Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1966 (Published 22 May 2020) Cite this as: BMJ 2020;369:m1966Linked Editorial
Covid-19 related hospital admissions in the United States
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Dear Editors
I wish to correct an obvious mistake made in my previous rapid response. (Ref 1)
I meant to write:
“Similarly the academic background of the medical center may also result in a skewed delayed presentation of UNinsured patients compared to other hospitals as ambulances may have been directed to distribute patients according to their insurance status.” (The correction in capital letters)
Thank you
Reference
1. https://www.bmj.com/content/369/bmj.m1966/rr
Competing interests: No competing interests
Dear Editors
I wonder if the authors considered another way of analysing their data in consideration of equity in access to healthcare.
Between 10-20% of New York City residents are uninsured for healthcare; uninsured rates among Hispanic people are at least 3x those who self identify as non-Hispanic white people.
As a result, it may be possible that there are racial differences in the advanced stage of COVID-19 requiring admission due to unwillingness to present for healthcare attention from the lack of healthcare coverage, including calling for an ambulance. Similarly the academic background of the medical center may also result in a skewed delayed presentation of insured patients compared to other hospitals as ambulances may have been directed to distribute patients according to their insurance status.
While not a fatal flaw in this study, the insurance status of patients may assist in understanding the equity issues and variation by ethnicity (if any), thereby giving some context to how the data can be viewed, and perhaps reframed.
Competing interests: No competing interests
Body temperature is also associated with hospitalization and critical illness of COVID-19
Dear Editor
Petrilli et al.1 analyzed the factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City, USA. They concluded that the strongest hospitalization risks were age ≥75 years, age 65-74, obesity and heart failure, and the strongest critical illness risks were admission oxygen saturation <88%, d-dimer >2500, ferritin >2500 and C-reactive protein >200.1 However all these biochemical tests rely on sophisticated equipments, and some convenient and efficient hospitalization-risk or severity-prediction methods still need to be developed urgently.
The most common symptom at onset of illness was fever.2 A clinical study of 1099 cases from Dec 11, 2019 to Jan 29, 2020 national-wide in China found that fever (definition of ≥37.5°C) was present in 43.8% of the patients on admission, but developed in 88.7% during hospitalization.2 The average body temperature of the patients on admission was 37.3°C, and the average maximum temperature during hospitalization was 38.3°C,2 which were 0.5°C and 1.5°C higher than the normal body temperature of 36.8°C respectively.3 Interestingly, although there is no significant difference in the median temperature on admission (37.3°C and 37.4°C for non-severe patients and severe patients respectively), the proportion of the severe patients with temperatures >38.0°C (38.1-39.0°C 21.6%; >39.0°C 4.7%) was higher than that of the mild patients with temperatures >38.0°C (38.1-39.0°C 17.6%; >39.0°C 3.3%).2 While Petrilli et al.1 collected clinical features of 4,103 patients in New York City, and similarly found that the average temperatures at presentation for non-hospitalized patients and hospitalized patients were 37.3°C and 37.5°C respectively.1 The proportions of temperatures ≥ 38°C at presentation were 5.0% and 33.5% for non-hospitalized patients and hospitalized patients respectively.1 And a little higher median temperatures have been reported in 36 children patients in Zhejiang, China (37.6°C and 38.0°C for mild cases and moderate cases respectively).4
In summary, body temperature is a good indicator for the viral infection. Body temperature ≥ 37.3°C or at least a rise of 0.5°C would be a diagnostic criteria or indicate a hospitalization risk. While body temperature ≥38°C implies a critical illness risk.
However in clinical practice, a rise of 0.5°C could not be discriminated accurately. The individual's body temperature changes significantly within a day (<1.0°C), influenced by diet, exercise state, mental factors and so on.5 In order to reflect the changing trend more accurately, axillary temperatures should be monitored every morning (immediately after getting up) and every night (about 2 hours after supper). And we should pay attention to the patients with temperatures ≥38.0°C, whose blood biochemical indexes should be measured immediately to better determine the severity of disease.
References
01. Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ 2020;369:m1966. doi:10.1136/bmj.m1966. pmid:32444366
02. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20. doi:10.1056/NEJMoa2002032. pmid:32109013
03. Geneva II, Cuzzo B, Fazili T, Javaid W. Normal body temperature: a systematic review. Open Forum Infect Dis 2019;6:ofz032. doi:10.1093/ofid/ofz032. pmid:30976605
04. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis 2020;20:689-96. doi:10.1016/S1473-3099(20)30198-5. pmid:32220650
05. Rodbard D, Wachslicht-Rodbard H, Rodbard S. Temperature: a critical factor determining localization and natural history of infectious, metabolic, and immunological diseases. Perspect Biol Med 1980;23:439-74. doi:10.1353/pbm.1980.0062. pmid:6994063
Competing interests: No competing interests