Abstract Estimating mortality risk in hospitalized patients with COVID-19 infection may help clinicians to early triage patients with poor prognostic outcome. The Coronavirus Clinical Characterization Consortium Mortality Score (4C Score) is one of the predictive models that was externally validated in large cohorts. However, its use may be limited in population with quite different demographic and epidemiologic features. Objective To externally validate the 4 C score in a large Tunisian population Methods Multicenter retrospective cohort study of patients aged ≥ 14 years, hospitalized with the diagnosis of COVID-19. The primary outcome was in-hospital mortality, need for ICU admission and combined outcome (in-hospital mortality and/or ICU admission). We calculated the area under the receiver operating characteristic (ROC) curve (C statistics) for the 4C Mortality Score to assess the discriminatory power of the 4C Mortality Score for predicting outcomes. To assess calibration of the model, we used the Hosmer-Lemeshow goodness-of-fit test. Results 2327 patients with diagnosis of COVID-19 based on positive RT-PCR assay or rapid antigen test of a nasopharyngeal swab were included for final analysis. Median time between symptoms start and hospital admission was 4 days [2-7], and 69.2% needed oxygen therapy at hospital admission. In-hospital mortality was 15.4% (n=358); most deaths (11%, n=257) occurred in the ICU. Mortality rates within the 4C Mortality Score risk groups were 0.6% (Low), 8.7% (Intermediate), 53.1% (High), and 37.7% (Very High). The score achieved a good estimated discrimination when predicting death (C-statistic:0.86; 95%, CI [0.84-0.88]), ICU admission (C-statistic: 0.69; 95%, CI [0.65-0.72]) and the combined outcome (C-statistic:0.79; 95%, CI [0.77-0.81]). The calibration plot indicated good calibration for both in-hospial mortality and combined outcome (HosmerLemeshow goodness-of-fit test p value of 0.86 and 0.28 respectively). Our study represents a new external validation of the 4C score in COVID-19 patients with high reliability in predicting disease severity. These findings imply that the 4C Mortality Score may be generalized to patients with COVID-19 regardless of ethnicity and healthcare system.
Introduction: The overcrowding of intensive care units during the corona virus pandemic increased the number of patients managed in the emergency department (ED). The detection timely of the predictive factors of mortality and bad outcomes improve the triage of those patients. Aim: To define the predictive factors of mortality at 30 days among patients admitted on ED for covid-19 pneumonia. Methods: This was a prospective, monocentric, observational study for 6 months. Patients over the age of 16 years admitted on the ED for hypoxemic pneumonia due to confirmed SARS-COV 2 infection by real-time reverse-transcription polymerase chain reaction (rRT-PCR) were included. Multivariate logistic regression was performed to investigate the predictive factors of mortality at 30 days. Results: 463 patients were included. Mean age was 65±14 years, Sex-ratio=1.1. Main comorbidities were hypertension (49%) and diabetes (38%). Mortality rate was 33%. Patients who died were older (70±13 vs. 61±14;p<0.001), and had more comorbidities: hypertension (57% vs. 43%, p=0.018), chronic heart failure (8% vs. 3%, p=0.017), and coronary artery disease (12% vs. 6%, p=0.030). By multivariable analysis, factors independently associated with 30-day mortality were age ≥65 years aOR: 6.9, 95%CI 1.09-44.01;p=0.04) SpO2<80% (aOR: 26.6, 95%CI 3.5-197.53;p=0.001) and percentage of lung changes on CT scan>70% (aOR: 5.6% 95%CI .01-31.29;p=0.04). Conclusion: Mortality rate was high among patients admitted in the ED for covid-19 pneumonia. The identification of predictive factors of mortality would allow better patient management.
Introduction: The initial medical certificate (CMI) is a medico-legal document of great importance. Writing CMIs is a frequent act in emergency medicine. In 2011, the Haute Authority of Medicine (HAS) published good practice recommendations concerning the writing and content of these certificates. Nevertheless, this practice faces a difficult reality in the emergency services. The aim of this study was to analyze the writing quality of CMIs in terms of compliance of all the criteria collected with respect to HAS recommendations. Method: This was a retrospective study, evaluating professional practices over a period of two years in Ben Arous ED. We analyzed CMIs written by EPs. The certificates were subjected to a critical reading to begin a comparative study of the quality of writing of these certificates with the HAS recommendations using a criteria grid relating to the theoretical content of the certificates. Results: 207 CMIs were analyzed (Acts of violence 88%, work accidents 12% and AVP less than 1%). The medical writers were mainly represented by general practitioners (98%). Not all of the CMIs complied with writing recommendations. The identity of the physician, the identity of the patient, the date of the examination and of the facts, the nature of the lesions, the handwritten signature of the doctor and the stamp were mentioned in more than 95% of the CMIs. The presence of CNOM registration number, the profession, the address and the number of the national identity of the patient, the place of the facts, the medical history and the previous condition of the patient were absent in more than 95% of the CMIs. The duration of the ITT was written in full in 36% of the cases. Conclusion: The study revealed insufficiencies in the quality of CMI drafting written by EP. Specific training is underway to improve certificate redactions.
