But since were learning new things about the vaccines and COVID-19, do we need to worry about other treatments or medications causing minor issues? Whenever anticoagulant or antiplatelet therapy is used, potential drug-drug interactions with other concomitant drugs must be considered. Aspirin in COVID-19: Pros and Cons - PubMed The IMPROVEDD VTE risk score: incorporation of D-dimer into the IMPROVE score to improve venous thromboembolism risk stratification. What Do The Numbers On Recyclable Plastics Mean? For example, its recommended that dermal fillers be scheduled either two weeks before or after getting vaccinated because a few people experienced facial swelling during Modernas phase three trial. For instance, say youre considering a steroid injection in your back. I don't think so. Shorr AF, Williams MD. If you have COVID-19 symptoms and are waiting for your test results, follow these instructions until: You get your test results and they are negative. Put your used tissues in a waste bin with a liner and lid. Open the window and turn on a fan to help air flow. In several cohort studies of pregnant women with COVID-19 in the United States and Europe, VTE was not reported as a complication even among women with severe disease, although the receipt of prophylactic or therapeutic anticoagulation varied across the studies.44-46 The American College of Obstetricians and Gynecologists (ACOG) advises that although there are not enough data to recommend either for or against the use of thromboprophylaxis, in the setting of COVID-19 during pregnancy, VTE prophylaxis can reasonably be considered for pregnant individuals hospitalized with COVID-19, particularly for those who have severe disease.47 If there are no contraindications, the Society for Maternal-Fetal Medicine recommends the use of prophylactic heparin or LMWH in pregnant patients who are critically ill or receiving mechanical ventilation.48 Several professional societies, including the American Society of Hematology and ACOG, have guidelines that specifically address the management of VTE in the context of pregnancy.49,50 If delivery is imminent, or if there are other risks for bleeding, the risk of bleeding may outweigh the potential benefit of using VTE prophylaxis in pregnant individuals. These are just a few examples. 2022. COVID-19 VACCINE: Questions and answers - WGAL But rapid tests are more likely than PCR tests to have a false negative result. There is insufficient evidence for the Panel to recommend either for or against the use of antiplatelet therapy in critically ill patients with COVID-19. In randomized controlled trials conducted prior to the pandemic, the incidence of VTE in hospitalized patients without COVID-19 who received VTE prophylaxis ranged from 0.3% to 1% for symptomatic VTE and from 2.8% to 5.6% for VTE overall.6-8 In randomized trials, the VTE incidence among critically ill patients without COVID-19 who received a prophylactic dose of anticoagulants ranged from 5% to 16%, and a prospective cohort study of critically ill patients with sepsis reported a VTE incidence of 37%.9-12, Guidelines for the use of antithrombotic therapy in patients with COVID-19 have been released by multiple organizations, including the American College of Chest Physicians,13 the American Society of Hematology,14 the Anticoagulation Forum,15 the International Society on Thrombosis and Haemostasis,16 the Italian Society on Thrombosis and Haemostasis,17 the National Institute for Health and Care Excellence (NICE),18 and the Royal College of Physicians.19. The guidelines referenced above agree that hospitalized, nonpregnant patients with COVID-19 should receive, at a minimum, a prophylactic dose of anticoagulation to prevent VTE. Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. What to Avoid Before the Covid Vaccine - Cleveland Clinic For more resources, visit www.mskcc.org/pe to search our virtual library. Do not share electronics (such as a cell phone or tablet), dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. There was no statistically significant difference between the arms for the primary endpoint, which was a composite of ICU admission, noninvasive or mechanical ventilation, or death by Day 28. These vaccines can help protect you and your baby. Another recent discovery was that both the Pfizer and Moderna COVID-19 vaccines can cause lymph nodes in your armpit to swell, especially on the side where the shot was administered. ACTIV-4b was a placebo-controlled, randomized trial that evaluated the efficacy of using aspirin or prophylactic doses (2.5 mg) or therapeutic doses (5 mg) of apixaban in outpatients with COVID-19 aged >40 years. Follow the instructions in this section to help keep COVID-19 from spreading to people in your home and community. If you think you need to take a higher dose, talk with your healthcare provider. If you're a patient at MSK and you need to reach a provider after. Its OK to take baby aspirin (81 milligrams (mg) per day) if your healthcare provider told you to. Your health care provider also might suggest that you take low-dose aspirin if you've had several miscarriages or other pregnancy loss. Do not shake your dirty laundry. Do not go to work, school, or other public areas. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. This information explains what to do at home if you have or might have COVID-19. Advertising on our site helps support our mission. Starting a new hobby or doing an activity you usually do not have time for. Aspirin is an OTC anti-inflammatory drug that helps with a number of symptoms that patients tend to experience following the second dose of the COVID-19 vaccine. Major bleeding occurred in 2.5% of patients in the intermediate-dose anticoagulation arm and in 1.4% of patients who received the prophylactic dose. You should complete your vaccine schedules as they were originally planned out. Managing COVID-19 at Home - Memorial Sloan Kettering Cancer Center Monday through Friday, 8 a.m. to 6 p.m. (Eastern time), Monday through Friday, 9 a.m. to 5 p.m. (Eastern time), Monday to Friday, 8 a.m. to 6 p.m. (Eastern time). 2022. The COVID-PACT trial randomized 292 adult patients with COVID-19 who required ICU-level care to receive either clopidogrel or no antiplatelet therapy.29 No differences occurred between the arms in the incidence of VTE, arterial thrombotic events, or bleeding. If you have hypertension or another common medical condition, you can have a little more peace of mind knowing that they did studies and trials on the COVID-19 vaccines which included people with the same conditions. Whats going on is that we want a robust immune response from the COVID-19 vaccine. It's hard to predict who will develop side effects and which ones they'll have. Many people take an aspirin or ibuprofen before getting vaccinations, but health experts say pain relievers and the COVID-19 vaccine might not be a good mix. Experts say the study is promising, but more research. The risk of rare side effects from COVID-19 vaccines like AstraZeneca are greatly exaggerated as they are far safer than many medicines people are taking every day. Stay in that room away from other people and pets as much as you can. If you have any questions, talk to your healthcare provider. Avoid using public transportation, ride-sharing services, and taxis. Eat light meals. Keep track of your temperature. Chow JH, Yin Y, Yamane DP, et al. For a list of common medications containing acetaminophen and abbreviations for acetaminophen, read the section About Acetaminophen in our resource. Doctors also recommend hydrating before and . Are immunocompromised or are on a medicine that affects your immune system. Its best if your caregiver is fully vaccinated against COVID-19. 9 Things to Do After Getting Your COVID-19 Vaccines - Healthline If any of your COVID-19 symptoms come back, start following these instructions again right away and call your healthcare provider. Baby aspirin no longer recommended to prevent first heart attack A positive result means the test showed you have COVID-19. Our highly-specialized educational programs shape leaders to be at the forefront of cancer care and research. The first shot tends to "prime" your immune system to recognize the spike protein of the coronavirus, so that when you get your second shot, your immune system is ready to attack it, which. At some point, a booster shot will likely be needed, probably within a year of your initial vaccine. One patient who received rivaroxaban and 10 patients who did not receive anticoagulation experienced symptomatic events. Dr. Vyas says that is a major dont. Knight M, Bunch K, Vousden N, et al. "We generally say wait until after you get your COVID-19 vaccination to take an anti-inflammatory medication. Wash used dishes, drinking glasses, cups, and eating utensils well with soap and hot water or in a dishwasher. You do not need to get another vaccine at this time. Bohula EA, Berg DD, Lopes MS, et al. Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. The pooled antiplatelet arm had improved survival by 90 days (median aHR 1.22; 95% CrI, 1.061.40). Multiple retrospective cohort studies have suggested that the use of aspirin reduced in-hospital mortality in patients who were treated prior to hospital admission or within 24 hours of admission. This is also true for many other vaccines. A VTE risk score of 4 on the modified International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) tool; A VTE risk score 2 on the modified IMPROVE tool. Measure your temperature 2 times every day: once in the morning and once in the evening. Available at: Bates SM, Rajasekhar A, Middeldorp S, et al. Several studies have evaluated the risks and benefits of using prophylactic or therapeutic doses of anticoagulants in patients with COVID-19. Based on the findings of the ACTIV-4a and RECOVERY trials, the Panel recommends against the use of antiplatelet therapy to prevent COVID-19 progression or death in noncritically ill patients (BIIa). Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Rub your hands together until theyre dry. Although some of the vaccine side effects are similar to the symptoms of COVID-19, the coronavirus vaccines won't give you COVID-19. If youre getting chemotherapy and have a new fever of 100.4 F (38 C) or higher, call your healthcare provider. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. An observational study of 4,297 veterans hospitalized with COVID-19 evaluated the benefit of prophylactic anticoagulation. Should I be nervous around unvaccinated and unmasked people?". Call us at 833-347-1665 to make an appointment. You can take care of yourself by doings things such as: MSK has many professionals, volunteers, and support programs that can help you cope during this time. Symptoms of COVID-19 may be mild or severe. ATTACC Investigators, ACTIV-4a Investigators, REMAP-CAP Investigators, et al. Here's Who Might Want to Avoid the J&J COVID Shot 196 summary: thromboembolism in pregnancy. Deborah asks, "I was wondering why does the second shot of the COVID vaccine makes you feel sicker?". For example, say you step on a rusty nail and you need a tetanus shot. Dr. Mallika is offering her best advice, but as always, consult your personal doctor before making any decisions about your personal health. If you take one before, there's a possibility that it could blunt the immune response to the vaccine. In nonhospitalized patients with COVID-19, the Panel recommends against the use of anticoagulants and antiplatelet therapy (i.e., aspirin, P2Y12 inhibitors) for the prevention of VTE or arterial thrombosis, except in a clinical trial (AIIa). Acetaminophen is a very common ingredient in over-the-counter and prescription medications. Major bleeding occurred in 4% of patients who received therapeutic anticoagulation and in 2% of patients who received usual care. Yes, I currently have Covid and was told to start taking one daily - the 81mg tablet. The inclusion and exclusion criteria for these studies varied, but most included a need for supplemental oxygen and no risk of a major bleeding event. We generally say wait until after you get your COVID-19 vaccination to take an anti-inflammatory medication. Available at: Barnes GD, Burnett A, Allen A, et al. Before prescribing ritonavir-boosted nirmatrelvir (Paxlovid) to patients who are receiving anticoagulant or antiplatelet therapy, clinicians should carefully review the patients concomitant medications to evaluate potential drug-drug interactions (see Drug-Drug Interactions Between Ritonavir-Boosted Nirmatrelvir [Paxlovid] and Concomitant Medications). Overall, there was no significant benefit of receiving an intermediate dose of anticoagulation for patients with COVID-19 who were in the ICU.28. The Centers for Disease Control says that you can take over-the-counter pain medicine, such as ibuprofen (like Advil), aspirin, antihistamines or acetaminophen (like Tylenol), if you have. For example, have 6 small meals throughout the day instead of 3 big ones. We do not endorse non-Cleveland Clinic products or services. Effect of antithrombotic therapy on clinical outcomes in outpatients with clinically stable symptomatic COVID-19: the ACTIV-4B randomized clinical trial. Antithrombotic Therapy | COVID-19 Treatment Guidelines But there's not an interaction between the drugs and the vaccine and it's certainly safe to take a baby aspirin." . Its normal to feel worried about COVID-19, especially if you or your loved one is sick. Given the results of the ATTACC/ACTIV-4a/REMAP-CAP, RAPID, and HEP-COVID trials, for hospitalized, nonpregnant adults with COVID-19 who do not require ICU-level care and have no evidence of VTE: Several randomized controlled trials have evaluated the role of therapeutic doses of heparin in reducing the incidence of VTE events or mortality in patients in the ICU setting. You can get a COVID-19 vaccine and other vaccines, including a flu vaccine, at the same visit. At least once a day, clean and disinfect the surfaces you touch often (such as phones, remote controls, doorknobs, bathroom fixtures, toilets, keyboards, tablets, counters, tabletops, and bedside tables). Driggin E, Madhavan MV, Bikdeli B, et al. Rub your hands together well for at least 20 seconds, then rinse. Thromboprophylaxis in patients with COVID-19: a brief update to the CHEST guideline and expert panel report. A prophylactic dose of anticoagulation was administered to 3,627 patients with COVID-19 within 24 hours of hospital admission.24 An inverse probability of treatment weighted analysis showed a cumulative 30-day mortality of 14% among patients who received prophylactic anticoagulation and 19% among patients who were not treated with anticoagulation (HR 0.73; 95% CI, 0.660.81). As in nonpregnant patients, VTE prophylaxis after hospital discharge is not routinely recommended for pregnant patients, The use of anticoagulation therapy during labor and delivery requires specialized care and planning. Do not wear a mask if you have breathing problems when you wear it or if you cannot take it off by yourself. Garth Warren, who . You may need to get a PCR or rapid test to make sure youre not still infectious. If you take one before, theres a possibility that it could blunt the immune response to the vaccine. A few studies show that taking aspirin around the time of . PROTECT Investigators for the Canadian Critical Care Trials Group, Australian and New Zealand Intensive Care Society Clinical Trials Group, Cook D, et al. The study was terminated early due to a low event rate and slow accrual of participants. Nopp S, Moik F, Jilma B, Pabinger I, Ay C. Risk of venous thromboembolism in patients with COVID-19: a systematic review and meta-analysis. There was no difference between the arms in the number of patients who met the composite endpoint of all-cause mortality and all-cause hospitalization (12 of 105 patients [11%] in the enoxaparin arm vs. 12 of 114 patients [11%] in the standard of care arm). It can spread in droplets in the air or left on surfaces after a sick person coughs or sneezes. By Professor Nathan Grills, University of Melbourne. The ACTIV-4a trial compared the use of P2Y12 inhibitor therapy plus a therapeutic dose of heparin to a therapeutic dose of heparin alone in hospitalized patients with COVID-19. Heres Why You Shouldnt Stop Wearing Your Face Mask Yet, Artificial Sweetener Erythritols Major Health Risks, Best Ingredients and Products for Your Anti-Aging Skin Care Routine. ACOG practice bulletin no. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. As a result, you may be tempted to take some pain relievers before or after vaccination. She also wants to start doing ultrasounds every 4 weeks to check on baby's growth too. If you use a device for sleep apnea (such as a CPAP machine) or a home nebulizer, talk with your healthcare provider before using it. Both anti-inflammatories can potentially lower the immune systems response to the vaccine. Possible Side Effects After Getting a COVID-19 Vaccine | CDC This will help you stay hydrated and help loosen mucus in your nose and lungs. Predictive and associative models to identify hospitalized medical patients at risk for VTE. 2021 CBS Broadcasting Inc. All Rights Reserved. 6. A PCR test, also called a molecular test. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. The probability of clinically relevant, nonmajor bleeding was greater in the rivaroxaban arm (5% in the rivaroxaban arm vs. 1% in the usual care arm; relative risk 5.23; 95% CI, 1.5417.77), but for major bleeding events, the difference in probability between the arms was not significant (3% in the rivaroxaban arm vs. 1% in the usual care arm; relative risk 2.45; 95% CI, 0.787.73). A meta-analysis of studies of hospitalized patients with COVID-19 who received VTE prophylaxis found an overall VTE prevalence of 14.1% (95% CI, 11.616.9).5 The VTE prevalence was higher in studies that used ultrasound screening (40.3%; 95% CI, 27.054.3) than in studies that did not (9.5%; 95% CI, 7.511.7). COVID symptoms may be stopped by baby aspirin - Deseret News The multiplatform ATTACC/ACTIV-4a/REMAP-CAP trial compared the effectiveness of a therapeutic dose of heparin or LMWH with usual care in reducing the number of organ support-free days among critically ill patients with COVID-19.25 All 3 trials were stopped for futility. Youre getting chemotherapy and have a new fever of 100.4 F (38 C) or higher. Do not take antibiotics unless your healthcare provider tells you to. Will the Coronavirus Have Any Long-Lasting Effects on the Climate? If you have a question,email heror message her onFacebookorTwitter. If youre using an alcohol-based hand sanitizer, be sure to cover all parts of your hands with it. For the Panels recommendations on the use of antithrombotic therapy in children, see, The Panel recommends that pregnant patients who are receiving anticoagulant or antiplatelet therapies for underlying conditions continue these medications after they receive a diagnosis of COVID-19. The vaccines will also not make you contagious.. This will help with nausea and appetite loss. Mortality at 28 days was 17% in both arms (rate ratio 0.96; 95% CI, 0.891.04). Crossover or discontinuation of the assigned treatment occurred in 31% to 37% of patients. With both types of tests, youll get either a positive or negative result. If you have COVID-19 and have symptoms, follow these instructions until: You have not had a fever above 100.4 F (38 C) for at least 3 days and are not using medication to lower fevers. dermal fillers be scheduled either two weeks before or after. Venous thromboembolism in critically ill patients: observations from a randomized trial in sepsis. More research on the matter is needed, but it's recommended to refrain from taking them beforehand, just to be safe. Outpatients with COVID-19 who are receiving warfarin and are in isolation and unable to have international normalized ratio monitoring may be candidates for switching to direct oral anticoagulant therapy. American Society of Hematology. The ETHIC trial was a multicenter, open-label randomized controlled trial of unvaccinated outpatients with COVID-19.22 Adults with at least 1 risk factor for severe disease were randomized to receive enoxaparin 40 mg subcutaneously (SUBQ) once daily (if they weighed <100 kg) or enoxaparin 40 mg SUBQ twice daily (if they weighed >100 kg) for 21 days or standard of care. Can Aspirin Blunt COVID Vaccine Effectiveness? Dr. Mallika Marshall These devices may spread the virus that causes COVID-19. Using aspirin as a painkiller while pregnant isn't recommended - but your healthcare provider may prescribe a daily low dose of aspirin to lower the risk of some pregnancy complications. Spyropoulos AC, Lipardi C, Xu J, et al. Aspirin may reduce deaths in severe COVID-19 - Medical News Today If you had a rapid test and get a negative result, get a PCR test to check your results. These events included death due to VTE or arterial thrombotic events, pulmonary embolism, clinically evident deep vein thrombosis, myocardial infarction, ischemic stroke, systemic embolic events or acute limb ischemia, and clinically silent deep vein thrombosis. Given the lack of benefit and the increased risk of bleeding events, the Panel recommends against the use of a therapeutic dose of oral anticoagulants for VTE prophylaxis or the prevention of COVID-19 progression, except in a clinical trial (BIIa). If you have a fever of 102 F (38.9 C) or higher that lasts for 24 hours and does not get better after you take acetaminophen, call your healthcare provider. Use the hot setting, if you can. Spyropoulos AC, Goldin M, Giannis D, et al. If you need help, choose one person in your home to be your caregiver. Cohen AT, Davidson BL, Gallus AS, et al. They were also randomized to receive either clopidogrel or no antiplatelet therapy.29 The trial was stopped early because the decreasing number of ICU admissions for patients with COVID-19 made recruitment difficult. Read labels carefully: Many over-the-counter drugs, such as antacids and cold and sinus medicines, contain aspirin. Spyropoulos AC, Anderson FA, Jr., FitzGerald G, et al. Follow the instructions on the label. Clinical characteristics of coronavirus disease 2019 in China. There is insufficient evidence for the Panel to recommend either for or against the use of thrombolytic agents for VTE prophylaxis in hospitalized patients with COVID-19 outside of a clinical trial. The trial was stopped early due to futility, as the median number of organ support-free days did not differ between the pooled antiplatelet arm and the control arm (7 days; IQR 116 days; 95.7% posterior probability of futility). There is evidence that the current vaccines last at least 6 months but probably considerably longer. Thachil J, Tang N, Gando S, et al. Coronavirus Pandemic Has Inspired 64 Percent of Americans to Live More Sustainably, Survey Finds. Researchers say aspirin may help people hospitalized with COVID-19, because of the drug's abilities to reduce the risk of blood clots. Sholzberg M, Tang GH, Rahhal H, et al. Offers may be subject to change without notice. These studies have been summarized in meta-analyses.31-34 These epidemiologic studies used propensity scoring or adjusted for potential confounders, but indication bias cannot be fully removed from these studies. If youre due for your shingles vaccine or another immunization, the CDC recommends a 14-day buffer between shots. For patients who start on a therapeutic dose of heparin in a non-ICU setting due to COVID-19 and then transfer to the ICU, the Panel recommends switching from the therapeutic dose to a. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. Decisions to use post-discharge VTE prophylaxis in patients with COVID-19 should include consideration of the individual patients risk factors for VTE, bleeding risks, and feasibility. Congratulations on being vaccinated! Not yet. Be prepared before you go into your vax appointment: the CDC recommends that you do not take over-the-counter drugsincluding ibuprofen, acetaminophen, aspirin, or antihistamines before receiving your shot. In the on-treatment analysis, the therapeutic dose of anticoagulation was more likely to benefit patients (win ratio 1.95; 95% CI, 1.083.55; P = 0.028). RECOVERY Collaborative Group. After leaving a vaccination provider site, if you think you or your child might be having a severe allergic reaction, seek immediate medical care by calling 911. Bleeding events occurred in 2 patients who received enoxaparin and in 1 patient who received standard of care. In patients without VTE who have started treatment with therapeutic doses of heparin, treatment should continue for 14 days or until they are transferred to the ICU or discharged from the hospital, whichever comes first. There was no difference between the arms in the number of patients who met the primary composite endpoint of all-cause hospitalization and mortality (8 of 234 patients [3%] in the enoxaparin arm vs. 8 of 238 patients [3%] in the standard of care arm). Keep your dirty laundry in a laundry bag. Getting a COVID jab is safer than taking aspirin. Rabies is another example, or say theres another measles outbreak in a community and everybody needs to be immunized. Not sure if you should stop taking your medicines or treatments before getting vaccinated for COVID-19? No major bleeding events occurred during the study. Stay tuned. Always read the label on the medications youre taking. For the Panels recommendations on the use of antithrombotic therapy in children, see Therapeutic Management of Hospitalized Children With COVID-19 and Therapeutic Management of Hospitalized Pediatric Patients With Multisystem Inflammatory Syndrome in Children (MIS-C) (With Discussion on Multisystem Inflammatory Syndrome in Adults [MIS-A]). The management of anticoagulation therapy in pregnant patients with COVID-19 should be similar to the management used for pregnant patients with other conditions, UFH, LMWH, and warfarin do not accumulate in breast milk and do not induce an anticoagulant effect in the newborn; therefore, they can be used by breastfeeding individuals who require VTE prophylaxis or treatment. These medications may hide the symptoms of COVID-19. All rights owned and reserved by Memorial Sloan Kettering Cancer Center, 2023 Memorial Sloan Kettering Cancer Center, Human Oncology & Pathogenesis Program (HOPP), Gerstner Sloan Kettering Graduate School of Biomedical Sciences, High school & undergraduate summer programs, Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs (NSAIDs), or Vitamin E, Managing COVID-19 at Home: Information for Caregivers. In general, people with cancer do not have different symptoms than other people. 1:43. Cover your mouth and nose with a tissue when you cough or sneeze. Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study. But if youre considering steroid injections, she suggests holding off until after youre vaccinated. Germany is offering the shot only to people aged 60 and over and in high-priority groups, with under-60s who have had a first shot recommended to get a different one, and Spain is giving it to. It also reviews the current high-quality clinical evidence highlighting the role of aspirin in SARS-CoV-2 infection. The median number of organ support-free days was 3 days (IQR -1 to 16) for patients who received a therapeutic dose of anticoagulation and 4 days (IQR -1 to 16) for patients who received usual care.