Deep phenotyping of 34,128 adult patients hospitalised with COVID-19 in an international network study

Comorbid conditions appear to be common among individuals hospitalised with coronavirus disease 2019 (COVID-19) but estimates of prevalence vary and little is known about the prior medication use of patients. Here, we describe the characteristics of adults hospitalised with COVID-19 and compare them with influenza patients. We include 34,128 (US: 8362, South Korea: 7341, Spain: 18,425) COVID-19 patients, summarising between 4811 and 11,643 unique aggregate characteristics. COVID-19 patients have been majority male in the US and Spain, but predominantly female in South Korea. Age profiles vary across data sources. Compared to 84,585 individuals hospitalised with influenza in 2014-19, COVID-19 patients have more typically been male, younger, and with fewer comorbidities and lower medication use. While protecting groups vulnerable to influenza is likely a useful starting point in the response to COVID-19, strategies will likely need to be broadened to reflect the particular characteristics of individuals being hospitalised with COVID-19.

Deep phenotyping of 34,128 patients hospitalised with COVID-19 and a comparison with 81,596 influenza patients in America, Europe and Asia: an international network study

Background In this study we phenotyped individuals hospitalised with coronavirus disease 2019 (COVID-19) in depth, summarising entire medical histories, including medications, as captured in routinely collected data drawn from databases across three continents. We then compared individuals hospitalised with COVID-19 to those previously hospitalised with influenza. Methods We report demographics, previously recorded conditions and medication use of patients hospitalised with COVID-19 in the US (Columbia University Irving Medical Center [CUIMC], Premier Healthcare Database [PHD], UCHealth System Health Data Compass Database [UC HDC], and the Department of Veterans Affairs [VA OMOP]), in South Korea (Health Insurance Review & Assessment [HIRA]), and Spain (The Information System for Research in Primary Care [SIDIAP] and HM Hospitales [HM]). These patients were then compared with patients hospitalised with influenza in 2014-19. Results 34,128 (US: 8,362, South Korea: 7,341, Spain: 18,425) individuals hospitalised with COVID-19 were included. Between 4,811 (HM) and 11,643 (CUIMC) unique aggregate characteristics were extracted per patient, with all summarised in an accompanying interactive website (http://evidence.ohdsi.org/Covid19CharacterizationHospitalization/). Patients were majority male in the US (CUIMC: 52%, PHD: 52%, UC HDC: 54%, VA OMOP: 94%,) and Spain (SIDIAP: 54%, HM: 60%), but were predominantly female in South Korea (HIRA: 60%). Age profiles varied across data sources. Prevalence of asthma ranged from 4% to 15%, diabetes from 13% to 43%, and hypertensive disorder from 24% to 70% across data sources. Between 14% and 33% were taking drugs acting on the renin-angiotensin system in the 30 days prior to hospitalisation. Compared to 81,596 individuals hospitalised with influenza in 2014-19, patients admitted with COVID-19 were more typically male, younger, and healthier, with fewer comorbidities and lower medication use. Conclusions We provide a detailed characterisation of patients hospitalised with COVID-19. Protecting groups known to be vulnerable to influenza is a useful starting point to minimize the number of hospital admissions needed for COVID-19. However, such strategies will also likely need to be broadened so as to reflect the particular characteristics of individuals hospitalised with COVID-19.

Sex Differences in the Prevalent Use of Oral Formulations of Cholinesterase Inhibitors in Older Adults with Dementia

BACKGROUND

Cholinesterase inhibitors (ChEIs) are one of only two drug therapies available to manage cognitive decline in dementia. Given sex-specific differences in medication access and effects, it is important to understand how ChEIs are used by women and men.

OBJECTIVE

The objective of this study was to provide contemporary sex-stratified evidence on patterns of ChEI use by community-dwelling older adults with dementia to inform opportunities to optimize drug prescribing.

METHODS

We conducted a population-based cross-sectional study examining ChEI use in older adults with dementia in Ontario, Canada. We identified all community-dwelling individuals aged 66 years and older with a pre-existing diagnosis of dementia as of 1 April, 2016. We examined the prevalence of ChEI use among women and men separately, and explored the association between ChEI use and age, sex, income status, geographic location of residence, use of palliative care services, comorbidity, and polypharmacy. Concurrent use of drugs known to impair cognition (including antipsychotics, benzodiazepines, and medications with strong anticholinergic properties) was separately assessed among women and men using multivariable analyses and prevalence risk ratios.

RESULTS

Of 74,799 women and 52,231 men living with dementia in the community, nearly 30% currently were using a ChEI (29.3% women, 28.6% men). Close to 70% of users were receiving the target therapeutic dose. Compared to men, women were less often taking the target therapeutic dose (67.8% women vs. 71.6% men, p < 0.001). Over 20% of users also were using drugs known to impair cognition, while being treated for cognitive decline using ChEIs. Compared to men, women were more often concurrently using drugs known to impair cognition (23.9% women vs. 21.8% men, p < 0.001).

CONCLUSIONS

This is one of the first studies of ChEI use to account for important sex differences. The results remind clinicians and researchers that patterns of ChEI therapy use differ by sex, as women were less likely to receive target therapeutic doses and more vulnerable to potentially problematic polypharmacy than men.

Reducing repeat imaging in hepato-pancreatico-biliary surgical cancer care through shared diagnostic imaging repositories

BACKGROUND

With regionalization of care, patients often undergo treatment in institutions other than where the initial investigation is conducted. This study assessed the impact of a shared diagnostic imaging repository (SDIR) on processes of care and outcomes in hepato-pancreatico-biliary (HPB) cancer surgery.

METHODS

Provincial administrative datasets were linked to study HPB cancer patients operated at a regional cancer centre (2003-2014). SDIR and non-SDIR groups were based on where initial imaging (CT or MRI) was conducted. Outcomes were repeat imaging before surgery and wait times for surgery from initial imaging and surgical consultation.

RESULTS

Of 839 patients, 474 were from SDIR institutions. Fewer SDIR patients underwent any repeat imaging (55.9% vs. 75.3%; p < 0.01) and repeat imaging with same modality and protocol (24.7% vs. 43.0%; p < 0.01). Median wait time to surgery from initial imaging (64 Vs. 79 days; p < 0.01) and surgical consultation (39 Vs. 45 days; p = 0.046) was shorter with SDIR. SDIR patients had lower adjusted odds of any repeat imaging (OR 0.20 [0.14-0.30]), and repeat imaging with same modality and protocol (OR 0.58 [0.41-0.80]).

CONCLUSION

Radiology sharing with SDIR reduced repeat imaging for HPB cancer surgery, including potentially redundant repeat imaging with same protocol, and shortened wait time to surgical care.

Effects of behavioural risk factors on high-cost users of healthcare: a population-based study

OBJECTIVES

High-cost users (HCUs) are known to disproportionally incur the majority of healthcare utilization costs relative to their counterparts. A number of studies have highlighted the detrimental effects of risky health behaviours; however, only a few have demonstrated the link to HCUs, a meaningful endpoint for program and policy decision-makers. We investigated the association between health behaviour risks and downstream high-cost healthcare utilization.

METHODS

A combined cohort of participants from the Canadian Community Health Survey (CCHS) cycles 2005-2009 was linked to future population-based health administrative data in Ontario. Using person-centered costing methodology, CCHS respondents were ranked according to healthcare utilization costs and categorized as ever having HCU status in the 4 years following interview. Logistic regression models were used to estimate the association between various health behaviours on future HCU status.

RESULTS

Models estimated that smoking and physical inactivity were associated with a significant increase in the odds of becoming an HCU. Compared to individual behaviours, increasing the number of health behaviour risks significantly strengthened the odds of becoming an HCU in subsequent years.

CONCLUSION

The analyses provide evidence that upstream health behaviours affect high-cost healthcare utilization. Health behaviours are a meaningful target for health promotion programs and policies. These findings can inform decision-makers on appropriate behavioural targets for those on an HCU trajectory and promote public health efforts to support healthcare system sustainability.

The Relationship Between Life Satisfaction and Healthcare Utilization: A Longitudinal Study

INTRODUCTION

Studies have highlighted the importance of life satisfaction or, more generally, happiness, on health. However, there are few studies that have prospectively assessed the relationship between life satisfaction and healthcare utilization and costs.

METHODS

Participants were from three national survey cycles conducted between 2005 and 2010 to future healthcare utilization up to 2015. Analysis was conducted in 2016-2017. Annual per person costs were calculated and individuals ranked. Adjusted multinomial logistic regression models were used to quantify the association between life satisfaction and being in the top 5% or top 6%-50%, compared to the bottom 50%, during follow-up.

RESULTS

After exclusions, the study population included 85,225 adults. Increasing life dissatisfaction was associated with higher healthcare utilization and costs. In the fully adjusted model, the odds for those with the lowest level of life satisfaction being in the top 5% of healthcare costs relative to the lowest 50% is 3.05 (95% CI=1.61, 5.80). Those with the lowest life satisfaction were also at increased odds of being in the middle utilization category (6%-50%) with a significant OR=2.24 (95% CI=1.60, 3.14). All trends for increasing dissatisfaction were significant (p<0.001).

CONCLUSIONS

Life dissatisfaction was significantly associated with being a high-cost user in the future. This relationship persisted after adjustment for demographic factors, comorbidity, socioeconomic factors, and health behaviors. This study points to the importance of considering broader correlates of well-being with respect to future healthcare utilization and costs.

The impact of access to health services on prediabetes awareness: A population-based study

Research demonstrates that prediabetes awareness has important implications for participation in diabetes risk-reducing behaviors. We examined the impact of levels of access to health services on prediabetes awareness. In 2016, we conducted an analysis among U.S. adults with prediabetes using cross-sectional data from three cycles (2007-2008, 2009-2010, and 2011-2012) of the National Health and Nutrition Examination Survey. Participants aware and unaware of their prediabetes were classified as having full, partial, or no access to health services based on current health insurance coverage and having a routine place to go for health care. Multivariable logistic regression was used to estimate the association between access to health services and prediabetes awareness. Among a total sample of 2999U.S. adults with prediabetes, an estimated 92.0% were unaware of their prediabetes status. Participants that were unaware of their prediabetes tended to be younger, male, and were less likely to be obese or have a family history of diabetes. Having no access to health services significantly increased the odds of being prediabetes unaware (AOR: 2.65; 95% CI: 1.10-6.38). However, participants with insurance but no place of regular care had the greatest odds of being prediabetes unaware (AOR: 3.21; 95% CI: 1.21-8.55). These findings suggest that access to health services is a key factor for prediabetes awareness. Health policies and interventions should strive to ensure equitable access to health services in order to detect prediabetes, and promote awareness and engagement in risk-reducing behaviors to decrease the incidence of diabetes.

Definition of the DNA-binding site repertoire for the Drosophila transcription factor SNAIL

The Drosophila gene snail (sna) which encodes a zinc finger protein is essential for dorsal-ventral pattern formation in the developing embryo. We have defined a repertoire of SNAIL (SNA) binding sites using recombinant SNA proteins to select specific binding sequences from a pool of random sequence nucleotides. The bound sequences which were selected by multiple rounds of gel retardation and amplification by the polymerase chain reaction (PCR) were subsequently cloned and sequenced. The consensus sequence, 5'G/A A/t G/A A CAGGTG C/t A C 3', with a highly conserved core of 6 bases, CAGGTG, shares no significant homology with known binding sequences of other Drosophila zinc finger proteins. However, the CAGGTG core is identical to the core motif of aHLH (helix-loop-helix) binding sites. The strongest SNA binding is obtained with sequences containing this core motif whereas reduced binding is seen for sequences with canonical CANNTG HLH motifs. Interestingly, SNA binding is detected in the promoter region of the snail gene. Transient expression in co-transfection experiments using a SNA binding element (SBE) linked to a heterologous promoter indicates that SNA has the ability to function as a transcription activator.

The snail gene required for mesoderm formation in Drosophila is expressed dynamically in derivatives of all three germ layers

The zygotic effect gene snail (sna) encodes a zinc-finger protein required for mesoderm formation in Drosophila embryos. By in situ analysis, sna transcripts are first detected at syncytial blastoderm and persist until very late stages of embryogenesis. Expression of sna is transient and is observed in tissues derived from all three germ layers. Prior to germband elongation, sna RNA accumulation is consistent with its genetically determined role in mesoderm formation. Starting at germband elongation, a second phase of sna expression appears to be initiated, characterized by a highly dynamic accumulation of transcripts in the developing central and peripheral nervous systems. Translation of sna RNA is apparently delayed as the sna protein is not detected before the onset of gastrulation. Its regional distribution generally correlates with that of sna transcripts. The complex pattern of sna expression strongly suggests that the function of the gene is not restricted to mesoderm formation.

The Drosophila developmental gene snail encodes a protein with nucleic acid binding fingers

Pattern formation in the Drosophila embryo requires the concerted expression of maternal and zygotic genes. At least nineteen genes, twelve of which are maternally expressed, are involved in the establishment of dorsal-ventral polarity. Mutations in any one of these genes result in distinct alterations of cell fates and in the formation of an abnormal dorsal-ventral pattern. Mutants of the 'dorsal group', eleven of the maternal genes, have a common recessive phenotype similar to that described for dorsal, in that cells located at ventral and lateral positions assume dorsal fates and ventral structures fail to develop. Thus the dorsal group gene products may be involved in the establishment of a gradient of positional information along the dorsal-ventral axis. We have cloned snail (sna), a zygotic gene, whose expression is essential for the correct specification of dorsal-ventral pattern. In this report, we present evidence that the complementary DNA-deduced protein product of sna contains five copies of a nucleic acid-binding finger motif previously identified in two transcription factors, and in the protein product of several putative regulatory genes.

A reappraisal of ecdysteroid binding in Drosophila

Ecdysteroid binding was investigated in Kc cells and larval fat body of Drosophila. After incubation of intact Kc cells, 200-300 specific binding sites were detected for both 20-OH ecdysone and ponasterone A. However, if cells were fractionated prior to incubation with 20-OH ecdysone, no specific binding was observed. In the fat body the number of specific nuclear binding sites appears to be enhanced by the factor of polyteny if compared with Kc cells. Both systems displayed a high degree of non-specific cytoplasmic binding. The intracellular distribution of specifically bound ponasterone A was different from that of the physiological hormones. In fat body, even after an incubation of 60 min at 22 degrees C, the majority of specifically bound ponasterone A was located in the cytoplasm. Differences between the results of this study and previous reports on ecdysteroid binding are discussed.

Distribution of estradiol receptor and vitellogenin gene in chick liver chromatin fractions

The distribution of estradiol receptor and vitellogenin gene was studied in estradiol stimulated chick liver chromatin fractions prepared by limited DNAse II digestion and MgCl2 precipitation. The receptor was found in all fractions, undigested chromatin (P1), Mg2+ insoluble chromatin (P2) and Mg2+ soluble chromatin (S2). This last fraction was rich in acidic proteins, had a high protein:DNA ratio (7.0 w/w), contained 28% of rapidly labelled RNA, 20% of the receptor, 3-5% of chromatin DNA and showed a 2 fold enrichment of vitellogenin DNA sequences over unfractionated chromatin as well as P1 and P2 DNA. On isopycnic metrizamide gradients, all chromatin fractions showed a receptor peak banding at 1.23 g/cm3, the density of nucleoproteins. Hybridization experiments showed that the DNA banding at this density in fraction S2 was enriched 4 fold in vitellogenin DNA sequences over unfractionated chromatin as well as P1 and P2 DNA. These results suggest an association of hormone receptor complex with nucleoprotein structures of an apparently active chromatin fraction.