Characterising the long-term clinical outcomes of 1190 hospitalised patients with COVID-19 in New York City: a retrospective case series

OBJECTIVE

To characterise the long-term outcomes of patients with COVID-19 admitted to a large New York City medical centre at 3 and 6 months after hospitalisation and describe their healthcare usage, symptoms, morbidity and mortality.

DESIGN

Retrospective cohort through manual chart review of the electronic medical record.

SETTING

NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical centre in New York City.

PARTICIPANTS

The first 1190 consecutive patients with symptoms of COVID-19 who presented to the hospital for care between 1 March and 8 April 2020 and tested positive for SARS-CoV-2 on reverse transcriptase PCR assay.

MAIN OUTCOME MEASURES

Type and frequency of follow-up encounters, self-reported symptoms, morbidity and mortality at 3 and 6 months after presentation, respectively; patient disposition information prior to admission, at discharge, and at 3 and 6 months after hospital presentation.

RESULTS

Of the 1190 reviewed patients, 929 survived their initial hospitalisation and 261 died. Among survivors, 570 had follow-up encounters (488 at 3 months and 364 at 6 months). An additional 33 patients died in the follow-up period. In the first 3 months after admission, most encounters were telehealth visits (59%). Cardiopulmonary symptoms (35.7% and 28%), especially dyspnoea (22.1% and 15.9%), were the most common reported symptoms at 3-month and 6-month encounters, respectively. Additionally, a large number of patients reported generalised (26.4%) or neuropsychiatric (24.2%) symptoms 6 months after hospitalisation. Patients with severe COVID-19 were more likely to have reduced mobility, reduced independence or a new dialysis requirement in the 6 months after hospitalisation.

CONCLUSIONS

Patients hospitalised with SARS-CoV-2 infection reported persistent symptoms up to 6 months after diagnosis. These results highlight the long-term morbidity of COVID-19 and its burden on patients and healthcare resources.

Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series

OBJECTIVE

To characterize patients with coronavirus disease 2019 (covid-19) in a large New York City medical center and describe their clinical course across the emergency department, hospital wards, and intensive care units.

DESIGN

Retrospective manual medical record review.

SETTING

NewYork-Presbyterian/Columbia University Irving Medical Center, a quaternary care academic medical center in New York City.

PARTICIPANTS

The first 1000 consecutive patients with a positive result on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who presented to the emergency department or were admitted to hospital between 1 March and 5 April 2020. Patient data were manually abstracted from electronic medical records.

MAIN OUTCOME MEASURES

Characterization of patients, including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition.

RESULTS

Of the first 1000 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 (732/1000), fever (728/1000), and dyspnea (631/1000). 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.

CONCLUSIONS

Patients admitted to hospital with covid-19 at this medical center faced major morbidity and mortality, with high rates of acute kidney injury and inpatient dialysis, prolonged intubations, and a bimodal distribution of time to intubation from symptom onset.

Characterization and clinical course of 1000 patients with COVID-19 in New York: retrospective case series

Objective

To characterize patients with coronavirus disease 2019 (COVID-19) in a large New York City (NYC) medical center and describe their clinical course across the emergency department (ED), inpatient wards, and intensive care units (ICUs).

Design

Retrospective manual medical record review.

Setting

NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), a quaternary care academic medical center in NYC.

Participants

The first 1000 consecutive patients with laboratory-confirmed COVID-19.

Methods

We identified the first 1000 consecutive patients with a positive RT-SARS-CoV-2 PCR test who first presented to the ED or were hospitalized at NYP/CUIMC between March 1 and April 5, 2020. Patient data was manually abstracted from the electronic medical record.

Main outcome measures

We describe patient characteristics including demographics, presenting symptoms, comorbidities on presentation, hospital course, time to intubation, complications, mortality, and disposition.

Results

Among the first 1000 patients, 150 were ED patients, 614 were admitted without requiring ICU-level care, and 236 were admitted or transferred to the ICU. The most common presenting symptoms were cough (73.2%), fever (72.8%), and dyspnea (63.1%). Hospitalized patients, and ICU patients in particular, most commonly had baseline comorbidities including of hypertension, diabetes, and obesity. ICU patients were older, predominantly male (66.9%), and long lengths of stay (median 23 days; IQR 12 to 32 days); 78.0% developed AKI and 35.2% required dialysis. Notably, for patients who required mechanical ventilation, only 4.4% were first intubated more than 14 days after symptom onset. Time to intubation from symptom onset had a bimodal distribution, with modes at 3-4 and 9 days. As of April 30, 90 patients remained hospitalized and 211 had died in the hospital.

Conclusions

Hospitalized patients with COVID-19 illness at this medical center faced significant morbidity and mortality, with high rates of AKI, dialysis, and a bimodal distribution in time to intubation from symptom onset.

A model for focal seizure onset, propagation, evolution, and progression

We developed a neural network model that can account for major elements common to human focal seizures. These include the tonic-clonic transition, slow advance of clinical semiology and corresponding seizure territory expansion, widespread EEG synchronization, and slowing of the ictal rhythm as the seizure approaches termination. These were reproduced by incorporating usage-dependent exhaustion of inhibition in an adaptive neural network that receives global feedback inhibition in addition to local recurrent projections. Our model proposes mechanisms that may underline common EEG seizure onset patterns and status epilepticus, and postulates a role for synaptic plasticity in the emergence of epileptic foci. Complex patterns of seizure activity and bi-stable seizure end-points arise when stochastic noise is included. With the rapid advancement of clinical and experimental tools, we believe that this model can provide a roadmap and potentially an in silico testbed for future explorations of seizure mechanisms and clinical therapies.

Predicting cancer cell invasion by single-cell physical phenotyping

The physical properties of cells are promising biomarkers for cancer diagnosis and prognosis. Here we determine the physical phenotypes that best distinguish human cancer cell lines, and their relationship to cell invasion. We use the high throughput, single-cell microfluidic method, quantitative deformability cytometry (q-DC), to measure six physical phenotypes including elastic modulus, cell fluidity, transit time, entry time, cell size, and maximum strain at rates of 102 cells per second. By training a k-nearest neighbor machine learning algorithm, we demonstrate that multiparameter analysis of physical phenotypes enhances the accuracy of classifying cancer cell lines compared to single parameters alone. We also discover a set of four physical phenotypes that predict invasion; using these four parameters, we generate the physical phenotype model of invasion by training a multiple linear regression model with experimental data from a set of human ovarian cancer cells that overexpress a panel of tumor suppressor microRNAs. We validate the model by predicting invasion based on measured physical phenotypes of breast and ovarian human cancer cell lines that are subject to genetic or pharmacologic perturbations. Taken together, our results highlight how physical phenotypes of single cells provide a biomarker to predict the invasion of cancer cells.

The physical origins of transit time measurements for rapid, single cell mechanotyping

The mechanical phenotype or 'mechanotype' of cells is emerging as a potential biomarker for cell types ranging from pluripotent stem cells to cancer cells. Using a microfluidic device, cell mechanotype can be rapidly analyzed by measuring the time required for cells to deform as they flow through constricted channels. While cells typically exhibit deformation timescales, or transit times, on the order of milliseconds to tens of seconds, transit times can span several orders of magnitude and vary from day to day within a population of single cells; this makes it challenging to characterize different cell samples based on transit time data. Here we investigate how variability in transit time measurements depends on both experimental factors and heterogeneity in physical properties across a population of single cells. We find that simultaneous transit events that occur across neighboring constrictions can alter transit time, but only significantly when more than 65% of channels in the parallel array are occluded. Variability in transit time measurements is also affected by the age of the device following plasma treatment, which could be attributed to changes in channel surface properties. We additionally investigate the role of variability in cell physical properties. Transit time depends on cell size; by binning transit time data for cells of similar diameters, we reduce measurement variability by 20%. To gain further insight into the effects of cell-to-cell differences in physical properties, we fabricate a panel of gel particles and oil droplets with tunable mechanical properties. We demonstrate that particles with homogeneous composition exhibit a marked reduction in transit time variability, suggesting that the width of transit time distributions reflects the degree of heterogeneity in subcellular structure and mechanical properties within a cell population. Our results also provide fundamental insight into the physical underpinnings of transit measurements: transit time depends strongly on particle elastic modulus, and weakly on viscosity and surface tension. Based on our findings, we present a comprehensive methodology for designing, analyzing, and reducing variability in transit time measurements; this should facilitate broader implementation of transit experiments for rapid mechanical phenotyping in basic research and clinical settings.

A field study conducted at Kidston Gold Mine, to evaluate the impact of arsenic and zinc from mine tailing to grazing cattle

The grazing trial at Kidston Gold Mine, North Queensland, was aimed specifically to assess the uptake of metals from the tailing and the potential for unacceptable contamination of saleable meat. Further aims included estimating metal dose rates and identifying potential exposure pathways including plant uptake of heavy metals, mine tailings adhered to plants and direct ingestion of mine tailing. It was found that of the 11 metals analysed (As, Zn, Co, Cd, Cr, Sn, Pb, Sb, Hg, Se and Ni) in the animal's liver, muscle and blood during the 8-month trial period, only accumulation of arsenic and zinc occurred. A risk assessment including these two metals was conducted to determine the potential for chronic metal toxicity and long-term contamination, using the estimates of metal dose rate. It was concluded that no toxicity or long-term contamination in cattle was likely at this site. Management procedures were therefore not required at this site; however, the results highlight percent ground cover and standing dry matter (DM) as important factors in decreasing metal exposure from direct ingestion of tailings and dust adhered to plants.

Cubital tunnel syndrome in a collegiate wrestler: a case report

OBJECTIVE

The authors present a case study involving a 21-year-old male collegiate wrestler diagnosed with cubital tunnel syndrome.

BACKGROUND

Cubital tunnel syndrome is a condition brought on by an increase in the pressure exerted upon the ulnar nerve at the elbow within the cubital tunnel. The wrestler was diagnosed with cubital tunnel syndrome after 6 weeks of increasing disability and dysfunction.

DIFFERENTIAL DIAGNOSIS

Ulnar nerve contusion, ulnar nerve neuritis, cubital tunnel syndrome, thoracic outlet syndrome, C8 nerve root entrapment, double-crush syndrome, tumor.

TREATMENT

The subject was treated conservatively for 3 months without resolution of the symptoms. Surgical treatment then involved a subcutaneous ulnar nerve transposition performed to decompress the cubital tunnel. Following surgery, the athlete participated in an aggressive rehabilitation program to restore function and strength to the elbow and adjacent joints. He was cleared for full unrestricted activity 15 days following surgery and returned to varsity athletic competition in 1 month.

UNIQUENESS

Our literature review found no reported cases of cubital tunnel syndrome in wrestlers. Cubital tunnel syndrome is usually seen in throwing athletes and results from either acute trauma or repetitive activities.

CONCLUSION

The athletic trainer should consider cubital tunnel syndrome as a possible pathology for nonthrowing athletes when presented with associated signs and symptoms.

The effect of a coronary artery risk evaluation program on serum lipid values and cardiovascular risk levels

In this study, serum lipid and cardiovascular risk levels of 195 military men and women were measured immediately before and 6 months after participation in a coronary artery risk evaluation (C.A.R.E.) program. Mean total cholesterol levels decreased from 257 mg/dl to 223 mg/dl (t(194) = -16.76, p = 0.00), low-density lipoprotein levels decreased from 170 mg/dl to 141 mg/dl (t(194) = -15.22, p = 0.00), and high-density lipoprotein levels increased from 45 mg/dl to 48 mg/dl (t(194) = 3.27, p = 0.01). Cardiovascular risk categories (based on serum lipid levels) were lowered from high to moderate risk in 54 subjects, high to low risk in 19 subjects, and moderate to low risk in 31 subjects (chi 2 = 98.28, p = 0.00). This study demonstrates that health education programs such as the C.A.R.E. Program can have a significant impact on serum lipid levels and cardiovascular risk levels and can potentially improve the health of high-risk populations.

Aspects of FHR tracings as warning signals

We have reviewed several different groups of common clinical problems with an eye toward their effects on FHR tracings. Although argument exists in the literature concerning the universal applicability of continuous EFM, most authors agree that continuous EFM is desirable, if not imperative, within these subgroups. Schifrin said, "It appears that potential benefits accrue when EFM and scalp sampling are employed with understanding and adequate training." With appropriate training, EFM and pH analysis can help the clinician to quickly and accurately assess fetal condition and to make necessary decisions regarding labor and delivery. The interpretation of fetal monitoring patterns necessitates consideration of gestational age and maternal condition as a starting point in analysis. The many other components of fetal-maternal interactions that occur with labor and delivery can be assessed satisfactorily only in this light.

Intrapartum monitoring and management of the postdate fetus

Postdate pregnancy presents a difficult problem in both the antepartum and intrapartum periods. Because of the various complications associated with prolonged gestation, the following precautions should be taken during intrapartum monitoring and delivery: 1. Strict criteria must be established for elective induction should it be needed. Elective induction should be limited to those postdate patients with inducible cervices. 2. Extensive intrapartum fetal heart rate and uterine activity monitoring should be done on all patients. Physicians should be alert and ready for intervention and for any possible abnormal finding. Fetal biochemical assessment should be done liberally, especially when meconium is passed. 3. For patients with thick meconium passage, close intrapartum surveillance should be done by both biophysical and biochemical means. During delivery, attention should be given to minimizing the possibility of meconium aspiration. Good neonatal resuscitation is essential. 4. When the estimated fetal weight is 4500 gm or greater, the possibility of shoulder dystocia should be considered. Unless the patient's previous obstetric history or the progress of labor suggests a possible successful vaginal delivery, cesarean section should be considered.

Control of postpartum uterine atony by intramyometrial prostaglandin

Five patients with severe postpartum hemorrhage due to uterine atony and unresponsive to oxytocin, ergonovine, and massage were treated with intramyometrial injection of 250 micrograms of prostaglandin (15S)-15-methyl PGF2 alpha-Tham. Four patients received 2 injections (500 micrograms), and 1 patient required 1 injection (250 micrograms). Three (60%) of 5 patients responded successfully with an increase in uterine tone and cessation of uterine hemorrhage, thus obviating the need for hysterectomy. Two patients had no uterine response, possibly because of delayed use of the drug, excessive blood loss, and accompanying shock; they required hysterectomy. Intramyometrial injection of prostaglandin is an effective and safe method of managing severe postpartum hemorrhage unresponsive to oxytocin and ergonovine, but it must be used early during the management of atony to obtain maximum effect. This method should precede surgical management of uterine atony.

Response of ovine uterine blood flow to angiotensin II: effect on the fetus

The effect of intravenous infusion of angiotensin II (2 to 200 ng/kg/min) on uterine blood flow and cardiovascular performance was studied in the normotensive, unanesthetized pregnant ewe. With low rates of infusion (2 to 4 ng/kg/min), only a transient increase in uterine blood flow, lasting 1 to 3 minutes, was observed. Higher rates (110 to 200 ng/kg/min) of infusion caused a decrease in uterine blood flow; this decrease was significantly correlated to the dose. Angiotensin II also caused a significant decrease in the maternal heart rate and an increase in mean maternal arterial blood pressure as the rate of infusion was increased. A high rate of infusion resulted in decreased fetal heart rate and PaO2, probably due to a marked reduction in uteroplacental blood flow.

Toxicity of lidocaine in adult, newborn, and fetal sheep

The relative central nervous system and cardiovascular toxicity of lidocaine was compared in adult, newborn, and fetal sheep during continuous infusion of lidocaine into the jugular vein at the rate of 2 mg x kg-1 x min-1. An identical sequence of toxic manifestations occurred in the adult, newborn, and fetus: convulsions, hypotension, respiratory arrest, and circulatory collapse. Doses necessary to produce these manifestations were highest in fetuses and lowest in adults. For example, in order to elicit convulsions, 5.8 +/- 1.8 mg/kg of lidocaine was required in the adults, 18.4 +/- 2.2 in the newborns, and 41.9 +/- 6.0 in the fetuses. Measurements of lidocaine concentrations in blood demonstrated that these toxic symptoms occurred at levels which were not significantly different among the three groups. The results indicate that fetal and newborn lambs are no more sensitive to lidocaine toxicity than are adult sheep. The fact that the highest doses were required in the fetuses is probably related to the placental clearance of the drug into mothers and better fetal maintenance of arterial Po2 despite convulsions and respiratory arrest (cessation of breathing-like movements).

The suspicious contraction stress test

From a clinical service using the contraction stress test as an evaluator of fetal well-being, a 37-month review of the significance of the suspicious contraction stress test was performed. There were no antepartum losses in a group of 107 patients whose initial test was suspicious. Following each testing a number of patients delivered spontaneously or were delivered for other reasons. Results in 5 of 67 patients at the second testing changed from a suspicious to a positive test, 36 became negative, and 26 remained suspicious. There were no further conversions to a positive test after the second testing. There is a strong correlation between the loss of fetal heart reactivity and the repeated suspicious contraction stress test. The chief value of the suspicious test is as a marker in the high-risk pregnancy appraisal for consideration of additional fetal and maternal evaluation and possible clinical management alteration.