Estimated plasma volume status in COVID-19 patients and its relation to comorbidities and clinical outcomes

Blood plasma is a large reservoir of circulating mediators of inflammation and its expansion has been associated with unfavorable outcomes in patients with inflammatory and cardiovascular diseases. The aim of this study was to determine clinical and prognostic value of estimated plasma volume status (ePVS) in hospitalized patients with COVID-19. We retrospectively investigated 5871 consecutive COVID-19 patient hospitalized in our tertiary-level institution in period 3/2020-6/2021. ePVS was determined using the Strauss-derived Duarte formula and was correlated with clinical characteristics and unwanted outcomes. Median ePVS was 4.77 dl/g with interquartile range 4.11-5.74. Higher ePVS was significantly associated with older age, female sex, higher comorbidity burden, worse functional status, less severe COVID-19 clinical presentation with lower severity and longer duration of symptoms, but more pronounced inflammatory profile with higher C-reactive protein, interleukin-6 and D-dimer levels (P < 0.05 for all analyses). In the multivariate regression analysis U shaped relationship of ePVS with mortality was revealed, present independently of age, sex, COVID-19 severity and comorbidity burden. In addition, higher ePVS was independently associated with higher tendency for mechanical ventilation, intensive care unit treatment, venous thromboembolism, major bleeding and bacteriemia and lower ePVS was independently associated with tendency for arterial thrombotic events. Higher ePVS, indicative of plasma volume expansion and inflammatory cytokine accumulation, may predispose respiratory deterioration and venous thromboembolism, despite less severe initial clinical presentation. Lower ePVS, indicative of hemoconcentration, may predispose arterial thrombotic events. Both may be associated with higher mortality in hospitalized COVID-19 patients.

Proton pump inhibitors use prior to COVID-19 hospitalization is associated with higher Clostridioides difficile infection rate

BACKGROUND

There are uncertainties regarding associations of prior proton pump inhibitor (PPI) use with susceptibility for COVID-19 and risks associated with SARS-CoV-2 infection. We aimed to evaluate the associations of prior PPI use with outcomes in hospitalized patients with COVID-19.

RESEARCH DESIGN AND METHODS

We have retrospectively evaluated a total of 5959 consecutively hospitalized patients with COVID-19 from a tertiary-level institution in the period 3/2020-6/2021. Associations of prior PPI use with outcomes of in-hospital mortality, mechanical ventilation, intensive care unit stay, venous thromboembolism, arterial thrombosis, major bleeding, bacteremia, and Clostridioides difficile infection (C. diff.) were evaluated in entire and case-matched cohorts.

RESULTS

Among 5959 evaluated patients, there were 1967 (33%) PPI users. In an entire cohort, prior PPI use was associated with higher in-hospital mortality and higher occurrence of C. diff. Association of prior PPI use with mortality diminished, whereas association with C. diff. persisted after multivariable adjustments. In a matched cohort, prior PPI use was associated only with higher risk of C. diff. but not other outcomes in line with multivariable analysis.

CONCLUSIONS

Although prior PPI use might not have a significant impact on clinical course and mortality of SARS-CoV-2 infection, it may predispose patients to the development of complications like higher occurrence of C. diff. and thus substantially impact the course of treatment.

Predictors of prolonged hospitalization of COVID-19 patients

PURPOSE

Despite the importance of hospital bed network during the pandemic, there are scarce data available regarding factors predictive of prolonged length of hospitalization of COVID-19 patients.

METHODS

We retrospectively analyzed a total of 5959 consecutive hospitalized COVID-19 patients in period 3/2020-6/2021 from a single tertiary-level institution. Prolonged hospitalization was defined as hospital stay > 21 days to account for mandatory isolation period in immunocompromised patients.

RESULTS

Median length of hospital stay was 10 days. A total of 799 (13.4%) patients required prolonged hospitalization. Factors that remained independently associated with prolonged hospitalization in multivariate analysis were severe or critical COVID-19 and worse functional status at the time of hospital admission, referral from other institutions, acute neurological, acute surgical and social indications for admission vs admission indication of COVID-19 pneumonia, obesity, chronic liver disease, hematological malignancy, transplanted organ, occurrence of venous thromboembolism, occurrence of bacterial sepsis and occurrence of Clostridioides difficile infection during hospitalization. Patients requiring prolonged hospitalization experienced higher post-hospital discharge mortality (HR = 2.87, P < 0.001).

CONCLUSIONS

Not only severity of COVID-19 clinical presentation but also worse functional status, referral from other hospitals, certain indications for admission, certain chronic comorbidities, and complications that arise during hospital stay independently reflect on the need of prolonged hospitalization. Development of specific measures aimed at improvement of functional status and prevention of complications might reduce the length of hospitalization.

Risks associated with prior oral anticoagulation use in hospitalized COVID-19 patients - A retrospective cohort study on 5392 patients from a tertiary centre

INTRODUCTION

There are conflicting data on prior oral-anticoagulant (OAC) use and outcomes of hospitalized COVID-19 patients. Due to uncertainties regarding associated risks with the prior OAC use, we have investigated this issue in a large cohort of hospitalized COVID-19 patients from our institution.

METHODS

We have retrospectively evaluated a total of 5392 consecutive COVID-19 patients hospitalized in our tertiary center institution in period 3/2020 to 6/2021. Majority of patients received low-molecular-weight-heparin thromboprophylaxis and corticosteroids during hospitalization. Patients' characteristics and clinical outcomes were documented as a part of a hospital registry project and were evaluated according to the prior non-OAC, warfarin and direct oral anticoagulants (DOAC) use.

RESULTS

Median age was 72 years, median Charlson comorbidity index (CCI) was 4 points. There were 56.2% male patients. Majority of patients had severe (70.5%) or critical (15.8%) COVID-19 on admission. A total of 84.8% patients did not receive prior OAC, 9% were previously anticoagulated with warfarin and 6.2% were previously anticoagulated with DOACs. In the multivariate regression analyses, prior warfarin use was associated increased in-hospital mortality (OR 1.24, P = 0.048) independently of older age (OR 2.12, P < 0.001), male sex (OR 1.27, P < 0.001), higher CCI (OR 1.26, P < 0.001) and severe or critical COVID-19 on admission (OR 22.66, P < 0.001). Prior DOAC use was associated with higher occurrence of major bleeding (OR 1.72, P = 0.045) independently of higher CCI (OR 1.08, P = 0.017).

CONCLUSION

Prior OAC use could be associated with worse clinical outcomes during COVID-19 hospitalization. These phenomena might be OAC type specific and persist after multivariate adjustments.

The Onset of Systemic Oxidative Stress Associated with the Accumulation of Lipid Peroxidation Product Acrolein in the Skin of Patients with Small-Vessel Vasculitis

Small-vessel vasculitis (SVV) is the inflammation of the vessel wall that can result in hemorrhage and/or ischemia. Among the histological findings in SVV are increased infiltrating neutrophils, which, due to their oxidative burst and myeloperoxidase activity, release excessive reactive oxygen species, triggering a chain reaction of lipid peroxidation and yielding reactive aldehydes such as acrolein. The implication of oxidative stress in the pathogenesis of SVV was studied, focusing on acrolein immunohistochemistry in the affected skin vessels and systemic stress response. Samples from SVV patients and healthy subjects were collected and analyzed for total serum peroxides, total antioxidant capacity, inflammatory and immunological parameters, as well as for the presence of acrolein–protein adducts in the skin tissue specimens. The obtained data showed that systemic redox homeostasis and iron metabolism are altered in SVV patients. Possible biomarkers in the evaluation of oxidative status, disease activity and prevalence were indicated. Furthermore, a strong correlation between the accumulation of acrolein–protein adducts in the skin and the progression of the disease was revealed. Thus, the results of this study demonstrate that SVV is not only associated with systemic oxidative stress but also with tissue-specific oxidative stress that promotes acrolein formation and protein modification correlating with the severity of cutaneous vasculitis.

THU0573 YOGA LEADS TO SUSTAINED IMPROVEMENT IN FATIGUE AND MOOD IN RHEUMATOID ARTHRITIS: PRELIMINARY RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:

Rheumatoid arthritis (RA) patients experience reduced health-related quality of life (HRQOL). Previous studies suggest that yoga, a mind-body practice, can improve physical and mental health but it has not been extensively studied in RA.

Objectives:

To investigate the effect of yoga on HRQOL and secondary on fatigue, anxiety, depression and disease activity in RA patients

Methods:

43 RA patients (mean (SD) age 55 (10) years, median (IQR) disease duration 5 (3,8) years, 93% female), stable on standard pharmacological treatment and DAS28CRP < 5.1 were randomly assigned to 12 weeks yoga intervention (2x/week 90 min; n=22) or arthritis-related educational lectures control (1x/week 60 min; n=21). Yoga based on „Yoga in daily life system“ included asanas, relaxation, pranayama and meditation. Study evaluations at baseline, post-intervention and 3-month follow-up included The Short Form-36 (SF-36) scores for Physical Component Summary (PCS) and Mental Component Summary (MCS), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Hospital Anxiety and Depression scale (HADS) and Disease Activity Score-28CRP (DAS28CRP) questionnaires. Data were presented as change from baseline to each time point. Between group differences were analyzed using the t-test for normally and Mann-Whitney U test for non-normally distributed variables. P values <0.05 were considered statistically significant.

Results:

35 patients (17 = intervention, 18 = control group) completed the trial period. Significant improvement in FACIT-F (p=0.013), HADS anxiety (p=0.047) and HADS depression (p=0.004) was found in yoga group compared to control at post-intervention and maintained at follow-up (p=0.025, p=0.02 and p=0.045, respectively). There was no significant difference found between groups for SF-36 MCS, PCS and DAS28CRP at all time points (all p>0.05). No serious adverse events were observed during trial period.

Conclusion:

Although no change in SF-36 scores and disease activity was observed, yoga practice produced significant and sustained improvement in fatigue and mood which strongly account for decreased life quality in RA. Despite limitations our findings suggest that yoga may be of benefit in management of RA patients.

Table.

Changes in outcomes

N= 37 (postintervention)N= 35 (follow-up)VariablesBaseline mean (SD)Change from baseline (95%CI)Difference between groups(95%CI, p-value)Change from baseline (95%CI)Difference between groups(95%CI, p-value)FACIT-F(0-52)Yoga 33.89 (10.77)Control 35.37 (9.3)4.18(-0.26,8.61)-2.17(-5.58,1.25)6.66(1.53,11.78)p= 0.0133.29(-1.23,7.82)-3.33(-7.27,0.61)6.63(0.85,12.4)p=0.025HADS-A(0-21)Yoga 7.39 (3.72)Control 6.89 (2.86)-1.94(-3.28,-0.6)0.056(-1.39,1.51)-1.83(-3.64,-0.024)p= 0.047-2.24(-3.63,-0.84)0.17(-1.38,1.71)-2.4(-4.4,-0.04)p=0.02HADS-D(0-21)Yoga 5.11 (3.03)Control 5.0 (1.82)-1.06(-1.92,-0.2)0.83(-0.06,1.72)-1.73(-2.88,-0.58)p= 0.004-0.2(-1.1,0.63)0.94(0.12,1.77)-1.18(-2.33,-0.03)p=0.045SF-36:MCS(0-100)Yoga 49.49 (11.99)Control 49.71 (8.99)2.97(-4.15,10.09)-1.59(-7.51,4.33)3.86(-4.66,12.33)p= 0.3661.25(-3.62,6.12)-0.45(-5.56,4.65)1.7(-5.09,8.49)p=0.618SF-36:PCS(0-100)Yoga 52.57 (10.11)Control 48.30 (9.76)0.44(-3.13,4.02)-1.16(-4.81,2.48)1.61(-3.31,6.53)p= 0.511-1.54(-5.44,2.35)0.35(-3.21,3.92)-1.9(-6.98,3.18)p=0.453DAS28CRPYoga 2.32 (0.81)Control 2.91 (0.84)-0.0024(-0.42,0.42)-0.096(-0.45,0.26)0.093(-0.44,0.63)p=0.7240.11(-0.43,0.66)-0.54(-0.92,-0.17)0.66(0.02,1.3)p=0.092

Disclosure of Interests:

Silva Puksic: None declared, Josko Mitrovic: None declared, Melanie-Ivana Culo: None declared, Marcela Zivkovic: None declared, Biserka Orehovec: None declared, Marko Lucijanic: None declared, Dubravka Bobek: None declared, Jadranka Morovic-Vergles Speakers bureau: Abbvie., Roche, MSD, Eli Lilly, Pfizer, Mylan, Amgen, Fresenius Kabi

Off label and unlicensed drugs use in paediatric cardiology

OBJECTIVES

The use of drugs in an off label or unlicensed manner to treat children is a widespread phenomenon in Europe and the United States. The incidence of unlicensed and off label prescribing in paediatric cardiology practice has not been studied to date. This study was designed to assess the extent and nature of off label and unlicensed drug use in paediatric cardiology inpatients.

METHODS

In a prospective study, drug prescriptions in a paediatric cardiology ward were reviewed during a 2-year period. Data were collected and analyzed by special software created for this purpose.

RESULTS

The children (n = 544) studied varied in age from 4 h to 18 years. One or more off label and unlicensed prescriptions were given to 414 (76%) patients. Of the 2,130 prescriptions given during the 2-year period, more than one-half were unlicensed (11%) or off label (47%). While children aged 2-11 years received most of the unlicensed drug prescriptions (17%), neonates, who did not receive unlicensed drugs, led (64%) in the use of off label drugs. CONCLUSIONS. This study showed that the problem of off label and unlicensed drug use also exists in paediatric cardiology. The findings imply that the phenomenon of off label and unlicensed use of drugs in children can be correlated with the deficiency of paediatric drug formulations on the global market and insufficient data from clinical studies which must be performed to confirm the efficacy and safety of drugs in the paediatric population. Therefore, efforts to improve paediatric labelling are important and need the full support of all involved.