Quality assessment of online patient information on upper gastrointestinal endoscopy using the modified Ensuring Quality Information for Patients tool

INTRODUCTION

Websites and online resources are increasingly becoming patients' main source of healthcare information. It is paramount that high quality information is available online to enhance patient education and improve clinical outcomes. Upper gastrointestinal (UGI) endoscopy is the gold standard investigation for UGI symptoms and yet little is known regarding the quality of patient orientated websites. The aim of this study was to assess the quality of online patient information on UGI endoscopy using the modified Ensuring Quality Information for Patients (EQIP) tool.

METHODS

Ten search terms were employed to conduct a systematic review. for each term, the top 100 websites identified via a Google search were assessed using the modified EQIP tool. High scoring websites underwent further analysis. Websites intended for professional use by clinicians as well as those containing video or marketing content were excluded.

FINDINGS

A total of 378 websites were eligible for analysis. The median modified EQIP score for UGI endoscopy was 18/36 (interquartile range: 14-21). The median EQIP scores for the content, identification and structure domains were 8/18, 1/6 and 9/12 respectively. Higher modified EQIP scores were obtained for websites produced by government departments and National Health Service hospitals (p=0.007). Complication rates were documented in only a fifth (20.4%) of websites. High scoring websites were significantly more likely to provide balanced information on risks and benefits (94.6% vs 34.4%, p<0.001).

CONCLUSIONS

There is an immediate need to improve the quality of online patient information regarding UGI endoscopy. The currently available resources provide minimal information on the risks associated with the procedure, potentially hindering patients' ability to make informed healthcare decisions.

Review article: Functional dyspepsia-a gastric disorder, a duodenal disorder or a combination of both?

BACKGROUND

Functional dyspepsia (FD) is one of the most frequent conditions in gastroenterological outpatient health care. Most recent research in FD has shifted its focus to duodenal pathophysiological mechanisms, although current treatments still focus mainly the stomach.

AIM

The aim of the study was to provide a comprehensive overview of the pathophysiology of FD focusing on a paradigm shift from gastric towards duodenal mechanisms.

METHODS

We conducted a literature search in PubMed for studies describing mechanisms that could possibly cause FD.

RESULTS

The pathophysiology of FD remains incompletely understood. Recent studies show that duodenal factors such as acid, bile salt exposure and eosinophil and mast cell activation correlate with symptom pattern and burden and can be associated with gastric sensorimotor dysfunction. The evolving data identify the duodenum an interesting target for new therapeutic approaches. Furthermore, the current first-line treatment, that is proton pump inhibitors, reduces duodenal low-grade inflammation and FD symptoms.

CONCLUSION

Future research for the treatment of FD should focus on the inhibition of duodenal mast cell activation, eosinophilia and loss of mucosal integrity.

Howell-Jolly Body-Like Inclusions in Coronavirus Disease 2019 (COVID-19): Possible Novel Findings

Background

During COVID-19 pandemic, it is difficult to distinguish febrile patient infected by SARS-CoV-2 or bacterial causes. Howell-Jolly bodies are a well-known entity found in red blood cells. They are nuclear fragments, composed of deoxyribonucleic acid, commonly observed in the peripheral blood smears of hyposplenic or asplenic patients. Recently, similar inclusions often referred to as Howell-Jolly body-like inclusions (HJBLIs) have been reported in the neutrophils of patients with acquired immune deficiency syndrome (AIDS) and COVID-19 patient.

Aim

To explore whether HJBLIs in peripheral blood smear could differentiate between patients with confirmed SARS-CoV-2 and bacterial pneumonia.

Methods

We performed cross-sectional study using secondary data from COVID-19 database and re-evaluated peripheral blood smears to identify HJBLIs. We included confirmed COVID-19 adults age >18 years who were hospitalized in Dr. Hasan Sadikin General Hospital, Bandung, Indonesia from March 1st 2020-May 31st 2020. We also examined peripheral blood smears in patients with confirmed bacterial pneumonia as a control group. Clinical characteristics including disease severity, CURB-65 score, comorbidity, and the present of HJBLIs in peripheral blood smears were evaluated.

Results

Overall, 33 patients were included: 22 were confirmed COVID-19 and 11 were confirmed bacterial pneumonia. The median (interquartile range) age in COVID-19 and patients with bacterial pneumonia were 53 years (40-64) vs 57 years (53-71), respectively. Compared with patients with bacterial pneumonia, HJBLIs were significantly higher in COVID-19 patients [21/22 (80.8%) vs 5/11 (45.5%), p 0.001].

Conclusion

Howell-Jolly body-like inclusions could be a potential feature to help differentiate between COVID-19 and bacterial pneumonia.

The effect of superoxide dismutase supplementation on TNF-α and TGF-β levels in patients undergoing hemodialysis

OBJECTIVE

Chronic kidney disease stage 5 on dialysis (CKD-5D) remains a global health problem associated with an increased risk of morbidity and mortality owing to cardiovascular disease. This condition is associated with chronic inflammation, which is characterized by an increase in cytokines, including tumor necrosis factor-α (TNF-α) and transforming growth factor-β (TGF-β). Superoxide dismutase (SOD) is a first-line endogenous enzymatic antioxidant capable of neutralizing the effects of inflammation and oxidative stress. Therefore, the main aim of this study was to determine the effect of SOD supplementation on serum TNF-α and TGF-β levels in patients undergoing hemodialysis (CKD-5D).

PATIENTS AND METHODS

A quasi-experimental study with a pretest-posttest design was conducted from October to December 2021 in the Hemodialysis Unit of Dr. Hasan Sadikin Hospital, Bandung. Patients with CKD-5D who routinely underwent hemodialysis therapy twice a week were included in the study. All participants received SOD-gliadin 250 IU twice a day for 4 weeks. Serum TNF-α and TGF-β levels were assessed before and after the intervention, and statistical analyses were performed.

RESULTS

This study enrolled 28 patients undergoing hemodialysis. The median age of the patients was 42 ± 11 years, with a male-to-female ratio of 1:1. The average duration of hemodialysis in the participants was 24 (5-72) months. A statistically significant decrease in serum TNF-α and TGF-β levels from 0.109 (0.087-0.223) to 0.099 (0.083-0.149) pg/mL (p=0.036) and 15.38 ± 3.64 to 13.47 ± 3.07 pg/mL (p=0.031), respectively, after SOD administration was noted.

CONCLUSIONS

Exogenous SOD supplementation decreased serum TNF-α and TGF-β levels in patients with CKD-5D. Further randomized controlled trials are required to confirm these findings.

The effect of antioxidants supplementation on oxidative stress and proinflammatory biomarkers in patients with chronic kidney disease: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to address the effect of antioxidant supplementation on oxidative stress and proinflammatory biomarkers in patients with Chronic Kidney Disease (CKD).

MATERIALS AND METHODS

Systematic literature searches from the date of inception up to September 16th, 2022, were performed on PubMed, SCOPUS, and the Cochrane Central Register of Controlled Trials using relevant keywords, i.e., "Chronic Kidney Disease" and "antioxidants", and "supplementation". All studies relevant to the selection criteria were included in the analysis, focusing on any type of oxidative stress and proinflammatory biomarkers. A meta-analysis of included literature was conducted if sufficient data was obtained.

RESULTS

This systematic review involved 32 published studies, with most having a Jadad score of ≥ 3 (65.6%). Only studies on antioxidants, i.e., polyphenols (n=5) and vitamin E (n=6) in curcumin/turmeric, were sufficient to be included in a meta-analysis. Curcumin/turmeric supplementation was found to significantly reduce the serum c-reative protein (CRP) [standardized mean difference (SMD) -0.5238 (95% CI: -1.0495, 0.0019); p = 0.05; I2 = 78%; p = 0.001]. Similarly, vitamin E supplementation was found to significantly reduce the serum CRP [SMD -0.37 (95% CI: -0.711, -0.029); p = 0.03;  I2= 53%; p = 0.06] , but not serum interleukin-6 (IL-6) [SMD -0.26 (95% CI: -0.68, 0.16); p = 0.22; I2 = 43%; p = 0.17] and malondialdehyde (MDA) content [SMD -0.94 (95% CI: -1.92, 0.04); p = 0.06; I2= 87%; p = 0.0005].

CONCLUSIONS

Our review suggests that curcumin/turmeric and vitamin E supplements effectively lower serum CRP levels in CKD patients, particularly those undergoing chronic dialysis (CKD-5D). Higher scales of randomized controlled trials (RCTs) are still needed for other antioxidants due to inconclusive and contradicting results.

Summated Xerostomia Inventory to detect both xerostomia and salivary gland hypofunction

OBJECTIVE

This study aims to evaluate the diagnostic performance of the Summated Xerostomia Inventory (SXI-ID) questionnaire in detecting xerostomia and salivary gland hypofunction (SGH).

SUBJECTS AND METHODS

This diagnostic study first underwent a validity and reliability test. Participants were randomly sampled from the Geriatric Clinics of Dr. Hasan Sadikin Hospital, Bandung, Indonesia. The SXI-ID was generated through a forward-backward translation, after which its validity (item-total item correlations), internal consistency (Cronbach's alpha), and test-retest reliability (kappa statistic) were all assessed. The diagnostic performance of the SXI-ID in detecting SGH was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 60 participants (aged ≥60 years) were involved in this study, most of whom were female (75%). The internal consistency of the SXI-ID was acceptable (α = 0.823), and its test-retest reliability was perfect (K= 1.00). ROC analysis showed that an SXI-ID cut-off value > 11 could detect SGH with a sensitivity of 96.0%, a specificity of 100.0%, and an area under the curve of 0.985 (p < 0.001).

CONCLUSIONS

The SXI-ID questionnaire is a valid and reliable tool to detect xerostomia and SGH in older Indonesians, and a score of 11 or above is useful to identify those with a low salivary flow.

Elevated De Ritis Ratio Is Associated With Poor Prognosis in COVID-19: A Systematic Review and Meta-Analysis

Objective: This meta-analysis aims to assess whether elevated De Ritis ratio is associated with poor prognosis in patients with coronavirus 2019 (COVID-19). Methods: A systematic literature search was performed using PubMed, Embase, and EuropePMC databases up until September 17, 2021. De Ritis ratio is also known as Aspartate aminotransferase/alanine transaminase (AST/ALT) ratio. The main outcome was poor prognosis, a composite of mortality, severity, the need for ICU care, and intubation. The effect measure was odds ratios (ORs) and mean differences. We generated sensitivity and specificity, negative and positive likelihood ratio (NLR and PLR), diagnostic odds ratio (DOR), and area under curve (AUC). Results: There were eight studies with 4,606 patients. De Ritis ratio was elevated in 44% of the patients. Patients with poor prognosis have higher De Ritis ratio [mean difference 0.41 (0.31, 0.50), p < 0.001; I 2: 81.0%] and subgroup analysis showed that non-survivors also have higher De Ritis Ratio [mean difference 0.47 (0.46, 0.48), p < 0.001; I 2: 0%]. Elevated De Ritis ratio was associated with poor prognosis [OR 3.28 (2.39, 4.52), p < 0.001; I 2: 35.8%]. It has a sensitivity of 55% (36-73), specificity of 71% (52-85), PLR 1.9, NLR.63, DOR of 3 (2-4), and AUC of.67 (0.63-0.71). The posterior probability of poor prognosis was 38% if De Ritis is elevated, while 17% if De Ritis is not elevated. Conclusion: Elevated De Ritis ratio is associated with poor prognosis in patients with COVID-19. Systematic Review Registration: PROSPERO ID: CRD42020216634.

The association of admission random blood glucose concentration and body-mass index with mortality in COVID-19 patients

OBJECTIVE

This study aimed to investigate the association between hyperglycemia and body mass index (BMI), along with other associated comorbidities in hospitalized COVID-19 patients among the Indonesian population.

PATIENTS AND METHODS

This was a retrospective study conducted at Hasan Sadikin Hospital, Bandung between March 1, 2020, and August 30, 2020. Data were analyzed using the chi-square test for categorical data and unpaired t-test and Mann-Whitney alternative test for numerical data using SPSS version 24.0 (IBM SPSS Statistics for Windows, Version 24.0. IBM, Armonk, NY, USA) and GraphPad Prism version 7.0 for Windows.

RESULTS

A total of 142 hospitalized COVID-19 patients were documented between March and August 2020 at the Hasan Sadikin Hospital. Among the 142 patients, 116 (81.7%) survived, while 26 (18.3%) died. Sex, age, BMI, number of comorbidities, heart rate, respiratory rate, peripheral oxygen saturation, platelet count, random blood glucose (RBG), and length of stay (LOS) were significantly associated with mortality. Multivariate analyses demonstrated that admission RBG levels > 140 mg/dl were independently associated with an increased risk of mortality in COVID-19 patients (OR 4.3, 95% CI 1.1-17.5, p = 0.043), while BMI > 25 kg/m2 was significantly associated with reduced mortality (OR, 0.22; 95% CI 0.05-0.88, p = 0.033).

CONCLUSIONS

Admission hyperglycemia, indicated by an increase in RBG levels >140 mg/dL, is independently associated with an increased risk of mortality in hospitalized COVID-19 patients, while obesity (BMI >25 kg/m2) might have protective properties against the risk of death.

The effects of aspirin on the outcome of COVID-19: A systematic review and meta-analysis

Background

Repurposing the use of aspirin to treat hospitalized patients with COVID-19 is a sensible approach. However, several previous studies showed conflicting results. This meta-analysis was aimed to assess the effect of aspirin on the outcome in patients with COVID-19.

Methods

Systematic search using relevant keywords was carried out via several electronic databases until February 21, 2021. Research studies on adults COVID-19 patients with documentation on the use of aspirin and reported our outcomes of interest were included in the analysis. Our main outcome of interest was all types of mortality, while the incidence of thrombosis and bleeding were considered as secondary outcomes. Estimated risk estimates of the included studies were then pooled using DerSimonian-Laird random-effect models regardless heterogeneity.

Results

Seven studies with a total of 34,415 patients were included in this systematic review and meta-analysis. The use of aspirin was associated with a reduced risk of mortality (RR 0.56, 95% CI 0.38–0.81, P = 0.002; I²: 68%, P = 0.005). Sensitivity analysis by differentiating in-hospital (active aspirin prescription) and pre-hospital use of aspirin could significantly reduce the heterogeneity (I²: 1%, P = 0.4). Only one study reported the incidence of major bleeding between aspirin and non-aspirin users (6.1% vs. 7.6%, P = 0.61). The association between the use of aspirin and the incidence of thrombosis were contradictory in two studies.

Conclusion

The use of aspirin was significantly associated with a reduced risk of mortality among patients with COVID-19. Due to limited studies, the effect of aspirin on the incidence of thrombosis and bleeding in patients with COVID-19 could not be drawn definitively.

The association between triglyceride-glucose index and the incidence of type 2 diabetes mellitus-a systematic review and dose-response meta-analysis of cohort studies

ABSTARCT

AIMS: We aimed to assess the dose-response relationship between triglyceride-glucose (TyG) index and the incidence of type 2 diabetes mellitus (T2DM).

METHODS

We performed a comprehensive systematic literature search using PubMed, Scopus, and Embase for records published from inception until 9 February 2021. The effect estimates were reported as relative risks (RRs).

RESULTS

270,229 subjects from 14 studies were included in this systematic review and meta-analysis. The pooled incidence of T2DM was 9%. Meta-regression analysis indicates that baseline age (coefficient: 0.67, p = 0.026), drinking (coefficient: 0.03, p = 0.035), and HDL (coefficient: -0.89, p = 0.035) affected the incidence of T2DM in future. High TyG index was associated with increased incidence of T2DM in pooled unadjusted (RR 4.68 [3.01, 7.29], p < 0.001; I²: 96.6%) and adjusted model (adjusted RR 3.54 [2.75, 4.54], p < 0.001; I²: 83.7%). Dose-response meta-analysis for the adjusted RR showed that the linear association analysis was not significant per 0.1 increase in TyG index (RR 1.01 [0.99, 1.03], p = 0.223). There is a non-linear trend (p < 0.001) for the association between TyG index and incidence of T2DM. The dose-response curve became increasingly steeper at TyG index above 8.6.

CONCLUSIONS

TyG index was associated with the incidence of T2DM in a non-linear fashion.

In-depth review of cardiopulmonary support in COVID-19 patients with heart failure

Coronavirus disease 2019 infection has spread worldwide and causing massive burden to our healthcare system. Recent studies show multiorgan involvement during infection, with direct insult to the heart. Worsening of the heart function serves as a predictor of an adverse outcome. This finding raises a particular concern in high risk population, such as those with history of preexisting heart failure with or without implantable device. Lower baseline and different clinical characteristic might raise some challenge in managing either exacerbation or new onset heart failure that might occur as a consequence of the infection. A close look of the inflammatory markers gives an invaluable clue in managing this condition. Rapid deterioration might occur anytime in this setting and the need of cardiopulmonary support seems inevitable. However, the use of cardiopulmonary support in this patient is not without risk. Severe inflammatory response triggered by the infection in combination with the preexisting condition of the worsening heart and implantable device might cause a hypercoagulability state that should not be overlooked. Moreover, careful selection and consideration have to be met before selecting cardiopulmonary support as a last resort due to limited resource and personnel. By knowing the nature of the disease, the interaction between the inflammatory response and different baseline profile in heart failure patient might help clinician to salvage and preserve the remaining function of the heart.

Effect of heart failure on the outcome of COVID-19 — A meta analysis and systematic review

Background

Several comorbidities have been associated with an increased risk of severity and mortality in coronavirus disease 2019 (COVID-19), including hypertension, diabetes, cerebrovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease.

Purpose

In this systematic review and meta-analysis, we attempted to investigate the association between heart failure (HF) and poor outcome in patients with COVID-19.

Methods

We performed a systematic literature search from PubMed, EuropePMC, SCOPUS, Cochrane Central Database, and medRxiv with the search terms, “Heart failure” and “COVID-19”. The outcome of interest was mortality and poor prognosis (defined by incidence of severe COVID-19 infection, admission to ICU, and use of ventilator) in patients with preexisting heart failure with coronavirus disease.

Results

We identified 204 potential articles from our search, and 22 duplicates were removed. After screening of the titles and abstracts of the remaining 182 articles we identified 92 potentially relevant articles. We excluded 74 studies due to the following reasons: four studies were systematic reviews, two studies were meta-analyses, three articles were literature reviews, and 65 articles did not report on the outcome of interest. Finally, we included the remaining 18 studies in our qualitative synthesis and meta-analysis. There were 21,640 patients from 18 studies. HF was associated with hospitalization in COVID19 HR was 2.37 [1.48, 3.79; p < 0.001], high heterogeneity [I², 82%; p < 0.001]. HF was associated with a poor outcome demonstrated by an OR of 2.86 [2.07; 3.95; p < 0.001] high heterogeneity [I², 80%; p < 0.001]. Patient with preexisting HF was associated with higher mortality OR of 3.46 [2.52, 4.75; p < 0.001] moderately high heterogeneity [I², 77%; p < 0.001].

Conclusion

Patients with heart failure are at increased risk for hospitalization, poor outcome, and death from COVID-19. A significant difference in mortality between patients with and without heart failure was observed, patients with heart failure having a higher mortality.

Challenge in diagnosis of COVID-19 in hemodialysis patient: a case report and brief review of the literature

Diagnosis of COVID-19 in end-stage kidney disease (ESKD) patients on hemodialysis is challenging,  as the symptoms are often atypical. Herein, we reported a confimed case of COVID-19 in a patient on maintenance hemodialysis. A 38-year-old man with ESKD on regular hemodialysis initially presented with progressive shortness of breath and dry cough, without fever. He had lymphopenia, and chest X-ray suggested pulmonary edema with cardiomegaly and suspected bilateral bronchopneumonia. The patient clinically improved after 7 days of hospitalization, and was subsequently discharged from hospital. Ten days after being discharged, the patient was re-admitted with progressive shortness of breath and dry cough, without fever. SARS-CoV-2 infection was later confirmed by a qualitative RT-PCR test and the diagnosis COVID-19 pneumonia was established. We presented a case of atypical presentation of COVID-19 in an ESKD patient on maintenance hemodialysis with a brief review of the current literature.

Diabetes and COVID-19: The past, the present, and the future

Diabetes, one of the most prevalent chronic diseases in the world, is strongly associated with a poor prognosis in COVID-19. Scrupulous blood sugar management is crucial, since the worse outcomes are closely associated with higher blood sugar levels in COVID-19 infection. Although recent observational studies showed that insulin was associated with mortality, it should not deter insulin use in hospitalized patients requiring tight glucose control. Back and forth dilemma in the past with regards to continue/discontinue certain medications used in diabetes have been mostly resolved. The initial fears of consequences related to continuing certain medications have been largely dispelled. COVID-19 also necessitates the transformation in diabetes care through the integration of technologies. Recent advances in health-related technologies, notably telemedicine and remote continuous glucose monitoring, have become essential in the management of diabetes during the pandemic. Today, these technologies have changed the landscape of medicine and become more important than ever. Being a high-risk population, patients with type 1 or type 2 diabetes, should be prioritized for vaccination. In the future, as the pandemic fades, the prevalence of non-communicable diseases is expected to rise due to lifestyle changes and medical issues/dilemma encountered during the pandemic.

POS1422 CORRELATES OF TESTING POSITIVE FOR SARS-COV-2 IN PATIENTS WITH RHEUMATIC AD MUSCULOSKELETAL DISEASES

Background:

Many studies on COVID-19 outcomes in patients with RMD have either restricted to COVID positive RMD patients or compared them to the general clinic population as a comparator. Given heterogeneity in behaviors and risks, clinical characteristics associated with a positive diagnosis among patients with RMD seeking testing for Sars-CoV-2 remain less well studied.

Objectives:

Among patients with RMD receiving a Sars-CoV-2 PCR test, we aimed to identify RMD-related factors associated with a positive test result.

Methods:

Among patients seen at least once in the University of Washington (UW) rheumatology clinics between March 2018 to March 2020, we reviewed electronic medical records to identify patients undergoing Sars-CoV-2 PCR testing from March 1 through October 31, 2020. Patients with RMD were categorized into two groups: those who tested positive for Sars-CoV-2 and those who tested negative. We randomly selected patients from the negative group in a 2:1 ratio for further data abstraction. Student’s t-test and Chi-squared tests were used to compare continuous and categorical variables, respectively, between the groups. To determine the correlates of testing positive for Sars-CoV-2, specifically RMD medication use and disease activity, we constructed different multivariable logistic regression models adjusted for age, sex, race/ethnicity, presence of comorbidities, body mass index, and smoking.

Results:

A total of 2768 RMD patients underwent SARS-CoV-2 PCR testing within the UW system, of whom 43 (1.5%) were positive at least once. Three patients with incomplete information were excluded. Patients who tested positive had higher prevalence of end stage renal disease (ESRD)/chronic kidney disease (CKD) (24% versus 11%), had higher rates of active disease (24% versus 20%), were older (>55 years) (mean age 57.3 versus 54.8 years), male (63% versus 55%), non-white race/ethnicity (32% versus 26%), and higher prevalence of multiple comorbidities (42% versus 31%) (Table 1). In the multivariable models, neither RMD medication use (versus no use, Table 1) nor high disease activity (vs low disease activity/remission) were statistically significantly associated with COVID-19 positivity. Among the 41 COVID-19 positive patients, a majority recovered without specific treatments, although approximately one third of the positive patients were hospitalized and three deaths were observed.

Conclusion:

In this study, patients who tested positive did not differ in many ways from those who tested negative.

Table 1.

Baseline characteristics of the patients prior to COVID testing

VariablesAll(N=126)COVID Positive (N=41)COVID Negative(N=85)P valueAge in years – mean (SD)55.6 (15.3)57.3 (16.3)54.8 (14.9)0.40Sex0.39 Male73 (57.9)26 (63.4)47 (55.3) Female53 (42.1)15 (36.6)38 (44.7)Race0.39 White89 (71.2)26 (63.4)63 (74.1) Other race35 (28.2)13 (31.7)22 (25.9) Missing2 (1.6)2 (4.9)0 (0.0)Rheumatic disease0.64 OA/Crystal/Fibromyalgia37 (29.4)11 (26.8)26 (30.6) RA/SpA32 (25.4)9 (22.0)23 (27.1) All others57 (45.2)21 (51.2)36 (42.3)Rheumatic disease activity0.57 Active27 (21.4)10 (24.4)17 (20.0) Not active99 (78.6)31 (75.6)68 (80.0)Co-morbidities  Diabetes mellitus (%)25 (19.8)9 (22.0)16 (18.8)0.68  Hypertension48 (38.1)20 (48.8)28 (32.9)0.09  Cardiovascular disease23 (18.3)9 (22.0)14 (16.5)0.46  Lung disease25 (19.8)10 (24.4)15 (17.7)0.37  Cancer10 (7.9)3 (7.3)7 (8.2)0.86  ESRD/CKD19 (15.1)10 (24.4)9 (10.6)0.04*

BMI: Body mass index; SD: Standard deviation; OA: Osteoarthritis; Crystal: Crystalline diseases; RA: Rheumatoid arthritis; SpA: Spondyloarthritis

Acknowledgements:

The work in this study was supported by grant UL1 TR002319 to Dr Singh from the Institute of Translational Health Sciences of the University of Washington.

Disclosure of Interests:

None declared

Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: A meta-analysis

Background

In this systematic review and meta-analysis, we aimed to explore the association between cardiac injury and mortality, the need for intensive care unit (ICU) care, acute respiratory distress syndrome (ARDS), and severe coronavirus disease 2019 (COVID-19) in patients with COVID-19 pneumonia.

Methods

We performed a comprehensive literature search from several databases. Definition of cardiac injury follows that of the included studies, which includes highly sensitive cardiac troponin I (hs-cTnl) >99th percentile.The primary outcome was mortality, and the secondary outcomes were ARDS, the need for ICU care, and severe COVID-19. ARDS and severe COVID-19 were defined per the World Health Organization (WHO) interim guidance of severe acute respiratory infection (SARI) of COVID-19.

Results

There were a total of 2389 patients from 13 studies. This meta-analysis showed that cardiac injury was associated with higher mortality (RR 7.95 [5.12, 12.34], p < 0.001; I2: 65%). Cardiac injury was associated with higher need for ICU care (RR 7.94 [1.51, 41.78], p = 0.01; I2: 79%), and severe COVID-19 (RR 13.81 [5.52, 34.52], p < 0.001; I2: 0%). The cardiac injury was not significant for increased risk of ARDS (RR 2.57 [0.96, 6.85], p = 0.06; I2: 84%). The level of hs-cTnI was higher in patients with primary + secondary outcome (mean difference 10.38 pg/mL [4.44, 16.32], p = 0.002; I2: 0%).

Conclusion

Cardiac injury is associated with mortality, need for ICU care, and severity of disease in patients with COVID-19.

The use of Janus Kinase inhibitors in hospitalized patients with COVID-19: Systematic review and meta-analysis

Background

The evidence of using JAK inhibitors among hospitalized patients with COVID-19 is conflicting. The systematic review and meta-analysis aimed to address the efficacy of Janus Kinase (JAK) Inhibitors in reducing risk of mortality among hospitalized patients with COVID-19.

Methods

Several electronic databases, including PubMed, EuropePMC, and the Cochrane Central Register of Controlled Trials, with relevant keywords "COVID-19″ AND ("JAK inhibitor" OR "Ruxolitinib" OR "Tofacitinib" OR "Fedratinib" OR "Baricitinib") AND ("Severe" OR "Mortality"), were used to perform a systematic literature search up to December 11, 2020. All studies pertinent to the predetermined eligibility criteria were included in the analysis. Our outcome of interest was all types of mortality, clinical improvement, and clinical deterioration. Dichotomous variables of our outcomes of interest were analyzed using Maentel-Haenszel formula to obtain odds ratios (ORs) and 95% confidence intervals (CI) with random-effects modeling regardless of heterogeneity.

Results

Five studies with a total of 1190 patients and were included in this systematic review and meta-analysis. The use of JAK inhibitors was associated with a reduced risk of mortality (OR 0.51, 95% CI 0.28-0.93, P = 0.02; I²: 7.8%, P = 0.354) and clinical improvement (OR 1.76, 95% CI 1.05-2.95, P = 0.032; I²: 26.4%, P = 0.253). The use of JAK inhibitors was not associated with a reduced risk of clinical deterioration (OR 0.58, 95% CI 0.28-1.19, P = 0.136; I²: 24.1%, P = 0.267).

Conclusion

The use of JAK inhibitors was significantly associated with a reduced risk of mortality, and clinical improvement in hospitalized patients with COVID-19.

Proton pump inhibitor on susceptibility to COVID-19 and its severity: a systematic review and meta-analysis

BACKGROUND

The negative impacts of proton pump inhibitor (PPI), including the risk of pneumonia and mortality, have been reported previously. This meta-analysis aimed to address the current interest of whether the administration of PPI could increase the susceptibility and risk of poor outcome in COVID-19.

METHODS

We performed a systematic literature search from PubMed, Embase, EBSCOhost, and EuropePMC databases up until 3 December 2020. The main outcome was composite poor outcome which comprised of mortality and severe COVID-19. Severe COVID-19 in this study was defined as patients with COVID-19 that fulfill the criteria for severe CAP, including the need for intensive unit care or mechanical ventilation. The secondary outcome was susceptibility, based on cohort comparing COVID-19 positive and COVID-19 negative participants.

RESULTS

There were a total of 290,455 patients from 12 studies in this meta-analysis. PPI use was associated with increased composite poor outcome (OR 1.85 [1.13, 3.03], p = 0.014; I² 90.26%). Meta-regression analysis indicate that the association does not vary by age (OR 0.97 [0.92, 1.02], p = 0.244), male (OR 1.05 [0.99, 1.11], p = 0.091), hypertension (OR 9.98 [0.95, 1.02], p = 0.317), diabetes (OR 0.99 [0.93, 1.05], p = 0.699), chronic kidney disease (OR 1.01 [0.93, 1.10], p = 0.756), non-steroidal anti-inflammatory drug use (OR 1.02 [0.96, 1.09], p = 0.499), and pre-admission/in-hospital PPI use (OR 0.77 [0.26, 2.31], p = 0.644). PPI use was not associated with the susceptibility to COVID-19 (OR 1.56 [0.48, 5.05], p = 0.46; I² 99.7%).

CONCLUSION

This meta-analysis showed a potential association between PPI use and composite poor outcome, but not susceptibility.

PROSPERO ID

CRD42020224286.

Visceral adiposity, subcutaneous adiposity, and severe coronavirus disease-2019 (COVID-19): Systematic review and meta-analysis

BACKGROUND AND AIMS

Body mass index (BMI) has previously been shown to increase mortality and disease severity in patients with COVID-19, but the pooled effect estimate was heterogeneous. Although BMI is widely used as an indicator, it cannot distinguish visceral from subcutaneous fat. This systematic review and meta-analysis aimed to investigate the association between visceral adiposity, subcutaneous fat, and severe COVID-19.

METHODS

We performed a systematic literature search using the databases: PubMed, Embase, and EuropePMC. Data on visceral fat area (VTA), subcutaneous fat area (SFA), and total fat area (TFA) were collected. The outcome of interest was severe COVID-19. We used a REML random-effects model to pool the mean differences and odds ratio (OR).

RESULTS

There were 5 studies comprising of 539 patients. Patients with severe COVID-19 have a higher VTA (mean difference 41.7 cm² [27.0, 56.4], p < 0.001; I²: 0%) and TFA (mean difference 64.6 cm² [26.2, 103.1], p = 0.001; I²: 0%). There was no significant difference in terms of SFA between patients with severe and non-severe COVID-19 (mean difference 9.3 cm² [-4.9, 23.4], p = 0.199; I²: 1.2%). Pooled ORs showed that VTA was associated with severe COVID-19 (OR 1.9 [1.1, 2.2], p = 0.002; I²: 49.3%).

CONCLUSION

Visceral adiposity was associated with increased COVID-19 severity, while subcutaneous adiposity was not.

PROSPERO ID

CRD42020215876.

The prevalence of uninvestigated dyspepsia and the association of physical exercise with quality of life of uninvestigated dyspepsia patients in Indonesia: An internet-based survey

BACKGROUND

Epidemiological data on the prevalence of uninvestigated dyspepsia (UD) and its impact on the health-related quality of life (HRQOL) in Indonesian population are still lacking. There is no study investigating the association between exercise and the HRQOL in UD patients. We aimed to investigate the prevalence of UD and its association with physical exercise, and its impact on HRQOL in Indonesian patients with UD.

METHODS

This was a population-based, cross-sectional study, conducted using an internet-based questionnaire which was randomly distributed throughout Indonesia using the social media. The questionnaire contained socio-demographic details, exercise levels, Rome III criteria for dyspepsia, and SF-NDI (Short Form-Nepean Dyspepsia Index). The frequency, duration, the intensity of exercise, and the classification of exercise according to ACSM (American College of Sports Medicine) were included in the assessment. The screening for UD was conducted using the Rome III criteria and the SF-NDI score was calculated to assess the HRQOL in patients with UD.

RESULTS

A total of 2725 valid responses were collected. The overall prevalence of UD in the study was 49.75%. Multiple logistic regression analysis showed that gender (female) and lack of exercise were independently associated with UD (OR 2.07, 95% CI 1.74-2.47, p < 0.001 and OR 1.72, 95% CI 1.42-2.07, p < 0.001). The median SF-NDI score among 1295 UD subjects in non-exercising and exercising groups was 21.00 and 18.00 (p < 0.001), respectively.

CONCLUSION

This study demonstrated the prevalence of UD and the association between exercise and HRQOL among UD patients in Indonesia.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

Delirium and Mortality in Coronavirus Disease 2019 (COVID-19) - A Systematic Review and Meta-analysis

Introduction: Older adults are indisputably struck hard by the coronavirus disease 2019 (COVID-19) pandemic. The main objective of this meta-analysis is to establish the association between delirium and mortality in older adults with COVID-19.

Methods: Systematic literature searches of PubMed, Embase, and Scopus databases were performed up until 28 November 2020. The exposure in this study was the diagnosis of delirium using clinically validated criteria. Delirium might be in-hospital, at admission, or both. The main outcome was mortality defined as clinically validated non-survivor/death. The effect estimates were reported as odds ratios (ORs) and adjusted odds ratios (aORs).

Results: A total of 3,868 patients from 9 studies were included in this systematic review and meta-analysis. The percentage of patients with delirium was 27% [20%, 34%]. Every 1 mg/L increase in CRP was significantly associated with 1% increased delirium risk (OR 1.01 [1.00. 1.02], p=0.033). Delirium was associated with mortality (OR 2.39 [1.64, 3.49], p<0.001; I²: 82.88%). Subgroup analysis on delirium assessed at admission indicate independent association (OR 2.12 [1.39, 3.25], p<0.001; I²: 82.67%). Pooled adjusted analysis indicated that delirium was independently associated with mortality (aOR 1.50 [1.16, 1.94], p=0.002; I²: 31.02%). Subgroup analysis on delirium assessed at admission indicate independent association (OR 1.40 [1.03, 1.90], p=0.030; I²: 35.19%). Meta-regression indicates that the association between delirium and mortality were not significantly influenced by study-level variations in age, sex [reference: male], hypertension, diabetes, and dementia.

Conclusion: The presence of delirium is associated with increased risk of mortality in hospitalized older adults with COVID-19.

Successful Nucleoside Analog and Corticosteroid Therapy for Chronic Inflammatory Demyelinating Polyneuropathy in a Patient With Hepatitis B Virus Liver Cirrhosis

Here, we describe the case of a 44-year-old man with chronic hepatitis B virus (HBV) infection, who was admitted with progressive muscle weakness and paresthesia in all extremities. He showed slight icterus. Positive HBV e-antigen test, significant HBV-deoxyribonucleic acid load, hypoalbuminemia, hyperbilirubinemia, mild ascites, and demyelinating peripheral axonal lesions in both sensory and motor nerves led to the diagnosis of Child-Pugh class B HBV cirrhosis with chronic inflammatory demyelinating polyneuropathy. Oral lamivudine, intravenous steroids, calcium, and vitamin D therapy led to a significant recovery of muscle strength within 6 weeks and a gradual return to normal after 24 weeks.

Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis

Introduction

National Institute for Health and Care Excellence (NICE) endorsed clinical frailty scale (CFS) to help with decision-making. However, this recommendation lacks an evidence basis and is controversial. This meta-analysis aims to quantify the dose-response relationship between CFS and mortality in COVID-19 patients, with a goal of supplementing the evidence of its use.

Methods

We performed a systematic literature search from several electronic databases up until 8 September 2020. We searched for studies investigating COVID-19 patients and reported both (1) CFS and its distribution (2) CFS and its association with mortality. The outcome of interest was mortality, defined as clinically validated death or non-survivor. The odds ratio (ORs) will be reported per 1% increase in CFS. The potential for a non-linear relationship based on ORs of each quantitative CFS was examined using restricted cubic splines with a three-knots model.

Results

There were a total of 3817 patients from seven studies. Mean age was 80.3 (SD 8.2), and 53% (48–58%) were males. The pooled prevalence for CFS 1–3 was 34% (32–36%), CFS 4–6 was 42% (40–45%), and CFS 7–9 was 23% (21–25%). Each 1-point increase in CFS was associated with 12% increase in mortality (OR 1.12 (1.04, 1.20), p = 0.003; I²: 77.3%). The dose-response relationship was linear (P_{non-linearity}=0.116). The funnel-plot analysis was asymmetrical; Trim-and-fill analysis by the imputation of two studies on the left side resulted in OR of 1.10 [1.03, 1.19].

Conclusion

This meta-analysis showed that increase in CFS was associated with increase in mortality in a linear fashion.

Lethal Arrhythmia (Torsade de Pointes) in COVID-19: An Event Synergistically Induced by Viral Associated Cardiac Injury, Hyperinflammatory Response, and Treatment Drug?

Arrhythmias in patients with coronavirus disease 2019 (COVID-19) are prevalent and deserve special attention because they are associated with an increased risk of fatal outcome. The mechanism of arrhythmia in COVID-19 remains unclear. Here, we report our first case of confirmed COVID-19 with documented Torsade de Pointes (TdP). A 64-year-old woman, previously healthy, presented to our emergency department with progressive shortness of breath, dry cough, and 1 week of fever. She was treated with chloroquine phosphate, meropenem, and ciprofloxacin. After 5 days of admission, her condition deteriorated and she was admitted to the intensive care unit. The patient had two episodes of malignant arrhythmias within 24 hours. The former was TdP, and the latter was a fatal pulseless ventricular tachycardia that occured even after chloroquine was discontinued. There was evidence of cardiac injury shown by increased serum level of troponin I. We propose a synergistic concept of lethal arrhythmia due to direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2-associated cardiac injury, hyperinflammatory response, and drug-induced arrhythmia.

Elevated interleukin levels are associated with higher severity and mortality in COVID 19 - A systematic review, meta-analysis, and meta-regression

BACKGROUND AND AIMS

COVID 19 pneumonia commonly leads to ARDS. The occurrence of ARDS in COVID 19 patients is thought to occur secondary to an exaggerated immunologic response. In this meta-analysis, we aim to comprehensively study the various levels of immunological parameters in patients with COVID 19.

MATERIALS AND METHODS

We performed a systematic literature search from PubMed, EuropePMC, SCOPUS, Cochrane Central Database, and medRxiv with the search terms, "COVID-19" and "Interleukin". The outcome of interest was prognosis in COVID 19 patients.

RESULTS

We performed meta analysis of 16 studies. Higher counts of CD4 and CD8 with Lower Levels of TNF-a, IL2R, IL6, IL8 were observed on patients with good prognosis compared to patients with poor prognosis; -0.57 (pg/mL) (-1.10, -0.04, p = 0.04), (I2 91%, p < 0.001); -579.84 (U/mL) (-930.11, -229.57, p < 0.001), (I2 96%, p < 0.001); -1.49 (pg/mL) (-1.97, -1.01, p < 0.001), (I2 94%, p < 0.001); -0.80 (pg/mL) (-1.21, -0.40, p < 0.001), (I2 79%, p < 0.001); -2.51 (pg/mL) (-3.64, -1.38, p < 0.00001), (I2 98%, p < 0.001) respectively. Meta-regression showed age and hypertension (coefficient: 1.99, and -1.57, p = 0.005, and 0.006) significantly influenced association between IL-6 and poor outcome.

CONCLUSION

Elevated immune response to coronavirus occurs in COVID 19 patients. Higher counts of CD4 and CD8 were seen in patients with good prognosis compared to patients with poor prognosis, with Lower levels of TNF-a, IL2R, IL6, IL8, were observed in patients with good prognosis compared to patients with poor prognosis.

The Association Between Chronic Kidney Disease and New Onset Renal Replacement Therapy on the Outcome of COVID-19 Patients: A Meta-analysis

OBJECTIVE

The aim of the study was to evaluate the association between chronic kidney disease (CKD) and new onset renal replacement therapy (RRT) with the outcome of Coronavirus Disease 2019 (COVID-19) in patients.

METHODOLOGY

A systematic literature search from several databases was performed on studies that assessed CKD, use of RRT, and the outcome of COVID-19. The composite of poor outcome consisted of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care, and use of mechanical ventilator.

RESULTS

Nineteen studies with a total of 7216 patients were included. CKD was associated with increased composite poor outcome (RR 2.63 [1.33, 5.17], P = .03; I 2 = 51%, P = .01) and its subgroup, consisting of mortality (RR 3.47 [1.36, 8.86], P = .009; I 2 = 14%, P = .32) and severe COVID-19 (RR 2.89 [0.98, 8.46], P = .05; I 2 = 57%, P = .04). RRT was associated with increased composite poor outcome (RR 18.04 [4.44, 73.25], P < .001; I 2 = 87%, P < .001), including mortality (RR 26.02 [5.01, 135.13], P < .001; I 2 = 60%, P = .06), severe COVID-19 (RR 12.95 [1.93, 86.82], P = .008; I 2 = 81%, P < .001), intensive care (IC) (RR 14.22 [1.76, 114.62], P < .01; I 2 = 0%, P < .98), and use of mechanical ventilator (RR 34.39 [4.63, 255.51], P < .0005).

CONCLUSION

CKD and new-onset RRT were associated with poor outcome in patients with COVID-19.

Effect of chronic obstructive pulmonary disease and smoking on the outcome of COVID-19

OBJECTIVE: To investigate the association between chronic obstructive pulmonary disease (COPD) and smoking with outcome in patients with COVID-19.METHODS: A systematic literature search was performed using PubMed, EuropePMC, SCOPUS and the Cochrane Central Database. A composite of poor outcome, mortality, severe COVID-19, the need for treatment in an intensive care unit (ICU) and disease progression were the outcomes of interest.RESULTS: Data on 4603 patients were pooled from 21 studies. COPD was associated with an increased risk for composite poor outcome (OR 5.01, 95%CI 3.06-8.22; P < 0.001; I² 0%), mortality (OR 4.36, 95%CI 1.45-13.10; P = 0.009; I² 0%), severe COVID-19 (OR 4.62, 95%CI 2.49-8.56; P < 0.001; I² 0%), ICU care (OR 8.33, 95%CI 1.27-54.56; P = 0.03; I² 0%), and disease progression (OR 8.42, 95%CI 1.60-44.27; P = 0.01; I² 0%). Smoking was found to increase the risk of composite poor outcome (OR 1.52, 95%CI 1.16-2.00; P = 0.005; I² 12%), and subgroup analysis showed that smoking was significant for increased risk of severe COVID-19 (OR 1.65, 95%CI 1.17-2.34; P = 0.004; I² 11%). Current smokers were at higher risk of composite poor outcomes (OR 1.58, 95%CI 1.10-2.27; P = 0.01; I² 0%) than former/non-smokers.CONCLUSION: Our systematic review and meta-analysis revealed that COPD and smoking were associated with poor outcomes in patients with COVID-19.

The use of renin angiotensin system inhibitor on mortality in patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

and Aims; To investigate the association between use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB) and outcomes of hypertensive COVID-19 patients, a systematic review and meta-analysis were performed.

METHODS

We systematically searched PubMed, EuropePMC, ProQuest, and Cochrane Central Databases using the terms "(COVID-19 OR SARS-CoV-2) AND (angiotensin converting enzyme OR angiotensin receptor blocker)". The primary and second outcomes were mortality (non-survivor) and severe COVID-19, respectively.

RESULTS

Totally, 7410 patients were included from 15 studies. Pooled analysis showed that the use of ACEI/ARB was not associated with mortality (OR 0.73 [0.38, 1.40], p = 0.34; I²: 81%) and severity (OR 1.03 [0.73, 1.45], p = 0.87; I²: 65%). Pooled adjusted OR showed no risk/benefit associated with ACEI/ARB use in terms of mortality (OR 0.83 [0.54, 1.27], p = 0.38; I²: 0%). Subgroup analysis showed that the use of ARB was associated with reduced mortality (OR 0.51 [0.29, 0.90], p = 0.02; I²: 22%) but not ACEI subgroup (OR 0.68 [0.39, 1.17], p = 0.16; I²: 0%). Meta-regression showed that the association between ACEI/ARB use and mortality in patients with COVID-19 do not varies by gender (p = 0.104). GRADE showed a very low certainty of evidence for effect of ACEI/ARB on mortality and severity. The certainty of evidence was very low for both ACEI and ARB subgroups.

CONCLUSION

Administration of a renin angiotensin system (RAS) inhibitor, was not associated with increased mortality or severity of COVID-19 in patients with hypertension. Specifically, ARB and not ACEI use, was associated with lower mortality.

Incidence and impact of cardiac arrhythmias in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

Studies have shown that cardiac arrhythmias may occur in up to 44% of patients with severe coronavirus disease 2019 (COVID-19) and has been associated with an increased risk of death. This systematic review and meta-analysis aimed to evaluate the incidence of cardiac arrhythmias in patients with COVID-19 and their implications on patient prognosis.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, Europe PMC, Cochrane Central Databases, and Google Scholar + Preprint Servers. The primary endpoint of the study was poor outcomes including mortality, severe COVID-19, and the need for ICU care.

RESULTS

A total of 4 studies including 784 patients were analyzed. The incidence of arrhythmia in patients with COVID-19 was 19% (9-28%; I²: 91.45). Arrhythmia occurred in 48% (38-57%; I²: 48.08) of patients with poor outcome and 6% (1-12%; I²: 85.33%) of patients without poor outcome. Patients with COVID-19 experiencing arrhythmia had an increased risk of poor outcome (RR 7.96 [3.77, 16.81], p < 0.001; I²: 71.1%). The funnel-plot analysis showed an asymmetrical funnel plot with most of the studies on the right side of the effect estimate. The regression-based Egger's test showed indication of small-study effects (p = 0.001).

CONCLUSION

Cardiac arrhythmias were significantly associated with an increased risk of poor outcome in COVID-19. Arrhythmias were observed in 19% of patients with COVID-19 and in 48% of patients with COVID-19 and poor outcomes.

Impact of cerebrovascular and cardiovascular diseases on mortality and severity of COVID-19-systematic review, meta-analysis, and meta-regression

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the latest evidence on the association between cerebrovascular, and cardiovascular diseases and poor outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

A comprehensive systematic literature search was performed using PubMed, SCOPUS, EuropePMC, and Cochrane Central Database. The outcome of interest was composite poor outcome that comprised of mortality and severe COVID-19.

RESULTS

A total of 4448 patients were obtained from 16 studies. Cerebrovascular disease was associated with an increased composite poor outcome (RR 2.04 [1.43,2.91], p<0.001; I2: 77%). Subgroup analysis revealed that cerebrovascular disease was associated with mortality (RR 2.38 [1.92,2.96], p<0.001; I2: 0%) and showed borderline significance for severe COVID-19 (RR 1.88 [1.00,3.51], p = 0.05; I2: 87%). Cardiovascular disease was associated with increased composite poor outcome (RR 2.23 [1.71,2.91], p<0.001; I2: 60%), mortality (RR 2.25 [1.53,3.29], p<0.001; I2: 33%) and severe COVID-19 (RR 2.25 [1.51,3.36], p<0.001; I2: 76%). Meta-regression demonstrate that the association was not influenced by gender, age, hypertension, diabetes, and respiratory comorbidities. Furthermore, the association between cerebrovascular disease and poor outcome was not affected by cardiovascular diseases and vice versa.

CONCLUSION

Cerebrovascular and cardiovascular diseases were associated with an increased risk for poor outcome in patients with COVID-19.

Multiorgan Failure With Emphasis on Acute Kidney Injury and Severity of COVID-19: Systematic Review and Meta-Analysis

BACKGROUND

Abnormalities in hematologic, biochemical, and immunologic biomarkers have been shown to be associated with severity and mortality in Coronavirus Disease 2019 (COVID-19). Therefore, early evaluation and monitoring of both liver and kidney functions, as well as hematologic parameters, are pivotal to forecast the progression of COVID-19.

OBJECTIVES

In this study, we performed a systematic review and meta-analysis to investigate the association between several complications, including acute kidney injury (AKI), acute liver injury (ALI), and coagulopathy, with poor outcomes in COVID-19.

DESIGN

Systematic review and meta-analysis.

SETTING

Observational studies reporting AKI, ALI, and coagulopathy along with the outcomes of clinically validated death, severe COVID-19, or intensive care unit (ICU) care were included in this study. The exclusion criteria were abstract-only publications, review articles, commentaries, letters, case reports, non-English language articles, and studies that did not report key exposures or outcomes of interest.

PATIENTS

Adult patients diagnosed with COVID-19.

MEASUREMENTS

Data extracted included author, year, study design, age, sex, cardiovascular diseases, hypertension, diabetes mellitus, respiratory comorbidities, chronic kidney disease, mortality, severe COVID-19, and need for ICU care.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, EuropePMC, and the Cochrane Central Database. AKI and ALI follow the definition of the included studies. Coagulopathy refers to the coagulopathy or disseminated intravascular coagulation defined in the included studies. The outcome of interest was a composite of mortality, need for ICU care, and severe COVID-19. We used random-effects models regardless of heterogeneity to calculate risk ratios (RRs) for dichotomous variables. Heterogeneity was assessed using I 2. Random effects meta-regression was conducted for comorbidities and the analysis was performed for one covariate at a time.

RESULTS

There were 3615 patients from 15 studies. The mean Newcastle-Ottawa scale of the included studies was 7.3 ± 1.2. The AKI was associated with an increased the composite outcome (RR: 10.55 [7.68, 14.50], P < .001; I 2: 0%). Subgroup analysis showed that AKI was associated with increased mortality (RR: 13.38 [8.15, 21.95], P < .001; I 2: 24%), severe COVID-19 (RR: 8.12 [4.43, 14.86], P < .001; I 2: 0%), and the need for ICU care (RR: 5.90 [1.32, 26.35], P = .02; I 2: 0%). The ALI was associated with increased mortality (RR: 4.02 [1.51, 10.68], P = .005; I 2: 88%) in COVID-19. Mortality was higher in COVID-19 with coagulopathy (RR: 7.55 [3.24, 17.59], P < .001; I 2: 69%). The AKI was associated with the composite outcome and was not influenced by age (P = .182), sex (P = .104), hypertension (P = .788), cardiovascular diseases (P = .068), diabetes (P = .097), respiratory comorbidity (P = .762), and chronic kidney disease (P = .77).

LIMITATIONS

There are several limitations of this study. Many of these studies did not define the extent of AKI (grade), which may affect the outcome. Acute liver injury and coagulopathy were not defined in most of the studies. The definition of severe COVID-19 differed across studies. Several articles included in the study were published at preprint servers and are not yet peer-reviewed. Most of the studies were from China; thus, some patients might overlap across the reports. Most of the included studies were retrospective in design.

CONCLUSIONS

This meta-analysis showed that the presence of AKI, ALI, and coagulopathy was associated with poor outcomes in patients with COVID-19.

Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the association between N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in patients with COVID-19.

METHODS

Systematic literature search from several electronic databases were performed. The outcome was mortality (non-survivor) in patients with COVID-19 pneumonia. NT-proBNP data were in continuous variable (pg/mL), dichotomous data (elevated/non-elevated) and effect estimate adjusted to cardiac injury/elevated biomarkers of cardiac injury.

RESULTS

A total of 967 patients from six studies were included in this analysis. NT-proBNP was higher in non-survivor group (standardised mean difference 0.75 (0.44, 1.07), p<0.001; I2: 61%). Elevated NT-proBNP was associated with increased mortality (RR 3.63 (92.21, 5.95), p<0.001; I2: 60%). Sensitivity analysis by removing a study reduces heterogeneity (risk ratio 3.47 (2.36, 5.11), p<0.001; I2: 49%). Pooled adjusted HR (adjusted to cardiac injury/elevated biomarkers of cardiac injury) showed that elevated NT-proBNP was independently associated with mortality (HR 1.37 (1.19, 1.57), p<0.001; I2: 0%, p=0.77). Pooled analysis of multiple cut-off point resulted in a sensitivity of 76% (46%-92%) and specificity of 88% (71%-96%). Summary receiver operating characteristic curve analysis demonstrates an area under curve of 0.90 (0.87-0.93). Elevated NT-proBNP has a likelihood ratio (LR) +6.4 and LR -0.3.

CONCLUSION

Elevated NT-proBNP level was associated with increased mortality in COVID-19 pneumonia.

Diabetes mellitus is associated with increased mortality and severity of disease in COVID-19 pneumonia - A systematic review, meta-analysis, and meta-regression

BACKGROUND AND AIMS

Diabetes Mellitus (DM) is chronic conditions with devastating multi-systemic complication and may be associated with severe form of Coronavirus Disease 2019 (COVID-19). We conducted a systematic review and meta-analysis in order to investigate the association between DM and poor outcome in patients with COVID-19 pneumonia.

METHODS

Systematic literature search was performed from several electronic databases on subjects that assess DM and outcome in COVID-19 pneumonia. The outcome of interest was composite poor outcome, including mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care, and disease progression.

RESULTS

There were a total of 6452 patients from 30 studies. Meta-analysis showed that DM was associated with composite poor outcome (RR 2.38 [1.88, 3.03], p < 0.001; I2: 62%) and its subgroup which comprised of mortality (RR 2.12 [1.44, 3.11], p < 0.001; I2: 72%), severe COVID-19 (RR 2.45 [1.79, 3.35], p < 0.001; I2: 45%), ARDS (RR 4.64 [1.86, 11.58], p = 0.001; I2: 9%), and disease progression (RR 3.31 [1.08, 10.14], p = 0.04; I2: 0%). Meta-regression showed that the association with composite poor outcome was influenced by age (p = 0.003) and hypertension (p < 0.001). Subgroup analysis showed that the association was weaker in studies with median age ≥55 years-old (RR 1.92) compared to <55 years-old (RR 3.48), and in prevalence of hypertension ≥25% (RR 1.93) compared to <25% (RR 3.06). Subgroup analysis on median age <55 years-old and prevalence of hypertension <25% showed strong association (RR 3.33) CONCLUSION: DM was associated with mortality, severe COVID-19, ARDS, and disease progression in patients with COVID-19.

Lymphopenia in severe coronavirus disease-2019 (COVID-19): systematic review and meta-analysis

OBJECTIVE

Clinical and laboratory biomarkers to predict the severity of coronavirus disease 2019 (COVID-19) are essential in this pandemic situation of which resource allocation must be urgently prepared especially in the context of respiratory support readiness. Lymphocyte count has been a marker of interest since the first COVID-19 publication. We conducted a systematic review and meta-analysis in order to investigate the association of lymphocyte count on admission and the severity of COVID-19. We would also like to analyze whether patient characteristics such as age and comorbidities affect the relationship between lymphocyte count and COVID-19.

METHODS

Comprehensive and systematic literature search was performed from PubMed, SCOPUS, EuropePMC, ProQuest, Cochrane Central Databases, and Google Scholar. Research articles in adult patients diagnosed with COVID-19 with information on lymphocyte count and several outcomes of interest, including mortality, acute respiratory distress syndrome (ARDS), intensive care unit (ICU) care, and severe COVID-19, were included in the analysis. Inverse variance method was used to obtain mean differences and its standard deviations. Maentel-Haenszel formula was used to calculate dichotomous variables to obtain odds ratios (ORs) along with its 95% confidence intervals. Random-effect models were used for meta-analysis regardless of heterogeneity. Restricted-maximum likelihood random-effects meta-regression was performed for age, gender, cardiac comorbidity, hypertension, diabetes mellitus, COPD, and smoking.

RESULTS

There were a total of 3099 patients from 24 studies. Meta-analysis showed that patients with poor outcome have a lower lymphocyte count (mean difference - 361.06 μL [- 439.18, - 282.95], p < 0.001; I 2 84%) compared to those with good outcome. Subgroup analysis showed lower lymphocyte count in patients who died (mean difference - 395.35 μL [- 165.64, - 625.07], p < 0.001; I 2 87%), experienced ARDS (mean difference - 377.56 μL [- 271.89, - 483.22], p < 0.001; I 2 0%), received ICU care (mean difference - 376.53 μL [- 682.84, - 70.22], p = 0.02; I 2 89%), and have severe COVID-19 (mean difference - 353.34 μL [- 250.94, - 455.73], p < 0.001; I 2 85%). Lymphopenia was associated with severe COVID-19 (OR 3.70 [2.44, 5.63], p < 0.001; I 2 40%). Meta-regression showed that the association between lymphocyte count and composite poor outcome was affected by age (p = 0.034).

CONCLUSION

This meta-analysis showed that lymphopenia on admission was associated with poor outcome in patients with COVID-19.

Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression

OBJECTIVE

To investigate the association between hypertension and outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

We performed a systematic literature search from several databases on studies that assess hypertension and outcome in COVID-19. Composite of poor outcome, comprising of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care and disease progression were the outcomes of interest.

RESULTS

A total of 6560 patients were pooled from 30 studies. Hypertension was associated with increased composite poor outcome (risk ratio (RR) 2.11 (95% confidence interval (CI) 1.85, 2.40), p < 0.001; I2, 44%) and its sub-group, including mortality (RR 2.21 (1.74, 2.81), p < 0.001; I2, 66%), severe COVID-19 (RR 2.04 (1.69, 2.47), p < 0.001; I2 31%), ARDS (RR 1.64 (1.11, 2.43), p = 0.01; I2,0%, p = 0.35), ICU care (RR 2.11 (1.34, 3.33), p = 0.001; I2 18%, p = 0.30), and disease progression (RR 3.01 (1.51, 5.99), p = 0.002; I2 0%, p = 0.55). Meta-regression analysis showed that gender (p = 0.013) was a covariate that affects the association. The association was stronger in studies with a percentage of males < 55% compared to ⩾ 55% (RR 2.32 v. RR 1.79).

CONCLUSION

Hypertension was associated with increased composite poor outcome, including mortality, severe COVID-19, ARDS, need for ICU care and disease progression in patients with COVID-19.

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

BACKGROUND

Patients critically ill with coronavirus disease-2019 (COVID-19) feature hyperinflammation, and the associated biomarkers may be beneficial for risk stratification. We aimed to investigate the association between several biomarkers, including serum C-reactive protein (CRP), procalcitonin (PCT), D-dimer, and serum ferritin, and COVID-19 severity.

METHODS

We performed a comprehensive systematic literature search through electronic databases. The outcome of interest for this study was the composite poor outcome, which comprises mortality, acute respiratory distress syndrome, need for care in an intensive care unit, and severe COVID-19.

RESULTS

A total of 5350 patients were pooled from 25 studies. Elevated CRP was associated with an increased composite poor outcome [risk ratio (RR) 1.84 (1.45, 2.33), p < 0.001; I2: 96%] and its severe COVID-19 (RR 1.41; I2: 93%) subgroup. A CRP ⩾10 mg/L has a 51% sensitivity, 88% specificity, likelihood ratio (LR) + of 4.1, LR- of 0.5, and an area under curve (AUC) of 0.84. An elevated PCT was associated with an increased composite poor outcome [RR 3.92 (2.42, 6.35), p < 0.001; I2: 85%] and its mortality (RR 6.26; I2: 96%) and severe COVID-19 (RR 3.93; I2: 63%) subgroups. A PCT ⩾0.5 ng/ml has an 88% sensitivity, 68% specificity, LR+ of 2.7, LR- of 0.2, and an AUC of 0.88. An elevated D-dimer was associated with an increased composite poor outcome [RR 2.93 (2.14, 4.01), p < 0.001; I2: 77%], including its mortality (RR 4.15; I2: 83%) and severe COVID-19 (RR 2.42; I2: 58%) subgroups. A D-dimer >0.5 mg/L has a 58% sensitivity, 69% specificity, LR+ of 1.8, LR- of 0.6, and an AUC of 0.69. Patients with a composite poor outcome had a higher serum ferritin with a standardized mean difference of 0.90 (0.64, 1.15), p < 0.0001; I2: 76%.

CONCLUSION

This meta-analysis showed that an elevated serum CRP, PCT, D-dimer, and ferritin were associated with a poor outcome in COVID-19. The reviews of this paper are available via the supplemental material section.

The Use of Therapeutic-Dose Anticoagulation and Its Effect on Mortality in Patients With COVID-19: A Systematic Review

The incidence of venous thromboembolism (VTE) events in patients with COVID-19 treated with a standard thromboprophylaxis dose of anticoagulants remains high. We conducted a systematic review in order to explore the association between therapeutic-dose anticoagulation and its effect on mortality in patients with COVID-19. A systematic search was carried out using the electronic databases of PubMed, EuropePMC, and the Cochrane Central Database, using specific keywords. All articles that fulfilled the inclusion criteria were included in the qualitative analysis. There were 8 observational studies included in the final qualitative analysis. Quality assessment using the Newcastle-Ottawa Scale (NOS) showed a mean score of 7.5 ± 1.06, indicating moderate to high quality of the studies. Three retrospective cohort studies reported a reduction in the mortality rate, while 6 other studies showed no mortality benefits among patients with COVID-19 treated with therapeutic-dose anticoagulation. There was a slight tendency toward a reduction in the mortality rate among mechanically-ventilated patients with COVID-19 receiving therapeutic-dose anticoagulation. Bleeding events and thrombotic complications among patients receiving therapeutic-dose anticoagulation were reported in 3 studies. Although it is too soon to draw any conclusions, this systematic review draws attention to current evidence regarding the association between therapeutic-dose anticoagulation and its effect on mortality in patients with COVID-19.

Markers of ventricular repolarization as an additional non-invasive electrocardiography parameters for predicting ventricular tachycardia/fibrillation in patients with Brugada Syndrome - A systematic review and meta-analysis

BACKGROUND

Controversies surrounded the management of asymptomatic Brugada syndrome. Prognostication using electrophysiology study (EPS) is disputable. Non-invasive parameters may be a valuable additional tool for risk stratification. We aim to evaluate the use markers of ventricular repolarization including Tpeak-to-Tend (TpTe), Tpe Dispersion, TpTe/QT ratio, and QTc interval as additional non-invasive electrocardiography parameters for predicting ventricular tachycardia/fibrillation in patients with Brugada syndrome.

METHODS

We performed a comprehensive search on TpTe, Tpe Dispersion, TpTe/QT ratio, and QTc interval as a predictor for ventricular tachycardia(VT)/fibrillation(VF)/aborted sudden cardiac death/appropriate ICD shock in patients with Brugada syndromes up until October 2018.

RESULTS

We included ten studies in the qualitative synthesis and eight studies in meta-analysis. There were a total of 2126 subjects from ten studies. We found that TpTe interval (mean difference 11.97 m s [5.02-18.91]; p < 0.001; I² 80% possibly on ≥80-100 m s and maximum QTc interval (mean difference 11.42 m s [5.90-16.93], p < 0.001; I² 28%) were the most potential ECG parameters to predict VT/VF/AT/SCD. Tpe dispersion and TpTe/QT ratio have a high heterogeneity. Upon sensitivity analysis, there is no single study found to markedly affect heterogeneity of Tpe dispersion and TpTe/QT ratio. Removal of a study reduced maximum QTc interval heterogeneity to 0%.

CONCLUSIONS

Measurement of TpTe interval, Tp-e dispersion, TpTe/QT ratio, and QTc interval on ECG emerge as a promising prognostication tool which needs further investigations with a more standardized method, outcome, and cut-off points. As for now, only maximum QTc interval has a reliable result with low heterogeneity sufficiently reliable for prognostication.

Ablation-index guided versus conventional contact-force guided ablation in pulmonary vein isolation - Systematic review and meta-analysis

Background

Contact-force sensing catheter is widely used for catheter ablation, however, it did not take account of radiofrequency power. Ablation index (AI) is a novel marker incorporating contact force-time-power, was shown to be reliable in predicting lesion size and depth for radiofrequency delivery. We aimed to assess the latest evidence on ablation index guided procedure versus conventional ablation procedure.

Methods

We performed a comprehensive search on topic that assesses ablation index guided procedure versus conventional procedures from inception up until February 2019 through PubMed, EuropePMC, EBSCOhost, Cochrane Central Database, and ClinicalTrials.gov.

Results

A total of 1727 subjects from five studies were included. 12 months’ incidence of AF/AT/AFL was lower in ablation index guided with an OR of 0.35 [0.17, 0.73], p = 0.005; I² 58%. Upon sensitivity analysis by removing a study, heterogeneity decreased to 0% with OR of 0.26 [0.15, 0.46], p < 0.001. First-pass isolation has a pooled OR of 11.29 [4.68, 27.20], p < 0.001; I² 58%. Pooled OR for acute pulmonary vein reconnection was 0.43 [0.29, 0.64], p < 0.001; I² 46%. AI group has a shorter fluoroscopy time of MD -1.62 [-2.62, −0.62] minutes, p = 0.001; I² 51% and total ablation time MD -9.96 [-17.16, −2.76] minutes, p < 0.001; I² 95%. Total procedural time and complication rate were similar.

Conclusion

Ablation index guided procedure resulted in a significantly lower incidence of AF/AT/AFL, shorter fluoroscopy time, and total ablation time. First-pass isolation was higher in AI group and acute PVR was lower in AI group. Ablation-index guided procedure has a similar safety profile to conventional ablation.

Using Deep Learning with Large Dataset of Microscope Images to Develop an Automated Embryo Grading System

The assessment of embryo viability for in vitro fertilization (IVF) is mainly based on subjective visual analysis, with the limitation of intra- and inter-observer variation and a time-consuming task. In this study, we used deep learning with large dataset of microscopic embryo images to develop an automated grading system for embryo assessment.

This study included a total of 171,239 images from 16,201 embryos of 4,146 IVF cycles at Stork Fertility Center (https://www.e-stork.com.tw) from March 6, 2014 to April 13, 2018. The images were captured by inverted microscope (Zeiss Axio Observer Z1) at 112 to 116 hours (Day 5) or 136 to 140 hours (Day 6) after fertilization. Using a pre-trained network trained on the ImageNet dataset as convolution base, we applied Convolutional Neural Network (CNN) on embryo images, using ResNet50 architecture to fine-tune ImageNet parameters. The predicted grading results was compared with the grading results from trained embryologists to evaluate the model performance.

The images were labeled by trained embryologists, based on Gardner’s grading system: blastocyst development ranking from 3–6, ICM quality as A, B, or C; and TE quality as a, b, or c. After pre-processing, the images were divided into training, validation, and test groups, in which 60% were allocated to the training group, 20% to the validation group, and 20% to the test group. The ResNet50 algorithm was trained on the 60% images allocated to the training group, and the algorithm’s performance was evaluated using the 20% images allocated to the test group. The results showed an average predictive accuracy of 75.36% for the all three grading categories: 96.24% for blastocyst development, 91.07% for ICM quality, and 84.42% for TE quality.

To the best of our knowledge, this is the first study of an automatic embryo grading system using large dataset from Asian population. Combing the promising results obtained in this study with time-lapse microscope system integrated with IVF Electronic Medical Record platform, a fully automated and non-invasive pipeline for embryo assessment will be achieved.

Fracture of the Port Catheter and Migration Into the Coronary Sinus: Case Report and Brief Review of the Literature

Introduction:

Totally implantable venous device has a good safety profile, although certain complications may occur. Late mechanical complications include catheter fracture and cardiac migration which are rarely occurring in approximately 0.1% to 1% of patients.

Case presentation:

A 33-year-old woman referred by the surgical oncologist for port catheter fragment extraction through endovascular approach. She was asymptomatic on presentation and has a history of hypertension and smoking. Chest X-ray showed a port catheter fragment previously thought to be in the right atrium at the level of 8-9 thoracic vertebrae (right heart catheterization showed that the port catheter fragment was in the coronary sinus). Angiography of the right outflow tract indicates that the fragment was not in the outflow tract or pulmonary arteries but posterior to it. It was concluded that the port catheter fragment had migrated deep into the coronary sinus and the snare was unable to pull the fragment. It was deemed unfeasible to remove the fragment through the endovascular approach.

Discussion:

The port catheter fracture had migrated entirely into the coronary sinus and to the deep of our knowledge; this was the fourth case reported in the current literature. We tried to do a review of previous similar case reports; interestingly, this was the only case where the fragmented catheter was situated deep within the coronary sinus without any part of the fragment projected to the right atrium. This made the retrieval of the fragment much more difficult with a high chance of failure.

Conclusions:

Migration of totally implantable venous device into coronary sinus is a rare but possible complication and might be difficult to remove if the position is unfavorable.

Abstract WP155: Diabetes Predicts for Poor Long-term Functional Outcome After Acute Ischemic Stroke

Background: Stroke and diabetes are important causes of disability. The impact of diabetes on long-term functional outcomes after stroke is unclear. Our primary aim was to compare functional outcomes periodically over 7 years between diabetic and non-diabetic ischemic stroke patients. We also investigated the impact of diabetes on the long-term trajectory of functional outcomes, and the influence of age on the diabetes-functional outcome association.

Methods: This is a longitudinal observational cohort study of 802 acute ischemic stroke patients recruited from a tertiary hospital in Singapore from 2005 to 2007. Functional outcomes were assessed using the modified Rankin Scale (mRS) with poor functional outcome defined as mRS ≥ 3. Follow-up data was determined at 6 months, a median of 29 months and 86 months.

Results: Among the 802 ischemic stroke patients studied, 45% were > 65 years old and 42% had diabetes. Diabetic patients were more likely to have poor functional outcomes at 6 months (OR = 2.122, 95% CI: 1.226-3.673), and at median follow-up durations of 29 months (OR = 1.957, 95% CI: 1.366-2.814) and 86 months (OR = 2.269, 95% CI: 1.583-3.253), after adjustment of covariates. Diabetes was not an interaction factor for both mRS distribution and poor functional outcome when comparing between the various follow-up time-points. There was a significant interaction between age and diabetic status in terms of poor functional outcome in the long-term.

Conclusion: Diabetes is a prognostic factor for poor functional outcomes after ischemic stroke; its impact remained consistent throughout the 7-year follow-up period and was influenced by age in the long-term.