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1.
Open Forum Infect Dis ; 9(5): ofac179, 2022 May.
Article in English | MEDLINE | ID: covidwho-1821760

ABSTRACT

Admission procalcitonin measurements and microbiology results were available for 1040 hospitalized adults with coronavirus disease 2019 (from 48 902 included in the International Severe Acute Respiratory and Emerging Infections Consortium World Health Organization Clinical Characterisation Protocol UK study). Although procalcitonin was higher in bacterial coinfection, this was neither clinically significant (median [IQR], 0.33 [0.11-1.70] ng/mL vs 0.24 [0.10-0.90] ng/mL) nor diagnostically useful (area under the receiver operating characteristic curve, 0.56 [95% confidence interval, .51-.60]).

2.
Sci Rep ; 12(1): 6843, 2022 04 27.
Article in English | MEDLINE | ID: covidwho-1815585

ABSTRACT

COVID-19 is clinically characterised by fever, cough, and dyspnoea. Symptoms affecting other organ systems have been reported. However, it is the clinical associations of different patterns of symptoms which influence diagnostic and therapeutic decision-making. In this study, we applied clustering techniques to a large prospective cohort of hospitalised patients with COVID-19 to identify clinically meaningful sub-phenotypes. We obtained structured clinical data on 59,011 patients in the UK (the ISARIC Coronavirus Clinical Characterisation Consortium, 4C) and used a principled, unsupervised clustering approach to partition the first 25,477 cases according to symptoms reported at recruitment. We validated our findings in a second group of 33,534 cases recruited to ISARIC-4C, and in 4,445 cases recruited to a separate study of community cases. Unsupervised clustering identified distinct sub-phenotypes. First, a core symptom set of fever, cough, and dyspnoea, which co-occurred with additional symptoms in three further patterns: fatigue and confusion, diarrhoea and vomiting, or productive cough. Presentations with a single reported symptom of dyspnoea or confusion were also identified, alongside a sub-phenotype of patients reporting few or no symptoms. Patients presenting with gastrointestinal symptoms were more commonly female, had a longer duration of symptoms before presentation, and had lower 30-day mortality. Patients presenting with confusion, with or without core symptoms, were older and had a higher unadjusted mortality. Symptom sub-phenotypes were highly consistent in replication analysis within the ISARIC-4C study. Similar patterns were externally verified in patients from a study of self-reported symptoms of mild disease. The large scale of the ISARIC-4C study enabled robust, granular discovery and replication. Clinical interpretation is necessary to determine which of these observations have practical utility. We propose that four sub-phenotypes are usefully distinct from the core symptom group: gastro-intestinal disease, productive cough, confusion, and pauci-symptomatic presentations. Importantly, each is associated with an in-hospital mortality which differs from that of patients with core symptoms.


Subject(s)
COVID-19 , Confusion , Cough , Dyspnea , Fatigue , Female , Fever , Humans , Prospective Studies
3.
BMJ ; 377: o880, 2022 04 22.
Article in English | MEDLINE | ID: covidwho-1807359

ABSTRACT

The studyDrake TM, Riad AM, Fairfield CJ, et al. Characterisation of in-hospital complications associated with covid-19 using the ISARIC WHO Clinical Characterisation Protocol UK: a prospective, multicentre cohort study. Lancet 2021;398:10296.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/one-in-two-people-hospitalised-with-covid-19-develop-complications-may-need-support/.


Subject(s)
COVID-19 , COVID-19/complications , Cohort Studies , Hospitalization , Hospitals , Humans , Prospective Studies
4.
Pediatr Res ; 2022 Apr 22.
Article in English | MEDLINE | ID: covidwho-1805591

ABSTRACT

BACKGROUND: We hypothesised that the clinical characteristics of hospitalised children and young people (CYP) with SARS-CoV-2 in the UK second wave (W2) would differ from the first wave (W1) due to the alpha variant (B.1.1.7), school reopening and relaxation of shielding. METHODS: Prospective multicentre observational cohort study of patients <19 years hospitalised in the UK with SARS-CoV-2 between 17/01/20 and 31/01/21. Clinical characteristics were compared between W1 and W2 (W1 = 17/01/20-31/07/20,W2 = 01/08/20-31/01/21). RESULTS: 2044 CYP < 19 years from 187 hospitals. 427/2044 (20.6%) with asymptomatic/incidental SARS-CoV-2 were excluded from main analysis. 16.0% (248/1548) of symptomatic CYP were admitted to critical care and 0.8% (12/1504) died. 5.6% (91/1617) of symptomatic CYP had Multisystem Inflammatory Syndrome in Children (MIS-C). After excluding CYP with MIS-C, patients in W2 had lower Paediatric Early Warning Scores (PEWS, composite vital sign score), lower antibiotic use and less respiratory and cardiovascular support than W1. The proportion of CYP admitted to critical care was unchanged. 58.0% (938/1617) of symptomatic CYP had no reported comorbidity. Patients without co-morbidities were younger (42.4%, 398/938, <1 year), had lower PEWS, shorter length of stay and less respiratory support. CONCLUSIONS: We found no evidence of increased disease severity in W2 vs W1. A large proportion of hospitalised CYP had no comorbidity. IMPACT: No evidence of increased severity of COVID-19 admissions amongst children and young people (CYP) in the second vs first wave in the UK, despite changes in variant, relaxation of shielding and return to face-to-face schooling. CYP with no comorbidities made up a significant proportion of those admitted. However, they had shorter length of stays and lower treatment requirements than CYP with comorbidities once those with MIS-C were excluded. At least 20% of CYP admitted in this cohort had asymptomatic/incidental SARS-CoV-2 infection. This paper was presented to SAGE to inform CYP vaccination policy in the UK.

5.
BMJ Surg Interv Health Technol ; 4(1): e000104, 2022.
Article in English | MEDLINE | ID: covidwho-1759375

ABSTRACT

Introduction: The postoperative period represents a time where patients are at a high-risk of morbidity, which warrants effective surveillance. While digital health interventions (DHIs) for postoperative monitoring are promising, a coordinated, standardized and evidence-based approach regarding their implementation and evaluation is currently lacking. This study aimed to identify DHIs implemented and evaluated in postoperative care to highlight research gaps and assess the readiness for routine implementation. Methods: A systematic review will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies describing the implementation and evaluation of DHIs for postoperative monitoring published since 2000 (PROSPERO ID: CRD42021264289). This will encompass the Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science and ClinicalTrials.gov databases, and manual search of bibliographies for relevant studies and gray literature. Methodological reporting quality will be evaluated using the Idea, Development, Exploration, Assessment and Long-term Follow-up (IDEAL) reporting guideline relevant to the IDEAL stage of the study, and risk of bias will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Data will be extracted according to the WHO framework for monitoring and evaluating DHIs, and a narrative synthesis will be performed. Discussion: This review will assess the readiness for implementation of DHIs for routine postoperative monitoring and will include studies describing best practice from service changes already being piloted out of necessity during the COVID-19 pandemic. This will identify interventions with sufficient evidence to progress to the next IDEAL stage, and promote standardized and comprehensive evaluation of future implementational studies.

7.
The Lancet. Digital health ; 4(4):e220-e234, 2022.
Article in English | EuropePMC | ID: covidwho-1755949

ABSTRACT

Background Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care. Methods We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260. Findings Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years;0·52 [0·46–0·58], p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021. Interpretation Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered. Funding UK National Institute for Health Research and UK Medical Research Council.

8.
Int J Popul Data Sci ; 5(4): 1697, 2020.
Article in English | MEDLINE | ID: covidwho-1754159

ABSTRACT

Introduction: COVID-19 risk prediction algorithms can be used to identify at-risk individuals from short-term serious adverse COVID-19 outcomes such as hospitalisation and death. It is important to validate these algorithms in different and diverse populations to help guide risk management decisions and target vaccination and treatment programs to the most vulnerable individuals in society. Objectives: To validate externally the QCOVID risk prediction algorithm that predicts mortality outcomes from COVID-19 in the adult population of Wales, UK. Methods: We conducted a retrospective cohort study using routinely collected individual-level data held in the Secure Anonymised Information Linkage (SAIL) Databank. The cohort included individuals aged between 19 and 100 years, living in Wales on 24th January 2020, registered with a SAIL-providing general practice, and followed-up to death or study end (28th July 2020). Demographic, primary and secondary healthcare, and dispensing data were used to derive all the predictor variables used to develop the published QCOVID algorithm. Mortality data were used to define time to confirmed or suspected COVID-19 death. Performance metrics, including R2 values (explained variation), Brier scores, and measures of discrimination and calibration were calculated for two periods (24th January-30th April 2020 and 1st May-28th July 2020) to assess algorithm performance. Results: 1,956,760 individuals were included. 1,192 (0.06%) and 610 (0.03%) COVID-19 deaths occurred in the first and second time periods, respectively. The algorithms fitted the Welsh data and population well, explaining 68.8% (95% CI: 66.9-70.4) of the variation in time to death, Harrell's C statistic: 0.929 (95% CI: 0.921-0.937) and D statistic: 3.036 (95% CI: 2.913-3.159) for males in the first period. Similar results were found for females and in the second time period for both sexes. Conclusions: The QCOVID algorithm developed in England can be used for public health risk management for the adult Welsh population.


Subject(s)
COVID-19 , Adult , Aged , Aged, 80 and over , Algorithms , Cohort Studies , Female , Humans , Male , Middle Aged , Retrospective Studies , Wales/epidemiology , Young Adult
9.
ERJ Open Res ; 8(1)2022 Jan.
Article in English | MEDLINE | ID: covidwho-1690978

ABSTRACT

Due to the large number of patients with severe coronavirus disease 2019 (COVID-19), many were treated outside the traditional walls of the intensive care unit (ICU), and in many cases, by personnel who were not trained in critical care. The clinical characteristics and the relative impact of caring for severe COVID-19 patients outside the ICU is unknown. This was a multinational, multicentre, prospective cohort study embedded in the International Severe Acute Respiratory and Emerging Infection Consortium World Health Organization COVID-19 platform. Severe COVID-19 patients were identified as those admitted to an ICU and/or those treated with one of the following treatments: invasive or noninvasive mechanical ventilation, high-flow nasal cannula, inotropes or vasopressors. A logistic generalised additive model was used to compare clinical outcomes among patients admitted or not to the ICU. A total of 40 440 patients from 43 countries and six continents were included in this analysis. Severe COVID-19 patients were frequently male (62.9%), older adults (median (interquartile range (IQR), 67 (55-78) years), and with at least one comorbidity (63.2%). The overall median (IQR) length of hospital stay was 10 (5-19) days and was longer in patients admitted to an ICU than in those who were cared for outside the ICU (12 (6-23) days versus 8 (4-15) days, p<0.0001). The 28-day fatality ratio was lower in ICU-admitted patients (30.7% (5797 out of 18 831) versus 39.0% (7532 out of 19 295), p<0.0001). Patients admitted to an ICU had a significantly lower probability of death than those who were not (adjusted OR 0.70, 95% CI 0.65-0.75; p<0.0001). Patients with severe COVID-19 admitted to an ICU had significantly lower 28-day fatality ratio than those cared for outside an ICU.

10.
EuropePMC; 2021.
Preprint in English | EuropePMC | ID: ppcovidwho-320392

ABSTRACT

Background: Microbiological characterisation of co-infections and secondary infections in COVID-19 is lacking, while antimicrobial usage is high. We aimed to describe microbiologically-confirmed co-/secondary infections, and antimicrobial usage, in hospitalised patients with COVID-19.Methods: Hospitalised patients in England, Scotland, and Wales with confirmed/high likelihood SARS-CoV-2 infection were recruited to the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) prospective cohort study. Patients admitted between 6th February–8th June 2020 with a recorded outcome 28 days after admission were included. Organisms considered clinically insignificant were excluded.Findings: Microbiological investigations were recorded for 8649/48 902 patients, with significant respiratory or bloodstream bacterial/fungal infections recorded for 1107 patients. These were mostly secondary infections diagnosed >2 days after admission (70·6%, 762/1080 with known sample timing). Staphylococcus aureus then Haemophilus influenzae were the most common pathogens causing respiratory co-infections (diagnosed ≤2 days after admission), with Enterobacteriaceae and S. aureus most common in secondary respiratory infections. Bloodstream infections were most frequently caused by Escherichia coli then S. aureus. Among patients with available data, 37·0% (13 390/36 145) received antimicrobials prior to admission and 85·2% (39 258/46 061) in hospital, highest in critical care. We identified frequent use of broad-spectrum agents and use of carbapenems over carbapenem-sparing alternatives.Interpretation: In hospitalised patients with COVID-19, microbiologically-confirmed bacterial/fungal infections are rare, and more likely to be secondary infections. Gram-negative organisms and S. aureus are the predominant pathogens. The frequency and nature of antimicrobial usage is concerning, but tractable targets for stewardship interventions exist.Funding: This work is supported by grants from: the National Institute for Health Research (NIHR) [award CO-CIN-01], the Medical Research Council [grant MC_PC_19059] and by the NIHR Health Protection Research Unit (HPRU)in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford [award 200907], NIHR HPRU in Respiratory Infections at Imperial College London with PHE [award 200927], Wellcome Trust and Department for International Development [215091/Z/18/Z], and the Bill and Melinda Gates Foundation[OPP1209135], and Liverpool Experimental Cancer Medicine Centre (Grant Reference: C18616/A25153), NIHR Biomedical Research Centre at Imperial College London [IS-BRC-1215-20013], EU Platform foR European Preparedness Against (Re-) emerging Epidemics (PREPARE) [FP7 project 602525] and NIHR Clinical Research Network for providing infrastructure support for this research. LT is supported by a Wellcome Trust fellowship [205228/Z/16/Z]. PJMO is supported by a NIHR Senior Investigator Award [award 201385]. This research was funded in whole, or in part, by the Wellcome Trust. For the purpose of Open Access, the authors have applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The views expressed are those of the authors and not necessarily those of the DHSC, DID, NIHR, MRC, Wellcome Trust or PHE.Conflict of Interest: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the National Institute for Health Research (NIHR), the Medical Research Council (MRC), the NIHR Health Protection Research Unit (HPRU) in Emerging and Zoonotic Infections at University of Liverpool, NIHR HPRU in Respiratory Infections at Imperial College London, NIHR Biomedical Research Centre at ImperialCollege Lo don, and NIHR Clinical Research Network for the submitted work;ABD reports grants fromDepartment of Health and Social Care (DHSC), during the conduct of the study, grants from Wellcome Trust, outside the submitted work;PJMO reports personal fees from consultancies and from European RespiratorySociety, grants from MRC, MRC Global Challenge Research Fund, EU, NIHR BRC, MRC/GSK, WellcomeTrust, NIHR (Health Protection Research Unit (HPRU) in Respiratory Infection), and is NIHR senior investigator outside the submitted work;his role as President of the British Society for Immunology was unpaid but travel and accommodation at some meetings was provided by the Society;JKB reports grants from MRC UK;MGS reportsgrants from DHSC NIHR UK, grants from MRC UK, grants from HPRU in Emerging and Zoonotic Infections,University of Liverpool, during the conduct of the study, other from Integrum Scientific LLC, Greensboro, NC, USA, outside the submitted work.Ethical Approval: Ethical approval was given by the South Central-Oxford C Research Ethics Committee in England (13/SC/0149), the Scotland A Research Ethics Committee (20/SS/0028), and the WHO Ethics Review Committee (RPC571 and RPC572, April 2013).

11.
Nephrol Dial Transplant ; 37(2): 271-284, 2022 01 25.
Article in English | MEDLINE | ID: covidwho-1648225

ABSTRACT

BACKGROUND: Acute kidney injury (AKI) is common in coronavirus disease 2019 (COVID-19). This study investigated adults hospitalized with COVID-19 and hypothesized that risk factors for AKI would include comorbidities and non-White race. METHODS: A prospective multicentre cohort study was performed using patients admitted to 254 UK hospitals with COVID-19 between 17 January 2020 and 5 December 2020. RESULTS: Of 85 687 patients, 2198 (2.6%) received acute kidney replacement therapy (KRT). Of 41 294 patients with biochemistry data, 13 000 (31.5%) had biochemical AKI: 8562 stage 1 (65.9%), 2609 stage 2 (20.1%) and 1829 stage 3 (14.1%). The main risk factors for KRT were chronic kidney disease (CKD) [adjusted odds ratio (aOR) 3.41: 95% confidence interval 3.06-3.81], male sex (aOR 2.43: 2.18-2.71) and Black race (aOR 2.17: 1.79-2.63). The main risk factors for biochemical AKI were admission respiratory rate >30 breaths per minute (aOR 1.68: 1.56-1.81), CKD (aOR 1.66: 1.57-1.76) and Black race (aOR 1.44: 1.28-1.61). There was a gradated rise in the risk of 28-day mortality by increasing severity of AKI: stage 1 aOR 1.58 (1.49-1.67), stage 2 aOR 2.41 (2.20-2.64), stage 3 aOR 3.50 (3.14-3.91) and KRT aOR 3.06 (2.75-3.39). AKI rates peaked in April 2020 and the subsequent fall in rates could not be explained by the use of dexamethasone or remdesivir. CONCLUSIONS: AKI is common in adults hospitalized with COVID-19 and it is associated with a heightened risk of mortality. Although the rates of AKI have fallen from the early months of the pandemic, high-risk patients should have their kidney function and fluid status monitored closely.


Subject(s)
Acute Kidney Injury , COVID-19 , Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Cohort Studies , Hospital Mortality , Humans , Male , Prospective Studies , Retrospective Studies , Risk Factors , SARS-CoV-2 , United Kingdom , World Health Organization
12.
ERJ open research ; 2021.
Article in English | EuropePMC | ID: covidwho-1610380

ABSTRACT

Due to the large number of patients with severe COVID-19, many were treated outside of the traditional walls of the ICU, and in many cases, by personnel who were not trained in critical care. The clinical characteristics and the relative impact of caring for severe COVID-19 patients outside of the ICU is unknown. This was a multinational, multicentre, prospective cohort study embedded in the ISARIC WHO COVID-19 platform. Severe COVID-19 patients were identified as those admitted to an ICU and/or those treated with one of the following treatments: invasive or non-invasive mechanical ventilation, high-flow nasal cannula, inotropes, and vasopressors. A logistic Generalised Additive Model was used to compare clinical outcomes among patients admitted and not to the ICU. A total of 40 440 patients from 43 countries and six continents were included in this analysis. Severe COVID-19 patients were frequently male (62.9%), older adults (median [IQR], 67 years [55, 78]), and with at least one comorbidity (63.2%). The overall median (IQR) length of hospital stay was 10 days (5–19) and was longer in patients admitted to an ICU than in those that were cared for outside of ICU (12 [6–23] versus 8 [4–15] days, p<0.0001). The 28-day fatality ratio was lower in ICU-admitted patients (30.7% [5797/18831] versus 39.0% [7532/19295], p<0.0001). Patients admitted to an ICU had a significantly lower probability of death than those who were not (adjusted OR:0.70, 95%CI: 0.65-0.75, p<0.0001). Patients with severe COVID-19 admitted to an ICU had significantly lower 28-day fatality ratio than those cared for outside of an ICU.

13.
EuropePMC; 2021.
Preprint in English | EuropePMC | ID: ppcovidwho-296652

ABSTRACT

Background: There are currently no effective pharmacological or non-pharmacological interventions for Long-COVID. To identify potential therapeutic targets, we focussed on previously described four recovery clusters five months after hospital discharge, their underlying inflammatory profiles and relationship with clinical outcomes at one year. Methods PHOSP-COVID is a prospective longitudinal cohort study, recruiting adults hospitalised with COVID-19 across the UK. Recovery was assessed using patient reported outcomes measures (PROMs), physical performance, and organ function at five-months and one-year after hospital discharge. Hierarchical logistic regression modelling was performed for patient-perceived recovery at one-year. Cluster analysis was performed using clustering large applications (CLARA) k-medoids approach using clinical outcomes at five-months. Inflammatory protein profiling from plasma at the five-month visit was performed. Findings 2320 participants have been assessed at five months after discharge and 807 participants have completed both five-month and one-year visits. Of these, 35.6% were female, mean age 58.7 (SD 12.5) years, and 27.8% received invasive mechanical ventilation (IMV). The proportion of patients reporting full recovery was unchanged between five months 501/165 (25.6%) and one year 232/804 (28.9%). Factors associated with being less likely to report full recovery at one year were: female sex OR 0.68 (95% CI 0.46-0.99), obesity OR 0.50 (95%CI 0.34-0.74) and IMV OR 0.42 (95%CI 0.23-0.76). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate/cognitive, mild relating to the severity of physical, mental health and cognitive impairments at five months in a larger sample. There was elevation of inflammatory mediators of tissue damage and repair in both the very severe and the moderate/cognitive clusters compared to the mild cluster including interleukin-6 which was elevated in both comparisons. Overall, there was a substantial deficit in median (IQR) EQ5D-5L utility index from pre-COVID (retrospective assessment) 0.88 (0.74-1.00), five months 0.74 (0.60-0.88) to one year: 0.74 (0.59-0.88), with minimal improvements across all outcome measures at one-year after discharge in the whole cohort and within each of the four clusters. Interpretation The sequelae of a hospital admission with COVID-19 remain substantial one year after discharge across a range of health domains with the minority in our cohort feeling fully recovered. Patient perceived health-related quality of life remains reduced at one year compared to pre-hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

14.
2021.
Preprint in English | Other preprints | ID: ppcovidwho-294849

ABSTRACT

Background The impact of COVID-19 on physical and mental health, and employment following hospitalisation is poorly understood. Methods PHOSP-COVID is a multi-centre, UK, observational study of adults discharged from hospital with a clinical diagnosis of COVID-19 involving an assessment between two- and seven-months later including detailed symptom, physiological and biochemical testing. Multivariable logistic regression was performed for patient-perceived recovery with age, sex, ethnicity, body mass index (BMI), co-morbidities, and severity of acute illness as co-variates. Cluster analysis was performed using outcomes for breathlessness, fatigue, mental health, cognition and physical function. Findings We report findings of 1077 patients discharged in 2020, from the assessment undertaken a median 5 [IQR4 to 6] months later: 36% female, mean age 58 [SD 13] years, 69% white ethnicity, 27% mechanical ventilation, and 50% had at least two co-morbidities. At follow-up only 29% felt fully recovered, 20% had a new disability, and 19% experienced a health-related change in occupation. Factors associated with failure to recover were female, middle-age, white ethnicity, two or more co-morbidities, and more severe acute illness. The magnitude of the persistent health burden was substantial and weakly related to acute severity. Four clusters were identified with different severities of mental and physical health impairment: 1) Very severe (17%), 2) Severe (21%), 3) Moderate with cognitive impairment (17%), 4) Mild (46%), with 3%, 7%, 36% and 43% feeling fully recovered, respectively. Persistent systemic inflammation determined by C-reactive protein was related to cluster severity, but not acute illness severity. Interpretation We identified factors related to recovery from a hospital admission with COVID-19 and four different phenotypes relating to the severity of physical, mental, and cognitive health five months later. The implications for clinical care include the potential to stratify care and the need for a pro-active approach with wide-access to COVID-19 holistic clinical services. Funding: UKRI and NIHR

15.
Thorax ; 2021 Nov 22.
Article in English | MEDLINE | ID: covidwho-1528562

ABSTRACT

PURPOSE: To prospectively validate two risk scores to predict mortality (4C Mortality) and in-hospital deterioration (4C Deterioration) among adults hospitalised with COVID-19. METHODS: Prospective observational cohort study of adults (age ≥18 years) with confirmed or highly suspected COVID-19 recruited into the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study in 306 hospitals across England, Scotland and Wales. Patients were recruited between 27 August 2020 and 17 February 2021, with at least 4 weeks follow-up before final data extraction. The main outcome measures were discrimination and calibration of models for in-hospital deterioration (defined as any requirement of ventilatory support or critical care, or death) and mortality, incorporating predefined subgroups. RESULTS: 76 588 participants were included, of whom 27 352 (37.4%) deteriorated and 12 581 (17.4%) died. Both the 4C Mortality (0.78 (0.77 to 0.78)) and 4C Deterioration scores (pooled C-statistic 0.76 (95% CI 0.75 to 0.77)) demonstrated consistent discrimination across all nine National Health Service regions, with similar performance metrics to the original validation cohorts. Calibration remained stable (4C Mortality: pooled slope 1.09, pooled calibration-in-the-large 0.12; 4C Deterioration: 1.00, -0.04), with no need for temporal recalibration during the second UK pandemic wave of hospital admissions. CONCLUSION: Both 4C risk stratification models demonstrate consistent performance to predict clinical deterioration and mortality in a large prospective second wave validation cohort of UK patients. Despite recent advances in the treatment and management of adults hospitalised with COVID-19, both scores can continue to inform clinical decision making. TRIAL REGISTRATION NUMBER: ISRCTN66726260.

16.
Lancet Respir Med ; 9(11): 1275-1287, 2021 11.
Article in English | MEDLINE | ID: covidwho-1514340

ABSTRACT

BACKGROUND: The impact of COVID-19 on physical and mental health and employment after hospitalisation with acute disease is not well understood. The aim of this study was to determine the effects of COVID-19-related hospitalisation on health and employment, to identify factors associated with recovery, and to describe recovery phenotypes. METHODS: The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a multicentre, long-term follow-up study of adults (aged ≥18 years) discharged from hospital in the UK with a clinical diagnosis of COVID-19, involving an assessment between 2 and 7 months after discharge, including detailed recording of symptoms, and physiological and biochemical testing. Multivariable logistic regression was done for the primary outcome of patient-perceived recovery, with age, sex, ethnicity, body-mass index, comorbidities, and severity of acute illness as covariates. A post-hoc cluster analysis of outcomes for breathlessness, fatigue, mental health, cognitive impairment, and physical performance was done using the clustering large applications k-medoids approach. The study is registered on the ISRCTN Registry (ISRCTN10980107). FINDINGS: We report findings for 1077 patients discharged from hospital between March 5 and Nov 30, 2020, who underwent assessment at a median of 5·9 months (IQR 4·9-6·5) after discharge. Participants had a mean age of 58 years (SD 13); 384 (36%) were female, 710 (69%) were of white ethnicity, 288 (27%) had received mechanical ventilation, and 540 (50%) had at least two comorbidities. At follow-up, only 239 (29%) of 830 participants felt fully recovered, 158 (20%) of 806 had a new disability (assessed by the Washington Group Short Set on Functioning), and 124 (19%) of 641 experienced a health-related change in occupation. Factors associated with not recovering were female sex, middle age (40-59 years), two or more comorbidities, and more severe acute illness. The magnitude of the persistent health burden was substantial but only weakly associated with the severity of acute illness. Four clusters were identified with different severities of mental and physical health impairment (n=767): very severe (131 patients, 17%), severe (159, 21%), moderate along with cognitive impairment (127, 17%), and mild (350, 46%). Of the outcomes used in the cluster analysis, all were closely related except for cognitive impairment. Three (3%) of 113 patients in the very severe cluster, nine (7%) of 129 in the severe cluster, 36 (36%) of 99 in the moderate cluster, and 114 (43%) of 267 in the mild cluster reported feeling fully recovered. Persistently elevated serum C-reactive protein was positively associated with cluster severity. INTERPRETATION: We identified factors related to not recovering after hospital admission with COVID-19 at 6 months after discharge (eg, female sex, middle age, two or more comorbidities, and more acute severe illness), and four different recovery phenotypes. The severity of physical and mental health impairments were closely related, whereas cognitive health impairments were independent. In clinical care, a proactive approach is needed across the acute severity spectrum, with interdisciplinary working, wide access to COVID-19 holistic clinical services, and the potential to stratify care. FUNDING: UK Research and Innovation and National Institute for Health Research.


Subject(s)
COVID-19 , Health Status , Mental Health , Acute Disease , Adult , Aged , COVID-19/complications , Cognition , Comorbidity , Female , Follow-Up Studies , Hospitalization , Humans , Male , Middle Aged , Prospective Studies , United Kingdom/epidemiology
17.
J R Soc Med ; 115(1): 22-30, 2022 01.
Article in English | MEDLINE | ID: covidwho-1480338

ABSTRACT

OBJECTIVES: We investigated the association between multimorbidity among patients hospitalised with COVID-19 and their subsequent risk of mortality. We also explored the interaction between the presence of multimorbidity and the requirement for an individual to shield due to the presence of specific conditions and its association with mortality. DESIGN: We created a cohort of patients hospitalised in Scotland due to COVID-19 during the first wave (between 28 February 2020 and 22 September 2020) of the pandemic. We identified the level of multimorbidity for the patient on admission and used logistic regression to analyse the association between multimorbidity and risk of mortality among patients hospitalised with COVID-19. SETTING: Scotland, UK. PARTICIPANTS: Patients hospitalised due to COVID-19. MAIN OUTCOME MEASURES: Mortality as recorded on National Records of Scotland death certificate and being coded for COVID-19 on the death certificate or death within 28 days of a positive COVID-19 test. RESULTS: Almost 58% of patients admitted to the hospital due to COVID-19 had multimorbidity. Adjusting for confounding factors of age, sex, social class and presence in the shielding group, multimorbidity was significantly associated with mortality (adjusted odds ratio 1.48, 95%CI 1.26-1.75). The presence of multimorbidity and presence in the shielding patients list were independently associated with mortality but there was no multiplicative effect of having both (adjusted odds ratio 0.91, 95%CI 0.64-1.29). CONCLUSIONS: Multimorbidity is an independent risk factor of mortality among individuals who were hospitalised due to COVID-19. Individuals with multimorbidity could be prioritised when making preventive policies, for example, by expanding shielding advice to this group and prioritising them for vaccination.


Subject(s)
COVID-19/mortality , Hospital Mortality , Hospitalization/statistics & numerical data , Multimorbidity , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Humans , Male , Middle Aged , SARS-CoV-2 , Scotland/epidemiology , Social Determinants of Health
18.
Journal of the Intensive Care Society ; : 17511437211052226, 2021.
Article in English | Sage | ID: covidwho-1480400

ABSTRACT

Background:We aimed to compare the prevalence and severity of fatigue in survivors of Covid-19 versus non-Covid-19 critical illness, and to explore potential associations between baseline characteristics and worse recovery.Methods:We conducted a secondary analysis of two prospectively collected datasets. The population included was 92 patients who received invasive mechanical ventilation (IMV) with Covid-19, and 240 patients who received IMV with non-Covid-19 illness before the pandemic. Follow-up data were collected post-hospital discharge using self-reported questionnaires. The main outcome measures were self-reported fatigue severity and the prevalence of severe fatigue (severity >7/10) 3 and 12-months post-hospital discharge.Results:Covid-19 IMV-patients were significantly younger with less prior comorbidity, and more males, than pre-pandemic IMV-patients. At 3-months, the prevalence (38.9% [7/18] vs. 27.1% [51/188]) and severity (median 5.5/10 vs 5.0/10) of fatigue were similar between the Covid-19 and pre-pandemic populations, respectively. At 6-months, the prevalence (10.3% [3/29] vs. 32.5% [54/166]) and severity (median 2.0/10 vs. 5.7/10) of fatigue were less in the Covid-19 cohort. In the total sample of IMV-patients included (i.e. all Covid-19 and pre-pandemic patients), having Covid-19 was significantly associated with less severe fatigue (severity <7/10) after adjusting for age, sex and prior comorbidity (adjusted OR 0.35 (95%CI 0.15?0.76, p=0.01).Conclusion:Fatigue may be less severe after Covid-19 than after other critical illness.

19.
Nephrol Dial Transplant ; 37(2): 271-284, 2022 01 25.
Article in English | MEDLINE | ID: covidwho-1475823

ABSTRACT

BACKGROUND: Acute kidney injury (AKI) is common in coronavirus disease 2019 (COVID-19). This study investigated adults hospitalized with COVID-19 and hypothesized that risk factors for AKI would include comorbidities and non-White race. METHODS: A prospective multicentre cohort study was performed using patients admitted to 254 UK hospitals with COVID-19 between 17 January 2020 and 5 December 2020. RESULTS: Of 85 687 patients, 2198 (2.6%) received acute kidney replacement therapy (KRT). Of 41 294 patients with biochemistry data, 13 000 (31.5%) had biochemical AKI: 8562 stage 1 (65.9%), 2609 stage 2 (20.1%) and 1829 stage 3 (14.1%). The main risk factors for KRT were chronic kidney disease (CKD) [adjusted odds ratio (aOR) 3.41: 95% confidence interval 3.06-3.81], male sex (aOR 2.43: 2.18-2.71) and Black race (aOR 2.17: 1.79-2.63). The main risk factors for biochemical AKI were admission respiratory rate >30 breaths per minute (aOR 1.68: 1.56-1.81), CKD (aOR 1.66: 1.57-1.76) and Black race (aOR 1.44: 1.28-1.61). There was a gradated rise in the risk of 28-day mortality by increasing severity of AKI: stage 1 aOR 1.58 (1.49-1.67), stage 2 aOR 2.41 (2.20-2.64), stage 3 aOR 3.50 (3.14-3.91) and KRT aOR 3.06 (2.75-3.39). AKI rates peaked in April 2020 and the subsequent fall in rates could not be explained by the use of dexamethasone or remdesivir. CONCLUSIONS: AKI is common in adults hospitalized with COVID-19 and it is associated with a heightened risk of mortality. Although the rates of AKI have fallen from the early months of the pandemic, high-risk patients should have their kidney function and fluid status monitored closely.


Subject(s)
Acute Kidney Injury , COVID-19 , Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Cohort Studies , Hospital Mortality , Humans , Male , Prospective Studies , Retrospective Studies , Risk Factors , SARS-CoV-2 , United Kingdom , World Health Organization
20.
Evans, Rachael A.; McAuley, Hamish, Harrison, Ewen M.; Shikotra, Aarti, Singapuri, Amisha, Sereno, Marco, Elneima, Omer, Docherty, Annemarie B.; Lone, Nazir I.; Leavy, Olivia C.; Daines, Luke, Baillie, J. Kenneth, Brown, Jeremy S.; Chalder, Trudie, De Soyza, Anthony, Diar Bakerly, Nawar, Easom, Nicholas, Geddes, John R.; Greening, Neil J.; Hart, Nick, Heaney, Liam G.; Heller, Simon, Howard, Luke, Hurst, John R.; Jacob, Joseph, Jenkins, R. Gisli, Jolley, Caroline, Kerr, Steven, Kon, Onn M.; Lewis, Keir, Lord, Janet M.; McCann, Gerry P.; Neubauer, Stefan, Openshaw, Peter J. M.; Parekh, Dhruv, Pfeffer, Paul, Rahman, Najib M.; Raman, Betty, Richardson, Matthew, Rowland, Matthew, Semple, Malcolm G.; Shah, Ajay M.; Singh, Sally J.; Sheikh, Aziz, Thomas, David, Toshner, Mark, Chalmers, James D.; Ho, Ling-Pei, Horsley, Alex, Marks, Michael, Poinasamy, Krisnah, Wain, Louise V.; Brightling, Christopher E.; Abel, K.; Adamali, H.; Adeloye, D.; Adeyemi, O.; Adeyemi, F.; Ahmad, S.; Ahmed, R.; Ainsworth, M.; Alamoudi, A.; Aljaroof, M.; Allan, L.; Allen, R.; Alli, A.; Al-Sheklly, B.; Altmann, D.; Anderson, D.; Andrews, M.; Angyal, A.; Antoniades, C.; Arbane, G.; Armour, C.; Armstrong, N.; Armstrong, L.; Arnold, H.; Arnold, D.; Ashworth, M.; Ashworth, A.; Assefa-Kebede, H.; Atkin, P.; Atkins, H.; Atkins, A.; Aul, R.; Avram, C.; Baggott, R.; Baguley, D.; Baillie, J. K.; Bain, S.; Bakali, M.; Bakau, M.; Baldry, E.; Baldwin, D.; Ballard, C.; Bambrough, J.; Barker, R. E.; Barratt, S.; Barrett, F.; Basu, N.; Batterham, R.; Baxendale, H.; Bayes, H.; Bayley, M.; Beadsworth, M.; Beirne, P.; Bell, R.; Bell, D.; Berry, C.; Betts, S.; Bhui, K.; Bishop, L.; Blaikely, J.; Bloomfield, C.; Bloss, A.; Bolger, A.; Bolton, C. E.; Bonnington, J.; Botkai, A.; Bourne, M.; Bourne, C.; Bradley, E.; Bramham, K.; Brear, L.; Breen, G.; Breeze, J.; Briggs, A.; Bright, E.; Brightling, C. E.; Brill, S.; Brindle, K.; Broad, L.; Broome, M.; Brown, J. S.; Brown, M.; Brown, J.; Brown, J.; Brown, R.; Brown, V.; Brown, A.; Brown, M.; Brown, A.; Brugha, T.; Brunskill, N.; Buch, M.; Bularga, A.; Bullmore, E.; Burn, D.; Burns, G.; Busby, J.; Buttress, A.; Byrne, S.; Cairns, P.; Calder, P. C.; Calvelo, E.; Card, B.; Carr, L.; Carson, G.; Carter, P.; Cavanagh, J.; Chalder, T.; Chalmers, J. D.; Chambers, R. C.; Channon, K.; Chapman, K.; Charalambou, A.; Chaudhuri, N.; Checkley, A.; Chen, J.; Chetham, L.; Chilvers, E. R.; Chinoy, H.; Chong-James, K.; Choudhury, N.; Choudhury, G.; Chowdhury, P.; Chowienczyk, P.; Christie, C.; Clark, D.; Clark, C.; Clarke, J.; Clift, P.; Clohisey, S.; Coburn, Z.; Cole, J.; Coleman, C.; Connell, D.; Connolly, B.; Connor, L.; Cook, A.; Cooper, B.; Coupland, C.; Craig, T.; Crisp, P.; Cristiano, D.; Crooks, M. G.; Cross, A.; Cruz, I.; Cullinan, P.; Daines, L.; Dalton, M.; Dark, P.; Dasgin, J.; David, A.; David, C.; Davies, M.; Davies, G.; Davies, K.; Davies, F.; Davies, G. A.; Daynes, E.; De Silva, T.; De Soyza, A.; Deakin, B.; Deans, A.; Defres, S.; Dell, A.; Dempsey, K.; Dennis, J.; Dewar, A.; Dharmagunawardena, R.; Diar Bakerly, N.; Dipper, A.; Diver, S.; Diwanji, S. N.; Dixon, M.; Djukanovic, R.; Dobson, H.; Dobson, C.; Dobson, S. L.; Docherty, A. B.; Donaldson, A.; Dong, T.; Dormand, N.; Dougherty, A.; Dowling, R.; Drain, S.; Dulawan, P.; Dunn, S.; Dunn, S.; Easom, N.; Echevarria, C.; Edwards, S.; Edwardson, C.; Elliott, B.; Elliott, A.; Ellis, Y.; Elmer, A.; Elneima, O.; Evans, R. A.; Evans, J.; Evans, H.; Evans, D.; Evans, R. I.; Evans, R.; Evans, T.; Fabbri, L.; Fairbairn, S.; Fairman, A.; Fallon, K.; Faluyi, D.; Favager, C.; Felton, T.; Finch, J.; Finney, S.; Fisher, H.; Fletcher, S.; Flockton, R.; Foote, D.; Ford, A.; Forton, D.; Francis, R.; Francis, S.; Francis, C.; Frankel, A.; Fraser, E.; Free, R.; French, N.; Fuld, J.; Furniss, J.; Garner, L.; Gautam, N.; Geddes, J. R.; George, P. M.; George, J.; Gibbons, M.; Gilmour, L.; Gleeson, F.; Glossop, J.; Glover, S.; Goodman, N.; Gooptu, B.; Gorsuch, T.; Gourlay, E.; Greenhaff, P.; Greenhalf, W.; Greenhalgh, A.; Greening, N. J.; Greenwood, J.; Greenwood, S.; Gregory, R.; Grieve, D.; Gummadi, M.; Gupta, A.; Gurram, S.; Guthrie, E.; Hadley, K.; Haggar, A.; Hainey, K.; Haldar, P.; Hall, I.; Hall, L.; Halling-Brown, M.; Hamil, R.; Hanley, N. A.; Hardwick, H.; Hardy, E.; Hargadon, B.; Harrington, K.; Harris, V.; Harrison, E. M.; Harrison, P.; Hart, N.; Harvey, A.; Harvey, M.; Harvie, M.; Havinden-Williams, M.; Hawkes, J.; Hawkings, N.; Haworth, J.; Hayday, A.; Heaney, L. G.; Heeney, J. L.; Heightman, M.; Heller, S.; Henderson, M.; Hesselden, L.; Hillman, T.; Hingorani, A.; Hiwot, T.; Ho, L. P.; Hoare, A.; Hoare, M.; Hogarth, P.; Holbourn, A.; Holdsworth, L.; Holgate, D.; Holmes, K.; Holroyd-Hind, B.; Horsley, A.; Hosseini, A.; Hotopf, M.; Houchen, L.; Howard, L.; Howard, L.; Howell, A.; Hufton, E.; Hughes, A.; Hughes, J.; Hughes, R.; Humphries, A.; Huneke, N.; Hurst, J. R.; Hurst, R.; Husain, M.; Hussell, T.; Ibrahim, W.; Ient, A.; Ingram, L.; Ismail, K.; Jackson, T.; Jacob, J.; James, W. Y.; Janes, S.; Jarvis, H.; Jayaraman, B.; Jenkins, R. G.; Jezzard, P.; Jiwa, K.; Johnson, S.; Johnson, C.; Johnston, D.; Jolley, C.; Jolley, C. J.; Jones, I.; Jones, S.; Jones, D.; Jones, H.; Jones, G.; Jones, M.; Jose, S.; Kabir, T.; Kaltsakas, G.; Kamwa, V.; Kar, P.; Kausar, Z.; Kelly, S.; Kerr, S.; Key, A. L.; Khan, F.; Khunti, K.; King, C.; King, B.; Kitterick, P.; Klenerman, P.; Knibbs, L.; Knight, S.; Knighton, A.; Kon, O. M.; Kon, S.; Kon, S. S.; Korszun, A.; Kotanidis, C.; Koychev, I.; Kurupati, P.; Kwan, J.; Laing, C.; Lamlum, H.; Landers, G.; Langenberg, C.; Lasserson, D.; Lawrie, A.; Lea, A.; Leavy, O. C.; Lee, D.; Lee, E.; Leitch, K.; Lenagh, R.; Lewis, K.; Lewis, V.; Lewis, K. E.; Lewis, J.; Lewis-Burke, N.; Light, T.; Lightstone, L.; Lim, L.; Linford, S.; Lingford-Hughes, A.; Lipman, M.; Liyanage, K.; Lloyd, A.; Logan, S.; Lomas, D.; Lone, N. I.; Loosley, R.; Lord, J. M.; Lota, H.; Lucey, A.; MacGowan, G.; Macharia, I.; Mackay, C.; Macliver, L.; Madathil, S.; Madzamba, G.; Magee, N.; Mairs, N.; Majeed, N.; Major, E.; Malim, M.; Mallison, G.; Man, W.; Mandal, S.; Mangion, K.; Mansoori, P.; Marciniak, S.; Mariveles, M.; Marks, M.; Marshall, B.; Martineau, A.; Maskell, N.; Matila, D.; Matthews, L.; Mayet, J.; McAdoo, S.; McAllister-Williams, H.; McArdle, P.; McArdle, A.; McAulay, D.; McAuley, H.; McAuley, D. F.; McCafferty, K.; McCann, G. P.; McCauley, H.; McCourt, P.; McGarvey, L.; McGinness, J.; McGovern, A.; McGuinness, H.; McInnes, I. B.; McIvor, K.; McIvor, E.; McMahon, A.; McMahon, M. J.; McMorrow, L.; McNally, T.; McNarry, M.; McQueen, A.; McShane, H.; Megson, S.; Meiring, J.; Menzies, D.; Michael, A.; Milligan, L.; Mills, N.; Mitchell, J.; Mohamed, A.; Molyneaux, P. L.; Monteiro, W.; Morley, A.; Morrison, L.; Morriss, R.; Morrow, A.; Moss, A.; Moss, A. J.; Moss, P.; Mukaetova-Ladinska, E.; Munawar, U.; Murali, E.; Murira, J.; Nassa, H.; Neill, P.; Neubauer, S.; Newby, D.; Newell, H.; Newton Cox, A.; Nicholson, T.; Nicoll, D.; Nolan, C. M.; Noonan, M. J.; Novotny, P.; Nunag, J.; Nyaboko, J.; et al..
The Lancet Respiratory Medicine ; 2021.
Article in English | ScienceDirect | ID: covidwho-1458603

ABSTRACT

Summary Background The impact of COVID-19 on physical and mental health and employment after hospitalisation with acute disease is not well understood. The aim of this study was to determine the effects of COVID-19-related hospitalisation on health and employment, to identify factors associated with recovery, and to describe recovery phenotypes. Methods The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a multicentre, long-term follow-up study of adults (aged ≥18 years) discharged from hospital in the UK with a clinical diagnosis of COVID-19, involving an assessment between 2 and 7 months after discharge, including detailed recording of symptoms, and physiological and biochemical testing. Multivariable logistic regression was done for the primary outcome of patient-perceived recovery, with age, sex, ethnicity, body-mass index, comorbidities, and severity of acute illness as covariates. A post-hoc cluster analysis of outcomes for breathlessness, fatigue, mental health, cognitive impairment, and physical performance was done using the clustering large applications k-medoids approach. The study is registered on the ISRCTN Registry (ISRCTN10980107). Findings We report findings for 1077 patients discharged from hospital between March 5 and Nov 30, 2020, who underwent assessment at a median of 5·9 months (IQR 4·9–6·5) after discharge. Participants had a mean age of 58 years (SD 13);384 (36%) were female, 710 (69%) were of white ethnicity, 288 (27%) had received mechanical ventilation, and 540 (50%) had at least two comorbidities. At follow-up, only 239 (29%) of 830 participants felt fully recovered, 158 (20%) of 806 had a new disability (assessed by the Washington Group Short Set on Functioning), and 124 (19%) of 641 experienced a health-related change in occupation. Factors associated with not recovering were female sex, middle age (40–59 years), two or more comorbidities, and more severe acute illness. The magnitude of the persistent health burden was substantial but only weakly associated with the severity of acute illness. Four clusters were identified with different severities of mental and physical health impairment (n=767): very severe (131 patients, 17%), severe (159, 21%), moderate along with cognitive impairment (127, 17%), and mild (350, 46%). Of the outcomes used in the cluster analysis, all were closely related except for cognitive impairment. Three (3%) of 113 patients in the very severe cluster, nine (7%) of 129 in the severe cluster, 36 (36%) of 99 in the moderate cluster, and 114 (43%) of 267 in the mild cluster reported feeling fully recovered. Persistently elevated serum C-reactive protein was positively associated with cluster severity. Interpretation We identified factors related to not recovering after hospital admission with COVID-19 at 6 months after discharge (eg, female sex, middle age, two or more comorbidities, and more acute severe illness), and four different recovery phenotypes. The severity of physical and mental health impairments were closely related, whereas cognitive health impairments were independent. In clinical care, a proactive approach is needed across the acute severity spectrum, with interdisciplinary working, wide access to COVID-19 holistic clinical services, and the potential to stratify care. Funding

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