Prevalence and characteristics of long COVID in elderly patients: An observational cohort study of over 2 million adults in the US.

BACKGROUND: Incidence of long COVID in the elderly is difficult to estimate and can be underreported. While long COVID is sometimes considered a novel disease, many viral or bacterial infections have been known to cause prolonged illnesses. We postulate that some influenza patients might develop residual symptoms that would satisfy the diagnostic criteria for long COVID, a condition we call "long Flu." In this study, we estimate the incidence of long COVID and long Flu among Medicare patients using the World Health Organization (WHO) consensus definition. We compare the incidence, symptomatology, and healthcare utilization between long COVID and long Flu patients. METHODS AND FINDINGS: This is a cohort study of Medicare (the US federal health insurance program) beneficiaries over 65. ICD-10-CM codes were used to capture COVID-19, influenza, and residual symptoms. Long COVID was identified by (a) the designated long COVID code B94.8 (code-based definition), or (b) any of 11 symptoms identified in the WHO definition (symptom-based definition), from 1 to 3 months post-infection. A symptom would be excluded if it occurred in the year prior to infection. Long Flu was identified in influenza patients from the combined 2018 and 2019 Flu seasons by the same symptom-based definition for long COVID. Long COVID and long Flu were compared in 4 outcome measures: (a) hospitalization (any cause); (b) hospitalization (for long COVID symptom); (c) emergency department (ED) visit (for long COVID symptom); and (d) number of outpatient encounters (for long COVID symptom), adjusted for age, sex, race, region, Medicare-Medicaid dual eligibility status, prior-year hospitalization, and chronic comorbidities. Among 2,071,532 COVID-19 patients diagnosed between April 2020 and June 2021, symptom-based definition identified long COVID in 16.6% (246,154/1,479,183) and 29.2% (61,631/210,765) of outpatients and inpatients, respectively. The designated code gave much lower estimates (outpatients 0.49% (7,213/1,479,183), inpatients 2.6% (5,521/210,765)). Among 933,877 influenza patients, 17.0% (138,951/817,336) of outpatients and 24.6% (18,824/76,390) of inpatients fit the long Flu definition. Long COVID patients had higher incidence of dyspnea, fatigue, palpitations, loss of taste/smell, and neurocognitive symptoms compared to long Flu. Long COVID outpatients were more likely to have any-cause hospitalization (31.9% (74,854/234,688) versus 26.8% (33,140/123,736), odds ratio 1.06 (95% CI 1.05 to 1.08, p < 0.001)), and more outpatient visits than long Flu outpatients (mean 2.9(SD 3.4) versus 2.5(SD 2.7) visits, incidence rate ratio 1.09 (95% CI 1.08 to 1.10, p < 0.001)). There were less ED visits in long COVID patients, probably because of reduction in ED usage during the pandemic. The main limitation of our study is that the diagnosis of long COVID in is not independently verified. CONCLUSIONS: Relying on specific long COVID diagnostic codes results in significant underreporting. We observed that about 30% of hospitalized COVID-19 patients developed long COVID. In a similar proportion of patients, long COVID-like symptoms (long Flu) can be observed after influenza, but there are notable differences in symptomatology between long COVID and long Flu. The impact of long COVID on healthcare utilization is higher than long Flu.

Impact of the COVID-19 pandemic on the epidemiology of severe burns : A single center study from a specialized burn center in Vienna.

INTRODUCTION: Currently, very little detailed information on the epidemiological distribution and specificities of severely burned patients during the coronavirus disease 2019 (COVID-19) pandemic is available. This retrospective study aims to describe and compare this specific patient population based on 114 patients who were treated between March 2019 and March 2021 at the Center for Severe Burn Injuries at the Medical University of Vienna. METHODS: To answer the research questions, a retrospective cohort study has been conducted over a period of 24 months, starting in March 2019 and ending in March 2021. To evaluate the epidemiological differences, the patients were divided into 2 observation periods of 12 months each. RESULTS: In the period from 12 March 2020 to 11 March 2021, a total of 62 patients were admitted to the Center for Severe Burn Injuries. In comparison, only 52 patients were admitted in the same period of the previous year, which corresponds to an increase of 19.2%. In addition, it was noted that during the 2019-2020 observation period, 27% of patients were female and 73% male, whereas during the pandemic the gender distribution was 42% female and only 58% male. During the pre-pandemic observational period, 13 out of 52 patients admitted died (25%), whereas during the pandemic, 17 out of 62 patients succumbed to their injuries (27%). CONCLUSION: Although the severity of the COVID-19 pandemic seems to be decreasing, especially due to the increasing availability of vaccines, there is a need for more data on the impact of the crisis on severely burned patients. In contrast to the current literature, we have seen a greater number of inpatient admissions to the Center for Severe Burn Injuries, as well as significant differences in gender distribution. Our data also suggest that the circumstances of the pandemic have no influence on the likelihood of survival for patients with severe burns.

Effet du decubitus ventral vigile chez des patients hospitalises hors reanimation pour une pneumonie hypoxemiante a COVID-19 : un essai randomise multicentrique

Declaration de liens d'interets: Les auteurs declarent ne pas avoir de liens d'interets. Copyright © 2022

Effect of common maintenance drugs on the risk and severity of COVID-19 in elderly patients.

BACKGROUND: Maintenance drugs are used to treat chronic conditions. Several classes of maintenance drugs have attracted attention because of their potential to affect susceptibility to and severity of COVID-19. METHODS: Using claims data on 20% random sample of Part D Medicare enrollees from April to December 2020, we identified patients diagnosed with COVID-19. Using a nested case-control design, non-COVID-19 controls were identified by 1:5 matching on age, race, sex, dual-eligibility status, and geographical region. We identified usage of angiotensin-converting enzyme inhibitors (ACEI), angiotensin-receptor blockers (ARB), statins, warfarin, direct factor Xa inhibitors, P2Y12 inhibitors, famotidine and hydroxychloroquine based on Medicare prescription claims data. Using extended Cox regression models with time-varying propensity score adjustment we examined the independent effect of each study drug on contracting COVID-19. For severity of COVID-19, we performed extended Cox regressions on all COVID-19 patients, using COVID-19-related hospitalization and all-cause mortality as outcomes. Covariates included gender, age, race, geographic region, low-income indicator, and co-morbidities. To compensate for indication bias related to the use of hydroxychloroquine for the prophylaxis or treatment of COVID-19, we censored patients who only started on hydroxychloroquine in 2020. RESULTS: Up to December 2020, our sample contained 374,229 Medicare patients over 65 who were diagnosed with COVID-19. Among the COVID-19 patients, 278,912 (74.6%) were on at least one study drug. The three most common study drugs among COVID-19 patients were statins 187,374 (50.1%), ACEI 97,843 (26.2%) and ARB 83,290 (22.3%). For all three outcomes (diagnosis, hospitalization and death), current users of ACEI, ARB, statins, warfarin, direct factor Xa inhibitors and P2Y12 inhibitors were associated with reduced risks, compared to never users. Famotidine did not show consistent significant effects. Hydroxychloroquine did not show significant effects after censoring of recent starters. CONCLUSION: Maintenance use of ACEI, ARB, warfarin, statins, direct factor Xa inhibitors and P2Y12 inhibitors was associated with reduction in risk of acquiring COVID-19 and dying from it.

Association of COVID-19 antigenicity with the development of antineutrophilic cytoplasmic antibody vasculitis.

Inflammatory processes, such as an infection or drug reaction, can cause antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV). Although quite rare, AAV may occur with SARS-coronavirus disease 2019 (COVID-19) antigenic exposure, either from infection or immunization. We present two cases of AAV: one that developed after COVID-19 infection presenting as diffuse alveolar haemorrhage and another that developed shortly after vaccination, presenting as granulomatous pulmonary nodules. Both patients improved with supportive care and immunosuppressive therapies. This adverse event appears to be a very rare complication of COVID-19 infection or vaccination. Early diagnosis of AAV is important because immunosuppressive therapy may improve patient outcomes.

Effect of bacillus calmette-guerin (BCG) exposure on severity of COVID-19 infection: A COVID-19 and cancer consortium (CCC19) study

Background: Oncology patients experience more severe disease outcomes from COVID-19 infection than the general population. BCG is a live bovine tuberculosis bacillus with immunotherapeutic effects in urothelial cancers;it is also used as vaccination against Mycobacterium tuberculosis in parts of the world. As BCG vaccination has been associated with broad protection against viral pathogens, BCG exposure through vaccination or intravesical therapy may modulate host immunity and reduce the severity of COVID-19 infection. We report the effect of BCG exposure on COVID-19 severity in oncology patients from the CCC19 registry. Methods: The CCC19 registry (NCT04354701) was used to identify patients with prior BCG exposure. Cohort A received intravesical treatment for bladder carcinoma, and cohort B received prior BCG vaccination. Each cohort was matched 3:1 to non-BCG-exposed controls by age, sex, race, primary cancer type, cancer status, ECOG performance status (PS) and calendar time of COVID-19 infection. The primary endpoint was COVID-19 severity reported on an ordinal scale (uncomplicated, hospitalized, admitted to ICU +/- ventilated, died within 30 days) of patients exposed to prior BCG compared to matched non-exposed controls. 2-sided Wilcoxon ranksum tests were used. Results: As of 6-Feb-2021 we included 124 patients with BCG exposure, 68 patients with bladder carcinoma who had received intravesical BCG (Cohort A), and 64 cancer patients with prior BCG vaccination (Cohort B). Median age was 76 years, IQR 69-83 (Cohort A) and 67 years, IQR 62-74 (Cohort B). Bladder cancer pts were predominately male (78%) vs 55% for Cohort B. Patients with PS 2+ were uncommon, 18% in Cohort A and 16% in Cohort B. COVID-19 illness severity was no different in patients exposed to prior intravesicular BCG (p=0.87). COVID-19 illness severity was no different in patients exposed to prior intradermal BCG vaccination (p=0.60). Conclusions: Despite this being the largest such cohort reported to date, we failed to demonstrate an association of prior BCG exposure with modulation of severity of COVID19 illness. Prospective trials evaluating the protective effect of BCG vaccination are ongoing and will add further insight into the effect of BCG on COVID-19 illness.

Estimation of excess mortality resulting from use of a ventilator triage protocol under SARS-CoV-2 pandemic surge conditions

Rationale: COVID-19 hospitalizations continue to surge rapidly throughout the world. Given the high morbidity and mortality and prolonged duration of illness experienced by patients with respiratory failure due to COVID-19, shortages of ventilators are expected. In New York State, the Crisis Standards of Care guidelines were codified by the New York State Taskforce on Life and the Law in the 2015 Ventilator Triage Guidelines (NYS guidelines). These guidelines outline clinical criteria for triage, including exclusion criteria and stratification of patients using the Sequential Organ Failure Assessment (SOFA) score. We aimed to estimate the excess mortality that would be associated with implementation of triage processes using this protocol. Methods: We included all 5,028 patients who were admitted with COVID-19 in three acute care hospitals at a single academic medical center in the Bronx from March 1, 2020 to May 27, 2020 during the peak of the pandemic surge in New York City. Importance sampling was used to estimate the likelihood of patient trajectories under the NYS guidelines and estimate survival rates. Pessimistic and optimistic estimations were derived to account for potential unobserved confounders. Overall estimated survival was then calculated over a range of hypothetical ventilator shortages (e.g. if it has not been possible to acquire the additional ventilators that were procured in the Spring) from 85-100% availability of the total ventilator capacity of these facilities. Results: The average age of the sample was 64.2 (SD 16.2) and 47% were female. The observed survival rate was 74.16%. A total of 721 patients (14%) required mechanical ventilation during admission. If there has been a ventilator shortfall with ventilator capacity at 85% and the NYS guidelines were enacted in this setting, the estimated survival would be between 70.3% (pessimistic estimation) and 71.5% (optimistic estimation) (Figure 1). Conclusions: A shortfall of ventilators at 85% ventilator capacity requiring implementation of the NYS guidelines triage protocol would have resulted in 2.7-3.9% excess mortality in hospitalized patients with COVID-19 during the pandemic surge, or 134-194 additional deaths. This study is limited by the exclusion of COVID-19 negative patients, who would be in the triage pool in an actual triage situation. Future directions include using this data set to compare NYS guideline performance to other triage strategies including first-come first-served and random allocation to better understand the utility of SOFA score-based triage strategies.

Variation in predicted COVID-19 risk among lemurs and lorises.

The novel coronavirus SARS-CoV-2, which in humans leads to the disease COVID-19, has caused global disruption and more than 2 million fatalities since it first emerged in late 2019. As we write, infection rates are at their highest point globally and are rising extremely rapidly in some areas due to more infectious variants. The primary target of SARS-CoV-2 is the cellular receptor angiotensin-converting enzyme-2 (ACE2). Recent sequence analyses of the ACE2 gene predict that many nonhuman primates are also likely to be highly susceptible to infection. However, the anticipated risk is not equal across the Order. Furthermore, some taxonomic groups show high ACE2 amino acid conservation, while others exhibit high variability at this locus. As an example of the latter, analyses of strepsirrhine primate ACE2 sequences to date indicate large variation among lemurs and lorises compared to other primate clades despite low sampling effort. Here, we report ACE2 gene and protein sequences for 71 individual strepsirrhines, spanning 51 species and 19 genera. Our study reinforces previous results while finding additional variability in other strepsirrhine species, and suggests several clades of lemurs have high potential susceptibility to SARS-CoV-2 infection. Troublingly, some species, including the rare and endangered aye-aye (Daubentonia madagascariensis), as well as those in the genera Avahi and Propithecus, may be at high risk. Given that lemurs are endemic to Madagascar and among the primates at highest risk of extinction globally, further understanding of the potential threat of COVID-19 to their health should be a conservation priority. All feasible actions should be taken to limit their exposure to SARS-CoV-2.

Preventing Toxic Childhood Stress in the COVID Era: A Role for Telemedicine.

The coronavirus pandemic has resulted in unprecedented stress for families and children. Curve-flattening measures have disrupted the relational networks of millions. Stress in the absence of protective relationships can quickly become toxic, harming mental and physical health. If toxic stress is characterized by an absence of protective relationships, telemedicine may have a role in collective prevention efforts by enabling and preserving patient-provider continuity. Through virtual visits and check-ins, trusted health care providers can serve as a source of emotional support and psychosocial buffering for families under stress. By leveraging technology to deliver care remotely, telemedicine lets patients and providers connect, relate, and engage. Connection enables the conveyance of compassion and empathy. Telemedicine may thus serve as an important conduit for fostering protective relationships, buffering toxic stressors, and promoting safety and healing. Telemedicine will not resolve the needs created by the pandemic, but it may be one component for addressing them.