,216 to 43,962, -16%; p < 0.01), but not replacements (16,591 to 17,331, + 4%; p = 0.16). In particular, in April 2020, there was a drop of first implants (- 53,4% vs the average value of April 2018 and April 2019; p < 0.01), while the reduction of replacements was less evident (-32.6%; p = NS). In 2021, PM procedures increased to values similar to the pre-pandemic period. A reduction of ICD procedures was observed in 2020 (22,355, -7% toward 2019), mainly in April 2020 (- 46% vs April 2018/April 2019; p = 0.03). In 2021, the rate of ICD procedures increased (+ 14% toward 2020). A non-significant reduction of "urgent" procedures (complete atrioventricular block for PM and ventricular fibrillation for ICD), even in April 2020, was observed. In 2020, there was a reduction of first PM implants and ICDs, offset by increased activity in 2021. No decrease in PM replacements was observed, and the drop in "urgent" PM and ICD procedures was not statistically significant.

Identifying Predominant Causes of Death Among Hospitalized COVID-19 Patients During Poland's Second and Third Waves

BACKGROUND Number of confirmed COVID-19 deaths per million population in Poland between November 2020 and May 2021 was one of the largest in Europe. This retrospective study was conducted at a single center in Poland between November 2020 and May 2021to evaluate the morbidity and mortality rates in 581 patients hospitalized with COVID-19. MATERIAL AND METHODS A retrospective single-center study was conducted in a dedicated COVID-19 hospital from November, 2020 to May, 2021. The data of 581 hospitalized patients were analyzed. Multimorbidity was assessed using the Charlson Comorbidity Index, including chronic kidney, respiratory, cardiovascular diseases, diabetes mellitus, cancer, and dementia. The observation period covered admission to the hospital for severe COVID-19 until discharge or death. Diagnosis of COVID-19 was confirmed by quantitative reverse transcription polymerase chain reaction test. Statistical analysis was carried out in the IBM SPSS Statistics program. RESULTS The mortality rate was 35% of all admitted patients. Lung damage was the cause of death in 60%, bacterial superinfection in 26%, arterial thrombosis or thromboembolism in 9%, and heart failure in 5% of patients. The chi-square test showed a significant relationship between sex and the cause of death related to COVID-19 pneumonia and bacterial ventilator-associated pneumonia (VAP). CONCLUSIONS The findings from this study supports findings from other countries that between November 2020 and May 2021, before SARS-CoV-2 vaccination programs were fully implemented and before effective medications and antiviral agents were developed, patients with severe COVID-19 had high rates of morbidity and mortality.

Differences in the severity and mortality risk factors for patients hospitalized for COVID-19 pneumonia between the early wave and the very late stage of the pandemic

Background

Since China's dynamic zero-COVID policy is cancelled on December 7, 2022, the rapidly growing number of patients has brought a major public health challenge. This study aimed to assess whether there were differences in the severity and mortality risk factors for patients hospitalized for COVID-19 pneumonia between the early wave and the very late stage of the pandemic.

Methods

A retrospective cross-sectional study was carried out using data from 223 hospitalized patients diagnosed with COVID-19 pneumonia during the Omicron surge in Xi'an People's Hospital (Xi'an Fourth Hospital) from December 8, 2022, to January 31, 2023. Univariable and multivariable logistic regression analyses were used to identify potential risk factors associated with the severity and mortality of COVID-19 pneumonia during the first wave of the pandemic after the dynamic zero-COVID policy was retracted. Differences in the severity and mortality risk factors were assessed at different stages of the pandemic, mainly from demographic, clinical manifestation, laboratory tests and radiological findings of patients on admission.

Results

The mean age of the 223 participants was 71.2 ± 17.4. Compared with the patients in the initial stage of the pandemic, the most common manifestation among patients in this study was cough (90.6%), rather than fever (79.4%). Different from the initial stage of the pandemic, older age, chest tightness, elevated neutrophil-to-lymphocyte ratio (NLR), decreased albumin (ALB) level and ground glass opacification (GGO) in radiological finding were identified as severity risk factors, instead of mortality risk factors for COVID-19 patients in the very late stage of the pandemic. Arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ≤300 mmHg, cardiovascular disease and laboratory findings including elevated levels of D-dimer, α-hydroxybutyrate dehydrogenase (α-HBDH), total bilirubin (TBIL), alanine aminotransferase (ALT), urea nitrogen (BUN), creatinine (CR), fasting blood glucose (FBG) and decreased platelet count (PLT) were still associated with mortality in the very late stage of the pandemic.

Conclusion

Monitoring continuously differences in the severity and mortality risk factors for COVID-19 patients between different stages of the pandemic could provide evidence for exploring uncharted territory in the coming post-pandemic era.

Two years of SARS-CoV-2 pandemic and COVID-19 in Lombardy, Italy

Lombardy, the largest and most densely populated Italian region, was severely hit in February 2020 by the first pandemic wave of SARS-CoV-2 and associated COVID-19. Since then, additional infection waves spread in the region. The aim of this study was to compare the first with the subsequent waves using the administrative database of the Lombardy Welfare directorate. In the time frames of the four 2020-2022 waves, the absolute number of infected cases, sites of management and crude mortality rate associated with SARS-CoV-2 positivity were extracted from the database. Infected cases progressively increased in the region by approximately 5-fold in the second versus the first wave, 4-fold in the third and 20-fold during the most recent wave mainly associated with the omicron variant. The crude death decreased from 18.7% in the first to 2% in the second and third wave to reach a 0.3% nadir at the time of the fourth wave. This study confirms that in Lombardy outcomes of public health and health-care relevance such as deaths and number of hospitalizations declined dramatically across the four virus waves and reached very low values in 2022 when, at variance with the first three SARS-CoV-2 waves, the majority of infected cases had been previously vaccinated.

Initial functional disability as a 1-year prognostic factor in geriatric patients hospitalized with SARS-CoV-2 infection

BACKGROUND

SARS-CoV2 infection has affected many older people and has required us to adapt our practices to this new pathology. Initial functional capacity is already considered an important prognostic marker in older patients particularly during infections.

AIM

The objective of this longitudinal study was to determine whether baseline functional disability was associated with mortality risk after 1 year in older patients hospitalized for COVID-19.

METHODS

All COVID-19 patients admitted to the geriatric acute care unit of Angers University Hospital, France, between March-June 2020 received a group iso-ressource (GIR) assessment upon admission. Disability was defined as a GIR score≤3. All-cause mortality was collected after 1 year of follow-up. Covariables were age, sex, history of malignancies, hypertension, cardiomyopathy, number of acute diseases at baseline, and use of antibiotics or respiratory treatments during COVID-19 acute phase.

RESULTS

In total, 97 participants (mean±SD 88.0+5.4 years; 49.5% women; 46.4% GIR score≤3) were included. 24 of the 36 patients who did not survive 1 year had a GIR score ≤ 3 (66.7%; P = 0.003). GIR score≤3 was directly associated with 1-year mortality (fully adjusted HR = 2.27 95% CI: 1.07-4.89). Those with GIR≤3 at baseline had shorter survival time than the others (log-rank P = 0.0029).

CONCLUSIONS

Initial functional disability was associated with poorer survival in hospitalized frail elderly COVID-19 patients.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT04560608 registered on September 23, 2022.

Comparative assessment of SARS CoV2-associated mortalities in 3 COVID waves and related risk factors: The South Kashmir's experience

Introduction

Severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) pandemic have spurted in three major waves in India at different times and had different levels of severity in different waves. The objective of our study was to determine the comparative mortality rate in three COVID-19 waves and determine the factors associated with mortality.

Methods

We identified a cohort of 1,132 COVID-19 patients who were admitted between April 14, 2020 and February 08, 2022 at our center. All the admitted patients with positive COVID-polymerase chain reaction were included in the study. Sample characteristics were determined by screening age, sex, socio-economic status, occupation, symptomatology of COVID, patient status on admission, baseline investigations, comorbidities, medical history, oxygen dosage needed during admission, the span of hospital stay, diagnosis, and vitals such as blood pressure, pulse, and oxygen saturation. All the data were procured from an institutional database.

Results

In total, 1,132 patients included in the study, the mean age was 65.08 ± 12.29 and 56% were males. The affliction rate was 42.13% in >60 years, 29.5% in 46-60 years, 20.8% in 31-45 years, and 7.4% in 30 years' group. In the first, second, and third waves of COVID-19, the mortality rates were 13.21%, 23.53%, and 11.39%, respectively. Among the comorbidities, mortality rates were proportionately higher in those with hypertension (6.7%), and diabetes (5.5%), than those with chronic obstructive pulmonary disease (3.3%), chronic kidney disease (CKD) (1.5%), heart disease (1.6%), and malignancy (0.2%).

Conclusion

We identify the peaked mortalities in the second encounter which was predicted by age, comorbidities such as hypertension, and diabetes.

Time From First Contact With Heart Team to Transcatheter Aortic Valve Replacement in the COVID-19 Era

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) has become the dominant form of aortic valve replacement in the United States. During the Coronavirus disease 2019 (COVID-19) pandemic, access to elective surgical care was decreased, particularly for TAVR patients. In this study, we examine the impact of each COVID-19 "wave," on our patient's access to TAVR procedures and their associated outcomes.  Methods: After institutional review board approval, we conducted a retrospective review of a prospectively maintained database and a review of our own center's database to assess time to TAVR pre-COVID-19 and during internally defined COVID-19 "waves." Statistical analysis was conducted via a t-test.

RESULTS

We measured the time from first contact to TAVR and compared each COVID-19 wave to our institution's pre-COVID-19 data. During Wave 1 and 2 of COVID-19, our mean time to TAVR increased significantly to 68.44 ± 48.66 days (p = 0.05) and 68.94 ± 53.16 days (p = 0.02), respectively. All three COVID-19 waves demonstrated a statistically significant increase in all-cause mortality post-operatively (PO) with mean PO mortality of 2.5 (p = 0.0035), 1.33 (p = 0.0009), and 0.67 (p = 0.006), respectively, compared to pre-COVID-19 data.  Conclusions: Multiple studies have shown that increased time from first contact to TAVR results in increased morbidity and mortality. COVID-19 increased our institution's time to TAVR significantly across two waves with an increase in all-cause mortality in each wave. This study highlights the importance that institutions should develop mechanisms to ensure access to care during crises so that patients do not face potentially avoidable harm.

Insights from comparison of the clinical presentation and outcomes of patients hospitalized with COVID-19 in an Italian internal medicine ward during first and third wave

Background

The reasons of variability of clinical presentation of coronavirus disease-19 (COVID-19) across different pandemic waves are not fully understood, and may include individual risk profile, SARS-CoV-2 lineage and seasonal variations of viral spread. The objective of this retrospective study was to compare the characteristics and outcomes of patients admitted with confirmed coronavirus disease-19 (COVID-19) in the same season during the first (March 2020) and the third pandemic wave (March 2021, dominance of SARS-CoV-2 B.1.1.7 lineage) in an internal medicine ward of a large teaching hospital in Italy.

Materials and methods

Data of 769 unvaccinated patients (399 from the first and 370 from the third wave) were collected from clinical records, including symptom type and duration, extension of lung abnormalities on chest computed tomography (CT) and PaO₂/FiO₂ ratio on admission arterial blood gas analysis.

Results

Third wave patients were in average younger (median 65, interquartile range [IQR] 55-75, vs. 72, IQR 61-81 years old, p < 0.001), with less comorbidities and better pulmonary (CT visual score median 25, IQR 15-40, vs. 30, IQR 15-50, age- and sex-adjusted p = 0.017) and respiratory involvement (PaO₂/FiO₂ median 288, IQR 237-338, vs. 233, IQR 121-326 mmHg, age- and sex-adjusted p < 0.001) than first wave patients. Hospital mortality was lower (19% vs. 36%, p < 0.001), but not for subjects over 75 years old (46 vs. 49%). Age, number of chronic illnesses, PCT levels, CT visual score [Odds Ratio (OR) 1.022, 95% confidence interval (CI) 1.009-1.036, p < 0.001] and PaO₂/FiO₂ (OR 0.991, 95% CI 0.988-0.994, p < 0.001), but not the pandemic wave, were associated with mortality on stepwise multivariate logistic regression analysis.

Conclusion

Despite the higher virulence of B.1.1.7 lineage, we detected milder clinical presentation and improved mortality in patients hospitalized during the third COVID-19 wave, with involvement of younger subjects. The reasons of this discrepancy are unclear, but could involve the population effect of vaccination campaigns, that were being conducted primarily in older frail subjects during the third wave.

Describing post-traumatic stress disorder and its associations with depression, anxiety and insomnia: a descriptive study in Italian adults with Marfan syndrome during the COVID-19 third wave

OBJECTIVE

The evaluation of post-traumatic stress disorder (PTSD), depression, anxiety and insomnia in patients with Marfan syndrome (MFS) during the third wave of the COVID-19 pandemic in a region of northern Italy (Lombardy) and the investigation of which mental health, sociodemographic and clinical factors were associated with PTSD.

DESIGN

Descriptive observational design with cross-sectional data collection procedure.

SETTING

A single Italian MFS-specific specialised and reference centre in Lombardy (Italy) between February and April 2021.

PARTICIPANTS

112 adults with MFS. The majority of participants were female (n=64; 57.1%), with a high school diploma (n=52; 46.4%) and active workers (n=66; 58.9%). The mean age was 41.89 years (SD=14.00), and the mean time from diagnosis was 15.18 years (SD=11.91).

PRIMARY AND SECONDARY OUTCOMES

Descriptive statistics described PTSD, which was the primary outcome, as well as depression, anxiety and insomnia, which were the secondary outcomes. Four linear regression models described the predictors of PTSD total score and its three domains: avoidance, intrusion and hyperarousal.

RESULTS

One out of 10 patients with MFS had mild psychological symptoms regarding depression, anxiety and insomnia, and scores of PTSD that indicated clinical worries about the mental health status. The presence of PTSD was mainly predicted by anxiety (β=0.647; p<0.001), being older, taking psychoactive medication and being unemployed.

CONCLUSION

Depression, anxiety and insomnia should be monitored in patients with MFS in order to minimise PTSD insurgence. Specific psychosocial interventions should be developed and tested for this population and adopted in clinical practice, given the relevance of mental health outcomes during the pandemic.

Clinical Characterization of the Three Waves of COVID-19 Occurring in Southern Italy: Results of a Multicenter Cohort Study

AIMS

To characterize patients hospitalized for COVID-19 in the three waves in Southern Italy.

METHODS

We conducted a multicenter observational cohort study involving seventeen COVID-19 Units in Campania, southern Italy: All adult (≥18 years) patients, hospitalized with a diagnosis of SARS-CoV-2 infection from 28 February 2020 to 31 May 2021, were enrolled.

RESULTS

Two thousand and fifteen COVID-19 hospitalized patients were enrolled; 392 (19%) in the first wave, 917 (45%) in the second and 706 (35%) in the third wave. Patients showed a less severe clinical outcome in the first wave than in the second and third waves (73%, 65% and 72%, respectively; p = 0.003), but hospitalization expressed in days was longer in the first wave [Median (Q1-Q3): 17 (13-25) v.s. 14 (9-21) and 14 (9-19), respectively, p = 0.001)] and also mortality during hospitalization was higher in the first wave than in the second and third waves: 16.6% v.s. 11.3% and 6.5%, respectively (p = 0.0001). Multivariate analysis showed that older age [OR: 1.069, CI (1046-1092); p = 0.001], a worse Charlson comorbidity index [OR: 1042, CI (1233-1594; p = 0.0001] and enrolment during the first-wave [OR: 1.917, CI (1.054-3.485; p = 0.033] were predictors of mortality in hospitalized patients.

CONCLUSIONS

Improved organization of the healthcare facilities and the increase in knowledge of clinical and therapeutic management have contributed to a trend in the reduction in mortality during the three waves of COVID-19.

Long-Term Survival among Patients Hospitalized for COVID-19 during the First Three Epidemic Waves: An Observational Study in a Northern Italy Hospital

The mortality rate of hospitalized COVID-19 patients differed strongly between the first three pandemic waves. Nevertheless, their long-term survival has been poorly assessed. The aim of this study was to compare the clinical characteristics and mortality rates of 825 patients with coronavirus disease 2019 (COVID-19) infection who were hospitalized at the Alessandria hub hospital, in Northern Italy, during the first fifty days of the first three pandemic waves. Each subject was followed in terms of vital status for six months from the date of hospital admission or until deceased. Patients admitted during the three waves differed in age (p = 0.03), disease severity (p < 0.0001), Charlson comorbidity index (p = 0.0002), oxygen therapy (p = 0.002), and invasive mechanical ventilation (p < 0.0001). By the end of follow-up, 309 deaths (38.7%) were observed, of which 186 occurred during hub hospitalization (22.5%). Deaths were distributed differently among the waves (p < 0.0001), resulting in being higher amongst those subjects admitted during the first wave. The COVID-19 infection was reported as the main cause of death and patients with a higher mortality risk were those aged ≥65 years [adjusted HR = 3.40 (95% CI 2.20-5.24)], with a higher disease severity [adjusted HR = 1.87 (95%CI 1.43-2.45)], and those requiring oxygen therapy [adjusted HR = 2.30 (95%CI 1.61-3.30)]. In conclusion, COVID-19 patients admitted to our hub hospital during the second and the third waves had a lower risk of long-term mortality than those admitted during the first. Older age, more severe disease, and the need for oxygen therapy were among the strongest risk factors for poor prognosis.