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1.
Cancer Cell ; 38(2): 161-163, 2020 08 10.
Article in English | MEDLINE | ID: covidwho-2130226

ABSTRACT

Two recent Lancet and Lancet Oncology papers report that cancer patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have higher mortality rates. Common independent factors associated with increased risk of death were older age, history of smoking status, number of comorbidities, more advanced performance status, and active cancer.


Subject(s)
Betacoronavirus/pathogenicity , Coronavirus Infections/mortality , Infection Control/standards , Infectious Disease Transmission, Professional-to-Patient/prevention & control , Neoplasms/mortality , Pneumonia, Viral/mortality , Age Factors , Aged , Betacoronavirus/immunology , COVID-19 , Coronavirus Infections/immunology , Coronavirus Infections/transmission , Coronavirus Infections/virology , Humans , Neoplasms/immunology , Neoplasms/therapy , Pandemics , Pneumonia, Viral/immunology , Pneumonia, Viral/transmission , Pneumonia, Viral/virology , Risk Assessment , Risk Factors , SARS-CoV-2
2.
Ann Intern Med ; 173(7): 536-541, 2020 10 06.
Article in English | MEDLINE | ID: covidwho-2110869

ABSTRACT

BACKGROUND: The incidence and severity of coronavirus disease 2019 (COVID-19) among HIV-positive persons receiving antiretroviral therapy (ART) have not been characterized in large populations. OBJECTIVE: To describe the incidence and severity of COVID-19 by nucleos(t)ide reverse transcriptase inhibitor (NRTI) use among HIV-positive persons receiving ART. DESIGN: Cohort study. SETTING: HIV clinics in 60 Spanish hospitals between 1 February and 15 April 2020. PARTICIPANTS: 77 590 HIV-positive persons receiving ART. MEASUREMENTS: Estimated risks (cumulative incidences) per 10 000 persons and 95% CIs for polymerase chain reaction-confirmed COVID-19 diagnosis, hospitalization, intensive care unit (ICU) admission, and death. Risk and 95% CIs for COVID-19 diagnosis and hospital admission by use of the NRTIs tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), tenofovir alafenamide (TAF)/FTC, abacavir (ABC)/lamivudine (3TC), and others were estimated through Poisson regression models. RESULTS: Of 77 590 HIV-positive persons receiving ART, 236 were diagnosed with COVID-19, 151 were hospitalized, 15 were admitted to the ICU, and 20 died. The risks for COVID-19 diagnosis and hospitalization were greater in men and persons older than 70 years. The risk for COVID-19 hospitalization was 20.3 (95% CI, 15.2 to 26.7) among patients receiving TAF/FTC, 10.5 (CI, 5.6 to 17.9) among those receiving TDF/FTC, 23.4 (CI, 17.2 to 31.1) among those receiving ABC/3TC, and 20.0 (CI, 14.2 to 27.3) for those receiving other regimens. The corresponding risks for COVID-19 diagnosis were 39.1 (CI, 31.8 to 47.6), 16.9 (CI, 10.5 to 25.9), 28.3 (CI, 21.5 to 36.7), and 29.7 (CI, 22.6 to 38.4), respectively. No patient receiving TDF/FTC was admitted to the ICU or died. LIMITATION: Residual confounding by comorbid conditions cannot be completely excluded. CONCLUSION: HIV-positive patients receiving TDF/FTC have a lower risk for COVID-19 and related hospitalization than those receiving other therapies. These findings warrant further investigation in HIV preexposure prophylaxis studies and randomized trials in persons without HIV. PRIMARY FUNDING SOURCE: Instituto de Salud Carlos III and National Institutes of Health.


Subject(s)
Antiretroviral Therapy, Highly Active , Coronavirus Infections/epidemiology , HIV Infections/drug therapy , Pneumonia, Viral/epidemiology , Adenine/analogs & derivatives , Adult , Aged , Betacoronavirus , COVID-19 , Coronavirus Infections/mortality , Dideoxynucleosides , Drug Combinations , Emtricitabine , Female , HIV Infections/mortality , Hospitalization/statistics & numerical data , Humans , Incidence , Intensive Care Units/statistics & numerical data , Lamivudine , Male , Middle Aged , Pandemics , Pneumonia, Viral/mortality , Reverse Transcriptase Polymerase Chain Reaction , SARS-CoV-2 , Severity of Illness Index , Spain/epidemiology , Tenofovir
3.
Ann Intern Med ; 173(3): 204-216, 2020 08 04.
Article in English | MEDLINE | ID: covidwho-2110840

ABSTRACT

BACKGROUND: Mechanical ventilation is used to treat respiratory failure in coronavirus disease 2019 (COVID-19). PURPOSE: To review multiple streams of evidence regarding the benefits and harms of ventilation techniques for coronavirus infections, including that causing COVID-19. DATA SOURCES: 21 standard, World Health Organization-specific and COVID-19-specific databases, without language restrictions, until 1 May 2020. STUDY SELECTION: Studies of any design and language comparing different oxygenation approaches in patients with coronavirus infections, including severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS), or with hypoxemic respiratory failure. Animal, mechanistic, laboratory, and preclinical evidence was gathered regarding aerosol dispersion of coronavirus. Studies evaluating risk for virus transmission to health care workers from aerosol-generating procedures (AGPs) were included. DATA EXTRACTION: Independent and duplicate screening, data abstraction, and risk-of-bias assessment (GRADE for certainty of evidence and AMSTAR 2 for included systematic reviews). DATA SYNTHESIS: 123 studies were eligible (45 on COVID-19, 70 on SARS, 8 on MERS), but only 5 studies (1 on COVID-19, 3 on SARS, 1 on MERS) adjusted for important confounders. A study in hospitalized patients with COVID-19 reported slightly higher mortality with noninvasive ventilation (NIV) than with invasive mechanical ventilation (IMV), but 2 opposing studies, 1 in patients with MERS and 1 in patients with SARS, suggest a reduction in mortality with NIV (very-low-certainty evidence). Two studies in patients with SARS report a reduction in mortality with NIV compared with no mechanical ventilation (low-certainty evidence). Two systematic reviews suggest a large reduction in mortality with NIV compared with conventional oxygen therapy. Other included studies suggest increased odds of transmission from AGPs. LIMITATION: Direct studies in COVID-19 are limited and poorly reported. CONCLUSION: Indirect and low-certainty evidence suggests that use of NIV, similar to IMV, probably reduces mortality but may increase the risk for transmission of COVID-19 to health care workers. PRIMARY FUNDING SOURCE: World Health Organization. (PROSPERO: CRD42020178187).


Subject(s)
Coronavirus Infections/transmission , Pneumonia, Viral/transmission , Respiration, Artificial/adverse effects , Respiration, Artificial/methods , Aerosols , Animals , Betacoronavirus , COVID-19 , Coronavirus Infections/mortality , Humans , Pandemics , Pneumonia, Viral/mortality , Randomized Controlled Trials as Topic , SARS-CoV-2 , Severe Acute Respiratory Syndrome/transmission , Systematic Reviews as Topic , World Health Organization
4.
Ann Intern Med ; 173(4): 268-277, 2020 08 18.
Article in English | MEDLINE | ID: covidwho-2110835

ABSTRACT

BACKGROUND: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features. OBJECTIVE: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests. DESIGN: Prospective cohort study. SETTING: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19. PATIENTS: The first 12 consecutive COVID-19-positive deaths. MEASUREMENTS: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. RESULTS: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart. LIMITATION: Limited sample size. CONCLUSION: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it. PRIMARY FUNDING SOURCE: University Medical Center Hamburg-Eppendorf.


Subject(s)
Autopsy/methods , Coronavirus Infections/mortality , Pneumonia, Viral/mortality , Pulmonary Embolism/mortality , Venous Thromboembolism/mortality , Aged , Aged, 80 and over , Betacoronavirus , COVID-19 , Cause of Death , Female , Germany/epidemiology , Humans , Male , Middle Aged , Pandemics , Prospective Studies , SARS-CoV-2 , Tomography, X-Ray Computed
9.
MMWR Morb Mortal Wkly Rep ; 69(46): 1725-1729, 2020 11 20.
Article in English | MEDLINE | ID: covidwho-1876240

ABSTRACT

New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 (1). During March-May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions. The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients. Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority. Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections.


Subject(s)
Coronavirus Infections/epidemiology , Disease Outbreaks , Pneumonia, Viral/epidemiology , Adolescent , Adult , Aged , Betacoronavirus/isolation & purification , COVID-19 , COVID-19 Testing , Child , Child, Preschool , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Coronavirus Infections/mortality , Coronavirus Infections/therapy , Female , Hospitalization/statistics & numerical data , Humans , Infant , Infant, Newborn , Male , Middle Aged , New York City/epidemiology , Pandemics , Pneumonia, Viral/diagnosis , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , SARS-CoV-2 , Young Adult
10.
Can J Anaesth ; 67(10): 1417-1423, 2020 10.
Article in English | MEDLINE | ID: covidwho-1777840

ABSTRACT

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.


RéSUMé: La prise en charge des symptômes et les soins de fin de vie sont des compétences de base pour tous les médecins, bien qu'en temps ordinaire, de nombreux anesthésiologistes n'ont que peu d'occasions de mettre en pratique ces compétences. La pandémie actuelle de coronavirus 2019 (COVID-19) a provoqué un taux de mortalité significatif dans un court intervalle et a nécessité une augmentation des besoins en soins intensifs et en soins palliatifs. Destiné aux anesthésiologistes déployés dans les unités prenant soin de patients atteints de la COVID-19, ce compte rendu narratif offre des recommandations quant à la façon de mener les discussions à propos des objectifs de soins, du retrait des thérapies de soutien vital, et de la prise en charge de symptômes de détresse.


Subject(s)
Coronavirus Infections/therapy , Critical Care/organization & administration , Pneumonia, Viral/therapy , Terminal Care/organization & administration , Anesthesiologists/organization & administration , Anesthesiologists/standards , COVID-19 , Clinical Competence , Coronavirus Infections/mortality , Critical Care/standards , Humans , Palliative Care/organization & administration , Pandemics , Physicians/organization & administration , Physicians/standards , Pneumonia, Viral/mortality , Terminal Care/standards , Withholding Treatment
11.
J Pharm Pharm Sci ; 23(1): 75-85, 2020.
Article in English | MEDLINE | ID: covidwho-1727068

ABSTRACT

The presented work summarizes the results of studies underlining the crucial role of estrogen receptor (ER) signaling in both innate and adaptive immune responses as well as in tissue repairing processes during respiratory virus infection. Experimental studies justify that among respiratory virus infected mice, a weaker ER signaling leads to increased morbidity and mortality in both males and females. In animal experiments, estrogen treatment silences the inflammatory reactions and decreases virus titers leading to improved survival rate; it seems to be an ideal prevention and therapy against COVID-19. We should overcome the widespread reluctance to estrogen therapy as we have a unique estrogen formula; conjugated estrogens, or conjugated equine estrogens available under the brand name of Premarin deriving from natural sources. Premarin can exert similar ER upregulative and gene repairing power like endogenous estrogen without any risk for adverse reactions. Premarin is capable of stopping the COVID-19 pandemic.


Subject(s)
Coronavirus Infections/drug therapy , Estrogens/therapeutic use , Pneumonia, Viral/drug therapy , Receptors, Estrogen/physiology , Adaptive Immunity , Age Factors , Animals , Betacoronavirus , COVID-19 , Comorbidity , Coronavirus Infections/mortality , Estrogens, Conjugated (USP)/therapeutic use , Female , Humans , Immunity, Innate , Inflammation/drug therapy , Male , Mice , Pandemics , Pneumonia, Viral/mortality , SARS-CoV-2 , Sex Factors , Signal Transduction , Up-Regulation/drug effects
12.
Int J Environ Res Public Health ; 17(12)2020 06 22.
Article in English | MEDLINE | ID: covidwho-1725662

ABSTRACT

Sars-cov-2 virus (Covid-19) is a member of the coronavirus family and is responsible for the pandemic recently declared by the World Health Organization. A positive correlation has been observed between the spread of the virus and air pollution, one of the greatest challenges of our millennium. Covid-19 could have an air transmission and atmospheric particulate matter (PM) could create a suitable environment for transporting the virus at greater distances than those considered for close contact. Moreover, PM induces inflammation in lung cells and exposure to PM could increase the susceptibility and severity of the Covid-19 patient symptoms. The new coronavirus has been shown to trigger an inflammatory storm that would be sustained in the case of pre-exposure to polluting agents. In this review, we highlight the potential role of PM in the spread of Covid-19, focusing on Italian cities whose PM daily concentrations were found to be higher than the annual average allowed during the months preceding the epidemic. Furthermore, we analyze the positive correlation between the virus spread, PM, and angiotensin-converting enzyme 2 (ACE2), a receptor involved in the entry of the virus into pulmonary cells and inflammation.


Subject(s)
Air Pollution/adverse effects , Betacoronavirus , Coronavirus Infections/transmission , Particulate Matter , Pneumonia, Viral/transmission , Aerosols , Angiotensin-Converting Enzyme 2 , COVID-19 , Cities , Coronavirus Infections/mortality , Coronavirus Infections/virology , Humans , Inflammation/etiology , Italy/epidemiology , Morbidity , Oxidative Stress , Pandemics , Peptidyl-Dipeptidase A/metabolism , Pneumonia, Viral/mortality , Pneumonia, Viral/virology , SARS-CoV-2
13.
Int J Environ Res Public Health ; 17(12)2020 06 21.
Article in English | MEDLINE | ID: covidwho-1725658

ABSTRACT

This study aims to underline the clinical characteristics of patients who died after testing positive for SARS-CoV-2 infection in one region of Italian and to evaluate the influence of underlying health conditions on the fatal outcome. A matched case-control study was designed by analyzing the data regarding positive subjects observed up to April 21, 2020. The case fatality rate was 7.9%, with a higher proportion of deaths in men than women. The specific standardized mortality ratio was 0.15-0.13 for males and 0.2 for females, showing that mortality is much lower than expected. Cardiovascular diseases, chronic lung diseases and diabetes mellitus showed a significant association with the outcome. Although the case fatality rate in Sardinia in regard to age and gender patterns seems to be similar to that for Italy as a whole, its quantitative value was far lower than the national one and possible explanations might include the genetic characteristics of the Sardinian population or the immediate closure of its borders as soon as the epidemic started. Our results highlighted that lethality is strongly dependent on the presence of multiple concomitant serious diseases. It is important to have epidemiological strategies for effective guidance on public health actions in order to improve chances of survival.


Subject(s)
Coronavirus Infections/mortality , Pneumonia, Viral/mortality , Adult , Aged , Aged, 80 and over , Betacoronavirus/isolation & purification , COVID-19 , Case-Control Studies , Coronavirus Infections/complications , Female , Humans , Italy/epidemiology , Male , Middle Aged , Pandemics , Pneumonia, Viral/complications , SARS-CoV-2
14.
Cien Saude Colet ; 25(suppl 1): 2403-2410, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-1725051

ABSTRACT

Mortality statistics due to COVID-19 worldwide are compared, by adjusting for the size of the population and the stage of the pandemic. Data from the European Centre for Disease Control and Prevention, and Our World in Data websites were used. Analyses are based on number of deaths per one million inhabitants. In order to account for the stage of the pandemic, the baseline date was defined as the day in which the 10th death was reported. The analyses included 78 countries and territories which reported 10 or more deaths by April 9. On day 10, India had 0.06 deaths per million, Belgium had 30.46 and San Marino 618.78. On day 20, India had 0.27 deaths per million, China had 0.71 and Spain 139.62. On day 30, four Asian countries had the lowest mortality figures, whereas eight European countries had the highest ones. In Italy and Spain, mortality on day 40 was greater than 250 per million, whereas in China and South Korea, mortality was below 4 per million. Mortality on day 10 was moderately correlated with life expectancy, but not with population density. Asian countries presented much lower mortality figures as compared to European ones. Life expectancy was found to be correlated with mortality.


Subject(s)
Betacoronavirus , Coronavirus Infections/mortality , Global Health/statistics & numerical data , Life Expectancy , Pandemics/statistics & numerical data , Pneumonia, Viral/mortality , COVID-19 , Humans , SARS-CoV-2
15.
Chin Med J (Engl) ; 133(11): 1261-1267, 2020 Jun 05.
Article in English | MEDLINE | ID: covidwho-1722623

ABSTRACT

BACKGROUND: The 2019 novel coronavirus has caused the outbreak of the acute respiratory disease in Wuhan, Hubei Province of China since December 2019. This study was performed to analyze the clinical characteristics of patients who succumbed to and who recovered from 2019 novel coronavirus disease (COVID-19). METHODS: Clinical data were collected from two tertiary hospitals in Wuhan. A retrospective investigation was conducted to analyze the clinical characteristics of fatal cases of COVID-19 (death group) and we compare them with recovered patients (recovered group). Continuous variables were analyzed using the Mann-Whitney U test. Categorical variables were analyzed by χ test or Fisher exact test as appropriate. RESULTS: Our study enrolled 109 COVID-19 patients who died during hospitalization and 116 recovered patients. The median age of the death group was older than the recovered group (69 [62, 74] vs. 40 [33, 57] years, Z = 9.738, P < 0.001). More patients in the death group had underlying diseases (72.5% vs. 41.4%, χ = 22.105, P < 0.001). Patients in the death group had a significantly longer time of illness onset to hospitalization (10.0 [6.5, 12.0] vs. 7.0 [5.0, 10.0] days, Z = 3.216, P = 0.001). On admission, the proportions of patients with symptoms of dyspnea (70.6% vs. 19.0%, χ = 60.905, P < 0.001) and expectoration (32.1% vs. 12.1%, χ = 13.250, P < 0.001) were significantly higher in the death group. The blood oxygen saturation was significantly lower in the death group (85 [77, 91]% vs. 97 [95, 98]%, Z = 10.625, P < 0.001). The white blood cell (WBC) in death group was significantly higher on admission (7.23 [4.87, 11.17] vs. 4.52 [3.62, 5.88] ×10/L, Z = 7.618, P < 0.001). Patients in the death group exhibited significantly lower lymphocyte count (0.63 [0.40, 0.79] vs. 1.00 [0.72, 1.27] ×10/L, Z = 8.037, P < 0.001) and lymphocyte percentage (7.10 [4.45, 12.73]% vs. 23.50 [15.27, 31.25]%, Z = 10.315, P < 0.001) on admission, and the lymphocyte percentage continued to decrease during hospitalization (7.10 [4.45, 12.73]% vs. 2.91 [1.79, 6.13]%, Z = 5.242, P < 0.001). Alanine transaminase (22.00 [15.00, 34.00] vs. 18.70 [13.00, 30.38] U/L, Z = 2.592, P = 0.010), aspartate transaminase (34.00 [27.00, 47.00] vs. 22.00 [17.65, 31.75] U/L, Z = 7.308, P < 0.001), and creatinine levels (89.00 [72.00, 133.50] vs. 65.00 [54.60, 78.75] µmol/L, Z = 6.478, P < 0.001) were significantly higher in the death group than those in the recovered group. C-reactive protein (CRP) levels were also significantly higher in the death group on admission (109.25 [35.00, 170.28] vs. 3.22 [1.04, 21.80] mg/L, Z = 10.206, P < 0.001) and showed no significant improvement after treatment (109.25 [35.00, 170.28] vs. 81.60 [27.23, 179.08] mg/L, Z = 1.219, P = 0.233). The patients in the death group had more complications such as acute respiratory distress syndrome (ARDS) (89.9% vs. 8.6%, χ = 148.105, P < 0.001), acute cardiac injury (59.6% vs. 0.9%, χ = 93.222, P < 0.001), acute kidney injury (18.3% vs. 0%, χ = 23.257, P < 0.001), shock (11.9% vs. 0%, χ = 14.618, P < 0.001), and disseminated intravascular coagulation (DIC) (6.4% vs. 0%, χ = 7.655, P = 0.006). CONCLUSIONS: Compared to the recovered group, more patients in the death group exhibited characteristics of advanced age, pre-existing comorbidities, dyspnea, oxygen saturation decrease, increased WBC count, decreased lymphocytes, and elevated CRP levels. More patients in the death group had complications such as ARDS, acute cardiac injury, acute kidney injury, shock, and DIC.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pneumonia, Viral/complications , Adult , Aged , Aged, 80 and over , C-Reactive Protein/analysis , COVID-19 , Coronavirus Infections/mortality , Female , Humans , Male , Middle Aged , Oxygen/blood , Pandemics , Pneumonia, Viral/mortality , Retrospective Studies , SARS-CoV-2
16.
J Pain Symptom Manage ; 60(4): e2-e13, 2020 10.
Article in English | MEDLINE | ID: covidwho-1638060

ABSTRACT

CONTEXT: Preparation for an impending death through end-of-life (EOL) discussions and human presence when a person is dying is important for both patients and families. OBJECTIVES: The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from coronavirus disease 2019 (COVID-19), comparing deaths in nursing homes and hospitals. METHODS: The national Swedish Register of Palliative Care was used. All expected deaths from COVID-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019). RESULTS: A total of 1346 expected COVID-19 deaths in nursing homes (n = 908) and hospitals (n = 438) were analyzed. Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (P < 0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, P < 0.001), and dying with someone present was much more uncommon (59% vs. 83%, P < 0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, P < 0.0001), and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, P < 0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (P < 0.001). The corresponding figures for staff were 52% and 38% (P < 0.0001). CONCLUSION: Dying from COVID-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.


Subject(s)
Betacoronavirus , Coronavirus Infections/psychology , Loneliness , Palliative Care , Pneumonia, Viral/psychology , Quality of Health Care , Terminal Care , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19 , Child , Child, Preschool , Communication , Coronavirus Infections/mortality , Coronavirus Infections/therapy , Female , Hospitalization , Humans , Infant , Male , Middle Aged , Nursing Homes , Pandemics , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , Registries , SARS-CoV-2 , Social Support , Sweden/epidemiology , Young Adult
17.
JAMA Pediatr ; 176(3): e216436, 2022 Mar 01.
Article in English | MEDLINE | ID: covidwho-1635814

ABSTRACT

IMPORTANCE: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. OBJECTIVE: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. EXPOSURES: Age, sex, preexisting comorbidities, and region of residence. MAIN OUTCOMES AND MEASURES: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. RESULTS: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.


Subject(s)
COVID-19/therapy , Child, Hospitalized , Outcome Assessment, Health Care , Pneumonia, Viral/therapy , Adolescent , Africa South of the Sahara/epidemiology , COVID-19/epidemiology , COVID-19/mortality , Child , Child, Preschool , Female , Humans , Infant , Length of Stay/statistics & numerical data , Male , Oxygen Inhalation Therapy , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/mortality , Pneumonia, Viral/virology , Respiration, Artificial , SARS-CoV-2
18.
J Med Internet Res ; 23(2): e23026, 2021 02 22.
Article in English | MEDLINE | ID: covidwho-1575588

ABSTRACT

BACKGROUND: For the clinical care of patients with well-established diseases, randomized trials, literature, and research are supplemented with clinical judgment to understand disease prognosis and inform treatment choices. In the void created by a lack of clinical experience with COVID-19, artificial intelligence (AI) may be an important tool to bolster clinical judgment and decision making. However, a lack of clinical data restricts the design and development of such AI tools, particularly in preparation for an impending crisis or pandemic. OBJECTIVE: This study aimed to develop and test the feasibility of a "patients-like-me" framework to predict the deterioration of patients with COVID-19 using a retrospective cohort of patients with similar respiratory diseases. METHODS: Our framework used COVID-19-like cohorts to design and train AI models that were then validated on the COVID-19 population. The COVID-19-like cohorts included patients diagnosed with bacterial pneumonia, viral pneumonia, unspecified pneumonia, influenza, and acute respiratory distress syndrome (ARDS) at an academic medical center from 2008 to 2019. In total, 15 training cohorts were created using different combinations of the COVID-19-like cohorts with the ARDS cohort for exploratory purposes. In this study, two machine learning models were developed: one to predict invasive mechanical ventilation (IMV) within 48 hours for each hospitalized day, and one to predict all-cause mortality at the time of admission. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value. We established model interpretability by calculating SHapley Additive exPlanations (SHAP) scores to identify important features. RESULTS: Compared to the COVID-19-like cohorts (n=16,509), the patients hospitalized with COVID-19 (n=159) were significantly younger, with a higher proportion of patients of Hispanic ethnicity, a lower proportion of patients with smoking history, and fewer patients with comorbidities (P<.001). Patients with COVID-19 had a lower IMV rate (15.1 versus 23.2, P=.02) and shorter time to IMV (2.9 versus 4.1 days, P<.001) compared to the COVID-19-like patients. In the COVID-19-like training data, the top models achieved excellent performance (AUROC>0.90). Validating in the COVID-19 cohort, the top-performing model for predicting IMV was the XGBoost model (AUROC=0.826) trained on the viral pneumonia cohort. Similarly, the XGBoost model trained on all 4 COVID-19-like cohorts without ARDS achieved the best performance (AUROC=0.928) in predicting mortality. Important predictors included demographic information (age), vital signs (oxygen saturation), and laboratory values (white blood cell count, cardiac troponin, albumin, etc). Our models had class imbalance, which resulted in high negative predictive values and low positive predictive values. CONCLUSIONS: We provided a feasible framework for modeling patient deterioration using existing data and AI technology to address data limitations during the onset of a novel, rapidly changing pandemic.


Subject(s)
COVID-19/diagnosis , COVID-19/mortality , Machine Learning , Pneumonia, Viral/diagnosis , Aged , Area Under Curve , Cohort Studies , Comorbidity , Female , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/mortality , Predictive Value of Tests , Prognosis , ROC Curve , Respiration, Artificial/statistics & numerical data , Retrospective Studies , SARS-CoV-2 , Treatment Outcome
19.
Ann Med ; 53(1): 151-159, 2021 12.
Article in English | MEDLINE | ID: covidwho-1574907

ABSTRACT

OBJECTIVE: To utilize publicly reported, state-level data to identify factors associated with the frequency of cases, tests, and mortality in the USA. MATERIALS AND METHODS: Retrospective study using publicly reported data collected included the number of COVID-19 cases, tests and mortality from March 14th through April 30th. Publicly available state-level data was collected which included: demographics comorbidities, state characteristics and environmental factors. Univariate and multivariate regression analyses were performed to identify the significantly associated factors with percent mortality, case and testing frequency. All analyses were state-level analyses and not patient-level analyses. RESULTS: A total of 1,090,500 COVID-19 cases were reported during the study period. The calculated case and testing frequency were 3332 and 19,193 per 1,000,000 patients. There were 63,642 deaths during this period which resulted in a mortality of 5.8%. Factors including to but not limited to population density (beta coefficient 7.5, p < .01), transportation volume (beta coefficient 0.1, p < .01), tourism index (beta coefficient -0.1, p = .02) and older age (beta coefficient 0.2, p = .01) are associated with case frequency and percent mortality. CONCLUSIONS: There were wide variations in testing and case frequencies of COVID-19 among different states in the US. States with higher population density had a higher case and testing rate. States with larger population of elderly and higher tourism had a higher mortality. Key messages There were wide variations in testing and case frequencies of COVID-19 among different states in the USA. States with higher population density had a higher case and testing rate. States with larger population of elderly and higher tourism had a higher mortality.


Subject(s)
Clinical Laboratory Techniques/statistics & numerical data , Coronavirus Infections/mortality , Pneumonia, Viral/mortality , COVID-19 , COVID-19 Testing , Comorbidity , Coronavirus Infections/diagnosis , Female , Healthcare Disparities , Humans , Male , Pandemics , Pneumonia, Viral/diagnosis , United States/epidemiology
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