Innate Immune Activation and Mitochondrial ROS Invoke Persistent Cardiac Conduction System Dysfunction after COVID-19 (preprint)

BackgroundCardiac risk rises during acute SARS-CoV-2 infection and in long COVID syndrome in humans, but the mechanisms behind COVID-19-linked arrhythmias are unknown. This study explores the acute and long term effects of SARS-CoV-2 on the cardiac conduction system (CCS) in a hamster model of COVID-19. MethodsRadiotelemetry in conscious animals was used to non-invasively record electrocardiograms and subpleural pressures after intranasal SARS-CoV-2 infection. Cardiac cytokines, interferon-stimulated gene expression, and macrophage infiltration of the CCS, were assessed at 4 days and 4 weeks post-infection. A double-stranded RNA mimetic, polyinosinic:polycytidylic acid (PIC), was used in vivo and in vitro to activate viral pattern recognition receptors in the absence of SARS-CoV-2 infection. ResultsCOVID-19 induced pronounced tachypnea and severe cardiac conduction system (CCS) dysfunction, spanning from bradycardia to persistent atrioventricular block, although no viral protein expression was detected in the heart. Arrhythmias developed rapidly, partially reversed, and then redeveloped after the pulmonary infection was resolved, indicating persistent CCS injury. Increased cardiac cytokines, interferon-stimulated gene expression, and macrophage remodeling in the CCS accompanied the electrophysiological abnormalities. Interestingly, the arrhythmia phenotype was reproduced by cardiac injection of PIC in the absence of virus, indicating that innate immune activation was sufficient to drive the response. PIC also strongly induced cytokine secretion and robust interferon signaling in hearts, human iPSC-derived cardiomyocytes (hiPSC-CMs), and engineered heart tissues, accompanied by alterations in electrical and Ca2+ handling properties. Importantly, the pulmonary and cardiac effects of COVID-19 were blunted by in vivo inhibition of JAK/STAT signaling or by a mitochondrially-targeted antioxidant. ConclusionsThe findings indicate that long term dysfunction and immune cell remodeling of the CCS is induced by COVID-19, arising indirectly from oxidative stress and excessive activation of cardiac innate immune responses during infection, with implications for long COVID Syndrome.

COVID-19 Coinfection with Malaria and Its Presentation with Bilateral Pleural Effusion: A Case Report and Literature Review (preprint)

Background There could be misdiagnosis of COVID 19 for malaria and vice versa because of their similar presentation, particularly when clinician relies mainly on symptoms. Coinfection with COVID-19 and malaria is associated with increased all-cause in-hospital mortality compared to isolated infection with SARS-CoV-2. Presentation with pleural effusion adds another challenge in the diagnosis of COVID-19.Case summary: This is a 57-year-old woman who presented with symptoms of acute febrile illness associated with shortness of breath and cough. Physical examination was remarkable for fever, hypotension, tachycardia, tachypnea, desaturation, decreased air entry and dullness over bilateral lower 1/3rd of the chest. Upon investigations, she was found to have ring-form trophozoites of plasmodium falciparum and bilateral ground glass opacities, bilateral consolidations and bilateral pleural effusions. She was managed with supportive treatments, antimalarial agents and antibiotics. COVID-19 was diagnosed late due to the initial high diagnostic inertia.Conclusion Clinicians should be aware of the possibility of COVID-19 in any patient who presents with acute febrile illness or respiratory complaints like shortness of breath and cough. In patients with symptoms such as fever, fatigue, and headache, both malaria and COVID-19 tests should always be performed. Though pleural effusion is rarely reported in COVID-19 patients, viral etiologies like COVID-19 should be considered if alternative diagnoses are lacking.

COVID-19 in patients with persistent tachypnea of infancy.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has raised substantial concern for patients with chronic lung diseases. The aim of this study was to evaluate the clinical characteristics and outcomes of coronavirus disease 2019 (COVID-19) in children with persistent tachypnea of infancy (PTI). METHODS: Data on the history of COVID-19, including diagnosis and clinical course of the infection, were collected during the regular follow-up visits of children previously diagnosed with PTI. The diagnosis of COVID-19 was based on laboratory criteria recommended by the European Centre for Disease Prevention and Control. RESULTS: Between January 1, 2021, and February 28, 2022, 62 patients with PTI (median age 3.7 years; 42 boys, 20 girls) were evaluated. COVID-19 was diagnosed in 38 patients (61.3%). Sixteen patients (42.1%) were asymptomatic, and 22 (57.9%) were symptomatic. The most common symptoms were rhinorrhea or nasal congestion, cough, and sore throat. Sixteen patients (42.1%) were classified as having a mild course of COVID-19, three children (7.9%) as moderate, and three children (7.9%) as severe. Follow-up performed after a median of 6 months (range 3-12 months) revealed that, after COVID-19, nearly all PTI patients returned to their prior status (32/38, 84.2%); 4 children (10.5%) suffered from exacerbating symptoms of PTI for 1 month. Two children (5.3%) became asymptomatic after COVID-19. CONCLUSION: The course of SARS-CoV-2 infection in children with PTI is usually mild, and the risk of hospitalization is low. The course of PTI did not change after COVID-19 in most children, and only a few patients experienced an exacerbation.

Early Detection of Deterioration in COVID-19 Patients by Continuous Ward Respiratory Rate Monitoring: A Pilot Prospective Cohort Study (preprint)

Background Tachypnea is among the earliest signs of pulmonary decompensation. Contactless continuously respiratory rate monitoring might beuseful in isolated COVID-19 patients admitted in wards. We aim to determine whether continuous untethered ward respiratory rate patterns in hospitalized COVID-19 identify patients who require escalation of pulmonary management 24 hours ahead of time.Methods Single-center pilot prospective cohort study in COVID-19 patients who were cared for in routine wards. COVID-19 patients who has at least one escalation of pulmonary management were matched to 3 non-escalated patients. Contactless Breathing Monitoring was instituted after patients enrolled, and continued for 15 days unless hospital discharge, initiation of invasive mechanical ventilation, or death occurred. Respiratory rate data from the continuous monitor was not available to clinicians. The exposures were respiratory features over rolling periods of 30 min, 24 hours, and 72 hours before respiratory care escalation. The primary outcome was escalation in the pulmonary care beyond Venturi-mask.Results Among 125 included patients, 13 exhibited at least one escalation and were each matched to 3 non-escalated patients. A total of 28 escalation events were matched to 84 non-escalation episodes. The 30-min mean respiratory rate in escalated patients was 23 breaths per minute (bpm) ranging from 13 to 40 bpm, similar to the 22 bpm in non-escalated patients, although with less variability (range 14 to 31 bpm). However, higher respiratory rate variability, especially skewness over 1 day, was associated with higher incidence of an escalation event. Our overall model, based on continuous data, had a moderate accuracy with an AUC 0.81 (95%CI:0.73,0.88) and a good specificity 0.93 (95%CI:0.87,0.99).Conclusions Our pilot observational study suggests that continuous respiratory monitoring and respiratory rate variability are associated with the need for care escalation 24 hours in advance. ur results suggest that continuous respiratory monitoring is a valuable increment over intermittent monitoring.

Primary Cardiac Angiosarcoma With Pulmonary Metastasis in a Young Female: A Case Report and Review of Literature (preprint)

Background: Sarcomas are the most prevalent type of malignant primary cardiac tumor. Clinical presentation differs according to the size and location of the tumor and involvement  of other structures. Case presentation: In this article, we present a 38 years old lady as a case of primary cardiac angiosarcoma with a huge challenge in diagnosis and management of the disease. On the 4th of June 2020, she emergently presented to the hospital with the chief complaint of cough and tachypnea, diarrhea, and malaise, and a history of blunt chest trauma three weeks ago. Based on the presentation and transthoracic echocardiography which was compatible with cardiac tamponade, emergent pericardiocentesis was performed. The first imaging showed bilateral pleural effusion, pericardial effusion, and no significant parenchymal lung involvement, which was not compatible with rheumatologic diseases or COVID-19. Based on cardiac CT angiography and evidence of dye entrance to the peri-right atrial area, right atrial free wall rupture was suspected as the cause of the massive pericardial effusion. Following multidisciplinary consensus, she underwent cardiac surgery; in addition to the 3*3 cm right atrium free wall rupture repair, concomitant sampling from the lung nodules, lymph nodes, pericardium, and also the surrounding tissue of the right atrium ruptured defect was performed. Based on immunohistochemistry, the diagnosis was compatible with cardiac angiosarcoma with metastasis to the lung. Due to the advanced stage of the tumor, oncologists advised against chemotherapy or radiotherapy and she went through palliative care. Finally, after a 53-day ICU stay and due to right-sided heart failure, the patient unfortunately died. Conclusion: COVID-19 pandemic has brought diagnostic challenges regarding differentiating SARS-CoV-2 infection from other diagnostic entities. On the other hand, due to the rarity and fatality of primary cardiac angiosarcomas, early diagnosis and possible management seem crucial for prolonged survival. Involving cardiac angiosarcoma in the initial differential diagnosis could warrant timely diagnosis and assessment of various therapies for cure or palliative care.

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study.

BACKGROUND: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). METHODS: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. RESULTS: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). CONCLUSIONS: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.

Syncope: an uncommon Pulmonary Embolism presentation in COVID infection with low Wells scoring (preprint)

Pulmonary Embolism has been well established to be a potential life threatening medical emergency. Patients typically present with pleuritic chest pain with pressure, tachycardia, tachypnea, and desaturation of oxygen levels. We describe a case in which a COVID positive male presented to the ED via ambulance with saddle PE.

Acute Disseminated Encephalomyelitis After SARS-CoV-2 Vaccination.

BACKGROUND Acute disseminated encephalomyelitis (ADEM) is a disorder of the central nervous system which has been associated with preceding infection as well as vaccinations. We present a case of a 61-year-old woman with ADEM after receiving her initial vaccination for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This case highlights management of this acute condition. CASE REPORT A 61-year-old woman with history of hypertension and anxiety presented with progressive generalized weakness and difficulty with communication which began a few weeks ago, shortly after receiving the Pfizer vaccine for the novel coronavirus (COVID-19). On arrival, she was found to be encephalopathic and tachypneic, ultimately requiring emergent intubation. During her hospital course, an MRI of her brain was obtained which showed nonspecific acute versus subacute leukoencephalopathy involving the brainstem and deep white matter. Her cerebrospinal fluid showed elevated protein but was otherwise unremarkable. Further testing to rule out tick-borne illnesses, viral etiology, and multiple sclerosis were negative. Electroencephalography showed nonspecific diffuse cerebral dysfunction but no seizures or epileptiform discharges. She was treated with 5 doses of methylprednisolone 1 g and intravenous immunoglobulin (IVIG) 2 g/kg over 5 days. She had marked improvement in her neurologic status after treatment. CONCLUSIONS In conclusion, ADEM should be acknowledged as a rare but potential complication related to COVID-19 vaccination. A proper history and physical exam in addition to a thorough work-up are necessary for prompt recognition of this condition. Initial treatment should consist of steroids followed by IVIG versus plasmapheresis for those not responsive to steroids.

Clinical Presentation and Outcomes of Hospitalized Children with COVID-19 in Mexico City (preprint)

We describe the demographic, clinical, radiological and laboratory findings relating them also to the severity and clinical outcome of 129 children (0-18 years) which were admitted to a tertiary care pediatric hospital in Mexico City due to SARS- CoV-2 infection between April 1, 2020, to March 31, 2021. The infection was confirmed using RT-PCR. Fever (82.2%), tachypnea (72.1%) and cough (71.3%) were the most commonly reported signs at the moment of hospitalization. The most frequent radiological pattern that stood out was the interstitial pattern (66.7%). History of oncologic pathology (25.6%) was the most frequent past medical history. ESR (erythrocyte sedimentation rate) was the only laboratory value significantly associated with severity (p=0.015). NSAIDs (93%), antibiotics (57.4%), and steroids (40.3%) were the most common medication given. The average hospitalization stay was 14.2 days, 21.7% of the total patients required transfer to the intensive care unit. At discharge, 20.2% required oxygen on an outpatient basis, and unfortunately 7.0% of the patients who were admitted to the institute for COVID-19 died. Our findings confirm that COVID‐19 in children has a mild presentation except for patients with hematologic/oncologic co-morbidities which had severe presentations.

Epidemiologic and clinical characteristics of neonates with late-onset COVID-19: 1-year data of Turkish Neonatal Society.

The literature on neonates with SARS-CoV-2 is mainly concerned with perinatal cases, and scanty data are available about environmentally infected neonates. To fill knowledge gaps on the course and prognosis of neonatal cases, we analyzed 1-year data from the Turkish Neonatal Society in this prospective cohort study of neonates with postnatal transmission. Data from 44 neonatal intensive care units (NICUs), of neonates with positive RT-PCR results at days 5-28 of life, were extracted from the online registry system and analyzed. Of 176 cases, most were term infants with normal birth weight. Fever was the most common symptom (64.2%), followed by feeding intolerance (25.6%), and cough (21.6%). The median length of hospitalization was 9 days, with approximately one quarter of infants receiving some type of ventilatory support. Myocarditis (5.7%) was the most common complication during follow-up. Among the clinical findings, cough (odds ratio [OR]: 9.52, 95% confidence interval [CI]: 4.17-21.71), tachypnea (OR: 26.5, 95% CI: 9.59-73.19), and chest retractions (OR: 27.5, 95% CI: 5.96-126.96) were associated with more severe clinical disease. Also, there were significant differences in the C-reactive protein level, prothrombin time (PT), partial thromboplastin time, international normalized ratio, and days in the NICU (p = 0.002, p = 0.012, p = 0.034, p = 0.008, and p < 0.001, respectively) between patients with mild-moderate and severe-critical presentations. A PT above 14 s was a significant predictor of severe/critical cases, with a sensitivity of 64% and specificity of 73%. CONCLUSIONS: Our data showed that late-onset COVID-19 infection in neonates who need hospitalization can be severe, showing associations with high rates of ventilatory support and myocarditis. Cough, tachypnea, and retractions on admission suggest a severe disease course. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04401540. WHAT IS KNOWN: • Neonatal cases of COVID-19 infection are mainly reported as perinatal COVID-19 cases. • Neonates with perinatal transmission have a mild course and favorable prognosis. WHAT IS NEW: • Among symptomatic neonates with late-onset COVID-19 infection, fever was the most common symptom, and almost one quarter of hospitalized cases needed some type of respiratory support. Myocarditis was the most common complication. • The presence of cough, tachypnea, retractions, and a PT above 14 s were associated with an increased risk of severe COVID-19.

Impact of SARS-CoV-2 variants on inpatient clinical outcome (preprint)

Background: Prior observation has shown differences in COVID-19 hospitalization rates between SARS-CoV-2 variants, but limited information describes differences in hospitalization outcomes. Methods: Patients admitted to 5 hospitals with COVID-19 were included if they had hypoxia, tachypnea, tachycardia, or fever, and data to describe SARS-CoV-2 variant, either from whole genome sequencing, or inference when local surveillance showed [≥]95% dominance of a single variant. The average effect of SARS-CoV-2 variant on 14-day risk of severe disease, defined by need for advanced respiratory support, or death was evaluated using models weighted on propensity scores derived from baseline clinical features. Results: Severe disease or death within 14 days occurred for 950 of 3,365 (28%) unvaccinated patients and 178 of 808 (22%) patients with history of vaccination or prior COVID-19. Among unvaccinated patients, the relative risk of 14-day severe disease or death for Delta variant compared to ancestral lineages was 1.34 (95% confidence interval [CI] 1.13-1.55). Compared to Delta variant, this risk for Omicron patients was 0.78 (95% CI 0.62-0.97) and compared to ancestral lineages was 1.04 (95% CI 0.84-1.24). Among Omicron and Delta infections, patients with history of vaccination or prior COVID-19 had one-half the 14-day risk of severe disease or death (adjusted hazard ratio 0.46, IQR 0.34-0.62) but no significant outcome difference between Delta and Omicron infections. Conclusions: Although the risk of severe disease or death for unvaccinated patients with Omicron was lower than Delta, it was similar to ancestral lineages. Severe outcomes were less common in vaccinated patients, but there was no difference between Delta and Omicron infections.

Covid-19 on Routine Testing In Eclampsia: A Duo Complication to Look out for in Pregnancy (preprint)

Background: Coronavirus Disease 2019 (COVID-19) has been associated with adverse pregnancy outcomes including preeclampsia. COVID-19 and pre-eclampsia have overlapping clinical features therefore challenging to differentiate. Since COVID-19 is not routinely tested among pregnant women, it’s prudent to test it among patients presenting with Pre-eclampsia-Eclampsia. Case Presentation: A 23 year old female Gravida 1 Para 0 at 36 weeks and 5 days of amenorrhea presented at Mal Super Specialty Hospital as a referral in a semi-conscious state after a severe attack of tonic-clonic seizures. Detailed history from the husband was insignificant except for a persistent cough for the last 7 days. She had denied any visual changes, headaches or vaginal discharge. Physical examination revealed a tachycardia (150 bpm), elevated blood pressure (187/111 mmHg), a tachypnea (36 breaths/minute) and SPO 2 of 94% at room air. Routine COVID-19 Rapid test turned positive, and the urine dipstick was +3. Additional tests revealed a leukocytosis and elevated liver enzymes. Chest radiograph revealed prominent interstitial markings and a bedside transabdominal ultrasonography showed a live single intrauterine fetus in cephalic presentation with normal cardiac activity and movements. A diagnosis of a prime gravida with eclampsia and COVID-19 was made. She was managed with intravenous labetalol, she had already received a loading dose of IV Magnesium sulphate and we administered two maintenance doses during monitoring. Within an hour of admission, she had a spontaneous rupture of the amniotic membranes, with meconium stained liquor (grade 2), and the fetal heart rate (148 beats per minute) was reassuring. She had an uncomplicated vaginal delivery of a live male newborn. Shortly after delivery, she developed slight respiratory distress and significant fluid overload that was managed with furosemide. A COVID-19 RT-PCR came back negative for the neonate and positive for the mother. She was shifted to the COVID-19 treatment unit and contact limited with the child. She was kept on a course of tablets Ivermectin, zinc, vitamin C, a montelukast, azithromycin, metronidazole and injectable pantoprazole. They were discharged on day 15 after recovery with a negative COVID nasopharyngeal swab. Conclusion: A diagnosis of pre-eclampsia-Eclampsia should prompt testing for COVID-19.

Clinical Course and Characteristics of COVID-19 in Patients With Inborn Errors of Immunity: A Retrospective Multicenter Experience From Iran (preprint)

Purpose: This study aimed to assess the effect of COVID-19 on patients with IEIs, the potentially at-risk population, regarding the clinical course, complications, severity, and outcomes. Methods This two-phase study was conducted on patients from three referral immunodeficiency centers in Iran. At phase one, 98 IEI patients with COVID-19 infection were evaluated by telephone follow-up (TFU). At phase two, the demographic, clinical, and laboratory records of clinically confirmed 33 IEI patients with COVID-19 infection were collected and analyzed. Results At phase one, 16.3% represented COVID-19 infection without any report of pediatric intensive care unit (PICU) admission or death. During the second phase, combined immunodeficiency (CID) (42.4%) and predominantly antibody deficiencies (PADs) (33.3%) were the predominant immune defects. Atopy (27.3%) and lung disorders (27.3%) were the frequent pre-existing comorbidities. Organomegaly (p=0.030) and renal disorders ( p=0.033 ) were significantly associated with the development of respiratory insufficiency. Cyanosis, tachypnea, intercostal retraction, and seizure were the chief complaints of patients who were more likely to progress respiratory insufficiency (p<0.05) , being admitted to the PICU (p<0.05) , and/or deceased (p<0.05) . Laboratory evaluation revealed a marked positive correlation between D-Dimer ( p=0.045 ), prothrombin time ( p=0.045 ), C-reactive protein ( p=0.041 ), proteinuria ( p=0.013 ), ferritin ( p=0.020 ), metabolic acidosis ( p=0.003 ), and troponin ( p=0.049 ) level with mortality. We detected a significant association between the chest X-ray pattern of COVID-19 infection with PICU admission (p=0.023) and death (p=0.046) . Conclusion In the current study, patients with CID and PAD were introduced as patients at high risk of COVID-19 infection, who may need extra protective and therapeutic measurements.

Bacterial infections and death among patients with Covid-19 versus non Covid-19 patients with pneumonia.

BACKGROUND: Many patients with Coronavirus disease-2019 (Covid-19) present with radiological evidence of pneumonia. Because it is difficult to determine co-existence of bacterial pneumonia, many of these patients are initially treated with antibiotics. We compared the rates of bacterial infections and mortality in Covid-19 patients with pulmonary infiltrates versus patients diagnosed with 'pneumonia' the year previously. METHODS: We conducted a medical record review of patients admitted with Covid-19 and a pulmonary infiltrate and compared them with patients diagnosed with pneumonia admitted in the prior year before the pandemic. Data abstracted included baseline demographics, comorbidities, signs and symptoms, laboratory and microbiological results, and imaging findings. Outcomes were bacterial infections and mortality. Patients presenting with and without Covid-19 were compared using univariable and multivariable analyses. RESULTS: There were 1398 and 1001 patients admitted through the emergency department (ED) with and without Covid-19 respectively. Compared with non-Covid-19 patients, those with Covid-19 were younger (61±18 vs. 65±25 years, P < 0.001) and had a lower Charlson Comorbidity Index (0.7 vs. 1.2, P < 0.001). Bacterial infections were present in fewer Covid-19 than non-Covid-19 patients (8% vs. 13%, P < 0.001), and most infections in Covid-19 were nosocomial as opposed to community acquired in non-Covid-19 patients. CXR was more often read as abnormal and with bilateral infiltrates in patients with Covid-19 (82% vs. 70%, P < 0.001 and 81% vs. 48%, P < 0.001, respectively). Mortality was higher in patients with Covid-19 vs. those without (15% vs. 9%, P < 0.001). Multivariable predictors (OR [95%CI]) of mortality were age (1.04 [1.03-1.05]/year), tachypnea (1.55 [1.12-2.14]), hypoxemia (2.98 [2.04-4.34]), and bacterial infection (2.80 [1.95-4.02]). Compared with non-Covid-19 patients with pneumonia, patients with Covid-19 were more likely to die (2.68 [1.97-3.63]). CONCLUSIONS: The rate of bacterial infections is lower in Covid-19 patients with pulmonary infiltrates compared with patients diagnosed with pneumonia prior to the pandemic and most are nosocomial. Mortality was higher in Covid-19 than non-Covid-19 patients even after adjusting for age, tachypnea, hypoxemia, and bacterial infection.

Characteristics, Hospital Referrals and 60-Day Mortality of Older Patients Living In Nursing Homes With Covid-19 Assessed by a Liaison Geriatric Team During The First Wave: A Research Article. (preprint)

Background: The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19. Methods: : A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality. Results: : 419 patients were included in the study (median age 89 years old, 71.6% women, 63.7% with moderate-severe dependence, and 43.8% with advanced dementia). 31.1% were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index <60 (p 0.002), presence of tachypnea (p 0.021), fever (p 0.006) and the use of ceftriaxone (p 0.004) were associated with mortality. No mortality differences were found between those referred to the hospital or cared at the nursing home. Conclusions: and implications: 31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.

Predicting Intensive Care Unit Admissions for COVID-19 Patients in the Emergency Department.

OBJECTIVE: Determining the parameters that can predict the requirement of intensive care unit (ICU) admissions among the coronavirus disease 2019 (COVID-19) patients presented to the emergency departments (EDs). METHODS: In adult consecutive patients admitted (March 15 - April 15, 2020) to the ED of a state hospital for COVID-19, we retrospectively analyzed demographic data, symptoms, laboratory tests, and chest computed tomography (CT) on arrival. RESULTS: We included 458 patients [213 (46.5%) females, median age 48 y]. Body temperature, respiration rate, C-reactive protein (CRP), D-dimer, ferritin values, and the number of comorbidities were significantly higher in patients admitted to the ICU than others. Also, diffuse infiltration in chest CT is more common in patients who need ICU follow-up. As a result of the binary regression analysis, a statistically significant correlation was found between the presence of dyspnea (odds ratio [OR]: 12.55), tachypnea (relative risk [RR] ≥ 18) (OR: 14.54), multiple comorbidities (≥2) (OR: 23.39), diffuse infiltration in CT (OR: 14.52), and CRP (≥45 mg/L) (OR: 4.71); and the need for ICU admission. CONCLUSION: It has been concluded that the presence of dyspnea and tachypnea, elevated CRP, presence of multiple comorbidities, and diffuse infiltration in CT may predict the need for ICU admissions of the patients, who presented to the EDs.

Predictors of severity and mortality among patients hospitalized with COVID-19 in Rhode Island.

BACKGROUND: In order for healthcare systems to prepare for future waves of COVID-19, an in-depth understanding of clinical predictors is essential for efficient triage of hospitalized patients. METHODS: We performed a retrospective cohort study of 259 patients admitted to our hospitals in Rhode Island to examine differences in baseline characteristics (demographics and comorbidities) as well as presenting symptoms, signs, labs, and imaging findings that predicted disease progression and in-hospital mortality. RESULTS: Patients with severe COVID-19 were more likely to be older (p = 0.02), Black (47.2% vs. 32.0%, p = 0.04), admitted from a nursing facility (33.0% vs. 17.9%, p = 0.006), have diabetes (53.9% vs. 30.4%, p<0.001), or have COPD (15.4% vs. 6.6%, p = 0.02). In multivariate regression, Black race (adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI]: 1.1-3.9) and diabetes (aOR 2.2, 95%CI: 1.3-3.9) were independent predictors of severe disease, while older age (aOR 1.04, 95% CI: 1.01-1.07), admission from a nursing facility (aOR 2.7, 95% CI 1.1-6.7), and hematological co-morbidities predicted mortality (aOR 3.4, 95% CI 1.1-10.0). In the first 24 hours, respiratory symptoms (aOR 7.0, 95% CI: 1.4-34.1), hypoxia (aOR 19.9, 95% CI: 2.6-152.5), and hypotension (aOR 2.7, 95% CI) predicted progression to severe disease, while tachypnea (aOR 8.7, 95% CI: 1.1-71.7) and hypotension (aOR 9.0, 95% CI: 3.1-26.1) were associated with increased in-hospital mortality. CONCLUSIONS: Certain patient characteristics and clinical features can help clinicians with early identification and triage of high-risk patients during subsequent waves of COVID-19.