Abstract P699: Trends in Ischemic Stroke Risk Factors and Outcomes in a Rural Population in the United States

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Durgesh Chaudhary ◽  
Ayesha Khan ◽  
Shima Shahjouei ◽  
Mudit Gupta ◽  
Clare Lambert ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Rural Population ◽  
The United States ◽  
Stroke Recurrence ◽  
Stroke Mortality ◽  
One Year ◽  
The One

Introduction: The stroke mortality rate has gradually declined due to improved interventions and controlled risk factors. We investigated the trends in stroke risk factors and outcomes among a rural population in the United States between 2004 and 2018. Methods: We built a comprehensive stroke database called “Geisinger NeuroScience Ischemic Stroke (GNSIS)” for this study. Clinical data were extracted from multiple sources, including electronic health records and quality data. Results: Our cohort comprised of 8,561 consecutive ischemic stroke patients (mean age: 70.1±13.9 years, men: 51.6%, 95.1% Caucasian). Hypertension was the most prevalent risk factor (75.2%). The rate of hypertension, diabetes, dyslipidemia, and history of stroke increased significantly over the fifteen years window. The one-year recurrence and mortality rates were 6.3% and 15.8%, respectively. Although the one-year stroke recurrence increased from 2004 to 2018 (Cochran-Armitage test Z = -3.66, p<0.001), the one-year stroke mortality rate decreased significantly (Cochran-Armitage test Z = 2.39, p=0.008). Age >65 years, atrial fibrillation or flutter, heart failure, and prior ischemic stroke were independently associated with one-year all-cause mortality in stratified Cox proportional hazards model. In the Fine-Gray competing risk model, diabetes mellitus and age <65 years was found to be associated with one-year ischemic stroke recurrence. In the logistic regression, chronic kidney disease (CKD), diabetes, and prior ischemic stroke were predictors of one-year recurrence while age >65 years, atrial fibrillation or flutter, CKD, heart failure, prior hemorrhagic and ischemic stroke, history of neoplasm, myocardial infarction, and rheumatic diseases were predictors of one-year mortality. Conclusion: Although stroke mortality has decreased, stroke recurrence and several vascular risk factors have significantly increased in our rural population between 2004-2018. Older age, atrial fibrillation or flutter, heart failure, and prior ischemic stroke were independently associated with one-year all-cause mortality while diabetes mellitus and age less than 65 years were predictors of ischemic stroke recurrence.

scholarly journals Sex disparity in long-term stroke recurrence and mortality in a rural population in the United States

2020 ◽  
Vol 13 ◽  
pp. 175628642097189
Author(s):  
Clare Lambert ◽  
Durgesh Chaudhary ◽  
Oluwaseyi Olulana ◽  
Shima Shahjouei ◽  
Venkatesh Avula ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Rural Population ◽  
The United States ◽  
Competing Risk ◽  
Stroke Recurrence ◽  
Composite Outcome ◽  
Stroke Patients ◽  
Central Pennsylvania ◽  
All Cause Mortality

Background: Several studies suggest women may be disproportionately affected by poorer stroke outcomes than men. This study aims to investigate whether women have a higher risk of all-cause mortality and recurrence after an ischemic stroke than men in a rural population in central Pennsylvania, United States. Methods: We analyzed consecutive ischemic stroke patients captured in the Geisinger NeuroScience Ischemic Stroke research database from 2004 to 2019. Kaplan–Meier (KM) estimator curves stratified by gender and age were used to plot survival probabilities and Cox Proportional Hazards Ratios were used to analyze outcomes of all-cause mortality and the composite outcome of ischemic stroke recurrence or death. Fine–Gray Competing Risk models were used for the outcome of recurrent ischemic stroke, with death as the competing risk. Two models were generated; Model 1 was adjusted by data-driven associated health factors, and Model 2 was adjusted by traditional vascular risk factors. Results: Among 8900 adult ischemic stroke patients [median age of 71.6 (interquartile range: 61.1–81.2) years and 48% women], women had a higher crude all-cause mortality. The KM curves demonstrated a 63.3% survival in women compared with a 65.7% survival in men ( p = 0.003) at 5 years; however, the survival difference was not present after controlling for covariates, including age, atrial fibrillation or flutter, myocardial infarction, diabetes mellitus, dyslipidemia, heart failure, chronic lung diseases, rheumatic disease, chronic kidney disease, neoplasm, peripheral vascular disease, past ischemic stroke, past hemorrhagic stroke, and depression. There was no adjusted or unadjusted sex difference in terms of recurrent ischemic stroke or composite outcome. Conclusion: Sex was not an independent risk factor for all-cause mortality and ischemic stroke recurrence in the rural population in central Pennsylvania.

scholarly journals Reevaluation of risk factors for time to subsequent events after first stroke occurrence using a new weighted all-cause effect measure

2019 ◽  
Author(s):  
Ann-Kathrin Ozga ◽  
Bernhard Rauch ◽  
Frederick Palm ◽  
Christian Urbanek ◽  
Armin Grau ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Risk Factors ◽  
Atrial Fibrillation ◽  
Recurrent Stroke ◽  
Composite Endpoint ◽  
Hazard Ratio ◽  
Specific Effects ◽  
Index Stroke ◽  
One Year ◽  
The One

Abstract Background : Risk factors for stroke include atrial fibrillation, hypertension, diabetes mellitus, smoking, and high cholesterol. However, the role of these factors on subsequent cardiovascular events or death is less clear due to therapeutic measures. We therefore aim to get insights into the persistence of known risk factors on subsequent stroke or death one year after the first stroke and to illustrate how the new weighted all-cause hazard ratio can ease the interpretation of competing time-to-event endpoints with different clinical relevance. Methods : This study evaluates the one year follow-up of 470 first ever stroke cases identified in the area of Ludwigshafen, Germany, with 23 deaths and 34 subsequent stroke events. The recently introduced weighted all-cause hazard ratio was used which allows a weighting of the competing endpoints in a composite endpoint. We extended this approach to allow adjustment for covariates. The investigated risk factors were atrial fibrillation, hypertension, diabetes mellitus, smoking, and hypercholesterolemia adjusting for age and sex. Results : None of these meanwhile treated risk factors of which some have been modified after first stroke remained to be associated with subsequent death or stroke. Cause-specific effects point sometimes into opposite directions. Conclusions : Using the new weighted hazard ratio, we can support that well established risk factors for the occurrence of an index stroke are no good predictors of further disease progress defined by death or recurrent stroke. It has been demonstrated that the new weighted hazard ratio provides interpretation advantages over the common all-cause hazard ratio.

scholarly journals ISCHEMIC STROKE

2018 ◽  
Vol 25 (01) ◽  
pp. 84-89
Author(s):  
Muhammad Naveed Alam ◽  
Tahir Habib Rizvi ◽  
Memoona Alam ◽  
Muhammad Tahir
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Congestive Heart Failure ◽  
Ischemic Stroke ◽  
Artery Bypass ◽  
Bypass Grafting ◽  
Contributing Factors ◽  
Cross Sectional ◽  
History Of

Objectives: To determine the frequency and contributing factors of atrialfibrillation in patients with first ischemic stroke. Methodology: This study included 150 patientswith first acute ischemic stroke. All the patients had electrocardiography to detect the presenceof atrial fibrillation. The patients were also labeled for risk factors like hypertension, congestiveheart failure, smoking, and hyperthyroidism, etc. Setting: Mayo Hospital Lahore. Duration ofStudy: 1st January 2013 to 30th June 2013. Type: Descriptive Cross Sectional. Results: Atrialfibrillation was present among 22 (14.6%) patients. Among patients with atrial fibrillation,smoking, congestive heart failure and hypertension were the most frequent risk factors whichwere present in 11 (50%), 6 (27%), and 5 (22.7%) patients, respectively. Conclusion: Frequencyof atrial fibrillation among patients with first ischemic stroke was high. Smoking, congestiveheart failure and history of coronary artery bypass grafting are frequent risk factors.

scholarly journals Experiences With Intravenous Thrombolysis in Acute Ischemic Stroke by Elderly Patients–A “Real World Scenario”

2021 ◽  
Vol 12 ◽  
Author(s):  
Máté Héja ◽  
István Fekete ◽  
László Horváth ◽  
Sándor Márton ◽  
Klára Edit Fekete
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Intravenous Thrombolysis ◽  
Stroke Severity ◽  
Complication Rates ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase ◽  
One Year ◽  
The One

Objectives: This retrospective single-center study aimed to investigate the risk factors, outcomes and complication rates in patients older vs. younger than 80 years treated with intravenous alteplase.Methods: Data of 1,253 thrombolysed patients were analyzed between January 1, 2004 and August 31, 2016. Vascular risk factors, stroke severity based on the NIHSS score, functional outcome using modified Rankin Scale (mRS), mortality and symptomatic intracerebral hemorrhage (SICH) were compared between two subgroups (&lt;80 and ≥80 years).Results: 1,125 patients were included, 199 (17.6%) among them were aged over 80 years, majority (63.3%) were female (p &lt; 0.00001). Mean age was 68.2 ± 12.4 years, i.e., 64.7 ± 10.8 years and 84.3 ± 3.4 years in the younger and the older groups, respectively (p &lt; 0.001). Atrial fibrillation and pre-stroke anticoagulation among patients over 80 years was more likely (p &lt; 0.0005 and p = 0.02, respectively). NIHSS scores on admission and at 24 h were higher in elderly patients (p &lt; 0.0001). ASPECT score at 24 h was less favorable in elderly patients (p = 0.007) and was associated with worse outcome. At 3 months, 59.8% of the patients from the older group had an unfavorable outcome (p &lt; 0.0001), however 34.7% had independent outcome. The one-year- survival was significantly worse in the older group (p &lt; 0.0001). The incidence of SICH was lower among older patients. In a logistic regression model, atrial fibrillation, heart failure, diabetes mellitus and smoking were proven as a significant independent risk factors for worse outcome.Conclusion: Although, the outcomes were less favorable in patients over 80 years of age, our results support the feasibility of using intravenous thrombolysis among patients over 80 years of age.

Abstract 2157: Racial Differences in Hospitalizations for Atrial Fibrillation in the United States

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Paul B Tabereaux ◽  
Todd M Brown ◽  
Jose Osorio ◽  
G. N Kay ◽  
Dawn M Bravada
Keyword(s):  
Diabetes Mellitus ◽  
United States ◽  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
The United States ◽  
Principal Diagnosis ◽  
Common Risk Factors

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the United States; however a paucity of population-based data about nonwhite individuals exist. The objectives of this study were to compare hospitalizations among Whites and African Americans (AA) and to determine whether race is an independent predictor of hospitalization for AF in the United States. Methods: Data was obtained from the National Hospital Discharge Survey (years 1996 –2005) and included hospitalizations with a principal diagnosis of AF for patients aged ≥18 yrs and race designated as either White or AA. Codes from the International Classification of Diseases -9th revision were used to define AF (427.31), hypertension (401– 405), ischemic heart disease (410 – 414), diabetes mellitus (250), heart failure (425,428) and valvular heart disease (424). Multivariable analysis with logistic regression was used to identify factors that were independently associated with AF hospitalizations Results: Among 297,962,043 hospitalizations between 1996 –2005, 3,676,787 (1.2%) had a principal diagnosis of AF. Among the hospitalizations for AF, white race was more common than AA race (2,393,659/186,904,962 of whites (1.3% of white’s hospitalized) and 209,788/33,972,665 of African Americans (0.6% of AA’s hospitalized), p<0.0001). After adjusting for the most common risk factors for AF (age, sex, hypertension, ischemic heart disease, diabetes mellitus, heart failure and valvular heart disease) AA race was independently associated with a decreased odds of hospitalizations for AF (Table 1 : adjusted OR=0.49, 95%CI 0.46 – 0.51). Conclusions: After adjusting for the most common risk factors for AF, the odds of hospitalization for AF in AA’s remained half that of whites. Race may be a novel and unaccounted risk factor for atrial fibrillation.

scholarly journals Stroke hospitalization and case-fatality in the United States, 1988–1997

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 320-320
Author(s):  
Jing Fang ◽  
Hillel Cohen ◽  
Michael H Alderman
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Ischemic Stroke ◽  
Case Fatality ◽  
The United States ◽  
Hospital Death ◽  
Stroke Mortality ◽  
Hospital Case ◽  
Hospitalization Rates ◽  
The Us

23 Age-adjusted stroke mortality in the US has declined in recent decades. However, little is known about stroke morbidity. Using the National Hospital Discharge Survey data from 1988 to 1997, we examined the change in stroke hospitalization and case-fatality in the US. During the 10 years, age-adjusted stroke hospitalization rate increased 22% (from 381 to 463/100,000, p=0.048). By regions, stroke hospitalization rates overall were 641, 600, 562 and 438 for the South, Midwest, Northeast, and West respectively (p<0.05), and were increased in all regions during the 10 years. Overall, 58% of stroke hospitalizations were due to ischemic stroke, 13% due to hemorrhagic stroke, and 29% were classified as other stroke. The hospitalization rates were 74.8 and 332.4 per 100,000 respectively for hemorrhagic and ischemic strokes and the increase rate in 10 years were 13.5% (p=0.214) and 31.5% (p=0.044) respectively. During 10 years, stroke patients with diabetes, hypertension and congestive heart failure increased 17.4% (p=0.17), 34% (p=0.05), and 31% (p=0.091) respectively. The average length of hospital stay reduced from 11.1 to 6.2 days (decrease of 44.1%), with an average annual percentage decrease of 6.1% (p=0.012). Although the total number of patients hospitalized for stroke increased during this period, the total person-days in hospital decreased 22% (p=006). In-hospital death among stroke decreased steadily from 12.7% to 7.6% (decrease of 40%, p=0.04). In-hospital case-fatality was estimated by stratifying patients on age, gender, region, type of stroke, and other co-morbidity. Case-fatality rate was substantially higher among patients with hemorrhagic than ischemic stroke (28.0% vs 5.8%, p<0.01); among patients with congestive heart failure than those without (17.9% vs 8.5%). In addition, patients of old age (≥75 years), men, those living in the Northeast had higher case-fatality rates than those younger, women and living in elsewhere. In conclusion, the declining of age-adjusted stroke mortality in the US has not been found to be related to the decrease in incidence. However, the observed reduction in hospital case-fatality might contribute to the decline of stroke mortality.

scholarly journals Acute Ischemic Stroke and COVID-19

Stroke ◽  
2021 ◽  
Author(s):  
Adnan I. Qureshi ◽  
William I. Baskett ◽  
Wei Huang ◽  
Daniel Shyu ◽  
Danny Myers ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Emergency Department ◽  
Ischemic Stroke ◽  
Relative Risk ◽  
Acute Ischemic Stroke ◽  
Health Care Facilities ◽  
Stroke Patients ◽  
Care Facilities

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P <0.0001) after adjusting for potential confounders. A total of 199 (1.0%) patients developed acute ischemic stroke among 19 513 patients without COVID-19. Among all ischemic stroke patients, COVID-19 was associated with discharge to destination other than home or death (relative risk, 1.2 [95% CI, 1.0–1.3]; P =0.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.

scholarly journals Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes

Stroke ◽  
2019 ◽  
Vol 50 (7) ◽  
pp. 1838-1845 ◽  
Author(s):  
Tiberiu A. Pana ◽  
David J. McLernon ◽  
Mamas A. Mamas ◽  
Joao H. Bettencourt-Silva ◽  
Anthony K. Metcalf ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Odds Ratio ◽  
Stroke Recurrence ◽  
Stroke Outcomes ◽  
Long Term Mortality

Background and Purpose— We aimed to determine individual and combined effects of atrial fibrillation (AF) and heart failure (HF) on acute ischemic stroke outcomes: in-hospital mortality, length-of-stay, and poststroke disability; long-term mortality and stroke recurrence. Methods— Prospective cohort study of patients with acute ischemic stroke admitted to a UK center with a catchment population of ≈900 000 between 2004 and 2016. Exposure groups were patients with neither AF nor HF (reference group), those with AF but without HF, those with HF but without AF, and those with AF+HF. Logistic and Cox regressions were used to model in-hospital and long-term outcomes, respectively. Results— A total of 10 816 patients with a mean age±SD =77.9±12.1 years, 48% male were included. Only 30 (4.9%) of the patients with HF but not AF were anticoagulated at discharge. Both AF (odds ratio, 1.24 [95% CI, 1.07–1.43]), HF (odds ratio, 1.40 [1.10–1.79]), and their combination (odds ratio, 2.23 [1.83–2.72]) were associated with increased odds of in-hospital mortality. All 3 exposure groups were associated with increased length-of-stay, while only AF predicted increased disability (1.36 [1.12–1.64]). Patients were followed for a median of 5.5 and 3.7 years for mortality and recurrence, respectively. Long-term mortality was associated with AF (hazard ratio, 1.45 [95% CI, 1.33–1.59]), HF (2.07 [1.83–2.36]), and their combination (2.20 [1.96–2.46]). Recurrent stroke was associated with AF 1.50 (1.26–1.78), HF (1.33 [1.01–1.75]), and AF with HF (1.62 [1.28–2.07]). Conclusions— The AF-associated excess risk of stroke recurrence was independent of comorbid HF. HF without AF was also associated with a significant risk of recurrence. Anticoagulation for secondary stroke prevention in patients with HF without AF may require further evaluation in a clinical trial setting.

Abstract P693: Sex Disparity in Long-Term Stroke Recurrence and Mortality in a Rural Population in the United States

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Clare M Lambert ◽  
Oluwaseyi Olulana ◽  
Durgesh Chaudhary ◽  
Shima Shahjouei ◽  
Venkatesh Avula ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Rural Population ◽  
The United States ◽  
Competing Risk ◽  
Stroke Recurrence ◽  
Composite Outcome ◽  
Stroke Patients ◽  
Central Pennsylvania ◽  
All Cause Mortality

Introduction: Several studies suggest women may be disproportionately affected by poorer stroke outcomes than men. This study aimed to investigate if women had a higher risk of all-cause mortality and recurrence after an ischemic stroke in a rural population in central Pennsylvania, United States. Methods: We analyzed consecutive ischemic stroke patients captured in our comprehensive research database from 2004 to 2019. Kaplan-Meier (KM) estimator curves stratified by gender and age were used to plot survival probabilities and Cox Proportional Hazards Ratios were used to analyze outcomes of all-cause mortality and the composite outcome of ischemic stroke recurrence or death. Fine-Gray Competing Risk models were used for the outcome of recurrent ischemic stroke, with death as the competing risk. Two models were generated; Model 1 was adjusted by data-driven associated health factors, and Model 2 was adjusted by traditional vascular risk factors. Results: Among 8,900 adult ischemic stroke patients (median age of 71.6 [IQR:61.1-81.2] years and 48% women), women had a higher crude all-cause mortality. The KM curves demonstrated a 63.3% survival in women compared to a 65.7% survival in men (p=0.003) at five years; however, the survival difference was not present after adjustment by the associated factors of age, atrial fibrillation or flutter, myocardial infarction, diabetes mellitus, dyslipidemia, heart failure, chronic lung diseases, rheumatic disease, chronic kidney disease, neoplasm, peripheral vascular disease, past ischemic stroke, past hemorrhagic stroke, and depression. There was no adjusted or unadjusted sex difference in terms of recurrent ischemic stroke or composite outcome. Conclusion: Sex was not an independent risk factor for all-cause mortality and ischemic stroke recurrence in the rural population in central Pennsylvania.

Abstract MP41: Acute Ischemic Stroke and Coronavirus Disease 2019: An Analysis of 27,676 Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Adnan I Qureshi ◽  
William Baskett ◽  
Wei Huang ◽  
Daniel Shyu ◽  
Danny Myers ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Relative Risk ◽  
Confidence Interval ◽  
Acute Ischemic Stroke ◽  
Stroke Patients ◽  
Healthcare Facilities

Background and Purpose: Acute ischemic stroke may occur in patients with Coronavirus disease 2019 but risk factors, in hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, co-morbidities, and outcomes in patients with Coronavirus disease 2019 with or without acute ischemic stroke and compared with patients without Coronavirus disease 2019 and acute ischemic stroke. Methods: We analyzed the data from 54 healthcare facilities using the Cerner de-identified Coronavirus disease 2019 dataset. The dataset included patients with an emergency department or inpatient encounter with a discharge diagnoses codes that could be associated to suspicion of or exposure to Coronavirus disease 2019, or confirmed Coronavirus disease 2019. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8,163 patients with Coronavirus disease 2019. Among all Coronavirus disease 2019 patients, the proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk 2.1, 95% confidence interval 1.7-2.4, p<.0001) after adjusting for potential confounders. A total of 199 (1.0%) patients developed acute ischemic stroke among 19,513 patents without Coronavirus disease 2019. Among all ischemic stroke patients, Coronavirus disease 2019 was associated with discharge to destination other than home or death (relative risk 1.2, 95% confidence interval 1.0-1.3, p=.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with Coronavirus disease 2019 and usually occurs in presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased two folds with occurrence of acute ischemic stroke in patients with Coronavirus disease 2019.

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