Nature in virtual reality improves mood and reduces stress: evidence from young adults and senior citizens.

Large populations worldwide have been deprived from nature experiences due to mass quarantines and lockdowns during the COVID-19 pandemic, and face a looming mental health crisis. Virtual reality offers a safe and practical solution to increase nature exposure. This research examined the effects of virtual nature using a within-subject design with young adults (Study 1) and senior citizens (Study 2). Results from the young adult sample showed that walking in a virtual forest reduced negative affect due to enhanced nature connectedness, and reduced stress measured by heart rate. Consistently, the senior citizen sample reported improved positive affect due to enhanced nature connectedness after the virtual nature walk. Our findings unveil the underlying mechanism of how virtual nature may improve psychological well-being and demonstrated how virtual nature can be used as an intervention to promote mental health. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10055-021-00604-4.

Statin Use and In-hospital Mortality in Patients with COVID-19 and Coronary Heart Disease.

The worsening progress of coronavirus disease 2019 (COVID-19) is attributed to the proinflammatory state, leading to increased mortality. Statin works with its anti-inflammatory effects and may attenuate the worsening of COVID-19. COVID-19 patients were retrospectively enrolled from two academic hospitals in Wuhan, China, from 01/26/2020 to 03/26/2020. Adjusted in-hospital mortality was compared between the statin and the non-statin group by CHD status using multivariable Cox regression model after propensity score matching. Our study included 3133 COVID-19 patients (median age: 62y, female: 49.8%), and 404 (12.9%) received statin. Compared with the non-statin group, the statin group was older, more likely to have comorbidities but with a lower level of inflammatory markers. The Statin group also had a lower adjusted mortality risk (6.44% vs. 10.88%; adjusted hazard ratio [HR] 0.47; 95% CI, 0.29-0.77). Subgroup analysis of CHD patients showed a similar result. Propensity score matching showed an overall 87% (HR, 0.13; 95% CI, 0.05-0.36) lower risk of in-hospital mortality for statin users than nonusers. Such survival benefit of statin was obvious both among CHD and non-CHD patients (HR = 0.30 [0.09-0.98]; HR = 0.23 [0.1-0.49], respectively). Statin use was associated with reduced in-hospital mortality in COVID-19. The benefit of statin was both prominent among CHD and non-CHD patients. These findings may further reemphasize the continuation of statins in patients with CHD during the COVID-19 era.

Different characteristics of critical COVID-19 and thinking of treatment strategies in non-elderly and elderly severe adult patients.

BACKGROUND: The differences in the characteristics and main causes of critical COVID-19 infection in non-elderly and elderly severe patients remain unknown. METHODS: We included 273 adult patients with confirmed severe COVID-19 from Tongji Hospital, Wuhan, China from February 10 to March 8, 2020. Clinical characteristics and risk factors for outcomes were compared between the young and middle-aged and the elderly severe patients. RESULTS: Hemoglobin, neutrophil percentage, inflammatory markers, hepatic, renal, and cardiovascularparameters differed between the non-elderly and elderly severe patients. In young and middle-aged patients, critical patients showed higher high-sensitivity C-reactive protein (hsCRP) during hospitalization than severe patients. However, in the elderly patients, critical patients showed decreased hsCRP during hospitalization and higher proBNP values. The hsCRP fluctuation and proBNP were independent risk factors for intensive care unit (ICU) admission in young and middle-aged severe patients (OR=1.068) and elderly severe patients (OR=1.026), respectively. CONCLUSION: The study revealed different potential causes of disease and predictive factors for non-elderly and elderly critical patients and treatment recommendations. Deterioration of inflammatory state was the main cause of ICU admission in young and middle-aged severe COVID-19 patients, while a decline in hsCRP was not associated with better outcomes in elderly severe patients, indicating the need for different treatments for non-elderly and elderly severe patients. Anti-inflammatory therapy with corticosteroids should be considered in the early disease stage among non-elderly severe patients, but cardiovascular protection plays a more important role in elderly severe patients.

The Association of Low Molecular Weight Heparin Use and In-hospital Mortality Among Patients Hospitalized with COVID-19.

PURPOSE: To determine the association between low molecular weight heparin (LMWH) use and mortality in hospitalized COVID-19 patients. METHODS: We conducted a retrospective study of patients consecutively enrolled from two major academic hospitals exclusively for COVID-19 in Wuhan, China, from January 26, 2020, to March 26, 2020. The primary outcome was adjusted in-hospital mortality in the LMWH group compared with the non-LMWH group using the propensity score. RESULTS: Overall, 525 patients with COVID-19 enrolled with a median age of 64 years (IQR 19), and 49.33% men. Among these, 120 (22.86%) were treated with LMWH. Compared with the non-LMWH group, the LMWH group was more likely to be older and male; had a history of hypertension, diabetes, coronary heart disease (CHD), or stroke; and had more severe COVID-19 parameters such as higher inflammatory cytokines or D-dimer. Compared with non-LMWH group, LMWH group had a higher unadjusted in-hospital mortality rate (21.70% vs. 11.10%; p = 0.004), but a lower adjusted mortality risk (adjusted odds ratio [OR], 0.20; 95% CI, 0.09-0.46). A propensity score-weighting analysis demonstrated similar findings (adjusted OR, 0.18; 95% CI, 0.10-0.30). Subgroup analysis showed a significant survival benefit among those who were severely (adjusted OR, 0.07; 95% CI, 0.02-0.23) and critically ill (adjusted OR, 0.32; 95% CI, 0.15-0.65), as well as among the elderly patients' age > 65, IL-6 > 10 times upper limit level, and D-dimer > 5 times upper limit level. CONCLUSIONS: Among hospitalized COVID-19 patients, LMWH use was associated with lower all-cause in-hospital mortality than non-LMWH users. The survival benefit was particularly significant among more severely ill patients.

Effectiveness of early treatment of lopinavir-ritonavir in patients with severe COVID-19: a case series.

AIM: The inconsistent effects of lopinavir-ritonavir (LPV/r) on COVID-19 seem to be caused by the therapeutic window. In the present study, we aim to present the effects of early LPV/r treatment on patients with severe COVID-19. METHODS: The demographics, characteristics, treatments, SARS-CoV-2 test results and outcomes of 19 patients with severe COVID-19 treated with LPV/r within 12 days of onset of symptoms were retrospectively assessed. RESULTS: Within 3 days of admission, three (15.79%) patients received noninvasive ventilation, and 16 (84.21%) patients received high-flow oxygen support. The median duration between the onset of symptoms and initiating LPV/r therapy was 9 (range 2-12) days. The median course of LPV/r treatment was 11 (range 7-17) days. One of the 19 patients (5.26%) died. Of the 18 patients discharged, the median hospital stay was 17 (range 11-45) days. At day 6 after LPV/r therapy was initiated, 68.42% of patients were virologically cured, increasing to 84.22% at day 12. CONCLUSION: In this cohort of patients with severe COVID-19 who were treated with LPV/r within 12 days of the onset of symptoms, clinical improvement was observed in 18/19 patients (94.74%). Randomised controlled trials are urgently needed to further evaluate this strategy.

Pregnant women with COVID-19 and risk of adverse birth outcomes and maternal-fetal vertical transmission: a population-based cohort study in Wuhan, China.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. However, little is known about the association between pregnant women with COVID-19 and the risk of adverse birth outcomes. METHOD: We conducted a retrospective cohort study based on the Maternal and Child Health Information System (MCHIMS) of Wuhan, China. All pregnant women with singleton live birth recorded by the system between January 13 and March 18, 2020, were included. The adverse birth outcomes were preterm birth, low birth weight, neonatal asphyxia, premature rupture of membrane (PROM), and cesarean section delivery. Multivariate logistic regression was used to evaluate the associations between maternal COVID-19 diagnosis and adverse birth outcomes. RESULTS: Out of 11,078 pregnant women, 65 were confirmed with coronavirus disease 2019 (COVID-19). No deaths occurred from these confirmed cases or their newborns. Compared to pregnant women without COVID-19, pregnant women with a confirmed COVID-19 diagnosis had an increased risk of preterm birth (OR 3.34, 95% CI 1.60-7.00) and cesarean section (OR 3.63, 95% CI 1.95-6.76). There was no statistical difference in low birth weight, neonatal asphyxia, and PROM between the mothers with and without COVID-19. Among these newborns that were born to mothers with confirmed COVID-19, none was tested severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive or had abnormal CT results. Only one had diarrhea and three had a fever. CONCLUSIONS: This population-based cohort study suggests that COVID-19 during the later pregnancy is associated with an increased risk of adverse birth outcomes, including iatrogenic preterm birth and cesarean section delivery. Our data provide little evidence for maternal-fetal vertical transmission of SARS-CoV-2. It is important to monitor the long-term health effects of SARS-CoV-2 infection on pregnant women and their children.

The association of diabetes and the prognosis of COVID-19 patients: A retrospective study.

AIMS: This study evaluated the impact of previous glycemic control and in-hospital use of antidiabetic/antihypertensive drugs on the prognosis of COVID-19 patients with diabetes. METHODS: In this retrospective cohort study, consecutive inpatients with laboratory confirmed COVID-19 were enrolled from Tongji Hospital (Wuhan, China). Patients without diabetes were matched to those with diabetes based on age, sex, and comorbidities. All patients were followed up to a clinical endpoint (discharge, worsening including transferring to ICU or immediate death). Data and outcomes were extracted from medical records and analyzed. RESULTS: 64 patients with pre-existing diabetes were included in this study, with 128 matched patients without diabetes included as a control group. Patients with diabetes had a higher rate of worsening (18.8% versus 7.8%, p = 0.025). Multivariable regression showed increased odds of worsening associated with previous glycemic control reflected by HbA1c (odds ratio 3.29, 95% CI 1.19-9.13, p = 0.022) and receiver-operating characteristics (ROC) curve identified HbA1c of 8.6% (70 mmol/mol) as the optimal cut-off value. Univariate analysis demonstrated the in-hospital use of antidiabetic/antihypertensive drugs were not associated with a higher risk of worsening. CONCLUSIONS: COVID-19 patients with diabetes had a higher risk of worsening, especially those with poorly-controlled HbA1c, with an optimal cut-off value of 8.6%. The in-hospital use of antidiabetic/antihypertensive drugs were not associated with increased odds of worsening in patients with diabetes.

Management of gynecology patients during the coronavirus disease 2019 pandemic: Chinese expert consensus

Since December 2019, the outbreak of novel coronavirus disease 2019 became a major epidemic threat in China and later spread worldwide. During the coronavirus disease 2019 outbreak in mainland China, the Chinese Obstetricians and Gynecologists Association distributed guidelines regarding the care of gynecologic patients. These guidelines were developed by the Department of Obstetrics and Gynecology at the Peking Union Medical College Hospital and represent an effort to integrate infection control strategy and promote professionalism in medical practice. The guidelines represent collaboration with experts from 31 provinces and autonomous regions of mainland China over 2 weeks' time. With the implementation of these guidelines, no nosocomial infections of coronavirus disease 2019 have been identified at the Peking Union Medical College Hospital. We think these guidelines might be helpful to departments of obstetrics and gynecology internationally during these unprecedented times. In our guidelines, we describe basic infection precaution principles, an epidemiologic screening tool, prioritization of surgical procedures, and operating room requirements. Using these principles, we then review the management of gynecologic patients during the coronavirus disease 2019 epidemic in the outpatient and operative and nonoperative inpatient settings and in clinical trials.

Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections.

The clinical features and immune responses of asymptomatic individuals infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have not been well described. We studied 37 asymptomatic individuals in the Wanzhou District who were diagnosed with RT-PCR-confirmed SARS-CoV-2 infections but without any relevant clinical symptoms in the preceding 14 d and during hospitalization. Asymptomatic individuals were admitted to the government-designated Wanzhou People's Hospital for centralized isolation in accordance with policy1. The median duration of viral shedding in the asymptomatic group was 19 d (interquartile range (IQR), 15-26 d). The asymptomatic group had a significantly longer duration of viral shedding than the symptomatic group (log-rank P = 0.028). The virus-specific IgG levels in the asymptomatic group (median S/CO, 3.4; IQR, 1.6-10.7) were significantly lower (P = 0.005) relative to the symptomatic group (median S/CO, 20.5; IQR, 5.8-38.2) in the acute phase. Of asymptomatic individuals, 93.3% (28/30) and 81.1% (30/37) had reduction in IgG and neutralizing antibody levels, respectively, during the early convalescent phase, as compared to 96.8% (30/31) and 62.2% (23/37) of symptomatic patients. Forty percent of asymptomatic individuals became seronegative and 12.9% of the symptomatic group became negative for IgG in the early convalescent phase. In addition, asymptomatic individuals exhibited lower levels of 18 pro- and anti-inflammatory cytokines. These data suggest that asymptomatic individuals had a weaker immune response to SARS-CoV-2 infection. The reduction in IgG and neutralizing antibody levels in the early convalescent phase might have implications for immunity strategy and serological surveys.

Hydroxychloroquine treatment in COVID-19: A descriptive observational analysis of 30 cases from a single center in Wuhan, China.

Hydroxychloroquine (HCQ) garnered scientific attention in early February following publication of reports showing in vitro activity of chloroquine (CQ) against coronavirus disease 2019 (COVID-19). While studies are mixed on this topic, the therapeutic effect of HCQ or CQ still need more valid clinical evidence. In this descriptive observational study, we aimed to discuss the treatment response of HCQ in COVID-19 infected patients and 30 cases were included. The demographic, treatment, laboratory parameters of C-reactive protein (CRP) and interleukin-6 (IL-6) before and after HCQ therapy and clinical outcome in the 30 patients with COVID-19 were assessed. To evaluate the effect of mediation time point, we also divided these cases into two groups, patients began administrated with HCQ within 7 days hospital (defined as early delivery group) and 7 days after hospital (defined as later delivery group). We found that, the elevated IL-6, a risk factor in severe patients were reduced to normal level after HCQ treatment. More importantly, patients treated with HCQ at the time of early hospital recovered faster than those who treated later or taken as second line choose for their obvious shorter hospitalization time. In summary, early use of HCQ was better than later use and the effect of IL-6 and CRP level cannot be ruled out.

Metformin Treatment Was Associated with Decreased Mortality in COVID-19 Patients with Diabetes in a Retrospective Analysis.

Metformin was proposed to be a candidate for host-directed therapy for COVID-19. However, its efficacy remains to be validated. In this study, we compared the outcome of metformin users and nonusers in hospitalized COVID-19 patients with diabetes. Hospitalized diabetic patients with confirmed COVID-19 in the Tongji Hospital of Wuhan, China, from January 27, 2020 to March 24, 2020, were grouped into metformin and no-metformin groups according to the diabetic medications used. The demographics, characteristics, laboratory parameters, treatments, and clinical outcome in these patients were retrospectively assessed. A total of 283 patients (104 in the metformin and 179 in the no-metformin group) were included in this study. There were no significant differences between the two groups in gender, age, underlying diseases, clinical severity, and oxygen-support category at admission. The fasting blood glucose level of the metformin group was higher than that of the no-metformin group at admission and was under effective control in both groups after admission. Other laboratory parameters at admission and treatments after admission were not different between the two groups. The length of hospital stay did not differ between the two groups (21.0 days for metformin versus 19.5 days for no metformin, P = 0.74). However, in-hospital mortality was significantly lower in the metformin group (3/104 (2.9%) versus 22/179 (12.3%), P = 0.01). Antidiabetic treatment with metformin was associated with decreased mortality compared with diabetics not receiving metformin. This retrospective analysis suggests that metformin may offer benefits in patients with COVID-19 and that further study is indicated.

COVIDNet-S: Towards computer-aided severity assessment via training and validation of deep neural networks for geographic extent and opacity extent scoring of chest X-rays for SARS-CoV-2 lung disease severity (preprint)

Background: A critical step in effective care and treatment planning for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the assessment of the severity of disease progression. Chest x-rays (CXRs) are often used to assess SARS-CoV-2 severity, with two important assessment metrics being extent of lung involvement and degree of opacity. In this proof-of-concept study, we assess the feasibility of computer-aided scoring of CXRs of SARS-CoV-2 lung disease severity using a deep learning system. Materials and Methods: Data consisted of 396 CXRs from SARS-CoV-2 positive patient cases. Geographic extent and opacity extent were scored by two board-certified expert chest radiologists (with 20+ years of experience) and a 2nd-year radiology resident. The deep neural networks used in this study, which we name COVIDNet-S, are based on a COVID-Net network architecture. 100 versions of the network were independently learned (50 to perform geographic extent scoring and 50 to perform opacity extent scoring) using random subsets of CXRs from the study, and evaluated the networks using stratified Monte Carlo cross-validation experiments. Findings: The COVIDNet-S deep neural networks yielded R$^2$ of 0.664 $\pm$ 0.001 and 0.635 $\pm$ 0.002 between predicted scores and radiologist scores for geographic extent and opacity extent, respectively, in stratified Monte Carlo cross-validation experiments. The best performing networks achieved R$^2$ of 0.739 and 0.741 between predicted scores and radiologist scores for geographic extent and opacity extent, respectively. Interpretation: The results are promising and suggest that the use of deep neural networks on CXRs could be an effective tool for computer-aided assessment of SARS-CoV-2 lung disease severity, although additional studies are needed before adoption for routine clinical use.

Tocilizumab treatment in COVID-19: A single center experience.

Tocilizumab (TCZ), a monoclonal antibody against interleukin-6 (IL-6), emerged as an alternative treatment for COVID-19 patients with a risk of cytokine storms recently. In the present study, we aimed to discuss the treatment response of TCZ therapy in COVID-19 infected patients. The demographic, treatment, laboratory parameters of C-reactive protein (CRP) and IL-6 before and after TCZ therapy and clinical outcome in the 15 COVID-19 patients were retrospectively assessed. Totally 15 patients with COVID-19 were included in this study. Two of them were moderately ill, six were seriously ill and seven were critically ill. The TCZ was used in combination with methylprednisolone in eight patients. Five patients received the TCZ administration twice or more. Although TCZ treatment ameliorated the increased CRP in all patients rapidly, for the four critically ill patients who received an only single dose of TCZ, three of them (No. 1, 2, and 3) still dead and the CRP level in the rest one patient (No. 7) failed to return to normal range with a clinical outcome of disease aggravation. Serum IL-6 level tended to further spiked firstly and then decreased after TCZ therapy in 10 patients. A persistent and dramatic increase of IL-6 was observed in these four patients who failed treatment. TCZ appears to be an effective treatment option in COVID-19 patients with a risk of cytokine storms. And for these critically ill patients with elevated IL-6, the repeated dose of the TCZ is recommended.

SARS-CoV-2 Is Not Detectable in the Vaginal Fluid of Women With Severe COVID-19 Infection.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spread mainly through respiratory droplets or direct contact. However, the infection condition of the genital system is unknown. Our aim in this study was to determine if SARS-CoV-2 is present in the vaginal fluid of women with coronavirus disease 2019 (COVID-19). METHODS: Ten women with confirmed severe COVID-19 pneumonia admitted to the Tongji Zhongfa Hospital intensive care unit from 4 February 2020 through 24 February 2020 were included. Clinical records, laboratory results, and computed tomography examinations were retrospectively reviewed. The potential for genital infection was accessed by testing for the presence of SARS-CoV-2 in vaginal fluids obtained from vaginal swab samples. Reverse transcriptase polymerase chain reaction was used to confirm the SARS-CoV-2 infection in vaginal fluids. RESULTS: The clinical characteristics of the 10 women were similar to those reported in other severe COVID-19 patients. All 10 patients were tested for SARS-CoV-2 in vaginal fluid, and all samples tested negative for the virus. CONCLUSIONS: Findings from this small group of cases suggest that SARS-CoV-2 virus does not exist in the vaginal fluids of severe COVID-19 patients.

Research on Emergency Management of Pharmaceutical Care in Designated Hospital for Patients with COVID-19 (preprint)

Background: The novel coronavirus pneumonia (COVID-19) was entered into the critical period of epidemic prevention. Our hospital was designated as a hospital for severe pneumonia in Wuhan. Timely and effective pharmaceutical emergency support system is of great significance for the epidemic prevention and control of COVID-19. Method:In order to ensure COVID-19 patients' medication needs and ensure the safety treatment, we focus on the key points and difficult problems in the practice of pharmaceutical management during the period of COVID-19, and then formulate appropriate pharmaceutical emergency support system combined with clinical practice. Results:The pharmaceutical department quickly launched the emergency mechanism, formulated the key drug catalog for COVID-19, purchased some treatment drugs, reformed the emergency pharmacy process, established the donated drug management system, established the pharmacist consultation team, set up the "cloud pharmacy" for patients with chronic diseases other than COVID-19, and strengthened pharmacist protection management. Conclusion:During the period of COVID-19, the pharmaceutical administration is a professional, comprehensive, complex and systematic emergency project to ensure the drug supply and safety administration.