Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Etiologia da baixa visão e cegueira em sete centros de referência na Colômbia entre os anos de 2012 a 2017

Introduction: Low vision and blindness have high global prevalence, with categories of disability common in Colombia. Studies that characterize the etiology of permanent visual impairments are required. Objective: To identify and characterize the different causes of low vision and blindness in seven reference centers for the visually impaired population in Colombia, attended between 2012 and 2017 in six capital cities. Materials and methods: retrospective, case series, descriptive and multicenter study. Results: A sample of 879 records of visually impaired patients was available. Low vision is more prevalent for all age groups. 70% (612/879) low vision and 30% (267/879) blindness. The most common etiology in patients with low vision was age-related macular degeneration (DMAE) (24%, 144/612); in patients with blindness it was glaucoma (17%, 45/267). Discussion: Possibly in Colombia the causes of low vision and blindness go beyond cataracts, un corrected refractive errors and infectious blindness. Conclusions: The most common etiologies found are chronic and diverse eye conditions, which require specific interventions to decrease their prevalence and prevent cases of low vision and blindness. How to cite this article: Suárez Escudero Juan Camilo, Oviedo Cáceres María del Pilar, Llano Naranjo Yuliana, Arias Uribe Johana, Villegas Mesa José Daniel, Zapata Vásquez María Camila, Ferreira Morales Jorge Luis, Reyes Cisneros Jessica Tatiana, Cano Calle Karen, Goldfeder de Gracia Sydney, González Franco Juan Felipe, Astudillo Valverde Esau. Etiología de baja visión y ceguera en siete centros de referencia en Colombia entre los años 2012 a 2017. Revista Cuidarte. 2022;13(2):e2036. http://dx.doi.org/10.15649/cuidarte.2036     Introducción: la baja visión y la ceguera tienen alta prevalencia mundial, siendo categorías de discapacidad frecuentes en Colombia. Se requieren estudios que caractericen la etiología de las deficiencias visuales permanentes. Objetivo: Identificar y caracterizar las diferentes causas de baja visión y ceguera en siete centros de referencia para la población con discapacidad visual en Colombia, atendida entre los años 2012 a 2017 en seis ciudades capitales. Materiales y métodos: estudio retrospectivo, serie de casos, descriptivo y multicéntrico. Resultados: Se contó con una muestra de 879 registros de pacientes con discapacidad visual. El 70% (612/879) con baja visión y 30% (267/879) con ceguera. Para todos los grupos de edad es más prevalente la baja visión. La etiología más frecuente en pacientes con baja visión fue la degeneración macular asociada a la edad (DMAE) (24%, 144/612); en pacientes con ceguera fue el glaucoma (17%, 45/267). Discusión: Posiblemente en Colombia las causas de baja visión y ceguera van más allá de las cataratas, errores de refracción no corregidos y ceguera infecciosa.  Conclusiones: las etiologías más frecuentes encontradas son condiciones oculares crónicas y diversas, que requieren intervenciones específicas para disminuir su prevalencia y prevenir casos de baja visión y ceguera. Como citar este artículo: Suárez Escudero Juan Camilo, Oviedo Cáceres María del Pilar, Llano Naranjo Yuliana, Arias Uribe Johana, Villegas Mesa José Daniel, Zapata Vásquez María Camila, Ferreira Morales Jorge Luis, Reyes Cisneros Jessica Tatiana, Cano Calle Karen, Goldfeder de Gracia Sydney, González Franco Juan Felipe, Astudillo Valverde Esau. Etiología de baja visión y ceguera en siete centros de referencia en Colombia entre los años 2012 a 2017. Revista Cuidarte. 2022;13(2):e2036. http://dx.doi.org/10.15649/cuidarte.2036     Introdução: Baixa visão e cegueira têm alta prevalência global, com categorias de incapacidade comuns na Colômbia. São necessários estudos que caracterizem a etiologia das deficiências visuais permanentes. Objetivo: Identificar e caracterizar as diferentes causas de baixa visão e cegueira em sete centros de referência para a população deficiente visual na Colômbia, atendidos entre 2012 e 2017 em seis capitais. Materiais e métodos: estudo retrospectivo, série de casos, descritivo e multicêntrico. Resultados: Uma amostra de 879 registros de pacientes com deficiência visual estava disponível. 54% (478/879) homens. A baixa visão é mais prevalente para todas as faixas etárias. 70% (612/879) baixa visão e 30% (267/879) cegueira. A etiologia mais comum em pacientes com baixa visão foi a degeneração macular relacionada à idade (DMAE) (24%, 144/612); em pacientes com cegueira foi glaucoma (17%, 45/267). Discussão: Possivelmente na Colômbia as causas da baixa visão e cegueira vão além da catarata, erros refrativos não corrigidos e cegueira infecciosa. Conclusões: As etiologias mais comuns encontradas são condições oculares crônicas e diversas, que requerem intervenções específicas para diminuir sua prevalência e prevenir casos de baixa visão e cegueira. Como citar este artigo: Suárez Escudero Juan Camilo, Oviedo Cáceres María del Pilar, Llano Naranjo Yuliana, Arias Uribe Johana, Villegas Mesa José Daniel, Zapata Vásquez María Camila, Ferreira Morales Jorge Luis, Reyes Cisneros Jessica Tatiana, Cano Calle Karen, Goldfeder de Gracia Sydney, González Franco Juan Felipe, Astudillo Valverde Esau. Etiología de baja visión y ceguera en siete centros de referencia en Colombia entre los años 2012 a 2017. Revista Cuidarte. 2022;13(2):e2036. http://dx.doi.org/10.15649/cuidarte.2036    &nbsp

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings