Caring for older adults during the COVID-19 pandemic

Risk factors for long COVID syndrome in postmenopausal women with previously reported diagnosis of COVID-19

PURPOSE

Long COVID-19 syndrome occurs in 10-20 % of people after a confirmed/probable SARS-COV-2 infection; new symptoms begin within three months of COVID-19 diagnosis and last > 8 weeks. Little is known about risk factors for long COVID, particularly in older people who are at greater risk of COVID complications.

METHODS

Data are from Women's Health Initiative (WHI) postmenopausal women who completed COVID surveys that included questions on whether they had ever been diagnosed with COVID and length and nature of symptoms. Long COVID was classified using standard consensus criteria. Using WHI demographic and health data collected at study enrollment (1993-98) through the present day, machine learning identified the top 20 risk factors for long COVID. These variables were tested in logistic regression models.

RESULTS

Of n = 37,280 survey respondents, 1237 (mean age = 83 years) reported a positive COVID-19 test and 425 (30 %) reported long COVID. Symptoms included an array of neurological, cardio-pulmonary, musculoskeletal, and general fatigue, and malaise symptoms. Long COVID risk factors included weight loss, physical and mobility limitations, and specific heath conditions (e.g., history of heart valve procedure, rheumatoid arthritis).

CONCLUSIONS

Knowledge of risk factors for long COVID may be the first step in understanding the etiology of this complex disease.

Spatial, temporal, and demographic nonstationary dynamics of COVID-19 exposure among older adults in the U.S

This study examines demographic disparities in COVID-19 exposures across older adults age 60-79 and older adults age 80 and over, and explores the factors driving these dynamics in the United States (U.S.) from January 2020 to July 2022. Spatial clusters were identified, and 14 main health determinants were synthesized from 62 pre-existing county-level variables. The study also assessed the correlation between these health determinants and COVID-19 incidence rates for both age groups during the pandemic years. Further examination of incidence rates in relation to health determinants was carried out through statistical and spatial regression models. Results show that individuals aged 80 and over had much higher hospitalization rates, death rates, and case-fatality rates in 2020-2022. Spatial results indicate that the geographical cluster of high incidence rates for both groups shifted from the Midwest at the beginning of the pandemic to the Southwest in 2022. The study revealed marked spatial, temporal, and demographic nonstationary dynamics in COVID-19 exposures, indicating that the health effects of contextual factors vary across age groups. COVID-19 incidence rates in older adults were strongly influenced by race, healthcare access, social capital, environment, household composition, and mobility. Future public health policies and mitigations should further their efforts by considering temporal and demographic nonstationarity as well as local conditions.

Disaster preparedness for people with kidney disease and kidney healthcare providers

PURPOSE OF REVIEW

Man-made and natural disasters become more frequent and provoke significant morbidity and mortality, particularly among vulnerable people such as patients with underlying kidney diseases. This review summarizes strategies to minimize the risks associated with mass disasters among kidney healthcare providers and patients affected by kidney disease.

RECENT FINDINGS

Considering patients, in advance displacement or evacuation are the only options to avoid harmful consequences of predictable disasters such as hurricanes. Following unpredictable catastrophes, one can only rely upon educational initiatives for disaster risk mitigation. Preparatory initiatives before disasters such as training courses should target minimizing hazards in order to decrease morbidity and mortality by effective interventions during and early after disasters. Retrospective evaluation of previous interventions is essential to identify adverse consequences of disaster-related health risks and to assess the efficacy of the medical response. However, preparations and subsequent responses are always open for ameliorations, even in well developed countries that are aware of disaster risks, and even after predictable disasters.

SUMMARY

Adverse consequences of disasters in patients with kidney diseases and kidney healthcare providers can be mitigated by predisaster preparedness and by applying action plans and pragmatic interventions during and after disasters. Preparing clear, practical and concise recommendations and algorithms in various languages is mandatory.

The relationship between comprehensive geriatric assessment on the pneumonia prognosis of older adults: a cross-sectional study

BACKGROUND

The mortality of pneumonia in older adults surpasses that of other populations, especially with the prevalence of coronavirus disease 2019 (COVID-19). Under the influence of multiple factors, a series of geriatric syndromes brought on by age is one of the main reasons for the poor prognosis of pneumonia. This study attempts to analyze the impact of geriatric syndrome on the prognosis of pneumonia.

METHODS

This is a prospective cross-sectional study. Patients over 65 years old with COVID-19 and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-negative community-acquired pneumonia (SN-CAP) were included in the research. General characteristics, laboratory tests, length of stay (LOS), and comprehensive geriatric assessment (CGA) were collected. Multivariate regression analysis to determine the independent predictors of the severity, mortality, and LOS of COVID-19. At the same time, the enrolled subjects were divided into three categories by clustering analysis of 10 CGA indicators, and their clinical characteristics and prognoses were analyzed.

RESULTS

A total of 792 subjects were included in the study, including 204 subjects of SN-CAP (25.8%) and 588 subjects (74.2%) of COVID-19. There was no significant difference between non-severe COVID-19 and SN-CAP regarding mortality, LOS, and CGA (P > 0.05), while severe COVID-19 is significantly higher than both (P < 0.05). The Barthel Index used to assess the activities of daily living was an independent risk factor for the severity and mortality of COVID-19 and linearly correlated with the LOS (P < 0.05). The cluster analysis based on the CGA indicators divided the geriatric pneumonia patients into three groups: Cluster 1 (n = 276), named low ability group, with the worst CGA, laboratory tests, severity, mortality, and LOS; Cluster 3 (n = 228), called high ability group with the best above indicators; Cluster 2 (n = 288), named medium ability group, falls between the two.

CONCLUSION

The Barthel Index indicates that decreased activities of daily living are an independent risk factor for the severity, mortality, and LOS of geriatric COVID-19. Geriatric syndrome can help judge the prognosis of pneumonia in older adults.

Impact of the First-Wave COVID-19 Pandemic on Medical Expenditure for Older Adults in China: Lessons from a Natural Experiment

Older adults' access to healthcare services may have been affected by the COVID-19 pandemic. This study explored the effect of the first wave pandemic on the medical expenditure of older adults in China. Difference-in-Difference models captured both temporal and geographical variation in COVID-19 exposure to estimate the impacts of the pandemic on medical expenditure through a quasi-natural experiment. Data derived from the China Family Panel Studies. Results indicate that exposure to the pandemic significantly decreased total medical expenditures, hospital expenditures, and non-hospital medical expenditures of Chinese older adults by 15% (95% CI 12%-17%), 5% (95% CI 2%-7%), and 15% (95% CI 13%-16%), respectively, for each standardized severity increment. Females, less well-educated people, and individuals without internet access were most susceptible to experiencing these reductions. This study revealed that COVID-19 exerted a detrimental influence on the medical expenditure of older adults in mainland China. The "hidden epidemic" of non-COVID-19 medical needs of older adults deserves more attention on the part of policymakers.

Depression and loneliness symptoms in Brazilian older people during the COVID-19 pandemic: a network approach

OBJECTIVES

Depression and loneliness in older people were a global challenge during the COVID-19 pandemic. Causal mechanisms to trigger depression might vary across different life events. We aimed to apply network analysis in a sample of Brazilian older people during the first wave of the COVID-19 pandemic, to investigate if loneliness and depression symptoms were connected within a psychological network. We explored how symptoms manifested and interacted, to discuss possible interventions that could mitigate late-life depression and loneliness symptoms in face of the COVID-19 pandemic.

METHOD

We collected data from 384 Brazilian older people who answered an online protocol to assess sociodemographic data, loneliness symptoms (assessed by the short version of UCLA-BR), and depression symptoms (assessed by the PHQ-2).

RESULTS

'Lack of companionship' was the bridge symptom connecting loneliness and depression communities. 'I feel shut out and excluded by others' and 'People are around me, but not with me' were the most predictable symptoms of loneliness.

CONCLUSION

Interventions aimed to promote older people's social participation and skills, combined with strategies to expand their sources of social support and combat ageism, might be relevant to mitigate symptoms of loneliness and depression in older people during a crisis like the COVID-19 pandemic.

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Skin and soft tissue infections in the elderly

PURPOSE OF REVIEW

To highlight the peculiarity of skin and soft tissue infections (SSTIs) in elderly patients and to provide useful elements for their optimal management.

RECENT FINDINGS

In the COVID-19 era, early discharge from the hospital and implementation of outpatient management is of key importance.

SUMMARY

Elderly patients are at high risk of SSTIs due to several factors, including presence of multiple comorbidities and skin factors predisposing to infections. Clinical presentation may be atypical and some signs of severity, such as fever and increase in C-reactive protein, may be absent or aspecific in this patients population. An appropriate diagnosis of SSTIs in the elderly is crucial to avoid antibiotic overtreatment. Further studies should explore factors associated with bacterial superinfections in patients with pressure ulcers or lower limb erythema. Since several risk factors for methicillin-resistant Staphylococcus aureus (MRSA) may coexist in elderly patients, these subjects should be carefully screened for MRSA risk factors and those with high risk of resistant etiology should receive early antibiotic therapy active against MRSA. Physicians should aim to several objectives, including clinical cure, patient safety, early discharge and return to community. SSTIs in the elderly may be managed using long-acting antibiotics, but clinical follow-up is needed.

Understanding actions and challenges in protecting older people during covid-19 pandemic in indonesia: A qualitative study with female caregivers

COVID-19 has rapidly impacted societies on a global scale, with older people among the most affected. To care for older people living in their own homes, female family caregivers play a pivotal role. The current study aimed to explore the actions of female family caregivers and the challenges they faced in taking care of older people living at homes during the COVID-19 pandemic in Belu district, Indonesia. This qualitative study involved twenty female family caregivers, who were recruited using a combination of purposive and snowball sampling techniques. Findings were grouped into two main categories: (i) actions of female family caregivers in taking care of older adults during the COVID-19 pandemic. These included limiting both visitations of extended family members and older adults' activities outside homes; explaining the virus to older adults and controlling their access to news, social media and smartphones; providing nutrition, supplement and maintaining daily diets; and (ii) challenges they faced in taking care of older adults included excessive fear of contracting COVID-19 and possibility of transmitting it to older people; feeling stressed; tired and overburdened. The study highlights the significant role family caregivers played to protect older people living at home. The findings can inform government to develop intervention programs that address and support the needs of both family caregivers and older people living at home.

Association of death or illness from COVID-19 among family and friends on vaccine uptake within four months of the Emergency Use Authorization. Findings from a national survey in the United States

OBJECTIVE

To examine the relationship between knowing that a friend or family member became ill with, or died from, COVID-19 and receiving a vaccine dose within four months of the FDA's Emergency Use Authorization.

METHODS

A national sample of 1,517 respondents were surveyed from April 7 to April 12, 2021, 1,193 of whom were eligible for the vaccine when the data were collected.

RESULTS

Respondents who knew someone who became ill with COVID-19 (AOR = 2.32, 95 % CI 1.74-3.09) or knew someone who died (AOR = 2.29, 95 % CI 1.32-3.99) from COVID-19 were more likely to receive at least a single COVID-19 vaccine dose.

CONCLUSION

Encouraging people to share their COVID-19 illness and bereavement experiences with their local network such as friends, families, social-networks and via social media might help increase vaccine uptake.

Predictors of survival in elderly patients with coronavirus disease 2019 admitted to the hospital: derivation and validation of the FLAMINCOV score

OBJECTIVE

To identify predictors of 30-day survival in elderly patients with coronavirus disease 2019 (COVID-19).

METHODS

Retrospective cohort study including patients with COVID-19 aged ≥65 years hospitalized in six European sites (January 2020 to May 2021). Data on demographics, comorbidities, clinical characteristics, and outcomes were collected. A predictive score (FLAMINCOV) was developed using logistic regression. Regression coefficients were used to calculate the score. External validation was performed in a cohort including elderly patients from a major COVID-19 centre in Israel. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC) in the derivation and validation cohorts. Survival risk groups based on the score were derived and applied to the validation cohort.

RESULTS

Among 3010 patients included in the derivation cohort, 30-day survival was 74.5% (2242/3010). The intensive care unit admission rate was 7.6% (228/3010). The model predicting survival included independent functional status (OR, 4.87; 95% CI, 3.93-6.03), a oxygen saturation to fraction of inspired oxygen (SpO₂/FiO₂₎ ratio of >235 (OR, 3.75; 95% CI, 3.04-4.63), a C-reactive protein level of <14 mg/dL (OR, 2.41; 95% CI, 1.91-3.04), a creatinine level of <1.3 (OR, 2.02; 95% CI, 1.62-2.52) mg/dL, and absence of fever (OR, 1.34; 95% CI, 1.09-1.66). The score was validated in 1174 patients. The FLAMINCOV score ranges from 0 to 15 and showed good discrimination in the derivation (AUC, 0.79; 95% CI, 0.77-0.81; p < 0.001) and validation cohorts (AUC, 0.79; 95% CI, 0.76-0.81; p < 0.001). Thirty-day survival ranged from 39.4% (203/515) to 95.3% (634/665) across four risk groups according to score quartiles in the derivation cohort. Similar proportions were observed in the validation set.

DISCUSSION

The FLAMINCOV score identifying elderly with higher or lower chances of survival may allow better triage and management, including intensive care unit admission/exclusion.

High-flow cannula for frail patients with SARS-CoV-2 infection non-eligible for intensive care unit management

OBJECTIVES

High-flow nasal cannula (HFNC) was widely used during the COVID-19 pandemic in intensive care units (ICU), but there is no recommendation for elderly patients non-eligible for ICU management. We aimed to describe the outcomes of HFNC treatment in patients with COVID-19 who are not eligible for ICU management.

METHODS

Retrospective bicentric cohort study performed between September 1, 2020 and June 30, 2021 in two infectious diseases departments of Colmar Hospital and Antoine Beclere University Hospital, France.

RESULTS

Sixty-four patients were treated with HFNC: 33 in Colmar and 31 in Beclere hospital (median age: 85 years; IQ, 82-92). Of these, 16 patients survived (25%). Surviving patients had a lower Charlson comorbidity index score than deceased patients (five vs six; p = 0.02).

CONCLUSIONS

Despite a high death rate, with survivors being younger and having fewer comorbidities, HFNC is an easy tool to implement in non-ICU wards for the frailest patients.

Atypical presentation of COVID-19 in older patients is associated with frailty but not with adverse outcomes

PURPOSE

Older patients with COVID-19 can present with atypical complaints, such as falls or delirium. In other diseases, such an atypical presentation is associated with worse clinical outcomes. However, it is not known whether this extends to COVID-19. We aimed to study the association between atypical presentation of COVID-19, frailty and adverse outcomes, as well as the incidence of atypical presentation.

METHODS

We conducted a retrospective observational multi-center cohort study in eight hospitals in the Netherlands. We included patients aged ≥ 70 years hospitalized with COVID-19 between February 2020 until May 2020. Atypical presentation of COVID-19 was defined as presentation without fever, cough and/or dyspnea. We collected data concerning symptoms on admission, demographics and frailty parameters [e.g., Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS)]. Outcome data included Intensive Care Unit (ICU) admission, discharge destination and 30-day mortality.

RESULTS

We included 780 patients, 9.5% (n = 74) of those patients had an atypical presentation. Patients with an atypical presentation were older (80 years, IQR 76-86 years; versus 79 years, IQR 74-84, p = 0.044) and were more often classified as severely frail (CFS 6-9) compared to patients with a typical presentation (47.6% vs 28.7%, p = 0.004). Overall, there was no significant difference in 30-day mortality between the two groups in univariate analysis (32.4% vs 41.5%; p = 0.173) or in multivariate analysis [OR 0.59 (95% CI 0.34-1.0); p = 0.058].

CONCLUSIONS

In this study, patients with an atypical presentation of COVID-19 were more frail compared to patients with a typical presentation. Contrary to our expectations, an atypical presentation was not associated with worse outcomes.

Effect of vaccine booster, vaccine type, and hybrid immunity on humoral and cellular immunity against SARS-CoV-2 ancestral strain and Omicron variant sublineages BA.2 and BA.5 among older adults with comorbidities: a cross sectional study

BACKGROUND

Vaccination reduces COVID-19-related hospitalization among older adults. However, how SARS-CoV-2 infection and vaccine regimens affect vaccine-elicited immunity remain unclear.

METHODS

This is a cross-sectional study recruiting adults aged ≥70 years with comorbidities in Hong Kong. Demographic and clinical information were collected using a questionnaire. Neutralizing antibody (nAb) titers (against ancestral and Omicron strains) and SARS-CoV-2-specific T cell response were analyzed according to infection and vaccination status. Multivariable regression analysis was performed to assess the associations of BNT162b2 and booster doses with higher nAb titers, with adjustment for comorbidities.

FINDINGS

In July 2022, 101 patients were recruited, of whom 25 (24%) had previous infection. Overall, the geometric mean titer (GMT) of BA.5 nAb was 2.8-fold lower than that against BA.2 (P < 0.0001). The ancestral strain and BA.2 titers were higher for the 3-4-dose-BNT162 group than the 2-dose-BNT162b2 group. Non-infected individuals in the 3-4-dose-CoronaVac group had a more robust T cell response than the 2-dose-CoronaVac group (P = 0.0181), but there was no significant difference between the 2-dose-BNT162b2 and 3-4-dose-BNT162b groups. Patients who had heterologous CoronaVac-BNT162b2 prime-boost regimen had 3.22-fold higher BA.5 nAb titers than those who were primed/boosted with CoronaVac (P = 0.0207). Patients with hybrid immunity had higher Omicron nAb titers than those with vaccine-only immunity. Multivariable analysis showed that BNT162b2 and booster doses were independently associated with higher ancestral strain nAb titers.

INTERPRETATION

Our data support the use of booster doses for older adults with or without prior infection. Non-infected individuals primed with CoronaVac will benefit from heterologous mRNA vaccine booster.

FUNDING

Richard and Carol Yu, May Tam Mak Mei Yin, The Shaw Foundation Hong Kong, Michael Tong, Marina Lee, Government Consultancy Service (See acknowledgements for full list).

Efficacy and Safety of Nirmatrelvir/Ritonavir, Molnupiravir, and Remdesivir in a Real-World Cohort of Outpatients with COVID-19 at High Risk of Progression: The PISA Outpatient Clinic Experience

INTRODUCTION

Different antivirals are available for the treatment of outpatients with COVID-19. Our aim was to describe a real-world experience of outpatient management of COVID-19 subjects at high risk of progression.

METHODS

This prospective observational study conducted in the University Hospital of Pisa (January 2022-July 2022) included consecutive COVID-19 outpatients with at least one risk factor for disease progression. Patients received nirmatrelvir/ritonavir, molnupiravir, or 3-day remdesivir, according to the Italian Medicines Agency (AIFA) indications. All patients were followed up until 30 days from the first positive nasopharyngeal swab. The primary endpoint was a composite of death or hospitalization. Secondary endpoints were occurrence of adverse events and a negative test within 10 days from the first positive test. Multivariable analysis was performed to identify factors associated with death or hospitalization.

RESULTS

Overall, 562 outpatients were included: 114 (20.3%) received molnupiravir, 252 (44.8%) nirmatrelvir/ritonavir, and 196 (34.9%) 3-day remdesivir. The composite endpoint occurred in 2.5% of patients and was more frequent in patients treated with remdesivir (5.1%) compared with molnupiravir (1.8%) or nirmatrelvir/ritonavir (0.8%, ANOVA among groups p = 0.012). On multivariable Cox regression analysis, presence of ≥ 3 comorbidities, hematological disease, gastrointestinal symptoms, and each-day increment from symptoms onset were factors associated with death or hospitalization, while antiviral treatment was not a predictor. Adverse events occurred more frequently in the nirmatrelvir/ritonavir group (49.2%). Nirmatrelvir/ritonavir compared with remdesivir was associated with a higher probability of having a negative test within 10 days from the first positive one.

CONCLUSION

Death or hospitalization did not differ among high-risk COVID-19 outpatients treated with currently available antivirals. Safety and time to a negative test differed among the three drugs.

Biomarkers of cell damage, neutrophil and macrophage activation associated with in-hospital mortality in geriatric COVID-19 patients

BACKGROUND

The risk for symptomatic COVID-19 requiring hospitalization is higher in the older population. The course of the disease in hospitalised older patients may show significant variation, from mild to severe illness, ultimately leading to death in the most critical cases. The analysis of circulating biomolecules involved in mechanisms of inflammation, cell damage and innate immunity could lead to identify new biomarkers of COVID-19 severity, aimed to improve the clinical management of subjects at higher risk of severe outcomes. In a cohort of COVID-19 geriatric patients (n= 156) who required hospitalization we analysed, on-admission, a series of circulating biomarkers related to neutrophil activation (neutrophil elastase, LL-37), macrophage activation (sCD163) and cell damage (nuclear cfDNA, mithocondrial cfDNA and nuclear cfDNA integrity). The above reported biomarkers were tested for their association with in-hospital mortality and with clinical, inflammatory and routine hematological parameters. Aim of the study was to unravel prognostic parameters for risk stratification of COVID-19 patients.

RESULTS

Lower n-cfDNA integrity, higher neutrophil elastase and higher sCD163 levels were significantly associated with an increased risk of in-hospital decease. Median (IQR) values observed in discharged vs. deceased patients were: 0.50 (0.30-0.72) vs. 0.33 (0.22-0.62) for n-cfDNA integrity; 94.0 (47.7-154.0) ng/ml vs. 115.7 (84.2-212.7) ng/ml for neutrophil elastase; 614.0 (370.0-821.0) ng/ml vs. 787.0 (560.0-1304.0) ng/ml for sCD163. The analysis of survival curves in patients stratified for tertiles of each biomarker showed that patients with n-cfDNA integrity < 0.32 or sCD163 in the range 492-811 ng/ml had higher risk of in-hospital decease than, respectively, patients with higher n-cfDNA integrity or lower sCD163. These associations were further confirmed in multivariate models adjusted for age, sex and outcome-related clinical variables. In these models also high levels of neutrophil elastase (>150 ng/ml) appeared to be independent predictor of in-hospital death. An additional analysis of neutrophil elastase in patients stratified for n-cfDNA integrity levels was conducted to better describe the association of the studied parameters with the outcome.

CONCLUSIONS

On the whole, biomarkers of cell-free DNA integrity, neutrophil and macrophage activation might provide a valuable contribution to identify geriatric patients with high risk of COVID-19 in-hospital mortality.

COVID-19 Clinical Features and Outcomes in Elderly Patients during Six Pandemic Waves

Many elderly patients with severe SARS-CoV-2 infections and COVID-19 infections are admitted to intensive care units. Age was previously identified as an independent risk factor for death and contributed to the greater severity of COVID-19. The elderly may have diminished lung functions, poor reactions to artificial ventilation, and compromised immune systems. However, it is yet uncertain how each pandemic wave and the predominant SARS-CoV-2 strains contribute to varying results and how patient groups such as the elderly are impacted. Comparing six COVID-19 pandemic waves, the objective of this study was to examine the variation in case severity, symptomatology, ICU hospitalizations, and mortality among SARS-CoV-2-infected elderly individuals. The study followed a retrospective design, including 60 eligible patients older than 70 years in each of the six pandemic wave groups, after matching them by the number of comorbidities and gender. SARS-CoV-2 infection during the first, third, and fourth pandemic waves had a significantly higher risk of mortality for hospitalized patients. Confusion and dyspnea at admission were significant risk factors for ICU admission in elderly patients (β = 1.92, respectively β = 3.65). The laboratory parameters identified decreased lymphocytes (β = 2.11), elevated IL-6 (β = 1.96), and procalcitonin (β = 2.46) as the most significant risk factors. The third and fourth COVID-19 waves had considerably more severe infections (31.7% and 26.7%) than the sixth wave (13.3%). Median ICU stay and percentage of patients receiving oxygen support also differed across pandemic waves. However, mortality rates between the six pandemic waves were similar. The average length of hospitalization varied dramatically among the six pandemic waves. Although senior patients are more likely to have worse COVID-19 outcomes after hospitalization, this risk is mitigated by the greater prevalence of comorbidities and frailty among the elderly. The six pandemic waves that were specifically evaluated did not reveal considerably disproportionate variations in terms of patient mortality; however, during the fourth pandemic wave, there were likely more hospitalized patients with severe COVID-19 in Romania. It is probable that certain circulating SARS-CoV-2 strains were more infectious, resulting in an increase in infections and a strain on healthcare systems, which might explain the variations found in our research.

Geriatric Health Care During the COVID-19 Pandemic: Managing the Health Crisis

COVID-19 pandemic significantly threatens the health and well-being of older adults. Aging-related changes, including multimorbidity, weakened immunity and frailty, may make older people more susceptible to severe infection and place them at higher risk of morbidity and mortality from COVID-19. Various quarantine measures have been implemented to control the spread of COVID-19. Nevertheless, such social distancing has disrupted routine health care practices, such as accessibility of medical services and long-term continuous care services. The medical management of older adults with multimorbidity is significantly afflicted by COVID-19. Older persons with frailty or multiple chronic disease may poorly adapt to the altered health care system, having detrimental consequences on their physical and mental health. COVID-19 pandemic has posed great challenges to the health of older adults. We highlighted the difficulties and obstacles of older adults during this unprecedented time. Also, we provided potential strategies and recommendations for actions to mitigate the COVID-19 pandemic threats. Certain strategies like community primary health care, medication delivery and home care support are adopted by many health facilities and caregivers, whereas other services such as internet hospital and virtual medical care are promoted to be accessible in many regions. However, guidelines and policies based on high-quality data are still needed for better health promotion of older groups with increasing resilience during the COVID-19 pandemic.

Short-course remdesivir for healthcare-associated COVID-19: case series from a non-acute care hospital

Healthcare-associated COVID-19 among vulnerable patients leads to disproportionate morbidity and mortality. Early pharmacologic intervention may reduce negative sequelae and improve survival in such settings. This study aimed to describe outcome of patients with healthcare-associated COVID-19 who received early short-course remdesivir therapy. We reviewed the characteristics and outcome of hospitalized patients who developed COVID-19 during an outbreak that involved two wards at a non-acute care hospital in Japan and received short-course remdesivir. Forty-nine patients were diagnosed with COVID-19, 34 on a comprehensive inpatient rehabilitation ward and 15 on a combined palliative care and internal medicine ward. Forty-seven were symptomatic and 46 of them received remdesivir. The median age was 75, and the median Charlson comorbidity index was 6 among those who received it. Forty-one patients had received one or two doses of mRNA vaccines, while none had received a third dose. Most patients received 3 days of remdesivir. Of the patients followed up to 14 and 28 days from onset, 41/44 (95.3%) and 32/38 (84.2%) were alive, respectively. Six deaths occurred by 38 days in the palliative care/internal medicine ward and two of them were possibly related to COVID-19. Among those who survived, the performance status was unchanged between the time of onset and at 28 days.

Phylogenetic analysis and comparative genomics of SARS-CoV-2 from survivor and non-survivor COVID-19 patients in Cordoba, Argentina

BACKGROUND

The SARS-CoV-2 virus is responsible for the COVID-19 pandemic. To better understand the evolution of SARS-CoV-2 early in the pandemic in the Province of Cordoba, Argentina, we performed a comparative genomic analysis of SARS-CoV-2 strains detected in survivors and non-survivors of COVID-19. We also carried out an epidemiological study to find a possible association between the symptoms and comorbidities of these patients with their clinical outcomes.

RESULTS

A representative sampling was performed in different cities in the Province of Cordoba. Ten and nine complete SARS-CoV-2 genomes were obtained by next-generation sequencing of nasopharyngeal specimens from non-survivors and survivors, respectively. Phylogenetic and phylodynamic analyses revealed multiple introductions of the most common lineages in South America, including B.1, B.1.1.1, B.1.499, and N.3. Fifty-six mutations were identified, with 14% of those in common between the non-survivor and survivor groups. Specific SARS-CoV-2 mutations for survivors constituted 25% whereas for non-survivors they were 41% of the repertoire, indicating partial selectivity. The non-survivors' variants showed higher diversity in 9 genes, with a majority in Nsp3, while the survivors' variants were detected in 5 genes, with a higher incidence in the Spike protein. At least one comorbidity was present in 60% of non-survivor patients and 33% of survivors. Age 75-85 years (p = 0.018) and hospitalization (p = 0.019) were associated with non-survivor patients. Related to the most common symptoms, the prevalence of fever was similar in both groups, while dyspnea was more frequent among non-survivors and cough among survivors.

CONCLUSIONS

This study describes the association of clinical characteristics with the clinical outcomes of survivors and non-survivors of COVID-19 patients, and the specific mutations found in the genome sequences of SARS-CoV-2 in each patient group. Future research on the functional characterization of novel mutations should be performed to understand the role of these variations in SARS-CoV-2 pathogenesis and COVID-19 disease outcomes. These results add new genomic data to better understand the evolution of the SARS-CoV-2 variants that spread in Argentina during the first wave of the COVID-19 pandemic.

Potential of outpatient steroid therapy in elderly patients with early COVID-19

Corticosteroids lower mortality in hospitalized patients with COVID-19 pneumonia requiring oxygen support. In this observational retrospective study (September 2020–June 2021), we explored the association between receiving home corticosteroids without oxygen supply and 30-day mortality in hospitalized patients with COVID-19 pneumonia. Among a total of 794 COVID-19 pneumonia patients, 763 were included into the study (males 68%; mean age 65 ±12 years), of whom 197 (26%) received home corticosteroids (mean daily prednisone equivalent-dose 40 mg ± 12 mg; range 10–50 mg; median 50 mg; IQR 25–50 mg; for 4 days). The overall 30-day mortality of the study population was 12%. The risk of death—adjusted for age, comorbidities, administration of remdesivir and respiratory failure severity—was lower (HR 0.405; p = 0.024) in patients receiving home corticosteroids. After stratifying the study population by age categories, home corticosteroids were associated with an adjusted decrease in mortality risk in patients > 77 years (HR 0.346; p = 0.040). Home corticosteroids may lower the 30-day mortality in elderly COVID-19 patients.