Adherence of Clinical Practice Guidelines for Pharmacologic Treatments of Hospitalized Patients With COVID-19 to Trustworthy Standards

Burns, Karen E. A.; Laird, Matthew; Stevenson, James; Honarmand, Kimia; Granton, David; Kho, Michelle E.; Cook, Deborah J.; Friedrich, Jan O.; Meade, Maureen O.; Duffett, Mark; Chaudhuri, Dipayan; Liu, Kuan; D’Aragon, Frédérick; Agarwal, Arnav; Adhikari, Neill K. J.; Noh, Hayle; Choong, Karen; Lucas, Andrea; Dionne, Joanna C.; Lozano, Colungo; Duan, Erick; Belley‐Côté, Emilie P.; Parker, Melissa; Basmaji, John; Lau, Vincent; Arora, Samantha

doi:10.1001/jamanetworkopen.2021.36263

Cited by 6 publications

(17 citation statements)

References 75 publications

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“…This report suggests many similarities with the actual pandemic situation and also describes similar autoptic findings with the central histologic hallmark, namely the presence of the hyaline membranes , which were known to represent fibrin deposition (97-99) and has been reported not only in premature children in the placenta ,in the lung of O2-intoxicated guinea pig and rabbits (97,101) but also in human adults (102,103).As it was described by Fujikura (97) fibrin deposition can be observed not only in the lungs of newborns but also in normal term placenta (97) perivillous fibrin deposition in the placenta of COVID-19-positive pregnant women after delivery has been recently reported together with throphoblast necrosis and histiocytic intervillositis .The triad has been called SARCOV-2 placentitis (187).…”

Section: Fig6 Hialyne Membranes (Periodic Acid-shiff Staining) In The...supporting

confidence: 72%

“…The negative prognostic value of hypoalbuminemia was repeatedly described (93) at the beginning of the pandemic.The crucial importance of normal serum albumin level has been, however, underestimated (94)(95)(96)(97)(98) The increased use of diuretics, which are routinely given on the assumption that ARDS is a kind of non-cardial"edema" of the lung, has only been reported in a recent publication (99).…”

Section: Fig3: Induction Of Chemokine-(cinc-1 Il-8) -Gene-expression ...mentioning

confidence: 99%

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SARS-CoV-2-Infection (COVID-19): Clinical Course and Cause(s) of Death

Ramadori¹

2022

Preprint

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Two years after first patients approached the emergency rooms of hospitals in Wuhan becouse of respiratory distress,thousend of SARS-CoV-2 infected persons continue to die every day worldwide.SARS-CoV-2-infected patients undergo a process of dehydration and malnutrition before they develop respiratory problems and approach the emergency room of a hospital.This is,in many cases, the consequence of high fever which causes massive loss of fluids. In addition loss of appetite, is responsible for the deficit of protein intake.Most of the virus-infected patients admitted to the emergency room are therefore hypovolemic and hypoproteinemic and suffer of respiratory distress accompanied by ground grass opacities at CT-scan of the lungs.Critically ill patients are treated following the guidelines for treatment of septic shock but with &bdquo;conservative“ fluid replacement and administration of diuretics to assure sufficient hourly urine production. The combination of conservative fluid administration with reduced protein content in the enterally administered diet, together with administration of diuretics, has severe hemodynamic consequenses in mostly aged,dehydrated,critically ill patients. Many of them will develop acute kidney injury in the next 24 hours.In most of the cases, patients continue to loose weight by loosing skeletal muscle mass. Ischemic damage in the lung capillaries is responsible for the acute respiratory distreass syndrome (ARDS) and for the hallmark of autoptic findings,diffuse alveolar damage (DAD) characterized by hyaline membrane formation,fluid invasion of the alveoli recruitment of some inflammatory cells and progressive arrest of blood flow in the pulmonary vessels.The consequence is progressive congestion , increase of lung weight and progressive hypoxia (progressive severity of ARDS).Sequestration of blood in the lungs worsen hypovolemia and ischemia in different organs.This is most probably responsible for recruitment of inflammatory cells and for persistance of elevated serum levels of positive acute-phase markers and of hypoalbuminemia. Autoptic studies have been performed mostly in patients who died in the ICU after SARS-CoV-2-infection because of progessive ARDS.In those patients, tubulus epithelium necrosis in the kidney is a frequent finding as it has been the case in the first SARS-CoV-1 pandemic.In the death certification charts, many times weeks after first symptoms have started ,cardiac arrest is the cause of death after respitatory insufficiency.Replacement therapy with sufficient amount of fluid and albumin should be part of the early individualized life-saving supportive measures avoiding mechanical ventilation.

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Section: Fig6 Hialyne Membranes (Periodic Acid-shiff Staining) In The...supporting

confidence: 72%

Section: Fig3: Induction Of Chemokine-(cinc-1 Il-8) -Gene-expression ...mentioning

confidence: 99%

SARS-CoV-2-Infection (COVID-19): Clinical Course and Cause(s) of Death

Ramadori¹

2022

Preprint

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“…Although hypoalbuminemia was repeatedly described [ 93 ] to be of crucial importance as a negative prognostic marker independent of comorbidities, the importance of sequential measurements of albumin serum levels in the emergency room and during the hospital stay has been, however, underestimated [ 94 , 95 , 96 , 97 ].…”

Section: Mortality Risk Scores In Symptomatic Hospitalized Sars-cov-2...mentioning

confidence: 99%

“…As mentioned above, the beginning of the clinical course of SARS-CoV-2 and of influenza infection is quite similar [ 13 , 16 , 17 , 19 , 38 , 40 , 97 ].…”

Section: How To Define the Cause Of Deathmentioning

confidence: 99%

SARS-CoV-2-Infection (COVID-19): Clinical Course, Viral Acute Respiratory Distress Syndrome (ARDS) and Cause(s) of Death

Ramadori

2022

Medical Sciences

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SARS-CoV-2-infected symptomatic patients often suffer from high fever and loss of appetite which are responsible for the deficit of fluids and of protein intake. Many patients admitted to the emergency room are, therefore, hypovolemic and hypoproteinemic and often suffer from respiratory distress accompanied by ground glass opacities in the CT scan of the lungs. Ischemic damage in the lung capillaries is responsible for the microscopic hallmark, diffuse alveolar damage (DAD) characterized by hyaline membrane formation, fluid invasion of the alveoli, and progressive arrest of blood flow in the pulmonary vessels. The consequences are progressive congestion, increase in lung weight, and progressive hypoxia (progressive severity of ARDS). Sequestration of blood in the lungs worsens hypovolemia and ischemia in different organs. This is most probably responsible for the recruitment of inflammatory cells into the ischemic peripheral tissues, the release of acute-phase mediators, and for the persistence of elevated serum levels of positive acute-phase markers and of hypoalbuminemia. Autopsy studies have been performed mostly in patients who died in the ICU after SARS-CoV-2 infection because of progressive acute respiratory distress syndrome (ARDS). In the death certification charts, after respiratory insufficiency, hypovolemic heart failure should be mentioned as the main cause of death.

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“…1,2 However, empirical evidence supporting this widely held belief is limited, prompting the critique that evidence-based medicine (EBM) overemphasises algorithmic decision rules over physicians' intuition and experience. 3,4 During the COVID-19 pandemic many inadequately tested and unproven therapies have, largely driven by uncontrolled physicians' experience, dominated the practice of medicine 5,6 raising the question if health interventions delivered according to evidenceprotocols could have improved health outcomes. 7 One of the challenges of evaluating evidence-based practices is the lack of a theoretical framework for their evaluation.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of a fast‐and‐frugal clinical decision algorithm (‘pathways’) on clinical outcomes in hospitalised patients with COVID‐19 treated with anticoagulants

Djulbegoviĉ

Hozo

Lizarraga

et al. 2022

Evaluation Clinical Practice

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Rationale, Aims and Objectives Critics have charged that evidence‐based medicine (EBM) overemphasises algorithmic rules over unstructured clinical experience and intuition, but the role of structured decision support systems in improving health outcomes remains uncertain. We aim to assess if delivery of anticoagulant prophylaxis in hospitalised patients with COVID‐19 according to an algorithm based on evidence‐based clinical practice guideline (CPG) improved clinical outcomes compared with administration of anticoagulant treatment given at individual practitioners' discretion. Methods An observational design consisting of the analysis of all acutely ill, consecutive patients (n = 1783) with confirmed COVID‐19 diagnosis admitted between 10 March 2020 to 11 January 2022 to an US academic center. American Society of Haematology CPG for anticoagulant prophylaxis in hospitalised patients with COVID‐19 was converted into a clinical pathway and translated into fast‐and‐frugal decision (FFT) tree (‘algorithm’). We compared delivery of anticoagulant prophylaxis in hospitalised patients with COVID‐19 according to the FFT algorithm with administration of anticoagulant treatment given at individual practitioners' discretion. Results In an adjusted analysis, using combination of Lasso (least absolute shrinkage and selection operator) and propensity score based weighting [augmented inverse‐probability weighting] statistical techniques controlling for cluster data, the algorithm did not reduce death, venous thromboembolism, or major bleeding, but helped avoid longer hospital stay [number of patients needed to be treated (NNT) = 40 (95% CI: 23–143), indicating that for every 40 patients (23–143) managed on FFT algorithm, one avoided staying in hospital longer than 10 days] and averted admission to intensive‐care unit (ICU) [NNT = 19 (95% CI: 13–40)]. All model's selected covariates were well balanced. The results remained robust to sensitivity analyses used to test the stability of the findings. Conclusions When delivered using a structured FFT algorithm, CPG shortened the hospital stay and help avoided admission to ICU, but it did not affect other relevant outcomes.

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Adherence of Clinical Practice Guidelines for Pharmacologic Treatments of Hospitalized Patients With COVID-19 to Trustworthy Standards

Cited by 6 publications

References 75 publications

SARS-CoV-2-Infection (COVID-19): Clinical Course and Cause(s) of Death

SARS-CoV-2-Infection (COVID-19): Clinical Course and Cause(s) of Death

SARS-CoV-2-Infection (COVID-19): Clinical Course, Viral Acute Respiratory Distress Syndrome (ARDS) and Cause(s) of Death

Evaluation of a fast‐and‐frugal clinical decision algorithm (‘pathways’) on clinical outcomes in hospitalised patients with COVID‐19 treated with anticoagulants

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