Predicting Mortality Risk in Older Hospitalized Persons With COVID-19: A Comparison of the COVID-19 Mortality Risk Score with Frailty and Disability

ObjectivesTo assess the association of pre-morbid functional status [Barthel Index (BI)] and frailty [modified Frailty Index (mFI)] with in-hospital mortality and a risk scoring system developed for COVID-19 in patients ≥75 years diagnosed with COVID-19.DesignRetrospective bicentric observational study.Setting and ParticipantsData on consecutive patients aged ≥75 years admitted with COVID-19 at 2 Italian tertiary care centers were collected from February 22 to May 30, 2020.MethodsOverall, 221 consecutive patients with COVID-19 aged ≥75 years were admitted to 2 hospitals in the study period and were included in the analysis. Clinical, functional (BI), frailty (mFI), laboratory, and imaging data were collected. Mortality risk on admission was assessed with the COVID-19 Mortality Risk Score (COVID-19 MRS), a dedicated score developed for hospital triage.ResultsNinety-seven (43.9%) patients died. BI, frailty, age, dementia, respiratory rate, Pao₂/Fio₂ ratio, creatinine, and platelet count were associated with mortality. Analysis of the area under the receiver operating characteristic (AUC) indicated that the predictivity of age was modest and the combination of BI, mFI, and COVID-19 MRS yielded the highest prediction accuracy (AUC_{COVID-19MRS+BI+mFI} vs AUC_Age: 0.87 vs 0.59; difference: +0.28, lower bound–upper bound: 0.17-0.34, P < .001).Conclusions and ImplicationsPremorbid BI and mFI are associated with mortality and improved the accuracy of the COVID-19 MRS. Functional status may prove useful to guide clinical management of older individuals.     

传染病医院面对新型冠状病毒肺炎疫情应急管理策略

在新型冠状病毒肺炎疫情流行期间,全国所有传染病医院积极参与到疫情防治工作中。作为新型冠状病毒肺炎病人省市定点收治单位,第一时间应急反应,转移安置原有病人、有序安排收治新型冠状病毒肺炎病人、治愈出院和后期随访等工作,科学管理,有效保证了病人的救治能力和医务人员安全。     

The Health and Social Needs of Patients Discharged From the Emergency Department With Suspected COVID-19

Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30–May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.     

Telemedicine and the Use of Korean Medicine for Patients With COVID-19 in South Korea: Observational Study

BackgroundCOVID-19 was first reported in Wuhan, China, in December 2019, and it has since spread worldwide. The Association of Korean Medicine (AKOM) established the COVID-19 telemedicine center of Korean medicine (KM telemedicine center) in Daegu and Seoul.ObjectiveThe aim of this study was to describe the results of the KM telemedicine center and the clinical possibility of using herbal medicines for COVID-19.MethodsAll procedures were conducted by voice call following standardized guidelines. The students in the reception group obtained informed consent from participants and they collected basic information. Subsequently, Korean Medicine doctors assessed COVID-19–related symptoms and prescribed the appropriate herbal medicine according to the KM telemedicine guidelines. The data of patients who completed the program by June 30, 2020, were analyzed.ResultsFrom March 9 to June 30, 2020, 2324 patients participated in and completed the KM telemedicine program. Kyung-Ok-Ko (n=2285) was the most prescribed herbal medicine, and Qingfei Paidu decoction (I and II, n=2053) was the second most prescribed. All COVID-19–related symptoms (headache, chills, sputum, dry cough, sore throat, fatigue, muscle pain, rhinorrhea, nasal congestion, dyspnea, chest tightness, diarrhea, and loss of appetite) improved after treatment (P<.001).ConclusionsThe KM telemedicine center has provided medical service to 10.8% of all patients with COVID-19 in South Korea (as of June 30, 2020), and it is still in operation. We hope that this study will help to establish a better health care system to overcome COVID-19.     

The Association between Nutritional Status and In-Hospital Mortality of COVID-19 in Critically-Ill Patients in the ICU

Background: Coronavirus disease 2019 (COVID-19) has become one of the leading causes of death worldwide. The impact of poor nutritional status on increased mortality and prolonged ICU (intensive care unit) stay in critically ill patients is well-documented. This study aims to assess how nutritional status and BMI (body mass index) affected in-hospital mortality in critically ill COVID-19 patients Methods: We conducted a retrospective study and analysed medical records of 286 COVID-19 patients admitted to the intensive care unit of the University Clinical Hospital in Wroclaw (Poland). Results: A total of 286 patients were analysed. In the sample group, 8% of patients who died had a BMI within the normal range, 46% were overweight, and 46% were obese. There was a statistically significantly higher death rate in men (73%) and those with BMIs between 25.0–29.9 (p = 0.011). Nonsurvivors had a statistically significantly higher HF (Heart Failure) rate (p = 0.037) and HT (hypertension) rate (p < 0.001). Furthermore, nonsurvivors were statistically significantly older (p < 0.001). The risk of death was higher in overweight patients (HR = 2.13; p = 0.038). Mortality was influenced by higher scores in parameters such as age (HR = 1.03; p = 0.001), NRS2002 (nutritional risk score, HR = 1.18; p = 0.019), PCT (procalcitonin, HR = 1.10; p < 0.001) and potassium level (HR = 1.40; p = 0.023). Conclusions: Being overweight in critically ill COVID-19 patients requiring invasive mechanical ventilation increases their risk of death significantly. Additional factors indicating a higher risk of death include the patient’s age, high PCT, potassium levels, and NRS ≥ 3 measured at the time of admission to the ICU.     

Nutritional Risk Assessment Scores Effectively Predict Mortality in Critically Ill Patients with Severe COVID-19

Background: Malnutrition predicts a worse outcome for critically ill patients. However, quick, easy-to-use nutritional risk assessment tools have not been adequately validated. Aims and Methods: The study aimed to evaluate the role of four biological nutritional risk assessment instruments (the Prognostic Nutritional Index—PNI, the Controlling Nutritional Status Score—CONUT, the Nutrition Risk in Critically Ill—NUTRIC, and the modified NUTRIC—mNUTRIC), along with CT-derived fat tissue and muscle mass measurements in predicting in-hospital mortality in a consecutive series of 90 patients hospitalized in the intensive care unit for COVID-19-associated ARDS. Results: In-hospital mortality was 46.7% (n = 42/90). Non-survivors had a significantly higher nutritional risk, as expressed by all four scores. All scores were independent predictors of mortality on the multivariate regression models. PNI had the best discriminative capabilities for mortality, with an area under the curve (AUC) of 0.77 for a cut-off value of 28.05. All scores had an AUC above 0.72. The volume of fat tissue and muscle mass were not associated with increased mortality risk. Conclusions: PNI, CONUT, NUTRIC, and mNUTRIC are valuable nutritional risk assessment tools that can accurately predict mortality in critically ill patients with COVID-19-associated ARDS.     

广州市新型冠状病毒肺炎疫情流行特征分析

目的 对广州市新型冠状病毒肺炎（COVID-19）疫情的流行特征进行分析,为指导疫情防控提供科学依据。 方法 对广州市COVID-19确诊病例及无症状感染者进行流行病学调查,采用描述流行病学方法描述流行特征及病例临床特征,分析感染来源及与疾病严重程度相关因素。 结果 截至2020年3月11日,广州市共报告361例新型冠状病毒感染者,其中确诊病例347例（占96.1%）,无症状感染者14例。病例以外地输入为主,占73.2%,其中80.3%为湖北省输入（204/254）。63.7%的病例与聚集性疫情关联,且以家庭聚集为主（占85.1%）。最常见症状为发热（占78.1%）,其次为干咳（占45.9%）。93.9%的病例表现为轻型或普通型,仅1例死亡。男性、高龄、职业为离退人员、自述有心脑血管疾病史和发病前14 d内有医疗机构就诊史等因素与重症型病例有关（P<0.05或P<0.01）。 结论 广州市COVID-19疫情以湖北省输入为主,部分地区出现本地感染,家庭聚集性疫情多发,但尚未发生社区传播,提示在以输入病例为主的地区采取加强主动排查、严格隔离确诊病例和密切接触者等措施,可有效控制本地传播。     

Effectiveness of In-Hospital Cholecalciferol Use on Clinical Outcomes in Comorbid COVID-19 Patients: A Hypothesis-Generating Study

Little information is available on the beneficial effects of cholecalciferol treatment in comorbid patients hospitalized for COVID-19. The aim of this study was to retrospectively examine the clinical outcome of patients receiving in-hospital high-dose bolus cholecalciferol. Patients with a positive diagnosis of SARS-CoV-2 and overt COVID-19, hospitalized from 15 March to 20 April 2020, were considered. Based on clinical characteristics, they were supplemented (or not) with 400,000 IU bolus oral cholecalciferol (200,000 IU administered in two consecutive days) and the composite outcome (transfer to intensive care unit; ICU and/or death) was recorded. Ninety-one patients (aged 74 ± 13 years) with COVID-19 were included in this retrospective study. Fifty (54.9%) patients presented with two or more comorbid diseases. Based on the decision of the referring physician, 36 (39.6%) patients were treated with vitamin D. Receiver operating characteristic curve analysis revealed a significant predictive power of the four variables: (a) low (<50 nmol/L) 25(OH) vitamin D levels, (b) current cigarette smoking, (c) elevated D-dimer levels (d) and the presence of comorbid diseases, to explain the decision to administer vitamin D (area under the curve = 0.77, 95% CI: 0.67–0.87, p < 0.0001). Over the follow-up period (14 ± 10 days), 27 (29.7%) patients were transferred to the ICU and 22 (24.2%) died (16 prior to ICU and six in ICU). Overall, 43 (47.3%) patients experienced the combined endpoint of transfer to ICU and/or death. Logistic regression analyses revealed that the comorbidity burden significantly modified the effect of vitamin D treatment on the study outcome, both in crude (p = 0.033) and propensity score-adjusted analyses (p = 0.039), so the positive effect of high-dose cholecalciferol on the combined endpoint was significantly amplified with increasing comorbidity burden. This hypothesis-generating study warrants the formal evaluation (i.e., clinical trial) of the potential benefit that cholecalciferol can offer in these comorbid COVID-19 patients.     

Early Improvement of Acute Respiratory Distress Syndrome in Patients With COVID-19 in the Intensive Care Unit: Retrospective Analysis

BackgroundSince the start of the COVID-19 pandemic, there have been over 2 million deaths globally. Acute respiratory distress syndrome (ARDS) may be the main cause of death.ObjectiveThis study aimed to describe the clinical features, outcomes, and ARDS characteristics of patients with COVID-19 admitted to the intensive care unit (ICU) in Chongqing, China.MethodsThe epidemiology of COVID-19 from January 21, 2020, to March 15, 2020, in Chongqing, China, was analyzed retrospectively, and 75 ICU patients from two hospitals were included in this study. On day 1, 56 patients with ARDS were selected for subgroup analysis, and a modified Poisson regression was performed to identify predictors for the early improvement of ARDS (eiARDS).ResultsChongqing reported a 5.3% case fatality rate for the 75 ICU patients. The median age of these patients was 57 (IQR 25-75) years, and no bias was present in the sex ratio. A total of 93% (n=70) of patients developed ARDS during ICU stay, and more than half had moderate ARDS. However, most patients (n=41, 55%) underwent high-flow nasal cannula oxygen therapy, but not mechanical ventilation. Nearly one-third of patients with ARDS improved (arterial blood oxygen partial pressure/oxygen concentration >300 mm Hg) in 1 week, which was defined as eiARDS. Patients with eiARDS had a higher survival rate and a shorter length of ICU stay than those without eiARDS. Age (<55 years) was the only variable independently associated with eiARDS, with a risk ratio of 2.67 (95% CI 1.17-6.08).ConclusionsA new subphenotype of ARDS—eiARDS—in patients with COVID-19 was identified. As clinical outcomes differ, the stratified management of patients based on eiARDS or age is highly recommended.     

Telehealth Management and Risk Stratification of Older Patients With Chronic Heart Failure During COVID-19 Pandemic: Prognostic Evaluation of the TeleHFCovid19-Score

ObjectivesTo evaluate 6-month risk stratification capacity of the newly developed TeleHFCovid19-Score for remote management of older patients with heart failure (HF) during the coronavirus disease 2019 pandemic.DesignMonocentric observational prospective study.Setting and ParticipantsOlder HF outpatients remotely managed during the first pandemic wave.MethodsThe TeleHFCovid19-Score (0-29) was obtained by an ad hoc developed multiparametric standardized questionnaire administered during telephone visits to older HF patients (and/or caregivers) followed at our HF clinic. Questions were weighed on the basis of clinical judgment and review of current HF literature. According to the score, patients were divided in progressively increasing risk groups: green (0-3), yellow (4-8), and red (≥9).ResultsA total of 146 patients composed our study population: at baseline, 112, 21, and 13 were classified as green, yellow, and red, respectively. Mean age was 81±9 years, and women were 40%. Compared to patients of red and yellow groups, those in the green group had a lower use of high-dose loop diuretics (P < .001) or thiazide-like diuretics (P = .027) and had reported less frequently dyspnea at rest or for basic activities, new or worsening extremity edema, or weight increase (all P < .001). At 6 months, compared with red (62.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization (P < .001). Moreover, receiver operating characteristic curve analysis showed a high sensibility and specificity of our score at 6 months (area under the curve = 0.789, 95% CI 0.682-0.896, P < .001) with a score <4.5 (very close to green group cutoff) that identified lower-risk subjects.Conclusions and ImplicationsThe TeleHFCovid19-Score was able to correctly identify patients with midterm favorable outcome. Therefore, our questionnaire might be used to identify low-risk chronic HF patients who could be temporarily managed remotely, allowing to devote more efforts to the care of higher-risk patients who need closer and on-site clinical evaluations.     

广州市白云区新型冠状病毒肺炎国内本地疫情阶段流行病学特征分析

目的 掌握新型冠状病毒(新冠)肺炎国内本地疫情阶段广州市白云区疫情流行病学特征.方法 从中国疾控中心传染病信息系统及病例流行病学调查资料获取白云区截至2020年2月29日的新冠病例疾病报告和流行病学信息进行分析.结果 国内本地疫情阶段白云区累计报告新冠病例74例.首例报告于1月21日,报告数高峰在1月29日,末例报告于...     

Haddon模型在新型冠状病毒肺炎疫情时期住院病案管理中的应用

2019年12月开始新型冠状病毒肺炎疫情迅速蔓延,给全球公共卫生系统带来了一系列挑战,也给医院病案管理科室日常工作提出了新的要求。文章基于Haddon模型,针对新型冠状病毒的流行病学特点,结合医院住院病历管理实践,提出传染病突发时期住院病历的管理方法,为传染病突发时期病案管理及医院内疫情防控提供参考。     

Healthcare Resource Utilization of Patients With COVID-19 Visiting US Hospitals

ObjectivesSevere cases of COVID-19 have overwhelmed hospital systems across the nation. This study aimed to describe the healthcare resource utilization of patients with COVID-19 from hospital visit to 30 days after discharge for inpatients and hospital-based outpatients in the United States.MethodsA retrospective cohort study was conducted using Premier Healthcare Database COVID-19 Special Release, a large geographically diverse all-payer hospital administrative database. Adult patients (age ≥ 18 years) were identified by their first, or “index,” visit between April 1, 2020, and February 28, 2021, with a principal or secondary discharge diagnosis of COVID-19.ResultsOf 1 454 780 adult patients with COVID-19, 33% (n = 481 216) were inpatients and 67% (n = 973 564) were outpatients. Among inpatients, mean age was 64.4 years and comorbidities were common. Most patients (80%) originated from home, 10% from another acute care facility, and 95% were admitted through the emergency department. Of these patients, 23% (n = 108 120) were admitted to intensive care unit and 14% (n = 66 706) died during index hospitalization; 44% were discharged home, 15% to nursing or rehabilitation facility, and 12% to home health. Among outpatients, mean age was 48.8 years, 44% were male, and 60% were emergency department outpatients (n = 586 537). During index outpatient visit, 79% were sent home but 10% had another outpatient visit and 4% were hospitalized within 30 days.ConclusionsCOVID-19 is associated with high level of healthcare resource utilization and in-hospital mortality. More than one-third of inpatients required post hospital healthcare services. Such information may help healthcare providers better allocate resources for patients with COVID-19 during the pandemic.     

The Cost-Effectiveness of Remdesivir for Hospitalized Patients With COVID-19

ObjectivesThis study aimed to estimate the cost-effectiveness of remdesivir, the first novel therapeutic to receive Emergency Use Authorization for the treatment of hospitalized patients with COVID-19, and identify key drivers of value to guide future pricing and reimbursement efforts.MethodsA Markov model evaluated the cost-effectiveness of remdesivir in patients hospitalized with COVID-19 from a US healthcare sector perspective. A lifetime time horizon captured potential long-term costs and outcomes. Model outcomes included discounted total costs, life-years, and quality-adjusted life-years (QALYs). Remdesivir was modeled as an addition to standard of care and compared with standard of care alone, including dexamethasone for patients requiring respiratory support. COVID-19 hospitalizations were assumed to be reimbursed through a single payment based on the respiratory support received alongside a remdesivir carveout payment in the base case. Sensitivity and scenario analyses identified key drivers.ResultsAt a unit price of $520 per vial and assuming no survival benefit with remdesivir, the incremental cost-effectiveness was $298 200/QALY for patients with moderate to severe COVID-19 and $1 847 000/QALY for patients with mild COVID-19. Although current data do not support a survival benefit, if one was assumed, the cost-effectiveness estimate was $50 100/QALY for the moderate to severe population and $103 400/QALY for the mild population. Another key driver included the hospitalization payment structure (per diem vs bundled payment).ConclusionsWith the current evidence available, remdesivir’s price is too high to align with its expected health gains for hospitalized patients with COVID-19. Results from this study provide a rationale for iterative health technology assessment.     

Dietetic-Led Nutrition Interventions in Patients with COVID-19 during Intensive Care and Ward-Based Rehabilitation: A Single-Center Observational Study

Background: In this study, a report of dietitian-led nutrition interventions for patients with COVID-19 during ICU and ward-based rehabilitation is provided. As knowledge of COVID-19 and its medical treatments evolved through the course of the pandemic, dietetic-led interventions were compared between surge 1 (S1) and surge 2 (S2). Methods: A prospective observational study was conducted of patients admitted to the ICU service in a large academic hospital (London, UK). Clinical and nutrition data were collected during the first surge (March–June 2020; n = 200) and the second surge (November 2020–March 2021; n = 253) of COVID-19. Results: A total of 453 patients were recruited. All required individualized dietetic-led interventions during ICU admission as the ICU nutrition protocol did not meet nutritional needs. Feed adjustments for deranged renal function (p = 0.001) and propofol calories (p = 0.001) were more common in S1, whereas adjustment for gastrointestinal dysfunction was more common in S2 (p = 0.001). One-third of all patients were malnourished on ICU admission, and all lost weight in ICU, with a mean (SD) total percentage loss of 8.8% (6.9%). Further weight loss was prevented over the remaining hospital stay with continued dietetic-led interventions. Conclusions: COVID-19 patients have complex nutritional needs due to malnutrition on admission and ongoing weight loss. Disease complexity and evolving nature of medical management required multifaceted dietetic-led nutritional strategies, which differed between surges.     

The Effect of Age on Mortality in Patients With COVID-19: A Meta-Analysis With 611,583 Subjects

ObjectivesInitial data on COVID-19 infection has pointed out a special vulnerability of older adults.DesignWe performed a meta-analysis with available national reports on May 7, 2020 from China, Italy, Spain, United Kingdom, and New York State. Analyses were performed by a random effects model, and sensitivity analyses were performed for the identification of potential sources of heterogeneity.Setting and participantsCOVID-19–positive patients reported in literature and national reports.MeasuresAll-cause mortality by age.ResultsA total of 611,1583 subjects were analyzed and 141,745 (23.2%) were aged ≥80 years. The percentage of octogenarians was different in the 5 registries, the lowest being in China (3.2%) and the highest in the United Kingdom and New York State. The overall mortality rate was 12.10% and it varied widely between countries, the lowest being in China (3.1%) and the highest in the United Kingdom (20.8%) and New York State (20.99%). Mortality was <1.1% in patients aged <50 years and it increased exponentially after that age in the 5 national registries. As expected, the highest mortality rate was observed in patients aged ≥80 years. All age groups had significantly higher mortality compared with the immediately younger age group. The largest increase in mortality risk was observed in patients aged 60 to 69 years compared with those aged 50 to 59 years (odds ratio 3.13, 95% confidence interval 2.61-3.76).Conclusions and ImplicationsThis meta-analysis with more than half million of COVID-19 patients from different countries highlights the determinant effect of age on mortality with the relevant thresholds on age >50 years and, especially, >60 years. Older adult patients should be prioritized in the implementation of preventive measures.     

传染病动力学模型及其在新型冠状病毒肺炎疫情仿真预测中的应用综述

介绍了GGM(generalized-growth model)、GRM(generalized Richards model)、SIR(susceptible-infected-recovered)、SEIR(susceptible-exposed-infected-removed)模型及元胞自动机模型、人工神经网络模型等常用的传染病动力学模型,结合新型冠状病毒肺炎疫情发展现状,总结了传染病动力学模型在疫情仿真预测中的应用情况,指出了传染病动力学模型应用的局限性,得出了加强传染病认知、推进疫情信息实时共享、开展多模型结合应用等未来发展启示。     

新冠肺炎疫情下慢性病患者就医延迟问题调查与分析

目的分析新冠肺炎疫情下慢性病患者就医延迟问题。方法2021年2月,采用网络调查,以321名慢性病患者作为调查对象,采用多种统计方法进行分析。结果调查的慢病患者中,37.1%出现就医延迟。就医延迟最多的疾病是心脑血管疾病(23.5%);就医延迟影响的首位原因是患者出现"医院恐慌"现象,害怕院内交叉感染而不敢去医院(54.6%);未及时就医带来的首位影响的是康复变慢(43.7%)。结论就医延迟发生的主要社会人口学特征是年龄和自评健康状况,患者就医延迟的心理行为特征是风险感知和过度防护,新冠肺炎疫情下,慢性病患者就医延迟现象较高,就医延迟后对患者产生不利影响,建议采取全方位的综合举措以缓解患者疫情期间的就医难题。     

应对新型冠状病毒肺炎疫情的方舱医院建设管理探讨

2019年12月以来,我国新型冠状病毒肺炎确诊患者数量在短时间内快速增长。为有效控制疫情,中央赴湖北指导组在组织专家充分论证的基础上,创造性地提出将方舱医院应用到疫情防控工作中。实践证明,利用方舱医院对确诊的轻症患者进行隔离治疗,实现了对传染源的规范化管理,有效地切断了病毒的传播途径,在本次疫情防控工作中,发挥了至关重要的作用。文章就本次应对新型冠状病毒肺炎疫情中,方舱医院建设管理相关工作进行简要分析探讨。