Epidemiological and clinical characteristics analysis of COVID-19 in the surrounding areas of Wuhan, Hubei Province in 2020

Assessing changes in incubation period, serial interval, and generation time of SARS-CoV-2 variants of concern: a systematic review and meta-analysis

BACKGROUND

After the first COVID-19 wave caused by the ancestral lineage, the pandemic has been fueled from the continuous emergence of new SARS-CoV-2 variants. Understanding key time-to-event periods for each emerging variant of concern is critical as it can provide insights into the future trajectory of the virus and help inform outbreak preparedness and response planning. Here, we aim to examine how the incubation period, serial interval, and generation time have changed from the ancestral SARS-CoV-2 lineage to different variants of concern.

METHODS

We conducted a systematic review and meta-analysis that synthesized the estimates of incubation period, serial interval, and generation time (both realized and intrinsic) for the ancestral lineage, Alpha, Beta, and Omicron variants of SARS-CoV-2.

RESULTS

Our study included 280 records obtained from 147 household studies, contact tracing studies, or studies where epidemiological links were known. With each emerging variant, we found a progressive shortening of each of the analyzed key time-to-event periods, although we did not find statistically significant differences between the Omicron subvariants. We found that Omicron BA.1 had the shortest pooled estimates for the incubation period (3.49 days, 95% CI: 3.13-4.86 days), Omicron BA.5 for the serial interval (2.37 days, 95% CI: 1.71-3.04 days), and Omicron BA.1 for the realized generation time (2.99 days, 95% CI: 2.48-3.49 days). Only one estimate for the intrinsic generation time was available for Omicron subvariants: 6.84 days (95% CrI: 5.72-8.60 days) for Omicron BA.1. The ancestral lineage had the highest pooled estimates for each investigated key time-to-event period. We also observed shorter pooled estimates for the serial interval compared to the incubation period across the virus lineages. When pooling the estimates across different virus lineages, we found considerable heterogeneities (I2 > 80%; I2 refers to the percentage of total variation across studies that is due to heterogeneity rather than chance), possibly resulting from heterogeneities between the different study populations (e.g., deployed interventions, social behavior, demographic characteristics).

CONCLUSIONS

Our study supports the importance of conducting contact tracing and epidemiological investigations to monitor changes in SARS-CoV-2 transmission patterns. Our findings highlight a progressive shortening of the incubation period, serial interval, and generation time, which can lead to epidemics that spread faster, with larger peak incidence, and harder to control. We also consistently found a shorter serial interval than incubation period, suggesting that a key feature of SARS-CoV-2 is the potential for pre-symptomatic transmission. These observations are instrumental to plan for future COVID-19 waves.

Neurological complications and effects of COVID-19: Symptoms and conceivable mechanisms

A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in December 2019 in Wuhan, China. The new coronavirus disease (COVID-19) was declared a global pandemic by the World Health Organization (WHO) in March 2020. SARS-CoV-2 can invade the nervous system aside from infecting the respiratory system as its primary target. The most common nervous system symptoms of COVID-19 are stated as headache, myalgia, fatigue, nausea, vomiting, sudden and unexplained anosmia, and ageusia. More severe conditions such as encephalomyelitis, acute myelitis, thromboembolic events, ischemic stroke, intracerebral hemorrhage, Guillain-Barré-syndrome, Bell's palsy, rhabdomyolysis, and even coma have also been reported. Cohort studies revealed that neurological findings are associated with higher morbidity and mortality. The neurological symptoms and manifestations caused by SARS-CoV-2 and COVID-19 are examined and summarized in this article.

Nomogram-based prediction model for survival of COVID-19 patients: A clinical study

The study aim to construct an effective model for predicting the survival period of COVID-19 patients.

METHODS

Clinical data of 386 COVID-19 patients were collected from December 2022 to January 2023. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. LASSO regression and multivariate Cox regression analyses were used to identify prognostic factors, and a nomogram was constructed. Nomogram was evaluated using decision curve analysis, receiver operating characteristic curve, consistency index (c-index), and calibration curve.

RESULTS

86 patients (22.3%) died. A new nomogram for predicting the survival was established based on age, resting oxygen saturation, Blood urea nitrogen (BUN), c-reactive protein-to-albumin ratio (CAR), and pneumonia visual score. The decision curve indicated high clinical applicability. The nomogram c-indexes in the training and validation cohorts were 0.846 and 0.81, respectively. The area under the curves (AUCs) for the 15-day and 30-day survival probabilities were 0.906 and 0.869 in the training cohort, and 0.851 and 0.843 in the validation cohort. The calibration curves demonstrated consistency between predicted and actual survival probabilities.

CONCLUSIONS

Our nomogram has the capacity to assist clinical practitioners in estimating the survival rate of COVID-19 patients, thereby facilitating more optimal management strategies and therapeutic interventions with substantial clinical applicability.

Hallmarks of Severe COVID-19 Pathogenesis: A Pas de Deux Between Viral and Host Factors

Two years into Coronavirus Disease 2019 (COVID-19) pandemic, a comprehensive characterization of the pathogenesis of severe and critical forms of COVID-19 is still missing. While a deep dysregulation of both the magnitude and functionality of innate and adaptive immune responses have been described in severe COVID-19, the mechanisms underlying such dysregulations are still a matter of scientific debate, in turn hampering the identification of new therapies and of subgroups of patients that would most benefit from individual clinical interventions. Here we review the current understanding of viral and host factors that contribute to immune dysregulation associated with COVID-19 severity in the attempt to unfold and broaden the comprehension of COVID-19 pathogenesis and to define correlates of protection to further inform strategies of targeted therapeutic interventions.

Does COVID-19 threat increase xenophobia? The roles of protection efficacy and support seeking

Background

In response to the COVID-19 pandemic, people in many countries have shown xenophobia toward China, where the pandemic began. Within China, xenophobia has also been observed toward the people of Wuhan, the city where the first cases were identified. The relationship between disease threat and xenophobia is well established, but the reasons for this relationship are unclear. This study investigated the mediation role of perceived protection efficacy and moderation role of support seeking in the relationship between perceived COVID-19 risk and xenophobia within China.

Methods

An online survey was administered to a nationally representative sample (N = 1103; 51.7% women; ages 18 to 88) of Chinese adults during the early stage of the COVID-19 pandemic. Participants completed questionnaires about their perceived COVID-19 risk, perceived protection efficacy in reducing risk, support seeking, and xenophobic attitudes toward people of the Wuhan area.

Results

Regression based analyses showed that the perceived COVID-19 risk positively predicted xenophobia. Low perceived protection efficacy partly mediated the relationship between perceived COVID-19 risk and xenophobic attitudes, and this indirect effect was moderated by support seeking. Specifically, the indirect effect was weaker among individuals who sought more social support.

Conclusions

Under disease threat, xenophobia can appear within a country that otherwise seems culturally homogeneous. This study extends the extant research by identifying a possible psychological mechanism by which individuals’ perception of disease threat elicits xenophobia, and by addressing the question of why this response is stronger among some people than others. Increasing the public’s perceived efficacy in protecting themselves from infection, and encouraging support seeking, could reduce xenophobic attitudes.

Worldwide Prevalence of Hypertension in Patients with COVID-19: A Meta-analysis and Systematic Review

Background: This systematic review and meta-analysis aimed to assess the ratio of patients with hypertension for whom coronavirus disease 2019 (COVID-19) has been diagnosed in the world. In addition, the effect of COVID-19 on the outcomes of hypertension was evaluated. Methods: To find articles published by July 2020, a comprehensive systematic search was carried out in five electronic databases, including PubMed, Scopus, Embase, and Web of Science. The meta-analysis entailed all relevant articles on the clinical and epidemiological features of patients with COVID-19. Two researchers independently reviewed the eligible post-selection studies, and finally, the discrepancies between the opinions of the two researchers were resolved by a third arbitrator. Two researchers independently examined the risk of bias using the Newcastle-Ottawa Scale. Results: The pooled prevalence of high blood pressure in patients hospitalized with COVID-19 worldwide was obtained as 31% (95% CI: 23 - 38%). The changes for hypertension prevalence in different studies included in the meta-analysis varied from 2 to 64%. Moreover, the results of subgroups analysis based on different countries demonstrated that the prevalence of hypertension in patients with COVID-19 in China and other countries was 29% (95% CI: 24 - 34%) and 32% (95% CI: 19 - 46%), respectively. Conclusions: The evidence revealed that a health condition that commonly accompanies and affects the outcomes of COVID-19 is hypertension. Therefore, COVID-19 patients with hypertension should be given priority and benefit from a preventive, therapeutic approach. Furthermore, essential training should be provided by health policymakers.

Current utilization of interferon alpha for the treatment of coronavirus disease 2019: A comprehensive review

Recent studies have identified an association between perturbed type I interferon (IFN) responses and the severity of coronavirus disease 2019 (COVID-19). IFNα intervention may normalize the dysregulated innate immunity of COVID-19. However, details regarding its utilization and therapeutic evidence have yet to be systematically evaluated. The aim of this comprehensive review was to summarize the current utilization of IFNα for COVID-19 treatment and to explore the evidence on safety and efficacy. A comprehensive review of clinical studies in the literature prior to December 1st_, 2021, was performed to identify the current utilization of IFNα, which included details on the route of administration, the number of patients who received the treatment, the severity at the initiation of treatment, age range, the time from the onset of symptoms to treatment, dose, frequency, and duration as well as safety and efficacy. Encouragingly, no evidence was found against the safety of IFNα treatment for COVID-19. Early intervention, either within five days from the onset of symptoms or at hospital admission, confers better clinical outcomes, whereas late intervention may result in prolonged hospitalization.

NLRP3 inflammasome activation in COVID-19: an interlink between risk factors and disease severity

NLRP3 inflammasome is a critical immune component that plays a crucial role in mounting innate immune responses. The deleterious effects of inflammasome activation have been correlated with the COVID-19 disease severity. In the presence of several underlying disorders, the immune components of our bodies are dysregulated, creating conditions that could adversely affect us other than providing a required level of protection. In this review, we focused on the occurrence of NLRP3 inflammasome activation in response to SARS-COV-2 infection, dysregulation of NLRP3 activation events in the presence of several comorbidities, the contribution of activated NLRP3 inflammasome to the severity of COVID-19, and available therapeutics for the treatment of such NLRP3 inflammasome related diseases based on current knowledge. The primed state of immunity in individuals with comorbidities (risk factors) could accelerate many deaths and severe COVID-19 cases via activation of NLRP3 inflammasome and the release of downstream inflammatory molecules. Therefore, a detailed understanding of the host-pathogen interaction is needed to clarify the pathophysiology and select a potential therapeutic approach.

Occurrence, Fate, Effects, and Risks of Dexamethasone: Ecological Implications Post-COVID-19

The recent outbreak of respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease (COVID-19), has led to the widespread use of therapeutics, including dexamethasone (DEXA). DEXA, a synthetic glucocorticoid, is among the widely administered drugs used to treat hospitalized COVID-19 patients. The global COVID-19 surge in infections, consequent increasing hospitalizations, and other DEXA applications have raised concerns on eminent adverse ecological implications to aquatic ecosystems. Here, we aim to summarize published studies on DEXA occurrence, fate, and effects on organisms in natural and engineered systems as, pre-COVID, the drug has been identified as an emerging environmental contaminant. The results demonstrated a significant reduction of DEXA in wastewater treatment plants, with a small portion, including its transformation products (TPs), being released into downstream waters. Fish and crustaceans are the most susceptible species to DEXA exposure in the parts-per-billion range, suggesting potential deleterious ecological effects. However, there are data deficits on the implications of DEXA to marine and estuarine systems and wildlife. To improve DEXA management, toxicological outcomes of DEXA and formed TPs should entail long-term studies from whole organisms to molecular effects in actual environmental matrices and at realistic exposure concentrations. This can aid in striking a fine balance of saving human lives and protecting ecological integrity.

High SARS-CoV-2 seroprevalence in persons experiencing homelessness and shelter workers from a day-shelter in São Paulo, Brazil

Brazil presents one of the highest COVID-19 death tolls in the world. The initial SARS-CoV-2 epicenter was São Paulo city. As of 2019, the homeless population of São Paulo city was estimated at 24,344 individuals, the largest national homeless population. The present study aimed to concomitantly assess the molecular and serological prevalence and associated risk factors of SARS-CoV-2 infection in a homeless population and related shelter workers from a day-shelter. Serum samples, nasopharyngeal and oropharyngeal swabs of persons who are homeless and shelter workers collected from August 25^th to 27^th, 2020 were tested for the presence of anti-SARS-CoV-2 IgM and IgG antibodies by ELISA and SARS-CoV-2 RNA by RT-qPCR, respectively. All swab samples tested negative by RT-qPCR. Seropositivity of IgM and IgG was 5/203 (2.5%) and 111/203 (54.7%) in persons who are homeless, and 5/87 (5.7%) and 41/87 (47.1%) in shelter workers, respectively, with no statistical differences between groups. The high seroprevalence found herein indicates early environmental and urban spreading of SARS-CoV-2, associated with sociodemographic and economic vulnerability.

Brazil is one of the world’s most social-economically unequal countries, with a rising homeless population potentialized by the SARS-CoV-2 pandemic, particularly in its largest city, São Paulo. While few studies, mostly in high-income countries, have addressed the impact of the coronavirus pandemic on homeless populations, none has been carried out in Brazil. Herein, we report a high SARS-CoV-2 IgG seroprevalence in a homeless population, with 111/203 (54.7%) seropositive individuals. At the time of the study (August 25^th- 27^th 2020), both homeless and social worker populations showed no active SARS-CoV-2 infection, indicating that they were likely exposed sometime within the pandemic’s first peak in the city. Our study has also shown significant risk and protective factors for SARS-CoV-2 infection, including that Black shelter workers were at higher risk of SARS-CoV-2 infection when compared with the white shelter workers.

Chronic Diseases as a Predictor for Severity and Mortality of COVID-19: A Systematic Review With Cumulative Meta-Analysis

Introduction: Given the ongoing coronavirus disease 2019 (COVID-19) pandemic and the consequent global healthcare crisis, there is an urgent need to better understand risk factors for symptom deterioration and mortality among patients with COVID-19. This systematic review aimed to meet the need by determining the predictive value of chronic diseases for COVID-19 severity and mortality.

Methods: We searched PubMed, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Complete to identify studies published between December 1, 2019, and December 31, 2020. Two hundred and seventeen observational studies from 26 countries involving 624,986 patients were included. We assessed the risk of bias of the included studies and performed a cumulative meta-analysis.

Results: We found that among COVID-19 patients, hypertension was a very common condition and was associated with higher severity, intensive care unit (ICU) admission, acute respiratory distress syndrome, and mortality. Chronic obstructive pulmonary disease was the strongest predictor for COVID-19 severity, admission to ICU, and mortality, while asthma was associated with a reduced risk of COVID-19 mortality. Patients with obesity were at a higher risk of experiencing severe symptoms of COVID-19 rather than mortality. Patients with cerebrovascular disease, chronic liver disease, chronic renal disease, or cancer were more likely to become severe COVID-19 cases and had a greater probability of mortality.

Conclusions: COVID-19 patients with chronic diseases were more likely to experience severe symptoms and ICU admission and faced a higher risk of mortality. Aggressive strategies to combat the COVID-19 pandemic should target patients with chronic diseases as a priority.

Predicting Severe/Critical Outcomes in Patients With SARS-CoV2 Pneumonia: Development of the prediCtion seveRe/crItical ouTcome in COVID-19 (CRITIC) Model

Objective: To create a prediction model of the risk of severe/critical disease in patients with Coronavirus disease (COVID-19). Methods: Clinical, laboratory, and lung computed tomography (CT) severity score were collected from patients admitted for COVID-19 pneumonia and considered as independent variables for the risk of severe/critical disease in a logistic regression analysis. The discriminative properties of the variables were analyzed through the area under the receiver operating characteristic curve analysis and included in a prediction model based on Fagan's nomogram to calculate the post-test probability of severe/critical disease. All analyses were conducted using Medcalc (version 19.0, MedCalc Software, Ostend, Belgium). Results: One hundred seventy-one patients with COVID-19 pneumonia, including 37 severe/critical cases (21.6%) and 134 mild/moderate cases were evaluated. Among all the analyzed variables, Charlson Comorbidity Index (CCI) was that with the highest relative importance (p = 0.0001), followed by CT severity score (p = 0.0002), and age (p = 0.0009). The optimal cut-off points for the predictive variables resulted: 3 for CCI [sensitivity 83.8%, specificity 69.6%, positive likelihood ratio (+LR) 2.76], 69.9 for age (sensitivity 94.6%, specificity 68.1, +LR 2.97), and 53 for CT severity score (sensitivity 64.9%, specificity 84.4%, +LR 4.17). Conclusion: The nomogram including CCI, age, and CT severity score, may be used to stratify patients with COVID-19 pneumonia.

Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: a systematic review and meta-analysis

BACKGROUND

Smoking impairs lung immune function and damages upper airways, increasing risks of contracting and severity of infectious diseases. This paper quantifies the association between smoking and COVID-19 disease progression.

METHODS

We searched PubMed and Embase for studies published from January 1-May 25, 2020. We included studies reporting smoking behavior of COVID-19 patients and progression of disease, including death. We used random effects meta-analysis, meta-regression and locally weighted regression and smoothing to examine relationships in the data.

RESULTS

We identified 46 peer-reviewed papers with a total of 22,939 COVID-19 patients, 5421 (23.6%) experienced disease progression and 2914 (12.7%) with a history of smoking (current and former smokers). Among those with a history of smoking, 33.5% experienced disease progression, compared with 21.9% of non-smokers. The meta-analysis confirmed an association between ever smoking and COVID-19 progression (OR 1.59, 95% CI 1.33-1.89, p = 0.001). Ever smoking was associated with increased risk of death from COVID-19 (OR 1.19, 95% CI 1.02-1.39, p = 0.003). We found no significant difference (p = 0.864) between the effects of ever smoking on COVID-19 disease progression between adjusted and unadjusted analyses, suggesting that smoking is an independent risk factor for COVID-19 disease progression. We also found the risk of having COVID-19 progression higher among younger adults (p = 0.001), with the effect most pronounced among younger adults under about 45 years old.

CONCLUSIONS

Smoking is an independent risk for having progression of COVID-19, including mortality. The effects seem to be higher among young people. Smoking prevention and cessation should remain a priority for the public, physicians, and public health professionals during the COVID-19 pandemic.

Neurological Manifestations in COVID-19 Patients: A Meta-Analysis

Common symptoms such as dizziness, headache, olfactory dysfunction, nausea, vomiting, etc. in COVID-19 patients have indicated the involvement of the nervous system. However, the exact association of the nervous system with COVID-19 infection is still unclear. Thus, we have conducted a meta-analysis of clinical studies associated with neurological problems in COVID-19 patients. We have searched for electronic databases with MeSH terms, and the studies for analysis were selected based on inclusion and exclusion criteria and quality assessment. The Stats Direct (version 3) was used for the analysis. The pooled prevalence with 95% confidence interval of various neurological manifestations reported in the COVID-19 patients was found to be headache 14.6% (12.2-17.2), fatigue 33.6% (29.5-37.8), olfactory dysfunction 26.4% (21.8-31.3), gustatory dysfunction 27.2% (22.3-32.3), vomiting 6.7% (5.5-8.0), nausea 9.8% (8.1-11.7), dizziness 6.7% (4.7-9.1), myalgia 21.4% (18.8-24.1), seizure 4.05% (2.5-5.8), cerebrovascular diseases 9.9% (6.8-13.4), sleep disorders 14.9% (1.9-36.8), altered mental status 17.1% (12.3-22.5), neuralgia 2.4% (0.8-4.7), arthralgia 19.9% (15.3-25.0), encephalopathy 23.5% (14.3-34.1), encephalitis 0.6% (0.2-1.3), malaise 38.3% (24.7-52.9), confusion 14.2% (6.9-23.5), movement disorders 5.2% (1.7-10.4), and Guillain-Barre syndrome 6.9% (2.3-13.7). However, the heterogeneity among studies was found to be high. Various neurological manifestations related to the central nervous system (CNS) and peripheral nervous system (PNS) are associated with COVID-19 patients.

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review

BACKGROUND

Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

OBJECTIVE

The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

METHODS

We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

RESULTS

Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

CONCLUSIONS

Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.

The association of smoking status with SARS-CoV-2 infection, hospitalization and mortality from COVID-19: a living rapid evidence review with Bayesian meta-analyses (version 7)

AIMS

To estimate the association of smoking status with rates of (i) infection, (ii) hospitalization, (iii) disease severity and (iv) mortality from SARS-CoV-2/COVID-19 disease.

DESIGN

Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via MEDLINE and medRxiv.

SETTING

Community or hospital, no restrictions on location.

PARTICIPANTS

Adults who received a SARS-CoV-2 test or a COVID-19 diagnosis.

MEASUREMENTS

Outcomes were SARS-CoV-2 infection, hospitalization, disease severity and mortality stratified by smoking status. Study quality was assessed (i.e. 'good', 'fair' and 'poor').

FINDINGS

Version 7 (searches up to 25 August 2020) included 233 studies with 32 'good' and 'fair' quality studies included in meta-analyses. Fifty-seven studies (24.5%) reported current, former and never smoking status. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection [relative risk (RR) = 0.74, 95% credible interval (CrI) = 0.58-0.93, τ = 0.41]. Data for former smokers were inconclusive (RR = 1.05, 95% CrI = 0.95-1.17, τ = 0.17), but favoured there being no important association (21% probability of RR ≥ 1.1). Former compared with never smokers were at somewhat increased risk of hospitalization (RR = 1.20, CrI = 1.03-1.44, τ = 0.17), greater disease severity (RR = 1.52, CrI = 1.13-2.07, τ = 0.29) and mortality (RR = 1.39, 95% CrI = 1.09-1.87, τ = 0.27). Data for current smokers were inconclusive (RR = 1.06, CrI = 0.82-1.35, τ = 0.27; RR = 1.25, CrI = 0.85-1.93, τ = 0.34; RR = 1.22, 95% CrI = 0.78-1.94, τ = 0.49, respectively), but favoured there being no important associations with hospitalization and mortality (35% and 70% probability of RR ≥ 1.1, respectively) and a small but important association with disease severity (79% probability of RR ≥ 1.1).

CONCLUSIONS

Compared with never smokers, current smokers appear to be at reduced risk of SARS-CoV-2 infection, while former smokers appear to be at increased risk of hospitalization, increased disease severity and mortality from COVID-19. However, it is uncertain whether these associations are causal.

Prevalence and prognosis of otorhinolaryngological symptoms in patients with COVID-19: a systematic review and meta-analysis

Objective

A systematic review and meta-analysis were performed to evaluate the prevalence and prognosis of otorhinolaryngological symptoms in patients with the diagnosed coronavirus disease 2019 (COVID-19).

Methods

A systematic search of PubMed, Embase, Web of Science, and Google Scholar databases was performed up to August 19, 2020.We included studies that reported infections with COVID-19 and symptoms of otolaryngology. The retrieved data from the respective studies were evaluated and summarized. The study's immediate result was to assess the combined prevalence of otorhinolaryngological symptoms in patients with COVID-19. However, the secondary result was to determine the exacerbation of COVID-19 infection in patients with otorhinolaryngological symptoms.

Results

Fifty-four studies with 16,478 patients were included. Olfactory dysfunction, sneezing and sputum production were the 3 most prevalent otorhinolaryngological symptoms in patients with COVID-19. The pooled prevalence amongst the prevalent symptoms was 47% (95% CI 29–65; range 0–98; I² = 99.58%), 27% (95% CI 11–48; range 12–40; I² = 93.34%), and 22% (95% CI 16–30; range 2–56; I² = 97.60%), respectively. The proportion of severely ill patients with sputum production and shortness of breath was significantly higher among patients with COVID-19 infections (OR 1.66 [95% CI 1.08–2.54]; P = 0.02, I² = 51% and 3.29 [95% CI 1.57–6.90]; P = 0.002, I² = 49%, respectively). Subgroup analysis showed no statistically significant differences between the incidence of otolaryngology symptoms in severely ill patients and non-severely ill patients (OR 1.43 [95% CI 1.12–1.82]; P = 0.07 I² = 53.1%). In contrast, the incidence of shortness of breath in severely ill patients was significantly increased (3.29 [1.57–6.90]; P = 0.002, I² = 49%).

Conclusion

Our research shows that otorhinolaryngology symptoms in patients with COVID-19 are not uncommon, which should attract otorhinolaryngologists' attention.

Clinical determinants of the severity of COVID-19: A systematic review and meta-analysis

Objective

We aimed to systematically identify the possible risk factors responsible for severe cases.

Methods

We searched PubMed, Embase, Web of science and Cochrane Library for epidemiological studies of confirmed COVID-19, which include information about clinical characteristics and severity of patients’ disease. We analyzed the potential associations between clinical characteristics and severe cases.

Results

We identified a total of 41 eligible studies including 21060 patients with COVID-19. Severe cases were potentially associated with advanced age (Standard Mean Difference (SMD) = 1.73, 95% CI: 1.34–2.12), male gender (Odds Ratio (OR) = 1.51, 95% CI:1.33–1.71), obesity (OR = 1.89, 95% CI: 1.44–2.46), history of smoking (OR = 1.40, 95% CI:1.06–1.85), hypertension (OR = 2.42, 95% CI: 2.03–2.88), diabetes (OR = 2.40, 95% CI: 1.98–2.91), coronary heart disease (OR: 2.87, 95% CI: 2.22–3.71), chronic kidney disease (CKD) (OR = 2.97, 95% CI: 1.63–5.41), cerebrovascular disease (OR = 2.47, 95% CI: 1.54–3.97), chronic obstructive pulmonary disease (COPD) (OR = 2.88, 95% CI: 1.89–4.38), malignancy (OR = 2.60, 95% CI: 2.00–3.40), and chronic liver disease (OR = 1.51, 95% CI: 1.06–2.17). Acute respiratory distress syndrome (ARDS) (OR = 39.59, 95% CI: 19.99–78.41), shock (OR = 21.50, 95% CI: 10.49–44.06) and acute kidney injury (AKI) (OR = 8.84, 95% CI: 4.34–18.00) were most likely to prevent recovery. In summary, patients with severe conditions had a higher rate of comorbidities and complications than patients with non-severe conditions.

Conclusion

Patients who were male, with advanced age, obesity, a history of smoking, hypertension, diabetes, malignancy, coronary heart disease, hypertension, chronic liver disease, COPD, or CKD are more likely to develop severe COVID-19 symptoms. ARDS, shock and AKI were thought to be the main hinderances to recovery.

Gastroenterology manifestations and COVID-19 outcomes: A meta-analysis of 25,252 cohorts among the first and second waves

A meta-analysis was performed to identify patients with coronavirus disease 2019 (COVID-19) presenting with gastrointestinal (GI) symptoms during the first and second pandemic waves and investigate their association with the disease outcomes. A systematic search in PubMed, Scopus, Web of Science, ScienceDirect, and EMBASE was performed up to July 25, 2020. The pooled prevalence of the GI presentations was estimated using the random-effects model. Pairwise comparison for the outcomes was performed according to the GI manifestations' presentation and the pandemic wave of infection. Data were reported as relative risk (RR), or odds ratio and 95% confidence interval. Of 125 articles with 25,252 patients, 20.3% presented with GI manifestations. Anorexia (19.9%), dysgeusia/ageusia (15.4%), diarrhea (13.2%), nausea (10.3%), and hematemesis (9.1%) were the most common. About 26.7% had confirmed positive fecal RNA, with persistent viral shedding for an average time of 19.2 days before being negative. Patients presenting with GI symptoms on admission showed a higher risk of complications, including acute respiratory distress syndrome (RR = 8.16), acute cardiac injury (RR = 5.36), and acute kidney injury (RR = 5.52), intensive care unit (ICU) admission (RR = 2.56), and mortality (RR = 2.01). Although not reach significant levels, subgroup-analysis revealed that affected cohorts in the first wave had a higher risk of being hospitalized, ventilated, ICU admitted, and expired. This meta-analysis suggests an association between GI symptoms in COVID-19 patients and unfavorable outcomes. The analysis also showed improved overall outcomes for COVID-19 patients during the second wave compared to the first wave of the outbreak.

From nicotine to the cholinergic anti-inflammatory reflex - Can nicotine alleviate the dysregulated inflammation in COVID-19?

The coronavirus SARS-CoV-2 of 2019 (COVID-19) causes a pandemic that has been diagnosed in more than 70 million people worldwide. Mild-to-moderate COVID-19 symptoms include coughing, fever, myalgia, shortness of breath, and acute inflammatory lung injury (ALI). In contrast, acute respiratory distress syndrome (ARDS) and respiratory failure occur in patients diagnosed with severe COVID-19. ARDS is mediated, at least in part, by a dysregulated inflammatory response due to excessive levels of circulating cytokines, a condition known as the "cytokine-storm syndrome." Currently, there are FDA-approved therapies that attenuate the dysregulated inflammation that occurs in COVID-19 patients, such as dexamethasone or other corticosteroids and IL-6 inhibitors, including sarilumab, tocilizumab, and siltuximab. However, the efficacy of these treatments have been shown to be inconsistent. Compounds that activate the vagus nerve-mediated cholinergic anti-inflammatory reflex, such as the α7 nicotinic acetylcholine receptor agonist, GTS-21, attenuate ARDS/inflammatory lung injury by decreasing the extracellular levels of high mobility group box-1 (HMGB1) in the airways and the circulation. It is possible that HMGB1 may be an important mediator of the "cytokine-storm syndrome." Notably, high plasma levels of HMGB1 have been reported in patients diagnosed with severe COVID-19, and there is a significant negative correlation between HMGB1 plasma levels and clinical outcomes. Nicotine can activate the cholinergic anti-inflammatory reflex, which attenuates the up-regulation and the excessive release of pro-inflammatory cytokines/chemokines. Therefore, we hypothesize that low molecular weight compounds that activate the cholinergic anti-inflammatory reflex, such as nicotine or GTS-21, may represent a potential therapeutic approach to attenuate the dysregulated inflammatory responses in patients with severe COVID-19.

The incubation period during the pandemic of COVID-19: a systematic review and meta-analysis

BACKGROUND

The aim of our study was to determine through a systematic review and meta-analysis the incubation period of COVID-19. It was conducted based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Criteria for eligibility were all published population-based primary literature in PubMed interface and the Science Direct, dealing with incubation period of COVID-19, written in English, since December 2019 to December 2020. We estimated the mean of the incubation period using meta-analysis, taking into account between-study heterogeneity, and the analysis with moderator variables.

RESULTS

This review included 42 studies done predominantly in China. The mean and median incubation period were of maximum 8 days and 12 days respectively. In various parametric models, the 95th percentiles were in the range 10.3-16 days. The highest 99th percentile would be as long as 20.4 days. Out of the 10 included studies in the meta-analysis, 8 were conducted in China, 1 in Singapore, and 1 in Argentina. The pooled mean incubation period was 6.2 (95% CI 5.4, 7.0) days. The heterogeneity (I² 77.1%; p < 0.001) was decreased when we included the study quality and the method of calculation used as moderator variables (I² 0%). The mean incubation period ranged from 5.2 (95% CI 4.4 to 5.9) to 6.65 days (95% CI 6.0 to 7.2).

CONCLUSIONS

This work provides additional evidence of incubation period for COVID-19 and showed that it is prudent not to dismiss the possibility of incubation periods up to 14 days at this stage of the epidemic.

Higher airborne pollen concentrations correlated with increased SARS-CoV-2 infection rates, as evidenced from 31 countries across the globe

Pollen exposure weakens the immunity against certain seasonal respiratory viruses by diminishing the antiviral interferon response. Here we investigate whether the same applies to the pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is sensitive to antiviral interferons, if infection waves coincide with high airborne pollen concentrations. Our original hypothesis was that more airborne pollen would lead to increases in infection rates. To examine this, we performed a cross-sectional and longitudinal data analysis on SARS-CoV-2 infection, airborne pollen, and meteorological factors. Our dataset is the most comprehensive, largest possible worldwide from 130 stations, across 31 countries and five continents. To explicitly investigate the effects of social contact, we additionally considered population density of each study area, as well as lockdown effects, in all possible combinations: without any lockdown, with mixed lockdown-no lockdown regime, and under complete lockdown. We found that airborne pollen, sometimes in synergy with humidity and temperature, explained, on average, 44% of the infection rate variability. Infection rates increased after higher pollen concentrations most frequently during the four previous days. Without lockdown, an increase of pollen abundance by 100 pollen/m3 resulted in a 4% average increase of infection rates. Lockdown halved infection rates under similar pollen concentrations. As there can be no preventive measures against airborne pollen exposure, we suggest wide dissemination of pollen-virus coexposure dire effect information to encourage high-risk individuals to wear particle filter masks during high springtime pollen concentrations.

Higher airborne pollen concentrations correlated with increased SARS-CoV-2 infection rates, as evidenced from 31 countries across the globe

Pollen exposure weakens the immunity against certain seasonal respiratory viruses by diminishing the antiviral interferon response. Here we investigate whether the same applies to the pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is sensitive to antiviral interferons, if infection waves coincide with high airborne pollen concentrations. Our original hypothesis was that more airborne pollen would lead to increases in infection rates. To examine this, we performed a cross-sectional and longitudinal data analysis on SARS-CoV-2 infection, airborne pollen, and meteorological factors. Our dataset is the most comprehensive, largest possible worldwide from 130 stations, across 31 countries and five continents. To explicitly investigate the effects of social contact, we additionally considered population density of each study area, as well as lockdown effects, in all possible combinations: without any lockdown, with mixed lockdown-no lockdown regime, and under complete lockdown. We found that airborne pollen, sometimes in synergy with humidity and temperature, explained, on average, 44% of the infection rate variability. Infection rates increased after higher pollen concentrations most frequently during the four previous days. Without lockdown, an increase of pollen abundance by 100 pollen/m³ resulted in a 4% average increase of infection rates. Lockdown halved infection rates under similar pollen concentrations. As there can be no preventive measures against airborne pollen exposure, we suggest wide dissemination of pollen-virus coexposure dire effect information to encourage high-risk individuals to wear particle filter masks during high springtime pollen concentrations.

Beware of Steroid-Induced Avascular Necrosis of the Femoral Head in the Treatment of COVID-19-Experience and Lessons from the SARS Epidemic

Summary

The recent outbreak of coronavirus disease 2019 (COVID-19) has become a global epidemic. Corticosteroids have been widely used in the treatment of severe acute respiratory syndrome (SARS), and the pathological findings seen in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are very similar to those observed in severe acute respiratory syndrome-related coronavirus (SARS-CoV) infection. However, the long-term use of corticosteroids (especially at high doses) is associated with potentially serious adverse events, particularly steroid-induced avascular necrosis of the femoral head (SANFH). In today’s global outbreak, whether corticosteroid therapy should be used, the dosage and duration of treatment, and ways for the prevention, early detection, and timely intervention of SANFH are some important issues that need to be addressed. This review aims to provide a reference for health care providers in COVID-19 endemic countries and regions.

Article Focus

Hormones are a double-edged sword. This review aims to provide a reference for health care providers in coronavirus disease 2019 (COVID-19) endemic countries and regions, especially with respect to the pros and cons of corticosteroid use in the treatment of patients with COVID-19.

Key Messages

In today’s global outbreak, whether corticosteroid therapy should be used, the dosage and duration of treatment, and ways for the prevention, early detection, and timely intervention of SANFH are some important issues that need to be addressed.

Strengths and Limitations

Since SARS was mainly prevalent in China at that time, many evidences in this paper came from the reports of Chinese scholars. There is a bias in the selection of data, which may ignore the differences in environment, race, living habits, medical level and so on. SANFH may be the result of multiple factors. Whether the virus itself is an independent risk factor for SANFH has not been confirmed. In this paper, through literature retrieval, some reference opinions on glucocorticoid usage, diagnosis and treatment of SANFH are given. However, due to the lack of large-scale research data support, it can not be used as the gold standard for the above problems.

Management of gastrointestinal endoscopy unit during post covid-19 endemic outbreak: A report from Wuhan epicenter

The COVID-19 pandemic is caused by severe acute respiratory syndrome coronavirus 2 and causing a global public health emergency. During the outbreak, Wuhan was the first reported and hardest-hit city. With the dramatic drop in number of confirmed cases and subsequent ending of Wuhan lock down, asymptomatic carriers and patients in their recovery period still pose an increased risk. Strict and effective infection control protocols should be established and followed.

East-West differences in clinical manifestations of COVID-19 patients: A systematic literature review and meta-analysis

The coronavirus disease 2019 (COVID-19) pandemic is currently not under control. We aimed to assess whether there are differences in clinical manifestations between COVID-19 patients from the East (East and South-East Asian countries including China, South Korea, and Thailand) and the West (North American, European, and Middle East countries, including the United States, Italy, France, and Iran). For this meta-analysis, we searched for eligible studies about COVID-19 in three databases: PubMed, EMBASE, and the Cochrane Library. Studies were divided into two cohorts for analysis: the East and the West. Stata 13.1 software was used for the meta-analysis. Of the 1527 studies initially identified by the literature search, 169 full-text articles were retrieved and screened for eligibility. Fifty-seven of these, describing 19,353 patients, were deemed eligible for inclusion. Of these, 45 studies with 8416 patients were from the East while 12 studies with 10,937 patients were from the West. The results indicated that the incidences of cough, headache, dizziness, nasal congestion, and digestive symptoms in COVID-19 patients from the East were lower than those in the West. The laboratory data showed that there were no significant differences in the levels of lymphocytes, leukocytes, C-reactive protein, and platelet counts between the two groups. In addition, our results also showed that the incidence of cardiac and kidney injury, as well as increased levels of creatinine, alanine transaminase, and aspartate transaminase, were significantly higher in patients from the West than from the East. Our meta-analysis indicated that there are differences in the clinical manifestations of COVID-19 in patients from the East and the West. COVID-19 patients from the West appear to suffer more severe liver, kidney, and heart damage due to SARS-CoV-2.

Association of smoking history with severe and critical outcomes in COVID-19 patients: A systemic review and meta-analysis

Introduction

The highly infectious coronavirus disease 2019 (COVID-19) has now rapidly spread around the world. This meta-analysis was strictly focused on the influence of smoking history on the severe and critical outcomes on people with COVID-19 pneumonia.

Methods

A systematic literature search was conducted in eight online databases before 1 February 2021. All studies meeting our selection criteria were included and evaluated. Stata 14.0 software was used to analyze the data.

Results

A total of 109 articles involving 517,020 patients were included in this meta-analysis. A statistically significant association was discovered between smoking history and COVID-19 severity, the pooled OR was 1.55 (95%CI: 1.41-1.71). Smoking was significantly associated with the risk of admission to intensive care unit (ICU) (OR=1.73, 95%CI: 1.36-2.19), increased mortality (OR=1.58, 95%CI: 1.38-1.81), and critical diseases composite endpoints (OR=1.61, 95%CI: 1.35-1.93), whereas there was no relationship with mechanical ventilation. The pooled prevalence of smoking using the random effects model (REM) was 15% (95%CI: 14%-16%). Meta-regression analysis showed that age (P=0.004), hypertension (P=0.007), diabetes (P=0.029), chronic obstructive pulmonary disease (COPD) (P=0.001) were covariates that affect the association.

Conclusions

Smoking was associated with severe or critical outcomes and increased the risk of admission to ICU and mortality in COVID-19 patients, but not associated with mechanical ventilation. This association was more significant for former smokers than in current smokers. Current smokers also had a higher risk of developing severe COVID-19 compared with non-smokers. More detailed data, which are representative of more countries, are needed to confirm these preliminary findings.

Smoking and risk of negative outcomes among COVID-19 patients: A systematic review and meta-analysis

INTRODUCTION

COVID-19 has major effects on the clinical, humanistic and economic outcomes among patients, producing severe symptoms and death. Smoking has been reported as one of the factors that increases severity and mortality rate among COVID-19 patients. However, the effect of smoking on such medical outcomes is still controversial. This study conducted a comprehensive systematic review and meta-analysis (SR/MA) on the association between smoking and negative outcomes among COVID-19 patients.

METHODS

Electronic databases, including PubMed, EMBASE, Cochrane Library, Science Direct, Google Scholar, were systematically searched from the initiation of the database until 12 December 2020. All relevant studies about smoking and COVID-19 were screened using a set of inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess the methodological quality of eligible articles. Random meta-analyses were conducted to estimate odds ratios (ORs) with 95% confidence interval (CIs). Publication bias was assessed using the funnel plot, Begg's test and Egger's test.

RESULTS

A total of 1248 studies were retrieved and reviewed. A total of 40 studies were finally included for meta-analysis. Both current smoking and former smoking significantly increase the risk of disease severity (OR=1.58; 95% CI: 1.16-2.15, p=0.004; and OR=2.48; 95% CI: 1.64-3.77, p<0.001; respectively) with moderate appearance of heterogeneity. Similarly, current smoking and former smoking also significantly increase the risk of death (OR=1.35; 95% CI: 1.12-1.62, p=0.002; and OR=2.58; 95% CI: 2.15-3.09, p<0.001; respectively) with moderate appearance of heterogeneity. There was no evidence of publication bias, which was tested by the funnel plot, Begg's test and Egger's test.

CONCLUSIONS

Smoking, even current smoking or former smoking, significantly increases the risk of COVID-19 severity and death. Further causational studies on this association and ascertianing the underlying mechanisms of this relation is warranted.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

Background

The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.

Objective

The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.

Data Sources

We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.

Study Eligibility Criteria

We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.

Participants

The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).

Methods

The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.

Results

We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.

Conclusions

Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Metabolic risk factors and risk of Covid-19: A systematic review and meta-analysis

OBJECTIVE

Based on the epidemiologic findings of Covid-19 incidence; illness and mortality seem to be associated with metabolic risk factors. This systematic review and meta-analysis aimed to assess the association of metabolic risk factors and risk of Covid-19.

METHODS

This study was designed according to PRISMA guidelines. Two independent researchers searched for the relevant studies using PubMed, Web of Science, Cochrane Library, and Scopus. The search terms developed focusing on two main roots of "Covid-19" and "metabolic risk factors". All relevant observational, analytical studies, review articles, and a meta-analysis on the adult population were included in this meta-analysis. Meta-analysis was performed using the random effect model for pooling proportions to address heterogeneity among studies. Data were analyzed using STATA package version 11.2, (StataCorp, USA).

RESULTS

Through a comprehensive systematic search in the targeted databases we found 1124 papers, after running the proses of refining, 13 studies were included in the present meta-analysis. The pooled prevalence of obesity in Covid-19 patients was 29% (95% CI: 14-47%). For Diabetes and Hypertension, these were 22% (95% CI: 12% 33%) and 32% (95% CI: 12% 56%), respectively. There was significant heterogeneity in the estimates of the three pooled prevalence without any significant small-study effects. Such warning points, to some extent, guide physicians and clinicians to better understand the importance of controlling co-morbid risk factors in prioritizing resource allocation and interventions.

CONCLUSION

The meta-analysis showed that hypertension is more prevalent than obesity and diabetes in patients with Covid-19 disease. The prevalence of co-morbid metabolic risk factors must be adopted for better management and priority settings of public health vaccination and other required interventions. The results may help to improve services delivery in COVID-19 patients, while helping to develop better policies for prevention and response to COVID-19 and its critical outcomes.

Prevalence and predictors of death and severe disease in patients hospitalized due to COVID-19: A comprehensive systematic review and meta-analysis of 77 studies and 38,000 patients

Introduction

Progression of COVID-19 to severe disease and death is insufficiently understood.

Objective

Summarize the prevalence of risk factors and adverse outcomes and determine their associations in COVID-19 patients who were hospitalized.

Methods

We searched Medline, Embase and Web of Science for case-series and observational studies of hospitalized COVID-19 patients through August 31, 2020. Data were analyzed by fixed-effects meta-analysis using Shore’s adjusted confidence intervals to address heterogeneity.

Results

Seventy-seven studies comprising 38906 hospitalized patients met inclusion criteria; 21468 from the US-Europe and 9740 from China. Overall prevalence of death [% (95% CI)] from COVID-19 was 20% (18–23%); 23% (19–27%) in the US and Europe and 11% (7–16%) for China. Of those that died, 85% were aged≥60 years, 66% were males, and 66%, 44%, 39%, 37%, and 27% had hypertension, smoking history, diabetes, heart disease, and chronic kidney disease (CKD), respectively. The case fatality risk [%(95% CI)] were 52% (46–60) for heart disease, 51% (43–59) for COPD, 48% (37–63) for chronic kidney disease (CKD), 39% for chronic liver disease (CLD), 28% (23–36%) for hypertension, and 24% (17–33%) for diabetes. Summary relative risk (sRR) of death were higher for age≥60 years [sRR = 3.6; 95% CI: 3.0–4.4], males [1.3; 1.2–1.4], smoking history [1.3; 1.1–1.6], COPD [1.7; 1.4–2.0], hypertension [1.8; 1.6–2.0], diabetes [1.5; 1.4–1.7], heart disease [2.1; 1.8–2.4], CKD [2.5; 2.1–3.0]. The prevalence of hypertension (55%), diabetes (33%), smoking history (23%) and heart disease (17%) among the COVID-19 hospitalized patients in the US were substantially higher than that of the general US population, suggesting increased susceptibility to infection or disease progression for the individuals with comorbidities.

Conclusions

Public health screening for COVID-19 can be prioritized based on risk-groups. Appropriately addressing the modifiable risk factors such as smoking, hypertension, and diabetes could reduce morbidity and mortality due to COVID-19; public messaging can be accordingly adapted.

Reduced risk of COVID-19 hospitalization in asthmatic and COPD patients: a benefit of inhaled corticosteroids?

Background: The comorbidities and clinical signs of coronavirus disease 2019 (COVID-19) patients have been reported mainly as descriptive statistics, rather than quantitative analysis even in very large investigations. The aim of this study was to identify specific patients’ characteristics that may modulate COVID-19 hospitalization risk.

Research design and methods: A pooled analysis was performed on high-quality epidemiological studies to quantify the prevalence (%) of comorbidities and clinical signs in hospitalized COVID-19 patients. Pooled data were used to calculate the relative risk (RR) of specific comorbidities by matching the frequency of comorbidities in hospitalized COVID-19 patients with those of general population.

Results: The most frequent comorbidities were hypertension, diabetes mellitus, and cardiovascular and/or cerebrovascular diseases. The RR of COVID-19 hospitalization was significantly (P < 0.05) reduced in patients with asthma (0.86, 0.77–0.97) or chronic obstructive pulmonary disease (COPD) (0.46, 0.40–0.52). The most frequent clinical signs were fever and cough.

Conclusion: The clinical signs of hospitalized COVID-19 patients are similar to those of other infective diseases. Patients with asthma or COPD were at lower hospitalization risk. This paradoxical evidence could be related with the protective effect of inhaled corticosteroids that are administered worldwide to most asthmatic and COPD patients.

Smoking and COVID-19: Similar bronchial ACE2 and TMPRSS2 expression and higher TMPRSS4 expression in current versus never smokers

Uncertainties remain concerning the pathophysiology, epidemiology, and potential therapeutics for COVID-19. Among unsettled controversies is whether tobacco smoking increases or protects from severe COVID-19. Several epidemiological studies reported reduced COVID-19 hospitalizations among smokers, while other studies reported the opposite trend. Some authors assumed that smokers have elevated airway expression of ACE2, the cell recognition site of the SARS-Cov-2 spike protein, but this suggestion remains unverified. We therefore performed data mining of two independent NCBI GEO genome-wide RNA expression files (GSE7894 and GSE994) and report that in both data sets, current smokers and never smokers have, on average, closely similar bronchial epithelial cell mRNA levels of ACE2, as well as TMPRSS2, coding for a serine protease priming SARS-Cov-2 for cell entry, and ADAM17, coding for a protease implicated in ACE2 membrane shedding. In contrast, the expression levels of TMPRSS4, coding for a protease that primes SARS-CoV-2 for cell entry similarly to TMPRSS2, were elevated in bronchial epithelial cells from current smokers compared with never smokers, suggesting that higher bronchial TMPRSS4 levels in smokers might put them at higher SARS-Cov-2 infection risk. The effects of smoking on COVID-19 severity need clarification with larger studies. Additionally, the postulated protective effects of nicotine and nitric oxide, which may presumably reduce the risk of a "cytokine storm" in infected individuals, deserve assessment by controlled clinical trials.

Factors associated with disease severity and mortality among patients with COVID-19: A systematic review and meta-analysis

BACKGROUND

Understanding the factors associated with disease severity and mortality in Coronavirus disease (COVID-19) is imperative to effectively triage patients. We performed a systematic review to determine the demographic, clinical, laboratory and radiological factors associated with severity and mortality in COVID-19.

METHODS

We searched PubMed, Embase and WHO database for English language articles from inception until May 8, 2020. We included Observational studies with direct comparison of clinical characteristics between a) patients who died and those who survived or b) patients with severe disease and those without severe disease. Data extraction and quality assessment were performed by two authors independently.

RESULTS

Among 15680 articles from the literature search, 109 articles were included in the analysis. The risk of mortality was higher in patients with increasing age, male gender (RR 1.45, 95%CI 1.23-1.71), dyspnea (RR 2.55, 95%CI 1.88-2.46), diabetes (RR 1.59, 95%CI 1.41-1.78), hypertension (RR 1.90, 95%CI 1.69-2.15). Congestive heart failure (OR 4.76, 95%CI 1.34-16.97), hilar lymphadenopathy (OR 8.34, 95%CI 2.57-27.08), bilateral lung involvement (OR 4.86, 95%CI 3.19-7.39) and reticular pattern (OR 5.54, 95%CI 1.24-24.67) were associated with severe disease. Clinically relevant cut-offs for leukocytosis(>10.0 x109/L), lymphopenia(< 1.1 x109/L), elevated C-reactive protein(>100mg/L), LDH(>250U/L) and D-dimer(>1mg/L) had higher odds of severe disease and greater risk of mortality.

CONCLUSION

Knowledge of the factors associated of disease severity and mortality identified in our study may assist in clinical decision-making and critical-care resource allocation for patients with COVID-19.

A Review of Neuro-Ophthalmological Manifestations of Human Coronavirus Infection

Introduction

Human coronavirus (HCoVs) are a group of viruses with recognized neurotropic and neuroinvasive capabilities. The reports on the neurological and ocular findings are increasing day after day and several central and peripheral neurological manifestations are already described. However, none specifically describes the neuro-ophthalmological manifestation of HCoVs. This is the first article specifically reviewing neuro-ophthalmological manifestations of HCoVs infection.

Methods

PubMed and Google Scholar databases were searched using the keywords: coronaviridae, coronavirus, COVID-19, SARS-CoV-2, SARS-CoV-1, MERS, ocular, ophthalmology, ophthalmological, neuro-ophthalmology, neurological, manifestations. A manual search through the reference lists of relevant articles was also performed. There were no restrictions concerning language or study type and publications not yet printed but available online were considered.

Results

Coronavirus eye involvement is not frequent and includes mostly a typical viral follicular conjunctivitis. Recently, retinal anatomical alterations were described using optic coherence tomography. Neuro-ophthalmological symptoms and signs can appear isolated or associated with neurological syndromes. The manifestations include headache, ocular pain, visual impairment, diplopia, and cranial nerve palsies secondary to Miller Fisher syndrome, Guillain-Barré syndrome, or encephalitis, and nystagmus.

Conclusion

Neurological and neuro-ophthalmological syndromes, symptoms, and signs should not be neglected and a complete ophthalmological examination of these patients should be performed to fully describe ocular manifestations related to HCoVs. We believe that major ocular and neuro-ophthalmological manifestations reports lack due to safety issues concerning detailed ophthalmological examination; on the other hand, in a large number of cases, the presence of life-threatening coronavirus disease hinders ocular examination and ophthalmologist’s visit to the intensive care unit.

Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: A systematic review and meta-analysis

BACKGROUND

Smoking impairs lung immune functions and damages upper airways, increasing risks of contracting and severity of infectious diseases.

METHODS

We searched PubMed and Embase for studies published from January 1-May 25, 2020. We included studies reporting smoking behavior of COVID-19 patients and progression of disease, including death. We used a random effects meta-analysis and used meta-regression and lowess regressions to examine relationships in the data.

RESULTS

We identified 47 peer-reviewed papers with a total of 31,871 COVID-19 patients, 5,759 (18.1%) experienced disease progression and 5,734 (18.0%) with a history of smoking. Among smokers, 29.2% experienced disease progression, compared with 21.1% of non-smokers. The meta-analysis confirmed an association between smoking and COVID-19 progression (OR 1.56, 95% CI 1.32-1.83, p=0.001). Smoking was associated with increased risk of death from COVID-19 (OR 1.19, 95% CI 1.05-1.34, p=0.007). We found no significant difference (p=0.432) between the effects of smoking on COVID-19 disease progression between adjusted and unadjusted analyses, suggesting that smoking is an independent risk factor for COVID-19 disease progression. We also found the risk of having COVID-19 progression among younger adults (p=0.023), with the effect most pronounced among people under about 45 years old.

CONCLUSIONS

Smoking is an independent risk for having severe progression of COVID-19, including mortality. The effects seem to be higher among young people. Smoking prevention and cessation should remain a priority for the public, physicians, and public health professionals during the COVID-19 pandemic.

Smoking and COVID-19: Adding Fuel to the Flame

The coronavirus disease 2019 (COVID-19) pandemic, an infection caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2), has led to more than 771,000 deaths worldwide. Tobacco smoking is a major known risk factor for severe illness and even death from many respiratory infections. The effects of smoking on COVID-19 are currently controversial. Here, we provide an overview of the current knowledge on the effects of smoking on the clinical manifestations, disease progression, inflammatory responses, immunopathogenesis, racial ethnic disparities, and incidence of COVID-19. This review also documents future directions of smoking related research in COVID-19. The current epidemiological finding suggests that active smoking is associated with an increased severity of disease and death in hospitalized COVID-19 patients. Smoking can upregulate the angiotensin-converting enzyme-2 (ACE-2) receptor utilized by SARS-CoV-2 to enter the host cell and activate a ‘cytokine storm’ which can lead to worsen outcomes in COVID-19 patients. This receptor can also act as a potential therapeutic target for COVID-19 and other infectious diseases. The COVID-19 pandemic sheds light on a legacy of inequalities regarding gender, racial, and ethnic health disparities associated with active smoking, thus, smoking cessation may help in improving outcomes. In addition, to flatten the COVID-19 curve, staying indoors, avoiding unnecessary social contact, and bolstering the immune defense system by maintaining a healthy diet/living are highly desirable.

A comparison of COVID-19, SARS and MERS

In mid-December 2019, a novel atypical pneumonia broke out in Wuhan, Hubei Province, China and was caused by a newly identified coronavirus, initially termed 2019 Novel Coronavirus and subsequently severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of 19 May 2020, a total of 4,731,458 individuals were reported as infected with SARS-CoV-2 among 213 countries, areas or territories with recorded cases, and the overall case-fatality rate was 6.6% (316,169 deaths among 4,731,458 recorded cases), according to the World Health Organization. Studies have shown that SARS-CoV-2 is notably similar to (severe acute respiratory syndrome coronavirus) SARS-CoV that emerged in 2002–2003 and Middle East respiratory syndrome coronavirus (MERS-CoV) that spread during 2012, and these viruses all contributed to global pandemics. The ability of SARS-CoV-2 to rapidly spread a pneumonia-like disease from Hubei Province, China, throughout the world has provoked widespread concern. The main symptoms of coronavirus disease 2019 (COVID-19) include fever, cough, myalgia, fatigue and lower respiratory signs. At present, nucleic acid tests are widely recommended as the optimal method for detecting SARS-CoV-2. However, obstacles remain, including the global shortage of testing kits and the presentation of false negatives. Experts suggest that almost everyone in China is susceptible to SARS-CoV-2 infection, and to date, there are no effective treatments. In light of the references published, this review demonstrates the biological features, spread, diagnosis and treatment of SARS-CoV-2 as a whole and aims to analyse the similarities and differences among SARS-CoV-2, SARS-CoV and MERS-CoV to provide new ideas and suggestions for prevention, diagnosis and clinical treatment.

The effect of smoking on COVID-19 severity: A systematic review and meta-analysis

Various comorbidities represent risk factors for severe coronavirus disease 2019 (COVID‐19). The impact of smoking on COVID‐19 severity has been previously reported in several meta‐analyses limited by small sample sizes and poor methodology. We aimed to rigorously and definitively quantify the effects of smoking on COVID‐19 severity. MEDLINE, Embase, CENTRAL, and Web of Science were searched between 1 December 2019 and 2 June 2020. Studies reporting smoking status of hospitalized patients with different severities of disease and/or at least one clinical endpoint of interest (disease progression, intensive care unit admission, need for mechanical ventilation, and mortality) were included. Data were pooled using a random‐effects model. This study was registered on PROSPERO: CRD42020180920. We analyzed 47 eligible studies reporting on 32 849 hospitalized COVID‐19 patients, with 8417 (25.6%) reporting a smoking history, comprising 1501 current smokers, 5676 former smokers, and 1240 unspecified smokers. Current smokers had an increased risk of severe COVID‐19 (risk ratios [RR]: 1.80; 95% confidence interval [CI]: 1.14‐2.85; P = .012), and severe or critical COVID‐19 (RR: 1.98; CI: 1.16‐3.38; P = .012). Patients with a smoking history had a significantly increased risk of severe COVID‐19 (RR: 1.31; CI: 1.12‐1.54; P = .001), severe or critical COVID‐19 (RR: 1.35; CI: 1.19‐1.53; P < .0001), in‐hospital mortality (RR: 1.26; CI: 1.20‐1.32; P < .0001), disease progression (RR: 2.18; CI: 1.06‐4.49; P = .035), and need for mechanical ventilation (RR: 1.20; CI: 1.01‐1.42; P = .043). Patients with any smoking history are vulnerable to severe COVID‐19 and worse in‐hospital outcomes. In the absence of current targeted therapies, preventative, and supportive strategies to reduce morbidity and mortality in current and former smokers are crucial.

The first high‐quality systematic review and meta‐analysis assessing the impact of smoking on COVID‐19 severity.

To date, the largest meta‐analysis among peer‐reviewed literature assessing the impact of smoking on COVID‐19 severity, including 32,849 hospitalised patients with COVID‐19.

Patients who were current smokers had an increased risk of severe COVID‐19 and severe or critical COVID‐19.

Patients with a smoking history had an increased risk of severe COVID‐19, severe or critical COVID‐19, in‐hospital mortality, disease progression and need for mechanical ventilation.

COVID-19 and Individual Genetic Susceptibility/Receptivity: Role of ACE1/ACE2 Genes, Immunity, Inflammation and Coagulation. Might the Double X-chromosome in Females Be Protective against SARS-CoV-2 Compared to the Single X-Chromosome in Males?

In December 2019, a novel severe acute respiratory syndrome (SARS) from a new coronavirus (SARS-CoV-2) was recognized in the city of Wuhan, China. Rapidly, it became an epidemic in China and has now spread throughout the world reaching pandemic proportions. High mortality rates characterize SARS-CoV-2 disease (COVID-19), which mainly affects the elderly, causing unrestrained cytokines-storm and subsequent pulmonary shutdown, also suspected micro thromboembolism events. At the present time, no specific and dedicated treatments, nor approved vaccines, are available, though very promising data come from the use of anti-inflammatory, anti-malaria, and anti-coagulant drugs. In addition, it seems that males are more susceptible to SARS-CoV-2 than females, with males 65% more likely to die from the infection than females. Data from the World Health Organization (WHO) and Chinese scientists show that of all cases about 1.7% of women who contract the virus will die compared with 2.8% of men, and data from Hong Kong hospitals state that 32% of male and 15% of female COVID-19 patients required intensive care or died. On the other hand, the long-term fallout of coronavirus may be worse for women than for men due to social and psychosocial reasons. Regardless of sex- or gender-biased data obtained from WHO and those gathered from sometimes controversial scientific journals, some central points should be considered. Firstly, SARS-CoV-2 has a strong interaction with the human ACE2 receptor, which plays an essential role in cell entry together with transmembrane serine protease 2 (TMPRSS2); it is interesting to note that the ACE2 gene lays on the X-chromosome, thus allowing females to be potentially heterozygous and differently assorted compared to men who are definitely hemizygous. Secondly, the higher ACE2 expression rate in females, though controversial, might ascribe them the worst prognosis, in contrast with worldwide epidemiological data. Finally, several genes involved in inflammation are located on the X-chromosome, which also contains high number of immune-related genes responsible for innate and adaptive immune responses to infection. Other genes, out from the RAS-pathway, might directly or indirectly impact on the ACE1/ACE2 balance by influencing its main actors (e.g., ABO locus, SRY, SOX3, ADAM17). Unexpectedly, the higher levels of ACE2 or ACE1/ACE2 rebalancing might improve the outcome of COVID-19 in both sexes by reducing inflammation, thrombosis, and death. Moreover, X-heterozygous females might also activate a mosaic advantage and show more pronounced sex-related differences resulting in a sex dimorphism, further favoring them in counteracting the progression of the SARS-CoV-2 infection.