RESEARCH BRIEFING – WEEK IN REVIEW
A new paper published in JAMA Internal Medicine looks at trends in hospitalizations for non-covid-19 acute and chronic medical conditions across four hospitals in the NYU Langone Health system in New York City. Hospital admission from the peak of the pandemic (March 1 to May 9, 2020) were analyzed and compared to hospital admission trends during the same time period in the years 2018 and 2019. The researchers identified 3,657 non-covid-19 hospitalizations during the aforementioned period in 2020. When compared to 2018 and 2019 admission, there was no significant difference in admission rates during the early pandemic period, though decreases in admissions were noted during the peak of the early pandemic period.Consistent with prior research, the researchers observed decreases in hospitalizations for the following disease processes: sepsis, heart failure, heart attacks, strokes, gallbladder disease, seizures, appendicitis, and emphysema (or chronic obstructive pulmonary disease/COPD) exacerbations. The authors note in their study, "while hospitalizations for acute events began recovering in the late covid-19 period, many of those related to chronic diseases generally did not."This study is limited by its inability to demonstrate causation. By nature of the study design, it does not and cannot prove with certainty that the results are due to sick patients avoiding the hospital during the pandemic. However, this study is yet another data point in the sea of data that suggest that there was less treatment of acute medical problems during the pandemic period. The question remains whether there were people who needed treatment who avoided it, or whether there were fewer triggers for these emergencies, such as decreases in stress, less pollution, and people staying home and eating healthier meals rather than eating out. 27 October 2020.
A new study conducted by researchers at the University of Maryland School of Medicine suggests a potential benefit of aspirin use for severe covid-19 patients. Aspirin is a commonly used medication for prevention and treatment of strokes and heart attacks as it helps prevent formation of blood clots. As previously discussed in Brief19, covid-19 results in a hypercoagulable state, meaning it puts patients at an increased risk for clots, particularly in the legs ("deep vein thrombosis") and lungs ("pulmonary embolism").
Published in Anesthesia & Analgesia, the retrospective study included patients admitted to the hospitals participating in a multicenter project called the Collaborative Research to Understand the Sequelae of Harm in COVID (CRUSH COVID) registry. Aspirin use was defined as administration within 24 hours of hospitalization or in the week prior. The main outcome of the study was the need for invasive mechanical ventilation. Other outcomes included admission to the intensive care unit and in-hospital mortality.
A total of 412 patients were included in the study, approximately 25 percent of whom received aspirin. Unsurprisingly, those receiving aspirin had significantly more existing medical conditions, which in turn placed them at a higher risk of covid-19-related mortality. In the final statistical analysis adjusting for patient characteristics, aspirin use was associated with a decreased risk of mechanical ventilation (adjusted hazard ratio=0.56, 95% confidence interval 0.37-0.85, p=0.007), ICU admission (adjusted HR 0.57, 95% CI 0.38-0.85, p=0.005) and in-hospital mortality (adjusted HR 0.53, 95% CI 0.31-0.90, p=0.02). Other predictors included older age, obesity and self-identifying as Latinx.
But does aspirin actually decrease the need for mechanical ventilation, ICU admissions and in-hospital mortality? Unlikely. The effect sizes reported above are quite large and lack "face validity." Furthermore, patients are risk stratified and placed on prophylactic heavy-duty blood thinning medications to prevent pulmonary emboli and deep vein thromboses. Based on these other treatments and the limitations of the study, it doesn't seem as though there is sufficient proof to determine aspirin's true benefit for covid-19 patients.
Nevertheless, the authors should be commended for this hypothesis-generating research and for their appropriate conclusion that "a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients." 30 October 2020.