(With inputs from Dr Monica Vasudev)

868: Even serious can recover: A WUHAN study found that survivors recovered after an array of complications: 42% had sepsis, 36% had respiratory failure, 12% had heart failure, and 7% had blood clotting problems.

869: Which doctors are at risk: A survey data reveal that among all resident physicians who worked within the greater New York City area from March to April, anesthesiology, emergency medicine, and ophthalmology residents appeared to be at greatest risk of contracting COVID-19.

870:  Children recover more from serious illnesses: A North American case series of children with COVID-19 suggests that the clinical course is typically less severe and the hospital outcomes better in critically ill children as compared to adults. Overall ICU mortality at the end of follow-up period was less than 5% compared to published mortalities of 50% to 62% in adults admitted to the ICU," Dr. Lara Shekerdemian of Texas Childrens Hospital, in Houston, and colleagues wrote in JAMA Pediatrics.

871: Preventing sudden deaths in athletes: In order to prevent cardiac injury, athletes should rest for at least 2 weeks after resolution of symptoms, and should then be subjected to cardiac testing before resuming high-level competitive sports, reported lead author Dermot Phelan, MD, PhD, of Atrium Health in Charlotte, N.C., and colleagues in JAMA Cardiology.

872: Time of serious illness: Severe illness usually begins approximately 1 week following the onset of symptoms, with dyspnea being the most common symptom of severe disease, often accompanied by hypoxemia.

873: A striking feature of COVID-19 is the rapid progression of respiratory failure soon after the onset of dyspnea and hypoxemia. Patients with severe COVID-19 often meet the criteria for acute respiratory distress syndrome (ARDS), which is characterized as the acute onset of bilateral infiltrates, severe hypoxemia, and lung edema not fully explained by cardiac failure or fluid overload.

874: Blood markers: A vast number of patients with severe COVID-19 have lymphopenia, and some have disorders of the central or peripheral nervous system.

875: Severe COVID-19 may also cause acute cardiac, kidney, and liver injury, besides cardiac arrhythmias, rhabdomyolysis, coagulopathy, and shock. Organ failures may be associated with a cytokine release syndrome that is marked by high fevers, thrombocytopenia, hyperferritinemia, and rise in other inflammatory markers.

876: Preliminary data from a randomized, placebo-controlled trial involving patients with severe COVID-19 suggest that the investigational antiviral remdesivir can potentially reduce the time to recovery.

877: Definition: Severe COVID-19 in adults is defined as dyspnea, a respiratory rate of >30 breaths per minute, a blood oxygen saturation of <93%, a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2:FIO2) of <300 mm Hg, or infiltrates in more than 50% of the lung field within 24 to 48 hours from the onset of symptoms.

878: Occurrence: In a large cohort of patients with COVID-19, 81% had mild disease, 14% had severe disease, and 5% were critically ill with organ failure; the mortality in the critically ill group was 49%. The majority of critically ill patients receive prolonged mechanical ventilation.

879: Who suffers more: People with chronic health conditions, including cardiovascular disease, diabetes mellitus, and obesity are more likely to become critically ill from COVID-19. The incidence of critical illness is also higher among men compared to women and higher among persons above 65 years than among younger persons.

880: Hall mark: The sudden appearance of an unprecedented number of critically ill patients in a small geographic area represents a hallmark of the COVID-19 pandemic.

881: Consent: As early as possible, clinicians should partner with patients by reviewing advanced directives, identifying surrogate medical decision makers, and establishing appropriate goals of care. Infection-control measures during the pandemic may not allow families to visit seriously ill patients; therefore, care teams should develop plans to communicate with patients’ families and surrogate decision makers.

882: Risk factors for severe illness: Severe illness can occur in otherwise healthy individuals of any age, but it more commonly occurs in adults with advanced age or underlying medical comorbidities.

Comorbidities and other conditions that have been associated with severe illness and mortality:

• Cardiovascular disease
• Diabetes mellitus
• Hypertension
• Chronic lung disease
• Cancer (in particular hematologic malignancies, lung cancer, and metastatic disease)
• Chronic kidney disease
• Obesity
• Smoking

The United States Centers for Disease Control and Prevention (CDC) also includes immunocompromising conditions and liver disease as potential risk factors for severe illness.

883: In a subset of 355 patients who died with COVID-19 in Italy, the mean number of pre-existing comorbidities was 2.7, and only 3 patients were found to have no underlying condition.

884: Age: Among patients with advanced age and comorbidities, COVID-19 is often severe. For instance, in a SARS-CoV-2 outbreak across several long-term care facilities in Washington State, the median age of the facility residents affected was 83 years. About 94% of these had a chronic underlying condition; the hospitalization and preliminary case fatality rates were 55% and 34%, respectively.

885: Males constitute a disproportionately high number of deaths in cohorts from China, Italy, and the United States.

886: Certain laboratory features have also been associated with worse outcomes:

• Lymphopenia
• Raised liver enzymes
• Raised lactate dehydrogenase (LDH)
• Raised inflammatory markers (eg, C-reactive protein [CRP], ferritin)
• Raised D-dimer (>1 mcg/mL)
• Raised prothrombin time (PT)
• Raised troponin
• Raised creatine phosphokinase (CPK)
• Acute kidney injury.

Progressive decline in the lymphocyte count and rise in the D-dimer over time have been noted in nonsurvivors compared with more stable levels in survivors.

886: Viral load:  Patients with severe disease have been found to have higher viral RNA levels in respiratory specimens compared to those with milder disease.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA