Publications

OBJECTIVES

Patients hospitalized for COVID-19 frequently develop hypoxemia and acute respiratory distress syndrome (ARDS) after admission. In non-COVID-19 ARDS studies, admission to hospital wards with subsequent transfer to intensive care unit (ICU) is associated with worse outcomes. We hypothesized that initial admission to the ward may affect outcomes in patient with COVID-19 ARDS.

METHODS

This was a retrospective study of consecutive adults admitted for COVID-19 ARDS between March 2020 and March 2021 at Stanford Health Care. Mortality scores at hospital admission (Coronavirus Clinical Characterization Consortium Mortality Score [4C score]) and ICU admission (Simplified Acute Physiology Score III [SAPS-III]) were calculated, as well as ROX index for patients on high flow nasal oxygen. Patients were classified by emergency department (ED) disposition (ward-first vs. ICU-direct), and 28- and 60-day mortality and highest level of respiratory support within 1 day of ICU admission were compared. A second cohort (April 2021‒July 2022,  = 129) was phenotyped to validate mortality outcome.

RESULTS

A total of 157 patients were included, 48% of whom were first admitted to the ward ( = 75). Ward-first patients had more comorbidities, including lung disease. Ward-first patients had lower 4C and similar SAPS-III score, yet increased mortality at 28 days (32% vs. 17%, hazard ratio [HR] 2.0, 95% confidence interval [95% CI] 1.0‒3.7,  = 0.039) and 60 days (39% vs. 23%, HR 1.83, 95% CI 1.04‒3.22,  = 0.037) compared to ICU-direct patients. More ward-first patients escalated to mechanical ventilation on day 1 of ICU admission (36% vs. 14%,  = 0.002) despite similar ROX index. Ward-first patients who upgraded to ICU within 48 h of ED presentation had the highest mortality. Mortality findings were replicated in a sensitivity analysis.

CONCLUSION

Despite similar baseline risk scores, ward-first patients with COVID-19 ARDS had increased mortality and escalation to mechanical ventilation compared to ICU-direct patients. Ward-first patients requiring ICU upgrade within 48 h were at highest risk, highlighting a need for improved identification of this group at ED admission.

Definitive data demonstrating the utility of coronavirus disease 2019 (COVID-19) convalescent plasma (CCP) for treating immunocompromised patients remains elusive. To better understand the mechanism of action of CCP, we studied viral replication and disease progression in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected hamsters treated with CCP obtained from recovered COVID-19 patients that were also vaccinated with an mRNA vaccine, hereafter referred to as Vaxplas. Vaxplas transiently enhanced disease severity and lung pathology in hamsters treated near peak viral replication due to immune complex and activated complement deposition in pulmonary endothelium, and recruitment of M1 proinflammatory macrophages into the lung parenchyma. However, aside from one report, transient enhanced disease has not been reported in CCP recipient patients, and the transient enhanced disease in Vaxplas hamsters may have been due to mismatched species IgG-FcR interactions, infusion timing, or other experimental factors. Despite transient disease enhancement, Vaxplas dramatically reduced virus replication in lungs and improved infection outcome in SARS-CoV-2-infected hamsters.

There is growing evidence that Asian and Latinx immigrants' health and health care access is shaped by immigrant policies that determine their rights, protections, and access to resources and the extent to which they are targeted by policing or deportation based on citizenship/legal status and other immigration-related social categories. However, there is limited population-based evidence of how immigrants experience the direct consequences of policies, nor of the impact of such consequences on their health. Between 2018 and 2020, we conducted the Research on Immigrant Health and State Policy (RIGHTS) Study, developing a population-based survey of Asian and Latinx immigrants in California (n = 2010) that measured 23 exclusionary experiences under health care and social services, education, labor/employment, and immigration enforcement policies. Applying Ruth Wilson Gilmore's concept of "disproportionate costs," we conducted a latent class analysis (LCA) and regression models of the RIGHTS data to 1) describe patterns of immigrant policy exclusion experienced by Asian and Latinx immigrants and 2) test relationships between patterns of policy exclusion and health care access and health status. LCA analyses identified 6 classes of distinct combinations of policy exclusions. In regression analyses, respondents in the class with cumulative exclusions across all policy sectors had the worst health care access and highest level of psychological distress, but the best self-rated health; while those in the class with employment and enforcement exclusions also had poor health care access. Respondents in the other 3 classes experienced combinations of health and social services exclusions, but these alone were not associated with worse outcomes. Findings show that the consequences of immigrant policies harm health through both cumulative exposure to and intersections of exclusions across policy sectors. Labor/employment and immigration enforcement policies, specifically, likely drive health inequities within immigrant populations. The RIGHTS study highlights the need to measure the cumulative and intersecting "disproportionate costs" of immigrant policy within diverse immigrant populations.