Epidemiology, outcomes, and utilization of intensive care unit resources for critically ill COVID-19 patients in Libya: A prospective multi-center cohort study

Iron Metabolism in the Recovery Phase of Critical Illness with a Focus on Sepsis

Iron is an essential nutrient for humans and microbes, such as bacteria. Iron deficiency commonly occurs in critically ill patients, but supplementary iron therapy is not considered during the acute phase of critical illness since it increases iron availability for invading microbes and oxidative stress. However, persistent iron deficiency in the recovery phase is harmful and has potential adverse outcomes such as cognitive dysfunction, fatigue, and cardiopulmonary dysfunction. Therefore, it is important to treat iron deficiency quickly and efficiently. This article reviews current knowledge about iron-related biomarkers in critical illness with a focus on patients with sepsis, and provides possible criteria to guide decision-making for iron supplementation in the recovery phase of those patients.

Predictors associated with successful weaning of veno-venous extracorporeal membrane oxygenation and mortality in adult patients with severe acute lung failure: Protocol of a pooled data analysis of cohort studies

BACKGROUND

Severe acute lung failure (ALF) often necessitates veno-venous extracorporeal membrane oxygenation (VV-ECMO), where identifying predictors of weaning success and mortality remains crucial yet challenging. The study aims to identify predictors of weaning success and mortality in adults undergoing VV-ECMO for severe ALF, a gap in current clinical knowledge.

METHODS AND ANALYSIS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials will be searched for cohort studies examining the predictive factors of successful weaning and mortality in adult patients on VV-ECMO due to severe ALF. Risk of bias assessment will be conducted using the Newcastle-Ottawa scale for each included study. The primary outcomes will be successful weaning from VV-ECMO and all-cause mortality. Between-study heterogeneity will be evaluated using the I2 statistic. Sensitivity, subgroup, and meta-regression analyses will be performed to ascertain potential sources of heterogeneity and assess the robustness of our results. We will use the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool to recommend the level of evidence.

DISCUSSION

This study seeks to provide clinically significant insights into predictors for weaning and mortality during VV-ECMO treatment for ALF, aiming to support clinical decisions and potentially influence health policy, thereby improving patient outcomes.

ETHICS AND DISSEMINATION

Given the absence of direct engagement with human subjects or access to personal medical records, ethical approval for this study is deemed unnecessary. The study findings will be shared at a scientific conference either at the global or national level. Alternatively, the results will be presented for publication in a rigorously peer-reviewed journal regarding critical care medicine.

Obesity and mortality in patients with COVID-19: A meta-analysis of prospective studies

BACKGROUND AND OBJECTIVES

Previous prospective studies have reported inconsistent findings on the associ-ation between obesity and mortality in patients with COVID-19. This study aimed to investigate the associa-tion between them by using a meta-analysis of prospective studies.

METHODS AND STUDY DESIGN

We searched PubMed and EMBASE to retrieve studies using keywords related to this topic on January 3, 2022. Data were extracted for a random-effects meta-analysis to calculate a pooled odds ratio (OR), relative risk (RR), or hazard ratio (HR) with a 95% confidence interval (CI).

RESULTS

In the meta-analysis of 15 prospective cohort studies, obesity significantly increased the risk of mortality in patients with COVID-19 (OR/RR/HR, 1.52; 95% CI, 1.26 to 1.84; I2 = 90.4%). Most of the included studies were conducted in European (n = 10) and North American (n = 4) countries. In the subgroup meta-analysis by continent, there was a significant association between them in European countries (OR/RR/HR, 1.78; 95% CI, 1.30 to 2.43; I2 = 81.4%). Also, in the subgroup meta-analysis by data source, obesity was significantly associated with the increased mortality in patients with COVID-19 in both population- and hospital-based data.

CONCLUSIONS

We found that obesity is associated with the increased risk of mortality in patients of COVID-19.

Seizures in COVID-19: the relationship between biomarkers and prognosis

OBJECTIVE

To assess the prevalence of seizure, associated risk factors, and prognosis in patients with SARS-CoV-2 infection and identify predictive biomarkers in SARS-CoV-2 patients with seizure.

METHODS

A cohort of 17,806 patients with SARS-CoV-2 infection admitted to two university hospitals in Adana between March 11, 2020 and January 1, 2021 was analyzed retrospectively. The patients' demographic characteristics, laboratory findings, and systemic and neurological symptoms at admission and on the day of seizure onset were evaluated.

RESULTS

Neurological findings were detected in 877 of the 17,806 patients. Of these, 45 patients (0.25%) had seizure (status epilepticus in 4/45 patients, 8.9%). Patients with seizure had a mean age of 55.3 years (range 17-88) and 57.8% were male. Seizure was more common in the 18-44 (24.4%) and ≥ 65 age groups (44.4%) and in those with multiple comorbidity. The case fatality rate for patients with seizure among all SARS-CoV-2 patients was 0.135% (95% CI 80.86-188.71). However, no patient with a previous diagnosis of epilepsy died during SARS-CoV-2 infection. High neutrophil, platelet, and ferritin levels and low lymphocyte and calcium levels on the day of seizure development compared to admission were associated with higher mortality (p = 0.004, 0.008, 0.028, 0003, and 0.002, respectively).

CONCLUSIONS

Seizures are not uncommon during SARS-CoV-2 infection, with a higher risk of mortality in older patients and those with higher inflammatory markers.

High mortality rates among COVID-19 intensive care patients in Iraq: insights from a retrospective cohort study at Médecins Sans Frontières supported hospital in Baghdad

Background

The Coronavirus Disease 2019 (COVID-19) pandemic has highlighted the challenges of the healthcare system in Iraq, which has limited intensive care unit beds, medical personnel, and equipment, contributing to high infection rates and mortality. The main purpose of the study was to describe the clinical characteristics, the length of Intensive Care Unit (ICU) stay, and the mortality outcomes of COVID-19 patients admitted to the ICU during the first wave and two subsequent surges, spanning from September 2020 to October 2021, in addition to identify potential risk factors for ICU mortality.

Methods

This retrospective cohort study analyzed data from COVID-19 patients admitted to the COVID-19 ICU at Al-Kindi Ministry of Health hospital in Baghdad, Iraq, between September 2020 and October 2021.

Results

The study included 936 COVID-19 patients admitted to the ICU at Al-Kindi Hospital. Results showed a high mortality rate throughout all waves, with 60% of deaths due to respiratory failure. Older age, male gender, pre-existing medical conditions, ICU procedures, and complications were associated with increased odds of ICU mortality. The study also found a decrease in the number of complications and ICU procedures between the first and subsequent waves. There was no significant difference in the length of hospital stay between patients admitted during different waves.

Conclusion

Despite improvements in critical care practices, the mortality rate did not significantly decrease during the second and third waves of the pandemic. The study highlights the challenges of high mortality rates among critical COVID-19 patients in low-resource settings and the importance of effective data collection to monitor clinical presentations and identify opportunities for improvement in ICU care.

Prospective cohort of COVID-19 patients requiring hospital admission in Douala, Cameroon

OBJECTIVES

To report characteristics and outcome of COVID-19 patients who required hospital admission in sub-Saharan Africa clinics with no access to invasive mechanical ventilation.

METHODS

Between April and June 2021, documented COVID-19 patients with SaO₂ <95% who were admitted in two clinics in Douala (Cameroon) were invited to participate. Data were prospectively collected using a standardized questionnaire.

RESULTS

We included 67 patients: 39 males (58%), median age 62 years [50-70]. Comorbidities included hypertension (n=38, 57%), obesity (n=26, 38%), and diabetes (n=16, 24%). No patient reported COVID-19 vaccination. On admission, 35 patients (52%) required O₂ >6L/min. CT scan demonstrated extended lesions (>50%) in 50/61 cases (82%). Most patients received dexamethasone (n=64, 96%), heparin (n=64, 96%), chloroquine/azithromycin (n=59, 88%), and broad-spectrum antibiotics (n=59, 88%). Sixteen patients died (24%), after a median of 11.5 days [7.5-15.5] post-admission.

CONCLUSIONS

Despite the lack of invasive mechanical ventilation, 76% of COVID-19 patients survived.

Super-infection by multiple microorganisms in COVID-19 patients

Introduction: This study aimed to describe the clinical characteristics of patients with COVID-19 co-infected with multiple multidrug-resistant bacteria.

Methods: Patients hospitalized in the AUNA network between January and May 2021, diagnosed with COVID-19 and at least two other infecting microorganisms, were retrospectively included in the analysis. Clinical and epidemiological data were extracted from clinical records. The susceptibility levels of the microorganisms were determined using automated methods. Antibiotic resistance was established among infecting bacteria accounting for ≥5 isolates.

Results: A total of 27 patients (21 male and 6 female patients) met the inclusion criteria, with a maximum of eight co-infecting bacteria or fungi during admission time. Seven patients (25.9%) died, with a higher but not significant lethality among women (50% vs. 19.0%). A total of 15 patients presented at least one established comorbidity, with hypertension being the most frequent. The time elapsed between COVID-19 diagnosis and hospital attendance was 7.0 days, with that of patients with a fatal outcome being longer than that of living patients (10.6 vs. 5.4). Up to 20 different microorganisms were isolated, with Pseudomonas aeruginosa being the most common (34 isolates). In general, antibiotic resistance levels were high, especially in Acinetobacter baumannii isolates, with resistance levels of 88.9% to all antimicrobial agents tested, except colistin (0%).

Conclusion: In conclusion, the present results show the presence of multiple microorganisms that co-infect COVID-19 patients. When fatal outcome rates are in the range of other reports, the presence of a series of multidrug-resistant microorganisms is of concern, showing the need to reinforce control measures to limit the expansion of almost untreatable microorganisms.

Intensive Care and Organ Support Related Mortality in Patients With COVID-19: A Systematic Review and Meta-Analysis

To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support.

DATA SOURCES

A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021.

STUDY SELECTION

Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients.

DATA EXTRACTION

Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included.

DATA SYNTHESIS

One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021.

CONCLUSIONS

We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.

Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania

OBJECTIVE

The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings.

METHODS

This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated.

RESULTS

Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively.

CONCLUSIONS

Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.

Incidence and Predictors of Inpatient Mortality Rate After Cases Started Care in the Intensive Care Unit in Debre Markos Referral Hospital

Background

The intensive care unit (ICU) is a separate area in which potential health care services for patients who are in critical condition with detailed observation, monitoring, and advanced treatment than other units. This study aimed to assess the incidence and predictors of inpatient mortality after inpatient treatment was started in Debre Markos Comprehensive Specialized Hospital.

Methods

A facility-based retrospective cohort study was employed among 384 ICU-admitted patients from December 30, 2020 to January 1, 2022. The collected data were entered into Epi Data version 4.2 and exported to STATA 14.0 for further analysis. The Cox proportional hazard regression model was fitted after checking using the Schoenfeld residual and log-log plot test. A categorical variable with an adjusted hazard ratio of 95% CI was claimed for predictors.

Result

Overall, 384 admitted adult patients were included in the final analysis with a mean (±SD) age of 42.1 (±17.1) years. At the end of the follow-up period, 150 (39.06%) cases died in the ICU. The overall incidence of the mortality rate was 16.9 (95% CI: 13.7-19.55) per 100 person per day. Epidemiologically, 347 (90.36%) cases were medical illness, 25 (6.51%) surgical, and 12 (3.13%) were obstetric cases, respectively. The median length of inpatient stay was found to be 4.9 (IQR  ±  2.8) days. In multivariable analysis; being (+) for human immunodeficiency virus (AHR  =  0.59, 95% CI: 0.39-0.91), age ≥65yearas (AHR  =  1.61, 95% CI: 1.11-2.32), and admission on weekend-time (AHR  =  1.48, 95% CI: 1.06-2.06) were predictors of inpatient death.

Conclusion

The overall in-hospital mortality rate was significantly higher than in the previous study in this hospital with a short median survival time. The inpatient mortality rate was significantly associated with age ≥65 years, being HIV positive, and admission during weekend time. Therefore, effective intervention strategies should be highly needed for ICU team members for early risk factors prevention.

Identification of Parameters Representative of Immune Dysfunction in Patients with Severe and Fatal COVID-19 Infection: a Systematic Review and Meta-analysis

Abnormal immunological indicators associated with disease severity and mortality in patients with COVID-19 have been reported in several observational studies. However, there are marked heterogeneities in patient characteristics and research methodologies in these studies. We aimed to provide an updated synthesis of the association between immune-related indicators and COVID-19 prognosis. We conducted an electronic search of PubMed, Scopus, Ovid, Willey, Web of Science, Cochrane library, and CNKI for studies reporting immunological and/or immune-related parameters, including hematological, inflammatory, coagulation, and biochemical variables, tested on hospital admission of COVID-19 patients with different severities and outcomes. A total of 145 studies were included in the current meta-analysis, with 26 immunological, 11 hematological, 5 inflammatory, 4 coagulation, and 10 biochemical variables reported. Of them, levels of cytokines, including IL-1β, IL-1Ra, IL-2R, IL-4, IL-6, IL-8, IL-10, IL-18, TNF-α, IFN-γ, IgA, IgG, and CD4⁺ T/CD8⁺ T cell ratio, WBC, neutrophil, platelet, ESR, CRP, ferritin, SAA, D-dimer, FIB, and LDH were significantly increased in severely ill patients or non-survivors. Moreover, non-severely ill patients or survivors presented significantly higher counts of lymphocytes, monocytes, lymphocyte/monocyte ratio, eosinophils, CD3⁺ T,CD4⁺T and CD8⁺T cells, B cells, and NK cells. The currently updated meta-analysis primarily identified a hypercytokinemia profile with the severity and mortality of COVID-19 containing IL-1β, IL-1Ra, IL-2R, IL-4, IL-6, IL-8, IL-10, IL-18, TNF-α, and IFN-γ. Impaired innate and adaptive immune responses, reflected by decreased eosinophils, lymphocytes, monocytes, B cells, NK cells, T cells, and their subtype CD4⁺ and CD8⁺ T cells, and augmented inflammation, coagulation dysfunction, and nonpulmonary organ injury, were marked features of patients with poor prognosis. Therefore, parameters of immune response dysfunction combined with inflammatory, coagulated, or nonpulmonary organ injury indicators may be more sensitive to predict severe patients and those non-survivors.

Comparison Between Physiological Scores SIPF, CURB-65, and APACHE II as Predictors of Prognosis and Mortality in Hospitalized Patients with COVID-19 Pneumonia: A Multicenter Study, Saudi Arabia

Background

A coronavirus pandemic (COVID-19) is associated with catastrophic effects on the world with high morbidity and mortality. We aimed to evaluate the accuracy of physiological shock index (SIPF) (shock index and hypoxemia), CURB -65, acute physiology, and chronic health assessment II (APACHE II) as predictors of prognosis and in-hospital mortality in patients with COVID-19 pneumonia.

Methods

In Saudi Arabia, a multicenter retrospective study was conducted on hospitalized adult patients confirmed to have COVID-19 pneumonia. Information needed to calculate SIPF, CURB-65, and APACHE II scores were obtained from medical records within 24 hours of admission.

Results

The study included 1131 COVID-19 patients who met the inclusion criteria. They were divided into two groups: (A) the ICU group (n=340; 30.1%) and (B) the ward group (n=791; 69.9%). The most common concomitant diseases of patients at initial ICU admission were hypertension (71.5%) and diabetes (62.4%), and most of them were men (63.8%). The overall mortality was 18.7%, and the mortality rate was higher in the ICU group than in the ward group (39.4% vs 9.6%; p < 0.001). The SIPF score showed a significantly higher ability to predict both ICU admission and mortality in patients with COVID-19 pneumonia compared with APACHE II and CURB -65; (AUC 0.89 vs 0.87; p < 0.001) and (AUC 0.89 vs 0.84; p < 0.001) for ICU admission and (AUC 0.90 vs 0.65; p < 0.001) and (AUC 0.90 vs 0.80; p < 0.001) for mortality, respectively.

Conclusion

The ability of the SIPF score to predict ICU admission and mortality in COVID-19 pneumonia is higher than that of APACHE II and CURB-65. The overall mortality was 18.7%, and the mortality rate was higher in the ICU group than in the ward group (39.4% vs 9.6%; p < 0.001).

"Day 25": a temporal indicator of stabilization of mortality risk among COVID-19 patients with high viral load

INTRODUCTION

The relationship between SARS-CoV-2 viral load and hospitalization and mortality among COVID-19 patients has been established. However, the estimation of the duration of time after which the risk of mortality of these patients stops escalating was not extensively discussed earlier. Stratifying patients according to their risk of mortality would optimize healthcare services and costs and reduce mortality.

METHODOLOGY

In this retrospective observational study, hospital records were used to collect data of 519 COVID-19 patients from May through November 2020. Data included the clinical condition of patients, their viral loads, their admission chest computed tomography results (CO-RAD scale), and the duration of their hospitalization. A Kaplan-Meier analysis was constructed to estimate mortality risk concerning viral load.

RESULTS

By the end of the study, 20.42% of patients were deceased. The cumulative mortality was: 36.1% (75/208) among patients with high viral load, 12.6% (28/222) in those with moderate viral load, and 3.4% (3/89) among those with low viral load. Predictors of mortality were: older age [adjusted hazard ratio (aHR) = 1.02, 95% CI: [1.00-1.03], (p = 0.05)], "being female" [aHR = 1.53 with 95% CI: [1.03-2.26], (p = 0.031), "high CO-RAD scale" [aHR = 1.32 (1.06-1.64), p = 0.013], "high viral load" [aHR = 4.59 (2.38-20.92), p = 0.017, ICU admission [aHR = 15.95; 95%CI:7.22-35.20, p < 0.001] and lymphocytosis [aHR = 1.89 45;95%CI:1.04-3.45, p = 0.036]. In the ICU-admitted patients, the median survival was 19 days and mortality stabilized at "day 25". For patients with high viral load, mortality rates stabilized at "day 25 post-admission" after which the risks of mortality did not change until day 40, while patients with low and moderate viral loads reached the peak and stabilized at day "20 post-admission".

CONCLUSIONS

Initial high SARS-CoV-2 viral load might be used as an indicator of a delayed stabilization of mortality risk among COVID-19 patients.

Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study

There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.

Acute Kidney Injury in Non-Intensive Care Unit (ICU) Hospitalizations for Coronavirus Disease (COVID-19)

Background: Acute kidney injury (AKI) is a common complication among SARS-CoV-2-positive patients who undergo hospitalization. Abundant evidence exists concerning the epidemiology of AKI in patients hospitalized in the ICU for COVID-19 but limited data are available about the occurrence of AKI in SARS-CoV-2-positive patients being hospitalized in a non-ICU setting. Aim and Methods: We have carried out a retrospective study to evaluate frequency and risk factors for AKI among patients consecutively admitted at a third-level university hospital starting from February 2020 (the beginning of the first wave of the SARS-CoV-2 pandemic); all patients were hospitalized outside the ICU. Results: A total of 387 SARS-CoV-2-positive patients were included in the current study; 372 (96.1%) had SARS-CoV-2-related pneumonia. In-hospital AKI onset was recorded in 119 (30.7%) patients, mainly with AKI stage 1 (n = 74, 62.2%); eighteen (4.6%) patients reported AKI stage 3 and six (1.5%) patients had HD-dependent AKI. There were 235 (60.7%) patients with severe COVID-19, and this was more common in patients developing AKI, 94.5% (86/119) vs. 86.1% (149/268), p = 0.02. Multivariate regression model (n = 144 patients) reported an independent and significant relationship between AKI occurrence and greater levels of ferritin (p = 0.036), IL-6 (p = 0.032), and azotemia at admission (p = 0.0001). A total of 69 (17.8%) SARS-CoV-2-positive patients died and strong predictors of in-hospital death resulted from age (p < 0.0001), serum ferritin (p < 0.0001) and white blood cells (p < 0.001). According to multivariable analysis (n = 163 patients), there was a consistent link between in-hospital death and AKI stage (1) (p = 0.021) and -stage (2) (p = 0.009). Our results support the notion that AKI occurs frequently among hospitalized COVID-19 patients even in a non-ICU setting and plays a pivotal role in the mortality of this population. Further studies are ongoing in order to clearly establish the frequency of AKI in patients with COVID-19; the mechanisms underlying kidney injury in this population are an area of active investigation. These data provide solid evidence to support close monitoring of COVID-19 patients for the development of AKI and measures taken to prevent this.

Calibration and validation of the Pneumonia Shock Score in critically ill patients with SARS-CoV-2 infection, a multicenter prospective cohort study

Background

Prognostic tools developed to stratify critically ill patients in Intensive Care Units (ICUs), are critical to predict those with higher risk of mortality in the first hours of admission. This study aims to evaluate the performance of the pShock score in critically ill patients admitted to the ICU with SARS-CoV-2 infection.

Methods

Prospective observational analytical cohort study conducted between January 2020 and March 2021 in four general ICUs in Salvador, Brazil. Descriptive statistics were used to characterize the cohort and a logistic regression, followed by cross-validation, were performed to calibrate the score. A ROC curve analysis was used to assess accuracy of the models analyzed.

Results

Six hundred five adult ICU patients were included in the study. The median age was 63 (IQR: 49–74) years with a mortality rate of 33.2% (201 patients). The calibrated pShock-CoV score performed well in prediction of ICU mortality (AUC of 0.80 [95% Confidence Interval (CI): 0.77–0.83; p-value < 0.0001]).

Conclusions

The pShock-CoV score demonstrated robust discriminatory capacity and may assist in targeting scarce ICU resources during the COVID-19 pandemic to those critically ill patients most likely to benefit.

Comorbidities and COVID-19 status influence the survival rate of geriatric patients in intensive care units: a prospective cohort study from the Indonesian Society of Anaesthesiology and Intensive Therapy

Background

With the more advanced science in the field of medicine and disease management, the population of geriatric intensive care patients is increasing. The COVID-19 pandemic has impacted healthcare management around the globe, especially on critically-ill elderly patients. We aim to analyse the relationship between underlying illnesses, including COVID-19, and the survival rate of elderly patients who are treated in the intensive care setting.

Methods

We conducted a prospective cohort study at 14 teaching hospitals for Anaesthesiology and Intensive Therapy Education in Indonesia. We selected all subjects with 60 years of age or older in the period between February to May 2021. Variables recorded included subject characteristics, comorbidities, and COVID-19 status. Subjects were followed for 30-day mortality as an outcome. We analysed the data using Kaplan-Meier survival analysis.

Results

We recruited 982 elderly patients, and 728 subjects were in the final analysis (60.7% male; 68.0 ± 6.6 years old). The 30-day mortality was 38.6%. The top five comorbidities are hypertension (21.1%), diabetes (16.2%), moderate or severe renal disease (10.6%), congestive heart failure (9.2%), and cerebrovascular disease (9.1%). Subjects with Charlson’s Comorbidity Index Score > 5 experienced 66% death. Subjects with COVID-19 who died were 57.4%. Subjects with comorbidities and COVID-19 had lower survival time than subjects without those conditions (p < 0.005). Based on linear correlation analysis, the more comorbidities the geriatric patients in the ICU had, the higher chance of mortality in 30 days (p < 0.005, R coefficient 0.22).

Conclusion

Approximately one in four elderly intensive care patients die, and the number is increasing with comorbidities and COVID-19 status.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

Patterns of presentation, prevalence and associated factors of mortality in ICU among adult patients during the pandemic of COVID 19: A retrospective cross-sectional study

Background

There is concern that patients admitted to the intensive care unit (ICU) with Corona Virus Disease 2019 (COVID-19) have variable prevalence reports of mortality. The survival rates are also inconsistently reported due to varying follow-up periods. Even if data on outcomes and baseline characteristics of ICU patients with COVID-19 is essential for action planning to manage complications, it is still left undisclosed in our study setting.

Materials and method

This cross-sectional study was conducted on 402 samples using a retrospective chart review of patient's data who were admitted in the past 2 years of the adult ICUs. All the data were entered and analyzed with SPSS version 21. A multivariable Logistic regression analysis was used to identify the association between outcome variables with independent factors and a p-value of less than 0.05 was taken as statistically significant with a 95% confidence interval. We used text, tables, and figures for the result.

Result

The overall prevalence of mortality among adult patients admitted to ICU during COVID-19 pandemics was 67.4%. From the multivariable logistic regression analysis, factors that were shown to have an association with an increase in ICU patient mortality were; lack of Vasopressor support, patients who had confirmed COVID 19 infection, core body temperature at admission greater than 37.5 °c, SPO2 at admission less than 90%, patients who had diagnosed ischemic heart disease (IHD), patients with acute respiratory distress syndrome (ARDS), patients who were intubated and mechanically ventilated (MV), and patient's ICU length of stay longer than two weeks.

Conclusion

The prevalence of ICU mortality in adult patients was higher in Debre Tabor Comprehensive specialized hospital. Therefore, clinicians need to minimize factors that maximize patient mortalities like ARDS, hyperthermia, Desaturation, Covid infection, IHD, intubation and MV, lack of Vasopressor use, and prolonged ICU stay.

-

The prevalence of mortality in ICU was 67.4%

-

Hyperthermia increases mortality in ICU

-

Use of vasopressor in ICU decreases mortality

Cardiovascular risk factors and clinical outcomes of patients hospitalized with COVID-19 pneumonia in Somalia

Background:

Coronavirus disease-2019 (COVID-19) is a potentially life-threatening illness with no established treatment. Cardiovascular risk factors (CRFs) exacerbate COVID-19 morbidity and mortality.

Objective:

To determine the prevalence of CRF and clinical outcomes of patients hospitalized with COVID-19 in a tertiary hospital in Somalia.

Methods:

We reviewed the medical records of patients aged 18 years or older with a real-time polymerase chain reaction (RT-PCR)–confirmed COVID-19 hospitalized at the De Martino Hospital in Mogadishu, Somalia, between March and July 2020.

Results:

We enrolled 230 participants; 159 (69.1%) males, median age was 56 (41–66) years. In-hospital mortality was 19.6% ( n = 45); 77.8% in the intensive care unit (ICU) compared with 22.2%, in the general wards ( p < 0.001). Age ⩾ 40 years [odds ratio (OR): 3.6, 95% confidence interval (CI): 1.2–10.6, p = 0.020], chronic heart disease (OR: 9.3, 95% CI: 2.2–38.9, p = 0.002), and diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.2, p < 0.001) were associated with increased odds of mortality. Forty-three (18.7%) participants required ICU admission. Age ⩾ 40 years (OR: 7.5, 95% CI: 1.7–32.1, p = 0.007), diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.3, p < 0.001), and hypertension (OR: 2.5, 95% CI: 1.2–5.2, p = 0.014) were associated with ICU admission. For every additional CRF, the odds of admission into the ICU increased threefold (OR: 2.7, 95% CI: 1.2–5.2, p < 0.001), while the odds of dying increased twofold (OR: 2.1, 95% CI: 1.3–3.2, p < 0.001).

Conclusions:

We report a very high prevalence of CRF among patients hospitalized with COVID-19 in Somalia. Mortality rates were unacceptably high, particularly among those with advanced age, underlying chronic heart disease, and diabetes.

The detrimental impact of elevated Ferritin to Iron ratio on in-hospital prognosis of patients with COVID-19

BACKGROUND

Acute viral infections, including coronavirus disease 2019 (COVID-19), are characterized by the dysregulation of iron metabolism, resulting in high serum ferritin and low iron levels.

RESEARCH DESIGN AND METHODS

This study aimed to evaluate the prospective impact of iron metabolism dysregulation, as expressed by serum Ferritin-to-Iron Ratio (FIR), on the in-hospital prognosis of patients with COVID-19. Serum levels of ferritin and iron, as well as other iron metabolism markers and recognized prognostic indicators of COVID-19 severity, were measured in 362 patients consecutively hospitalized for COVID-19. The prospective relationship between FIR and the risk of the composite outcome of intensive care unit (ICU) admission/in-hospital death was analyzed.

RESULTS

In the population examined (mean age 74 ± 15 years, males 55%), the rates of radiographic signs of pneumonia, respiratory distress, and the need for noninvasive ventilation were higher in patients with high FIR (≥29.2, the 75th percentile) than in those with low FIR (<29.2, the 75th percentile) (p < 0.05 for all comparisons). High FIR was associated with a 1.7-fold (HR 1.709, 95% CI 1.017-2.871, p = 0.043) higher risk of ICU admission/in-hospital death.

CONCLUSIONS

Increasing FIR values significantly and independently predicts worse in-hospital prognosis in hospitalized patients with COVID-19.

Predictive Value of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Acute Physiology and Chronic Health Evaluation (APACHE II), and New Early Warning Signs (NEWS-2) Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit (ICU)

Introduction

Various mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients.

Materials and methods

We conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality.

Result

qSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%).

Conclusion

All scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate.

How to cite this article

Asmarawati TP, Suryantoro SD, Rosyid AN, Marfiani E, Windradi C, Mahdi BA, et al. Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit. Indian J Crit Care Med 2022;26(4):464–471.

Modelling the cost-effectiveness of essential and advanced critical care for COVID-19 patients in Kenya

BACKGROUND

Case management of symptomatic COVID-19 patients is a key health system intervention. The Kenyan government embarked to fill capacity gaps in essential and advanced critical care (ACC) needed for the management of severe and critical COVID-19. However, given scarce resources, gaps in both essential and ACC persist. This study assessed the cost-effectiveness of investments in essential and ACC to inform the prioritisation of investment decisions.

METHODS

We employed a decision tree model to assess the incremental cost-effectiveness of investment in essential care (EC) and investment in both essential and ACC (EC +ACC) compared with current healthcare provision capacity (status quo) for COVID-19 patients in Kenya. We used a health system perspective, and an inpatient care episode time horizon. Cost data were obtained from primary empirical analysis while outcomes data were obtained from epidemiological model estimates. We used univariate and probabilistic sensitivity analysis to assess the robustness of the results.

RESULTS

The status quo option is more costly and less effective compared with investment in EC and is thus dominated by the later. The incremental cost-effectiveness ratio of investment in essential and ACC (EC+ACC) was US$1378.21 per disability-adjusted life-year averted and hence not a cost-effective strategy when compared with Kenya's cost-effectiveness threshold (US$908).

CONCLUSION

When the criterion of cost-effectiveness is considered, and within the context of resource scarcity, Kenya will achieve better value for money if it prioritises investments in EC before investments in ACC. This information on cost-effectiveness will however need to be considered as part of a multicriteria decision-making framework that uses a range of criteria that reflect societal values of the Kenyan society.

Factors That Influence Mortality in Critically Ill Patients with SARS-CoV-2 Infection: A Multicenter Study in the Kingdom of Saudi Arabia

BACKGROUND

SARS-CoV-2 infection has a high mortality rate and continues to be a global threat, which warrants the identification of all mortality risk factors in critically ill patients.

METHODS

This is a retrospective multicenter cohort study conducted in five hospitals in the Kingdom of Saudi Arabia (KSA). We enrolled patients with confirmed SARS-COV-2 infection admitted to any of the intensive care units from the five hospitals between March 2020 and July 2020, corresponding to the peak of recorded COVID-19 cases in the KSA.

RESULTS

In total, 229 critically ill patients with confirmed SARS-CoV-2 infection were included in the study. The presenting symptoms and signs of patients who died during hospitalization were not significantly different from those observed among patients who survived. The baseline comorbidities that were significantly associated with in-hospital mortality were diabetes (62% vs. 48% among patients who died and survived (p = 0.046)), underlying cardiac disease (38% vs. 19% (p = 0.001)), and underlying kidney disease (32% vs. 12% (p < 0.001)).

CONCLUSION

In our cohort, the baseline comorbidities that were significantly associated with in-hospital mortality were diabetes, underlying cardiac disease, and underlying kidney disease. Additionally, the factors that independently influenced mortality among critically ill COVID-19 patients were high Activated Partial Thromboplastin Time (aPTT )and international normalization ratio (INR), acidosis, and high ferritin.

Epidemiologic Characteristics of and Prognostic Factors for COVID-19 Among Hospitalized Patients: Updated Implications From Hubei Province, China

Introduction: The roles of some indicators in the prognosis of patients with coronavirus disease-19 (COVID-19) remain unclear and controversial. This study aimed to explore the epidemiologic characteristics of and prognostic factors for COVID-19 to provide updated recommendations for its prevention, diagnosis, and treatment.

Methods: For this retrospective study, demographic, epidemiologic, and clinical data were extracted from the medical records of patients admitted to the Maternal and Child Hospital of Hubei Province (Optical Valley) with COVID-19 between February 19, 2020, and March 19, 2020. The primary outcome was the prognosis that was determined at discharge as mentioned in the medical records. Descriptive statistics, univariate analyses, and stepwise logistic regression analysis were used for data analysis.

Results: Of the 1,765 patients included, 93.1% were cured and the mortality was 1.8%. Univariate analyses identified 63 factors significantly associated with COVID-19 prognosis. Logistic regression analysis revealed that a poorer prognosis was associated with undergoing resuscitation, complex disease manifestations, consultation with outside specialists, elevated basophil or lymphocyte counts, an albumin (ALB)/globulin (A/G) ratio > 2.4, and elevated levels of serum aspartate aminotransferase (AST) or creatinine. Patients had a better prognosis if the following conditions were met: dry cough reported as an initial symptom, fatigue as a clinical manifestation, and a diagnosis based on laboratory testing.

Conclusion: To prevent clinical deterioration, clinicians should provide special care to patients who underwent resuscitation, with a critical disease, or requiring consultation with outside specialists. Extra attention should be paid to patients with high basophil or lymphocyte counts, a high A/G ratio, and elevated AST or creatinine levels.

Factors influencing access and utilization of health services among older people during the COVID - 19 pandemic: a scoping review

BACKGROUND

Access to healthcare and service utilization are both considered essential factors for improving the general health and wellbeing of older people, especially at the time of COVID-19 pandemic. The aim of the study is to explore factors affecting healthcare access and health service utilization for older people during the pandemic.

METHODS

PubMed, Web of Science, Scopus and Embase were systematically searched for relevant articles. Access, utilization, health, elderly and COVID-19 were used as keywords in the search strategy. A total of 4308 articles were identified through the initial database search; 50 articles were included in the review as passing the eligibility criteria. The searches were conducted up to August 2021. Data extraction was performed, and evidence was descriptively illustrated. Thematic analysis was used to explore factors influencing the elderly's access and utilization of healthcare services, using Max QDA10, a qualitative analysis software.

RESULTS

Among articles included in the review (n = 50), a majority of the studies were from the United States (36%), followed by India (8%). According to the main healthcare services, a large number of articles (18%) were related to mental health services, followed by digital health services (16%). Factors were identified at an individual, provider and systems level. Seven main themes emerged from the thematic analysis, as determinants of elderly's access and utilization of healthcare services during COVID-19 pandemic. These included: access to non-COVID related services, access to COVID-related services, literacy and education, accommodation challenges, perceived attitudes of aging, and policies and structures, and social determinants.

CONCLUSION

Mental health and digital health services were identified as major issues influencing or contributing to or influencing older people's health during the COVID-19 pandemic. We also argue on the importance of a rounded view, as attention to a range of factors is vital for policy decisions towards sustainable care and equitable interventions for improving the health of older people.

The Association of Asthma With COVID-19 Mortality: An Updated Meta-Analysis Based on Adjusted Effect Estimates

Background

The association of asthma with the risk for mortality among coronavirus disease 2019 (COVID-19) patients is not clear.

Objective

To investigate the association between asthma and the risk for mortality among COVID-19 patients.

Methods

We performed systematic searches through electronic databases including PubMed, EMBASE, and Web of Science to identify potential articles reporting adjusted effect estimates on the association of asthma with fatal COVID-19. A random-effects model was conducted to estimate pooled effects. Sensitivity analysis, subgroup analysis, meta-regression, Begg's test and Egger's test were also performed.

Results

Based on 62 studies with 2,457,205 cases reporting adjusted effect estimates, COVID-19 patients with asthma had a significantly reduced risk for mortality compared with those without it (15 cohort studies: 829,670 patients, pooled hazard ratio [HR] = 0.88, 95% confidence interval [CI], 0.82-0.95, I² = 65.9%, P < .001; 34 cohort studies: 1,008,015 patients, pooled odds ratio [OR] = 0.88, 95% CI, 0.82-0.94, I² = 39.4%, P = .011; and 11 cross-sectional studies: 1,134,738 patients, pooled OR = 0.87, 95% CI, 0.78-0.97, I² = 41.1%, P = .075). Subgroup analysis based on types of adjusted factors indicated that COVID-19 patients with asthma had a significantly reduced risk for mortality among studies adjusting for demographic, clinical, and epidemiologic variables (pooled OR = 0.87, 95% CI, 0.83-0.92, I² = 36.3%, P = .013; pooled HR = 0.90, 95% CI, 0.83-0.97, I² = 69.2%, P < .001), but not among studies adjusting only for demographic variables (pooled OR = 0.88, 95% CI, 0.70-1.12, I² = 40.5%, P = .097; pooled HR = 0.82, 95% CI, 0.64-1.06, I² = 0%, P = .495). Sensitivity analysis proved that our results were stable and robust. Both Begg's test and Egger's test indicated that potential publication bias did not exist.

Conclusions

Our data based on adjusted effect estimates indicated that asthma was significantly related to a reduced risk for COVID-19 mortality.

Mortality and Clinical Interventions in Critically ill Patient With Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

Objective: The aims of this systematic review and meta-analysis were to summarize the current existing evidence on the outcome of critically ill patients with COVID-19 as well as to evaluate the effectiveness of clinical interventions. Data Sources: We searched MEDLINE, the Cochrane library, Web of Science, the China Biology Medicine disc, China National Knowledge Infrastructure, and Wanfang Data from their inception to May 15, 2021. The search strings consisted of various search terms related to the concepts of mortality of critically ill patients and clinical interventions. Study Selection: After eliminating duplicates, two reviewers independently screened all titles and abstracts first, and then the full texts of potentially relevant articles were reviewed to identify cohort studies and case series that focus on the mortality of critically ill patients and clinical interventions. Main Outcomes and Measures: The primary outcome was the mortality of critically ill patients with COVID-19. The secondary outcomes included all sorts of supportive care. Results: There were 27 cohort studies and six case series involving 42,219 participants that met our inclusion criteria. All-cause mortality in the intensive care unit (ICU) was 35% and mortality in hospital was 32% in critically ill patients with COVID-19 for the year 2020, with very high between-study heterogeneity (I 2 = 97%; p < 0.01). In a subgroup analysis, the mortality during ICU hospitalization in China was 39%, in Asia-except for China-it was 48%, in Europe it was 34%, in America it was 15%, and in the Middle East it was 39%. Non-surviving patients who had an older age [-8.10, 95% CI (-9.31 to -6.90)], a higher APACHE II score [-4.90, 95% CI (-6.54 to -3.27)], a higher SOFA score [-2.27, 95% CI (-2.95 to -1.59)], and a lower PaO2/FiO2 ratio [34.77, 95% CI (14.68 to 54.85)] than those who survived. Among clinical interventions, invasive mechanical ventilation [risk ratio (RR) 0.49, 95% CI (0.39-0.61)], kidney replacement therapy [RR 0.34, 95% CI (0.26-0.43)], and vasopressor [RR 0.54, 95% CI (0.34-0.88)] were used more in surviving patients. Conclusions: Mortality was high in critically ill patients with COVID-19 based on low-quality evidence and regional difference that existed. The early identification of critical characteristics and the use of support care help to indicate the outcome of critically ill patients.