IMPORTANCE The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. OBJECTIVES To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. EXPOSURES Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. MAIN OUTCOMES AND MEASURES The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. RESULTS A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (Ն80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (Ն40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (PaO 2 :FIO 2 <100 vs Ն300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs Ն100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. CONCLUSIONS AND RELEVANCE This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.

IMPORTANCE Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. OBJECTIVE To test whether tocilizumab decreases mortality in this population. DESIGN, SETTING, AND PARTICIPANTS The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. EXPOSURES Treatment with tocilizumab in the first 2 days of ICU admission. MAIN OUTCOMES AND MEASURES Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. RESULTS Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). CONCLUSIONS AND RELEVANCE Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.

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BackgroundToddlerhood is an important age for physical activity (PA) promotion to prevent obesity and support a physically active lifestyle throughout childhood. Accurate assessment of PA is needed to determine trends/correlates of PA, time spent in sedentary, light, or moderate-vigorous PA (MVPA), and the effectiveness of PA promotion programs. Due to the limited availability of objective measures that have been validated and evaluated for feasibility in community studies, it is unclear which subgroups of toddlers are at the highest risk for inactivity. Using Actical ankle accelerometry, the objectives of this study are to develop valid thresholds, examine feasibility, and examine demographic/ anthropometric PA correlates of MVPA among toddlers from low-income families.MethodsTwo studies were conducted with toddlers (12–36 months). Laboratory Study (n = 24)- Two Actical accelerometers were placed on the ankle. PA was observed using the Child Activity Rating Scale (CARS, prescribed activities). Analyses included device equivalence reliability (correlation: activity counts of two Acticals), criterion-related validity (correlation: activity counts and CARS ratings), and sensitivity/specificity for thresholds. Community Study (n = 277, low-income mother-toddler dyads recruited)- An Actical was worn on the ankle for > 7 days (goal >5, 24-h days). Height/weight was measured. Mothers reported demographics. Analyses included frequencies (feasibility) and stepwise multiple linear regression (sMLR).ResultsLaboratory Study- Acticals demonstrated reliability (r = 0.980) and validity (r = 0.75). Thresholds demonstrated sensitivity (86 %) and specificity (88 %). Community Study- 86 % wore accelerometer, 69 % had valid data (mean = 5.2 days). Primary reasons for missing/invalid data: refusal (14 %) and wear-time ≤2 days (11 %). The MVPA threshold (>2200 cpm) yielded 54 min/day. In sMLR, MVPA was associated with age (older > younger, β = 32.8, p < 0.001), gender (boys > girls, β = −11.21, p = 0.032), maternal MVPA (β = 0.44, p = 0.002) and recruitment location (suburban > urban, β = 19.6, p < 0.001), or race (non-Black > Black, β = 18.5, p = 0.001). No association with toddler weight status.ConclusionsAnkle accelerometry is a valid, reliable, and feasible method of assessing PA in community studies of toddlers from low-income families. Sub-populations of toddlers may be at increased risk for inactivity, including toddlers that are younger, female, Black, those with less active mothers, and those living in an urban location.

Objectives: To examine (1) accuracy of maternal perceptions of toddler body size; (2) factors associated with accuracy of toddler body size; and (3) how maternal satisfaction relates to accuracy/toddler body size. Design: Cross-sectional. Setting: Low-income community sample from suburban Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)/urban pediatric clinics. Participants: Two hundred eighty-one mother-toddler dyads (toddlers: 54.1% male; mean age, 20.2 months; 70.8% African American; 8.5% underweight [<15th weight-for-length percentile]; and 29.2% overweight [≥85th weight-for-length percentile]). Main Exposure: Measured anthropometry (mother/toddler) and demographics. Outcome Measure: Validated toddler silhouette scale (accuracy and satisfaction). Results: Nearly 70% of mothers were inaccurate in assessing their toddler’s body size. Compared with mothers of healthy-weight toddlers, mothers of underweight toddlers were 9.13 times more likely to be accurate (95% CI, 2.94-28.36) and mothers of overweight toddlers were 87% less likely to be accurate (95% CI, 0.05-0.33); accuracy did not differ by toddler age, sex, or race or mother’s education or weight status. More than 70% of all mothers and 81.7% of mothers of overweight toddlers were satisfied with their toddler’s body size. Accurate mothers of underweight toddlers were less likely to be satisfied than accurate mothers of healthy-weight toddlers (30.0% vs 76.8%; P< .001). Conclusions: Mothers of overweight toddlers had inaccurate perceptions of their toddler’s body size and were highly satisfied, suggesting a view of heavy toddlers as normative. Mothers of underweight toddlers had accurate perceptions yet were dissatisfied, suggesting recognition of their child as outside the norm. Because inaccurate perceptions begin early in toddlerhood, pediatric providers should help improve families’ understanding of healthy body size. Future studies should examine how satisfaction and accuracy relate to parenting behaviors.