Purpose COVID-19 pandemic has multifaceted presentations with rising evidence of immune-mediated mechanisms underplay. We sought to explore the outcomes of severe COVID-19 patients treated with a multi-mechanism approach (MMA) in addition to standard-of-care (SC) versus patients who only received SC treatment. Materials and methods Data were collected retrospectively for patients admitted to the intensive care unit (ICU). This observational cohort study was performed at five institutions, 3 in the United States and 2 in Honduras. Patients were stratified for MMA vs. SC treatment during ICU stay. MMA treatment consists of widely available medications started immediately upon hospitalization. These interventions target immunomodulation, anticoagulation, viral suppression, and oxygenation. Primary outcomes included in-hospital mortality and length of stay (LOS) for the index hospitalization and were measured using logistic regression. Results Of 86 patients admitted, 65 (76%) who had severe COVID-19 were included in the study; 30 (46%) patients were in SC group, compared with 35 (54%) patients treated with MMA group. Twelve (40%) patients in the SC group died, compared with 5 (14%) in the MMA group (p-value = 0.01, Chi squared test). After adjustment for gender, age, treatment group, Q-SOFA score, the MMA group had a mean length of stay 8.15 days, when compared with SC group with 13.55 days. ICU length of stay was reduced by a mean of 5.4 days (adjusted for a mean age of 54 years, p-value 0.03) and up to 9 days (unadjusted for mean age), with no significant reduction in overall adjusted mortality rate, where the strongest predictor of mortality was the use of mechanical ventilation. Conclusion The finding that MMA decreases the average ICU length of stay by 5.4 days and up to 9 days in older patients suggests that implementation of this treatment protocol could allow a healthcare system to manage 60% more COVID-19 patients with the same number of ICU beds.
Background: COVID-19 pandemic has impacted lives globally. While COVID-19 did not discriminate against developed or developing nations, it has been a significant challenge for third world countries like Honduras to have widespread availability of advanced therapies. The concept of early treatment was almost unheard-of when early outpatient treatment with repurposed drugs in Latin American countries showed promising results. One such drug is fluvoxamine, that has shown tremendous potential in two major studies, following which fluvoxamine was added to the standard of care in Honduras. Methods: This is a prospective observational study performed at the Hospital Centro Medico Sanpedrano (CEMESA) in San Pedro Sula, Cortes, Honduras in the COVID-19 outpatient clinic. All patients fifteen years of age or older, with mild or moderate signs and symptoms of COVID-19, and a positive SARS-CoV-2 antigen or Reverse Transcription Polymerase Chain Reaction (RT-PCR) were included in the study and prescribed fluvoxamine. Cohort of patients who decided to take fluvoxamine were compared to the cohort who did not take fluvoxamine for mortality risk and risk of hospitalization as primary endpoints. Patient were monitored for 30 days with first follow up at 7 days and second follow up at 10-14 days of symptom onset. Categorical variables were compared by Pearson Chi-square test. The Odds ratio was calculated using univariate and multivariate logistic regression. Continuous variables were compared by t-test and Wilcoxon rank-sum tests. Results: Of 657 total COVID-19 cases, 594 patients took fluvoxamine and 63 did not. A total of five patients (0.76 percent) died, of which only one death occurred in the fluvoxamine group. Patients who did not receive fluvoxamine had a significantly higher mortality (OR 24, p0.005, CI 2.6 to 233.5). Odds ratio of hospitalization in patients who did not take fluvoxamine was 2.38 (30 vs 10 hospitalizations, p 0.040, CI 1.04-5.47). The odds ratio of requiring oxygen in patients in the non-fluvoxamine group was 5.08 (p<0.001, CI 2.18- 11.81). Mean lymphocytes count on the first follow-up visit was significantly higher in the fluvoxamine group (1.72 vs. 1.38, Δ 0.33, p 0.007, CI 0.09 to 0.58). Conclusion: The results of our study suggest lowers odds of mortality and hospitalization in patients who took fluvoxamine vs fluvoxamine non-takers. Non-fluvoxamine group had higher odds of oxygen requirement than fluvoxamine group as well.
Patient: Female, 38-year-old Final Diagnosis: Non-alcoholic steatohepatitis (NASH) Symptoms: Elevated liver enzymes Medication:— Clinical Procedure: — Specialty: General and Internal Medicine Objective: Unusual or unexpected effect of treatment Background: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States, and 25% of patients with NAFLD progress to non-alcoholic steatohepatitis (NASH). NAFLD is predicted to be the most common indication for liver transplantation by 2030. Despite associated high morbidity and mortality, there is currently no approved therapy for NASH. PCSK9 inhibitors are approved for reducing LDL in patients who are statin-intolerant or need further LDL reduction. Increased LDL levels are independently associated with an elevated risk of NAFLD. Case Report: We present a case of a 39-year-old woman with acute NASH with familial hypercholesterolemia that was refractory to lifestyle modifications and HMG-CoA reductase inhibitors. An episode of rhabdomyolysis warranted a search for alternatives to statin therapy. Results of a liver biopsy showed microvesicular and macrovesicular steatosis with ballooning degeneration, indicating acute NASH. She was started on PCSK9 inhibitors as salvage therapy. Three monthly doses resulted in a more than an 80% reduction in ALT and AST and a 48% reduction in LDL levels. A liver biopsy done 8 months after the first biopsy showed normalization of liver histology. Conclusions: The use of PCSK9 inhibitors showed a dramatic response in this patient who failed conventional therapies, and the encouraging results seen in this case merit further research into the use of PCSK9 inhibitors as first-line therapy for the acute phase of NASH.
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