Contents
General
- Characteristics, Outcomes, and Trends of Patients With COVID-19–Related Critical Illness at a Learning Health System in the United States
Among 468 patients with COVID-19–related critical illness, 319 (68.2%) were treated with mechanical ventilation and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (IQR: 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. Among patients with COVID-19–related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. - Characteristics of Adults aged 18–49 Years Without Underlying Conditions Hospitalized with Laboratory-Confirmed COVID-19 in the United States, COVID-NET — March–August 2020
Among 513 adults aged 18–49 years without underlying medical conditions hospitalized with COVID-19 during March–August 2020, 22% were admitted to intensive care unit; 10% required mechanical ventilation; and three patients died (0.6%). These data demonstrate that healthy younger adults can develop severe COVID-19. - Case Characteristics, Resource Use, and Outcomes of 10,021 Patients with COVID-19 Admitted to 920 German Hospitals: An Observational Study
Of 10,021 hospitalised patients being treated in 920 different hospitals, 1727 (17%) received mechanical ventilation (of whom 422 [24%] were aged 18–59 years, 382 [22%] were aged 60–69 years, 535 [31%] were aged 70–79 years, and 388 [23%] were aged ≥80 years). The median age was 72 years. Men and women were equally represented in the non-ventilated group, whereas twice as many men than women were in the ventilated group. The most common comorbidities were hypertension (56%), diabetes (28%), cardiac arrhythmia (27%), renal failure (23%), heart failure (20%), and chronic pulmonary disease (14%). Dialysis was required in 599 (6%) of all patients and in 469 (27%) of 1727 ventilated patients. The mean duration of ventilation was 13.5 days (SD 12.1). In-hospital mortality was 22% overall, with wide variation between patients without ventilation (16%) and with ventilation (53%). In-hospital mortality in ventilated patients requiring dialysis was 73%. In-hospital mortality for patients with ventilation by age ranged from 28% (117 of 422) in patients aged 18–59 years to 72% (280 of 388) in patients aged 80 years or older. - Factors Associated with Hospital Admission and Critical Illness among 5279 People with Coronavirus Disease 2019 in New York City: Prospective Cohort Study (NYU)
5,279 patients were included. 2,741 of these 5,279 (51.9%) were admitted, of whom 1,904 (69.5%) were discharged alive without hospice care and 665 (24.3%) [CFR of 12.6%] were discharged to hospice care or died. Of 647 (23.6%) patients requiring mechanical ventilation, 391 (60.4%) died and 170 (26.2%) were extubated or discharged. The strongest risk for hospital admission was associated with age, with an odds ratio of >2 for all age groups older than 44 years and 37.9 (95% confidence interval 26.1 to 56.0) for ages 75 years and older. Other risks were heart failure, male sex, chronic kidney disease, and any increase in body mass index (BMI). The strongest risks for critical illness besides age were associated with heart failure, BMI >40, and male sex. Admission oxygen saturation of <88%, troponin level >1, C reactive protein level >200, and D-dimer level >2500 were, however, more strongly associated with critical illness than age or comorbidities. Risk of critical illness decreased significantly over the study period. Similar associations were found for mortality alone. - Epidemiology, Clinical Course, and Outcomes of Critically Ill Adults with COVID-19 in New York City: A Prospective Cohort Study (Columbia University Medical Center)
Between March 2 and April 1, 2020, 1,150 adults were admitted to both hospitals [Milstein and the Allen] with laboratory-confirmed COVID-19, of which 257 (22%) were critically ill. The median age of patients was 62 years (IQR 51–72), 67% were men. 212 (82%) patients had at least one chronic illness, the most common of which were hypertension (63%) and diabetes (36%). 119 (46%) patients had obesity. As of April 28, 2020, 101 (39%) patients had died and 94 (37%) remained hospitalised [CFR of 8.8%]. 203 (79%) patients received invasive mechanical ventilation for a median of 18 days (IQR 9–28), 170 (66%) of 257 patients received vasopressors and 79 (31%) received renal replacement therapy. The median time to in-hospital deterioration was 3 days (IQR 1–6). In the multivariable Cox model, older age, chronic cardiac disease, chronic pulmonary disease, higher concentrations of interleukin-6, and higher concentrations of D-dimer were independently associated with in-hospital mortality. - Characterization and Clinical Course of 1,000 Patients with Coronavirus Disease 2019 in New York: Retrospective Case Series (Columbia University Medical Center)
Of the first 1,000 patients, 150 presented to the emergency department, 614 were admitted to hospital (not intensive care units), and 236 were admitted or transferred to intensive care units. The most common presenting symptoms were cough (732/1,000), fever (728/1,000), and dyspnea (631/1,000). Patients in hospital, particularly those treated in intensive care units, often had baseline comorbidities including hypertension, diabetes, and obesity. Patients admitted to intensive care units were older, predominantly male (158/236, 66.9%), and had long lengths of stay (median 23 days, interquartile range 12-32 days); 78.0% (184/236) developed acute kidney injury and 35.2% (83/236) needed dialysis. Only 4.4% (6/136) of patients who required mechanical ventilation were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at three to four days, and at nine days. As of 30 April, 90 patients remained in hospital and 211 had died in hospital. - Presenting Characteristics, Comorbidities, and Outcomes Among 5,700 Patients Hospitalized With COVID-19 in the New York City Area (Northwell Health)
A total of 5,700 patients were included (median age, 63 years; 39.7% female). The most common comorbidities were hypertension (56.6%), obesity (41.7%), and diabetes (33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/minute, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2,634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. Mortality for those requiring mechanical ventilation was 88.1%. A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days. 3,066 patients remained hospitalized at the final study follow-up date. - Clinical Characteristics of COVID-19 in New York City (Weill Cornell Medicine)
Among the 393 patients, median age was 62.2 years, 60.6% were male, and 35.8% had obesity. The most common presenting symptoms were cough (79.4%), fever (77.1%), dyspnea (56.5%), myalgias (23.8%), diarrhea (23.7%), and nausea and vomiting (19.1%). Most of the patients (90.0%) had lymphopenia, 27% had thrombocytopenia, and many had elevated liver-function values and inflammatory markers. Between March 5 and April 10, respiratory failure leading to invasive mechanical ventilation developed in 130 patients (33.1%); to date, only 43 of these patients (33.1%) have been extubated. In total, 40 of the patients (10.2%) have died, and 260 (66.2%) have been discharged from the hospital; outcome data are incomplete for the remaining 93 patients (23.7%). - COVID-19-Associated Critical Illness—Report of the First 300 Patients Admitted to Intensive Care Units at a New York City Medical Center (Montefiore)
This report is a description of the first 300 patients admitted with COVID-19 to a Montefiore Medical Center ICU. Male gender, older age, and total number of medical comorbidities, most notably obesity, hypertension, and active tobacco use, were associated with increased mortality risk. Acute kidney injury was common, and overall mortality was 55.8% for patients admitted to the ICU. Of the patients who died, 97.8% received mechanical ventilation. - COVID-19 in Critically Ill Patients in the Seattle Region — Case Series
The case fatality rate of 50% in this series (to date) is similar to that reported among critically ill patients in Chinese hospitals but lower than that in a single-center experience reported from our area. Although the case fatality rate was higher in persons 65 years of age or older, it was still substantial (37%) in persons younger than 65 years of age. Our case fatality rate may be an underestimate, given that 3 patients remained intubated at the time data were censored. - CDC: Severe Outcomes Among Patients with COVID-19
This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55-64 years. - Baseline Characteristics and Outcomes of 1,591 Patients with SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy
This is the first large retrospective observational report on the characteristics of patients with COVID-19 in Italy, describing the course of more than 1500 critically ill adults over a 4-week period in February and March. All patients with a positive laboratory test for SARS-CoV-2 (17,713 as of March 28, 2020) who were admitted to one of the 72 ICUs in the Lombardy ICU network were enrolled (totaling 1591 patients, or 9% of all positive SARS-CoV-2 tests). The patients in the ICU were largely male (82%) with a median age of 63, and they tended to have cardiovascular comorbidities, including hypertension. Overall, 88% patients required invasive mechanical ventilation. Detailed respiratory treatment data were available for 875 patients, who tended to have high requirements for ventilatory support including a median PEEP of 14 cm H2O, a median PaO2/FiO2 ratio of 160, and, in 27% of patients, treatment with prone ventilation. The in-ICU mortality rate was 26%, and an additional 58% remained in intensive care at the time of publication.
The very first paper out of China in January 2020:
- Clinical Features of Patients Infected with 2019 Novel Coronavirus in Wuhan, China
By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (73%); less than half had underlying diseases. Median age was 49·0 years. 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (98%), cough (76%), and myalgia or fatigue (44%); less common symptoms were sputum production (28%), headache (8%), haemoptysis (5%), and diarrhoea (3%). Dyspnoea developed in 55% of patients (median time from onset to dyspnoea 8·0 days). 63% of patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (29%), RNAaemia (15%), acute cardiac injury (12%) and secondary infection (10%). 32% patients were admitted to an ICU and 15% died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies.
Pediatrics
- Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses
A total of 192 children (mean age 10.2 +/- 7 years) were enrolled. Forty-nine children (26%) were diagnosed with acute SARS-CoV-2 infection; an additional 18 children (9%) met criteria for MIS-C. Only 25 (51%) of children with acute SARS-CoV-2 infection presented with fever; symptoms of SARS-CoV-2 infection, if present, were non-specific. Nasopharyngeal viral load was highest in children in the first 2 days of symptoms, significantly higher than hospitalized adults with severe disease (P = .002). Age did not impact viral load, but younger children had lower ACE2 expression (P=0.004). IgM and IgG to the receptor binding domain (RBD) of the SARS-CoV-2 spike protein were increased in severe MIS-C (P<0.001), with dysregulated humoral responses observed. This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious MIS-C. - Characteristics and Outcomes of Children With COVID-19 Infection Admitted to US and Canadian Pediatric ICUs
This study was designed to examine 46 PICUs in North America—despite the number of beds that represents, that was still only 48 children who were afflicted with COVID-19. The median age was 13 years, split about evenly between male and female patients. Overall, 83% had significant preexisting conditions and 73% had a presentation that was primarily respiratory. Even though they were requiring intensive care, only 38% required ventilation, and only 1 patient required ECMO. Notably, only 2 died at the completion of the study period. - Characteristics of Hospitalized Children With SARS-CoV-2 in the New York City Metropolitan Area
This was a multicenter, retrospective cohort study at four hospitals comprising 82 hospitalized children (0-21 years) who tested positive for SARS-CoV-2 after symptoms and risk screening between March 1 and May 10, 2020. We subdivided patients based on their admission to acute or critical care units and by age groups. Twenty-three (28%) patients required critical care. Twenty-nine (35%) patients requiring respiratory support with 9% needing mechanical ventilation and one required extracorporeal support. All patients survived to discharge. Children with any comorbidity were more likely to require critical care (70% vs. 37%, P=0.008), with obesity as the most common risk factor for critical care (63% vs. 28%, P=0.02). Children with asthma were more likely to receive respiratory support (28% vs. 8%, P=0.02), with no difference in need for critical care (P=0.26). Children admitted to critical care had higher rates of renal dysfunction at presentation (43% vs. 10%, P=0.002). - Symptoms Associated with a Positive Result for a Swab for SARS-CoV-2 Infection among Children in Alberta
The authors analyzed results for 2,463 children who underwent testing for SARS-CoV-2 infection; 1,987 children had a positive result and 476 had a negative result. Of children with a positive test result for SARS-CoV-2, 714 (35.9%) reported being asymptomatic. Although cough (24.5%) and rhinorrhea (19.3%) were 2 of the most common symptoms among children with SARS-CoV-2 infection, they were also common among those with negative test results and were not predictive of a positive test. Anosmia/ageusia (positive LR 7.33, 95% CI 3.03–17.76), nausea/vomiting (positive LR 5.51, 95% CI 1.74–17.43), headache (positive LR 2.49, 95% CI 1.74–3.57) and fever (positive LR 1.68, 95% CI 1.34–2.11) were the symptoms most predictive of a positive result for a SARS-CoV-2 swab. The positive LR for the combination of anosmia/ageusia, nausea/vomiting and headache was 65.92 (95% CI 49.48–91.92). - Epidemiological Characteristics of 2,143 Pediatric COVID-19 Patients in China
Chinese case series of 2,143 pediatric patients with COVID-19. There were 731 (34.1%) laboratory-confirmed cases and 1,412 (65.9%) suspected cases. The median age of all patients was 7 years (interquartile range: 2-13), and 1213 cases (56.6%) were boys. Over 90% of all patients were asymptomatic, mild, or moderate cases. The median time from illness onset to diagnoses was 2 days (range: 0 to 42 days). There was a rapid increase of disease at the early stage of the epidemic and then there was a gradual and steady decrease. Disease rapidly spread from Hubei Province to surrounding provinces over time. Children at all ages appeared susceptible to COVID-19, and there was no significant gender difference. Although clinical manifestations of children’s COVID-19 cases were generally less severe than those of adults, young children, particularly infants, were vulnerable to infection.
Obstetrics
- Outcomes of Critically Ill Pregnant Women with COVID-19 in the United States
The authors report the maternal and fetal outcomes of 32 pregnant women in a multicenter cohort study of geographically-diverse critically ill patients with COVID-19. In contrast to nonpregnant women of childbearing age, all pregnant women survived, and there were no fetal deaths. Treatments and outcomes, including receipt of invasive mechanical ventilation, the incidence of acute organ injury, and ICU and hospital length of stay, were generally similar between pregnant and non-pregnant women. Pregnant women had high rates of preterm delivery and cesarean section—primarily for the indication of critical illness. Our finding that 13 pregnant women survived to hospital discharge without delivery raises an interesting question of whether or not delivery is required for non-obstetric indications among critically-ill pregnant women. - Clinical Findings and Disease Severity in Hospitalized Pregnant Women With Coronavirus Disease 2019 (COVID-19)
Seventy-seven patients were included, 14 of whom had severe disease (18%). Two thirds of the patients in the cohort were admitted during the third trimester, and 84% were symptomatic on admission. Eleven patients underwent urgent delivery for respiratory compromise (16%), and six were admitted to the ICU (8%). One woman received extracorporeal membrane oxygenation; no deaths occurred. Preterm delivery occurred in 12% of patients, and nine newborns were admitted to the neonatal intensive care unit. Patients in the severe subgroup had significantly higher pregestational body mass indexes (BMIs) and heart and respiratory rates and a greater frequency of fever or dyspnea on admission compared with women with a nonsevere disease evolution. - COVID-19 in Pregnancy: Early Lessons
Five of the seven patients presented with symptoms of COVID-19, including cough, myalgias, fevers, chest pain, and headache. Four patients were admitted to the hospital, including two who required supportive care with intravenous hydration. Most notably, the other two admitted patients were asymptomatic on admission to the hospital, presenting instead for obstetrically-indicated labor inductions; both of these patients became symptomatic post-partum, each requiring intensive care unit admission.
Other
- Cutaneous Manifestations in COVID-19: A First Perspective
Of 88 patients, 18 (20%) had cutaneous manifestations, 8 of them at the onset and 10 after hospitalization. Fourteen had an erythematous rash, 3 had widespread urticaria, and 1 had chickenpox-like vesicles. The authors speculate that the cutaneous manifestations are similar to those of other common viral infections. - Case Report: COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy
The authors report the first presumptive case of acute necrotizing hemorrhagic encephalopathy associated with COVID-19. Acute necrotizing encephalopathy (ANE) is rare but has been associated with influenza and other viral infections and has been related to intracranial cytokine storms that result in breakdown of the blood–brain barrier, but without direct viral invasion or parainfectious demyelination. In this case, the patient, a female airline worker in her late 50s, demonstrated hemorrhagic rim-enhancing lesions within the bilateral thalami, medial temporal lobes, and subinsular regions on brain MRI. Noncontrast CT images showed symmetric hypoattenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram. While predominantly described in the pediatric population, ANE is known to occur in adults as well.