Why does COVID-19 kill more elderly men than women? Is there a role for testosterone?

Reevaluation of prognostic and severity indicators for COVID-19 patients in the emergency department

AIMS

This study aimed to re-evaluate whether the scoring systems, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were effective in predicting prognosis and severity of COVID-19 patients in the emergency department (ED).

METHODS

COVID-19 patients enrolled in this retrospective study divided into the death (DEA) and survival (SUR) groups, the severe/critical (SC) and non-severe/critical (non-SC) groups. The Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), National Early Warning Score (NEWS) and CCEDRRN COVID-19 Mortality Score were calculated. The neutrophil, lymphocyte and platelet counts were extracted from the first routine blood examination, and NLR and PLR were calculated accordingly. Receiver Operating Characteristic (ROC) curve and logistic regression were performed.

RESULTS

All the scoring systems, as well as NLR and PLR, significantly increased in both the DEA and SC groups. The ROC curve showed that the CCEDRRN COVID-19 Mortality Score had the highest predictive value for mortality and severity (AUC 0.779, 0.850, respectively), which outperformed the APACHE II, SOFA and NEWS. NLR presented better predictive ability for severity (AUC 0.741) than death (AUC 0.702). The APACHE II, NEWS and CCEDRRN COVID-19 Mortality Score were positively correlated with both prognosis and severity, whereas NLR only with severity.

CONCLUSION

The NEWS and CCEDRRN COVID-19 Mortality Score were reconfirmed for early and rapid predicting the poor prognosis and severity of COVID-19 patients in ED, especially the CCEDRRN COVID-19 Mortality Score with the highest discrimination capacity, and NLR was more appropriate for predicting the severity.

Pre-existing sleep disturbances and risk of COVID-19: a meta-analysis

Background

Sleep disturbances are widespread but usually overlooked health risk factors for coronavirus disease 2019 (COVID-19). We aimed to investigate the influence of pre-existing sleep disturbances on the susceptibility, severity, and long-term effects of COVID-19.

Methods

We searched PubMed, Web of Science, and Embase for relevant articles from inception to October 27, 2023 and updated at May 8, 2024. Sleep disturbances included obstructive sleep apnea (OSA), insomnia, abnormal sleep duration, night-shift work, and any other sleep disturbances. Outcomes were COVID-19 susceptibility, hospitalization, mortality, and long COVID. The effect sizes were pooled odds ratios (ORs) and 95% confidence intervals (95% CIs). This study is registered with PROSPERO (CRD42024503518).

Findings

A total of 48 observational studies (n = 8,664,026) were included. Pre-existing sleep disturbances increased the risk of COVID-19 susceptibility (OR = 1.12, 95% CI 1.07-1.18), hospitalization (OR = 1.25, 95% CI 1.15-1.36), mortality (OR = 1.45, 95% CI 1.19-1.78), and long COVID (OR = 1.36 95% CI 1.17-1.57). Subgroup analysis showed that younger individuals with sleep disturbances were associated with higher susceptibility and hospitalization and a lower risk of mortality than older individuals. Males with sleep disturbances were associated with higher mortality. For specific sleep disturbances, the susceptibility and hospitalization of COVID-19 were associated with OSA, abnormal sleep duration, and night-shift work; mortality of COVID-19 was linked to OSA; risk of long COVID was related to OSA, abnormal sleep duration and insomnia.

Interpretation

Pre-existing sleep disturbances, especially OSA, increased the risk of COVID-19 susceptibility, hospitalization, mortality, and long COVID. Age and sex played important roles in the effect of sleep disturbances on COVID-19.

Funding

The National Natural Science Foundation of China and the Key Laboratory of Respiratory Diseases of Liaoning Province.

Predictive value of hematocrit, serum albumin level difference, and fibrinogen-to-albumin ratio for COVID-19-associated acute respiratory failure

Background

Acute respiratory failure is the main clinical manifestation and a major cause of death in patients with COVID-19. However, few reports on its prevention and control have been published because of the need for laboratory predictive indicators. This study aimed to evaluate the predictive value of hematocrit level, serum albumin level difference, and fibrinogen-to-albumin ratio for COVID-19-associated acute respiratory failure.

Material and methods

A total of 120 patients with COVID-19 from the First Affiliated Hospital of Anhui Medical University were selected between December 2022 and March 2023. Patients were divided into acute respiratory failure and non-acute respiratory failure groups and compared patient-related indicators between them using univariate and multivariate logistic regression analyses. Receiver operating characteristic analysis was performed to determine the discrimination accuracy.

Results

In total, 48 and 72 patients were enrolled in the acute respiratory failure and non-acute respiratory failure groups, respectively. The Quick COVID-19 Severity Index scores, fibrinogen-to-albumin ratio, hematocrit and serum albumin level difference, fibrinogen, and hematocrit levels were significantly higher in the acute respiratory failure group than in the non-acute respiratory failure group. A Quick COVID-19 Severity Index >7, fibrinogen-to-albumin ratio >0.265, and hematocrit and serum albumin level difference >12.792 had a 96.14 % positive predictive rate and a 94.06 % negative predictive rate.

Conclusion

Both fibrinogen-to-albumin ratio and hematocrit and serum albumin level difference are risk factors for COVID-19-associated acute respiratory failure. The Quick COVID-19 Severity Index score combined with fibrinogen-to-albumin ratio, and hematocrit and serum albumin level difference predict high and low risks with better efficacy and sensitivity than those of the Quick COVID-19 Severity Index score alone; therefore, these parameters can be used collectively as a risk stratification method for assessing patients with COVID-19.

Clinical characteristics and factors for serious outcomes among outpatients infected with the Omicron subvariant BF.7

To evaluate clinical characteristics and identify risk factors associated with severe outcomes in outpatients infected with the Omicron subvariant BF.7, data were collected from outpatients diagnosed with Corona Virus Disease 2019 from December 19, 2022 to January 5, 2023. Clinical characteristics were analyzed using descriptive statistics. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with serious outcomes. Variables with a p < 0.10 in the univariate analysis were included in the multivariate model. Our study analyzed 770 patients, of whom 380 (49.4%) were male, with a median age of 59. The most common symptoms reported were cough (71.2%), fever (64.7%), and sore throat (37.7%). Fever lasted an average of 5.93 ± 3.37 days for the general population and 10.64 ± 7.12 days for impaired-immunity patients. Most cases were mild (68.7%), followed by moderate (27.1%). Severe cases accounted for 2.2%, with 0.5% critically ill. Serious outcomes occurred in 4.2% of cases, with 11 deaths during follow-up. Underlying-diseases patients had a higher rate of serious outcomes. Factors associated with serious outcomes included receiving a three-dose vaccination (odds ratio [OR] = 0.324, 95% confidence interval [CI]: 0.113-0.932, p = 0.037), male gender (OR = 2.890, 95% CI: 1.107-7.548, p = 0.030), age (OR = 1.060, 95% CI: 1.024-1.097, p = 0.001), and chest tightness or dyspnea at the time of visit (OR = 4.861, 95% CI: 2.054-11.507, p < 0.001). Our study found that cough, fever, and sore throat were the most common symptoms reported by patients. Receiving a three-dose vaccination was protective, while male gender, age, and chest tightness or dyspnea were identified as risk factors for serious outcomes.

SARS-CoV-2 Enters Human Leydig Cells and Affects Testosterone Production In Vitro

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a SARS-like coronavirus, continues to produce mounting infections and fatalities all over the world. Recent data point to SARS-CoV-2 viral infections in the human testis. As low testosterone levels are associated with SARS-CoV-2 viral infections in males and human Leydig cells are the main source of testosterone, we hypothesized that SARS-CoV-2 could infect human Leydig cells and impair their function. We successfully detected SARS-CoV-2 nucleocapsid in testicular Leydig cells of SARS-CoV-2-infected hamsters, providing evidence that Leydig cells can be infected with SARS-CoV-2. We then employed human Leydig-like cells (hLLCs) to show that the SARS-CoV-2 receptor angiotensin-converting enzyme 2 is highly expressed in hLLCs. Using a cell binding assay and a SARS-CoV-2 spike-pseudotyped viral vector (SARS-CoV-2 spike pseudovector), we showed that SARS-CoV-2 could enter hLLCs and increase testosterone production by hLLCs. We further combined the SARS-CoV-2 spike pseudovector system with pseudovector-based inhibition assays to show that SARS-CoV-2 enters hLLCs through pathways distinct from those of monkey kidney Vero E6 cells, a typical model used to study SARS-CoV-2 entry mechanisms. We finally revealed that neuropilin-1 and cathepsin B/L are expressed in hLLCs and human testes, raising the possibility that SARS-CoV-2 may enter hLLCs through these receptors or proteases. In conclusion, our study shows that SARS-CoV-2 can enter hLLCs through a distinct pathway and alter testosterone production.

Long COVID and risk of erectile dysfunction in recovered patients from mild to moderate COVID-19

Patients with coronavirus disease 2019 (COVID-19) were shown to have reduced serum testosterone levels compared to healthy individuals. Low testosterone levels are linked with the development of erectile dysfunction (ED). In this case-controlled study, 20 healthy controls and 39 patients with ED 3 months after recovering from mild-to-moderate COVID-19 pneumonia were studied. The patients ranged in age from 31 to 47 years. To identify early and late COVID-19 infections, real-time polymerase-chain reaction (RT-PCR) and COVID-19 antibody testing were done. The levels of luteinizing hormone (LH), follicular stimulating hormone (FSH), total testosterone (TT), free testosterone (FT), free androgenic index (FAI), and sex hormone-binding globulin (SHBG) were measured. The sexual health inventory for patients (SHIM) score was used to measure the erectile function of the patients and controls. When compared to the controls, the TT serum level in long COVID-19 (LC) patients with ED was low (p = 0.01). In contrast to controls, FT and FAI were both lower in LC patients with ED. (p = 0.001). FSH serum levels did not significantly differ (p = 0.07), but in ED patients, LH serum levels were elevated. SHIM scores were associated with low TT (p = 0.30), FT (p = 0.09), and high LH (p = 0.76) in LC patients with ED. Male patients with decreased serum levels of LH and testosterone may have hypothalamic-pituitary-gonadal axis dysfunction, which could lead to the development of LC-induced ED. Therefore, an in-depth research is necessary to confirm the causal link between COVID-19 and ED in LC patients.

Association of government effectiveness, logistics performance, IT systems and income with COVID-19 mortality

The COVID-19 pandemic has unprecedentedly shaken the public health system worldwide. It has been one of the greatest humanitarian crises faced by all countries, regardless of their economic prosperity. However, some countries have been able to minimize the deaths caused by the coronavirus even in the face of a large number of cases, while others have failed to control the death rate even in a comparatively small number of cases. This study explores possible causes of this disparity using cross-sectional data from 126 countries associated with demography, governance, income level, the extent of ICT maturity and the geographical divide. The results of this study suggest that while government effectiveness is negatively associated with the COVID-19 death rate, the logistics performance of governments is positively linked to the COVID-19 mortality rate. The ICT maturity proxied through online service delivery did not confirm its association with the COVID-19 mortality rate. This study informs that poverty and the location of countries do not necessarily influence COVID-19 deaths. Hence, it behoves governments to focus on improving government effectiveness and putting in place more effective and efficient mobility systems, healthcare supply chains and digital administration to address the global health crisis posed by the COVID-19 pandemic and mitigate its harsh effects, including mortality.

Predictors of COVID-19 related death in elderly patients hospitalized due to COVID-19 infection: a cross-sectional study in the west of Iran

Aim

Identifying risk factors associated with mortality in elderly patients hospitalized with COVID-19 can be helpful in managing the disease in this age group. Therefore, the aim of this study was to determine the risk factors of death in elderly patients hospitalized with COVID-19 in Hamadan in 2020.

Subject and methods

This cross-sectional study was performed on the medical records of 1694 patients aged 60 years and older who were diagnosed with COVID-19 disease between March and August 2020 and were admitted to Shahid Beheshti and Sina Hospitals. A researcher-made checklist included demographic information, clinical information, laboratory results, type of procedures performed for the patient in the hospital, and the number of hospitalization days.

Results

The results showed that 30% of the elderly patients died due to COVID-19 complications. The results of adapted logistic regression showed that the variables of gender, age, inpatient ward and laboratory indices of albumin, hemoglobin, ESR, and LDH were the main predictors of COVID-19 related death in elderly patients (p < 0.05).

Conclusion

The rate of COVID-19 related death in the hospitalized elderly patients is remarkable. The death rate increased among male patients, age older than 75 years, hospitalization in the ICU, increased ESR and HDR levels, and decreased albumin and hemoglobin.

Percutaneous Dilatational Tracheostomy in Patients with COVID-19 Supported by Extracorporeal Membrane Oxygenation

Background

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 can cause acute respiratory distress syndrome, often requiring prolonged mechanical ventilation and eventually tracheostomy. Both procedures occur in isolation units where personal protective equipment is needed. Additionally, the high bleeding risk in patients with extracorporeal membrane oxygenation (ECMO) places a great strain on surgeons. We investigated the clinical characteristics and outcomes of percutaneous dilatational tracheostomy (PDT) in patients with coronavirus disease 2019 (COVID-19) supported by ECMO, and compared the outcomes of patients with and without ECMO.

Methods

This retrospective, single-center, observational study included patients with severe COVID-19 who underwent elective PDT (n=29) from April 1, 2020, to October 31, 2021. The patients were divided into ECMO and non-ECMO groups. Data were collected from electronic medical records at Ajou University Hospital in Suwon, Korea.

Results

Twenty-nine COVID-19 patients underwent PDT (24 men [82.8%] and 5 women [17.2%]; median age, 61 years; range, 26-87 years; interquartile range, 54-71 years). The mean procedure time was 17±10.07 minutes. No clinically or statistically significant difference in procedure time was noted between the ECMO and non-ECMO groups (16.35±7.34 vs. 18.25±13.32, p=0.661). Overall, 12 patients (41.4%) had minor complications; 10 had mild subdermal bleeding from the skin incision, which was resolved with local gauze packing, and 2 (6.9%) had dislodgement. No healthcare provider infection was reported.

Conclusion

Our PDT approach is safe for patients and healthcare providers. With bronchoscopy assistance, PDT can be performed quickly and easily even in isolation units and with acceptable risk, regardless of the hypo-coagulable condition of patients on ECMO.

Investigating the interrelatedness of clinical and non-clinical parameters affecting outcomes in COVID-19 patients: a retrospective study

The COVID-19 pandemic has affected millions globally. Several studies have been carried out to uncover factors affecting the severity of the resulting infection. Available location-specific data concerning the affective demographics as well as clinical aspect of the disease remains limited. In this study, a number of non-clinical as well as the clinical parameters were investigated for their role in adverse progression of the disease in patients admitted to intensive care unit (ICU) in a private tertiary hospital in Peshawar. The prevalence of comorbidities hypertension and diabetes as well as mortality was higher in age group of 70-79 years. Dyspnea was significantly linked to sepsis, invasive ventilation, and mortality; its late presentation, i.e. 15 to 20 days was significantly associated with mortality (p-value < 0.02). Acute kidney injury and acute respiratory distress syndrome were found to be the most strongly associated with sepsis and septic shock. Neither remdesivir nor tocilizumab was effective in preventing the infection-related complications, invasive ventilation, and mortality. Overall, dyspnea was found to be an indicator of the worst progression of the disease. Furthermore, while some parameters were closely linked, others were not.

[Risk factors for outcome and mortality in hospitalized geriatric patients with SARS-CoV-2 infection : Data from a hospital of maximum care during in the period of the second corona wave 2020/2021 in Germany]

BACKGROUND

From autumn 2020 until spring 2021 Germany experienced the second wave of SARS-CoV‑2 infections. As in the previous wave, the older population in nursing homes was hard hit by this infection because of the lack of available vaccines. Due to the multimorbidity in this susceptible group the mortality was high.

METHODS

Retrospectively collected patient data of geriatric patients treated from 1 October 2020 to 31 March 2021 due to proven SARS-CoV‑2 infection were evaluated concerning the duration of symptoms, hospital stay, and laboratory results. The results are presented descriptively and significance tests were performed with t‑test and log-rank test to reveal some risk factors for a worse outcome.

RESULTS

A total of 168 patients aged from 65 to 97 years were included, with a mean mortality rate of 28% and was highest in the age group over 90 years old. Most patients died within the first 10 days of hospitalization. Intensive care treatment prolonged the hospital stay by 6 days, but the average survival time became equal at the end. Risk factors for worse outcome and the need of intensive care treatment were neutrophilia, lymphopenia, high levels of ferritin and high D‑dimer levels on the day of admission. Age, short duration of symptoms and pre-existing dementia, administration of neuroleptic drugs and antidepressants increased the risk of death.

SARS-CoV-2, fertility and assisted reproduction

BACKGROUND

In 2020, SARS-CoV-2 and the COVID-19 pandemic had a huge impact on the access to and provision of ART treatments. Gradually, knowledge of the virus and its transmission has become available, allowing ART activities to resume. Still, questions on the impact of the virus on human gametes and fertility remain.

OBJECTIVE AND RATIONALE

This article summarizes published data, aiming to clarify the impact of SARS-CoV-2 and the COVID-19 disease on human fertility and assisted reproduction, as well as the impact of vaccination, and from this, provide answers to questions that are relevant for people contemplating pregnancy and for health care professionals.

SEARCH METHODS

PUBMED/MEDLINE and the WHO COVID-19 database were searched from inception to 5 October 2022 with search terms focusing on 'SARS-CoV-2' and gametes, embryos, reproductive function, fertility and ART. Non-English studies and papers published prior to 2020 were excluded, as well as reviews and non-peer reviewed publications. Full papers were assessed for relevance and quality, where feasible.

OUTCOMES

From the 148 papers included, the following observations were made. The SARS-CoV-2-binding proteins, angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), are expressed in the testis, but co-expression remains to be proven. There is some evidence of SARS-CoV-2 RNA in the ejaculate of COVID-19 patients with severe disease, but not in those with mild/moderate disease. SARS-CoV-2 infection can impair spermatogenesis, but this seems to resolve after one spermatogenic cycle. Testosterone levels seem to be lower during and after COVID-19, but long-term data are lacking; disease severity may be associated with testosterone levels. COVID-19 cannot be considered a sexually transmitted disease. There is no co-expression of ACE2 and TMPRSS2 in the myometrium, uterus, ovaries or fallopian tubes. Oocytes seem to have the receptors and protease machinery to be susceptible to SARS-CoV-2 infection; however, viral RNA in oocytes has not been detected so far. Women contemplating pregnancy following COVID-19 may benefit from screening for thyroid dysfunction. There is a possible (transient) impact of COVID-19 on menstrual patterns. Embryos, and particularly late blastocysts, seem to have the machinery to be susceptible to SARS-CoV-2 infection. Most studies have not reported a significant impact of COVID-19 on ovarian reserve, ovarian function or follicular fluid parameters. Previous asymptomatic or mild SARS-CoV-2 infection in females does not seem to negatively affect laboratory and clinical outcomes of ART. There are no data on the minimum required interval, if any, between COVID-19 recovery and ART. There is no evidence of a negative effect of SARS-CoV-2 vaccination on semen parameters or spermatogenesis, ovarian function, ovarian reserve or folliculogenesis. A transient effect on the menstrual cycle has been documented. Despite concerns, cross reactivity between anti-SARS-CoV-2 spike protein antibodies and Syncytin-1, an essential protein in human implantation, is absent. There is no influence of mRNA SARS-CoV-2 vaccine on patients' performance during their immediate subsequent ART cycle. Pregnancy rates post-vaccination are similar to those in unvaccinated patients.

WIDER IMPLICATIONS

This review highlights existing knowledge on the impact of SARS-CoV-2 infection or COVID-19 on fertility and assisted reproduction, but also identifies gaps and offers suggestions for future research. The knowledge presented should help to provide evidence-based advice for practitioners and couples contemplating pregnancy alike, facilitating informed decision-making in an environment of significant emotional turmoil.

Causal Inference of Central Nervous System-Regulated Hormones in COVID-19: A Bidirectional Two-Sample Mendelian Randomization Study

We assessed the causal association of three COVID-19 phenotypes with insulin-like growth factor 1, estrogen, testosterone, dehydroepiandrosterone (DHEA), thyroid-stimulating hormone, thyrotropin-releasing hormone, luteinizing hormone (LH), and follicle-stimulating hormone. We used bidirectional two-sample univariate and multivariable Mendelian randomization (MR) analyses to evaluate the direction, specificity, and causality of the association between CNS-regulated hormones and COVID-19 phenotypes. Genetic instruments for CNS-regulated hormones were selected from the largest publicly available genome-wide association studies of the European population. Summary-level data on COVID-19 severity, hospitalization, and susceptibility were obtained from the COVID-19 host genetic initiative. DHEA was associated with increased risks of very severe respiratory syndrome (odds ratio [OR] = 4.21, 95% confidence interval [CI]: 1.41-12.59), consistent with multivariate MR results (OR = 3.72, 95% CI: 1.20-11.51), and hospitalization (OR = 2.31, 95% CI: 1.13-4.72) in univariate MR. LH was associated with very severe respiratory syndrome (OR = 0.83; 95% CI: 0.71-0.96) in univariate MR. Estrogen was negatively associated with very severe respiratory syndrome (OR = 0.09, 95% CI: 0.02-0.51), hospitalization (OR = 0.25, 95% CI: 0.08-0.78), and susceptibility (OR = 0.50, 95% CI: 0.28-0.89) in multivariate MR. We found strong evidence for the causal relationship of DHEA, LH, and estrogen with COVID-19 phenotypes.

Risk and Protective Factors for COVID-19 Morbidity, Severity, and Mortality

The outbreak of the coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become an evolving global health crisis. Currently, a number of risk factors have been identified to have a potential impact on increasing the morbidity of COVID-19 in adults, including old age, male sex, pre-existing comorbidities, and racial/ethnic disparities. In addition to these factors, changes in laboratory indices and pro-inflammatory cytokines, as well as possible complications, could indicate the progression of COVID-19 into a severe and critical stage. Children predominantly suffer from mild illnesses due to COVID-19. Similar to adults, the main risk factors in pediatric patients include age and pre-existing comorbidities. In contrast, supplementation with a healthy diet and sufficient nutrition, COVID-19 vaccination, and atopic conditions may act as protective factors against the infection of SARS-CoV-2. COVID-19 vaccination not only protects vulnerable individuals from SARS-CoV-2 infection, more importantly, it may also reduce the development of severe disease and death due to COVID-19. Currently used therapies for COVID-19 are off-label and empiric, and their impacts on the severity and mortality of COVID-19 are still unclear. The interaction between asthma and COVID-19 may be bidirectional and needs to be clarified in more studies. In this review, we highlight the clinical evidence supporting the rationale for the risk and protective factors for the morbidity, severity, and mortality of COVID-19.

Aging-related predictive factors for oxygenation improvement and mortality in COVID-19 and acute respiratory distress syndrome (ARDS) patients exposed to prone position: A multicenter cohort study

BACKGROUND

Elderly patients are more susceptible to Coronavirus Disease-2019 (COVID-19) and are more likely to develop it in severe forms, (e.g., Acute Respiratory Distress Syndrome [ARDS]). Prone positioning is a treatment strategy for severe ARDS; however, its response in the elderly population remains poorly understood. The main objective was to evaluate the predictive response and mortality of elderly patients exposed to prone positioning due to ARDS-COVID-19.

METHODS

This retrospective multicenter cohort study involved 223 patients aged ≥ 65 years, who received prone position sessions for severe ARDS due to COVID-19, using invasive mechanical ventilation. The PaO₂/FiO₂ ratio was used to assess the oxygenation response. The 20-point improvement in PaO₂/FiO₂ after the first prone session was considered for good response. Data were collected from electronic medical records, including demographic data, laboratory/image exams, complications, comorbidities, SAPS III and SOFA scores, use of anticoagulants and vasopressors, ventilator settings, and respiratory system mechanics. Mortality was defined as deaths that occurred until hospital discharge.

RESULTS

Most patients were male, with arterial hypertension and diabetes mellitus as the most prevalent comorbidities. The non-responders group had higher SAPS III and SOFA scores, and a higher incidence of complications. There was no difference in mortality rate. A lower SAPS III score was a predictor of oxygenation response, and the male sex was a risk predictor of mortality.

CONCLUSION

The present study suggests the oxygenation response to prone positioning in elderly patients with severe COVID-19-ARDS correlates with the SAPS III score. Furthermore, the male sex is a risk predictor of mortality.

COVID-19 Vaccines and the Virus: Impact on Drug Metabolism and Pharmacokinetics

This article reports on an American Society of Pharmacology and Therapeutics, Division of Drug Metabolism and Disposition symposium held at Experimental Biology on April 2, 2022, in Philadelphia. As of July 2022, over 500 million people have been infected with SARS-CoV-2 (the virus causing COVID-19) and over 12 billion vaccine doses have been administered. Clinically significant interactions between viral infections and hepatic drug metabolism were first recognized over 40 years ago during a cluster of pediatric theophylline toxicity cases attributed to reduced hepatic drug metabolism amid an influenza B outbreak. Today, a substantive body of research supports that the activated innate immune response generally decreases hepatic cytochrome P450 activity. The interactions extend to drug transporters and other organs and have the potential to impact drug absorption, distribution, metabolism, and excretion (ADME). Based on this knowledge, altered ADME is predicted with SARS-CoV-2 infection or vaccination. The report begins with a clinical case exploring the possibility of SARS-CoV-2 vaccination increasing clozapine levels. This is followed by discussions of how SARS-CoV-2 infection or vaccines alter the metabolism and disposition of complex drugs, such as nanoparticles and biologics and small molecule therapies. The review concludes with a discussion of the effects of viral infections on placental amino acid transport and their potential to impact fetal development. The session improved our understanding of the impact of emerging viral infections and vaccine technologies on drug metabolism and disposition, which will help mitigate drug toxicity and improve drug and vaccine safety and effectiveness. SIGNIFICANCE STATEMENT: Altered pharmacokinetics of small molecule and complex molecule drugs and fetal brain distribution of amino acids following SARS-CoV-2 infection or immunization are possible. The proposed mechanisms involve decreased liver cytochrome P450 metabolism of small molecules, enhanced innate immune system metabolism of complex molecules, and altered placental and fetal blood-brain barrier amino acid transport, respectively. Future research is needed to understand the effects of these interactions on adverse drug responses, drug and vaccine safety, and effectiveness and fetal neurodevelopment.

Pathophysiology of SARS-CoV2 Mediated Depression, Therapeutics, and Consequences: A Comprehensive Narrative

The Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus type 2 (SARS-CoV-2), belongs to emerging and reemerging diseases, which was first identified and reported in Wuhan, China, in December 2019. The genetic sequence of SARS-CoV-2 was similar to the SARS virus, a β-coronavirus. The epidemiological studies suggest that the transmission of SARS-CoV-2 mainly occurs from an infected person to others through close contact with the respiratory droplets or by having contact with SARS-CoV-2 adhering to objects and surfaces. The incubation period ranges from 5 to14 days. The symptoms include fever, dry cough, tiredness, aches, chest pain, conjunctivitis, diarrhea, headache, difficulty in breathing or short breath, loss of taste, smell, rashes on the skin, and sore throat. Some reports indicated that males exhibited lower scores than females, the younger populations displayed increased symptoms, Chinese/Taiwanese people registered only scarce symptoms, and Canadians experienced more symptoms. The results of several studies suggested that while COVID-19 had a significant effect on depression, job instability affected anxiety and depression. The diagnostics to detect the presence of coronavirus involve ELISA and RT-PCR. There is no specific treatment available to eradicate COVID-19. The therapeutics used to treat COVID 19 exhibited severe side effects. Recently, some Indian traditional medicinal plants have shown promise in reducing the risk of viral infection and also boosting the immunity of an individual. This paper presents an overview of the current status of depression in the SARS CoV2 infected people and the measures required to overcome COVID-19 induced depression in patients even after recovery.

The longitudinal evaluation of COVID-19 in pediatric patients and the impact of delta variant

BACKGROUND

Pediatric patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) displayed milder symptoms than adults. However, they play an important role in case numbers and virus transmission. Therefore, we aimed to determine the epidemiological features of all pediatric patients infected with SARS-CoV-2 and put forth case numbers longitudinally throughout the delta variant dominant period.

METHODS

A retrospective study was conducted at a university hospital and included patients between 0 and18 years old with a SARS-CoV-2 polymerase chain reaction (PCR) positive result, including inpatients and outpatients. Epidemiological and clinical features were recorded from electronic files, and telephone visits were performed between March 2020 and December 2021.

RESULTS

During the study period, 3175 coronavirus disease 2019 (COVID-19) pediatric patients were admitted to our hospital with a mean age of 10.61 ± 4.6 years. Of the 1815 patients who could be interviewed, 85.7% reported at least one symptom. Before the delta variant period, 0-4 years aged children were more commonly infected, while school-aged children and adolescents were more common, and the rate of pediatric cases to all COVID-19 cases increased to 35.8% after the delta variant became dominant. Symptomatic cases were significantly higher before the delta variant (87.8% vs. 84.06%, p = 0.016). The hospitalization rate was higher before the delta variant (p < 0.001), whereas PICU admission showed no statistical difference.

CONCLUSIONS

The frequency of school-aged children and adolescents raised with the impact of both school openings and the delta variant, and the rate of pediatric cases increased in total COVID-19 patient numbers.

Androgens' Role in Severity and Mortality Rates of COVID-19

By the end of December 2019 new corona virus began to spread from Wuhan, China and caused a worldwide pandemic. COVID-19 deaths and prevalence represented sex discrepant patterns with higher rate of deaths and infection in males than females which could be justified by androgen-mediated mechanisms. This review aimed to assess the role of androgens in COVID-19 severity and mortality. Androgens increase expressions of Type II transmembrane Serine Protease (TMPRSS2) and Angiotensin Converting Enzyme 2 (ACE2), which both facilitate new corona virus entry into host cell and their expression is higher in young males than females. According to observational studies, prevalence of COVID-19 infections and deaths was more in androgenic alopecic patients than patients without androgenic alopecia. The COVID-19 mortality rates in aged men (>60 years) were substantially higher than aged females and even young males caused by high inflammatory activities such as cytokine storm due to hypogonadism in this population. Use of anti-androgen and TMPRSS2 inhibitor drugs considerably modified COVID-19 symptoms. Androgen deprivation therapy also improved COVID-19 symptoms in prostate cancer: overall the role of androgens in severity of COVID-19 and its associated mortality seemed to be very important. So, more studies in variety of populations are required to define the absolute role of androgens.

A comparison of seasonal influenza and novel Covid-19 vaccine intentions: A cross-sectional survey of vaccine hesitant adults in England during the 2020 pandemic

We compared intention to receive the seasonal influenza vaccine with a prospective coronavirus (COVID-19) vaccine among undecided or COVID-19 vaccine hesitant individuals to better understand the underlying differences and similarities in factors associated with vaccine intention. We delivered a cross-sectional online survey in October-November 2020. We included psychological constructs and sociodemographic variables informed by theory. We conducted pairwise comparisons and multiple linear regression models to explore associations between vaccine intention and psychological constructs. We recruited 1,660 participants, where 47.6% responded that they would likely receive the influenza vaccine, 31.0% that they would probably not accept the vaccination and 21.4% were unsure. In relation to the prospective COVID-19 vaccine, 39.0% responded that they would likely receive the vaccination, 23.7% that they would probably not accept the vaccination and 37.3% were unsure. Unique factors positively associated with COVID-19 vaccine intention were: perceived knowledge sufficiency about vaccine safety, beliefs about vaccine safety, and living in an area of low deprivation. The only unique factor positively associated with influenza intention was past influenza behavior. The strongest common predictors positively associated with intention were: favorable vaccine attitudes, the anticipated regret they may feel following infection if they were not to receive a vaccine, and the expectation from family or friends to accept the vaccine. Despite overall similarities in those factors associated with vaccination intention, we identified unique influences on intention. This additional insight will help support the planning and tailoring of future immunizations programmes for the respective viruses.

COVID-19 in Older Individuals Requiring Hospitalization

Older individuals have an increased risk for severe coronavirus disease 2019 (COVID-19) and a higher risk for complications and death. The aim of this study was to investigate the clinical characteristics of older patients admitted with COVID-19 and describe their outcomes. This was a retrospective cohort study of patients older than 65 years admitted to the COVID-19 Department of the University Hospital of Heraklion. Data recorded and evaluated included age, gender, Infectious Diseases Society of America (IDSA) severity score, Charlson comorbidity index (CCI), high-flow nasal oxygen (HFNO) use, admission to the Intensive Care Unit (ICU), laboratory exams, treatment administered, and outcome. In total, 224 patients were evaluated in the present study. The median age was 75 years and 105 (46.9%) were female. In 50 patients (22.7%), HFNO was used and 23 (10.3%) were admitted to the ICU. Mortality was 13.4% (30 patients). Patients that died had higher age, were more likely to be male, had an IDSA severity score of 3, had prior HFNO use, had been admitted to the ICU, and were also more likely to have a higher white blood cell (WBC) count, CRP, ferritin, procalcitonin, d-dimers, and troponin. A multivariate logistic regression analysis identified age and the need for HFNO use to be independently positively associated with mortality. To conclude, COVID-19 carries significant mortality in hospitalized older patients, which increases with age, while the need for HFNO also increased the likelihood of worse outcomes. Clinicians caring for patients with COVID-19 should bear in mind these two factors. Future studies could elaborate on the effect of new variants on the dynamics of mortality in older patients.

Premenopausal and postmenopausal women during the COVID-19 pandemic

The current global COVID-19 mortality rate is estimated to be around 3.4%; however, it is dependent on age, sex, and comorbidities. Epidemiological evidence shows gender disparities in COVID-19 severity and fatality, with non-menopausal females having milder severity and better outcomes than age-matched males. However, the difference vanishes when comparing postmenopausal women with age-matched men. It has been suggested that, to some extent, this is due to the protective role of female hormones, such as anti-Müllerian hormone and oestradiol (E2), in non-menopausal women. Oestrogens have been hypothesized to be crucial in modulating viral infection and the progression of the disease via an action on immune/inflammatory responses and angiotensin-converting enzyme type 2 expression. Hence, the most likely explanation is that, because the levels of oestrogen in females after menopause decrease, oestrogen no longer offers a beneficial effect as seen in younger females. The COVID-19 pandemic has highlighted the serious negative effects arising from the state of E2 deficiency. Therefore, hormone replacement therapy gains further support as the damaging effect of the decline in ovarian function affects many biological systems, and recently with the COVID-19 pandemic, oestrogen's vital role within the immune system has become quite clear. However, additional clinical investigations regarding hormone replacement therapy are urgently needed to further verify the protective and therapeutic effects of E2 on menopausal women with COVID-19.

SARS-CoV-2 pre-exposure prophylaxis: A potential COVID-19 preventive strategy for high-risk populations, including healthcare workers, immunodeficient individuals, and poor vaccine responders

The unprecedented worldwide spread of SARS-CoV-2 has imposed severe challenges on global health care systems. The roll-out and widespread administration of COVID-19 vaccines has been deemed a major milestone in the race to restrict the severity of the infection. Vaccines have as yet not entirely suppressed the relentless progression of the pandemic, due mainly to the emergence of new virus variants, and also secondary to the waning of protective antibody titers over time. Encouragingly, an increasing number of antiviral drugs, such as remdesivir and the newly developed drug combination, Paxlovid® (nirmatrelvir/ritonavir), as well as molnupiravir, have shown significant benefits for COVID-19 patient outcomes. Pre-exposure prophylaxis (PrEP) has been proven to be an effective preventive strategy in high-risk uninfected people exposed to HIV. Building on knowledge from what is already known about the use of PrEP for HIV disease, and from recently gleaned knowledge of antivirals used against COVID-19, we propose that SARS-CoV-2 PrEP, using specific antiviral and adjuvant drugs against SARS-CoV-2, may represent a novel preventive strategy for high-risk populations, including healthcare workers, immunodeficient individuals, and poor vaccine responders. Herein, we critically review the risk factors for severe COVID-19 and discuss PrEP strategies against SARS-CoV-2. In addition, we outline details of candidate anti-SARS-CoV-2 PrEP drugs, thus creating a framework with respect to the development of alternative and/or complementary strategies to prevent COVID-19, and contributing to the global armamentarium that has been developed to limit SARS-CoV-2 infection, severity, and transmission.

Examining Male Predominance of Severe COVID-19 Outcomes: A Systematic Review

Although not universal, many epidemiological data sources signal that a higher proportion of males than females with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections have adverse outcomes, such as intensive care unit (ICU) admission and death. Though likely multifactorial, the various hypotheses that have been proposed as underlying factors behind this trend are related to greater smoking prevalence among males, testosterone (T) deficiency causing an inflammatory storm, androgen-driven pathogenesis of SARS-CoV-2, a protective effect of estrogen in females, and inborn errors of cytokine immunity. This review aims at examining the evidence and at assessing the likelihood that the factors being investigated are contributory to the reported trend of male predominance of severe COVID-19 cases. Sources were obtained using the PubMed database and were selected based on their relevance to one of the primary hypotheses attempting to explain the strong male sex bias of severe SARS-CoV-2 infections. Emphasis was placed on meta-analyses and population-based studies. Sources are current through February 22, 2022. A severe COVID-19 case or outcome is defined in this review as a progression of the SARS-CoV-2 virus that results in either admission to an ICU for management of symptoms and clinical stabilization or which leads to death. Although the trend of male predominance of severe COVID-19 cases is likely multifactorial, the hypothesis of T deficiency causing an inflammatory storm has support from many studies with limited conflicting evidence. An inborn error in cytokine immunity is also well supported, but it needs more studies to add support to the hypothesis. The immunologic protective effect of estrogen is supported by multiple studies, but it also has conflicting evidence. It appears less likely that the trend is caused solely by an increased prevalence of smoking among males or an androgen-driven pathogenesis, based on the extent of conflicting evidence.

Relationship between moral sensitivity and the quality of nursing care for the elderly with Covid-19 in Iranian hospitals

BACKGROUND

The quality of care has a significant impact on the condition of elderly patients. Many factors affect the quality of care, including ethical considerations. Ethical considerations, such as moral sensitivity, change in times of crisis. The present study was conducted to assess the relationship between moral sensitivity and the quality of nursing care for the elderly with Covid-19 in Iranian hospitals.

METHODS

This was a cross-sectional descriptive correlational study. The participants included 445 nurses that were selected by quota sampling method from hospitals admitting COVID-19 patients. The data were collected using the Moral Sensitivity Questionnaire (MSQ) and Quality Patient Care Scale (QUALPAC) as self-reports. We used the SPSS software v.16 for statistical analysis.

RESULTS

The total score of moral sensitivity and quality of care was 52.29 ± 16.44 and 2.83 ± 0.23, respectively. Moral sensitivity negatively correlates with psychological, social, and physical aspects (P < 0.05). Modifying autonomy, interpersonal orientation, and experiencing moral conflict predicted β = 0.10 of the psychosocial aspect of quality of care. Structural moral meaning and expressing benevolence predicted the changes in the physical dimension of quality of care (β = 0.02).

CONCLUSION

The quality of care had a significant inverse correlation with moral sensitivity. Multiple regression analysis showed that modifying autonomy, interpersonal orientation, and experiencing moral conflict could predict the psychosocial dimensions. Structuring moral meaning could predict the physical dimension. The communication aspects were not related to any of the dimensions of moral sensitivity.

Clinical Characteristics and Outcomes in Elderly Patients With COVID-19: A Single-Centre Retrospective Study

Background: Even with the wide base of knowledge that has been accumulated regarding coronavirus disease 2019 (COVID-19), only limited studies have tried to establish differences in outcomes of elderly patients hospitalized with COVID-19. We, thus, conducted a retrospective study on a large cohort of hospitalized patients with COVID-19 to improve the understanding of such differences and add to the evidence available regarding this age group. 

Methods: This is a single-centre retrospective study conducted at a tertiary level hospital in the state of Uttarakhand in North India to determine clinical characteristics and outcomes in elderly patients (≥ 60 years) hospitalized with COVID-19 between May 1, 2020, and May 31, 2021. Our study included a retrospective follow-up at six months to also determine rehospitalizations and post-discharge mortality.

Results: There was a statistically significant difference (p<0.05) in in-hospital mortality, various in-hospital complications, duration of stay, number of rehospitalizations at six months, and post-discharge mortality up to six months in the elderly age group hospitalized with COVID-19.

Conclusions: This retrospective study demonstrates that the clinical characteristics and outcomes in hospitalized elderly with COVID-19 differ significantly from the younger adult population and demonstrates a need for greater hospital resource utilization in this age group. These results will help policymakers be better prepared for future pandemics. 

Sex Differences in Clinical Outcomes Among Patients With COVID-19 and Cardiovascular Disease ― Insights From the CLAVIS-COVID Registry ―

Background: Male sex is associated with a worse clinical course and outcomes of COVID-19, particularly in older patients. However, studies on COVID-19 patients with cardiovascular disease and/or risk factors (CVDRF), which are representative risk factors of COVID-19, are limited. In this study, we investigated the effect of sex on the outcomes of hospitalized COVID-19 patients with CVDRF.

Methods and Results: We analyzed 693 COVID-19 patients with CVDRF. Patients were divided into 2 groups based on sex, and baseline characteristics and in-hospital outcomes were compared between the 2 groups. The mean age of the 693 patients was 68 years; 64.8% were men and 96.1% were Japanese. In a univariate analysis model, sex was not significantly associated with in-hospital mortality (odds ratio [OR] 1.22; 95% confidence interval [CI] 0.74–2.02; P=0.43). However, men had higher in-hospital mortality than women, especially among older (age ≥80 years) patients (OR 2.21; 95% CI 1.11–4.41; P=0.024). After adjusting for age and pivotal risk factors (hypertension, diabetes, heart failure, coronary artery disease, chronic lung disease, and chronic kidney disease), multivariate analysis suggested that male sex was an independent predictor of in-hospital mortality (OR 2.20; 95% CI 1.23–3.92; P=0.008).

Conclusions: In this post hoc analysis of a nationwide registry focusing on patients with COVID-19 and CVDRF, men had higher in-hospital mortality than women, especially among older patients.

Effect of diabetes on short-term mortality and incidence of first hospitalizations for cardiovascular events after recovery from SARS-CoV-2 infection

AIM

To evaluate the impact of diabetes and COVID-19 on all-cause-mortality and first hospitalizations for cardiovascular events (CVE): myocardial infarction or stroke, within six months after being tested positive and having recovered from SARS-CoV-2 infection.

METHODS

Resident population in Tuscany, Italy of age 45-94 yr without prior hospitalization for CVE, tested positive for SARS-CoV-2 by March 1st, 2020 and afterwards recovering from COVID-19 was compared with age, gender and diabetes matched controls without infection, for incidence rate ratio (IRR) of all-cause-deaths or first CVE at six months follow up.

RESULTS

46,152 subjects of whom 4,597 with diabetes, tested positive and recovered from SARS-CoV-2 were compared with 1:1 age, gender and diabetes matched controls without infection. COVID-19 was associated with higher all-cause-mortality: IRR:1.92(95 %CI:1.63-2.25) while diabetes with increased risk of first CVE hospitalizations: IRR:2.24(2.18-4.25). Co-presence of COVID-19 and diabetes didn't add any additional excess risk. Being women and statins' use significantly reduced death risk.

CONCLUSIONS

After recovery from COVID-19, independently of diabetes, all-cause-mortality risk at six months was twofold increased, while risk of first CVE hospitalization remained unmodified. Diabetes, independently of prior COVID-19, resulted in higher six-months risk of first CVE not of death. Female gender and statins' use reduced both excess risks.

Vitamin D Status in Relation to the Clinical Outcome of Hospitalized COVID-19 Patients

Coronavirus Disease (COVID-19) is a newly emerged infectious disease that first appeared in China. Vitamin D is a steroid hormone with an anti-inflammatory protective role during viral infections, including SARS-CoV-2 infection, via regulating the innate and adaptive immune responses. The study aimed to investigate the correlation between serum 25-hydroxyvitamin D (25[OH]D) levels and clinical outcomes of COVID-19. This was a retrospective study of 126 COVID-19 patients treated in NMC Royal Hospital, UAE. The mean age of patients was 43 ± 12 years. Eighty three percentage of patients were males, 51% patients were with sufficient (> 20 ng/mL), 41% with insufficient (12-20 ng/mL), and 8% with deficient (<12 ng/mL) serum 25(OH)D levels. There was a statistically significant correlation between vitamin D deficiency and mortality (p = 0.04). There was a statistically significant correlation between 25(OH)D levels and ICU admission (p = 0.03), but not with the need for mechanical ventilation (p = 0.07). The results showed increased severity and mortality by 9 and 13%, respectively, for each one-year increase in age. This effect was maintained after adjustment for age and gender (Model-1) and age, gender, race, and co-morbidities (Models-2,3). 25(OH)D levels (<12 ng/mL) showed a significant increase in mortality by eight folds before adjustments (p = 0.01), by 12 folds in Model-1 (p = 0.04), and by 62 folds in the Model-2. 25(OH)D levels (< 20 ng/mL) showed no association with mortality before adjustment and in Model-1. However, it showed a significant increase in mortality by 29 folds in Model-3. Neither 25(OH)D levels (<12 ng/mL) nor (< 20 ng/mL) were risk factors for severity. Radiological findings were not significantly different among patients with different 25(OH)D levels. Despite observed shorter time till viral clearance and time from cytokine release storm to recovery among patients with sufficient 25(OH)D levels, the findings were statistically insignificant. In conclusion, we demonstrated a significant correlation between vitamin D deficiency and poor COVID-19 outcomes.

Higher testosterone is associated with increased inflammatory markers in women with SARS-CoV-2 pneumonia: preliminary results from an observational study

PURPOSE

Objective of this study was to assess the association between testosterone (T) levels and biochemical markers in a cohort of female patients admitted for SARS-CoV-2 infection in a respiratory intensive care unit (RICU).

METHODS

A consecutive series of 17 women affected by SARSCoV-2 pneumonia and recovered in the RICU of the Hospital of Mantua were analyzed. Biochemical inflammatory markers as well as total testosterone (TT), calculated free T (cFT), sex hormone-binding globulin (SHBG), and luteinizing hormone (LH) were determined.

RESULTS

TT and cFT were significantly and positively associated with PCT, CRP, and fibrinogen as well as with a worse hospital course. We did not observe any significant association between TT and cFT with LH; conversely, both TT and cFT showed a positive correlation with cortisol. By LOWESS analysis, a linear relationship could be assumed for CRP and fibrinogen, while a threshold effect was apparent in the relationship between TT and procalcitonin, LDH and ferritin. When the TT threshold value of 1 nmol/L was used, significant associations between TT and PCT, LDH or ferritin were observed for values above this value. For LDH and ferritin, this was confirmed also in an age-adjusted model. Similar results were found for the association of cFT with the inflammatory markers with a threshold effect towards LDH and ferritin with increased LDH and ferritin levels for values above cFT 5 pmol/L. Cortisol is associated with serum inflammatory markers with similar trends observed for TT; conversely, the relationship between LH and inflammatory markers had different trends.

CONCLUSION

Opposite to men, in women with SARS-CoV-2 pneumonia, higher TT and cFT are associated with a stronger inflammatory status, probably related to adrenal cortex hyperactivity.

Relation of vitamin D to COVID-19

The coronavirus pandemic has lasted for more than a year now and still remains the leading cause of concern, worldwide. The causal agent; SARS- CoV-2, leads to the development of respiratory distress in the lower respiratory tract, sometimes leading to fatalities. Keeping in mind the discovery of mutant strains across the world, as well as the delay in vaccinations across vast populations, most people speculate boosting their immune systems as a preventive and precautionary measure. One of the most commonly observed conditions that hamper immunity; Vitamin D deficiency has been linked to the onset and the alteration of course of the disease in patients and is also being explored as a potential drug supplement. These surmises make it essential to study deep into the speculations. This review aims to overview the possible correlations between Vitamin D and COVID-19.

Waning of Anti-SARS-CoV-2 Spike Antibody Levels 100 to 200 Days after the Second Dose of the BNT162b2 Vaccine

Anti-SARS-CoV-2 antibodies of 444 vaccinated hospital employees in Japan were measured 94–109 days and 199–212 days after receiving the second BNT162b2 vaccine dose to evaluate the intensity and duration of antibody response in our own cohort. Among uninfected participants, anti-S antibody levels were greatly decreased 199–212 days after the second vaccination compared to the levels measured 94–109 days after the second vaccination (median levels: 830 AU/mL and 2425 AU/mL, respectively; p < 0.001). The rate of decrease between the two testing periods was lower in infected participants than in uninfected participants (median: 47.7% and 33.9%, respectively; p < 0.001). Anti-S antibody levels were significantly higher in females (median: females, 2546 AU/mL; males, 2041 AU/mL; p = 0.002 during the first test period). The peak body temperature after vaccination was higher in females than in males (median: females, 37.4 °C; males: 37.1 °C; p = 0.044). Older males tended to have lower antibody levels. In conclusion, the duration of the anti-S antibody response to the BNT162b2 vaccine was short-lived, particularly in males. Anti-S antibody levels of 1000 AU/mL or lower according to SARS-CoV-2 IgG II Quant (Abbott) might indicate insufficient prevention against the delta variant, and the majority of participants appeared to have lost their protection 200 days after vaccination.

Factor Related the Use of Respiratory Supports among COVID-19 Patients in Sardjito Hospital Yogyakarta: A Cross-sectional Study

BACKGROUND: In patients with coronavirus disease-19 (COVID-19), respiratory failure is a serious condition that requires immediate respiratory supports. Various clinical conditions can be determinant factors to the need for used of ventilators. AIM: The aim of the study was to determine factor related to the used of ventilators among COVID-19 patients transferred to intensive care unit Sardjito Hospital. METHODS: Using a cross-sectional design, a total of 171 of 300 medical records selected in accordance to the inclusion criteria. Association of each clinical characteristics and outcome variable used contingency coefficient and Spearman rank tests, while multivariate logistic regression model was performed for hypothesis testing. The area under curve (AUC) was test to determine model fit of the logistic approach. RESULTS: There was a significant correlation between age (p = 0.004), blood sugar levels (p < 0.001), and oxygen saturation (p < 0.001), and the used of ventilator. Patients with hypoxia and severe hypoxia had odds of using ventilation supports 5 times and 114 times (OR = 5.623) and (OR = 114.3). The AUC test indicated that null hypothesis was rejected. CONCLUSION: The clinical characteristics were associated with age, blood sugar levels, and oxygen saturation. Patients with COVID-19 who admitted to hospital with hypoxia and severe hypoxia increased the odds of the use ventilators.

Does Coronavirus Disease 2019 Kill More Elderly Men than Women Due to Different Hormonal Milieu

Preliminary data depicts a much greater prevalence and high case-fatality rate in advanced age males as compared to age-matched women with severe acute respiratory syndrome-coronavirus-2 infections with high morbidity, mortality, high referral, and admission to intensive care unit with severe sequelae. However, the literature search revealed both for and against studies in this context. Thus, at present, in light of the mixed studies, it cannot be established whether low testosterone levels in aging hypogonadal males create a permissive environment for severe response to coronavirus disease 2019 (COVID-19) infection and can it increase the morbidity or mortality, or on the contrary if the virus inhibits androgen formation. Hence, it is highly warranted to establish the said hypothesis by conducting large statistically powered clinical studies in future. Further, it is highly indicated that impact of sex hormones and gender on the incidence and case fatality of the disease and hormones as a treatment according to sex and gender for COVID requires further scientific research by the research community before it is actually recommended to mitigate the COVID-19 disease course among elderly men and women at large.

Report of Low Incidence of Thrombosis with Early Prophylaxis in Hospitalized Patients with COVID-19 from Two Saudi Tertiary Centers

BACKGROUND

Thrombotic events can increase the COVID-19 associated disease mortality. The administration of prophylactic anticoagulants had been shown to decrease the incidence of thrombosis, mortality, and ICU admission rates in COVID-19 patients.

AIMS

The present study investigates the rate of thrombosis with early anticoagulation prophylaxis, the various risk factors for thrombotic events, and the overall survival rate in hospitalized COVID-19 cases.

METHODS

In this prospective observational study, 425 patients aged ≥14 years were included in the study who were hospitalized with COVID-19 related symptoms from March to October 2020 at two tertiary care hospitals in the Kingdom of Saudi Arabia. Venous thromboembolism (VTE) score was evaluated, and VTE prophylaxis was administered according to the hospital guidelines. Patients' demographics, comorbidities, disease presentation, and sequential hematological profiles were also recorded. Samples were collected at different time points to determine the hematological profiles.

RESULTS

Out of 425 with positive COVID-19 subjects, eight (1.9%) patients developed thrombosis during admission, with pulmonary embolism being the most common type. VTE prophylaxis was administered to 394 (92.7%) patients. These anticoagulants included enoxaparin (86.3%), heparin (12.7%), warfarin (0.8%) and apixaban (0.3%). Comorbid conditions were recorded in 253 (59.5%) patients. ICU admission rate was 28% (n = 119), with a median time to transfer to ICU of 1 day (r: 0-33 days). A trend of high VTE score (5.0) with ICU admission and mortality (P = <.001) was observed. The observed mortality rate for our cohort was 5.9% (25 events out of 425); however, for patients admitted in ICU, it was 16% (19 events out of 119 admissions).

CONCLUSION

We are reporting a low incidence of thrombosis in COVID-19 patients. We have demonstrated that the early administration of prophylactic anticoagulants might reduce the risk of thrombotic events and the associated mortality. We observed a higher VTE score and thrombosis in patients admitted to the ICU.

Social Response to the Vaccine against COVID-19: The Underrated Power of Influence

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has highlighted the need for preventive medicine and vaccinology to be paralleled to eliminate COVID-19 cases.

METHODS

A web-based questionnaire was disseminated through social media in the late November assessing the factors that may have influenced the final response to vaccination against COVID-19 in vaccinated and non-vaccinated Greek people.

RESULTS

Women, the younger generations, and university graduates were more likely to accept vaccination, whereas men, those with a basic education level, and the older generation showed a hesitance to the vaccine against COVID-19. About half of the vaccinated participants were influenced in their final decision mainly by being informed from the internet (50.4%), their work (51.7%), and social life (53,1%) while half of the non-vaccinated individuals were mostly influenced by keeping updated from the internet (55.5%) and by government policies (51.3%). COVID-19 risk (OR 2.511; CI 2.149-2.934; p = 0.000), frequent vaccinations for emerging pathogens (OR 14.022; CI 11.998-16.389), and social life (OR 2.828; CI 2.417-3.309; p = 0.000) had a significant impact on people's positive response to vaccination against COVID-19.

CONCLUSIONS

Monitoring and assessing the influence factors for the response to vaccination can be favourable strategies to further manage societal vaccination rates.

PREVALENCE OF MORTALITY AND ITS DISTRIBUTION BY SEX AND AGE GROUPS IN INDOOR COVID-19 PATIENTS IN D.I.KHAN DIVISION, PAKISTAN

Background: COVID-19 has become one of the leading causes of morbidity and mortality. The objectives of this study were to determine the prevalence of mortality and its distribution by sex and age groups in indoor COVID-19 patients in D.I.Khan Division, Pakistan.Materials Methods: This cross-sectional study was conducted in the Department of Medicine, Gomal Medical College, D.I.Khan, Pakistan. A sample of 438 patients with positive SARS-CoV-2 RT-PCR was selected. Sex age-groups were two demographic and presence of mortality was a research variable. The data type for all variables was nominal, except ordinal age groups. Prevalence distribution were described by count and percentage with 95%CI. The hypotheses were tested by chi-square goodness of fit test.Results: Out of 438 COVID-19 patients, mortality was 43 (9.82%), including 34 (7.76%) men and nine (2.06%) women. The mortality was 0% for 0-19 years, four (0.92%) for 20-39 years, 12 (2.74%) for 40-59 years and 27 (6.16%) ≥60 years. Our mortality 9.82% was lower than expected 20.95% (p=.001). It was higher in men than women (p=.001). It was highest in age group ≥60 years, while 0% in 0-19 years. It was similar to expected by sex (p=.070) and age group (p=.207).Conclusion: Our study showed 9.82% mortality in indoor COVID-19 patients. The mortality was lower than expected. The mortality was higher in men than women. It was highest in elderly, while zero in children and adolescents. It was similar to expected by sex and age group.

Erectile dysfunction and testosterone levels prior to COVID-19 disease: What is the relationship?

OBJECTIVE

We aimed to investigate the relationship between COVID-19 and Erectile Dysfunction (ED) and the effect of serum testosterone level on the disease prognosis.

METHODS

Between April-December 2020, 70 patients who were admitted with a complaint of ED after having COVID-19 and whose serum testosterone level was checked for varicocele, premature ejaculation, and infertility reasons before COVID-19. The patients filled the International Index of Erectile Function (IIEF-5) and their testosterone level was checked. The questionnaire was arranged to assess the first month before COVID-19 and after COVID-19. Testosterone levels of the patients before and after COVID-19 were compared. The relationship between testosterone levels and hospitalization in the intensive care was evaluated.

RESULTS

It was revealed that testosterone levels and IIEF-5 scores after COVID-19 in all patients were statisticaly and significantly different compared to the period before COVID-19 (p < 0.05). Testosterone levels of patients in need of intensive care were significantly higher than those without any need of intensive care (p < 0.05).

CONCLUSIONS

Our study has presented that COVID-19 may cause ED and high testosterone levels increase the rate of hospitalization in the intensive care by intensifying the disease.

Androgens in SARS-CoV-2 coronavirus infections

Recent molecular biology findings have shown that for the penetration of the SARS-CoV-2 coronavirus into host cells, a key role is played by protease serine 2, the activity of which is dependent on androgens. The important role of androgens is also evidenced by clinical observations that men in some age categories are infected by this novel coronavirus up to two times more frequently than women. In addition, men with androgenic alopecia tend to have more serious clinical courses, while men with androgen deprivation as a result of prostate cancer treatments tend to have milder courses. This is in line with the fact that preadolescent children are only rarely sickened with serious forms of SARS-CoV-2 infections. Even though these observations may be explained by other factors, many authors have hypothesized that lowered androgen levels and blocking their activity using anti-androgen medication may moderate the course of the viral infection in intermediately- to critically-affected cases. Clearly, it would be important for androgen deprivation to block not just gonadal androgens, but also adrenal androgens. On the other hand, low androgen levels are considered to be a risk factor for the course of SARS-CoV-2 infections, either because low androgen levels have a general effect on anabolic-catabolic equilibrium and energy metabolism, or because of the ability of testosterone to modify the immune system. It is not yet clear if infection with this novel coronavirus might induce hypogonadism, leading to undesirable side effects on male fertility.

Public health concerns and increased risk of severe COVID-19 disease through androgen use

PURPOSE OF REVIEW

Given governmental policy responses to the COVID-19 pandemic include various foci on establishing preventive measures to increase the health and constitution of populations (i.e. through renewed efforts to tackle obesity), the use of androgens in a recreational manner requires attention because of existing medical evidence related to their role in immunosuppression.

RECENT FINDINGS

Whilst a broad body of work exists that outlines the mechanisms that underpin COVID-19 and public health responses, as well as the use of androgens in both recreational and medicinal contexts, the recent nature of the disease has left an area requiring greater investigation and clarification. There is emerging literature that highlights the potential complications that existing androgens use may bring to those infected with COVID-19, as well as the start of empirical evidence detailing this.

SUMMARY

In this article, we outline the latest viewpoints and literature related to how the use of androgens may contribute to less robust immunoresponses.

Analysis of Covid-19 Hospital Admissions in Ivano-Frankivsk, Ukraine

The Covid-19 pandemic has a substantial impact on socioeconomic, political, demographic, and other aspects of life. Effective healthcare is, however, a primary determinant of successful fighting against Covid-19. The analysis of local healthcare indicators serves as a source for estimating pandemic magnitude and the adaptation of healthcare at a national level. In this study, the rates of Covid-19 hospital admissions to the Ivano-Frankivsk City Hospital, Ukraine, from April 2020 to May 2021 were analysed. All cases were grouped by age, sex, and the type of admission; data were analyzed monthly and seasonally. The peaks of hospital admissions were observed in November 2020 and March 2021; however, the highest mortality rates were seen from August to November 2020. The analysis of age- and sex-disaggregated Covid-19 mortality data showed the predominance of elderly males (61.9%, 66.6 ± 3.9 years) over females (38.1%, 71.8 ± 2.3 years). The ratio of hospital admissions was unstable: the percentage of emergency, GP-referred and self-referred admissions was similar from April to May 2020; however, GP-referred admissions prevailed, and the number of self-referral patients decreased twice between March and May 2021. In conclusions, the trends in hospital admissions were similar to those reported in other studies. However, the differences in time frames and socio-demographic characteristics were observed that highlights the importance of considering regional, social and geographic aspects of the population when improving the capacity of healthcare system and establishing effective preventive measures against the pandemic at the local level.

Testosterone in COVID-19: An Adversary Bane or Comrade Boon

COVID-19 is a pandemic disease caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), which leads to pulmonary manifestations like acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In addition, COVID-19 may cause extra-pulmonary manifestation such as testicular injury. Both high and low levels of testosterone could affect the severity of COVID-19. Herein, there is substantial controversy regarding the potential role of testosterone in SARS-CoV-2 infection and COVID-19 severity. Therefore, the present study aimed to review and elucidate the assorted view of preponderance regarding the beneficial and harmful effects of testosterone in COVID-19. A related literature search in PubMed, Scopus, Web of Science, Google Scholar, and Science Direct was done. All published articles related to the role of testosterone and COVID-19 were included in this mini-review. The beneficial effects of testosterone in COVID-19 are through inhibition of pro-inflammatory cytokines, augmentation of anti-inflammatory cytokines, modulation of the immune response, attenuation of oxidative stress, and endothelial dysfunction. However, its harmful effects in COVID-19 are due to augmentation of transmembrane protease serine 2 (TMPRSS2), which is essential for cleaving and activating SARS-CoV-2 spike protein during acute SARS-CoV-2 infection. Most published studies illustrated that low testosterone levels are linked to COVID-19 severity. A low testosterone level in COVID-19 is mainly due to testicular injury, the primary source of testosterone.

Chest Radiological Findings and Clinical Characteristics of Laboratory-Confirmed COVID-19 Patients from Saudi Arabia

Background

Coronavirus disease 2019 (COVID-19) is a viral respiratory disease that first emerged in China in December 2019 and quickly spread worldwide. As the prevalence of COVID-19 increases, radiological examination is becoming an essential diagnostic tool for identifying and managing the disease’s progression. Therefore, we aimed to identify the chest imaging features and clinical characteristics of patients with laboratory-confirmed COVID-19 in Saudi Arabia.

Material/Methods

In this retrospective study, data of laboratory-confirmed COVID-19 patients were collected from 4 hospitals in Jeddah, Saudi Arabia. Their common clinical characteristics, as well as imaging features of chest X-rays and computed tomography (CT) images, were analyzed.

Results

A total of 297 patients with laboratory-confirmed COVID-19 who underwent chest imaging were investigated in this study. Of these patients, 77.9% were male and 22.2% were female. Their mean age was 48 years old. The most common clinical symptoms were fever (187 patients; 63%) and cough (174 patients; 58.6%). The predominant descriptive chest imaging findings were ground-glass opacities and consolidation. Locations of abnormalities were bilateral, mainly distributed peripherally, in the lower lung zones, and in the middle lung zones.

Conclusions

This study provides an understanding of the most common clinical and radiological features of patients with laboratory-confirmed COVID-19 in Saudi Arabia. The majority of COVID-19 patients in our study cohort had either stable or worse progression of lung lesions during follow-ups; thus, they presented moderate disease cases. Elderly males were more affected by COVID-19 than females, with fever and cough being the most common clinical symptoms.

Different SARS-CoV-2 haplotypes associate with geographic origin and case fatality rates of COVID-19 patients

The current pandemic of COVID-19 is caused by the SARS-CoV-2 virus for which many variants at the Single Nucleotide Polymorphism (SNP) level have now been identified. We show here that different allelic variants among 692 SARS-CoV-2 genome sequences display a statistically significant association with geographic origin (p < 0.000001) and COVID-19 case severity (p = 0.016). Geographic variation in itself is associated with both case severity and allelic variation especially in strains from Indian origin (p < 0.000001). Using an new alternative bioinformatics approach we were able to confirm that the presence of the D614G mutation correlates with increased case severity in a sample of 127 sequences from a shared geographic origin in the US (p = 0.018). While leaving open the question on the pathogenesis mechanism involved, this suggests that in specific geographic locales certain genotypes of the virus are more pathogenic than others. We here show that viral genome polymorphisms may have an effect on case severity when other factors are controlled for, but that this effect is swamped out by these other factors when comparing cases across different geographic regions.

Synergy Between Vitamin D and Sex Hormones in Respiratory Functionality of Patients Affected by COVID-19

The outcome of COVID-19 appears to be influenced by vitamin D status of population. Although epidemiological data indicate that COVID-19 produces more severe symptoms and higher mortality in elderly in comparison to young patients and in men in comparison to women to date sex and age differences in vitamin D status in infected patients have not been evaluated yet. In this study we evaluated the levels of circulating 25(OH)D in patients hospitalized for COVID-19 divided accordingly to their sex and age. We also correlated 25(OH)D levels with patient's respiratory status (i.e., PaO2/FiO2 ratio) and with sex hormones plasma levels to analyze the potential relationship of these parameters. We found no significant differences in plasma levels of 25(OH)D between pre- and post-menopausal female patients and age matched male patients. Interestingly, the 25(OH)D plasma levels positively correlated to PaO2/FiO2 ratio only in young patients, regardless of their sex. We also found a significantly positive correlation between 17β-estradiol and 25(OH)D in elderly women and between testosterone and 25(OH)D in elderly men, supporting the role of sex hormones in maintaining 25(OH)D levels. In conclusion, we suggest that a synergy between vitamin D and sex hormones could contribute to the age-related outcome of COVID-19.

The clinical course of critically ill COVID-19 patients receiving invasive mechanical ventilation with subsequent terminal weaning: Primary data from 11 cases

ABSTRACT

The coronavirus disease (COVID-19) outbreak was first reported in December 2019 in Wuhan, China. Specific information about critically ill COVID-19 patients receiving invasive mechanical ventilation (IMV) is rare.To describe the clinical course and complications of critically ill patients with COVID-19 who received IMV and were successfully weaned from it.This retrospective study included patients admitted to 3 intensive care units (ICUs) and 1 sub-ICU of Renmin Hospital of Wuhan University and Wuhan Jin Yin-tan Hospital between December 24, 2019, and March 12, 2020. Eleven patients who had been diagnosed with critically ill COVID-19 according to the World Health Organization interim guidance, received invasive ventilation, and were finally successfully weaned from it, were enrolled in our study. Their presenting symptoms, comorbidity conditions, laboratory values, ICU course, ventilator parameters, treatments, and relative complications were recorded.Of 108 critically ill COVID-19 patients who received invasive ventilation, 11 patients who underwent tracheal extubation or terminal weaning were included. The mean age of the 11 patients was 52.8 years (range, 38-70 years), 8 (72.7%) were male, and 2 were health care workers. The median time from onset of symptoms to dyspnea was 6.6 days (range, 3-13 days), and the median duration of IMV was 15.7 days (range, 6-29 days). All 11 patients presented with acute severe hypoxemic respiratory failure and received IMV, and 1 patient switched to extracorporeal membrane oxygenation assistance. A lung-protective strategy with lower tidal volume ventilation and proper driving pressure is the main strategy of IMV. All patients had extrapulmonary manifestations, including acute kidney injury, hepatic dysfunction, myocardial damage, and/or lymphopenia. Hospital-acquired infections occurred in 7 (63.6%) patients.Critical COVID-19 illness is characterized by acute hypoxemic respiratory failure and subsequent dysfunction of other organs with a high mortality rate. Correct ventilation strategies and other clinical strategies to improve oxygenation based on the skilled trained group and the availability of equipment are the key methods to rescue lives.

ACE2, COVID-19 Infection, Inflammation, and Coagulopathy: Missing Pieces in the Puzzle

Engulfed by the grave consequences of the coronavirus disease 2019 (COVID-19) pandemic, a better understanding of the unique pattern of viral invasion and virulence is of utmost importance. Angiotensin (Ang)-converting enzyme (ACE) 2 is a key component in COVID-19 infection. Expressed on cell membranes in target pulmonary and intestinal host cells, ACE2 serves as an anchor for initial viral homing, binding to COVID-19 spike-protein domains to enable viral entry into cells and subsequent replication. Viral attachment is facilitated by a multiplicity of membranal and circulating proteases that further uncover attachment loci. Inherent or acquired enhancement of membrane ACE2 expression, likely leads to a higher degree of infection and may explain the predisposition to severe disease among males, diabetics, or patients with respiratory or cardiac diseases. Additionally, once attached, viral intracellular translocation and replication leads to depletion of membranal ACE2 through degradation and shedding. ACE2 generates Ang 1-7, which serves a critical role in counterbalancing the vasoconstrictive, pro-inflammatory, and pro-coagulant effects of ACE-induced Ang II. Therefore, Ang 1-7 may decline in tissues infected by COVID-19, leading to unopposed deleterious outcomes of Ang II. This likely leads to microcirculatory derangement with endothelial damage, profound inflammation, and coagulopathy that characterize the more severe clinical manifestations of COVID-19 infection. Our understanding of COVID-ACE2 associations is incomplete, and some conceptual formulations are currently speculative, leading to controversies over issues such as the usage of ACE inhibitors or Ang-receptor blockers (ARBs). This highlights the importance of focusing on ACE2 physiology in the evaluation and management of COVID-19 disease.