Latest COVID-19 studies identify predictors of poor outcomes, neurologic manifestations
Data from China provide new insights into disease characteristics, experts offer advice on caring for isolated older adults, and ACP and others release guidance on easing social distancing and other restrictions.
Two recent studies offered methods to predict severity of illness among patients with COVID-19.
The first study, published by CHEST on April 15, included 1,590 patients hospitalized with COVID-19 in China in January. It found a number of factors to be significantly associated with mortality: age 75 years or older (hazard ratio [HR], 7.86; 95% CI, 2.44 to 25.35), age between 65 and 74 years (HR, 3.43; 95% CI, 1.24 to 9.5), coronary heart disease (HR, 4.28; 95% CI, 1.14 to 16.13), cerebrovascular disease (HR, 3.1; 95% CI, 1.07 to 8.94), dyspnea (HR, 3.96; 95% CI, 1.42 to 11), procalcitonin level greater than 0.5 ng/mL (HR, 8.72; 95% CI, 3.42 to 22.28), and aspartate aminotransferase level greater than 40 U/L (HR, 2.2; 95% CI, 1.1 to 6.73). Based on these findings, the authors developed a nomogram to predict clinical outcomes of patients with COVID-19 based on their individual characteristics. “Earlier identification, more intensive surveillance and appropriate therapy should be considered in patients with high risk,” they concluded.
The other study, published by Clinical Infectious Diseases on April 16, included 372 patients who presented to three Chinese hospitals with COVID-19 but not severe illness. During follow-up of at least 15 days from admission, 19.35% of the patients developed severe disease. The study found that older age, lower albumin level, higher serum lactate dehydrogenase level, C-reactive protein level, coefficient of variation of red blood cell distribution width, blood urea nitrogen level, and direct bilirubin level were associated with severe COVID-19. Based on these factors, the authors created and validated a nomogram, which they believe could help clinicians risk-stratify patients and could “be helpful for alleviating insufficiency of medical resources and reducing mortality.”
Other recent research found that neurologic manifestations of COVID-19 are fairly common. A Chinese study published by JAMA Neurology on April 10 included 214 patients (41.1% with severe infection), of whom 78 (36.4%) had neurologic manifestations. Severity of infection was associated with greater likelihood of neurologic manifestations, including acute cerebrovascular diseases, impaired consciousness, and skeletal muscle injury. The authors noted that most neurologic manifestations occurred early in the illness course and in some cases were patients' only initial symptoms. “During the epidemic period of COVID-19, when seeing patients with neurologic manifestations, clinicians should suspect severe acute respiratory syndrome coronavirus 2 infection as a differential diagnosis to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission,” the study concluded. An accompanying editorial noted that some of the observed neurologic symptoms, such as headache, depressed level of consciousness, dizziness, and seizure, were nonspecific. “Whether these more nonspecific symptoms are manifestations of the disease itself or consistent with a systemic inflammatory response in patients who were quite ill will need to be defined in future studies,” the editorial said.
A Viewpoint on COVID-19, published by JAMA Internal Medicine on April 16, offered advice on providing care to older adults isolated at home during the pandemic. It pointed out a number of likely challenges, including fear of seeking health care and limited access to healthy food, exercise, and usual sources of support. In order to mitigate these problems, the article suggested that clinicians conducting virtual visits enlist the help of caregivers to familiarize patients with the technology in advance and make sure that patients are wearing their hearing aids during the visit. They should also consider creative solutions to the need for in-person care such as home health nursing evaluation, phlebotomy, or a house call. During visits, clinicians should inquire about unmet social or functional needs and offer solutions. Finally, it's important to recognize that procedures considered elective in younger patients may be urgent for older ones. “Although older adults living in the community are highly susceptible to death from COVID-19, their non–COVID-19 care should not be forgotten,” the authors concluded.
On April 17, ACP identified five necessary elements that need to be in place in order to safely ease restrictions related to COVID-19, noting that these are not currently ready in most communities. The five elements are widespread administration of a reliable method of testing for COVID-19; an approach to scale up contact tracing; sufficient workforce and supply capacity for testing, analysis, and follow-up; personal protective equipment (PPE) for every frontline physician, nurse, or other professional health care worker; and sufficient hospital, physician, and health system capacity to treat patients with the virus.
The same day, the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and the American Hospital Association issued a joint statement on requirements to resume elective surgeries, and on April 19, CMS issued guidance on resuming essential care to patients without symptoms of COVID-19 in regions with low and stable incidence of the virus.
ACP has continued to advocate for clinicians and patients' needs during the pandemic, including increased supply of personal protective equipment and regulatory relief and support for physician practices. Most recently, the College recommended additional emergency actions to CMS, including changes to the Medicare Accelerated and Advance Payment programs to decrease processing time and to extend the loan repayment timeframe. ACP has also called for pay parity to make telephone services equal to in-office visits, coverage of telehealth Medicare wellness visits, and additional changes to the direct supervision requirements for trainees. In addition, the College urged the administration to immediately restore funding to the World Health Organization and for Congress to take appropriate action to ensure continued funding.