Background The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men.
Recent innovations in palliative care education for medical students represent varied settings, learner levels, instructors, educational modalities, and palliative care topics. Future curricula should continue to incorporate interdisciplinary faculty. Studies could be improved by integrating longitudinal curricula and longer-term outcomes; collaborating across institutions; using validated measures; and assessing higher-level outcomes including skills, behaviors, and impact on patient care.
Objective High incidence of poor neurologic sequelae after resuscitation from cardiac arrest underscores the need for objective electrophysiological markers for assessment and prognosis. This study aims to develop a novel marker based on somatosensory evoked potentials (SSEPs). Normal SSEPs involve thalamocortical circuits suggested to play a role in arousal. Due to the vulnerability of these circuits to hypoxic-ischemic insults, we hypothesize that quantitative SSEP markers may indicate future neurologic status. Design Laboratory investigation. Setting University Medical School and Animal Research Facility. Subjects Sixteen adult male Wistar rats. Interventions None. Measurements and Main Results SSEPs were recorded during baseline, during the first 4 hrs, and at 24, 48, and 72 hrs postasphyxia from animals subjected to asphyxia-induced cardiac arrest for 7 or 9 mins (n = 8/group). Functional evaluation was performed using the Neurologic Deficit Score (NDS). For quantitative analysis, the phase space representation of the SSEPs—a plot of the signal vs. its slope—was used to compute the phase space area bounded by the waveforms recorded after injury and recovery. Phase space areas during the first 85–190 mins postasphyxia were significantly different between rats with good (72 hr NDS ≥50) and poor (72 hr NDS <50) outcomes (p = .02). Phase space area not only had a high outcome prediction accuracy (80 –93%, p < .05) during 85–190 mins postasphyxia but also offered 78% sensitivity to good outcomes without compromising specificity (83–100%). A very early peak of SSEPs that precedes the primary somatosensory response was found to have a modest correlation with the 72 hr NDS subscores for thalamic and brainstem function (p = .066) and not with sensory-motor function (p = .30). Conclusions Phase space area, a quantitative measure of the entire SSEP morphology, was shown to robustly track neurologic recovery after cardiac arrest. SSEPs are among the most reliable predictors of poor outcome after cardiac arrest; however, phase space area values early after resuscitation can enhance the ability to prognosticate not only poor but also good long-term neurologic outcomes.
Aim We tested the hypothesis that early recovery of cortical SEP would be associated with milder hypoxic-ischemic injury and better outcome after resuscitation from CA. Methods Sixteen adult male Wistar rats were subjected to asphyxial cardiac arrest. Half underwent 7 min of asphyxia (Group CA7) and half underwent 9 min (Group CA9). Continuous SEPs from median nerve stimulation were recorded from these rats for 4hr immediately following CA, and at 24, 48, and 72hr. Clinical recovery was evaluated using the Neurologic Deficit Scale. Results All rats in group CA7 survived to 72hr, while only 50% of rats in group CA9 survived to that time. Mean NDS values in the CA7 group at 24, 48, and 72hr after CA were significantly higher than those of CA9. The N10 (first negative potential at 10 ms) amplitude was significantly lower within 1 hr after CA in rats that suffered longer CA durations. SEPs were also analyzed by separating the rats into good (NDS ≥ 50) vs. bad (NDS < 50) outcomes at 72hr, again showing significant difference in N10 and peak-to-peak amplitudes between the two groups. In addition, a smaller N7 potential was consistently observed to recover earlier in all rats. Conclusions The diminished recovery of N10 is associated with longer CA times in rats. Higher N10 and peak-to-peak amplitudes during early recovery are associated with better neurologic outcomes. N7, which may represent thalamic activity, recovers much earlier than cortical responses (N10), suggesting failure of thalamocortical conduction during early recovery.
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