Chronic Oral Anticoagulation Therapy and Prognosis of Patients Admitted to Hospital for COVID-19: Insights from the HOPE COVID-19 Registry

Background. Most evidence regarding anticoagulation and COVID-19 refers to the hospitalization setting, but the role of oral anticoagulation (OAC) before hospital admission has not been well explored. We compared clinical outcomes and short-term prognosis between patients with and without prior OAC therapy who were hospitalized for COVID-19. Methods. Analysis of the whole cohort of the HOPE COVID-19 Registry which included patients discharged (deceased or alive) after hospital admission for COVID-19 in 9 countries. All-cause mortality was the primary endpoint. Study outcomes were compared after adjusting variables using propensity score matching (PSM) analyses. Results. 7698 patients were suitable for the present analysis (675 (8.8%) on OAC at admission: 427 (5.6%) on VKAs and 248 (3.2%) on DOACs). After PSM, 1276 patients were analyzed (638 with OAC; 638 without OAC), without significant differences regarding the risk of thromboembolic events (OR 1.11, 95% CI 0.59-2.08). The risk of clinically relevant bleeding (OR 3.04, 95% CI 1.92-4.83), as well as the risk of mortality (HR 1.22, 95% CI 1.01-1.47; log-rank p value = 0.041), was significantly increased in previous OAC users. Amongst patients on prior OAC only, there were no differences in the risk of clinically relevant bleeding, thromboembolic events, or mortality when comparing previous VKA or DOAC users, after PSM. Conclusion. Hospitalized COVID-19 patients on prior OAC therapy had a higher risk of mortality and worse clinical outcomes compared to patients without prior OAC therapy, even after adjusting for comorbidities using a PSM. There were no differences in clinical outcomes in patients previously taking VKAs or DOACs. This trial is registered with NCT04334291/EUPAS34399

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Chronic Oral Anticoagulation Therapy and Prognosis of Patients Admitted to Hospital for COVID-19: Insights from the HOPE COVID-19 Registry

BackgroundMost evidence regarding anticoagulation and COVID-19 refers to the hospitalization setting, but the role of oral anticoagulation (OAC) before hospital admission has not been well explored. We compared clinical outcomes and short-term prognosis between patients with and without prior OAC therapy who were hospitalized for COVID-19.MethodsAnalysis of the whole cohort of the HOPE COVID-19 Registry which included patients discharged (deceased or alive) after hospital admission for COVID-19 in 9 countries. All-cause mortality was the primary endpoint. Study outcomes were compared after adjusting variables using propensity score matching (PSM) analyses.Results7698 patients were suitable for the present analysis (675 (8.8%) on OAC at admission: 427 (5.6%) on VKAs and 248 (3.2%) on DOACs). After PSM, 1276 patients were analyzed (638 with OAC; 638 without OAC), without significant differences regarding the risk of thromboembolic events (OR 1.11, 95% CI 0.59-2.08). The risk of clinically relevant bleeding (OR 3.04, 95% CI 1.92-4.83), as well as the risk of mortality (HR 1.22, 95% CI 1.01-1.47; log-rank p value = 0.041), was significantly increased in previous OAC users. Amongst patients on prior OAC only, there were no differences in the risk of clinically relevant bleeding, thromboembolic events, or mortality when comparing previous VKA or DOAC users, after PSM.ConclusionHospitalized COVID-19 patients on prior OAC therapy had a higher risk of mortality and worse clinical outcomes compared to patients without prior OAC therapy, even after adjusting for comorbidities using a PSM. There were no differences in clinical outcomes in patients previously taking VKAs or DOACs. This trial is registered with NCT04334291/EUPAS34399

Optimal Gearshift Control for a Novel Hybrid Electric Drivetrain

Torque-fill capability during gearshifts is an important customer requirement in automated transmission systems. This functionality can be achieved through transmission system layouts (e.g., based on dual-clutch technology) characterized by significant mechanical complexity, and hence with relatively high cost and mass. This paper describes a parallel hybrid electric drivetrain concept, based on the integration of an electric motor drive into a relatively simple six-speed automated manual transmission. The resulting hybrid electric drivetrain actuates the torque-fill function through control of the electric motor torque during the gearshifts on the engine side of the drivetrain. An optimal controller, based on the off-line computation of the control gain profiles, is presented for the clutch re-engagement phase. The novel controller allows computationally efficient consideration of clutch energy dissipation during the clutch re-engagement phase of the gearshift. The performance with the optimal controller is contrasted with that of two conventional clutch engagement controllers, along a set of gearshifts simulated with an experimentally validated vehicle model

Optimal gearshift control for a novel hybrid electric drivetrain

Torque-fill capability during gearshifts is an important customer requirement in automated transmission systems. This functionality can be achieved through transmission system layouts (e.g., based on dual-clutch technology) characterized by significant mechanical complexity, and hence with relatively high cost and mass. This paper describes a parallel hybrid electric drivetrain concept, based on the integration of an electric motor drive into a relatively simple six-speed automated manual transmission. The resulting hybrid electric drivetrain actuates the torque-fill function through control of the electric motor torque during the gearshifts on the engine side of the drivetrain. An optimal controller, based on the off-line computation of the control gain profiles, is presented for the clutch re-engagement phase. The novel controller allows computationally efficient consideration of clutch energy dissipation during the clutch re-engagement phase of the gearshift. The performance with the optimal controller is contrasted with that of two conventional clutch engagement controllers, along a set of gearshifts simulated with an experimentally validated vehicle model

Selection of the Optimal Gearbox Layout for an Electric Vehicle

The paper describes the advantages due to the adoption of multi-speed transmission systems within fully electric vehicles. In particular, the article compares a conventional single-speed transmission layout, a 2-speed layout based on a novel gearbox architecture capable of seamless gearshifts, and a Continuously Variable Transmission layout. The selection of the optimal gear ratios for the 2-speed system has been based on an optimization procedure, taking into account the efficiency characteristics of the components of the whole vehicle powertrain. The control system for the Continuously Variable Transmission system has been designed with the aim of maximizing the efficiency of the operating points of the electric motor. The results show that there is a significant advantage in adopting a 2-speed transmission system over the single-speed layout, and, despite a reduction in motor losses, the typically lower efficiency characteristics of Continuously Variable Transmissions do not result in lower energy consumption for the four case study vehicles

Selection of the Optimal Gearbox Layout for an Electric Vehicle

The paper describes the advantages due to the adoption of multi-speed transmission systems within fully electric vehicles. In particular, the article compares a conventional single-speed transmission layout, a 2-speed layout based on a novel gearbox architecture capable of seamless gearshifts, and a Continuously Variable Transmission layout. The selection of the optimal gear ratios for the 2-speed system has been based on an optimization procedure, taking into account the efficiency characteristics of the components of the whole vehicle powertrain. The control system for the Continuously Variable Transmission system has been designed with the aim of maximizing the efficiency of the operating points of the electric motor. The results show that there is a significant advantage in adopting a 2-speed transmission system over the single-speed layout, and, despite a reduction in motor losses, the typically lower efficiency characteristics of Continuously Variable Transmissions do not result in lower energy consumption for the four case study vehicles