[Revisit after discharge from the emergency department in a cohort of patients with COVID-19 pneumonia and analysis based on the healthcare resource used for follow-up. RESALSEVID study]. / Análisis de la evolucion tras el alta de urgencias en pacientes con neumonía por COVID-19 en función del recurso sanitario utilizado para el seguimiento: estudio RESALSEVID.

INTRODUCTION: COVID-19 pneumonia is a manifestation of SARS-CoV-2 infection and in most cases involves hospital admission. There are recommendations according to which these patients can be discharged without hospital admission, but there is no evidence regarding the revisit and the most appropriate type of follow-up. The objective of the RESALSEVID study was to investigate the variables associated with the 30-day revisit (Rev30d) in a group of patients discharged directly from 4 emergency departments (ED) with COVID-19 pneumonia, and analyze whether there were differences based on 4 different tracking devices. METHOD: Analysis of a prospective cohort of patients discharged directly from the ED with COVID-19 pneumonia in 4 hospital with different models of follow-up at discharge (primary care, hospitalization at home [HaH] phone and in person, HaH phone, hospital phone). RESULTS: Five hundred twenty patients were included, with a mean age of 50.1 years and 51% men. Rev30d was 18.3% and was related only to immunosuppression, odds ratio 4.49 (95% confidence interval 1.10-18.24); p=0.022. There was no difference in Rev30d based on the follow-up model used at discharge from the ED. CONCLUSIONS: There are some recommendations that allow the safe discharge of patients with COVID-19 pneumonia, with no differences in Rev30d depending on the type of follow-up.

Quality of hospital emergency department care for patients with COVID-19 during the first wave in 2020: the CALUR-COVID-19 study. / Estudio CALUR-COVID-19: calidad asistencial en urgencias del proceso de atención a pacientes con COVID-19 durante el primer pico pandémico de 2020.

OBJECTIVES: To define quality of care indicators and care process standards for treating patients with COVID-19 in hospital emergency departments (EDs), to determine the level of adherence to standards during the first wave in 2020, and to detect factors associated with different levels of adherence. MATERIAL AND METHODS: We selected care indicators and standards by applying the Delphi method. We then analyzed the level of adherence in the SIESTA cohort (registered by the Spanish Investigators in Emergency Situations Team). This cohort was comprised of patients with COVID-19 treated in 62 Spanish hospitals in March and April 2020. Adherence was compared according to pandemic-related ED caseload pressure, time periods during the wave (earlier and later), and age groups. RESULTS: Fourteen quality indicators were identified. Three were adhered to in less than 50% of the patients. Polymerase chain reaction testing for SARS-CoV-2 infection was the indicator most often disregarded, in 29% of patients when the caseload was high vs 40% at other times (P .001) and in 30% of patients in the later period vs 37% in the earlier period (P = .04). Adherence to the following indicators was better in the later part of the wave: monitoring of oxygen saturation (100% vs 99%, P = .035), electrocardiogram monitoring in patients treated with hydroxychloroquine (87% vs 65%, P .001), and avoiding of lopinavir/ritonavir treatment in patients with diarrhea (79% vs 53%, P .001). No differences related to age groups were found. CONCLUSION: Adherence to certain quality indicators deteriorated during ED treatment of patients with COVID-19 during the first wave of the pandemic. Pressure from high caseloads may have exacerbated this deterioration. A learning effect led to improvement. No differences related to patient age were detected.

OBJETIVO: Definir indicadores de calidad y sus estándares para el proceso asistencial del paciente con COVID-19 en servicios de urgencias hospitalarios (SUH), así como determinar su grado de cumplimiento durante el primer pico pandémico e investigar si existieron diferencias en relación con diferentes factores. METODO: Siguiendo la metodología del Delphi, los autores seleccionaron los indicadores y sus estándares. Posteriormente, se analizó el grado de cumplimiento en la cohorte SIESTA, formada por pacientes COVID-19 de 62 SUH españoles atendidos en marzo y abril de 2020. Se comparó el cumplimiento de los indicadores según la presión asistencial generada por la pandemia en el SUH, el periodo asistencial y el grupo etario. RESULTADOS: Se definieron 14 indicadores. Tres de ellos se cumplieron en 50% de los pacientes. La realización de la reacción en cadena de la polimerasa (PCR) para el SARS-CoV-2 tuvo peor cumplimiento en SUH con alta presión (29% frente a 40%, p 0,001) y durante el periodo tardío (30% frente a 37%, p = 0,04). Durante el periodo tardío, mejoró la medida de saturación de oxígeno (100% frente a 99%, p = 0,035), la realización de electrocardiograma en pacientes tratados con hidroxicloroquina (87% frente a 65%, p 0,001) y la no administración de lopinavir-ritonavir en pacientes con diarrea (79% frente a 53%, p 0,001). No hubo diferencias en relación con el grupo etario. CONCLUSIONES: Durante el primer pico pandémico, diversos aspectos de la calidad de la atención a pacientes COVID-19 en los SUH españoles se vieron deteriorados. La presión asistencial pudo incrementar este deterioro. Hubo un efecto de aprendizaje que condicionó una mejora, pero no se observaron diferencias según la edad de los pacientes.

Estudio CALUR-COVID-19: calidad asistencial en urgencias del proceso de atención a pacientes con COVID-19 durante el primer pico pandémico de 2020

Objectives. To define quality of care indicators and care process standards for treating patients with COVID-19 in hospital emergency departments (EDs), to determine the level of adherence to standards during the first wave in 2020, and to detect factors associated with different levels of adherence. Methods. We selected care indicators and standards by applying the Delphi method. We then analyzed the level of adherence in the SIESTA cohort (registered by the Spanish Investigators in Emergency Situations Team). This cohort was comprised of patients with COVID-19 treated in 62 Spanish hospitals in March and April 2020. Adherence was compared according to pandemic-related ED caseload pressure, time periods during the wave (earlier and later), and age groups. Results. Fourteen quality indicators were identified. Three were adhered to in less than 50% of the patients. Polymerase chain reaction testing for SARS-CoV-2 infection was the indicator most often disregarded, in 29% of patients when the caseload was high vs 40% at other times (P < .001) and in 30% of patients in the later period vs 37% in the earlier period (P = .04). Adherence to the following indicators was better in the later part of the wave: monitoring of oxygen saturation (100% vs 99%, P = .035), electrocardiogram monitoring in patients treated with hydroxychloroquine (87% vs 65%, P < .001), and avoiding of lopinavir/ritonavir treatment in patients with diarrhea (79% vs 53%, P < .001). No differences related to age groups were found. Conclusions. Adherence to certain quality indicators deteriorated during ED treatment of patients with COVID-19 during the first wave of the pandemic. Pressure from high caseloads may have exacerbated this deterioration. A learning effect led to improvement. No differences related to patient age were detected. Objetivo. Definir indicadores de calidad y sus estándares para el proceso asistencial del paciente con COVID-19 en servicios de urgencias hospitalarios (SUH), así como determinar su grado de cumplimiento durante el primer pico pandémico e investigar si existieron diferencias en relación con diferentes factores. Método. Siguiendo la metodología del Delphi, los autores seleccionaron los indicadores y sus estándares. Posteriormente, se analizó el grado de cumplimiento en la cohorte SIESTA, formada por pacientes COVID-19 de 62 SUH españoles atendidos en marzo y abril de 2020. Se comparó el cumplimiento de los indicadores según la presión asistencial generada por la pandemia en el SUH, el periodo asistencial y el grupo etario. Resultados. Se definieron 14 indicadores. Tres de ellos se cumplieron en < 50% de los pacientes. La realización de la reacción en cadena de la polimerasa (PCR) para el SARS-CoV-2 tuvo peor cumplimiento en SUH con alta presión (29% frente a 40%, p < 0,001) y durante el periodo tardío (30% frente a 37%, p = 0,04). Durante el periodo tardío, mejoró la medida de saturación de oxígeno (100% frente a 99%, p = 0,035), la realización de electrocardiograma en pacientes tratados con hidroxicloroquina (87% frente a 65%, p < 0,001) y la no administración de lopinavir-ritonavir en pacientes con diarrea (79% frente a 53%, p < 0,001). No hubo diferencias en relación con el grupo etario. Conclusiones. Durante el primer pico pandémico, diversos aspectos de la calidad de la atención a pacientes COVID-19 en los SUH españoles se vieron deteriorados. La presión asistencial pudo incrementar este deterioro. Hubo un efecto de aprendizaje que condicionó una mejora, pero no se observaron diferencias según la edad de los pacientes.

Pulmonary embolism in patients with COVID-19: incidence, risk factors, clinical characteristics, and outcome.

AIMS: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. METHODS AND RESULTS: We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. CONCLUSIONS: PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Análisis de la evolucion tras el alta de urgencias en pacientes con neumonía por COVID19 en función del recurso sanitario utilizado para el seguimiento: Estudio RESALSEVID Revisit after discharge from the emergency department in a cohort of patients with COVID19 pneumonia and analysis based on the healthcare resource used for follow-up. RESALSEVID study

Introducción: la neumonía COVID19 es una manifestación de la infección por SARS-CoV-2 y en la mayoría de casos supone ingreso hospitalario. Existen recomendaciones según las cuales se puede dar de alta a estos pacientes sin precisar ingreso hospitalario, pero no hay evidencia en relación a la revisita y el tipo de seguimiento más adecuado. El objetivo del estudio RESALSEVID fue investigar las variables asociadas a la revisita a los 30 días (Rev30d) en un grupo de pacientes dados de alta directamente en 4 servicios de urgencias hospitalarios (SUH) con neumonía COVID19, y analizar si existieron diferencias en función de 4 dispositivos de seguimiento diferentes. Método: análisis de una cohorte prospectiva de pacientes dados de alta directamente desde urgencias con neumonía COVID19 en 4 SUH con diferentes modelos de seguimiento al alta (atención primaria, hospitalización a domicilio [HaD] telefónico y presencial, HaD telefónico, telefónico hospitalario). Resultados: se incluyeron 520 pacientes, con una media de edad de 50,1 años y 51% varones. La Rev30d fue del 18,3% y se relacionó únicamente con la inmunosupresión, odds ratio 4,49 (intervalo de confianza del 95% 1,10 – 18,24);p=0,022. No hubo ninguna diferencia en la Rev30d en función del modelo de seguimiento utilizado al alta de urgencias. Conclusiones: existen una serie de recomendaciones que permiten dar de alta de manera segura a pacientes con neumonía COVID19, no existiendo diferencias en la Rev30d en función del tipo de seguimiento.

A case-control, multicentre study of consecutive patients with COVID-19 and acute (myo)pericarditis: incidence, risk factors, clinical characteristics and outcomes.

OBJECTIVE: To estimate incidence, risk factors, clinical characteristics and outcomes of acute (myo)pericarditis (AMP) in patients with COVID-19. METHODS: Case-control, retrospective review, consecutive case inclusion performed in 62 Spanish EDs. All COVID-19 patients with AMP (cases) were compared in clinical characteristics and outcomes with COVID-19 without AMP (control group A) and non-COVID patients with AMP (control group B). We estimated unadjusted standardised incidence (SI, not adjusted by population's age/sex) of AMP in COVID-19 and non-COVID populations (per 100 000/year). RESULTS: We identified 67 AMP in COVID-19 patients (SI=56.5, OR with respect to non-COVID patients=4.43, 95% CI=3.98 to 4.94). Remarkably, COVID-19 cases presented with chest pain less frequently than non-COVID patients and had less typical ECG changes, higher NT-proBNP (N-terminal prohormone of brain natriuretic peptide), more left and right ventricular dysfunction in echocardiography and more need of inotropic/vasopressor drugs. Admission to intensive care was higher than control group A (OR=3.22, 95% CI=1.43 to 7.23), and in-hospital mortality was higher than control group B (OR=7.75, 95% CI=2.77 to 21.7). CONCLUSION: AMP is unusual as a form of COVID-19 presentation (about 1‰ cases), but SI is more than fourfold higher than non-COVID population, and it is less symptomatic, more severe and has higher in-hospital mortality; therefore, rapid recognition, echocardiographic assessment of myopericardial inflammation/dysfunction and treatment with vasoactive drugs when needed are recommended in AMP in patients with COVID-19.

Incidence, Clinical Characteristics, Risk Factors and Outcomes of Acute Coronary Syndrome in Patients With COVID-19: Results of the UMC-19-S1010.

BACKGROUND: There is a lack of knowledge about the real incidence of acute coronary syndrome (ACS) in patients with COVID-19, their clinical characteristics, and their prognoses. OBJECTIVE: We investigated the incidence, clinical characteristics, risk factors, and outcomes of ACS in patients with COVID-19 in the emergency department. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with ACS in 62 Spanish emergency departments between March and April 2020 (the first wave of COVID-19). We formed 2 control groups: COVID-19 patients without ACS (control A) and non-COVID-19 patients with ACS (control B). Unadjusted comparisons between cases and control subjects were performed regarding 58 characteristics and outcomes. RESULTS: We identified 110 patients with ACS in 74,814 patients with COVID-19 attending the ED (1.48% [95% confidence interval {CI} 1.21-1.78%]). This incidence was lower than that observed in non-COVID-19 patients (3.64% [95% CI 3.54-3.74%]; odds ratio [OR] 0.40 [95% CI 0.33-0.49]). The clinical characteristics of patients with COVID-19 associated with a higher risk of presenting ACS were: previous coronary artery disease, age ≥60 years, hypertension, chest pain, raised troponin, and hypoxemia. The need for hospitalization and admission to intensive care and in-hospital mortality were higher in cases than in control group A (adjusted OR [aOR] 6.36 [95% CI 1.84-22.1], aOR 4.63 [95% CI 1.88-11.4], and aOR 2.46 [95% CI 1.15-5.25]). When comparing cases with control group B, the aOR of admission to intensive care was 0.41 (95% CI 0.21-0.80), while the aOR for in-hospital mortality was 5.94 (95% CI 2.84-12.4). CONCLUSIONS: The incidence of ACS in patients with COVID-19 attending the emergency department was low, around 1.48%, but could be increased in some circumstances. Patients with COVID-19 with ACS had a worse prognosis than control subjects with higher in-hospital mortality.

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11.

OBJECTIVE: We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization. METHODS: We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls. RESULTS: We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively). CONCLUSIONS: The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

Syncope and COVID-19 disease - A systematic review.

BACKGROUND: Syncope is not a common manifestation of COVID-19, but it may occur in this context and it can be the presenting symptom in some cases. Different mechanisms may explain the pathophysiology behind COVID-19 related syncope. In this report, we aimed to examine the current frequency and etiology of syncope in COVID-19. METHODS: A systematic review across PubMed, ISI Web of Knowledge and SCOPUS was performed, according to PRISMA guidelines, in order to identify all relevant articles regarding both COVID-19 and syncope. RESULTS: We identified 136 publications, of which 99 were excluded. The frequency of syncope and pre-syncope across the selected studies was 4.2% (604/14,437). Unexplained syncope was the most common type (87.9% of the episodes), followed by reflex syncope (7.8% of the cases). Orthostatic hypotension was responsible for 2.2% of the cases and syncope of presumable cardiac cause also accounted for 2.2% of cases. Arterial hypertension was present in 52.0% of syncope patients. The use of angiotensin receptor blockers or angiotensin converting enzyme inhibitors were not associated with an increased incidence of syncope (chi-square test 1.07, p 0.30), unlike the use of beta-blockers (chi-square test 12.48, p < 0.01). CONCLUSION: Syncope, although not considered a typical symptom of COVID-19, can be associated with it, particularly in early stages. Different causes of syncope were seen in this context. A reevaluation of blood pressure in patients with COVID-19 is suggested, including reassessment of antihypertensive therapy, especially in the case of beta-blockers.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation < 92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer ≥ 500 ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH ≥ 500 U/L, CRP ≥ 10 mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

OBJETIVO: Evaluar la densidad vascular (DV) y la perfusión vascular (PV) retiniana en pacientes con COVID-19 mediante una angiografía por tomografía de coherencia óptica (OCTA), e investigar si existe una correlación entre las anomalías vasculares de la retina y los parámetros clínicos y de laboratorio. MÉTODOS: Análisis transversal realizado en el Hospital Clínico San Carlos, Madrid. Se incluyeron pacientes con diagnóstico confirmado de COVID-19 atendidos en el Servicio de Urgencias (SU) del 23 al 29 de marzo del 2020. Se realizó una exploración oftalmológica y OCTA cuatro semanas después de acudir al SU. Se analizaron los parámetros maculares de OCTA y se correlacionaron con parámetros clínicos (gravedad e hipoxemia-saturación de oxígeno < 92%) y de laboratorio durante la estancia hospitalaria (dímero D [DD], lactato deshidrogenasa [LDH] y proteína C reactiva [CRP]. RESULTADOS: Se incluyeron 80 pacientes, edad media 55 (DE nueve) años; 46,3% hombres. Las personas con DD > 500 ng/mL durante la infección por SARS-CoV-2 tuvieron una disminución de la DV central (diferencia de medias 2,2; IC 95% 0,4 a 3,9) y PV central (diferencia de medias 4,9; IC 95% 0,9 a 8,9) después de la fase aguda de COVID-19. Estas variaciones no se documentaron en los pacientes con LDH > = 500 U/L, CRP > = 10 mg/L y con hipoxemia. CONCLUSIONES: Los pacientes con COVID-19 mostraron anomalías de la vasculatura retiniana a corto plazo que pueden estar relacionadas con un estado protrombótico asociado con la infección por SARS-CoV-2. Dado que la microvasculatura de la retina comparte muchas propiedades morfológicas y fisiológicas con la vasculatura de otros órganos vitales, es necesario seguir investigando para determinar si los pacientes con niveles elevados de DD requieren una evaluación y un seguimiento más cuidadoso.

Reduced macular vessel density in COVID-19 patients with and without associated thrombotic events using optical coherence tomography angiography.

PURPOSE: Thrombotic events (TE) represent one of the major complications of SARS-CoV-2 infection. The objective is to evaluate vessel density (VD) and perfusion density (PD) by optical coherence tomography angiography (OCTA) in COVID-19 patients, and compare the findings with healthy controls. The secondary objective is to evaluate if there are differences in OCTA parameters between COVID-19 patients with and without associated TE. METHODS: Cross-sectional case-control study that included patients with laboratory-confirmed diagnosis of COVID-19 with and without TE related to the infection and age-matched healthy controls. Ophthalmological examination and OCTA were performed 12 weeks after diagnosis. Demographic data and medical history were collected. Macular OCTA parameters in the superficial retinal plexus were analyzed according to ETDRS sectors. RESULTS: Ninety patients were included, 19 (20%) COVID-19 patients with associated TE, 47 (49.5%) COVID-19 patients without TE, and 29 (30.5%) healthy controls. Fifty-three (55.7%) were male, mean age 54.4 (SD 10.2) years. COVID-19 patients presented significantly lower VD than healthy controls: central (p = 0.003), inner ring (p = 0.026), outer ring (p = 0.001). PD was also significantly decreased: outer ring (p = 0.003), full area (p = 0.001). No differences in OCTA parameters were found between COVID-19 patients with and without TE. CONCLUSIONS: OCTA represents a promising tool for the in vivo assessment of microvascular changes in COVID-19. Patients with SARS-CoV-2 infection show lower VD and PD compared to healthy controls. However, no differences were found between COVID-19 when considering TE. Prospective studies are required to further evaluate the retinal microvascular involvement of SARS-CoV-2 and its impact on the vasculature of other organs.

Optic nerve and macular optical coherence tomography in recovered COVID-19 patients.

PURPOSE: To investigate the peripapillary retinal nerve fiber layer thickness (RNFLT), macular RNFLT, ganglion cell layer (GCL), and inner plexiform layer (IPL) thickness in recovered COVID-19 patients compared to controls. METHODS: Patients previously diagnosed with COVID-19 were included, while healthy patients formed the historic control group. All patients underwent an ophthalmological examination, including macular and optic nerve optical coherence tomography. In the case group, socio-demographic data, medical history, and neurological symptoms were collected. RESULTS: One hundred sixty patients were included; 90 recovered COVID-19 patients and 70 controls. COVID-19 patients presented increases in global RNFLT (mean difference 4.3; CI95% 0.8 to 7.7), nasal superior (mean difference 6.9; CI95% 0.4 to 13.4), and nasal inferior (mean difference 10.2; CI95% 2.4 to 18.1) sectors of peripapillary RNFLT. Macular RNFL showed decreases in COVID-19 patients in volume (mean difference -0.05; CI95% -0.08 to -0.02), superior inner (mean difference -1.4; CI95% -2.5 to -0.4), nasal inner (mean difference -1.1; CI95% -1.8 to -0.3), and nasal outer (mean difference -4.7; CI95% -7.0 to -2.4) quadrants. COVID-19 patients presented increased GCL thickness in volume (mean difference 0.04; CI95% 0.01 to 0.07), superior outer (mean difference 2.1; CI95% 0.8 to 3.3), nasal outer (mean difference 2.5; CI95% 1.1 to 4.0), and inferior outer (mean difference1.2; CI95% 0.1 to 2.4) quadrants. COVID-19 patients with anosmia and ageusia presented an increase in peripapillary RNFLT and macular GCL compared to patients without these symptoms. CONCLUSIONS: SARS-CoV-2 may affect the optic nerve and cause changes in the retinal layers once the infection has resolved.

Incidence, clinical characteristics, risk factors and outcomes of meningoencephalitis in patients with COVID-19.

We investigated the incidence, clinical characteristics, risk factors, and outcome of meningoencephalitis (ME) in patients with COVID-19 attending emergency departments (ED), before hospitalization. We retrospectively reviewed all COVID patients diagnosed with ME in 61 Spanish EDs (20% of Spanish EDs, COVID-ME) during the COVID pandemic. We formed two control groups: non-COVID patients with ME (non-COVID-ME) and COVID patients without ME (COVID-non-ME). Unadjusted comparisons between cases and controls were performed regarding 57 baseline and clinical characteristics and 4 outcomes. Cerebrospinal fluid (CSF) biochemical and serologic findings of COVID-ME and non-COVID-ME were also investigated. We identified 29 ME in 71,904 patients with COVID-19 attending EDs (0.40‰, 95%CI=0.27-0.58). This incidence was higher than that observed in non-COVID patients (150/1,358,134, 0.11‰, 95%CI=0.09-0.13; OR=3.65, 95%CI=2.45-5.44). With respect to non-COVID-ME, COVID-ME more frequently had dyspnea and chest X-ray abnormalities, and neck stiffness was less frequent (OR=0.3, 95%CI=0.1-0.9). In 69.0% of COVID-ME, CSF cells were predominantly lymphocytes, and SARS-CoV-2 antigen was detected by RT-PCR in 1 patient. The clinical characteristics associated with a higher risk of presenting ME in COVID patients were vomiting (OR=3.7, 95%CI=1.4-10.2), headache (OR=24.7, 95%CI=10.2-60.1), and altered mental status (OR=12.9, 95%CI=6.6-25.0). COVID-ME patients had a higher in-hospital mortality than non-COVID-ME patients (OR=2.26; 95%CI=1.04-4.48), and a higher need for hospitalization (OR=8.02; 95%CI=1.19-66.7) and intensive care admission (OR=5.89; 95%CI=3.12-11.14) than COVID-non-ME patients. ME is an unusual form of COVID presentation (<0.5‰ cases), but is more than 4-fold more frequent than in non-COVID patients attending the ED. As the majority of these MEs had lymphocytic predominance and in one patient SARS-CoV-2 antigen was detected in CSF, SARS-CoV-2 could be the cause of most of the cases observed. COVID-ME patients had a higher unadjusted in-hospital mortality than non-COVID-ME patients.

Reduced retinal vessel density in COVID-19 patients and elevated D-dimer levels during the acute phase of the infection.

PURPOSE: To describe macular vessel density and perfusion in COVID-19 patients using coherence tomography angiography (OCTA) and to investigate whether there is a correlation between retinal vascular abnormalities and clinical and laboratory parameters. METHODS: Cross-sectional analysis conducted at the Hospital Clinico San Carlos in Madrid, Spain. Patients with laboratory-confirmed COVID-19 that were attended in the Emergency Department (ED) from March 23 to March 29, 2020 were included. Fundus examination and OCTA were performed 4 weeks after being attended in ED. Macular OCTA parameters were analyzed and correlated with clinical (severity and hypoxemia- oxygen saturation<92%) and laboratory parameters during hospital stay (D-Dimer-DD, lactate dehydrogenase-LDH and C-reactive protein-CRP). RESULTS: 80 patients were included, mean age 55(SD9) years old; 46.3% male. We reported macular vessel density and perfusion measurements in COVID-19 patients. Those patients with D-Dimer≥500ng/ml during SARS-CoV-2 infection had a decrease of central vessel density (mean difference 2.2; 95%CI 0.4-3.9) and perfusion density (mean difference 4.9; 95%CI 0.9-8.9) after the acute phase of COVID-19. These variations of vessel density and perfusion density were not documented in patients with LDH≥500U/L, CRP≥10mg/L and hypoxemia. CONCLUSIONS: COVID-19 patients showed short-term retinal vasculature abnormalities which may be related to a prothrombotic state associated with SARS-CoV-2 infection. Since the retinal microvasculature shares many morphological and physiological properties with the vasculature of other vital organs, further research is needed to establish whether patients with increased D-Dimer levels require more careful assessment and follow-up after COVID-19.

Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study.

BACKGROUND: Recent reports of patients with coronavirus disease 2019 (COVID-19) developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined. RESEARCH QUESTION: Do the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP? STUDY DESIGN AND METHODS: This case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes. RESULTS: We identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56‰; 95% CI, 0.40‰-0.76‰). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28‰; 95% CI, 0.26‰-0.32‰; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups. INTERPRETATION: SP as a form of COVID-19 presentation at the ED is unusual (< 1‰ cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP.

Impacto organizativo de la pandemia COVID-19 de 2020 en los servicios de urgencias hospitalarios españoles: resultados del estudio ENCOVUR

Objective. To estimate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the organization of Spanish hospital emergency departments (EDs). To explore differences between Spanish autonomous communities or according to hospital size and disease incidence in the area. Methods. Survey of the heads of 283 EDs in hospitals belonging to or affiliated with Spain's public health service. Respondents evaluated the pandemic's impact on organization, resources, and staff absence from work in March and April 2020. Assessments were for 15-day periods. Results were analyzed overall and by autonomous community, hospital size, and local population incidence rates. Results. A total of 246 (87%) responses were received. The majority of the EDs organized a triage system, first aid, and observation wards;areas specifically for patients suspected of having COVID-19 were newly set apart. The nursing staff was increased in 83% of the EDs (with no subgroup differences), and 59% increased the number of physicians (especially in large hospitals and locations where the COVID-19 incidence was high). Diagnostic tests for the severe acute respiratory syndrome coronavirus 2 were the resource the EDs missed most: 55% reported that tests were scarce often or very often. Other resources reported to be scarce were FPP2 and FPP3 masks (38% of the EDs), waterproof protective gowns (34%), and space (32%). More than 5% of the physicians, nurses, or other emergency staff were on sick leave 20%, 19%, and 16% of the time. These deficiencies were greatest during the last half of March, except for tests, which were most scarce in the first 15 days. Large hospital EDs less often reported that diagnostic tests were unavailable. In areas where the COVID-19 incidence was higher, the EDs reported higher rates of staff on sick leave. Resource scarcity differed markedly by autonomous community and was not always associated with the incidence of COVID-19 in the population. Conclusions. The COVID-19 pandemic led to organizational changes in EDs. Certain resources became scarce, and marked differences between autonomous communities were detected. Objetivo. Estimar el impacto del brote pandémico de COVID-19 en diversos aspectos organizativos de los servicios de urgencias hospitalarios (SUH) españoles e investigar si difirió en función de la comunidad autónoma, tamaño del hospital e incidencia local de la pandemia. Método. Encuesta a los responsables de los 283 SUH españoles de uso público, quienes valoraron el impacto de la pandemia en aspectos organizativos, disponibilidad de recursos, y bajas del personal durante marzo-abril de 2020, diferenciando dicho impacto por quincenas. Los resultados se analizaron en conjunto, por comunidad autónoma, según tamaño del hospital y según incidencia local de la pandemia. Resultados. Se recibieron 246 encuestas (87% de los SUH españoles). La mayoría de SUH reorganizaron el triaje, primera asistencia y observación y habilitó nuevos espacios específicos para pacientes con sospecha de COVID-19. Un 83% aumentó dotación enfermera (sin diferencias entre grupos) y un 59% la dotación de médicos (más frecuente en hospitales grandes y zonas de alta incidencia). El recurso que más escaseó fue el test diagnóstico de SARS-CoV-2 (55% del tiempo insuficiente con cierta o mucha frecuencia), seguido de mascarillas FPP2-FPP3 (38%), batas impermeables (34%) y espacio asistencial (32%). Hubo más del 5% de médicos/enfermería/otro personal de baja el 20%/19%/16% del tiempo. Estos déficits fueron máximos la segunda quincena de marzo, excepto para los test diagnósticos (primera quincena de marzo). Los SUH de grandes centros tuvieron menos escasez de tests diagnósticos, y los de zonas de alta incidencia pandémica más profesionales de baja. Existieron marcadas diferencias en todas estos déficits entre comunidades autónomas, no siempre concordantes con el grado de afectación pandémica en cada comunidad. Conclusiones. La pandemia COVID-19 generó cambios estructurales en los SUH, que sufrieron una escasez considerable en ciertos recursos, con diferencias marcadas entre comunidades autónomas.