A population-based cohort study of sex and risk of severe outcomes in covid-19.

There is a male sex disadvantage in morbidity and mortality due to COVID-19. Proposed explanations to this disparity include gender-related health behaviors, differential distribution of comorbidities and biological sex differences. In this study, we investigated the association between sex and risk of severe COVID-19 while adjusting for comorbidities, socioeconomic factors, as well as unmeasured factors shared by cohabitants which are often left unadjusted. We conducted a total-population-based cohort study (n = 1,854,661) based on individual-level register data. Cox models was used to estimate the associations between sex and risk for severe COVID-19. We additionally used a within-household design and conditional Cox models aiming to account for unmeasured factors shared by cohabitants. A secondary aim was to compare the risk of COVID-19 related secondary outcomes between men and women hospitalized due to COVID-19 using logistic regression. Men were at higher risk for hospitalization (HR = 1.63;95%CI = 1.57-1.68), ICU admission (HR = 2.63;95%CI = 2.38-2.91) and death (HR = 1.81;95%CI = 1.68-1.95) due to COVID-19, based on fully adjusted models. However, the effect of sex varied significantly across age groups: Among people in their 50s, men had > four times higher risk of COVID-19 death. The within-household design did not provide any further explanation to the sex disparity. Among patients hospitalized due to COVID-19, men had an increased risk for viral pneumonia, acute respiratory distress syndrome, acute respiratory insufficiency, acute kidney injury, and sepsis which persisted in fully adjusted models. Recognition of the combined effect of sex and age on COVID-19 outcomes has implications for policy strategies to reduce the adverse effects of the disease.

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries.

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.

Two novel human coronavirus OC43 genotypes circulating in hospitalized children with pneumonia in China.

HCoV-OC43 is one of the mildly pathogenic coronaviruses with high infection rates in common population. Here, 43 HCoV-OC43 related cases with pneumonia were reported, corresponding genomes of HCoV-OC43 were obtained. Phylogenetic analyses based on complete genome, orf1ab and spike genes revealed that two novel genotypes of HCoV-OC43 have emerged in China. Obvious recombinant events also can be detected in the analysis of the evolutionary dynamics of novel HCoV-OC43 genotypes. Estimated divergence time analysis indicated that the two novel genotypes had apparently independent evolutionary routes. Efforts should be conducted for further investigation of genomic diversity and evolution analysis of mildly pathogenic coronaviruses.

Management of individuals with multiple chronic conditions: a continuing challenge.

Individuals with multiple chronic conditions (MCCs) represent a growing proportion of the adult population in the United States, particularly among lower-income individuals and people of color. Despite ongoing efforts to characterize this population and develop approaches for effective management, individuals with MCCs continue to contribute substantially to health care expenditures. Based on a review of recent literature, several identified barriers limit the effectiveness of care for patients with MCCs. Health care delivery system structural limitations, evidence-based care concerns, patient-clinician relationship constraints, and barriers to inclusion of patient-centered priorities may singly or in combination negatively affect outcomes for individuals with MCCs. The COVID-19 pandemic has shed further light on inequities contributing to suboptimal MCC patient management. Awareness of the prevalence and demographic attributes of patients with MCCs and the identified barriers to care may help improve patient engagement and treatment outcomes for this high-cost population. This paper provides recommendations for enhancing MCC patient care outcomes in the current and post-COVID-19 health care delivery settings.

[Early Detection of COVID-19 in Portugal: Use of Clinical Records]. / Deteção Precoce de COVID-19 em Portugal: Uso de Registos Clínicos.

INTRODUCTION: Syndromic surveillance allows early detection of changes in the population's morbidity pattern. The aim of this study is to evaluate the usefulness of indicators related to access to healthcare services, in COVID-19 surveillance. MATERIAL AND METHODS: A time series analysis was performed using the weekly incidence rate of COVID-19 in Mainland Portugal, between weeks 14/2020 (March 30 to April 5) and 25/2020 (June 15 to 21), and six indicators: 1) COVID-19 consultations in primary healthcare; 2) number of COVID-19 emergency department visits; 3) number of emergency department visits due to viral pneumonia; 4) number of hospitalizations due to viral pneumonia; 5) proportion of emergency department visits due to viral pneumonia; and 6) proportion of hospitalizations for viral pneumonia. Pearson correlation and cross-correlations were computed. RESULTS: A strong correlation was found between the weekly incidence rate of COVID-19 and all indicators. [(1) 0.76; (2) 0.82; (3) 0.77; (4) 0.84; (5) 0.86; e (6) 0.90]. Emergency department visits and hospitalizations for viral pneumonia detect variations in the frequency of the disease with a one week lag compared to the incidence rate of COVID-19, in one week. COVID-19 consultations in primary healthcare and emergency department visits trail behind the incidence rate of COVID-19, in one week. The proportion of viral pneumonias in emergency department visits, or hospitalizations, is temporally aligned with the weekly incidence rate of COVID-19. DISCUSSION: The delay found in the COVID-19 primary healthcare consultations and emergency department visits, may be related to changes in access to healthcare services and clinical coding. Emergency department visits and hospitalizations for viral pneumonia may be useful in the early detection of COVID-19. Viral pneumonia may have been coded as being of unknown origin. Future monitoring of these indicators is necessary to ascertain whether the incidence of COVID-19 is significantly influenced by changes in testing strategies. The indicators described in this study will be an asset for the optimization of testing strategies, allocation of healthcare resources to the communities that are most vulnerable to severe morbidity and assessing vaccination impact. As such, surveillance systems based on clinical data will be a valuable complementary tool to SINAVE. CONCLUSION: The indicators under analysis could be used regularly, with special attention to viral pneumonias, to detect outbreaks of COVID-19. Information on pneumonia of unknown etiology may be considered in the surveillance of COVID-19.

Introdução: A vigilância sindrómica permite a identificação precoce de alterações no padrão de morbilidade da população. Este estudo tem como objetivo avaliar a utilidade de indicadores relativos a cuidados de saúde primários e hospitalares, na vigilância da COVID-19.Material e Métodos: Foi realizada uma análise de séries temporais utilizando a taxa de incidência semanal de COVID-19 em Portugal Continental, entre as semanas 14/2020 (30 março a 05 abril) e 25/2020 (15 a 21 junho), e seis indicadores: 1) consultas em cuidados de saúde primários por COVID-19; 2) número de episódios de urgência por COVID-19; 3) número de episódios de urgência por pneumonia vírica; 4) número de internamentos por pneumonia vírica; 5) proporção de episódios de urgência por pneumonia vírica face ao total de episódios de urgência por pneumonia; e 6) proporção de internamentos por pneumonia vírica face ao total de internamentos por pneumonia. Foram calculadas correlações de Pearson e correlações cruzadas.Resultados: Foi encontrada uma correlação forte entre a taxa de incidência semanal de COVID-19 e todos os indicadores [(1) 0,76; (2) 0,82; (3) 0,77; (4) 0,84; (5) 0,86; e (6) 0,90]. Os episódios de urgência e internamento por pneumonias víricas detetam variações na frequência da doença, com uma semana de antecedência. As consultas em cuidados de saúde primários e urgências por COVID-19 registam uma semana de atraso relativamente à evolução da taxa de incidência. A proporção de pneumonias víricas face ao número de pneumonias em episódios de urgência, ou internamentos, encontra-se alinhada temporalmente com a evolução da taxa de incidência semanal de COVID-19.Discussão: O atraso encontrado no padrão de evolução de consultas em CSP, e de episódios de urgência por COVID-19 face à incidência de COVID-19, poderá estar relacionado com a reorganização dos serviços de saúde e criação de códigos específicos para estas consultas. Episódios de urgência e internamentos por pneumonia vírica poderão ser úteis para a deteção precoce de possíveis surtos de COVID-19. Pneumonias víricas poderão ter sido classificadas como pneumonias de causa indeterminada. A monitorização futura destes indicadores é necessária de modo a averiguar se a incidência de COVID-19 é influenciada significativamente por alterações na estratégia de testagem. Os indicadores deste trabalho serão uma mais valia para a adequação de estratégias de testagem, alocação de recursos de saúde a comunidades mais vulneráveis à morbilidade severa e avaliação de programas de vacinação. Como tal, os sistemas de vigilância com base em registos de saúde serão um complemento valioso ao SINAVE.Conclusão: Sugere-se que os indicadores em análise sejam utilizados de forma regular, com especial atenção à informação relativa a pneumonias víricas, como forma de detetar precocemente surtos de COVID-19. A informação relativa a pneumonias de causa indeterminada poderá ser considerada na monitorização da COVID-19.

The federal spending power: Building forward after the pandemic.

The phrase, "the federal spending power," identifies the federal government's ability to spend in areas beyond its constitutional authority to legislate-a power that has supported the development of a national system of universal healthcare coverage in Canada. Even before the COVID-19 pandemic, this power was critical to the expansion of Canada's narrow but deep basket of universally covered services. The challenges exposed by the pandemic mean that still more federal investment will be required. Yet for traditionalists, the material basis of this power is now constrained: the federal government may possess the constitutional authority to invest, but it lacks the fiscal capacity; some form of belt tightening-even austerity-will be necessary. As debates over public spending intensify, health leaders will need to address these questions. Depending on how they do so, health leaders will either support or detract from a healthy recovery.

Temporal Trends, Management and Outcomes of Acute Myocardial Infarction with Concomitant Respiratory Infections.

There are limited contemporary data on the management and outcomes of acute myocardial infarction (AMI) in patients with concomitant acute respiratory infections. Hence, using the National Inpatient Sample from 2000-2017, adult AMI admissions with and without concomitant respiratory infections were identified. We evaluated in-hospital mortality, utilization of cardiac procedures, hospital length of stay, hospitalization costs, and discharge disposition. Among 10,880,856 AMI admissions, respiratory infections were identified in 745,536 (6.9%). Temporal trends revealed a relatively stable tr end with a peak during 2008-2009. Admissions with respiratory infections were on average older (74 vs. 67 years), female (45% vs 39%), with greater comorbidity (mean Charlson comorbidity index 5.9 ± 2.2 vs 4.4 ± 2.3), and had higher rates of non-ST-segment-elevation AMI presentation (71.8% vs. 62.2%) (all p < 0.001). Higher rates of cardiac arrest (8.2% vs 4.8%), cardiogenic shock (10.7% vs 4.4%), and acute organ failure (27.8% vs 8.1%) were seen in AMI admissions with respiratory infections. Coronary angiography (41.4% vs 65.6%, p < 0.001) and percutaneous coronary intervention (20.7% vs 43.5%, p < 0.001) were used less commonly in those with respiratory infections. Admissions with respiratory infections had higher in-hospital mortality (14.5% vs 5.5%; propensity matched analysis: 14.6% vs 12.5%; adjusted odds ratio 1.25 [95% confidence interval 1.24-1.26], p < 0.001), longer hospital stay, higher hospitalization costs, and less frequent discharges to home compared to those without respiratory infections. In conclusion, respiratory infections significantly impact AMI admissions with higher rates of complications, mortality and resource utilization.

Assessment of basic reproductive number for COVID-19 at global level: A meta-analysis.

BACKGROUND: There are large knowledge gaps regarding how transmission of 2019 novel coronavirus disease (COVID-19) occurred in different settings across the world. This study aims to summarize basic reproduction number (R0) data and provide clues for designing prevention and control measures. METHODS: Several databases and preprint platforms were retrieved for literature reporting R0 values of COVID-19. The analysis was stratified by the prespecified modeling method to make the R0 values comparable, and by country/region to explore whether R0 estimates differed across the world. The average R0 values were pooled using a random-effects model. RESULTS: We identified 185 unique articles, yielding 43 articles for analysis. The selected studies covered 5 countries from Asia, 5 countries from Europe, 12 countries from Africa, and 1 from North America, South America, and Australia each. Exponential growth rate model was most favored by researchers. The pooled global R0 was 4.08 (95% CI, 3.09-5.39). The R0 estimates for new and shifting epicenters were comparable or even higher than that for the original epicenter Wuhan, China. CONCLUSIONS: The high R0 values suggest that an extraordinary combination of control measures is needed for halting COVID-19.

Public preferences for allocating absolute scarce critical healthcare resources during the COVID-19 pandemic.

PURPOSE: This paper aims to investigate the Portuguese general public views regarding the criteria that should guide critical COVID-19 patients to receive medical devices (ventilators and IUC beds) during the current pandemic context. Based on rationing principles and protocols proposed in ethical and medical literature the authors explore how Portuguese general public evaluates the fairness of five allocation principles: "prognosis", "severity of health condition", "patients age", "instrumental value" (frontline healthcare professionals should be prioritized during the pandemic) and "lottery". DESIGN/METHODOLOGY/APPROACH: An online questionnaire was used to collect data from a sample of 586 Portuguese citizens. Descriptive statistics and non-parametric tests were used to define a hierarchy of prioritization criteria and to test for the association between respondents support to them and their socio-demographic and health characteristics. FINDINGS: Respondents gave top priority to prognosis when faced with absolute scarcity, followed closely by the severity of health condition, patient's age with instrumental value receiving lowest support, on average. However, when the age of the patients was confronted with survival, younger-first principle prevailed over recovery. In a pandemic context, lottery was considered the least fair allocation method. The findings suggest that respondents' opinions are aligned with those of ethicists but are partially in disagreement with the protocol suggested for Portugal. ORIGINALITY/VALUE: This study represents the first attempt to elicit public attitudes towards distributive criteria during a pandemic and, therefore, in a real context where the perception is that life and death decisions have to be made.

Variations in volume of emergency surgeries and emergency department access at a third level hospital in Milan, Lombardy, during the COVID-19 outbreak.

BACKGROUND: During the recent outbreak of COVID-19 (coronavirus disease 2019), Lombardy was the most affected region in Italy, with 87,000 patients and 15,876 deaths up to May 26, 2020. Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed. The aim of our study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy, and provide possible explanations for the observed phenomena. METHODS: This retrospective, observational study assessed the volume of emergency surgeries and attendance at an ED during the course of the pandemic, i.e. immediately before, during and after a progressive community lockdown in response to the COVID-19 pandemic. These data were compared with data from the same time periods in 2019. The results are presented as means, standard error (SE), and 95% studentized confidence intervals (CI). The Wilcoxon rank signed test at a 0.05 significance level was used to assess differences in per-day ED access distributions. RESULTS: Compared to 2019, a significant overall drop in emergency surgeries (60%, p < 0.002) and in ED admittance (66%, p ≅ 0) was observed in 2020. In particular, there were significant decreases in medical (40%), surgical (74%), specialist (ophthalmology, otolaryngology, traumatology, and urology) (92%), and psychiatric (60%) cases. ED admittance due to domestic violence (59%) and individuals who left the ED without being seen (76%) also decreased. Conversely, the number of deaths increased by 196%. CONCLUSIONS: During the COVID-19 outbreak the volume of urgent surgeries and patients accessing our ED dropped. Currently, it is not known if mortality of people who did not seek care increased during the pandemic. Further studies are needed to understand if such reductions during the COVID-19 pandemic will result in a rebound of patients left untreated or in unwanted consequences for population health.

Higher risk of death from COVID-19 in low-income and non-White populations of São Paulo, Brazil.

INTRODUCTION: Little evidence exists on the differential health effects of COVID-19 on disadvantaged population groups. Here we characterise the differential risk of hospitalisation and death in São Paulo state, Brazil, and show how vulnerability to COVID-19 is shaped by socioeconomic inequalities. METHODS: We conducted a cross-sectional study using hospitalised severe acute respiratory infections notified from March to August 2020 in the Sistema de Monitoramento Inteligente de São Paulo database. We examined the risk of hospitalisation and death by race and socioeconomic status using multiple data sets for individual-level and spatiotemporal analyses. We explained these inequalities according to differences in daily mobility from mobile phone data, teleworking behaviour and comorbidities. RESULTS: Throughout the study period, patients living in the 40% poorest areas were more likely to die when compared with patients living in the 5% wealthiest areas (OR: 1.60, 95% CI 1.48 to 1.74) and were more likely to be hospitalised between April and July 2020 (OR: 1.08, 95% CI 1.04 to 1.12). Black and Pardo individuals were more likely to be hospitalised when compared with White individuals (OR: 1.41, 95% CI 1.37 to 1.46; OR: 1.26, 95% CI 1.23 to 1.28, respectively), and were more likely to die (OR: 1.13, 95% CI 1.07 to 1.19; 1.07, 95% CI 1.04 to 1.10, respectively) between April and July 2020. Once hospitalised, patients treated in public hospitals were more likely to die than patients in private hospitals (OR: 1.40%, 95% CI 1.34% to 1.46%). Black individuals and those with low education attainment were more likely to have one or more comorbidities, respectively (OR: 1.29, 95% CI 1.19 to 1.39; 1.36, 95% CI 1.27 to 1.45). CONCLUSIONS: Low-income and Black and Pardo communities are more likely to die with COVID-19. This is associated with differential access to quality healthcare, ability to self-isolate and the higher prevalence of comorbidities.

Characteristics of a COVID-19 confirmed case series in primary care (COVID-19-PC project): a cross-sectional study.

BACKGROUND: To estimate the prevalence of symptoms and signs related to a COVID-19 case series confirmed by polymerase chain reaction (PCR) for SARS-CoV-2. Risk factors and the associated use of health services will also be analysed. METHODS: Observational, descriptive, retrospective case series study. The study was performed at two Primary Care Health Centres located in Madrid, Spain. The subjects studied were all PCR SARS-CoV-2 confirmed cases older than 18 years, diagnosed from the beginning of the community transmission (March 13) until April 15, 2020. We collected sociodemographic, clinical, health service utilization and clinical course variables during the following months. All data was gathered by their own attending physician, and electronic medical records were reviewed individually. STATISTICAL ANALYSIS: A descriptive analysis was carried out and a Poisson regression model was adjusted to study associated factors to Health Services use. RESULTS: Out of the 499 patients studied from two health centres, 55.1% were women and mean age was 58.2 (17.3). 25.1% were healthcare professionals. The most frequent symptoms recorded related to COVID-19 were cough (77.9%; CI 95% 46.5-93.4), fever (77.7%; CI95% 46.5-93.4) and dyspnoea (54.1%, CI95% 46.6-61.4). 60.7% were admitted to hospital. 64.5% first established contact with their primary care provider before going to the hospital, with a mean number of 11.4 Healthcare Providers Encounters with primary care during all the follow-up period. The number of visit-encounters with primary care was associated with being male [IRR 1.072 (1.013, 1.134)], disease severity {from mild respiratory infection [IRR 1.404 (1.095, 1.801)], up to bilateral pneumonia [IRR 1.852 (1.437,2.386)]}, and the need of a work leave [IRR 1.326 (1.244, 1.413]. CONCLUSION: Symptoms and risk factors in our case series are similar to those in other studies. There was a high number of patients with atypical unilateral or bilateral pneumonia. Care for COVID has required a high use of healthcare resources such as clinical encounters and work leaves.

Impact of the COVID-19 pandemic on the activity of the Radiological Emergency Department: the experience of the Maggiore della Carità Hospital in Novara.

PURPOSE: During the first peak of the COVID-19 pandemic, the activity of Emergency Departments worldwide changed dramatically, focusing on diagnosis and care of the Sars-Cov-2 associated disease. These major changes also involved the activity of the Emergency Radiology Department (ERD). This study aimed to analyse the impact of the COVID-19 pandemic on imaging studies, both in terms of the amount, frequency and subspecialty of different imaging modalities requested to the ERD of the Maggiore della Carità Hospital in Novara (Italy). METHODS: To this end, our observational study took into account the imaging studies requested by the emergency department during three-time spans. These were defined as phase 0 (pre-pandemic), phase 1 (pandemic peak with complete lockdown) and phase 2 (post-pandemic peak with partial lifting of restrictive measures), as derived from Italian urgent decrees by the President of the Council of Ministers (DPCM) which established the duration and entity of the lockdown measures throughout the pandemic. The dataset was processed and then compared with Pearson's chi-squared test. RESULTS: During the pandemic peak, our data showed a significant drop in the total number of studies requested and a significant rise in computed tomography (CT) studies. In particular, a statistically significant increase in chest CT studies was found, probably due to the high sensitivity of this imaging method in identifying pulmonary involvement during respiratory tract infection of possible viral etiology (SARS-Cov-2). Moreover, we observed a statistically significant decrease of X-ray (XR) and ultrasound (US) studies during phase 1 compared to phase 0 and phase 2 probably due to a reduction in the numbers of ER visits for minor traumas given the mobility restrictions and people hesitancy in visiting the ER due to fear of contagion. CONCLUSIONS: We can conclude that the activity of the ERD was heavily impacted by the SARS-Cov-2 pandemic. Further studies will be needed to estimate the impact of the pandemic on public health in terms of excess mortality related to delayed diagnosis and care of non-COVID diseases.