Diarrhea Is Associated with Increased Severity of Disease in COVID-19: Systemic Review and Metaanalysis

Antidiarrheal effect of Psidium guajava L. extract in acute diarrhea: a systematic review

Acute diarrheal diseases are a leading cause of childhood mortality and morbidity worldwide. Psidium guajava has been globally used for its antidiarrheal potential. We conducted a systematic review of scientific articles published up to the year 2021, which included in vivo pre-clinical tests and clinical trials involving patients with acute infectious diarrhea to verify the antidiarrheal, antibacterial and antispasmodic effects of galenic preparations or phytopharmaceuticals from P. guajava. PRISMA and Rayyan were used as tools for the selection of studies collected in four databases (Pubmed, Scopus, Web of Science and Science Direct). The keywords used to carry out the search were: 'Psidium guajava', 'guava', 'antidiarrhe*' and 'diarrhe*', joined by Boolean operators 'OR' or 'AND'. The characteristics of studies in animal models of acute diarrhea induction, as well as in vivo and in vitro motility and microbiological tests linked with its main pathophysiological mechanisms, were collected. Twenty-three articles were included. Twenty (87%) of these reported heterogenic preclinical studies, predominating pharmacological studies of efficacy against conventional antidiarrheal agents, which utilized relevant outcomes and models of infectious diarrhea from the top pathogens in the clinic along with classical castor oil-induced diarrhea associated with motility tests. Only three articles (13%) corresponded to clinical trials investigating the efficacy, dose and safety of these preparations. Most studies reported positive results and significant mechanistic evidence from antibacterial, anti-motility, anti-secretory and protective/anti-inflammatory perspectives. However, further studies are needed to define the clinical significance and safety treatment with P. guajava extracts. © 2024 Society of Chemical Industry.

Gastrointestinal Manifestations and Outcomes of COVID-19: A Comprehensive Systematic Review and Meta-analysis

Introduction Pulmonary symptoms are the most prominent manifestations of Coronavirus disease 2019 (COVID-19). However, gastrointestinal (GI) symptoms have been reported widely as well. Literature describing the relation of these symptoms with outcomes of COVID-19 patients is limited in terms of sample size, geographic diversity, and the spectrum of GI symptoms included. We aim to evaluate the association of GI symptoms with outcomes of hospitalized COVID-19 patients. Methods A systematic review and meta-analysis of observational studies assessing GI symptoms and outcomes in COVID-19 patients were undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist. Details on outcomes included ICU vs. non-ICU admission, severe vs. non-severe disease, invasive mechanical ventilation (IMV) vs. no-IMV use, oxygen saturation <90% vs. >90%, in-hospital mortality vs. discharged alive and survivors. We obtained the odds ratio (OR), 95% confidence interval (95%CI), and forest plots. Sensitivity analysis was used to analyze publication bias and heterogeneity. Results In 35 studies with 7931 confirmed COVID-19 patients, we found that anorexia (pooled OR:2.05; 95%CI: 1.36-3.09, p=0.0006) and abdominal pain (OR 2.80; 95%CI: 1.41-5.54, p=0.003) were associated with a higher risk of poor outcomes and no such association was found for diarrhea (OR 1.04; 95%CI: 0.85-1.26, p=0.71), nausea (OR 0.73; 95%CI: 0.38-1.39, p=0.34) and vomiting (OR 1.24; 95%CI 0.86-1.79, p=0.25). Conclusion The meta-analysis concludes that anorexia and abdominal pain are associated with poor outcomes in hospitalized COVID-19 patients, while diarrhea, nausea, and vomiting have no association. Future research should focus on whether detecting GI invasion in conjunction with fecal polymerase chain reaction (PCR) testing can aid in the early triage of high-risk individuals and improve outcomes.

COVID-19 screening: use of an artificial neural network

OBJECTIVES

COVID-19 is the biggest pandemic of the 21st century. The disease can be influenced by various sociodemographic factors and can manifest as clinical, pulmonary and gastrointestinal symptoms. This study used an artificial neural network (ANN) model with important sociodemographic factors as well as clinical, pulmonary and gastrointestinal symptoms to screen patients for COVID-19. Patients themselves can screen for these symptoms at home.

METHODS

Data on all registered patients were extracted in autumn. The best ANN model was selected from different combinations of connections, some hidden layers and some neurons in each hidden layer. In this study, 70% of the data were used in the network training process and the remaining 30% were used to evaluate the function of the multilayer, feed-forward, back-propagation algorithm.

RESULTS

The sensitivity and specificity of the ANN model in diagnosing patients with COVID-19 were 94.5% and 17.4%. In order of priority, clinical symptoms, sociodemographic factors, pulmonary symptoms and gastrointestinal symptoms were important predictive factors for COVID-19 using the ANN model. Screening patients for COVID-19 using clinical symptoms and sociodemographic factors (80% importance) remains essential.

CONCLUSIONS

Home monitoring of oxygen saturation and body temperature as well as old age and drug addiction can be helpful in self-screening symptoms of COVID-19 at home, thereby preventing unnecessary visits to medical centres and reducing burden on medical services.

COVID-19 und chronisch-entzündliche Darmerkrankungen

Die Pandemie durch die Coronavirus Disease 2019 (COVID-19) beeinflusst weiter das Leben von Patient*innen mit chronisch-entzündlichen Darmerkrankungen (CED). Umfangreiche Untersuchungen der letzten 3 Jahre ergaben, dass die allermeisten Infektionen durch „severe acute respiratory syndrome coronavirus type 2“ (SARS-CoV-2) bei CED-Patient*innen blande verlaufen. In der Regel wird die Krankheitsaktivität der CED nicht negativ beeinflusst; bei einem Teil der Patient*innen können passager gastrointestinale Symptome auftreten. Häufig eingesetzte immunmodulierende Medikamente hatten mit Ausnahme systemischer Glukokortikoide keinen Einfluss auf den Schweregrad einer COVID-19-Erkrankung und die Gesamtletalität unterschied sich nicht von der übrigen Bevölkerung. Die Impfantwort ist jedoch substanzabhängig erniedrigt. In dieser Übersichtsarbeit werden die wichtigsten Studien praxisrelevant zusammengefasst.

Severity of COVID-19 in Patients with Diarrhoea: A Systematic Review and Meta-Analysis

COVID-19 patients occasionally present with diarrhoea. Our objective was to estimate the risk of developing the severe disease in COVID-19 patients with and without diarrhoea and to provide a more precise estimate of the prevalence of COVID-19-associated digestive symptoms. A total of 88 studies (n = 67,794) on patients with a COVID-19 infection published between 1 January 2020 and 20 October 2022 were included in this meta-analysis. The overall prevalence of digestive symptoms was 27% (95% confidence interval (CI): 21-34%; I² = 99%). According to our data, the pooled prevalence of diarrhoea symptoms in the 88 studies analysed was 17% (95% CI: 14-20%; I² = 98%). The pooled estimate of nausea or vomiting in a total of 60 studies was 12% (95% CI: 8-15%; I² = 98%). We also analysed 23 studies with eligible individuals (n = 3800) to assess the association between the disease severity and diarrhoea. Individuals who had diarrhoea were more likely to have experienced severe COVID-19 (odds ratio: 1.71; 95% CI: 1.31-2.24; p < 0.0001; I² = 10%). Gastrointestinal symptoms and diarrhoea are frequently presenting COVID-19 manifestations that physicians should be aware of.

Non-Typical Clinical Presentation of COVID-19 Patients in Association with Disease Severity and Length of Hospital Stay

BACKGROUND

This study aimed to investigate the incidence of non-typical symptoms in ambulatory patients with mild-to-moderate COVID-19 infection and their potential association with disease progression.

MATERIALS AND METHODS

Data on the symptomatology of COVID-19 patients presenting to the fast-track emergency department were collected between March 2020 and March 2021. Fever, cough, shortness of breath, and fatigue-weakness were defined as "typical" symptoms, whereas all other symptoms such as nasal congestion, rhinorrhea, gastrointestinal symptoms, etc., were defined as "non-typical".

RESULTS

A total of 570 COVID-19 patients with a mean age of 42.25 years were included, the majority of whom were male (61.3%; N = 349), and were divided according to their symptoms into two groups. The mean length of hospital stay was found to be 9.5 days. A higher proportion of patients without non-typical symptoms were admitted to the hospital (p = 0.001) and the ICU (p = 0.048) as well. No significant differences were observed between non-typical symptoms and outcome (p = 0.685). Patients who did not demonstrate at least one non-typical symptom had an extended length of stay (p = 0.041). No statistically significant differences in length of hospital stay were associated with individual symptoms.

CONCLUSION

With the possible exception of gastrointestinal symptoms, non-typical symptoms of COVID-19 at baseline appear to predispose to a milder disease.

Contextualizing Wastewater-Based surveillance in the COVID-19 vaccination era

SARS-CoV-2 wastewater-based surveillance (WBS) offers a tool for cost-effective oversight of a population's infections. In the past two years, WBS has proven to be crucial for managing the pandemic across different geographical regions. However, the changing context of the pandemic due to high levels of COVID-19 vaccination warrants a closer examination of its implication towards SARS-CoV-2 WBS. Two main questions were raised: 1) Does vaccination cause shedding of viral signatures without infection? 2) Does vaccination affect the relationship between wastewater and clinical data? To answer, we review historical reports of shedding from viral vaccines in use prior to the COVID-19 pandemic including for polio, rotavirus, influenza and measles infection and provide a perspective on the implications of different COVID-19 vaccination strategies with regard to the potential shedding of viral signatures into the sewershed. Additionally, we reviewed studies that looked into the relationship between wastewater and clinical data and how vaccination campaigns could have affected the relationship. Finally, analyzing wastewater and clinical data from the Netherlands, we observed changes in the relationship concomitant with increasing vaccination coverage and switches in dominant variants of concern. First, that no vaccine-derived shedding is expected from the current commercial pipeline of COVID-19 vaccines that may confound interpretation of WBS data. Secondly, that breakthrough infections from vaccinated individuals contribute significantly to wastewater signals and must be interpreted in light of the changing dynamics of shedding from new variants of concern.

SARS-CoV-2 variants-associated outbreaks of COVID-19 in a tertiary institution, North-Central Nigeria: Implications for epidemic control

The COVID-19 global pandemic is being driven by evolving SARS-CoV-2 variants with consequential implications on virus transmissibility, host immunity, and disease severity. Continuous molecular and genomic surveillance of the SARS-CoV-2 variants is therefore necessary for public health interventions toward the management of the pandemic. This study is a retrospective analysis of COVID-19 cases reported in a Nigerian tertiary institution from July to December 2021. In total, 705 suspected COVID-19 cases that comprised 547 students and 158 non-students were investigated by real time PCR (RT-PCR); of which 372 (~52.8%) tested positive for COVID-19. Using a set of selection criteria, 74 (~19.9%) COVID-19 positive samples were selected for next generation sequencing. Data showed that there were two outbreaks of COVID-19 within the university community over the study period, during which more females (56.8%) tested positive than males (47.8%) (p<0.05). Clinical data together with phylogenetic analysis suggested community transmission of SARS-CoV-2 through mostly asymptomatic and/or pre-symptomatic individuals. Confirmed COVID-19 cases were mostly mild, however, SARS-CoV-2 delta (77%) and omicron (4.1%) variants were implicated as major drivers of respective waves of infections during the study period. This study highlights the importance of integrated surveillance of communicable disease during outbreaks.

Tryptophan Metabolism 'Hub' Gene Expression Associates with Increased Inflammation and Severe Disease Outcomes in COVID-19 Infection and Inflammatory Bowel Disease

The epithelial barrier's primary role is to protect against entry of foreign and pathogenic elements. Both COVID-19 and Inflammatory Bowel Disease (IBD) show commonalities in symptoms and treatment with sensitization of the epithelial barrier inviting an immune response. In this study we use a multi-omics strategy to identify a common signature of immune disease that may be able to predict for more severe patient outcomes. Global proteomic approaches were applied to transcriptome and proteome. Further semi- and relative- quantitative targeted mass spectrometry methods were developed to substantiate the proteomic and metabolomics changes in nasal swabs from healthy, COVID-19 (24 h and 3 weeks post infection); serums from Crohn's disease patients (scored for epithelial leak), terminal ileum tissue biopsies (patient matched inflamed and non-inflamed regions, and controls). We found that the tryptophan/kynurenine metabolism pathway is a 'hub' regulator of canonical and non-canonical transcription, macrophage release of cytokines and significant changes in the immune and metabolic status with increasing severity and disease course. Significantly modified pathways include stress response regulator EIF2 signaling (p = 1 × 10^-3); energy metabolism, KYNU (p = 4 × 10^-4), WARS (p = 1 × 10^-7); inflammation, and IDO activity (p = 1 × 10^-6). Heightened levels of PARP1, WARS and KYNU are predictive at the acute stage of infection for resilience, while in contrast, levels remained high and are predictive of persistent and more severe outcomes in COVID disease. Generation of a targeted marker profile showed these changes in immune disease underlay resolution of epithelial barrier function and have the potential to define disease trajectory and more severe patient outcomes.

Reduced circulating FABP2 in patients with moderate to severe COVID-19 may indicate enterocyte functional change rather than cell death

The gut is of importance in the pathology of COVID-19 both as a route of infection, and gut dysfunction influencing the severity of disease. Systemic changes caused by SARS-CoV-2 gut infection include alterations in circulating levels of metabolites, nutrients and microbial products which alter immune and inflammatory responses. Circulating plasma markers for gut inflammation and damage such as zonulin, lipopolysaccharide and β-glycan increase in plasma along with severity of disease. However, Intestinal Fatty Acid Binding Protein / Fatty Acid Binding Protein 2 (I-FABP/FABP2), a widely used biomarker for gut cell death, has paradoxically been shown to be reduced in moderate to severe COVID-19. We also found this pattern in a pilot cohort of mild (n = 18) and moderately severe (n = 19) COVID-19 patients in Milan from March to June 2020. These patients were part of the first phase of COVID-19 in Europe and were therefore all unvaccinated. After exclusion of outliers, patients with more severe vs milder disease showed reduced FABP2 levels (median [IQR]) (124 [368] vs. 274 [558] pg/mL, P < 0.01). A reduction in NMR measured plasma relative lipid-CH3 levels approached significance (median [IQR]) (0.081 [0.011] vs. 0.073 [0.024], P = 0.06). Changes in circulating lipid levels are another feature commonly observed in severe COVID-19 and a weak positive correlation was observed in the more severe group between reduced FABP2 and reduced relative lipid-CH3 and lipid-CH2 levels. FABP2 is a key regulator of enterocyte lipid import, a process which is inhibited by gut SARS-CoV-2 infection. We propose that the reduced circulating FABP2 in moderate to severe COVID-19 is a marker of infected enterocyte functional change rather than gut damage, which could also contribute to the development of hypolipidemia in patients with more severe disease.

Risk factors for mortality in kidney transplant recipients with COVID-19: a single centre experience and case-control study

BACKGROUND

COVID-19 infection is considered to cause high mortality in kidney transplant recipients (KTR). Old age, comorbidities and acute kidney injury are known risk factors for increased mortality in KTR. Nevertheless, mortality rates have varied across different regions. Differences in age, comorbidities and varying standards of care across geographies may explain some variations. However, it is still unclear whether post-transplant duration, induction therapy, antirejection therapy and co-infections contribute to increased mortality in KTR with COVID-19. The present study assessed risk factors in a large cohort from India.

METHODS

A matched case-control study was performed to analyze risk factors for death in KTR (N = 218) diagnosed with COVID-19 between April 2020 to July 2021 at the study centre. Cases were KTR who died (non-survivors, N = 30), whereas those who survived were taken as controls (survivors, N = 188).

RESULTS

A high death-to-case ratio of 13.8% was observed amongst study group KTR infected with COVID-19. There was a high incidence (12.4%) of co-infections, with cytomegalovirus being the most common co-infection among non-survivors. Diarrhea, co-infection, high oxygen requirement, and need for mechanical ventilation were significantly associated with mortality on regression analyses. Antirejection therapy, lymphopenia and requirement for renal replacement therapy were associated with worse outcomes.

CONCLUSIONS

The mortality was much higher in KTR who required mechanical ventilation and had co-infections. Mortality did not vary with the type of transplant, post-transplant duration and usage of depletion induction therapy. An aggressive approach has to be taken for an early diagnosis and therapeutic intervention of associated infections.

Clinical features of COVID-19 for integration of COVID-19 into influenza surveillance: A systematic review

Background

In November 2020, the World Health Organization (WHO) created interim guidance on how to integrate testing for SARS-CoV-2 into existing influenza surveillance systems. Influenza-like illness (ILI) and severe acute respiratory illness (SARI) case definitions have been used to specify the case definition of COVID-19 for surveillance purposes. This review aims to assess whether the common clinical features of COVID-19 have changed to the point that the criteria used to identify both COVID-19 and influenza in surveillance programs needs to be altered.

Methods

A systematic review of reviews following PRISMA-P guidelines was conducted using the "COVID-19 evidence review" database from August 19, 2020, to August 19, 2021. Reviews providing pooled estimates of the prevalence of clinical features of COVID-19 within the general population, diagnosed by polymerase chain reaction or rapid diagnostic test, were included. These were critically appraised and sensitivity analysis was undertaken to examine potential causes of bias.

Results

Fourteen reviews were identified, including three on adults only and three on children only. For all reviews, combined fever (median prevalence = 73.0%, IQR = 58.3-78.7) and cough (45.1%, IQR = 28.9-54.0) were the most common features. These were followed by loss of taste or smell (45.1%, IQR = 28.9-54.0), hypoxemia (33%, one review), fatigue (26.4%, IQR = 9.0-39.4) and expectoration (23.9%, IQR = 23.3-25.5). Fever and cough continued to be the most prevalent features for adults and children, with subsequent symptoms being similar for adults only. However, the pattern differed for children, with headache (34.3%, IQR = 18-50.7) and nasal congestion (20%, one review) being the third and fourth commonest symptoms.

Conclusions

The prevalent features found in this recent review were the same as the ones identified at the beginning of the pandemic. Therefore, the current approach of using the ILI and SARI criteria which incorporate fever and cough will identify COVID-19 cases in addition to influenza. Interestingly, children may present with different features, as headaches and nasal congestion were more common in this group. Future research could examine this further and investigate whether symptomology changes with new variants of COVID-19.

Demographic and Clinical Overview of Hospitalized COVID-19 Patients during the First 17 Months of the Pandemic in Poland

Long-term analyses of demographical and clinical characteristics of COVID-19 patients can provide a better overview of the clinical course of the disease. They can also help understand whether changes in infection symptomatology, disease severity, and outcome occur over time. We aimed to analyze the demographics, early symptoms of infection, laboratory parameters, and clinical manifestation of COVID-19 patients hospitalized during the first 17 months of the pandemic in Poland (March 2020-June 2021). The patients' demographical and clinical data (n = 5199) were extracted from the national SARSTer database encompassing 30 medical centers in Poland and statistically assessed. Patients aged 50-64 were most commonly hospitalized due to COVID-19 regardless of the pandemic period. There was no shift in the age of admitted patients and patients who died throughout the studied period. Men had higher C-reactive protein and interleukin-6 levels and required oxygenation and mechanical ventilation more often. No gender difference in fatality rate was seen, although the age of males who died was significantly lower. A share of patients with baseline SpO₂ < 91%, presenting respiratory, systemic and gastrointestinal symptoms was higher in the later phase of a pandemic than in the first three months. Cough, dyspnea and fever were more often presented in men, while women had a higher frequency of anosmia, diarrhea, nausea and vomiting. This study shows some shifts in SARS-CoV-2 pathogenicity between March 2020 and July 2021 in the Polish cohort of hospitalized patients and documents various gender-differences in this regard. The results represent a reference point for further analyses conducted under the dominance of different SARS-CoV-2 variants.

Does Fecal-Oral Transmission of SARS-CoV-2 Due to Low Sanitation Conditions Contribute to Low Mortality Rates From COVID-19

BACKGROUND

 The novel coronavirus disease 2019 (COVID-19) is a global pandemic generated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The primary infection site is mucosal surfaces, mainly the lungs and the intestine, where epithelial cells can be infected. COVID-19 has spread throughout the world, causing millions of deaths and hundreds of millions of confirmed infections. Despite the global spread of SARS-CoV-2, there are extreme differences between countries in mortality rates and confirmed infections.

METHODS

 Pearson correlations and a t-test were performed on data from 137 countries in order to test the correlation between number of deaths from diarrheal diseases (pre-COVID-19 pandemic data) as a marker for countries' sanitation level, and the number of confirmed COVID-19 cases and deaths per million.

RESULTS

 It was found that countries' prevalence of confirmed COVID-19 cases and deaths per million are statistically correlated with their sanitation level.

CONCLUSIONS

 The hypothesis proposed in this article is that the low mortality rates from COVID-19 in countries where the level of sanitation is low are due to fecal-oral infection of the population by SARS-CoV-2, rather than infection of the respiratory system. This hypothesis is supported by the protective effect of the low sanitation level presented in this work and the fact that lung infection by SARS-CoV-2 can cause severe pathology, while infection in the intestine generally causes minor or no symptoms.

Colonic expression of Ace2, the SARS-CoV-2 entry receptor, is suppressed by commensal human microbiota

Infection with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is responsible for the COVID-19 pandemic. Angiotensin-converting enzyme 2 (Ace2) is expressed in the gastrointestinal (GI) tract and a receptor for SARS-CoV-2, making the GI tract a potential infection site. This study investigated the effects of commensal intestinal microbiota on colonic Ace2 expression using a humanized mouse model. We found that colonic Ace2 expression decreased significantly upon microbial colonization. Humanization with healthy volunteer or dysbiotic microbiota from irritable bowel syndrome (IBS) patients resulted in similar Ace2 expression. Despite the differences in microbiota, no associations between α-diversity, β-diversity or individual taxa, and Ace2 were noted post-humanization. These results highlight that commensal microbiota play a key role in regulating intestinal Ace2 expression and the need to further examine the underlying mechanisms of this regulation.

Shared Food, Meals and Drinks: 10 Arguments Suggesting an Oral Transmission Route of SARS-CoV-2

Numerous observational, epidemiologic data have suggested that the risk of COVID19 is related to shared meals or drinks. The presence of ACE2 receptors in the gastrointestinal tract supports this hypothesis. Furthermore, several patients experience gastrointestinal symptoms without any respiratory disease. The SARS-CoV-2 found on food and packaging in China and the epidemic resurgence attributed to foods are also strong indications of an oral transmission route. Unprecedented biopersistence on skin, food, and beverages supports this theory. Finally, animal models reproducing the disease by oral inoculation are additional arguments in favor of an oro-digestive route of infection.