Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Routinely collected health data, obtained for administrative and clinical purposes without specific a priori research goals, are increasingly used for research. The rapid evolution and availability of these data have revealed issues not addressed by existing reporting guidelines, such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement was created to fill these gaps. RECORD was created as an extension to the STROBE statement to address reporting items specific to observational studies using routinely collected health data. RECORD consists of a checklist of 13 items related to the title, abstract, introduction, methods, results, and discussion section of articles, and other information required for inclusion in such research reports. This document contains the checklist and explanatory and elaboration information to enhance the use of the checklist. Examples of good reporting for each RECORD checklist item are also included herein. This document, as well as the accompanying website and message board (http://www.record-statement.org), will enhance the implementation and understanding of RECORD. Through implementation of RECORD, authors, journals editors, and peer reviewers can encourage transparency of research reporting.

https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1001885&type=printable

[The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement].

The Clinical Practice Research Datalink (CPRD) is an ongoing primary care database of anonymised medical records from general practitioners, with coverage of over 11.3 million patients from 674 practices in the UK. With 4.4 million active (alive, currently registered) patients meeting quality criteria, approximately 6.9% of the UK population are included and patients are broadly representative of the UK general population in terms of age, sex and ethnicity. General practitioners are the gatekeepers of primary care and specialist referrals in the UK. The CPRD primary care database is therefore a rich source of health data for research, including data on demographics, symptoms, tests, diagnoses, therapies, health-related behaviours and referrals to secondary care. For over half of patients, linkage with datasets from secondary care, disease-specific cohorts and mortality records enhance the range of data available for research. The CPRD is very widely used internationally for epidemiological research and has been used to produce over 1000 research studies, published in peer-reviewed journals across a broad range of health outcomes. However, researchers must be aware of the complexity of routinely collected electronic health records, including ways to manage variable completeness, misclassification and development of disease definitions for research.

Data Resource Profile: Clinical Practice Research Datalink (CPRD)

https://www.journal-of-hepatology.eu/article/S0168-8278(18)32388-2/pdf

Burden of liver diseases in the world

A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P = 0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P = 0.01), and adverse events occurred in 40% as compared with 48% (P = 0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P = 0.03) but not in those assigned to the restrictive strategy. Conclusions As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundacio Investigacio Sant Pau; ClinicalTrials.gov number, NCT00414713.)

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Transfusion strategies for acute upper gastrointestinal bleeding.

It is important for patient safety to assess if international changes in perioperative care, such as the focus on venous thromboembolism (VTE) prevention and minimally invasive surgery, have reduced the high post colectomy VTE risks previously reported. This study assesses the impact of changes in perioperative care on VTE risk following colorectal resection.

/pdf/time-trends-in-the-incidence-rates-of-venous-thromboembolism-3bhhqbqy.pdf

Time trends in the incidence rates of venous thromboembolism following colorectal resection by indication and operative technique

BACKGROUND & AIMS: It is unclear whether mortality from upper gastrointestinal hemorrhage is changing: any differences observed might result from changes in age or comorbidity of patient populations. We estimated trends in 28-day mortality in England following hospital admission for gastrointestinal hemorrhage. METHODS: We used a case-control study design to analyze data from all adults administered to a National Health Service hospital, for upper gastrointestinal hemorrhage, from 1999 to 2007 (n 516,153). Cases were deaths within 28 days of admission (n 74,992), and controls were survivors to 28 days. The 28-day mortality was derived from the linked national death register. A logistic regression model was used to adjust trends in nonvariceal and variceal hemorrhage mortality for age, sex, and comorbidities and to investigate potential interactions. RESULTS: During the study period, the unadjusted, overall, 28-day mortality following nonvariceal hemorrhage was reduced from 14.7% to 13.1% (unadjusted odds ratio, 0.87; 95% confidence interval: 0.84‐0.90). The mortality following variceal hemorrhage was reduced from 24.6% to 20.9% (unadjusted odds ratio, 0.8; 95% confidence interval: 0.69‐ 0.95). Adjustments for age and comorbidity partly accounted for the observed trends in mortality. Different mortality trends were identified for different age groups following nonvariceal hemorrhage. CONCLUSIONS: The 28-day mortality in England following both nonvariceal and variceal upper gastrointestinal hemorrhage decreased from 1999 to 2007, and the reduction had been partly obscured by changes in patient age and comorbidities. Our findings indicate that the overall management of bleeding has improved within the first 4 weeks of admission.

https://www.gastrojournal.org/article/S0016-5085(11)00419-7/pdf

CLINICAL—ALIMENTARY TRACT Reductions in 28-Day Mortality Following Hospital Admission for Upper Gastrointestinal Hemorrhage

OBJECTIVE
To determine the maximal response of the temperature and inflammatory response to SARS-CoV-2 infection and how these are modified by age.


METHODS
Participants were patients admitted to hospital with SARS-CoV-2 infection. For each participant, the maximal temperature and serum C-reactive protein (CRP) were identified and stratified by age. In a secondary analysis, these were compared in patients treated before and after dexamethasone.


RESULTS
Mean maximal temperature varied by age (p<0.001; ANOVA) with the highest mean maximal temperature of 37.3°C observed in patients aged 30-49 years and decreasing maximal mean temperatures in the older age groups, with the lowest measure of 36.8°C observed in individuals aged 90-99 years. The mean maximal serum CRP also varied across age groups (p<0.001; ANOVA) and increased with age across all age categories from 34.5 mg/dL (95% confidence interval (CI) 22.0-47.0) for individuals aged 20-29 years to 77.6 mg/dL (95% CI 72.0-83.2) in those aged 80-89 years. After dexamethasone became standard treatment for COVID-19 pneumonia, mean maximal CRP decreased by 17 mg/dL (95% CI -22 to -11).


CONCLUSION
Age modifies both maximal temperature and systemic inflammatory response in patients with SARS-CoV-2 infection.

/pdf/age-modifies-both-the-maximal-temperature-and-inflammatory-2b1cw4dd.pdf

Age modifies both the maximal temperature and inflammatory response in patients with SARS-CoV-2 infection.

Background The management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease. Methods Patients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission. Results In total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation. Conclusion Non-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study.

Objective: To assess the impact of current guidelines by reporting weekly postoperative postdischarge venous thromboembolism (VTE) rates. Summary Background Data: Disparity exists between the postoperative thromboprophylaxis duration colectomy patients receive based on surgical indication, where malignant resections routinely receive 28 days extended thromboprophylaxis into the postdischarge period and benign resections do not. Methods: English national cohort study of colectomy patients between 2010 and 2019 using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data. Stratified by admission type and surgical indication, absolute incidence rates (IRs) per 1000 person-years and adjusted incidence rate ratios (aIRRs) for postdischarge VTE were calculated for the first 4 weeks following resection and postdischarge VTE IRs for each postoperative week to 12 weeks postoperative. Results: Of 104,744 patients, 663 (0.63%) developed postdischarge VTE within 12 weeks after colectomy. Postdischarge VTE IRs per 1000 person-years for the first 4 weeks postoperative were low following elective resections [benign: 20.66, 95% confidence interval (CI): 13.73–31.08; malignant: 28.95, 95% CI: 23.09–36.31] and higher following emergency resections (benign: 47.31, 95% CI: 34.43–65.02; malignant: 107.18, 95% CI: 78.62–146.12). Compared with elective malignant resections, there was no difference in postdischarge VTE risk within 4 weeks following elective benign colectomy (aIRR=0.92, 95% CI: 0.56–1.50). However, postdischarge VTE risks within 4 weeks following emergency resections were significantly greater for benign (aIRR=1.89, 95% CI: 1.22–2.94) and malignant (aIRR=3.13, 95% CI: 2.06–4.76) indications compared with elective malignant colectomy. Conclusions: Postdischarge VTE risk within 4 weeks of colectomy is ∼2-fold greater following emergency benign compared with elective malignant resections, suggesting emergency benign colectomy patients may benefit from extended VTE prophylaxis.

https://journals.lww.com/annalsofsurgery/Abstract/9900/The_Duration_and_Magnitude_of_Post_Discharge.118.aspx

Colin J Crooks

Papers

Time trends in the incidence rates of venous thromboembolism following colorectal resection by indication and operative technique

CLINICAL—ALIMENTARY TRACT Reductions in 28-Day Mortality Following Hospital Admission for Upper Gastrointestinal Hemorrhage

Age modifies both the maximal temperature and inflammatory response in patients with SARS-CoV-2 infection.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study.

The Duration and Magnitude of Postdischarge Venous Thromboembolism Following Colectomy