Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study

Seroprevalence of SARS-CoV-2 antibodies in children: a prospective multicentre cohort study

BACKGROUND

Studies based on molecular testing of oral/nasal swabs underestimate SARS-CoV-2 infection due to issues with test sensitivity, test timing and selection bias. The objective of this study was to report the presence of SARS-CoV-2 antibodies, consistent with previous infection.

DESIGN

This multicentre observational cohort study, conducted between 16 April to 3 July 2020 at 5 UK sites, recruited children of healthcare workers, aged 2-15 years. Participants provided blood samples for SARS-CoV-2 antibody testing and data were gathered regarding unwell contacts and symptoms.

RESULTS

1007 participants were enrolled, and 992 were included in the final analysis. The median age of participants was 10·1 years. There were 68 (6.9%) participants with positive SARS-CoV-2 antibody tests indicative of previous SARS-CoV-2 infection. Of these, 34/68 (50%) reported no symptoms prior to testing. The presence of antibodies and the mean antibody titre was not influenced by age. Following multivariable analysis four independent variables were identified as significantly associated with SARS-CoV-2 seropositivity: known infected household contact OR=10.9 (95% CI 6.1 to 19.6); fatigue OR=16.8 (95% CI 5.5 to 51.9); gastrointestinal symptoms OR=6.6 (95% CI 3.0 to 13.8); and changes in sense of smell or taste OR=10.0 (95% CI 2.4 to 11.4).

DISCUSSION

Children demonstrated similar antibody titres in response to SARS-CoV-2 irrespective of age. Fatigue, gastrointestinal symptoms and changes in sense of smell or taste were the symptoms most strongly associated with SARS-CoV-2 antibody positivity.

TRIAL REGISTRATION NUMBER

NCT0434740.

Updates on the coronavirus disease 2019 vaccine and consideration in children

Humanity has been suffering from the global severe acute respiratory syndrome coronavirus 2 pandemic that began late in 2019. In 2020, for the first time in history, new vaccine platforms-including mRNA vaccines and viral vector-based DNA vaccines-have been given emergency use authorization, leading to mass vaccinations. The purpose of this article is to review the currently most widely used coronavirus disease 2019 vaccines, investigate their immunogenicity and efficacy data, and analyze the vaccine safety profiles that have been published, to date.

Clinical features and follow-up of pediatric patients hospitalized for COVID-19

OBJECTIVE

This report summarizes the clinical features and 1-month follow-up observations for pediatric patients who were hospitalized with coronavirus disease 2019 (COVID-19) in Wuhan Women and Children's Hospital.

METHODS

The 1-month follow-up data included clinical manifestations and results from serum severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG and IgM tests, reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2, lung computed tomography (CT) scans, and laboratory tests.

RESULTS

Between January 20 and March 15, 2020, 127 patients aged 0-15 years were hospitalized for COVID-19 treatment, including 3 severe cases and 124 mild or moderate cases. The main therapies included inhalation of aerosolized interferon-α (122/127) and additional antiviral drugs (28/127). Among the 81 patients who had pneumonia at admission, 35 with right lobe pneumonia had the longest hospital stay (mean 14.5 ± 7 days); 17 with left lobe pneumonia had the highest creatine kinase (154 ± 106 U/L) and creatine kinase myocardial band  (CK-MB, 43 ± 48 U/L) levels; and 29 with bilateral pneumonia had the highest white blood cell counts (8.3 ± 4 × 109 /L). Among the 46 patients who were successfully followed up 1 month after discharge, two notable findings were right lobe pneumonia in 22% (95% confidence interval [CI]: 11%-37%) of patients and persistently elevated serum creatine kinase and CK-MB levels. The median duration of elevated CK-MB was 45 days. The mean concentrations of serum SARS-CoV-2 IgG and IgM in 41 patients were 8.0 ± 7.5 and 98 ± 40 ng/ml, respectively. At follow-up, four patients retested positive for SARS-CoV-2.

CONCLUSIONS

The involvement of different lung lobes in patients with COVID-19 was associated with variations in the persistence of pneumonia and elevation of CK-MB levels and body temperature.

COVID-19 in Turkey: A tertiary center experience

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused a serious epidemic in our country and all over the world since December 2019 and has become a global health problem. The disease caused by the SARS-CoV-2 virus has been named as coronavirus disease 19 (COVID-19).

METHODS

We report on the epidemiological and clinical features of 37 children diagnosed with COVID-19.

RESULTS

The median age was of the children was 10 years and 57.1% were male. In addition, 78.3% of the children had a history of contact with adult patients who had been diagnosed with COVID-19, and 27.0% had coexisting medical conditions. We found that 40.5% of our patients had mild infection, while 32.4% had moderate infection, and 27.1% had developed severe or critical illness. The most common abnormal laboratory findings in our patients were decreased lymphocytes (45.9%) and increased D-dimer values (43.2%), while abnormal radiological findings were detected in 56.7% of the children. In addition, 64.8% of the children had received azithromycin, 59.4% had received oseltamivir, and hydroxychloroquine was used in combination with azithromycin in 35.1% of the children. Non-invasive mechanical ventilation was required in 27.0% of the children.

CONCLUSIONS

Although COVID-19 infection is usually mild in children, severe illness can be seen in children with comorbidities, or even in children who were previously healthy.

COVID-19 infection in children with underlying malignancies in Iran

OBJECTIVES

Although coronavirus disease 2019 (COVID-19) prognosis is mostly good in pediatric patients with no underlying diseases, there are a few reports on children with oncological underlying malignancies. This study aimed to describe the clinical and laboratory features of 20 children with COVID-19 who had underlying malignancies in an Iranian referral pediatrics hospital.

METHODS

All children under 15-year-old of age with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive real-time polymerase chain reaction (PCR) and presence of an underlying malignancy were included in the study.

RESULTS

In this study, among 20 patients, 11 were male (55%). The mean age of the patients was 6.0 ± 4.1 years. Twelve patients (60%) had acute lymphocytic leukemia, two had acute myeloid leukemia (10%), and six had solid organ tumors (30%). The most common symptoms were fever (65%) and cough (65%). We reported severe pneumonia in seven hospitalized patients (35%) and three patients (20%) required intensive care unit admission and mechanical ventilation. Procalcitonin was normal in 73% of the cases (11 out of 15), but it was highly elevated in four cases (27%). Five patients (25%) had positive blood cultures and a mortality of 20% was reported.

CONCLUSIONS

This is the largest study on SARS-CoV-2 infected pediatric patients with underlying malignancies in Iran. Since the risk of exposure to SARS-CoV-2 and even death in children with malignancy, either in the hospital or community setting during the pandemic is high, special precautions to reduce the risk of transmission are highly suggested.

Demographic and Clinical Characteristics of COVID-19 in Children and the Effect of Household Tobacco Smoke Exposure on COVID-19

OBJECTIVE

Environmental tobacco smoke (ETS) exposure is associated with many diseases, including lower respiratory tract infections, in pediatric age groups. In this study, we aimed to assess the effect of household ETS exposure on symptom frequency and clinical severity in children and adolescents with COVID-19.

MATERIALS AND METHODS

This retrospective study included pediatric cases (<18 years old) with a positive SARS-CoV-2 test, who were admitted to our hospital between 20.03.2020 and 01.05.2020. Patients with respiratory diseases and active smokers were excluded. Demographic characteristics, symptoms, and clinical severity of COVID-19 were obtained from parents and children using a questionnaire and from patients' files. Household ETS exposure was assessed by questionnaire.

RESULTS

A total of 167 patients (median age 145 months, 50.7 % male) were included in the study. The frequency of household ETS exposure was 50.9%, and the frequency of cough was significantly higher in exposed children than non-exposed children (71.4% vs 50.8% respectively, p=0.02). The frequency of both fever and cough was significantly higher ETS-exposed in the subgroup of cases with a mild clinical course (69.5% vs 48.1% respectively, p= 0.02 for fever and 67.8% vs 44.4% respectively, p=0.01 for cough). There was no relationship between clinical severity and household ETS exposure.

CONCLUSION

Household ETS exposure may impact COVID-19 pediatric cases as demonstrated by the increased frequency of cough and fever in ETS-exposed children. As new lockdown measures are implemented, increasing public awareness about the effect of household ETS exposure on COVID-19as well as encouraging a decrease in ETS exposure are essential.

Clinical profiles associated with SARS-CoV-2 infection and complications from coronavirus disease-2019 in children from a national registry in Saudi Arabia

CONTEXT

Exploring clinical characteristics of coronavirus disease-19 (COVID-19) in children may help in prevention and treatment guidelines.

AIMS

The aim of the to describe the spectrum of pediatric COVID-19 in Saudi Arabia.

SETTINGS AND DESIGN

A multicenter, retrospective, cross-sectional study involving pediatric COVID-19 patients across all Saudi regions.

METHODS

All patients aged between 2 months and 18 years with a confirmed diagnosis of COVID-19 were included. The primary end point was the hospitalization.

STATISTICAL ANALYSIS USED

Descriptive statistics were used to describe the baseline demographic data and clinical characteristics. Numerical data were explored using Kolmogorov-Smirnov test and Shapiro-Wilk test, while Chi-square or Fisher's exact test were used for categorical data.

RESULTS

Among the 654 pediatric COVID-19 patients, 4.7% (n = 31) were hospitalized, with one patient only needing pediatric intensive care admission. Sex, breastfeeding, birth status, and the patients' living environment showed no significant association with hospitalization. Most children (80.3%, n = 525) were symptomatic, with two symptoms that were significantly associated with admission, namely, vomiting (P = 0.007) and nausea (P = 0.026). History of admission within the last year was identified in 10.4% (n = 68) children but had no association with worse outcome. The median duration of hospitalization for the entire group was 5.5 days, with longest hospital stay for age group 7-12 years (median 6 days).

CONCLUSIONS

COVID-19 is usually a milder disease in children. Although having preexisting medical conditions was linked to a longer hospitalization, it was not associated with worse outcome. Continuous surveillance will allow additional characterization of the burden and outcomes of pediatric COVID-19-associated hospitalizations.

SARS-CoV-2 Infection: Differences in Hematological Parameters Between Adults and Children

Since December 2019, corona virus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic, posing a huge threat to human health, and the current epidemic prevention situation is still severe. Hematological parameters directly reflect the damage of SARS-CoV-2 to human blood cells, which can better assess the severity and prognosis of patients infected with COVID-19, but hematological parameters have some differences between adults and children. This article comprehensively reviews the differences in hematological parameters between adults and children after SARS-CoV-2 infection, and provides a reference for the diagnosis and treatment of COVID-19.

Clinical Spectrum of Children With Multisystem Inflammatory Syndrome Associated With SARS-CoV-2 Infection

Objectives

To compare the clinical profile, treatment, and outcomes of PCR-positive and PCR-negative antibody-positive critically ill children with multisystem inflammatory syndrome (MIS-C).

Methods

This retrospective observational study was done at a tertiary care coronavirus disease 19 (COVID-19) pediatric intensive care unit in India. The baseline characteristics, clinical profile, treatment, and outcomes in seventeen critically ill children diagnosed with MIS-C were analyzed from 1 July to 31 October, 2020.

Results

Sixteen out of 17 children presented with hypotensive shock and respiratory distress. Mean (SD) age of PCR-negative antibody-positive and PCR-positive children was 11 (4.4) and 5 (3.7) years, respectively (P=0.007). The former group had significantly higher mean (SD) D-dimer levels [16,651 (14859) ng/mL vs 3082 (2591) ng/mL; P=0.02]. All received intensive care management and steroid therapy; 7 children received intravenous immunoglobulin. 14 children survived and 3 died.

Conclusions

The outcome of children with MIS-C was good if recognized early and received intensive care.

COVID-19 related stigma and health-protective behaviours among adolescents in the Netherlands: An explorative study

The COVID-19 pandemic has forced many governments to impose social distancing measures upon its citizens, including in the Netherlands. Motivating adolescents to adhere to measures such as social distancing can be challenging, since adolescents are relatively more affected by them, while experiencing virtually no personal health benefit. In addition, the COVID-19 pandemic seems to impact the social environment of adolescents in schools, as some media sources have reported bullying and stigmatisation of students with an Asian appearance. This study aims to explore the experiences of adolescents regarding their Health-Protective Behaviour (HPB), as well as the prevalence and expression of stigma towards ethnic minorities within the context of the first wave of COVID-19 pandemic. We performed a cross-sectional mixed-methods study, including two independent online questionnaires. An adapted version of the "HPB" questionnaire (n = 528) and the "Measure of Disease-Related Stigma (MDRS)" questionnaire (n = 380), were administered to Dutch adolescents of 10-16 years old, attending primary or secondary school. Furthermore, 15 interviews were held with eight male and seven female adolescents. All data collection took place between March 17 and April 20, 2020. Results show that adolescents perceive COVID-19 as a threat to other peoples' health, rather than their own, and report adherence to public health measures in the interest of older and more vulnerable members of their community. We found no convincing evidence for widespread misinformation or stigmatising of certain ethnic groups among adolescents related to COVID-19 during this study. Participants acknowledged such behaviour happened in the early stages of the pandemic, before this study was initiated. Adolescents are a vital group for public health researchers to engage with during a pandemic, even when reaching them can be challenging.

SARS-CoV-2-related Multisystem Inflammatory Syndrome in Children: A case series

On 27 April 2020, the National Health Service England issued an emergency alert for a new condition owing to the observation of an increasing number of cases of a COVID-19-related hyperinflammatory syndrome termed multisystem inflammatory syndrome in children (MIS-C). Some of the presenting symptoms appeared similar to the Kawasaki disease and toxic shock syndrome. We report the cases of six children fitting the criteria of MIS-C, admitted to Royal Hospital and Sohar Hospital, Oman, between the months of June and July in 2020. Four of these patients required admission at the paediatric intensive care unit for inotropic support while two were admitted to the paediatric ward on suspicion of appendicitis. MIS-C has been reported in a small number of individuals below the age of 21 years with a median age of 9–10 years. Five of the current patients were aged less than the median age reported in the existing literature. All of the patients showed complete recovery with supportive management, intravenous immunoglobulin and steroids, with one patient requiring interleukin-6 inhibitor (tocilizumab).

A Case of COVID-19-Related Thrombocytopenia and Leukopenia in an Adolescent with Mild Symptoms

Since the beginning of the COVID-19 pandemic, there have been numerous reports and reviews on the complications caused by the disease, analyzing the acute and chronic consequences. The main symptoms of SARS-CoV-2 are dry cough, fever, and fatigue. COVID-19 appears to affect all systems, including renal, cardiovascular, circulatory, and respiratory systems, causing chronic obstructive pulmonary disease. We report on a 14-year-old male adolescent, who presented with thrombocytopenia (platelet count 92 × 10⁹ /L) and leukopenia (white blood count 4.2 × 10³ /μL) that was observed two months ago. Ten days before the first blood test, a viral infection with nasal congestion and runny nose was reported, without other accompanying symptoms. Viral antibodies screening revealed positivity for all the three specific COVID-19 antibodies. Further haematological evaluation with bone marrow aspiration revealed non-specific dysplastic features of the red cell and megakaryocyte progenitors. Although haematological alterations due to COVID-19 infection are available from adult patients’ reports, the effect of COVID-19 infection in the pediatric population is underestimated and this is the first case with such haematological involvement. Noteworthy, in the current case, the impact of the COVID-19 infection was not related to the severity of the disease, as the symptoms were mild. In similar cases, bone marrow aspiration would not be performed as a part of routine work-up. Thus, it is important when evaluating pediatric patients with COVID-19 infection to search and report those alterations in order to better understand the impact and the spectrum of clinical manifestations of the specific viral infection in children and adolescents.

Seroprevalence of SARS-CoV-2 infection among children in Children's Hospital Zagreb during the initial and second wave of COVID-19 pandemic in Croatia

INTRODUCTION

The study aimed to investigate the prevalence and titres of anti-SARS-CoV-2 antibodies in children treated at the Children's Hospital Zagreb in the first and the second wave of the COVID-19 pandemic. Statistical significance of difference at two time points was done to determine how restrictive epidemiological measures and exposure of children to COVID-19 infection affect this prevalence in different age groups.

MATERIALS AND METHODS

At the first time point (13th to 29th May 2020), 240 samples and in second time point (24th October to 23rd November 2020), 308 serum samples were tested for anti-SARS-CoV-2 antibodies by enzyme-linked immunosorbent assay (ELISA) and electrochemiluminescence immunoassay (ECLIA). Confirmation of results and titre determination was done using virus micro-neutralization test. Subjects were divided according to gender, age and epidemiological history.

RESULTS

Seroprevalence of anti-SARS-CoV-2 antibodies differs significantly in two time points (P = 0.010). In first time point 2.9% of seropositive children were determined and in second time point 8.4%. Statistically significant difference (P = 0.007) of seroprevalence between two time points was found only in a group of children aged 11-19 years. At the first time point, all seropositive children were asymptomatic with titre < 8. At the second time point, 69.2% seropositive children were asymptomatic with titre ≥ 8.

CONCLUSIONS

The prevalence of anti-SARS-CoV-2 antibodies was significantly lower at the first time point than at the second time point. Values of virus micro-neutralization test showed that low titre in asymptomatic children was not protective at the first time point but in second time point all seropositive children had protective titre of anti-SARS-CoV-2 antibodies.

Neumonía por COVID-19 en niña con síndrome de Down

Actualmente, no existe información estadística ni evidencias sobre cómo está afectando el SARS-CoV-2 en el síndrome de Down. Sin embargo, es frecuente que estas personas tengan comorbilidades asociadas a su síndrome como cardiopatías, enfermedad pulmonar crónica, hipertensión, diabetes u otras patologías que les hacen ser un colectivo más vulnerable. Presentamos el caso clínico de una niña de 7 meses con diagnóstico de síndrome de Down con una comunicación interauricular asociada, que padeció una neumonía por COVID-19 con una evolución tórpida y que requirió ingreso hospitalario. Es pertinente tenerlo en cuenta en nuestras consultas, dado el ambiente epidemiológico del SARS-CoV-2, puesto que son pacientes con múltiples comorbilidades que determinan factores de riesgo y mal pronóstico para esta infección. Palabras clave: atelectasia pulmonar, COVID-19, síndrome de Down, neumonía, insuficiencia respiratoria, virus de la bronquitis infecciosa.

COVID-19 and pediatric fatty liver disease: Is there interplay?

The rapid global spread of coronavirus disease 2019 (COVID-19) infection has become a major health issue with higher morbidity and mortality rates. Besides respiratory symptoms, a growing body of evidence indicates a variety of gastrointestinal manifestations including liver involvement. In this regard, several data supported an association between COVID-19 infection and liver injury in adults, while in children there is compelling but currently limited evidence. In particular, patients with COVID-19 have shown a higher risk of liver injury (mainly expressed as increased transaminase levels or hepatic steatosis). Conversely, a greater risk of more severe forms of COVID-19 infection has been observed in subjects with pre-existing chronic liver diseases. The dramatic interplay between COVID-19 and liver damage has been related to the inflammatory pathways chronically active in patients with nonalcoholic fatty liver disease and acutely in those affected by COVID-19, but other different pathogenic mechanisms have also been supposed. Of note, patients with previous metabolic comorbidities also had a higher risk of severe COVID-19 infection. This emphasizes the pathogenic interrelation of the inflammatory pathways with a dysregulated metabolic milieu in COVID-19 patients. Taking into account the prognostic role of fatty liver in COVID-19 patients and its intrinsic relationship with metabolic abnormalities even in childhood, a strict monitoring of this condition is recommended. We aimed to summarize the most recent evidence regarding the potential interplay between pediatric fatty liver and COVID-19.

Can Clinical Symptoms and Laboratory Results Predict CT Abnormality? Initial Findings Using Novel Machine Learning Techniques in Children With COVID-19 Infections

The rapid spread of coronavirus 2019 disease (COVID-19) has manifested a global public health crisis, and chest CT has been proven to be a powerful tool for screening, triage, evaluation and prognosis in COVID-19 patients. However, CT is not only costly but also associated with an increased incidence of cancer, in particular for children. This study will question whether clinical symptoms and laboratory results can predict the CT outcomes for the pediatric patients with positive RT-PCR testing results in order to determine the necessity of CT for such a vulnerable group. Clinical data were collected from 244 consecutive pediatric patients (16 years of age and under) treated at Wuhan Children's Hospital with positive RT-PCR testing, and the chest CT were performed within 3 days of clinical data collection, from January 21 to March 8, 2020. This study was approved by the local ethics committee of Wuhan Children's Hospital. Advanced decision tree based machine learning models were developed for the prediction of CT outcomes. Results have shown that age, lymphocyte, neutrophils, ferritin and C-reactive protein are the most related clinical indicators for predicting CT outcomes for pediatric patients with positive RT-PCR testing. Our decision support system has managed to achieve an AUC of 0.84 with 0.82 accuracy and 0.84 sensitivity for predicting CT outcomes. Our model can effectively predict CT outcomes, and our findings have indicated that the use of CT should be reconsidered for pediatric patients, as it may not be indispensable.

American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 2

OBJECTIVE

To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9-point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1-3, 4-6, and 7-9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus.

RESULTS

To date, 39 guidance statements have been approved by the task force. Those with similar recommendations were combined to form a total of 33 final guidance statements, all of which received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n = 5) or high consensus (n = 28).

CONCLUSION

These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS-CoV-2 infection. This guidance is presented as a "living document," recognizing that the literature on COVID-19 is rapidly evolving, with future updates anticipated.

A predictive paradigm for COVID-19 prognosis based on the longitudinal measure of biomarkers

Novel coronavirus disease 2019 (COVID-19) is an emerging, rapidly evolving crisis, and the ability to predict prognosis for individual COVID-19 patient is important for guiding treatment. Laboratory examinations were repeatedly measured during hospitalization for COVID-19 patients, which provide the possibility for the individualized early prediction of prognosis. However, previous studies mainly focused on risk prediction based on laboratory measurements at one time point, ignoring disease progression and changes of biomarkers over time. By using historical regression trees (HTREEs), a novel machine learning method, and joint modeling technique, we modeled the longitudinal trajectories of laboratory biomarkers and made dynamically predictions on individual prognosis for 1997 COVID-19 patients. In the discovery phase, based on 358 COVID-19 patients admitted between 10 January and 18 February 2020 from Tongji Hospital, HTREE model identified a set of important variables including 14 prognostic biomarkers. With the trajectories of those biomarkers through 5-day, 10-day and 15-day, the joint model had a good performance in discriminating the survived and deceased COVID-19 patients (mean AUCs of 88.81, 84.81 and 85.62% for the discovery set). The predictive model was successfully validated in two independent datasets (mean AUCs of 87.61, 87.55 and 87.03% for validation the first dataset including 112 patients, 94.97, 95.78 and 94.63% for the second validation dataset including 1527 patients, respectively). In conclusion, our study identified important biomarkers associated with the prognosis of COVID-19 patients, characterized the time-to-event process and obtained dynamic predictions at the individual level.

The impact of National Containment Measures on a Pediatric Italian regional Hub for COVID-19, an observational study

Background

Numerous studies described the epidemiological link and main clinical features of pediatric COVID-19, during the first pandemic period. Our study encompasses several different phases since the National Lockdown in Italy. The primary outcome is (I) to analyze the prevalence of positive NST (Nasopharyngeal Swab Test) among the largest Italian Pediatric cohort admitted to a single regional PED Hub for COVID-19 during an eight-month period. Secondary outcomes are: (II) the description of trend of admissions in our PED and (III) the categorization of the positive patients according to clinical manifestations and epidemiological link.

Methods

We described 316 patients with a positive NST for SARS-CoV2, on a total of 5001 nasopharyngeal swabs performed among 13,171 admissions at our PED, over a period starting from March 17th, 2020 to December 1st, 2020. Age, epidemiological link, clinical features and hospitalizations were analyzed according to different lockdown phases. Data were collected anonymously from electronic records and analyzed using SPSS 22.00 statistics software (Chicago, IL).

Results

Thirty-six percent of total admissions have been tested. During the post lockdown period, we performed the highest percentage of NST (Nasopharyngeal Swab Test) 49.7%, and among them 7.9% were positive. The prevalence of infection during a 10-month period was 2.3%. Mean age was 6.5 years old. Familial Link accounted for the 67.7% of infection, while Extrafamilial and Unknown link accounted for 17 and 14.9%, respectively. Familial link is predominant during all phases. Seventeen patients showed an intra-scholastic link, and the highest prevalence was observed in the 7–10 years age group, with a prevalence of 12.8% (5 patients). Fever was the most frequent symptom (66%), in particular among preschooler children aged 0–6 years (71.9%). Older children were more frequently symptomatic. Seven patients were admitted with MIS-C diagnosis.

Conclusions

Different levels of containment measures caused important changes in number of positive NST for SARS-CoV2. Familial link was predominant in our cohort, during all phases of Lockdown. The risk of being infected at home is four time greater than the risk of being infected from an extra familial individual. Further studies are needed to evaluate the clear impact of intra-scholastic link. The constant improvement in knowledge on onset symptoms and risk factor for SARS-CoV2 infection and its complications (e.g. MIS-C), can impact on number of hospitalizations, ICU admissions and early management.

Fitness for work during the COVID-19 disease: principles and suggested assistive tool for protecting workers during the pandemic era

Objective

Amongst the many intricacies engendered by the COVID-19 pandemic was the posed risk of exposure to SARS-COV2 infections among workers and the need to evaluate fitness for work (FFW) of individuals in high exposure groups or those with background morbidity. A designated task force of the Israeli Association of Occupational Medicine has evaluated the relevant literature and published guidelines concerning medical work restrictions for employees in high-risk occupations during the epidemic of novel COVID-19.

Methods

The study depicts a case series of 17 FFW evaluations performed in Maccabi Health Services occupational clinics using the guidelines formulated by the Israeli Occupational Medicine Association.

Results

17 patients, mainly healthcare workers, whose major health hazards were immunodeficiency, respiratory diseases and pregnancy, were assessed in this case series. We present the essential parameters of these FFW evaluations and discuss decision-making in selected cases.

Conclusions

Applying guidelines in various work settings and health risk levels during the SARS-CoV-2 pandemic allows for both patients' health preservation and efficient workforce deployment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01722-x.

Severe acute respiratory syndrome coronavirus 2 infection and critically ill children

PURPOSE OF REVIEW

Amidst an ongoing pandemic, the delineation of the pediatric consequence of infection from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus is emerging. This review summarizes available pediatric data and covers the aspects of epidemiology, critical illness with acute infection [coronavirus disease 2019 (COVID-19)], the discovered multi-inflammatory syndrome in children (MIS-C), and management options.

RECENT FINDINGS

The available data from the source of the initial viral transmission and then through Europe, Africa, and the Western Hemisphere identifies important aspects of the SARS-CoV2 pandemic: 1) Pediatric infection occurs commonly, is likely underestimated, and transmission patterns remain incompletely described, 2) Pediatric patients suffer multiple end-organ injuries but COVID-19 is not the same prevalence in terms of severity as in adults, 3) MIS-C is a novel and life-threatening manifestation of exposure to the virus, 4) Management using a combination of supportive care, standard practice intensive care management, and anti-inflammatory agents is associated with recovery, 5) Long-term sequelae of viral exposure is unknown at this time.

SUMMARY

Emerging evidence suggests pediatric patients are at risk for severe and life-threatening effects of exposure to SARS-CoV2. As the pandemic continues, further research is warranted - particularly as a vaccine is not yet available for use in children.

SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS-2 (SARS-COV-2) INFECTION: AN EPIDEMIOLOGICAL REVIEW

BACKGROUND

New strains of different organisms, three of which has been caused by betacorona viruses (SARS-CoV, MERS-CoV and SARSCoV- 2) have caused epidemics and pandemics. The COVID-19, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) started in China in December 2019 has spread globally. Understanding its pattern of spread and how it affects the populace helps to guide formulation of strategies at curbing its spread, managing the disease and allocation of limited resources in tackling the pandemic.

METHODOLOGY

This is a review article about the epidemiology of the coronavirus disease -2019 (COVID-19). Various search engines were used to accumulate literature on the topic; these include PubMed, Google scholar, Ajol.

RESULTS

As at October 29, 2020, SARS-CoV2 has spread to all continents except the Antarctica. Though a zoonotic disease, human to human transmission has resulted to this pandemic is via direct and indirect contact of droplets with mucosal surfaces. Most severe cases occur among the elderly, males, and people with co-morbid diseases. The average incubation period is 2-10 days. When compared with SARS-CoV (Ro: 2.3-3.7, mortality rate 11%) and MERS-CoV (Ro: 0.8-1.3, mortality rate: 34.3%), SARS-Cov-2 is a highly infective (Ro: as high as 6.5) with low mortality rates (average range mortality rates 1.83- 6.3%).

CONCLUSION

COVID-19 is a highly infective novel virus. Older persons and people with medical comorbidities are more susceptible to the severe form of the disease and mortality. As the second wave comes on, a sustainable measure of limiting the spread and consequences of COVID-19 should be more emphasized.

Risk-based stratification triaging system in pediatric urology: what COVID-19 pandemic has taught us

INTRODUCTION AND OBJECTIVE

SARS-COV-2 pandemic has affected the population worldwide requiring social distancing, quarantine and isolation as strategies to control virus propagation. Initial measures to reduce the burden to the health care system during the pandemic included deferring elective surgery. These damage control measures did not take into account the mid- and long-term implications. Management of congenital anomalies can be time sensitive with delays resulting in permanent disability, morbidity and increased costs to the healthcare system. This study reports the results of using a novel scoring system that enables triage of time sensitive congenital anomalies and pediatric surgical conditions and how implementation of Enhanced Recovery After Surgery (ERAS®) principles allowed optimization of resources and reduced the burden to the system while allowing for appropriate care of pediatric patients with urgent urologic surgical conditions.

METHODS

We present a prospective case series of patients with congenital urological conditions scheduled and taken to surgery during COVID-19 pandemic. All pediatric urology cases that were pending and or scheduled for surgery at the moment the pandemic struck as well as all cases that presented to the emergency department with urological conditions were triaged and included for analysis using a modified Medically Necessary, Time-Sensitive Procedures: Scoring System (MeNTS). A modified MeNTS was implemented for pediatric patients, giving more priority to the impact of deferring surgical intervention on patient's prognosis. An individualized evaluation using this scoring system was applied to each patient. Intra- and postoperative ERAS^® principles were applied to all cases operated during the pandemic between March 20th and April 24th to reduce the burden to the healthcare system.

RESULTS

A total of 49 patients were triaged and included for analysis with a mean age of 6.47 years of age. Adjusted MeNTS showed that all clinically emergent cases had a score of 12 or less. Cases that could be postponed for 2 weeks but no longer had a score between 13 and 15. The ones that could wait 6 weeks or longer had scores higher than 16. Score results were not the same for similar procedures and individualized assessments resulted in scores based on an individual patient's conditions. From the total cases, implementation of ERAS^® principles increased outpatient procedures from 68 to 90.4%.

CONCLUSION

Our results provide a novel triaging method to rank pediatric urological surgical management based on individualized patient's clinical conditions. Cutoff values of 12 and 16 allowed appropriate triage preventing the postponement of urgent urologic cases during the COVID-19 pandemic. Implementation of ERAS^® principles allowed for these procedures to be done in the outpatient setting, preserving valuable healthcare resources.

TYPE OF STUDY

Prospective cohort study.

LEVEL OF EVIDENCE

IV.

Comparison of chest radiography and chest CT for evaluation of pediatric COVID-19 pneumonia: Does CT add diagnostic value?

PURPOSE

First, to investigate the added diagnostic value of chest computed tomography (CT) for evaluating COVID-19 in symptomatic children by comparing chest CT findings with chest radiographic findings, and second, to identify the imaging signs and patterns on CT associated with COVID-19 pneumonia in children.

MATERIALS AND METHODS

From March 2020 to December 2020, 56 consecutive children (33 males and 23 girls; mean age ± SD, 14.8 ± 5.0 years; range, 9 months-18 years) with mild to moderate symptom and laboratory confirmed COVID-19 (based on Centers for Disease Control criteria) underwent both chest radiography and chest CT on the same day within the first 2 days of initial presentation to the hospital. Two experienced radiologists independently evaluated chest radiographs and chest CT studies for thoracic abnormalities. The findings from chest radiography and chest CT were compared to evaluate the added diagnostic value of chest CT for affecting patient management. Interobserver agreement was measured with Cohen's κ statistics.

RESULTS

Eleven (19.6%) of 56 patients had abnormal chest radiographic findings, including ground-glass opacity (GGO) in 5/11 (45.4%) and combined GGO and consolidation in 6/11 (54.5%). On chest CT, 26 (46.4%) of 56 patients had abnormal CT findings, including combined GGO and consolidation in 19/26 (73.1%), GGO in 6/26 (23.1%), and consolidation in 1/26 (3.8%). Chest CT detected all thoracic abnormalities seen on chest radiography in 11/26 (42.3%) cases. In 15/26 (57.7%), chest CT detected lung abnormalities that were not observed on chest radiography, which included GGO and consolidation in 9/15 (60%), GGO in 5/15 (33.3%), and consolidation in 1/15 (6.6%) cases. These additional CT findings did not affect patient management. In addition, chest CT detected radiological signs and patterns, including the halo sign, reversed halo sign, crazy paving pattern, and tree-in-bud pattern. There was almost perfect interobserver agreement between the two reviewers for detecting findings on both chest radiographs (κ, 0.89, p = .001) and chest CT (κ, 0.96, p = .001) studies.

CONCLUSION

Chest CT detected lung abnormalities, including GGO and/or consolidation, that were not observed on chest radiography in more than half of symptomatic pediatric patients with COVID-19 pneumonia. However, these additional CT findings did not affect patient management. Therefore, CT is not clinically indicated for the initial evaluation of mild to moderately symptomatic pediatric patients with COVID-19 pneumonia.

Variants in ACE2; potential influences on virus infection and COVID-19 severity

The third pandemic of coronavirus infection, called COVID-19 disease, was first detected in November 2019th. Various determinants of disease progression such as age, sex, virus mutations, comorbidity, lifestyle, host immune response, and genetic background variation have caused clinical variability of COVID-19. The causative agent of COVID-19 is an enveloped coronavirus named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that invades host cells using an endocytic pathway. The SARS-CoV-2 spike protein is the main viral protein that contributes to the fusion of the virus particle to the host cell through angiotensin-converting enzyme 2 (ACE2). The highly conserved expression of ACE2 is found in various animals, which indicates its pivotal physiological function. The ACE2 has a crucial role in vascular, renal, and myocardial physiology. Genetic factors contributing to the outcome of SARS-CoV-2 infection are unknown; however, variants in the specific sites of ACE2 gene could be regarded as a main genetic risk factor for COVID-19. Given that ACE2 is the main site for virus landing on host cells, the effect of amino acid sequences of ACE2 on host susceptibility to COVID-19 seems reasonable. It would likely have a substantial role in the occurrence of a wide range of clinical symptoms. Several ACE2 variants can affect the protein stability, influencing the interaction between spike protein and ACE2 through imposing conformational changes while some other variants are known to cause a decrease or an increase in the ligand-receptor affinity. The other variations are located at the proteolytic cleavage site, which can influence virus infection; because soluble ACE2 can act as a decoy receptor for virus and decrease virus intake by cell surface ACE2. Notably, polymorphisms of regulatory and non-coding regions such as promoter in ACE2, can play crucial role in different expression levels of ACE2 among different individuals. Many studies should be performed to investigate the involvement of ACE2 polymorphism with susceptibility to COVID-19. Herein, we discuss some reported associations between variants of ACE2 and COVID-19 in details. In addition, the mode of action of ACE2 and its role in SARS-CoV-2 infection are highlighted which is followed by addressing the effects of several ACE2 variants on its protein stability, viral tropism or ligand-receptor affinity, secondary and tertiary structure or protein conformation, proteolytic cleavage site, and finally inter-individual clinical variability in COVID-19. The polymorphisms of regulatory regions of ACE2 and their effect on expression levels of ACE2 are also provided in this review. Such studies can improve the prediction of the affinity of mutant ACE2 variations with spike protein, and help the biopharmaceutical industry to design effective approaches for recombinant hACE2 therapy and vaccination of COVID-19 disease.

COVID-19 under 19: A meta-analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic continues to cause global havoc posing uncertainty to educational institutions worldwide. Understanding the clinical characteristics of COVID-19 in children is important because of the potential impact on clinical management and public health decisions.

METHODS

A meta-analysis was conducted for pediatric COVID-19 studies using PubMed and Scopus. It reviewed demographics, co-morbidities, clinical manifestations, laboratory investigations, radiological investigations, treatment, and outcomes. The 95% confidence interval (CI) was utilized.

RESULTS

Out of 3927 articles, 31 articles comprising of 1816 patients were selected from December 2019 to early October 2020 and were defined by 77 variables. Of these studies 58% originated from China and the remainder from North America, Europe and the Middle East. This meta-analysis revealed that 19.2% (CI 13.6%-26.4%) of patients were asymptomatic. Fever (57%, CI 49.7%-64%) and cough (44.1%, CI 38.3%-50.2%) were the most common symptoms. The most frequently encountered white blood count abnormalities were lymphopenia 13.5% (CI 8.2%-21.4%) and leukopenia 12.6% (CI 8.5%-18.3%). Ground glass opacities were the most common radiological finding of children with COVID-19 (35.5%, CI 28.9%-42.7%). Hospitalization rate was 96.3% (CI 92.4%-98.2%) of which 10.8% (CI 4.2%-25.3%) were ICU admissions, and 2.4% (CI 1.7%-3.4%) died.

CONCLUSION

The majority of pediatric patients with COVID-19 were asymptomatic or had mild manifestations. Among hospitalized patients there remains a significant number that require intensive care unit care. Overall across the literature, a considerable level of understanding of COVID-19 in children was reached, yet emerging data related to multisystemic inflammatory syndrome in children should be explored.

Gastrointestinal Manifestations of Pediatric Coronavirus Disease and Their Relationship with a Severe Clinical Course: A Systematic Review and Meta-analysis

BACKGROUND

Data on the gastrointestinal (GI) manifestations of Pediatric Corona Virus Disease (COVID-19) are conflicting and the relationship between GI involvement and the severity of COVID-19 disease has not been evaluated. The objectives of this systematic review were to determine the GI manifestations of pediatric COVID-19 and to evaluate their role as risk factors for a severe clinical course.

METHODS

: A systematic literature search was carried out in PubMed and Scopus for studies published before 31 December 2020 with information about the GI manifestations of pediatric COVID-19. Patients with a severe and nonsevere clinical course were compared using the inverse variance heterogeneity model and odds ratio (OR) as the effect size. A sensitivity analysis was performed if the heterogeneity was high among studies.

RESULTS

A total of 811 studies were identified through a systematic search of which 55 studies (4369 patients) were included in this systematic review. The commonest GI symptoms were diarrhea-19.08% [95% confidence interval (CI) 10.6-28.2], nausea/vomiting 19.7% (95% CI 7.8-33.2) and abdominal pain 20.3% (95% CI 3.7-40.4). The presence of diarrhea was significantly associated with a severe clinical course with a pooled OR of 3.97 (95% CI 1.80-8.73; p < 0.01). Abdominal pain and nausea/vomiting were not associated with disease severity.

CONCLUSIONS

Diarrhea, nausea/vomiting or abdominal pain are present in nearly one-fifth of all children with COVID-19. The presence of diarrhea portends a severe clinical course.

Coronavirus Disease 2019 in Children

Since its appearance in Wuhan in mid-December 2019, acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related 19 coronavirus disease (COVID-19) has spread dramatically worldwide. It soon became apparent that the incidence of pediatric COVID-19 was much lower than the adult form. Morbidity in children is characterized by a variable clinical presentation and course. Symptoms are similar to those of other acute respiratory viral infections, the upper airways being more affected than the lower airways. Thus far, over 90% of children who tested positive for the virus presented mild or moderate symptoms and signs. Most children were asymptomatic, and only a few cases were severe, unlike in the adult population. Deaths have been rare and occurred mainly in children with underlying morbidity. Factors as reduced angiotensin-converting enzyme receptor expression, increased activation of the interferon-related innate immune response, and trained immunity have been implicated in the relative resistance to COVID-19 in children, however the underlying pathogenesis and mechanism of action remain to be established. While at the pandemic outbreak, mild respiratory manifestations were the most frequently described symptoms in children, subsequent reports suggested that the clinical course of COVID-19 is more complex than initially thought. Thanks to the experience acquired in adults, the diagnosis of pediatric SARS-CoV-2 infection has improved with time. Data on the treatment of children are sparse, however, several antiviral trials are ongoing. The purpose of this narrative review is to summarize current understanding of pediatric SARS-CoV-2 infection and provide more accurate information for healthcare workers and improve the care of patients.

Persistence of SARS-CoV-2-Specific IgG in Children 6 Months After Infection, Australia

The duration of the humoral immune response in children infected with severe acute respiratory syndrome coronavirus 2 is unknown. We detected specific IgG 6 months after infection in children who were asymptomatic or had mild symptoms of coronavirus disease. These findings will inform vaccination strategies and other prevention measures.

Utility of inflammatory biomarkers in patients with COVID-19 infections: Bahrain experience

Aim: COVID-19 pandemic continues and dearth of information remains considering the utility of various inflammatory biomarkers. We carried out the present study to delineate the roles of these biomarkers in various strata of patients with coronavirus infection. Materials & methods: A retrospective study was carried out after obtaining approval from the relevant Ethics Committee. Patients established with COVID-19 infection as shown by positive real-time quantitative PCR test were included. Details on their demographics, diagnosis, whether they received tocilizumab, and the values of the following biomarkers were obtained: IL-6, C-reactive protein (CRP), serum ferritin, D-dimer, procalcitonin, fibrinogen, lactate dehydrogenase and creatinine kinase. Receiver operating characteristic curves were plotted and correlation of biomarkers with IL-6 were estimated. Results: One-hundred and three patients were recruited. We observed that serum ferritin followed by D-dimer had better predictive accuracy in identifying patients with pneumonia compared with asymptomatic; and CRP in addition to the earlier markers had better accuracy for predicting severe illness compared with mild–moderate. Serum IL-6 levels were significantly higher in patients with severe illness admitted in intensive care unit. Significantly, higher levels of IL-6 and serum ferritin were observed in patients receiving tocilizumab. A trend of increased IL-6 levels was observed immediately following the initiation of tocilizumab therapy followed by a drop thereafter. Conclusion: We observed serum ferritin, D-dimer and CRP to accurately predict patients developing severe COVID-19 infections as well as those at risk of developing COVID pneumonia. A trend in IL-6 levels was observed in patients on tocilizumab therapy.

The COVID-19 Vaccine Landscape

The history of vaccine development spans centuries. At first, whole pathogens were used as vaccine agents, either inactivated or attenuated, to reduce virulence in humans. Safety and tolerability were increased by including only specific proteins as antigens and using cell culture methods, while novel vaccine strategies, like nucleic acid- or vector-based vaccines, hold high promise for the future. Vaccines have generally not been employed as the primary tools in outbreak response, but this might change since advances in medical technology in the last decades have made the concept of developing vaccines against novel pathogens a realistic strategy. Wandering the uncharted territory of a novel pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), we can learn from other human Betacoronaviridae that emerged in the last decades, SARS-CoV-1 and MERS-CoV. We can identify the most likely target structures of immunity, establish animal models that emulate human disease and immunity as closely as possible, and learn about complex mechanisms of immune interaction such as cross-reactivity or antibody-dependent enhancement (ADE). However, significant knowledge gaps remain. What are the correlates of protection? How do we best induce immunity in vulnerable populations like the elderly? Will the immunity induced by vaccination (or by natural infection) wane over time? To date, at least 149 vaccine candidates against SARS-CoV-2 are under development. At the time of writing, at least 17 candidates have already progressed past preclinical studies (in vitro models and in vivo animal experiments) into clinical development. This chapter will provide an overview of this rapidly developing field.

Evaluation of 6 Commercial SARS-CoV-2 Serology Assays Detecting Different Antibodies for Clinical Testing and Serosurveillance

Background

Serological testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) complements nucleic acid tests for patient diagnosis and enables monitoring of population susceptibility to inform the coronavirus disease 2019 (COVID-19) pandemic response. It is important to understand the reliability of assays with different antigen or antibody targets to detect humoral immunity after SARS-CoV-2 infection and to understand how antibody (Ab) binding assays compare to those detecting neutralizing antibody (nAb), particularly as we move into the era of vaccines.

Methods

We evaluated the performance of 6 commercially available enzyme-linked immunosorbent assays (ELISAs), including a surrogate virus neutralization test (sVNT), for detection of SARS-CoV-2 immunoglobulins (IgA, IgM, IgG), total or nAb. A result subset was compared with a cell culture-based microneutralization (MN) assay. We tested sera from patients with prior reverse transcription polymerase chain reaction-confirmed SARS-CoV-2 infection, prepandemic sera, and potential cross-reactive sera from patients with other non-COVID-19 acute infections.

Results

For sera collected >14 days post-symptom onset, the assay achieving the highest sensitivity was the Wantai total Ab at 100% (95% CI, 94.6%-100%), followed by 93.1% for Euroimmun NCP-IgG, 93.1% for GenScript sVNT, 90.3% for Euroimmun S1-IgG, 88.9% for Euroimmun S1-IgA, and 83.3% for Wantai IgM. Specificity for the best-performing assay was 99.5% for the Wantai total Ab, and for the lowest-performing assay it was 97.1% for sVNT (as per the Instructions for Use [IFU]). The Wantai Total Ab had the best agreement with MN at 98% followed by Euroimmun S1-IgA, Euro NCP-IgG, and sVNT (as per IFU) with 97%, 97% and 95%, respectively; Wantai IgM had the poorest agreement at 93%.

Conclusions

Performance characteristics of the SARS-CoV-2 serology assays detecting different antibody types are consistent with those found in previously published reports. Evaluation of the surrogate virus neutralization test in comparison to the Ab binding assays and a cell culture-based neutralization assay showed good result correlation between all assays. However, correlation between the cell-based neutralization test and some assays detecting Ab's not specifically involved in neutralization was higher than with the sVNT. This study demonstrates the reliability of different assays to detect the humoral immune response following SARS-CoV-2 infection, which can be used to optimize serological test algorithms for assessing antibody responses post-SARS-CoV-2 infection or vaccination.

Associations of D-Dimer on Admission and Clinical Features of COVID-19 Patients: A Systematic Review, Meta-Analysis, and Meta-Regression

Background

Dynamic D-dimer level is a key biomarker for the severity and mortality of COVID-19 (coronavirus disease 2019). How aberrant fibrinolysis influences the clinical progression of COVID-19 presents a clinicopathological dilemma challenging intensivists.

Methods

We performed meta-analysis and meta regression to analyze the associations of plasma D-dimer with 106 clinical variables to identify a panoramic view of the derangements of fibrinolysis in 14,862 patients of 42 studies. There were no limitations of age, gender, race, and country. Raw data of each group were extracted separately by two investigators. Individual data of case series, median and interquartile range, and ranges of median or mean were converted to SDM (standard deviation of mean).

Findings

The weighted mean difference of D-dimer was 0.97 µg/mL (95% CI 0.65, 1.29) between mild and severe groups, as shown by meta-analysis. Publication bias was significant. Meta-regression identified 58 of 106 clinical variables were associated with plasma D-dimer levels. Of these, 11 readouts were negatively related to the level of plasma D-dimer. Further, age and gender were confounding factors. There were 22 variables independently correlated with the D-dimer level, including respiratory rate, dyspnea plasma K+, glucose, SpO2, BUN (blood urea nitrogen), bilirubin, ALT (alanine aminotransferase), AST (aspartate aminotransferase), systolic blood pressure, and CK (creatine kinase).

Interpretation

These findings support elevated D-dimer as an independent predictor for both mortality and complications. The identified D-dimer-associated clinical variables draw a landscape integrating the aggregate effects of systemically suppressive and pulmonary hyperactive derangements of fibrinolysis, and the D-dimer-associated clinical biomarkers, and conceptually parameters could be combined for risk stratification, potentially for tracking thrombolytic therapy or alternative interventions.

Cautions on the laboratory indicators of COVID-19 patients on and during admission

BACKGROUND

Different disease severities of COVID-19 patients could be reflected on clinical laboratory findings.

METHODS

In this single-centered retrospective study, demographic, clinical, and laboratory indicators on and during admission were compared among 74 participants with mild, moderate, critical severe, or severe classification. Risk factors associated with disease severity were analyzed by multivariate analyses. The AUC and 95% CI of the ROC curve were calculated.

RESULTS

The most common manifestations of these patients were fever and cough. Critical severe or severe group owned the longest length of stay (23 (19,31), p < 0.001). After multivariate logistic regression, independent influence factors on admission for severity of disease were CK-MB (OR 0.674; 95% CI 0.489-0.928; p = 0.016), LDH (OR 1.111 or 1.107; 95% CI 1.026-1.204 or 1.022-1.199; p = 0.009 or 0.013), normal T-BIL (OR 4.58 × 10^-8 ; 95% CI 3.05 × 10^-9 -6.88 × 10^-7 ; p < 0.001), LYM% (OR 0.008; 95% CI 0-0.602; p = 0.029), and normal ESR (OR 0.016; 95% CI 0-0.498; p = 0.019). Factors during hospitalization were normal T-BIL (OR 8.56 × 10^-9 ; 95% CI 8.30 × 10^-10 -8.83 × 10^-8 ; p < 0.001), LYM (OR 0.068; 95% CI 0.005-0.934; p = 0.044), albumin (OR 0.565; 95% CI 0.327-0.977; p = 0.041), and normal NEU% (OR 0.013; 95% CI 0.000-0.967; p = 0.048). Combined indicators of AUC were 0.860 (LYM, LDH, and normal ESR on admission, p < 0.001) and 0.750 (CK-MB, LDH, and normal T-BIL during hospitalization, p = 0.020) when predicting for severe or critical severe patients.

CONCLUSION

To pay close attention to the progression of COVID-19 and take measures promptly, we should be cautious of the laboratory indicators when patients on admission especially CK-MB, LDH, LYM%, T-BIL as well as ESR; and T-BIL, LYM, albumin, NEU% with the process of disease.

Safety of Healthcare Workers During the Airway Management in Adult and Pediatric Patients with COVID-19

Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has spread worldwide. Although the majority of patients show mild symptoms, the disease can rapidly progress in severe cases and develop acute respiratory distress syndrome (ARDS) that may lead to therapeutic interventions, including oxygenation, tracheal intubation, and mechanical ventilation. It is suggested that the new coronavirus spreads mostly via droplets, surface contact, and natural aerosols. Hence, high-risk aerosol-producing procedures, such as endotracheal intubation, may put the healthcare workers at a high risk of infection. In the course of managing patients with COVID-19, it is essential to prioritize the safety of healthcare workers. Hence, this review study aimed to summarize new guidelines and proper airway management in adult and pediatric COVID-19 patients.

Prevalence and factors associated with psychological burden in COVID-19 patients and their relatives: A prospective observational cohort study

BACKGROUND

Due to the dramatic measures accompanying isolation and the general uncertainty and fear associated with COVID-19, patients and relatives may be at high risk for adverse psychological outcomes. Until now there has been limited research focusing on the prevalence of psychological distress and associated factors in COVID-19 patients and their relatives. The objective of our study was to assess psychological distress in COVID-19 patients and their relatives 30 days after hospital discharge.

METHODS

In this prospective observational cohort study at two Swiss tertiary-care hospitals we included consecutive adult patients hospitalized between March and June 2020 for a proven COVID-19 and their relatives. Psychological distress was defined as symptoms of anxiety and/or depression measured with the Hospital Anxiety and Depression Scale (HADS), i.e., a score of ≥8 on the depression and/or anxiety subscale. We further evaluated symptoms of post-traumatic stress disorder (PTSD), defined as a score of ≥1.5 on the Impact of Event Scale-Revised (IES-R).

RESULTS

Among 126 included patients, 24 (19.1%) had psychological distress and 10 (8.7%) had symptoms of PTSD 30 days after hospital discharge. In multivariate logistic regression analyses three factors were independently associated with psychological distress in patients: resilience (OR 0.82; 95%CI 0.71 to 0.94; p = 0.005), high levels of perceived stress (OR 1.21; 95%CI 1.06 to 1.38; p = 0.006) and low frequency of contact with relatives (OR 7.67; 95%CI 1.42 to 41.58; p = 0.018). The model showed good discrimination, with an area under the receiver-operating characteristic curve (AUC) of 0.92. Among 153 relatives, 35 (22.9%) showed symptoms of psychological distress, and 3 (2%) of PTSD. For relatives, resilience was negatively associated (OR 0.85; 95%CI 0.75 to 0.96; p = 0.007), whereas perceived overall burden caused by COVID-19 was positively associated with psychological distress (OR 1.72; 95%CI 1.31 to 2.25; p<0.001). The overall model also had good discrimination, with an AUC of 0.87.

CONCLUSION

A relevant number of COVID-19 patients as well as their relatives exhibited psychological distress 30 days after hospital discharge. These results might aid in development of strategies to prevent psychological distress in COVID-19 patients and their relatives.

Estimating the Instantaneous Asymptomatic Proportion With a Simple Approach: Exemplified With the Publicly Available COVID-19 Surveillance Data in Hong Kong

Background: The asymptomatic proportion is a critical epidemiological characteristic that modulates the pandemic potential of emerging respiratory virus, which may vary depending on the nature of the disease source, population characteristics, source-host interaction, and environmental factors. Methods: We developed a simple likelihood-based framework to estimate the instantaneous asymptomatic proportion of infectious diseases. Taking the COVID-19 epidemics in Hong Kong as a case study, we applied the estimation framework to estimate the reported asymptomatic proportion (rAP) using the publicly available surveillance data. We divided the time series of daily cases into four stages of epidemics in Hong Kong by examining the persistency of the epidemic and compared the rAPs of imported cases and local cases at different stages. Results: As of July 31, 2020, there were two intermittent epidemics in Hong Kong. The first one was dominated by imported cases, accounting for 63.2% of the total cases, and the second one was dominated by local cases, accounting for 86.5% of the total cases. The rAP was estimated at 23.1% (95% CI: 10.8-39.7%) from January 23 to July 31, and the rAPs were estimated at 22.6% (95% CI: 11.1-38.9%) among local cases and 38.7% (95% CI: 9.0-72.0%) among imported cases. Our results showed that the rAPs of local cases were not significantly different between the two epidemics, but increased gradually during the first epidemic period. In contrast, the rAPs of imported cases in the latter epidemic period were significantly higher than that in the previous epidemic period. Conclusion: Hong Kong has a high rAP of imported COVID-19 cases and should continue to strengthen the detection and isolation of imported individuals to prevent the resurgence of the disease.

Non-Contact Monitoring and Classification of Breathing Pattern for the Supervision of People Infected by COVID-19

During the pandemic of coronavirus disease-2019 (COVID-19), medical practitioners need non-contact devices to reduce the risk of spreading the virus. People with COVID-19 usually experience fever and have difficulty breathing. Unsupervised care to patients with respiratory problems will be the main reason for the rising death rate. Periodic linearly increasing frequency chirp, known as frequency-modulated continuous wave (FMCW), is one of the radar technologies with a low-power operation and high-resolution detection which can detect any tiny movement. In this study, we use FMCW to develop a non-contact medical device that monitors and classifies the breathing pattern in real time. Patients with a breathing disorder have an unusual breathing characteristic that cannot be represented using the breathing rate. Thus, we created an Xtreme Gradient Boosting (XGBoost) classification model and adopted Mel-frequency cepstral coefficient (MFCC) feature extraction to classify the breathing pattern behavior. XGBoost is an ensemble machine-learning technique with a fast execution time and good scalability for predictions. In this study, MFCC feature extraction assists machine learning in extracting the features of the breathing signal. Based on the results, the system obtained an acceptable accuracy. Thus, our proposed system could potentially be used to detect and monitor the presence of respiratory problems in patients with COVID-19, asthma, etc.

Otolaryngology manifestations of COVID-19 in pediatric patients

BACKGROUND

The coronavirus disease 2019 pandemic has affected millions of people since its outbreak in December 2019. Limited data exist on otolaryngology manifestations of COVID-19 in pediatrics. This study aims to discuss the clinical features of COVID-19 in pediatrics, with an emphasis on otolaryngology manifestations.

METHODS

The study included 660 COVID-19 laboratory-confirmed positive pediatric patients (aged 3-15 years) diagnosed at King Abdullah Specialist Children Hospital, Riyadh, Saudi Arabia. Data were retrospectively retrieved from January to July 2020 from electronic medical records and included patients' epidemiological and clinical features. Patients were then followed-up via phone calls to document any symptoms encountered after the first visit. Patients were categorized into three main groups according to age (3-6 years, 7-10 years, 11-15 years).

RESULTS

Nearly half of the patients (43.6%) had asymptomatic infections. Fever and cough were the most commonly reported manifestations accounting for 39.2% and 19.8%, respectively. The most frequently reported otolaryngology symptoms were sore throat (17.3%) and rhinorrhea (14.4%). Moreover, 10.4% and 13.1% of children aged 7-15 years old experienced smell and taste disturbances, respectively. Older children (11-15 years) were more likely to report taste disturbances when compared to the younger children (17.2% vs 9.8%, p-value 0.02). Children aged between 3 and 6 years had significantly higher rates of admission (13.7%) and mortality (0.9%) when compared to the older groups (p-value 0.00).

CONCLUSION

COVID-19 in pediatrics has a milder disease course and a better prognosis than adults. Multiple otolaryngology symptoms were reported in pediatric patients with COVID-19, which can help identify the suspected cases before the test result.

Host-dependent molecular factors mediating SARS-CoV-2 infection to gain clinical insights for developing effective targeted therapy

Coronavirus disease 2019 (COVID-19), a recent viral pandemic that first began in December 2019, in Hunan wildlife market, Wuhan, China. The infection is caused by a coronavirus, SARS-CoV-2 and clinically characterized by common symptoms including fever, dry cough, loss of taste/smell, myalgia and pneumonia in severe cases. With overwhelming spikes in infection and death, its pathogenesis yet remains elusive. Since the infection spread rapidly, its healthcare demands are overwhelming with uncontrollable emergencies. Although laboratory testing and analysis are developing at an enormous pace, the high momentum of severe cases demand more rapid strategies for initial screening and patient stratification. Several molecular biomarkers like C-reactive protein, interleukin-6 (IL6), eosinophils and cytokines, and artificial intelligence (AI) based screening approaches have been developed by various studies to assist this vast medical demand. This review is an attempt to collate the outcomes of such studies, thus highlighting the utility of AI in rapid screening of molecular markers along with chest X-rays and other COVID-19 symptoms to enable faster diagnosis and patient stratification. By doing so, we also found that molecular markers such as C-reactive protein, IL-6 eosinophils, etc. showed significant differences between severe and non-severe cases of COVID-19 patients. CT findings in the lungs also showed different patterns like lung consolidation significantly higher in patients with poor recovery and lung lesions and fibrosis being higher in patients with good recovery. Thus, from these evidences we perceive that an initial rapid screening using integrated AI approach could be a way forward in efficient patient stratification.

Alterations of frontal-temporal gray matter volume associate with clinical measures of older adults with COVID-19

COVID-19, the infectious disease caused by the most recently discovered severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become a global pandemic. It dramatically affects people's health and daily life. Neurological complications are increasingly documented for patients with COVID-19. However, the effect of COVID-19 on the brain is less studied, and existing quantitative neuroimaging analyses of COVID-19 were mainly based on the univariate voxel-based morphometry analysis (VBM) that requires corrections for a large number of tests for statistical significance, multivariate approaches that can reduce the number of tests to be corrected have not been applied to study COVID-19 effect on the brain yet. In this study, we leveraged source-based morphometry (SBM) analysis, a multivariate extension of VBM, to identify changes derived from computed tomography scans in covarying gray matter volume patterns underlying COVID-19 in 120 neurological patients (including 58 cases with COVID-19 and 62 patients without COVID-19 matched for age, gender and diseases). SBM identified that lower gray matter volume (GMV) in superior/medial/middle frontal gyri was significantly associated with a higher level of disability (modified Rankin Scale) at both discharge and six months follow-up phases even when controlling for cerebrovascular diseases. GMV in superior/medial/middle frontal gyri was also significantly reduced in patients receiving oxygen therapy compared to patients not receiving oxygen therapy. Patients with fever presented significant GMV reduction in inferior/middle temporal gyri and fusiform gyrus compared to patients without fever. Patients with agitation showed GMV reduction in superior/medial/middle frontal gyri compared to patients without agitation. Patients with COVID-19 showed no significant GMV differences from patients without COVID-19 in any brain region. Results suggest that COVID-19 may affect the frontal-temporal network in a secondary manner through fever or lack of oxygen.

Different School Reopening Plans on Coronavirus Disease 2019 Case Growth Rates in the School Setting in the United States

BACKGROUND

In fall 2020, all public K-12 schools reopened in broadly 3 learning models. The hybrid model was considered a mid-risk option compared with remote and in-person learning models. The current study assesses school-based coronavirus disease 2019 (COVID-19) spread in the early fall using a national data set.

METHODS

We assess COVID-19 case growth rates from August 10 to October 14, 2020 based on a crowdsourcing data set from the National Education Association. The study follows a retrospective cohort design with the baseline exposures being 3 teaching models: remote learning only, hybrid, and in-person learning. To assess the consistency of our findings, we estimated the overall, as well as region-specific (Northeast, Midwest, South, and West) and poverty-specific (low, mid, and high) COVID-19 case-growth rates. In addition, we validated our study sample using another national sample survey data.

RESULTS

The baseline was from 617 school districts in 48 states, where 47% of school districts were in hybrid, 13% were in remote, and 40% were in-person. Controlling for state-level risk and rural-urban difference, the case growth rates for remote and in-person were lower than the hybrid (odds ratio [OR]: 0.963, 95% confidence interval [CI]: 0.960-0.965 and OR: 0.986, 95% CI: 0.984-0.988, respectively). A consistent result was found among school districts in all 4 regions and each poverty level.

CONCLUSIONS

Hybrid may not necessarily be the next logical option when transitioning from the remote to in-person learning models due to its consistent higher case growth rates than the other 2 learning models.

Lung ultrasound in the diagnosis and monitoring of 30 children with coronavirus disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) has caused a new global pandemic and is responsible for millions of infections and thousands of deaths in the world. The lung ultrasound (LUS) is a noninvasive and easily repeatable tool and can be carried out by the pediatrician at the bedside of children with a consequent reduction in the risk of transmission of the virus.

OBJECTIVE

We hypothesized that ultrasound findings in these patients would (1) be associated with their disease severity and (2) change over time in alignment with clinical outcome.

METHODS

The study was made in the emergency department (ED) in a tertiary level pediatric hospital. All patients with swab-confirmed COVID-19 infection were subjected to a LUS within 6 h from admission and after 96 h.

RESULTS

Among a total of 30 children, 18 (60%) were males, 4 reported exertional dyspnea, and only 1 chest pain. The mean oxygen saturation was 98.8 ± 1.0% in ambient air in the ED and no patient needed oxygen therapy during hospitalization. Children with moderate disease presented more B line (p = .03). After 96 h, we had observed ultrasound abnormality only in 20% of the children. We found a statistically significant reduction in pleural irregularities (30% vs. 16.7; p = .001) and in B lines (50% vs. 20%; p = .008).

CONCLUSIONS

The LUS is a useful, feasible, and safe tool for the clinician to complement the clinical evaluation and to monitor the evolution of lung disease in children with COVID-19.

Is leukopenia and lymphopenia a characteristic feature of COVID-19 in children?

OBJECTIVES

To analyze whether leucopenia and lymphopenia a characteristic feature of children with COVID-19 and to find out its association with the disease severity.

METHODS

This was a descriptive cross-sectional study conducted at The Children's Hospital Lahore from March 2020 to October 2020. All confirmed cases of COVID-19 infection and post-COVID MIS-C/Kawasaki Disease diagnosed on the basis of RT-PCR and Antibody test respectively were included. Complete blood and differential counts were performed on the day of admission.

RESULTS

Out of a total of 83 patients 60 (72%) were diagnosed as COVID-19 and 23 (28%) as post-COVID MIS-C/KD. The mean age of children was 7.0±4.3 years (95%CI: 6.07 - 8.75) with a male preponderance 51 (61%). Twenty (24%) children had an underlying comorbidity and 7 (8%) were surgical cases. Our case fatality rate was 5 (6%) and all children who died had an underlying comorbid condition. In both, COVID and MIS-C/KD the mean leukocyte count was (14.0 ± 12.5 vs 13.6 ± 6.9 x109/L), respectively (p=0.888). The mean lymphocyte count in children with COVID was (39.1 ± 21.4%). Patients with MIS-C/KD showed significantly higher levels of neutrophil count (76.5 ± 15.0%) as compared to children with COVID (52.0 ± 22.1%), absolute lymphocyte count was (5.02±4.81 vs 2.13±0.95 x109/L) in COVID and MIS-C respectively (p=<0.001). In 60 COVID-19 patients, the mean neutrophil lymphocyte ratio (NLR) in mild-moderate and severe-critical group was 2.00 and 5.08 respectively (p=0.009).

CONCLUSION

The blood picture of COVID-19 in children does not show leukopenia. NLR was a prognostic factor to assess the severity in COVID-19 patients. The presence of an underlying comorbid conditions is significant a risk factor for poor outcome.

Clinical Characteristics and Outcomes of COVID-19 in Children in Northern Iran

OBJECTIVE

Since December 2019, the coronavirus disease 2019 (COVID-19) has been spread rapidly all over the world, infecting all age groups with this novel virus. In this manuscript, we report characteristics of children with COVID-19 in Mazandaran province, northern Iran.

METHOD

From 12 February to 28 July 2020, medical records of 100 children diagnosed with COVID-19 admitted to the hospitals of Mazandaran province were collected. Patients' age, gender, clinical symptoms, and signs, in addition to therapeutic management and outcomes, were reported.

RESULTS

57 (57%) boys and 43 girls with the mean age of 104.63 ± 79.14 months were evaluated. 20 patients (20%) were transferred to the PICU (pediatric intensive care unit), and 13 children experienced a severe form of the disease, pediatric inflammatory multisystem syndrome (PIMS). The mean duration of hospitalization was 5.3 ± 4.7 days. Fever (81%), respiratory (79%), gastrointestinal (47%), and neurologic complaints (29%) were experienced by the patients in addition to skin rash (14%). Sixty-two patients needed supplemental oxygen, and 6 of them underwent endotracheal intubation. Leukopenia was reported in 7, anemia in 24, and thrombocytopenia in 12 patients. 4 patients with underlying diseases including chronic renal failure, Down syndrome with cerebral palsy, and morbid obesity died.

CONCLUSION

COVID-19 can cause symptoms in children in two stages. In the first week, upper and lower respiratory symptoms can occur which has lower severity and prevalence compared to adults. But after 2-3 weeks following infection, symptoms of MIS-C or multisystem involvement can occur and COVID-19 should be considered. The most common indication for admission is fever, rash, and respiratory problems.

SARS-COV-2 infection in pregnant women and newborns in a Spanish cohort (GESNEO-COVID) during the first wave

BACKGROUND

Knowledge about SARS-CoV-2 infection in pregnancy and newborns is scarce. The objective of this study is to analyse clinical and epidemiological characteristics of a cohort of women infected with SARS-CoV-2 during pregnancy and their newborns exposed to SARS-CoV-2 during gestation.

METHODS

Multicentric observational study of Spanish hospitals from the GESNEO-COVD cohort, participants in RECLIP (Spanish Network of Paediatric Clinical Assays). Women with confirmed SARS-CoV-2 infection by PCR and/or serology during pregnancy, diagnosed and delivering during the period 15/03/2020-31/07/2020 were included. Epidemiological, clinical, and analytical data was collected.

RESULTS

A total of 105 pregnant women with a median of 34.1 years old (IQR: 28.8-37.1) and 107 newborns were included. Globally, almost 65% of pregnant women had some COVID-19 symptoms and more than 43% were treated for SARS-COV-2. Overall, 30.8% of pregnant women had pneumonia and 5 (4.8%) women were admitted to the intensive care unit needing invasive mechanical ventilation. There was a rate of 36.2% of caesarean sections, which was associated with pneumonia during pregnancy (OR: 4.203, CI 95%: 1.473-11.995) and lower gestational age at delivery (OR: 0.724, CI 95%: 0.578-0.906). The prevalence of preterm birth was 20.6% and prematurity was associated with pneumonia during gestation (OR: 6.970, CI95%: 2.340-22.750) and having a positive SARS-CoV-2 PCR at delivery (OR: 6.520, CI95%: 1.840-31.790). All nasopharyngeal PCR in newborns were negative at birth and one positivized at 15 days of life. Two newborns died, one due to causes related to prematurity and another of unexpected sudden death during early skin-to-skin contact after delivery.

CONCLUSIONS

Although vertical transmission has not been reported in this cohort, the prognosis of newborns could be worsened by SARS-CoV-2 infection during pregnancy as COVID-19 pneumonia increased the risk of caesarean section deliveries and preterm births.