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In a large observational study in patients with COVID-19 and cancer, survival was not significantly influenced by receipt of COVID-19 treatments, except hydroxychloroquine plus any other treatment, which was associated with reduced survival., Among 2,186 U.S. adults with invasive cancer and laboratory-confirmed SARS-CoV-2 infection, we examined the association of COVID-19 treatments with 30-day all-cause mortality and factors associated with treatment. Logistic regression with multiple adjustments (e.g., comorbidities, cancer status, baseline COVID-19 severity) was performed. Hydroxychloroquine with any other drug was associated with increased mortality versus treatment with any COVID-19 treatment other than hydroxychloroquine or untreated controls; this association was not present with hydroxychloroquine alone. Remdesivir had numerically reduced mortality versus untreated controls that did not reach statistical significance. Baseline COVID-19 severity was strongly associated with receipt of any treatment. Black patients were approximately half as likely to receive remdesivir as white patients. Although observational studies can be limited by potential unmeasured confounding, our findings add to the emerging understanding of patterns of care for patients with cancer and COVID-19 and support evaluation of emerging treatments through inclusive prospective controlled trials. Significance: Evaluating the potential role of COVID-19 treatments in patients with cancer in a large observational study, there was no statistically significant 30-day all-cause mortality benefit with hydroxychloroquine or high-dose corticosteroids alone or in combination; remdesivir showed potential benefit. Treatment receipt reflects clinical decision-making and suggests disparities in medication access. This article is highlighted in the In This Issue feature, p. 1426

A 40-year-old woman was admitted to hospital with fever and cough during the pandemic of COVID-19. Past medical was notable for advanced chronic kidney disease. On admission, nucleic acid testing of a nasopharyngeal swab was positive for SARS-CoV-2. After 11 days she was considered cure with two negative tests in a row. Eight weeks later, she was going to receive a kidney transplant from a deceased donor, but she was tested again for SARS-CoV-2 and the result came out positive. After that, surgery was cancelled. In our opinion, this test should not have been performed. Through this case we overview the knowledge about infectivity, reinfection and reactivation of SARS-CoV-2. We believe who has been considered cured in the last three months should undertake immunosuppression treatment in case of transplant or cancer treatment. In these cases, benefits outweigh the eventual risks for most patients.

Serology is a crucial part of the public health response to the ongoing SARS-CoV-2 pandemic. Here, we describe the development, validation and clinical evaluation of a protein micro-array as a quantitative multiplex immunoassay that can identify S and N-directed SARS-CoV-2 IgG antibodies with high specificity and sensitivity and distinguish them from all currently circulating human coronaviruses. The method specificity was 100% for SARS-CoV-2 S1 and 96% for N antigen based on extensive syndromic (n=230 cases) and population panel (n=94) testing that also confirmed the high prevalence of seasonal human coronaviruses. To assess its potential role for both SARS-CoV-2 patient diagnostics and population studies, we evaluated a large heterogeneous COVID-19 cohort (n=330) and found an overall sensitivity of 89% (≥ 21 days post onset symptoms (dps)), ranging from 86% to 96% depending on severity of disease. For a subset of these patients longitudinal samples were provided up to 56 dps. Mild cases showed absent or delayed, and lower SARS-CoV-2 antibody responses. Overall, we present the development and extensive clinical validation of a multiplex coronavirus serological assay for syndromic testing, to answer research questions regarding to antibody responses, to support SARS-CoV-2 diagnostics and to evaluate epidemiological developments efficiently and with high-throughput.

Introdução: A vigilância sindrómica permite a identificação precoce de alterações no padrão de morbilidade da população. Este estudo tem como objetivo avaliar a utilidade de indicadores relativos a cuidados de saúde primários e hospitalares, na vigilância da COVID-19.Material e Métodos: Foi realizada uma análise de séries temporais utilizando a taxa de incidência semanal de COVID-19 em Portugal Continental, entre as semanas 14/2020 (30 março a 05 abril) e 25/2020 (15 a 21 junho), e seis indicadores: 1) consultas em cuidados de saúde primários por COVID-19; 2) número de episódios de urgência por COVID-19; 3) número de episódios de urgência por pneumonia vírica; 4) número de internamentos por pneumonia vírica; 5) proporção de episódios de urgência por pneumonia vírica face ao total de episódios de urgência por pneumonia; e 6) proporção de internamentos por pneumonia vírica face ao total de internamentos por pneumonia. Foram calculadas correlações de Pearson e correlações cruzadas.Resultados: Foi encontrada uma correlação forte entre a taxa de incidência semanal de COVID-19 e todos os indicadores [(1) 0,76; (2) 0,82; (3) 0,77; (4) 0,84; (5) 0,86; e (6) 0,90]. Os episódios de urgência e internamento por pneumonias víricas detetam variações na frequência da doença, com uma semana de antecedência. As consultas em cuidados de saúde primários e urgências por COVID-19 registam uma semana de atraso relativamente à evolução da taxa de incidência. A proporção de pneumonias víricas face ao número de pneumonias em episódios de urgência, ou internamentos, encontra-se alinhada temporalmente com a evolução da taxa de incidência semanal de COVID-19.Discussão: O atraso encontrado no padrão de evolução de consultas em CSP, e de episódios de urgência por COVID-19 face à incidência de COVID-19, poderá estar relacionado com a reorganização dos serviços de saúde e criação de códigos específicos para estas consultas. Episódios de urgência e internamentos por pneumonia vírica poderão ser úteis para a deteção precoce de possíveis surtos de COVID-19. Pneumonias víricas poderão ter sido classificadas como pneumonias de causa indeterminada. A monitorização futura destes indicadores é necessária de modo a averiguar se a incidência de COVID-19 é influenciada significativamente por alterações na estratégia de testagem. Os indicadores deste trabalho serão uma mais valia para a adequação de estratégias de testagem, alocação de recursos de saúde a comunidades mais vulneráveis à morbilidade severa e avaliação de programas de vacinação. Como tal, os sistemas de vigilância com base em registos de saúde serão um complemento valioso ao SINAVE.Conclusão: Sugere-se que os indicadores em análise sejam utilizados de forma regular, com especial atenção à informação relativa a pneumonias víricas, como forma de detetar precocemente surtos de COVID-19. A informação relativa a pneumonias de causa indeterminada poderá ser considerada na monitorização da COVID-19.

Introduction: Aerosol-generating procedures (AGPs) put the dental health care professionals (DHCPs) at a greater risk for acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In late June 2020, the Centers for Disease Control and Prevention advised elective dental procedures provision to asymptomatic patients while mandating strict infection control protocol and suggested the use of preprocedural testing as an adjunct. A cost-effective method for mass preprocedural testing is pool testing, which has specificity and sensitivity similar to polymerase chain reaction. This article aims to assess the outcomes and utility of incorporating preprocedural testing protocol for SARS-CoV-2 in dental clinics before providing AGPs. Method: The patients who were recommended AGPs where rubber dam placement was not possible were advised to undergo preprocedural testing for SARS-CoV-2. Pool testing strategy was employed, and patients were asked to get tested 48 h before the day of the procedure. Results: Out of a total of 1,000 patients, who presented from June 2020 to late July 2020, 464 were recommended dental procedures. In 194 of 464, AGPs could not be performed under rubber dam isolation; therefore, the patients were advised to get a preprocedural pool test. In total, 111 patients deferred the procedure and testing. Out of 83 who got tested, 7 were positive for SARS-CoV-2, 5 of whom were tested in early June 2020 and 2 in late July 2020. Conclusion: Pool testing within its limitations can be a useful preprocedure test in asymptomatic low-risk patients for AGP in dentistry, especially when the disease prevalence is low or moderate (Knowledge Transfer Statement: The results of this study can be used by clinicians when deciding which preprocedure testing approach they wish to use when performing aerosol-generating procedures in asymptomatic patients with consideration of cost sensitivity and specificity values.

ilustraciones, gráficas, tablas Introducción: La enfermedad por Coronavirus 2019 afecta especialmente a los pacientes inmunocomprometidos hemato-oncológicos, no solo por la historia natural de la infección viral, sino por la necesidad de reprogramar o suspender tratamientos inicialmente considerados para el control de su enfermedad de base. Esta población, con necesidad de ciclos de inicio, consolidación o mantenimiento de quimioterapia, ve impactada su calidad de vida y pronostico al no obtener a tiempo este tipo de estrategias terapéuticas. Materiales y métodos: Se realizó una revisión sistemática de la literatura. Se consultaron las bases de datos Medline vía Pubmed, Embase, Cochrane Library of Clinical Trials, Proquest Central y HINARI, a través de términos MeSH, Entry y términos libres. Entre febrero 01 de 2020 y el 14 de mayo de 2021. La tamización y selección de la evidencia se realizó por dos revisores independientes y los desacuerdos se resolvieron por consenso entre ambos. Se incluyeron estudios en inglés y español. La calidad de la evidencia fue evaluada con la herramienta de Joanna Briggs. Los hallazgos se presentan a manera de síntesis narrativa. Resultados: En total se tamizaron 487 documentos a título y resumen, y 47 documentos se revisaron a texto completo para verificar los criterios de elegibilidad. Solo un estudio fue incluido: Un programa de cribado para infección asintomática por SARS-CoV-2 en pacientes cáncer en órgano sólido en un hospital de Arabia Saudita. De 25 pacientes con tamización positiva , 28% requirieron hospitalización, el 8% requirió cuidados avanzados en la unidad de cuidados intensivos, el 88% tuvo retraso en la terapia contra el cáncer y el 12% fallecieron. La mediana del tiempo de retraso de la terapia fue de 16 días. Discusion: Teniendo en cuenta el contexto actual, limitado por la novedad que representa el diagnóstico y tratamiento de esta enfermedad, esta revisión, basada en un solo estudio incluído, sugiere que el cribado para COVID-19 podría representar un beneficio mayor al riesgo para los pacientes, permitiendo tomar medidas sobre el momento oportuno de aplicación de quimioterapia que impacten sobre morbimortalidad; todo esto teniendo en cuenta un escenario de toma de decisión basada en incertidumbre y la aplicación de los principios éticos de beneficencia y no maleficencia. (Texto tomado de la fuente). Background: In December 2019 several cases of atypical and severe viral pneumonia were documented in Wuhan, China, and a couple of weeks after this, the local and global spread increased to the point of being imperative the declaration of a pandemic by the WHO in March 11, 2020 (1). Immunocompromised patients (due to neoplastic pathology or not) have been particularly affected, not only by the natural history of the viral infection, but also by the need to reschedule or suspend treatments initially considered for the control of their underlying disease. Such is the case of patients with hematological and solid organ neoplasms. This population, who needs chemotherapy initiation, consolidation, or maintenance cycles, sees their quality of life and prognosis impacted by not obtaining these types of therapeutic strategies on time. Objective: To recognize the benefit of screening for asymptomatic SARS- Cov-2 infection in a patient with hemato-oncological pathology who is a candidate for systemic treatment with chemotherapy. Methodology: A systematic review of the literature was carried out. The Medline databases were consulted via Pubmed, Embase, Cochrane Library of Clinical Trials, Proquest Central and HINARI, using MeSH, Entry and free terms between February 01, 2020 and May 14, 2021. The screening and selection of the evidence was carried out by two independent reviewers and disagreements were resolved by consensus between the two. Studies in English and Spanish were included. The quality of the evidence was assessed with the Joanna Briggs tool. The findings are presented as a narrative synthesis. Results In total, 487 documents were screened for title and abstract, and 47 documents were reviewed in full text to verify the eligibility criteria. At the end, only one study was included, which documented a screening program for SARS-CoV-2 infection, carried out in asymptomatic patients diagnosed with solid organ cancer in a hospital in Saudi Arabia, 48 hours before the cycle of weekly chemotherapy, daily radiation therapy or chemoradiotherapy, and monthly for hormone therapy. Of 25 patients included in the study, 28% required hospitalization, 8% required advanced care in the intensive care unit, 88% had delayed cancer therapy, and 12% died. The median delay time of therapy was 16 days. Conclusion: Although currently, screening for SARS-CoV-2 infection is an increasingly accepted practice in specialized cancer centers and is widely recommended by clinical experts, this review concludes that there is currently insufficient evidence to determine the effect of screening for infection SARS-Cov-2 in hemato-oncological patients on mortality outcomes, disease progression and requirement for mechanical ventilation. New studies are required and this review may be updated in light of the new evidence. Incluye anexos Especialidades Médicas Especialista en Infectología

On 11 March 2020, the WHO declared COVID-19, an infection produced by the virus SARS-CoV-2 with a wide range of symptoms ranging from mild symptoms to severe illness, as a pandemic.1 The health authorities and governments of several countries declared confinement measures to decelerate the propagation of the disease, which resulted in sport training and competition being suspended. Professional athletes have been unable to train as usual during home confinement, and it is thought that they will have to return to sports competition in most countries once the risk of infection has been adequately reduced. On 20 March 2020, the Royal Spanish Football Federation created a task force, composed of sport physicians, sport scientists, and strength and conditioning coaches to constitute guidelines in order to resume football activities after the COVID-19 pandemic. This task force established a framework based on scientific evidence to reduce health risks on the return to competition while fostering players’ fitness levels from the resumption of training activities for the teams prior to the first official competition. The framework encompasses guidelines at three levels: (1) clinical measures to assess player’s health status after the confinement and procedures to reduce the probability of COVID-19 infection during training and competition, (2) training recommendations to develop …

ObjectiveKnowledge on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in liver transplant recipients is lacking, particularly in terms of severity of the disease. The aim of this study was to describe the demographic, baseline clinical characteristics and early outcomes of a European cohort of liver transplant recipients with SARS-CoV-2 infection.DesignWe conducted an international prospective study across Europe on liver transplant recipients with SARS-CoV-2 infection confirmed by microbiological assay during the first outbreak of COVID-19 pandemic. Baseline characteristics, clinical presentation, management of immunosuppressive therapy and outcomes were collected.Results57 patients were included (70% male, median (IQR) age at diagnosis 65 (57–70) years). 21 (37%), 32 (56%) and 21 (37%) patients had one cardiovascular disease, arterial hypertension and diabetes mellitus, respectively. The most common symptoms were fever (79%), cough (55%), dyspnoea (46%), fatigue or myalgia (56%) and GI symptoms (33%). Immunosuppression was reduced in 22 recipients (37%) and discontinued in 4 (7%). With this regard, no impact on outcome was observed. Forty-one (72%) subjects were hospitalised and 11 (19%) developed acute respiratory distress syndrome. Overall, we estimated a case fatality rate of 12% (95% CI 5% to 24%), which increased to 17% (95% CI 7% to 32%) among hospitalised patients. Five out of the seven patients who died had a history of cancer.ConclusionIn this European multicentre prospective study of liver transplant recipients, COVID-19 was associated with an overall and in-hospital fatality rate of 12% (95% CI 5% to 24%) and 17% (95% CI 7% to 32%), respectively. A history of cancer was more frequent in patients with poorer outcome.

Objectives The OVID study will demonstrate whether prophylactic-dose enoxaparin improves survival and reduces hospitalizations in symptomatic ambulatory patients aged 50 or older diagnosed with COVID-19, a novel viral disease characterized by severe systemic, pulmonary, and vessel inflammation and coagulation activation. Trial design The OVID study is conducted as a multicentre open-label superiority randomised controlled trial. Participants Inclusion Criteria 1. Signed patient informed consent after being fully informed about the study’s background. 2. Patients aged 50 years or older with a positive test for SARS-CoV2 in the past 5 days and eligible for ambulatory treatment. 3. Presence of respiratory symptoms (i.e. cough, sore throat, or shortness of breath) or body temperature >37.5° C. 4. Ability of the patient to travel to the study centre by private transportation, performed either by an accompanying person from the same household or by the patient themselves 5. Ability to comply with standard hygiene requirements at the time of in-hospital visit, including a face mask and hand disinfectant. 6. Ability to walk from car to study centre or reach it by wheelchair transport with the help of an accompanying person from the same household also complying with standard hygiene requirements. 7. Ability to self-administer prefilled enoxaparin injections after instructions received at the study centre or availability of a person living with the patient to administer enoxaparin. Exclusion Criteria 1. Any acute or chronic condition posing an indication for anticoagulant treatment, e.g. atrial fibrillation, prior venous thromboembolism (VTE), acute confirmed symptomatic VTE, acute coronary syndrome. 2. Anticoagulant thromboprophylaxis deemed necessary in view of the patient's history, comorbidity or predisposing strong risk factors for thrombosis: a. Any of the following events occurring in the prior 30 days: fracture of lower limb, hospitalization for heart failure, hip/knee replacement, major trauma, spinal cord injury, stroke, b. previous VTE, c. histologically confirmed malignancy, which was diagnosed or treated (surgery, chemotherapy, radiotherapy) in the past 6 months, or recurrent, or metastatic, or inoperable. 3. Any clinically relevant bleeding (defined as bleeding requiring hospitalization, transfusion, surgical intervention, invasive procedures, occurring in a critical anatomical site, or causing disability) within 30 days prior to randomization or sign of acute bleeding. 4. Intracerebral bleeding at any time in the past or signs/symptoms consistent with acute intracranial haemorrhage. 5. Haemoglobin 9 cells/L confirmed by recent laboratory test ( 6. Subjects with any known coagulopathy or bleeding diathesis, including known significant liver disease associated with coagulopathy. 7. Severe renal insufficiency (baseline creatinine clearance 8. Contraindications to enoxaparin therapy, including prior heparin-induced thrombocytopenia and known hypersensitivity. 9. Current use of dual antiplatelet therapy. 10. Participation in other interventional studies over the past 30 days. 11. Non-compliance or inability to adhere to treatment or lack of a family environment or support system for home treatment. 12. Cognitive impairment and/or inability to understand information provided in the study information. Patient enrolment will take place at seven Swiss centres, including five university hospitals and two large cantonal hospitals. Intervention and comparator Patients randomized to the intervention group will receive subcutaneous enoxaparin at the recommended dose of 4,000 IU anti-Xa activity (40 mg/0.4 ml) once daily for 14 days. Patients randomized to the comparator group will receive no anticoagulation. Main outcomes Primary outcome: a composite of any hospitalization or all-cause death occurring within 30 days of randomization. Secondary outcomes: (i) a composite of cardiovascular events, including deep vein thrombosis (including catheter-associated), pulmonary embolism, myocardial infarction/myocarditis, arterial ischemia including mesenteric and extremities, acute splanchnic vein thrombosis, or ischemic stroke within 14 days, 30 days, and 90 days of randomization; (ii) each component of the primary efficacy outcome, within 14 days, 30 days, and 90 days of randomization; (iii) net clinical benefit (accounting for the primary efficacy outcome, composite cardiovascular events, and major bleeding), within 14 days, 30 days, and 90 days of enrolment; (iv) primary efficacy outcome, within 14 days, and 90 days of enrolment; (v) disseminated intravascular coagulation (ISTH criteria, in-hospital diagnosis) within 14 days, 30 days, and 90 days of enrolment. Randomisation Patients will undergo block stratified randomization (by age: 50-70 vs. >70 years; and by study centre) with a randomization ratio of 1:1 with block sizes varying between 4 and 8. Randomization will be performed after the signature of the informed consent for participation and the verification of the eligibility criteria using the electronic data capture software (REDCAP, Vanderbilt University, v9.1.24). Blinding (masking) In this open-label study, no blinding procedures will be used. Numbers to be randomised (sample size) The sample size calculation is based on the parameters α = 0.05 (2-sided), power: 1−β = 0.8, event rate in experimental group, pexp = 0.09 and event rate in control group, pcon = 0.15. The resulting total sample size is 920. To account for potential dropouts, the total sample size was fixed to 1000 with 500 patients in the intervention group and 500 in the control group. Trial Status Protocol version 1.0, 14 April 2020. Protocol version 3.0, 18 May 2020 Recruiting start date: June 2020. Last Patient Last Visit: March 2021. Trial registration ClinicalTrials.gov Identifier: NCT04400799 First Posted: May 26, 2020 Last Update Posted: July 16, 2020 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

To validate the diagnostic accuracy of the Augurix SARS-CoV-2 IgM/IgG rapid immunoassay diagnostic test (RDT) for COVID-19.In this unmatched 1:1 case-control study, blood samples from 46 real-time RT-PCR-confirmed SARS-CoV-2 hospitalized cases and 45 healthy donors (negative controls) were studied. Diagnostic accuracy of the IgG RDT was assessed against both an in-house recombinant spike-expressing immunofluorescence assay (rIFA), as an established reference method (primary endpoint), and the Euroimmun SARS-CoV-2 IgG enzyme-linked immunosorbent assays (ELISA) (secondary endpoint).COVID-19 patients were more likely to be male (61% vs 20%; P = .0001) and older (median 66 vs 47 years old; P .001) than controls. Whole blood IgG-RDT results showed 86% and 93% overall Kendall concordance with rIFA and IgG ELISA, respectively. IgG RDT performances were similar between plasma and whole blood. Overall, RDT sensitivity was 88% (95% confidence interval [95%CI]: 70-96), specificity 98% (95%CI: 90-100), PPV 97% (95%CI: 80-100) and NPV 94% (95%CI: 84-98). The IgG-RDT carried out from 0 to 6 days, 7 to 14 days and 14 days after the SARS-CoV-2 RT-PCR test displayed 30%, 73% and 100% positivity rates in the COVID-19 group, respectively. When considering samples taken14 days after RT-PCR diagnosis, NPV was 100% (95%CI:90-100), and PPV was 100% (95%CI:72-100).The Augurix IgG-RDT done in whole blood displays a high diagnostic accuracy for SARS-CoV-2 IgG in high COVID-19 prevalence settings, where its use could be considered in the absence of routine diagnostic serology facilities.

INTRODUCTION: Due to the coronavirus disease 2019 (COVID-19) exposure in Denmark, first-line referral centres were established to handle all patients suspected of COVID-19 or other upper respiratory tract infection. Here we report the first experiences from a first-line referral centre from Amager-Hvidovre Hospital, situated on the outskirts of Copenhagen.METHODS: A retrospective quality assessment was performed with collection of symptom patterns and COVID-19 status.RESULTS: During the first 24 days, a total of 3,551 patients were referred for assessment of symptoms of upper respiratory tract infection and COVID-19. A total of 2,048 patients were assessed as having mild symptoms and referred for COVID-19 testing alone, whereas 337 patients were assessed clinically by a physician. Thirty-seven were positive for COVID-19 infection, 286 were negative. The most common symptoms reported were fever, coughing and dyspnoea. Fever was an independent predictor of COVID-19 infection (odds ratio (OR) = 2.25 (95% confidence interval (CI): 1.08-5.04); p = 0.037); whereas sore throat was not (OR = 0.40 (95% CI: 0.15-0.92); p = 0.045). Only a small number of patients reported loss of taste or anosmia. In total, 113 patients were admitted to hospital, the majority of patients were discharged within 24 hours with mild symptoms of upper respiratory tract infections. Three of the COVID-19-positive patients developed a severe infection and two had a fatal outcome.CONCLUSIONS: The present study is the first to report the experiences and symptom patterns of a COVID-19 first-line referral centre with efficient triage of patients in need of hospitalisation.FUNDING: none.TRIAL REGISTRATION: not relevant.

During a meeting in Munich, Germany, a presymptomatic attendee with severe acute respiratory syndrome coronavirus 2 infected at least 11 of 13 other participants. Although 5 participants had no or mild symptoms, 6 had typical coronavirus disease, without dyspnea. Our findings suggest hand shaking and face-to-face contact as possible modes of transmission.

SUMMARY BACKGROUND Healthcare personnel are at risk of becoming infected while taking upper and/or lower respiratory tract specimens. Therefore, there is a need for sampling methods that do not risk infecting them. In this study, we aimed to compare the saliva and Oro-Nasopharyngeal Swab (ONS) sampling methods. METHODS Patients were divided into three groups. Group 1 included patients whose diagnosis of COVID-19 was confirmed by polymerase chain reaction (PCR). Group 2 included patients with COVID-19 compatible findings in lung computed tomography (CT), but with a negative PCR. Group 3 included patients who presented to the emergency department with COVID-19 compatible complaints but had normal CT. Saliva and ONS samples were taken on the third day of hospitalization in groups 1 and 2, whereas in group 3, they were taken at the time of admission to the hospital. RESULTS A total of 64 patients were included in the study. The average age was 51.04 ± 17.9 years, and 37 (57.8%) were male. SARS-CoV-2 was detected in 27 (42.2%) patients’ saliva samples. While the sensitivity and positive predictive value of saliva samples were 85.2%, specificity and negative predictive value were 89.2%. The value of kappa was in substantial agreement (0.744), and it was found statistically significant (

There are questions and challenges regarding neurologic complications in COVID-19 patients. EEG is a safe and efficient tool for the evaluation of brain function, even in the context of COVID-19. However, EEG technologists should not be put in danger if obtaining an EEG does not significantly advance diagnosis or change management in the patient. Not every neurologic problem stems from a primary brain injury: confusion, impaired consciousness that evolves to stupor and coma, and headaches are frequent in hypercapnic/hypoxic encephalopathies. In patients with chronic pulmonary disorders, acute symptomatic seizures have been reported in acute respiratory failure in 6%. The clinician should be aware of the various EEG patterns in hypercapnic/hypoxic and anoxic (post-cardiac arrest syndrome) encephalopathies as well as encephalitides. In this emerging pandemic of infectious disease, reduced EEG montages using single-use subdermal EEG needle electrodes may be used in comatose patients. A full 10-20 EEG complement of electrodes with an ECG derivation remains the standard. Under COVID-19 conditions, an expedited study that adequately screens for generalized status epilepticus, most types of regional status epilepticus, encephalopathy or sleep may serve for most clinical questions, using simplified montages may limit the risk of infection to EEG technologists. We recommend noting whether the patient is undergoing or has been placed prone, as well as noting the body and head position during the EEG recording (supine versus prone) to avoid overinterpretation of respiratory, head movement, electrode, muscle or other artifacts. There is slight elevation of intracranial pressure in the prone position. In non-comatose patients, the hyperventilation procedure should be avoided. At present, non-specific EEG findings and abnormalities should not be considered as being specific for COVID-19 related encephalopathy.

A 64-year-old man presented with severe myocarditis 6 weeks after an initial almost asymptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection. He was found to have a persistent positive swab. Mechanisms explaining myocardial injury in patients with COVID-19 remains unclear, but this case suggests that severe acute myocarditis can develop in the late phase of COVID-19 infection, even after a symptom-free interval.

RT-PCRs to detect SARS-CoV-2 RNA is key to manage the COVID-19 pandemic. We analyzed SARS-CoV-2 viral loads from 22’323 RT-PCR results according to samples types, gender, age, and health units. Viral load did not show any difference across age and appears to be a poor predictor of disease outcome. SARS-CoV-2 viral load showed similar high viral loads than the one observed for RSV and influenza B. The importance of viral load to predict contagiousness and to assess disease progression is discussed.

SUMMARY OBJECTIVES The 2019 Novel coronavirus disease puts a serious burden on the health system. Therefore, the detection of particularly serious patients at an early stage is extremely important in terms of controlling the outbreak and improving the prognosis. We investigated the role of inflammatory markers studied in patients suspected of COVID-19 at an emergency department in predicting PCR and CT results. METHODS This retrospective study was carried out with 133 patients who were admitted between 13 March and 1st April 2020 with suspicion of COVID-19. The patients were divided into four groups according to CT and RT-PCR results and evaluated. RESULTS Considering all patients, no specific findings were found in the hematological and biochemical values of patients in the laboratory analyses. Although all of the results remained within the reference range, there was a significant difference in white blood cell, neutrophil, platelet, and lymphocyte values when the groups were compared [p = 0.000; p = 0.004; p = 0.022; p = 0.023]. CONCLUSION Laboratory is not specific enough in the pre-diagnosis. In addition, this result does not alter with PCR or CT positivity. However, minimal changes observed in laboratory results may be partially guiding in patients in whom both PCR and CT are positive. RESUMO OBJETIVOS A nova doença de coronavírus de 2019 coloca um fardo sério para o sistema de saúde. Portanto, a detecção de pacientes especialmente graves em um estágio inicial é extremamente importante em termos de controle do surto e melhoria do prognóstico. Investigamos o papel dos marcadores inflamatórios estudados em pacientes suspeitos de COVID-19 no pronto-socorro na previsão de resultados de PCR e CT. MÉTODOS Este estudo retrospectivo foi realizado entre 133 pacientes que foram admitidos entre 13 de março e 1o de abril de 2020 com suspeita de COVID-19. Os pacientes foram divididos em quatro grupos de acordo com os resultados da TC e RT-PCR e avaliados. RESULTADOS Considerando todos os pacientes, não foram encontrados achados específicos nos valores hematológicos e bioquímicos dos pacientes em análises laboratoriais. Embora todos os resultados tenham permanecido dentro do intervalo de referência, houve uma diferença significativa nos valores de glóbulos brancos, neutrófilos, plaquetas e linfócitos quando os grupos foram comparados [p = 0,000; p = 0,004; p = 0,022; p = 0,023]. CONCLUSÃO O laboratório não é suficientemente específico no pré-diagnóstico. Além disso, este resultado não se altera com a positividade para PCR ou CT. No entanto, alterações mínimas observadas nos resultados laboratoriais podem ser parcialmente norteadoras em pacientes com PCR e CT positivos.

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in hospitals and cancer centers. In this review based on official recommendations of different international societies, but also on local solutions found in different expert large-volume centers, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology. A literature review of potential solutions in a context of scarce anesthesiologic resources, limited staff and limited access to hospital beds are proposed and discussed based on the literature data.

The COVID-19 pandemic situation may be viewed as an opportunity to accelerate some of the ongoing transformations in modern pathology. This refers primarily to the digitalisation of the practice of tissue and cellular pathology diagnostics. However, it is also an opportunity to analyse the modus operandi of a discipline that has been practised in a similar manner for more than 100 years. The challenge is to define the next generation of interconnectivity tools that would be necessary to achieve a new operational model that, while ensuring low face-to-face interaction between the main players of the diagnostic pipeline, allows maximum interconnectivity to serve our patients and the immediate teaching and research needs associated with clinical tissue/cellular samples. This viewpoint aims to describe what this new paradigm, a low-contact and high-interconnectivity pathology (LC&HC Path) operation, may require in the near future.

Study objectiveWe aimed to describe the preparedness and response to the COVID-19 pandemic in referral EDs caring for children across Europe.MethodsWe did a cross-sectional point prevalence survey, which was developed and disseminated through the pediatric emergency medicine research networks for Europe (REPEM) and the United Kingdom and Ireland (PERUKI). We included a pre-determined number of centers based on each country population: five to ten EDs for countries with > 20 million inhabitants and one to five EDs for the other countries. ED directors or named delegates completed the survey between March 20th and 21st to report practice in use one month after the outbreak in Northern Italy. We used descriptive statistics to analyse data.ResultsOverall 102 centers from 18 countries completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on PPE items was shown for recommended PPE use at pre-triage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items. COVID-19 positive ED staff was reported in 25% of centers. Only 17% of EDs had negative pressure isolation rooms.ConclusionWe identified variability and gaps in preparedness and response to the COVID-19 epidemic across European referral EDs for children. Early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as key factors that should be optimized to improve preparedness and inform responses to future pandemics.

Children infected with SARS-CoV-2 are underrepresented during the current COVID-19 outbreak. Unlike other respiratory viruses, SARS-CoV-2 rather infects adults who subsequently infect their children. From recent Chinese and Italian data, children commonly present mild to moderate disease, a large proportion of them being asymptomatic. In particular, children present significantly less fever, cough and pneumonia compared to adults. However, more cases of pneumonia were reported from children infected with SARS-CoV-2 compared to those infected with H1N1. No vertical transmission of SARS-CoV-2 has been described so far.

During the actual pandemic of COVID-19, it has become clear that the virus causing this devastating disease, SARS-CoV2, targets not only the lungs but also other organs. In this article, we discuss the known or suspected interactions between the virus and the kidneys, as well as their clinical presentations. We also discuss how the pandemic has altered the activities of nephrologists and the logistics of a Swiss dialysis center.

Anosmia associated or not with dysgeusia seems to be a frequent symptom in cases of infection with SARS-CoV-2 responsible for COVID-19. It can be the initial symptom of the disease or remain isolated in pauci-symptomatic patients. Waiting for scientific confirmation and in the context of the current pandemic, it seems essential to consider any patient with a new anosmia as being infected with SARS-CoV-2 until proven otherwise. These patients should therefore isolate themselves and remain alert to the occurrence of other symptoms suggestive of the infection and/or be tested. Topical and systemic corticosteroids and nose washes are contraindicated. The natural course of anosmia seems to be favorable in most cases.

The Covid-19 pandemic imposes new diagnostic strategies in order to optimize the medical care of our patients. The current biblio-graphy, although of low quality, shows a sensitivity of 56 to 83 % for the Covid-19 PCR. Even though one negative test can exclude a Covid-19 in the majority of cases, the NPV (Negative Predictive Value) decreases with increasing prevalence (pre-test probability). This finding suggests the need for strict auto-isolation of patients until the resolution of their symptoms. For patients that present with typical symptoms, who have a presumed Covid-19 prevalence of -40-50 %, a negative test should be interpreted with caution and a repeat test may be needed.

Objective To review and appraise the validity and usefulness of published and preprint reports of prediction models for prognosis of patients with covid-19, and for detecting people in the general population at increased risk of covid-19 infection or being admitted to hospital or dying with the disease.Design Living systematic review and critical appraisal by the covid-PRECISE (Precise Risk Estimation to optimise covid-19 Care for Infected or Suspected patients in diverse sEttings) group.Data sources PubMed and Embase through Ovid, up to 17 February 2021, supplemented with arXiv, medRxiv, and bioRxiv up to 5 May 2020.Study selection Studies that developed or validated a multivariable covid-19 related prediction model.Data extraction At least two authors independently extracted data using the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist; risk of bias was assessed using PROBAST (prediction model risk of bias assessment tool).Results 126 978 titles were screened, and 412 studies describing 731 new prediction models or validations were included. Of these 731, 125 were diagnostic models (including 75 based on medical imaging) and the remaining 606 were prognostic models for either identifying those at risk of covid-19 in the general population (13 models) or predicting diverse outcomes in those individuals with confirmed covid-19 (593 models). Owing to the widespread availability of diagnostic testing capacity after the summer of 2020, this living review has now focused on the prognostic models. Of these, 29 had low risk of bias, 32 had unclear risk of bias, and 545 had high risk of bias. The most common causes for high risk of bias were inadequate sample sizes (n=408, 67%) and inappropriate or incomplete evaluation of model performance (n=338, 56%). 381 models were newly developed, and 225 were external validations of existing models. The reported C indexes varied between 0.77 and 0.93 in development studies with low risk of bias, and between 0.56 and 0.78 in external validations with low risk of bias. The Qcovid models, the PRIEST score, Carr’s model, the ISARIC4C Deterioration model, and the Xie model showed adequate predictive performance in studies at low risk of bias. Details on all reviewed models are publicly available at https://www.covprecise.org/.Conclusion Prediction models for covid-19 entered the academic literature to support medical decision making at unprecedented speed and in large numbers. Most published prediction model studies were poorly reported and at high risk of bias such that their reported predictive performances are probably optimistic. Models with low risk of bias should be validated before clinical implementation, preferably through collaborative efforts to also allow an investigation of the heterogeneity in their performance across various populations and settings. Methodological guidance, as provided in this paper, should be followed because unreliable predictions could cause more harm than benefit in guiding clinical decisions. Finally, prediction modellers should adhere to the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) reporting guideline.Systematic review registration Protocol https://osf.io/ehc47/, registration https://osf.io/wy245.Readers’ note This article is the final version of a living systematic review that has been updated over the past two years to reflect emerging evidence. This version is update 4 of the original article published on 7 April 2020 (BMJ 2020;369:m1328). Previous updates can be found as data supplements (https://www.bmj.com/content/369/bmj.m1328/related#datasupp). When citing this paper please consider adding the update number and date of access for clarity.

Widespread testing for the respiratory syndrome coronavirus-2 (SARS-CoV-2) will represent an important part of any strategy designed to safely reopen societies from lockdown. Healthcare settings have the potential to become reservoirs of infectivity, and therefore many hospital trusts are beginning to carry out routine screening of staff and patients. This could promote the effective cohorting of patients and reduce the rate of nosocomial infection. However, for various reasons, some individuals may refuse this testing. Here we highlight this as an emergent ethicolegal issue which we expect to become increasingly relevant as testing becomes ubiquitous. We explore this position from an ethical and legal perspective, determining whether refusal of testing is acceptable under UK law. Individual patients refusing testing could undermine a hospital's testing strategy; therefore clinicians and policy makers must prospectively determine the best course of action if this were to occur.

International audience

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) pandemic has attracted interest because of its global rapid spread, clinical severity, high mortality rate, and capacity to overwhelm healthcare systems [1, 2]. SARS-CoV-2 transmission occurs mainly through droplets, although surface contamination contributes and debate continues on aerosol transmission [3–5].

INTRODUCTION: As the coronavirus disease 2019 (COVID-19) epidemic evolves and test strategies change, understanding the concepts of testing (gold standard and test performance measures) becomes essential. The challenge of any novel disease is that the gold standard has yet to be defined.METHODS: We reanalysed published data on real-time reverse transcription quantitative polymerase chain reaction (RT-qPCR) of severe acute respiratory syndrome coronavirus-2 to illustrate how predictive values vary with disease prevalence, sensitivity (set to values between 30% and 95%) and specificity (set to 99% or 99.98%). We used published data on chest CT and RT-qPCR to examine the potential of latent class analysis to estimate the sensitivity and specificity of RT-qPCR when no single gold standard exists.RESULTS: For the various sensitivity values, the negative predictive value of a RT-qPCR test remained above 92% until a COVID-19 prevalence of > 10%. The positive predictive value (PPV) was more variable. For a sensitivity of 95% and a specificity of 99%, the PPV was less-than 10% at a prevalence of 0.1%, increasing to about 90% at a prevalence of 10%. This improved to a PPV of 85% and almost 100%, respectively, when specificity increased to 99.98%. In a restricted latent class analysis, the sensitivity was 97.1% and the specificity was 99.9%, which is similar to figures from the Danish Health Authority. However, derived predictive values depended on model specification.CONCLUSIONS: A high risk of false-positives should be considered when extending the testing strategy, whereas false-negatives may occur during local outbreaks. This may have consequences for, e.g., containment strategies and research. A confirmatory test (e.g., demonstrating seroconversion or repeated RT-qPCR) may be warranted.FUNDING: none.TRIAL REGISTRATION: not relevant.

To circumvent the limited availability of RNA extraction reagents, we aimed to develop a protocol for direct RT-qPCR to detect SARS-CoV-2 in nasopharyngeal swabs without RNA extraction. Nasopharyngeal specimens positive for SARS-CoV-2 and other coronaviruses collected in universal viral transport (UVT) medium were pre-processed by several commercial and laboratory-developed methods and tested by RT-qPCR assays without RNA extraction using different RT-qPCR master mixes. The results were compared to that of standard approach that involves RNA extraction. Incubation of specimens at 65°C for 10 minutes along with the use of TaqPath™ 1-Step RT-qPCR Master Mix provides higher analytical sensitivity for detection of SARS-CoV-2 RNA than many other conditions tested. The optimized direct RT-qPCR approach demonstrated a limit of detection of 6.6×103 copy/ml and high reproducibility (co-efficient of variation = 1.2%). In 132 nasopharyngeal specimens submitted for SARS-CoV-2 testing, the sensitivity, specificity and accuracy of our optimized approach were 95%, 99% and 98.5%, respectively, with reference to the standard approach. Also, the RT-qPCR CT values obtained by the two methods were positively correlated (Pearson correlation coefficient r=0.6971, p=0.0013). The rate of PCR inhibition by the direct approach was 8% compared to 9% by the standard approach. Our simple approach to detect SARS-CoV-2 RNA by direct RT-qPCR may help laboratories continue testing for the virus despite reagent shortages or expand their testing capacity in resource limited settings.

Many centres have noticed a high number of venous thromboembolism (VTE) events among critically ill inpatients with COVID-19 pneumonia. The aims of this study were (1) to summarise the reported risk of VTE associated with COVID-19 infections and (2) to summarise guidance documents on thromboprophylaxis in COVID-19 patients, in a systematic review.

Background Extensive measures to reduce person-to-person transmission of COVID-19 are required to control the current outbreak. Special attention is directed at healthcare professionals as reducing the risk of infection in healthcare is essential. The purpose of this study was to explore healthcare professionals’ experiences of awaiting a test result for a potential COVID-19 infection. Methods Qualitative interviews with 15 healthcare professionals were performed, underpinned by a phenomenological hermeneutical analytical framework. Results The participating healthcare professionals’ experiences of awaiting a COVID-19 test result were found to be associated with a stoic and altruistic orientation towards their work. These healthcare professionals presented a strong professional identity overriding most concerns about their own health. The result of the coronavirus test was a decisive parameter for whether healthcare professionals could return to work. The healthcare professionals were aware that their family and friends were having a hard time knowing that the COVID-19 infection risk was part of their jobs. This concern did not, however, cause the healthcare professionals to falter in their belief that they were doing the right thing by focusing on their core area. The threat to own health ran through the minds of the healthcare professionals occasionally, which makes access to testing particularly important. Conclusion The participating healthcare professionals had a strong professional identity. However, a discrepancy between an altruistic role as a healthcare professional and the expectations that come from the community was illuminated. A mental health coronavirus hotline for healthcare professionals is suggested.

Rapid and comprehensive genetic sequencing has shed light on the origin of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and allowed timely implementation of PCR tests to determine the presence of viral RNA. PCR tests for SARS-CoV-2 are some way from being reliably qualitative and will never indicate how the disease might progress in an individual. As COVID-19 becomes endemic, there is a concomitant need for accurate serological assays to detect antibodies to SARS-CoV-2 antigens and ultimately tests for prognostic markers to target treatment options.1,2 With this considerable genetic insight, and the emerging structural information, comes associated questions regarding the molecular descriptors that contribute to disease progression, especially when we consider spread across different populations. The power of mass spectrometry to generate rapid, precise, and reproducible diagnostic information that complements genomic information and accelerates our understanding of the disease, is now becoming a reality.

Highlights • We performed retrospectively RT-PCR for SARS-CoV-2 on frozen naso-pharyngeal swabs of patients with lower respiratory tract infections collected in Western Switzerland between November 2019 and March 2020. • We did not identify any case before the first officially diagnosed cases • This may suggest that the targeted screening approach was adequate when faced with a difficulties in upscaling testing capacity

Aim This study was aimed to compare the virological, suspect reported outcomes and provider preferences during COVID-19 swab taking procedure used for sampling. Methods The COVID-19 suspects are subjected to nasopharyngeal (NP) and oropharyngeal (OP) swabs for testing. Two types of swabs (Nylon and Dacron) are used for sample collection. Prospectively each suspect's response is collected and assessed for self-reported comfort level. The provider's experience with each suspect and virological outcomes recorded separately. The sample adequacy was compared based on swab types and demographic characteristics. Results A total of 1008 COVID-19 suspects were considered for comparison of various outcomes. Dacron and flocked Nylon swab sticks are used for taking 530 and 478 samples, respectively. Suspects who underwent the procedure using Nylon swabs were six times more likely to have pain/discomfort compared to when Dacron swab was used (Adj RR (95% CI: 6.76 (3.53 to 13, p=0.0001))). The providers perceived six times more resistance with the Nylon swabs compared to Dacron Swabs (Adj RR (95% CI: 5.96 (3.88 to 9.14, p=0.0001))). The pediatric population had a higher rate of blood staining in Dacron swab [Dacron 66 (80.5%); Nylon 51 (54.8%) p=0.0001]. The sample adequacy rate and laboratory positivity rate were not significantly different from each other. Conclusions Given the comparable virological outcomes, the difference in suspect and providers comfort should drive swab selection based on characteristics of the suspects. The bulbous Nylon swab caused more pain/discomfort in adults compared to Dacron.

Background COVID-19 appeared in late 2019, causing a pandemic spread. This led to a reorganisation of oncology care in order to reduce the risk of spreading infection between patients and healthcare staff. Here we analysed measures taken in major oncological units in Europe and the USA. Methods A 46-item survey was sent by email to representatives of 30 oncological centres in 12 of the most affected countries. The survey inquired about preventive measures established to reduce virus spread, patient education and processes employed for risk reduction in each oncological unit. Results Investigators from 21 centres in 10 countries answered the survey between 10 April and 6 May 2020. A triage for patients with cancer before hospital or clinic visits was conducted by 90.5% of centres before consultations, 95.2% before day care admissions and in 100% of the cases before overnight hospitalisation by means of phone calls, interactive online platforms, swab test and/or chest CT scan. Permission for caregivers to attend clinic visits was limited in many centres, with some exceptions (ie, for non-autonomous patients, in the case of a new diagnosis, when bad news was expected and for terminally ill patients). With a variable delay period, the use of personal protective equipment was unanimously mandatory, and in many centres, only targeted clinical and instrumental examinations were performed. Telemedicine was implemented in 76.2% of the centres. Separated pathways for COVID-19-positive and COVID-19-negative patients were organised, with separate inpatient units and day care areas. Self-isolation was required for COVID-19-positive or symptomatic staff, while return to work policies required a negative swab test in 76.2% of the centres. Conclusion Many pragmatic measures have been quickly implemented to deal with the health emergency linked to COVID-19, although the relative efficacy of each intervention should be further analysed in large observational studies., SCOPUS: ar.j, info:eu-repo/semantics/published