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      High-dose versus low-dose corticosteroid treatment strategy in patients hospitalised with COVID-19: effect on ICU admission rate Translated title: Estrategia de tratamiento corticoide en altas dosis versus bajas dosis en pacientes COVID-19 hospitalizados: efecto en la tasa de ingreso en UCI

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          Abstract

          SUMMARY Objective: COVID-19 is associated with lung damage and a high mortality rate in hospitalised patients. Corticoids may reduce the evolution to respiratory failure and death. This study aims to assess the effect on the ICU admission rate of a change in corticosteroid treatment strategy, administering low versus high doses. Methods: A retrospective, observational study was designed. Confirmed COVID-19 patients indicated to start treatment with corticosteroids were enrolled. To study the association between the type of corticosteroid used and admission to the ICU, a binary logistic regression model was constructed. This model included variables that could cause confusion or influence the response: gender, age, comorbidities, and analytical data. Results: From 190 admitted patients, 127 were enrolled in the study. In both groups, patients received a minimum of two doses of corticosteroids during admission. 12.4% (12/97) of the patients who received methylprednisolone (high doses) were subsequently admitted to the ICU, compared to 30.0% (9/30) of the patients who received dexamethasone (low doses). In the logistic regression model constructed, the type of corticosteroid (low-dose dexamethasone) (p=0.002), male gender (p=0.023), age over 50 years (p=0.014) and IL-6 level >70 pg/mL (p=0.004) remained as predictive factors for admission to the ICU. Conclusions: In the studied population of patients hospitalised for COVID-19, the use of high-dose methylprednisolone is associated with a lower rate of admission to the ICU than the administration of low-dose dexamethasone.

          Translated abstract

          RESUMEN Objetivo: La COVID-19 está asociada a daño pulmonar y alta tasa de mortalidad en pacientes ingresados. Los corticoides pueden reducir la progresión a insuficiencia respiratoria y muerte. El objetivo del presente estudio es evaluar el efecto sobre la tasa de ingreso en UCI tras el cambio de estrategia en el tratamiento con corticoides, administración de bajas dosis frente a altas dosis. Métodos: Se diseñó un estudio retrospectivo observacional en el que se seleccionaron pacientes COVID-19 confirmado con indicación de inicio de tratamiento con corticoides. Para estudiar la asociación entre el tipo de corticoide utilizado y el ingreso en UCI, se construyó un modelo de regresión logística binaria en el que se incluyeron variables que podrían causar confusión o influir en la respuesta: sexo, edad, comorbilidades y datos analíticos. Resultados: De 190 pacientes ingresados, 127 se incluyeron en el estudio. En ambos grupos los pacientes recibieron un mínimo de dos dosis de corticoides durante el ingreso. El 12,4% (12/97) de los pacientes que recibieron metilprednisolona (altas dosis) ingresaron posteriormente en UCI, frente al 30,0% (9/30) de los pacientes que recibieron dexametasona (bajas dosis). En el modelo de regresión logística construido permanecieron como factores predictivos de ingreso en UCI el tipo de corticoide (dexametasona a bajas dosis) (p=0,002), el sexo masculino (p=0,023), edad superior a 50 años (p=0,014) y nivel de IL-6 >70 pg/mL (p=0,004). Conclusiones: En la población estudiada de pacientes hospitalizados por COVID-19, el uso de metilprednisolona a altas dosis se asocia a una menor tasa de ingreso en UCI que dexametasona a bajas dosis.

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          Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

          Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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            Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study

            Summary Background In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia. Methods In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020. Findings Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure. Interpretation The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection. Funding National Key R&D Program of China.
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              COVID-19: consider cytokine storm syndromes and immunosuppression

              As of March 12, 2020, coronavirus disease 2019 (COVID-19) has been confirmed in 125 048 people worldwide, carrying a mortality of approximately 3·7%, 1 compared with a mortality rate of less than 1% from influenza. There is an urgent need for effective treatment. Current focus has been on the development of novel therapeutics, including antivirals and vaccines. Accumulating evidence suggests that a subgroup of patients with severe COVID-19 might have a cytokine storm syndrome. We recommend identification and treatment of hyperinflammation using existing, approved therapies with proven safety profiles to address the immediate need to reduce the rising mortality. Current management of COVID-19 is supportive, and respiratory failure from acute respiratory distress syndrome (ARDS) is the leading cause of mortality. 2 Secondary haemophagocytic lymphohistiocytosis (sHLH) is an under-recognised, hyperinflammatory syndrome characterised by a fulminant and fatal hypercytokinaemia with multiorgan failure. In adults, sHLH is most commonly triggered by viral infections 3 and occurs in 3·7–4·3% of sepsis cases. 4 Cardinal features of sHLH include unremitting fever, cytopenias, and hyperferritinaemia; pulmonary involvement (including ARDS) occurs in approximately 50% of patients. 5 A cytokine profile resembling sHLH is associated with COVID-19 disease severity, characterised by increased interleukin (IL)-2, IL-7, granulocyte-colony stimulating factor, interferon-γ inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1-α, and tumour necrosis factor-α. 6 Predictors of fatality from a recent retrospective, multicentre study of 150 confirmed COVID-19 cases in Wuhan, China, included elevated ferritin (mean 1297·6 ng/ml in non-survivors vs 614·0 ng/ml in survivors; p 39·4°C 49 Organomegaly None 0 Hepatomegaly or splenomegaly 23 Hepatomegaly and splenomegaly 38 Number of cytopenias * One lineage 0 Two lineages 24 Three lineages 34 Triglycerides (mmol/L) 4·0 mmol/L 64 Fibrinogen (g/L) >2·5 g/L 0 ≤2·5 g/L 30 Ferritin ng/ml 6000 ng/ml 50 Serum aspartate aminotransferase <30 IU/L 0 ≥30 IU/L 19 Haemophagocytosis on bone marrow aspirate No 0 Yes 35 Known immunosuppression † No 0 Yes 18 The Hscore 11 generates a probability for the presence of secondary HLH. HScores greater than 169 are 93% sensitive and 86% specific for HLH. Note that bone marrow haemophagocytosis is not mandatory for a diagnosis of HLH. HScores can be calculated using an online HScore calculator. 11 HLH=haemophagocytic lymphohistiocytosis. * Defined as either haemoglobin concentration of 9·2 g/dL or less (≤5·71 mmol/L), a white blood cell count of 5000 white blood cells per mm3 or less, or platelet count of 110 000 platelets per mm3 or less, or all of these criteria combined. † HIV positive or receiving longterm immunosuppressive therapy (ie, glucocorticoids, cyclosporine, azathioprine).
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                Author and article information

                Journal
                ofil
                Revista de la OFIL
                Rev. OFIL·ILAPHAR
                Organización de Farmacéuticos Ibero-Latinoamericanos (Madrid, Madrid, Spain )
                1131-9429
                1699-714X
                2021
                : 31
                : 1
                : 13-17
                Affiliations
                [1] orgnameHospital General Universitario de Castellón orgdiv1Hospital Pharmacy Department Spain
                Article
                S1699-714X2021000100003 S1699-714X(21)03100100003
                10.4321/s1699-714x2021000100003
                1500b05e-e444-4521-a823-816ccd9a3510

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 19 November 2020
                : 24 November 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 23, Pages: 5
                Product

                SciELO Spain

                Categories
                Originals

                corticosteroids,ICU,COVID-19,SARS-Cov-2,UCI,corticoides
                corticosteroids, ICU, COVID-19, SARS-Cov-2, UCI, corticoides

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