1. Demographics And Clinical Characteristics of COVID Oncology Patients:
A total of 89 oncology covid patients were included in the study. Their average age was 66 years (± 13.6). The majority were males (64%), and with solid cancer (74.2%). About half of them were smokers (52.8%) and had chemotherapy within 1 month of presentation (52.8%). Only 6 patients did BMT within 1 year of presentation. Hypertension was the main comorbidity among patients (39.3%), followed by cardiovascular diseases (25.8%), dyslipidemia (23.6%), diabetes mellitus (14.6%). About 34.8% died (n = 31) and 37% were admitted to the ICU (n = 33). Of the total 33 patients admitted to ICU (37%), the mean age of patients admitted to ICU was 67 years (± 11.2) and were mainly males (69.7%) (Table 1)
Table 1: Association of Baseline Characteristics of Oncology COVID Patients with ICU Admission
Characteristics
|
Total N=89
|
No ICU n=56 (63%)
|
ICU n=33 (37%)
|
p value
|
OR
|
95%
CI
|
Age (years)
|
66.3 (13.6)
|
65.9 (14.8)
|
67 (11.2)
|
0.711
|
|
|
Sex
|
Female
|
32 (36%)
|
22 (39.3%)
|
10 (30.3%)
|
0.394
|
Ref
|
|
Male
|
57 (64%)
|
34 (60.7%)
|
23 (69.7%)
|
1.488
|
0.596-3.719
|
History of smoking
|
47 (52.8%)
|
28 (50%)
|
19 (57.6%)
|
0.489
|
1.357
|
0.571-3.228
|
Type of Cancer
|
Liquid
|
23 (26.7%)
|
14 (25.5%)
|
9 (29%)
|
0.801
|
Ref
|
|
Solid
|
63 (73.3%)
|
41 (74.5%)
|
22 (71%)
|
0.835
|
0.312-2.234
|
Metastatic tumor
|
34 (52.3%)
|
20 (47.6%)
|
14 (60.9%)
|
0.306
|
1.711
|
0.609-4.809
|
Bone Marrow Transplant within 1 year
|
6 (6.8%)
|
3 (5.4%)
|
3 (9.4%)
|
0.664
|
1.828
|
0.346-9.642
|
Chemo within 1 month
|
47 (52.8%)
|
26 (46.4%)
|
21 (63.6%)
|
0.116
|
2.019
|
0.835-4.88
|
Immunotherapy
|
19 (21.3%)
|
12 (21.4%)
|
7 (21.2%)
|
0.981
|
0.987
|
0.345-2.823
|
Comorbidities
|
Cardiovascular Diseases
|
23 (25.8%)
|
17 (30.4%)
|
6 (18.2%)
|
0.205
|
0.51
|
0.178-1.46
|
Diabetes Mellitus
|
13 (14.6%)
|
6 (10.7%)
|
7 (21.2%)
|
0.219
|
2.244
|
0.683-7.367
|
Hypertension
|
35 (39.3%)
|
22 (39.3%)
|
13 (39.4%)
|
0.992
|
1.005
|
0.416-2.423
|
Dyslipidemia
|
21 (23.6%)
|
14 (25%)
|
7 (21.2%)
|
0.684
|
0.808
|
0.288-2.264
|
Cerebrovascular accident/TIA
|
2 (2.2%)
|
1 (1.8%)
|
1 (3%)
|
1
|
1.719
|
0.104-28.43
|
Chronic Obstructive Pulmonary Disease
|
8 (9%)
|
7 (12.5%)
|
1 (3%)
|
0.249
|
0.219
|
0.026-1.863
|
Chronic Kidney Disease
|
16 (18%)
|
10 (17.9%)
|
6 (18.2%)
|
0.969
|
1.022
|
0.334-3.127
|
Hemiplegia
|
1 (1.1%)
|
1 (1.8%)
|
0 (0%)
|
1
|
|
|
Peptic ulcer disease
|
2 (2.2%)
|
1 (1.8%)
|
1 (3%)
|
1
|
1.719
|
0.104-28.43
|
Liver Disease
|
3 (3.4%)
|
1 (1.8%)
|
2 (6.1%)
|
0.552
|
3.548
|
0.309-40.73
|
Other*
|
58 (65.2%)
|
40 (71.4%)
|
18 (54.5%)
|
0.106
|
0.48
|
0.196-1.178
|
Data are presented as numbers with percentages.
P-value for difference between two adjacent columns is calculated by chi-square or Fisher´s exact test where appropriate.
Abbreviations: OR: odds ratio, 95%CI: 95% Confidence Interval, Ref=Reference,ICU=intensive care unit, ED=emergency department
*Other comorbidities are thyroid disease, psychiatric disorders, and rheumatologicdiseases.
Most of the patients had tachycardia (n = 79, 89.8%) and 40.4% had low oxygen saturation at triage < 95mmHg (n = 36, 40.4%). (Table 2)
Table 2
Association of Vital Signs and ED treatment of COVID Oncology Patients with ICU Admission
|
Total n = 89
|
No ICU n = 56 (63%)
|
ICU n = 33 (37%)
|
p value
|
OR
|
95%CI
|
ED treatment
|
Mechanical Ventilation in ED
|
11 (12.4%)
|
0
|
11 (33.3%)
|
< .001
|
|
|
Vasopressors
|
7 (7.9%)
|
1 (1.8%)
|
6 (18.2%)
|
0.01
|
12.222
|
1.4-106.674
|
Steroid
|
50 (56.2%)
|
26 (46.4%)
|
24 (72.7%)
|
0.016
|
3.077
|
1.215–7.789
|
Antibiotics
|
43 (48.3%)
|
31 (55.4%)
|
12 (36.4%)
|
0.083
|
0.461
|
0.19–1.115
|
Anticoagulants
|
42 (47.2%)
|
22 (39.3%)
|
20 (60.6%)
|
0.052
|
2.378
|
0.986–5.735
|
Plasma
|
6 (6.7%)
|
4 (7.1%)
|
2 (6.1%)
|
1
|
0.839
|
0.145–4.849
|
Remdesivir
|
17 (19.1%)
|
13 (2 3.2%)
|
4 (12.1%)
|
0.198
|
0.456
|
0.135–1.539
|
Ivermectin
|
13 (14.6%)
|
7 (12.5%)
|
6 (18.2%)
|
0.54
|
1.556
|
0.475–5.099
|
Tocilizumab
|
8 (9%)
|
2 (3.6%)
|
6 (18.2%)
|
0.048
|
6
|
1.134–31.735
|
Baricitinib
|
3 (3.4%)
|
1 (1.8%)
|
2 (6.1%)
|
0.552
|
3.548
|
0.309–40.73
|
Vital Signs
|
Heart rate at triage
|
<=100
|
46 (51.7%)
|
32 (57.1%)
|
14(42.4%)
|
0.180
|
Ref
|
|
> 100
|
43(48.3%)
|
24(42.9%)
|
19(57.6%)
|
1.180
|
0.758–4.319
|
Systolic blood pressure at triage
|
<=100
|
9 (10.2%)
|
7 (12.5%)
|
2 (6.3%)
|
0.478
|
Ref
|
|
> 100
|
79 (89.8%)
|
49 (87.5%)
|
30 (93.8%)
|
2.143
|
0.417–11.001
|
Respiratory rate at triage
|
<=22
|
72 (83.7%)
|
53 (94.6%)
|
19 (63.3%)
|
0.001
|
0.098
|
0.025–0.389
|
> 22
|
14 (16.3%)
|
3 (5.4%)
|
11 (36.7%)
|
Ref
|
|
Temperature
(°C) at triage
|
< 37.5
|
50 (57.5%)
|
30 (53.6%)
|
20 (64.5%)
|
0.323
|
Ref
|
|
>=37.5
|
37 (42.5%)
|
26 (46.4%)
|
11 (35.5%)
|
0.635
|
0.257–1.567
|
Oxygen Saturation level (mmHg)
|
SpO2 < 95
|
36 (40.4%)
|
16 (28.6%)
|
20 (60.6%)
|
0.003
|
3.846
|
1.552–9.523
|
SpO2 > = 95
|
53 (59.6%)
|
40 (71.4%)
|
13 (39.4%)
|
Ref
|
0.105–0.644
|
Data are presented as numbers with percentages. |
P-value for difference between two adjacent columns is calculated by chi-square or Fisher´s exact test where appropriate. |
Abbreviations: OR: odds ratio, 95%CI: 95% Confidence Interval, Ref = Reference, SpO2 = Oxygen saturation, ICU = intensive care unit, ED = emergency department |
Patients with liquid or solid tumors were homogenous in terms of age, smoking status, and presence of comorbidities. However, patients with liquid tumors were mainly males (95.7% vs 50.8%, p < 0.001) and had more moderate to severe kidney diseases (34.8% vs 11.1%, p = .021).
2. Treatments And Health Related Complications Of COVID Oncology Patients
In the emergency department, the patients were treated mainly with steroids (56.2%), antibiotics (48.3%), and anticoagulants (47.2%). They were also treated with Remdesivir (19.1%), Ivermectin (14.6%), Tocilizumab (9%), or convalescent plasma (6.7%). Only7.9% of patients were treated with vasopressors (n = 7). (Table 2)
As for the complications during their hospital stay, 33.7% developed respiratory complications including ARDS, pneumothorax, or respiratory failure while 15.7% had septic shock, and 7.9% developed cardiovascular complications. Only 9% of patients required dialysis (n = 8). About 28.1% were endotracheal intubated (n = 25). The average length of hospital stay was 30.7 days (+- 65.1).
2.1 Characteristics Of Patients Who Required Intubation In The Ed
There were 11 patients intubated in the ED (12.4%). There was no significant difference in gender, age, smoking status, and presence of comorbidities between patients who were endotracheal intubated in the ED and those who were not. The average age of intubated patients was 66.7 years (± 10.2) and were mainly males (81.8%).
For vital signs, patients who were intubated in the ED had significantly more low oxygen saturation level at triage < 95 mmHg (81.8% vs 34.6%, p = .006), tachypnea with a RR > 22 breaths/minute (72.7% vs 8%, p < .001), or tachycardia (HR > 100 beats/minute) (81.8% vs 43.6%, p = .018).
Patients who were intubated were more on Ivermectin (36.4% vs 11.5%, p = .051), vasopressors (54.5% vs 1.3%, p < .001), or anticoagulants (81.8% vs 42.3%, p = .014). Intubated patients were less on antibiotics (9.1% vs 53.8%, p = .005). The CRP level was significantly higher in intubated patients (187.5 ± 93.3 vs 85.5 ± 74.6, p < .001).
2.2 Characteristics Of Patients Who Had Respiratory Complications
About 30 patients developed respiratory complications (33.7%) including pneumothorax, acute respiratory distress syndrome, and respiratory failure. However, patients with respiratory complications or not didn’t show significant differences in terms of gender, age, smoking status, or presence of comorbidities.
For vital signs, patients with respiratory complications had significantly lower oxygen saturation level at triage < 95 mmHg (56.7% vs 32.2%, p = .026) or tachypnea RR > 22 (35.7% vs 6.9%, p = .001).
Patients with respiratory complications were significantly more on Tocilizumab (20% vs 3.4%, p = .016), steroids (76.7% vs 45.8%, p = .005) or anticoagulants (66.7% vs 37.3%, p = .009). They had significantly elevated CRP level (132.8 ± 94.2 vs 82.6 ± 74.5, p = .011). They were also more admitted to the ICU (75.8% vs 13.6%, p < .001) and more died (23.3% vs 1.7%, p = .002).
3. Predictors Of ICU Admission in Covid Oncology Patients
None of the baseline characteristics including gender, age, smoking status, and presence of comorbidities significantly associated with ICU admission (p > 0.05). (Table 1)
Patients in ICU were significantly more on vasopressors (18.2% vs 1.8%, p = .01) and more mechanically ventilated in the ED (p < .001) than patients who were not admitted to the ICU. They were also significantly 6 times more on Tocilizumab (18.2% vs 12.5%, p = .048) and 3 times more on steroids (72.7% vs 46.4%, p = .016). (Table 2)
For vital signs, low oxygen saturation level at triage < 95 mmHg (60.6% vs 28.6%, p = .003) and elevated respiratory rate (> 22 breaths/min) (36.7% vs 5.4%, p = .001) were significantly associated with ICU admission. However, there was no significant difference in systolic blood pressure and temperature of patients who were admitted to the ICU compared to patients who were not admitted to the ICU (p > 0.05). (Table 2)
The CRP level upon ED presentation was significantly higher in patients admitted to ICU than patients who didn’t require an ICU admission (140.8 ± 98.2 vs 76.1 ± 65.9, p = .003). (Table 3)
Table 3
Association of ED laboratory data of COVID Oncology with ICU Admission
Laboratory Data
|
Total N = 89
|
No ICU n = 56 (63%)
|
ICU n = 33 (37%)
|
p value
|
White blood cells. count
|
8735.830 (11719.0215)
|
7548.5 (7071.2)
|
10714.7 (16808.96)
|
0.31
|
Hemoglobin
|
11 (1.9456)
|
11.1 (1.9)
|
10.8 (2.1)
|
0.393
|
Platelets
|
184323.864 (92905.1327)
|
178514.55 (86596.1)
|
194006.1 (103234.996)
|
0.452
|
Lactate Dehydrogenase
|
568.77 (560.581)
|
658.8 (738.7)
|
465.3 (204.2)
|
0.239
|
Lactic acid Venous
|
1.9024 (1.39752)
|
1.8 (1.7)
|
2.1 (0.82)
|
0.445
|
C-Reactive Protein
|
99.5 (84.5)
|
76.1 (65.9)
|
140.8 (98.2)
|
0.003
|
d-dimer
|
1379.9 (3418.1)
|
944 (1061.9)
|
2142.7 (5482.1)
|
0.3
|
Procalcitonin
|
1 (2.9)
|
0.8 (3.5)
|
1.2 (1.8)
|
0.552
|
Troponin T
|
0 (0.1)
|
0 (0.1)
|
0 (0)
|
0.539
|
Data are presented as mean with standard deviation. |
P-value for difference between two adjacent columns is calculated by T test. |
Additionally, patients admitted to ICU significantly develop more respiratory complications (75.8% vs 8.9%, p < .001), AKI (42.4% vs 7.1%, p < .001), pulmonary embolism (p = .048), septic shock (p < .001). They were significantly more on Dialysis (21.2% vs 1.8%, p = 0.004) and more died (p < .001).
3.1 Predictors Of ICU Admission in Covid Oncology Patients Using Logistic Regression
After adjusting for confounding variables using logistic regression, Remdesivir (aOR = .05, 95%CI = .005-.463) and antibiotics (aOR = .15, 95%CI = .031-.73) were found to reduce the risk of ICU admission. Patients admitted to ICU were more on steroids (aOR = 13.4, 95%CI = 2.3–78.2) and more on Tocilizumab (aOR = 18.5, 95%CI = 1.9-179.6). They had significantly more respiratory rate at triage (aOR = 17.431, 95%CI = 2.4-125.1). They had also significantly received more chemotherapy within 1 month of presentation (aOR = 5.5, 95%CI = 1.2–25.8). (Table 3)
Table 4
Logistic Regression: Factors associated with mortality in COVID ICU patients
|
p-value
|
aOR
|
95% C.I.
|
Remdesivir
|
0.008
|
0.05
|
0.005
|
.463
|
Tocilizumab
|
0.012
|
18.481
|
1.902
|
179.595
|
Steroid
|
0.004
|
13.399
|
2.297
|
78.159
|
Antibiotics
|
0.019
|
.15
|
.031
|
.73
|
RR at triage
|
0.004
|
17.431
|
2.429
|
125.111
|
Chemotherapy within 1 month of presentation
|
0.029
|
5.545
|
1.193
|
25.78
|
Variable(s) entered on step 1: Vasopressors, Remdesivir, Tocilizumab, Steroid, Antibiotics, Anticoagulant, CRP, RR at triage (reference ≤ 22), O2 at triage (reference ≥ 95 mmHg), Chemotherapywithin1monthofpresentation. |
Omnibus < .001, R2 = .577, Hosmer = 0.918 |
95%C.I.: 95% Confidence Interval, aOR: adjusted Odds Ratio |