Nursing Management of Adult Ostomy Patients During the COVID-19 Pandemic.

The continuation of the COVID-19 epidemic poses novel challenges for adult ostomy patients care. It is essential to explore nursing management for ostomy patients to ensure patients receive standardized care while minimizing exposure to COVID-19. This article reviews the perioperative nursing of Chinese adult ostomy patients in the post-epidemic era, as well as outpatient review after discharge and home care, to provide reference and basis for medical staff and patients in the post-pandemic era.

AI based satisfaction survey of patients in fever clinics during the outbreak of COVID-19 (preprint)

Background: We assessed patient by automated survey method in understanding and satisfaction with the use of fever clinic, and observed the effectiveness of this method. Methods: Total 873 patients in fever clinc at Jiangsu Province Hospital (JSPH) from 20 January 2019 to 18 June 2020 were investigated by an antomated survey method conbined by Wechat, Short Message Service (SMS) and AI voice call. Responses were assessed for overall positivity or negativity and further compared according to patients types (isolated patients and non-isolated patients). Responses were also described and compared for each type of survey. Results: A total of 379 patient surveys were returned, for a total response rate of 43.4%. Isolated and non-isolated patients responses were similar and all with more than 90% satisfaction. Most isolated patient represent that the medical staff had explained to them the reason for the isolation and know that can helps prevent COVID-19. AI voice calls had the highest percentage of all response types, followed by WeChat and SMS. Conclusion: The patient has a positive response to the use of fever clinic. The automated survey method combine by different survey types can bring great convenience to the investigation while ensuring good investigation efficiency.

Unraveling COVID-19: a large-scale characterization of 4.5 million COVID-19 cases using CHARYBDIS (preprint)

Background: Routinely collected real world data (RWD) have great utility in aiding the novel coronavirus disease (COVID-19) pandemic response [1,2]. Here we present the international Observational Health Data Sciences and Informatics (OHDSI) [3] Characterizing Health Associated Risks, and Your Baseline Disease In SARS-COV-2 (CHARYBDIS) framework for standardisation and analysis of COVID-19 RWD.Methods: We conducted a descriptive cohort study using a federated network of data partners in the United States, Europe (the Netherlands, Spain, the UK, Germany, France and Italy) and Asia (South Korea and China). The study protocol and analytical package were released on 11th June 2020 and are iteratively updated via GitHub [4]. Findings: We identified three non-mutually exclusive cohorts of 4,537,153 individuals with a clinical COVID-19 diagnosis or positive test, 886,193 hospitalized with COVID-19, and 113,627 hospitalized with COVID-19 requiring intensive services. All comorbidities, symptoms, medications, and outcomes are described by cohort in aggregate counts, and are available in an interactive website: https://data.ohdsi.org/Covid19CharacterizationCharybdis/. Interpretation: CHARYBDIS findings provide benchmarks that contribute to our understanding of COVID-19 progression, management and evolution over time. This can enable timely assessment of real-world outcomes of preventative and therapeutic options as they are introduced in clinical practice.

[Effect of hypertension on outcomes of patients with COVID-19].

OBJECTIVE: To determine the impact of hypertension on the outcomes of patients with COVID-19. METHODS: This matched cohort study was conducted among a total 442 patients with COVID-19 admitted in Honghu People's Hospital and First Affiliated Hospital of Nanchang University between January 1 to March 18, 2020, including 61 patients with hypertension and 381 normotensive patients. To minimize the effects of the confounding factors including age, gender and other comorbidities, we excluded patients with comorbidities other than hypertension, and matched the patients with and without hypertension for age and gender at a 1:1 ratio. We analyzed the clinical characteristics, laboratory findings and clinical outcomes of in 32 matched pairs of patients with and without hypertension. RESULTS: Compared with the normotensive patients, COVID-19 patients with hypertension were more likely to develop bacterial infections (P=0.002) and had higher neutrophil counts (P=0.007), neutrophil/lymphocyte ratio (P=0.045), and lactate dehydrogenase levels (P=0.035). A greater proportion of patients had bilateral patchy opacities on chest CT (P=0.012) in the hypertension group than in the normotensive group. COVID-19 patients with hypertension group were more likely to receive antibiotics (P=0.035) and corticosteroid therapies (P=0.035). CONCLUSIONS: Hypertension increases the risk of bacterial infection in patients with COVID-19. Hypertensive patients with COVID-19 have higher neutrophil counts and neutrophil/ lymphocyte ratios and are more likely to require treatment with antibiotics. Hypertensive patients with COVID-19 should therefore take cautions to avoid bacterial infections.

Heterogeneity and temporal variation in the management of COVID-19: a multinational drug utilization study including 71,921 hospitalized patients from China, South Korea, Spain, and the United States of America (preprint)

Objectives: A plethora of medicines have been repurposed or used as adjunctive therapies for COVID-19. We characterized the utilization of medicines as prescribed in routine practice amongst patients hospitalized for COVID-19 in South Korea, China, Spain, and the USA. Design: International network cohort Setting: Hospital electronic health records from Columbia University Irving Medical Centre (NYC, USA), Stanford (CA, USA), Tufts (MA, USA), Premier (USA), Optum EHR (USA), department of veterans affairs (USA), NFHCRD (Honghu, China) and HM Hospitals (Spain); and nationwide claims from HIRA (South Korea) Participants: patients hospitalized for COVID-19 from January to June 2020 Main outcome measures: Prescription/dispensation of any medicine on or 30 days after hospital admission date Analyses: Number and percentage of users overall and over time Results: 71,921 people were included: 304 from China, 2,089 from Spain, 7,599 from South Korea, and 61,929 from the USA. A total of 3,455 medicines were identified. Common repurposed medicines included hydroxychloroquine (<2% in NFHCRD to 85.4% in HM), azithromycin (4.9% in NFHCRD to 56.5% in HM), lopinavir/ritonavir (<3% in all US but 34.9% in HIRA and 56.5% in HM), and umifenovir (0% in all except 78.3% in NFHCRD). Adjunctive medicines were used with great variability, with the ten most used treatments being (in descending order): bemiparin, enoxaparin, heparin, ceftriaxone, aspirin, vitamin D, famotidine, vitamin C, dexamethasone, and metformin. Hydroxychloroquine and azithromycin increased rapidly in use in March-April but declined steeply in May-June. Conclusions: Multiple medicines were used in the first months of COVID-19 pandemic, with substantial geographic and temporal variation. Hydroxychloroquine, azithromycin, lopinavir-ritonavir, and umifenovir (in China only) were the most prescribed repurposed medicines. Antithrombotics, antibiotics, H2 receptor antagonists and corticosteroids were often used as adjunctive treatments. Research is needed on the comparative risk and benefit of these treatments in the management of COVID-19.

Characteristics and outcomes of 627 044 COVID-19 patients with and without obesity in the United States, Spain, and the United Kingdom (preprint)

Background: COVID-19 may differentially impact people with obesity. We aimed to describe and compare the demographics, comorbidities, and outcomes of obese patients with COVID-19 to those of non-obese patients with COVID-19, or obese patients with seasonal influenza. Methods: We conducted a cohort study based on outpatient/inpatient care, and claims data from January to June 2020 from the US, Spain, and the UK. We used six databases standardized to the OMOP common data model. We defined two cohorts of patients diagnosed and/or hospitalized with COVID-19. We created corresponding cohorts for patients with influenza in 2017-2018. We followed patients from index date to 30 days or death. We report the frequency of socio-demographics, prior comorbidities, and 30-days outcomes (hospitalization, events, and death) by obesity status. Findings: We included 627 044 COVID-19 (US: 502 650, Spain: 122 058, UK: 2336) and 4 549 568 influenza (US: 4 431 801, Spain: 115 224, UK: 2543) patients. The prevalence of obesity was higher among hospitalized COVID-19 (range: 38% to 54%) than diagnosed COVID-19 (30% to 47%), or diagnosed/hospitalized influenza (15% to 48%) patients. Obese hospitalized COVID-19 patients were more often female and younger than non-obese COVID-19 patients or obese influenza patients. Obese COVID-19 patients were more likely to have prior comorbidities, present with cardiovascular and respiratory events during hospitalization, require intensive services, or die compared to non-obese COVID-19 patients. Obese COVID-19 patients were also more likely to require intensive services or die compared to obese influenza patients, despite presenting with fewer comorbidities. Interpretation: We show that obesity is more common among COVID-19 than influenza patients, and that obese patients present with more severe forms of COVID-19 with higher hospitalization, intensive services, and fatality than non-obese patients. These data are instrumental for guiding preventive strategies of COVID-19 infection and complications

Longitudinal single-cell immune profiling revealed distinct innate immune response in asymptomatic COVID-19 patients (preprint)

Recent studies have characterized the single-cell immune landscape of host immune response of coronavirus disease 2019 (COVID-19), specifically focus on the severe condition. However, the immune response in mild or even asymptomatic patients remains unclear. Here, we performed longitudinal single-cell transcriptome sequencing and T cell/B cell receptor sequencing on 3 healthy donors and 10 COVID-19 patients with asymptomatic, moderate, and severe conditions. We found asymptomatic patients displayed distinct innate immune responses, including increased CD56briCD16- NK subset, which was nearly missing in severe condition and enrichment of a new Th2-like cell type/state expressing a ciliated cell marker. Unlike that in moderate condition, asymptomatic patients lacked clonal expansion of effector CD8+ T cells but had a robust effector CD4+ T cell clonal expansion, coincide with previously detected SARS-CoV-2-reactive CD4+ T cells in unexposed individuals. Moreover, NK and effector T cells in asymptomatic patients have upregulated cytokine related genes, such as IFNG and XCL2. Our data suggest early innate immune response and type I immunity may contribute to the asymptomatic phenotype in COVID-19 disease, which could in turn deepen our understanding of severe COVID-19 and guide early prediction and therapeutics.

Circulating Mitochondrial DNA is an Early Indicator of Severe Illness and Mortality from COVID-19 (preprint)

Mitochondrial DNA (MT-DNA) are intrinsically inflammatory nucleic acids released by damaged solid organs. Whether the appearance of cell-free MT-DNA is linked to poor COVID-19 outcomes remains undetermined. Here, we quantified circulating MT-DNA in prospectively collected, cell-free plasma samples from 97 subjects with COVID-19 at the time of hospital presentation. Circulating MT-DNA were sharply elevated in patients who eventually died, required ICU admission or intubation. Multivariate regression analysis revealed that high circulating MT-DNA levels is an independent risk factor for all of these outcomes after adjusting for age, sex and comorbidities. Additionally, we found that circulating MT-DNA has a similar or superior area-under-the curve when compared to clinically established measures of systemic inflammation, as well as emerging markers currently of interest as investigational targets for COVID-19 therapy. These results show that high circulating MT-DNA levels is a potential indicator for poor COVID-19 outcomes.

Efficacy and safety of chloroquine or hydroxychloroquine in moderate type of COVID-19: a prospective open-label randomized controlled study (preprint)

The outbreak of novel coronavirus disease 2019 (COVID-19) has become a pandemic. Drug repurposing may represent a rapid way to fill the urgent need for effective treatment. We evaluated the clinical utility of chloroquine and hydroxychloroquine in treating COVID-19. Forty-eight patients with moderate COVID-19 were randomized to oral treatment with chloroquine (1000 mg QD on Day 1, then 500 mg QD for 9 days; n=18), hydroxychloroquine (200 mg BID for 10 days; n=18), or control treatment (n=12). Adverse events were mild, except for one case of Grade 2 ALT elevation. Adverse events were more commonly observed in the chloroquine group (44.44%) and the hydroxychloroquine group (50.00%) than in the control group (16.67%). The chloroquine group achieved shorter time to clinical recovery (TTCR) than the control group (P=0.019). There was a trend toward reduced TTCR in the hydroxychloroquine group (P=0.049). The time to reach viral RNA negativity was significantly faster in the chloroquine group and the hydroxychloroquine group than in the control group (P=0.006 and P=0.010, respectively). The median numbers of days to reach RNA negativity in the chloroquine, hydroxychloroquine, and control groups was 2.5 (IQR: 2.0-3.8) days, 2.0 (IQR: 2.0-3.5) days, and 7.0 (IQR: 3.0-10.0) days, respectively. The chloroquine and hydroxychloroquine groups also showed trends toward improvement in the duration of hospitalization and findings on lung computerized tomography (CT). This study provides evidence that (hydroxy)chloroquine may be used effectively in treating moderate COVID-19 and supports larger trials.

Development and Validation of the HNC-LL Score for Predicting the Severity of Coronavirus Disease 2019 (preprint)

Background: The severity of coronavirus disease 2019 (COVID-19) varies widely, ranging from asymptomatic to fatal. However, there is limited information regarding the risk factors associated with severe disease. In this study, we aimed to develop a model for predicting COVID-19 severity. Methods: A total of 690 patients with confirmed COVID-19 were recruited between January 1 and March 18, 2020 from hospitals in Honghu and Nanchang, and finally, 442 patients were analyzed. Data were partitioned into the training set and test sets to develop and validate the model, respectively. Results: A predictive HNC-LL (Hypertension–Neutrophil count–C-reactive protein– Lymphocyte count– Lactate dehydrogenase) score was established based on multivariate logistic regression analysis results. The HNC-LL score accurately predicted disease severity in the Honghu training cohort (area under the curve [AUC] = 0.861, 95% confidence interval [CI]: 0.800–0.922; P <0.001); the Honghu internal validation cohort (AUC = 0.871, 95% CI: 0.769–0.972; P <0.001); and the Nanchang external validation cohort (AUC = 0.826, 95% CI: 0.746–0.907; P <0.001), and outperformed other models including the CURB-65 score model, MuLBSTA score model, and neutrophil-to-lymphocyte ratio model. Moreover, the clinical significance of HNC-LL in accurately predicting patients with severe COVID-19 in the early phase was confirmed. Conclusions: We developed an accurate tool for predicting disease severity in patients with COVID-19. This model can potentially be used to identify patients at risk of developing severe disease in the early stage and therefore, guide treatment decisions.Funding Statement: This work was supported by the National Nature Science Foundation of China (Grant Nos. 81972897) and Guangdong Province Universities and Colleges Pearl River Scholar Funded Scheme (2015).Declaration of Interests: The authors declare that they do not have any conflicts of interest.Ethics Approval Statement: This retrospective analysis was approved by Medical Ethics committee of Nanfang Hospital of Southern Medical University, and the requirement for informed consent was waived by the ethics committee.

Association of Cardiovascular Manifestations with In-hospital Outcomes in Patients with COVID-19: A Hospital Staff Data (preprint)

Background: The outbreaks of coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain a huge threat to the public health worldwide. Clinical data is limited up to now regarding the risk factors in favor of severe conversion of non-severe case with COVID-19. Aims: This study analyzed a hospital staff data to figure out general clinical features of COVID-19 in terms of the association of cardiovascular manifestations (CVMs) with in-hospital outcomes of COVID-19 cases. Methods: Retrospective, single-center case series of 41 consecutive hospitalized health staff with confirmed COVID-19 were collected at the Central Hospital of Wuhan in Wuhan, China, from January 15 to January 24, 2020. Epidemiological, demographic, clinical, laboratory, radiological, treatment data and in-hospital adverse events were collected and analyzed. Final date of follow-up was March 3, 2020. A comparative study was applied between cases with CVMs and those without CVMs. Results: Of all, clinicians and clinical nurses accounted for 80.5%, while 87.8% of all had history of patient contact. The population was presented with a mean age of 39.1 +- 9.2 and less comorbidities than community population. The three most frequent symptoms of COVID-19 cases analyzed were fever (82.9%), myalgia or fatigue (80.5%) and cough (63.4%). While, the three most frequent initial symptoms were myalgia or fatigue (80.5%), fever (73.2%) and cough (41.5%). There were 95.1% cases featured as non-severe course of disease according to the official standard in China. Patients with CVMs and those without CVMs accounted for 58.5% and 41.5%, respectively. Compared with cases without CVMs, patients with CVMs were presented with lower baseline lymphocyte count (0.99 +- 0.43 and 1.55 +- 0.61, P<0.001), more who had at least once positive nucleic acid detection of throat swab during admission (50.0% and 11.8%, P=0.011), and more received oxygen support (79.2% and 23.5%, P<0.001). The rate of in-hospital adverse events was significantly higher in patients with CVMs group (75.0% and 23.5%, P=0.001). Multivariable logistic regression model indicated that, coexisting with CVMs in COVID-19 patients was not independently associated with in-hospital adverse events. Conclusions: Most of hospital staff with COVID-19 had history of patient contact, featured non-severe course of disease. Cases with CVMs suffered from more in-hospital adverse events than those without CVMs. But concomitant CVMs were not independently associated with in-hospital adverse events in COVID-19 patients.

Prevalence and clinical features of 2019 novel coronavirus disease (COVID-19) in the Fever Clinic of a teaching hospital in Beijing: a single-center, retrospective study (preprint)

Background With the spread of COVID-19 from Wuhan, Hubei Province to other areas of the country, medical staff in Fever Clinics faced the challenge of identifying suspected cases among patients with respiratory infections manifested with fever. We aimed to describe the prevalence and clinical features of COVID-19 as compared to pneumonias of other etiologies in a Fever Clinic in Beijing. Methods In this single-center, retrospective study, 342 cases of pneumonia were diagnosed in Fever Clinic in Peking University Third Hospital between January 21 to February 15, 2020. From these patients, 88 were reviewed by panel discussion as possible or probable cases of COVID-19, and received 2019-nCoV detection by RT-PCR. COVID-19 was confirmed by positive 2019-nCoV in 19 cases, and by epidemiological, clinical and CT features in 2 cases (the COVID-19 Group, n=21), while the remaining 67 cases served as the non-COVID-19 group. Demographic and epidemiological data, symptoms, laboratory and lung CT findings were collected, and compared between the two groups. Findings The prevalence of COVID-19 in all pneumonia patients during the study period was 6.14% (21/342). Compared with the non-COVID-19 group, more patients with COVID-19 had an identified epidemiological history (90.5% versus 32.8%, P<0.001). The COVID-19 group had lower WBC [5.19x10^9/L ({+/-}1.47) versus 7.21x10^9/L ({+/-}2.94), P<0.001] and neutrophil counts [3.39x10^9/L ({+/-}1.48) versus 5.38x10^9/L ({+/-}2.85), P<0.001] in peripheral blood. However, the percentage and count of lymphocytes were not different. On lung CT scans, involvement of 4 or more lobes was more common in the COVID-19 group (45% versus 16.4%, P=0.008). Interpretation In the period of COVID-19 epidemic outside Hubei Province, the prevalence of COVID-19 in patients with pneumonia visiting to our Fever Clinic in Beijing was 6.14%. Epidemiological evidence was important for prompt case finding, and lower blood WBC and neutrophil counts may be useful for differentiation from pneumonia of other etiologies.