On the analysis of mortality risk factors for hospitalized COVID-19 patients: A data-driven study using the major Brazilian database

Survival of hospitalised COVID-19 patients in Hawassa, Ethiopia: a cohort study

The COVID-19 pandemic, caused by SARS-CoV-2, led to 622,119,701 reported cases and 6,546,118 deaths. Most studies on COVID-19 patients in hospitals are from high-income countries, lacking data for developing countries such as Ethiopia.This study assesses clinical features, demographics, and risk factors for in-hospital mortality in Hawassa, Ethiopia. The research cohort comprises 804 cases exhibiting clinical diagnoses and/or radiological findings and indicative of symptoms consistent with COVID-19 at Hawassa University Comprehensive Specialized Hospital from September 24, 2020, to November 26, 2021. In-hospital mortality rate was predicted using Cox regression. The median age was 45 years, with males making up 64.1% of the population. 173 (21.5%) fatalities occurred, with 125 (72.3%) among males. Male patients had higher mortality rates than females. Severe and critical cases were 24% and 21%. 49.1% had at least one comorbidity, with 12.6% having multiple. Common comorbidities were diabetes (15.9%) and hypertension (15.2%). The Cox regression in Ethiopian COVID-19 patients found that factors like gender, advanced age group, disease severity, symptoms upon admission, shortness of breath, sore throat, body weakness, hypertension, diabetes, multiple comorbidities, and prior health facility visits increased the risk of COVID-19 death, similar to high-income nations. However, in Ethiopia, COVID-19 patients were young and economically active. Patients with at least one symptom had reduced death risk. As a conclusion, COVID-19 in Ethiopia mainly affected the younger demographic, particularly economically active individuals. Early detection can reduce the risk of mortality. Prompt medical attention is essential, especially for individuals with comorbidities. Further research needed on diabetes and hypertension management to reduce mortality risk. Risk factors identified at admission play a crucial role in guiding clinical decisions for intensive monitoring and treatment. Broader risk indicators help prioritize patients for allocation of hospital resources, especially in regions with limited medical facilities. Government's focus on timely testing and strict adherence to regulations crucial for reducing economic impact.

COVID-19 Nursing Staff Sizing Technology

This study shows the development of a software for calculating the number of nursing team members required for providing care during the coronavirus disease 2019 pandemic. Study about the development of a technology based on the literature about data and indicators. The indicators were systematized in the following dimensions: institutional, professional, and occupational structure, all with a focus on coronavirus disease 2019. The software was created to be used on the Web, client-server, in browsers such as Internet Chrome, Explorer, and/or Mozilla Firefox, accessing via an Internet address and also allowing access by Windows, Android, and Linux operating systems, with MySQL database used for data storage. The data and indicators related to the institutional structure for coronavirus disease 2019 were systematized with 10 dimensions and indicators, and the professional and occupational structure, with 14 dimensions and indicators. The construction of computer requirements followed the precepts of software engineering, with theoretical support from the area. In the evaluation of the software, data simulation revealed points that had to be adjusted to ensure security, data confidentiality, and easy handling. The software provides to calculate the size and quality of the team, nursing sizing required due to the needs generated by the coronavirus disease 2019 pandemic.

Evaluation of the relationship of treatment and vaccination with prognosis in patients with a diagnosis of COVID-19

PURPOSE

Coronavirus disease 2019 (COVID-19) has affected millions of people worldwide and caused mortality. Many factors have been reported to affect the prognosis of COVID-19. In this study, we aimed to investigate the effects of drug therapy and vaccination on prognosis in patients hospitalized with a COVID-19 diagnosis.

METHODS

In this single-center, cross-sectional study, data were retrospectively collected from patients receiving inpatient treatment at a university hospital with a diagnosis of COVID-19 between January 1, 2020, and April 30, 2022. The patients' demographic and clinical characteristics were recorded. The Chi-square, Cox and logistic regression was performed, P < 0.05 was considered statistically significant.

RESULTS

Total 1723 patients (50.1% were men, mean age: 60.6 ± 16.90) who had not been vaccinated rate was 27.0% (> 3 doses: 45.7%). Mortality rate was 17.0%. Increasing age, male, a high Charlson Comorbidity Index (CCI), and no vaccination significantly increased mortality (P < 0.05). The mortality rate was significantly lower in the chloroquine treatment group than in the other treatment groups. Increasing age, male, and a high CCI were determined to be factors that significantly increased the length of hospital stay (LOHS). LOHS found to be significantly lower in the favipiravir or chloroquine groups compared to the remaining treatment groups (P < 0.001). Both mortality and the LOHS significantly differed according to AST, d-dimer, ferritin, and GFR.

CONCLUSION

This study primarily investigated the effect of treatment and vaccination on the prognosis of COVID-19. This was determined to be prepared for another potential pandemic that may arise due to COVID-19.

Impact and evolution of risk factors associated with hospitalization and mortality due to COVID-19 during the six epidemic waves in Mexico

Objectives

This study aims to analyze and compare the main risk factors for hospitalization and deaths due to COVID-19 during the six epidemic waves from February 2020 to June 2023 in Mexico.

Methods

First, a descriptive analysis of the risk factors that led to hospitalization and mortality due to COVID-19 was performed. Next, the degree of relationship of each risk factor with hospitalization and death was determined using Cramer's V coefficient. Finally, logistic regression models were applied to estimate the odds ratios of the most statistically significant risk factors for hospitalization and mortality.

Results

A direct relationship between age and the possibility of hospitalization and death due to COVID-19 was found. Moreover, the comorbidities most likely to lead to hospitalization and death were pneumonia, hypertension, diabetes, obesity and CKD. It is also remarkable that the second factor of death is endotracheal intubation.

Conclusion

The COVID-19 pandemic in Mexico revealed the reality of an epidemiological scenario where infectious diseases and chronic degenerative diseases coexist and interrelate.

Health inequity assessment in Brazil: is EQ-5D-3L sensible enough to detect differences among distinct socioeconomic groups?

BACKGROUND

Multidimensional health-related quality of life (HRQOL) instruments, such as the EQ-5D, are increasingly used to assess inequalities in health. However, it is necessary to explore the ability of these instruments to capture differences between population groups, especially in low/middle-income countries. This study aimed to investigate whether the EQ-5D-3L instrument can detect differences in HRQOL between groups of different socioeconomic status (SES) in Brazil.

METHODS

Data collection occurred during the Brazilian EQ-5D-3L valuation study and included respondents aged 18 to 64 years enrolled in urban areas. SES was aggregated into three categories: "higher" (A and B), "intermediate" (C) and "lower" (D and E). EQ-5D-3L index was calculated considering the Brazilian value set. A mixed-effects regression model was estimated with random effects on individuals and marginal effects on SES, sex, and educational attainment. Odds ratios for the chance of reporting problems for each EQ-5D dimension were estimated by logistic regression.

RESULTS

A total of 9,148 respondents were included in the study. Mean age was 37.80 ± 13.13 years, 47.4% were men and the majority was ranked as classes B or C (38.4% and 50.7%, respectively). Participants in lower SES classes reported increasingly poorer health compared to individuals in higher classes. The mean EQ-5D-3L index decreased as SES deteriorates being significantly higher for classes A and B (0.874 ± 0.14) compared to class C (0.842 ± 0.15) and classes D and E (0.804 ± 0.17) (p < 0.001). The same was observed for the mean EQ-VAS scores (84.0 ± 13.8 in classes A and B, 81.0 ± 17 in class C and 78.3 ± 18.7 in class C [p < 0.001]). The multivariate analysis confirmed that SES is an independent factor that effects EQ-5D-3L index measures. Participants in intermediate and lower SES classes have a statistically significant lower EQ-5D-3L index compared to participants in classes A and B, regardless of age, sex, and educational attainment.

CONCLUSION

In a Brazilian population sample, the EQ-5D-3L instrument was able to detect important differences between groups with distinct socioeconomic statuses (SES). The EQ-5D-3L is useful for exploring inequities in health.

Hospitalisations and fatality due to respiratory diseases according to a national database in Brazil: a longitudinal study

BACKGROUND

Respiratory diseases (RDs) cause millions of hospitalisations and deaths worldwide, resulting in economic and social impacts. Strategies for health promotion and disease prevention based on the epidemiological profile of the population may reduce hospital costs.

AIM

To characterise hospitalisations and deaths due to RDs in Brazilian adults above 20 years old between 2008 and 2021.

METHODS

This ecological study used secondary data of hospitalisations and deaths due to RDs from the Hospital Information System of the Brazilian Unified Health System between 2008 and 2021. Data were grouped according to region, age group and sex. The period was divided into first (2008-2011), second (2012-2015) and third (2016-2019) quadrennia and one biennium (2020-2021), and all data were analysed using the GraphPad Prism; statistical significance was set at p<0.05.

RESULTS

A total of 9 502 378 hospitalisations due to RDs were registered between 2008 and 2021. The south and southeast regions presented the highest hospitalisation and fatality rate, respectively, in the age group ≥80 years with no significant differences between sexes. Also, RDs caused 1 170 504 deaths, with a national fatality rate of 12.32%.

CONCLUSION

RDs affected the Brazilian population and impaired the health system, especially the hospital environment. The south/southeast regions were the most affected, and the ageing process contributed to the increased incidence of RDs.

Combinatorial analysis of ACE and ACE2 polymorphisms reveals protection against COVID-19 worsening: A genetic association study in Brazilian patients

Since angiotensin-converting enzyme 2, ACE2, was identified as the receptor for SARS-CoV-2 and considering the intense physiological interplay between the two angitensinases isoforms, ACE and ACE2, as counter-regulatory axis of the renin-angiotensin system, we proposed the evaluation of polymorphisms in these two key regulators in relation to COVID-19 severity. A genetic association study involving 621 COVID-19 hospitalized patients from Brazil was performed. All subjects had a confirmed diagnosis of COVID-19 via RT-PCR. Patients were categorized into two groups: the "mild" group (N = 296), composed of individuals hospitalized in ward beds who progressed to cure, and the "severe" group (N = 325), composed of individuals who required hospitalization in an intensive care unit (ICU), or who died. Blood samples were genotyped for ACE I/D polymorphism and ACE2 G8790A polymorphism by real-time PCR via TaqMan assay. The analysis of combined polymorphisms revealed a protective role for genotypic profile II/A_ (ORA = 0,26; p = 0,037) against the worsening of COVID-19 in women. The results indicate a protection profile to COVID-19 progression, in which the II/A_ carriers have almost four times less chance of a severe outcome. It is proposed that a decreased activity of ACE (deleterious effects) in conjunction with an increased ACE2 activity (protective effects), should be the underlying mechanism. The findings are unprecedented once other studies have not explored the genotypic combination analysis for ACE and ACE2 polymorphisms and bring perspectives and expectations for dealing with the COVID-19 pandemic based on definitions of genetically-based risk groups within the context of personalized medicine.

Epidemiological analysis over two years of SARS-CoV-2 circulation in southern Brazil: old and novel predictors of COVID-19 outcome

The overwhelming majority of SARS-CoV-2 epidemiological studies cover a narrow time period, making general knowledge about the COVID-19 pandemic difficult. To assess COVID-19-related host aspects in the overall pandemic, we analyzed COVID-19 cases during the first two years of SARS-CoV-2 circulation in southern Brazil. Herein, 390 patients admitted in 2020-2022 to a Brazilian public referral hospital were allocated into two groups according to the COVID-19 outcome: hospital discharge (n=237) or death (n=153). In the univariate analysis, several variables, including sociodemographic, clinical and laboratory aspects (primary data), were significantly different between the analyzed groups. In multivariate logistic regression, eight of these factors remained associated with the COVID-19 outcome. In particular, we report oxygen supplementation and the need for hemodialysis as predictors of hospital discharge and death from COVID-19, respectively. To the best of our knowledge, none of these findings have been previously reported in the Brazilian or world population. In conclusion, our results contribute to current knowledge by demonstrating that factors described at different times may remain associated with COVID-19 over the pandemic and by identifying novel predictors of COVID-19 outcome.

Medication management of COVID-19 patients during transition to virtual models of care: a qualitative study

INTRODUCTION

Expansion of hospital service models was one of the strategies implemented to manage the COVID-19 pandemic through virtual models of care. COVID-19 patients were hospital inpatients transferred to virtual wards and managed outside the hospital. Pharmacists had to provide distance medication management and support services. Virtual care patient support incorporated telehealth consultations by doctors, pharmacists and nurses. This study explored hospital clinicians' experiences and perspectives on medication management and safety issues of the COVID-19 patients transferred from inpatient units (IPUs) to virtual models of care at the time of transfer.

METHODS

Semi-structured qualitative interviews were conducted with purposively selected doctors, pharmacists and nurses involved in the management of COVID-19 patients in a virtual model of care (home or hotel). Clinicians were interviewed face-to-face or via MS Teams between March and May 2022. An interview schedule included 13 questions and prompts to explore perceptions of medication management and safety aspects.

RESULTS

Twenty clinicians were interviewed: six doctors, seven pharmacists, and seven nurses. The average interview time was 26 min (SD: 4.7; range 21-39). Four major medication management and safety themes emerged from the data: (1) complexities involved in efficient handover between IPU and virtual models of care; (2) lack of clarity on roles and responsibilities between hospital and primary care clinicians; (3) communication challenges when pharmacists work remotely; and (4) proactive management of specific medication safety risks. A common thread throughout the themes was concerns for potential impact on patient safety.

CONCLUSION

Overall, clinicians were supportive of the virtual models although patient safety issues were raised that need to be addressed in the development of future services. The results from this study may inform improvements in medication safety implementation of future virtual models of care.

Diabetes related phenotypes and their influence on outcomes of patients with corona virus disease 2019 (COVID-19)

INTRODUCTION

Diabetes mellitus (DM) is associated with severe forms of COVID-19 but little is known about the diabetes-related phenotype considering pre-admission, on-admission and data covering the entire hospitalization period.

METHODS

We analyzed COVID-19 inpatients (n = 3327) aged 61.2(48.2-71.4) years attended from March to September 2020 in a public hospital.

RESULTS

DM group (n = 1218) differed from Non-DM group (n = 2109) by higher age, body mass index (BMI), systolic blood pressure and lower O2 saturation on admission. Gender, ethnicity and COVID-19-related symptoms were similar. Glucose and several markers of inflammation, tissue injury and organ dysfunction were higher among patients with diabetes: troponin, lactate dehydrogenase, creatine phosphokinase (CPK), C-reactive protein (CRP), lactate, brain natriuretic peptide, urea, creatinine, sodium, potassium but lower albumin levels. Hospital (12 × 11 days) and intensive care unit permanence (10 × 9 days) were similar but DM group needed more vasoactive, anticoagulant and anti-platelet drugs, oxygen therapy, endotracheal intubation and dialysis. Lethality was higher in patients with diabetes (39.3% × 30.7%) and increased with glucose levels and age, in male sex and with BMI < 30 kg/m2 in both groups (obesity paradox). It was lower with previous treatment with ACEi/BRA in both groups. Ethnicity and education level did not result in different outcomes between groups. Higher frequency of comorbidities (hypertension, cardiovascular/renal disease, stroke), of inflammatory (higher leucocyte number, RCP, LDH, troponin) and renal markers (urea, creatinine, potassium levels and lower sodium, magnesium) differentiated lethality risk between patients with and without diabetes.

CONCLUSIONS

Comorbidities, inflammatory markers and renal disfunction but not Covid-19-related symptoms, obesity, ethnicity and education level differentiated lethality risk between patients with and without diabetes.

COVID-19 Patients' Medication Management during Transition of Care from Hospital to Virtual Care: A Cross-Sectional Survey and Audit

BACKGROUND

Virtual models of care were implemented to ease hospital bed pressure during COVID-19. We evaluated the medication management of COVID-19 patients transferred to virtual models of care.

METHOD

A retrospective audit of COVID-19 patients transferred from inpatient units to virtual care during January 2022 and surveys from patients transferred during December 2021-February 2022 was carried out.

RESULTS

One hundred patients were randomly selected: mean age 59 years (SD: 19.8), mean number of medicines at admission 4.3 (SD: 4.03), mean length of virtual ward stay 4.4 days (SD: 2.1). Pharmacists reviewed 43% (43/100) of patients' medications during their hospital stay and provided 29% (29/100) with discharge medicine lists at transfer. Ninety-two (92%) patients were prescribed at least one new high-risk medicine whilst in hospital, but this was not a factor considered to receive a pharmacist medication review. Forty patients (40%) were discharged on newly commenced high-risk medicines, and this was also not a factor in receiving a pharmacist discharge medication list. In total, 25% of patient surveys (96/378) were returned: 70% (66/96) reported adequate medicine information at transfer and 55% (52/96) during the virtual model period.

CONCLUSION

Patient survey data show overall positive experiences of medication management and support. Audit data highlight gaps in medication management during the transfer to a virtual model, highlighting the need for patient prioritisation.

Risks of Adverse Outcomes for Hospitalized COVID-19 Patients during the Four Waves in Brazil According to SARS-CoV-2 Variants, Age Group, and Vaccine Status

Brazil was hit with four consecutive waves of COVID-19 until 2022 due to the ancestral SARS-CoV-2 (B.1 lineage), followed by the emergence of variants/subvariants. Relative risks of adverse outcomes for COVID-19 patients hospitalized during the four waves were evaluated. Data were extracted from the largest Brazilian database (SIVEP-Gripe), and COVID-19 patients who were hospitalized during the peak of each of the four waves (15-week intervals) were included in this study. The outcomes of in-hospital death, invasive (IMV) and non-invasive (NIV) ventilation requirements, and intensive care unit (ICU) admission were analyzed to estimate the relative risks. A higher risk of in-hospital death was found during the second wave for all age groups, but a significant reduction was observed in the risk of death for the elderly during the third and fourth waves compared to patients in the first wave. There was an increased risk of IMV requirement and ICU admissions during the second wave for patients aged 18-59 years old compared to the first wave. Relative risk analysis showed that booster-vaccinated individuals have lower risks of in-hospital death and IMV requirement in all age groups compared to unvaccinated/partially vaccinated patients, demonstrating the relevance of full/booster vaccination in reducing adverse outcomes for patients who were hospitalized during the variant prevalence.

Risk factors for death and illness severity in vaccinated versus unvaccinated COVID-2019 inpatients: a retrospective cohort study

OBJECTIVE

To determine the clinical profile of COVID-19 inpatients who were vaccinated prior to hospitalization and to compare the risk factors for death and the 28-day survival rate of between those inpatients vaccinated with one, two, or three doses and unvaccinated COVID-19 inpatients.

METHODS

This was a retrospective observational cohort study involving COVID-19 patients admitted to a referral hospital in the city of Recife, Brazil, between July of 2020 and June of 2022.

RESULTS

The sample comprised 1,921 inpatients, 996 of whom (50.8%) were vaccinated prior to hospitalization. After adjusting the mortality risk for vaccinated patients, those undergoing invasive mechanical ventilation (IMV) had the highest mortality risk (adjusted OR [aOR] = 7.4; 95% CI, 3.8-14.1; p < 0.001), followed by patients > 80 years of age (aOR = 7.3; 95% CI, 3.4-15.4; p < 0.001), and those needing vasopressors (aOR = 5.6; 95% CI, 2.9-10.9; p < 0.001). After adjusting the mortality risk for all patients, having received three vaccine doses (aOR = 0.06; 95% CI, 0.03-0.11; p < 0.001) was the most important protective factor against death. There were progressive benefits of vaccination, reducing the frequency of ICU admissions, use for IMV, and death (respectively, from 44.9%, 39.0% and 39.9% after the first dose to 16.7%, 6.2% and 4.4% after the third dose), as well as significant improvements in survival after each subsequent dose (p < 0.001).

CONCLUSIONS

Vaccines were effective in reducing illness severity and death in this cohort of COVID-19 inpatients, and the administration of additional doses conferred them with accumulative vaccine protection.

Body mass index and sex differences for mortality in hospitalized COVID-19 patients: a path analysis using a brazilian national database

Previous studies have shown that associations between obesity and other comorbidities favor worse outcomes in COVID-19. However, it is not clear how these factors interrelate and whether effects on men and women differ. We conducted an observational, cross-sectional study using a national COVID-19 inpatient database. We studied differences in direct and indirect effects of obesity and comorbidities according to sex and body mass index (BMI) categories in hospitalized COVID-19 patients in Brazil using path analysis models and logistic regression. For men, path analysis showed a direct association between BMI and death and a negative correlation of death and chronic cardiovascular disease (CCD). For women, the association of BMI and death was indirect, mediated by admission to the ICU and comorbidities and association with CCD was non-significant. In the logistic regression analyses, there was a positive association between death and BMI, age, diabetes mellitus, kidney and lung diseases and ICU admission. We highlight the need to consider the distinct impact of obesity and sex on COVID-19, of monitoring of BMI and of the design for specific male-targeted approaches to manage obesity.

Complexity of the COVID-19 pandemic in Maringá

While extensive literature exists on the COVID-19 pandemic at regional and national levels, understanding its dynamics and consequences at the city level remains limited. This study investigates the pandemic in Maringá, a medium-sized city in Brazil's South Region, using data obtained by actively monitoring the disease from March 2020 to June 2022. Despite prompt and robust interventions, COVID-19 cases increased exponentially during the early spread of COVID-19, with a reproduction number lower than that observed during the initial outbreak in Wuhan. Our research demonstrates the remarkable impact of non-pharmaceutical interventions on both mobility and pandemic indicators, particularly during the onset and the most severe phases of the emergency. However, our results suggest that the city's measures were primarily reactive rather than proactive. Maringá faced six waves of cases, with the third and fourth waves being the deadliest, responsible for over two-thirds of all deaths and overwhelming the local healthcare system. Excess mortality during this period exceeded deaths attributed to COVID-19, indicating that the burdened healthcare system may have contributed to increased mortality from other causes. By the end of the fourth wave, nearly three-quarters of the city's population had received two vaccine doses, significantly decreasing deaths despite the surge caused by the Omicron variant. Finally, we compare these findings with the national context and other similarly sized cities, highlighting substantial heterogeneities in the spread and impact of the disease.

Risk and Severity of COVID-19 Infection in Monoclonal Gammopathy of Undetermined Significance: A 3-Year Propensity Matched Cohort Study

INTRODUCTION

Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant disorder causing monoclonal plasma cell proliferation in bone marrow. This population is at risk of developing multiple myeloma (MM) and severe viral infections; risk factors of severe COVID-19 infection. Using TriNetX, a global platform providing data of 120 million patients, we aimed to quantify the risk and severity of COVID-19 in MGUS patients.

PATIENTS AND METHODS

A retrospective cohort analysis was performed using the TriNetX Global Collaborative Network. From January 20, 2020, to January 20, 2023, we identified a cohort of 58,859 MGUS patients and compared to non-MGUS patients, determined by relevant diagnosis/LOINC test codes. After 1:1 propensity score-matching, we identified COVID-19 cases to quantify risk and identify patients who had been hospitalized, ventilated/intubated, and deceased to quantify severity. Measures of association and Kaplan-Meier analysis were conducted.

RESULTS

After propensity-score matching, there were 58,668 patients in both cohorts. MGUS patients were found to be at a reduced risk of contracting COVID-19 (RR 0.88, 95% CI 0.85-0.91). MGUS patients with COVID-19 showed higher mortality risk and decreased survival time compared to the general population (HR 1.14, 95% CI 1.01-1.27). MGUS patients with COVID-19 who were hospitalized exhibited significantly decreased survival time (log-rank test, P = 0.04).

CONCLUSION

As COVID-19 remains a looming health concern, especially amongst vulnerable populations, our analysis emphasizes the need for adequate vaccination and treatment regimens as well as an understanding of the severity of infection in MGUS patients and justification for precautionary measures.

Obesity as an independent risk factor for COVID-19 severity and mortality

BACKGROUND

Since December 2019, the world has struggled with the COVID-19 pandemic. Even after the introduction of various vaccines, this disease still takes a considerable toll. In order to improve the optimal allocation of resources and communication of prognosis, healthcare providers and patients need an accurate understanding of factors (such as obesity) that are associated with a higher risk of adverse outcomes from the COVID-19 infection.

OBJECTIVES

To evaluate obesity as an independent prognostic factor for COVID-19 severity and mortality among adult patients in whom infection with the COVID-19 virus is confirmed.

SEARCH METHODS

MEDLINE, Embase, two COVID-19 reference collections, and four Chinese biomedical databases were searched up to April 2021.

SELECTION CRITERIA

We included case-control, case-series, prospective and retrospective cohort studies, and secondary analyses of randomised controlled trials if they evaluated associations between obesity and COVID-19 adverse outcomes including mortality, mechanical ventilation, intensive care unit (ICU) admission, hospitalisation, severe COVID, and COVID pneumonia. Given our interest in ascertaining the independent association between obesity and these outcomes, we selected studies that adjusted for at least one factor other than obesity. Studies were evaluated for inclusion by two independent reviewers working in duplicate.  DATA COLLECTION AND ANALYSIS: Using standardised data extraction forms, we extracted relevant information from the included studies. When appropriate, we pooled the estimates of association across studies with the use of random-effects meta-analyses. The Quality in Prognostic Studies (QUIPS) tool provided the platform for assessing the risk of bias across each included study. In our main comparison, we conducted meta-analyses for each obesity class separately. We also meta-analysed unclassified obesity and obesity as a continuous variable (5 kg/m2 increase in BMI (body mass index)). We used the GRADE framework to rate our certainty in the importance of the association observed between obesity and each outcome. As obesity is closely associated with other comorbidities, we decided to prespecify the minimum adjustment set of variables including age, sex, diabetes, hypertension, and cardiovascular disease for subgroup analysis.  MAIN RESULTS: We identified 171 studies, 149 of which were included in meta-analyses.  As compared to 'normal' BMI (18.5 to 24.9 kg/m2) or patients without obesity, those with obesity classes I (BMI 30 to 35 kg/m2), and II (BMI 35 to 40 kg/m2) were not at increased odds for mortality (Class I: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.94 to 1.16, high certainty (15 studies, 335,209 participants); Class II: OR 1.16, 95% CI 0.99 to 1.36, high certainty (11 studies, 317,925 participants)). However, those with class III obesity (BMI 40 kg/m2 and above) may be at increased odds for mortality (Class III: OR 1.67, 95% CI 1.39 to 2.00, low certainty, (19 studies, 354,967 participants)) compared to normal BMI or patients without obesity. For mechanical ventilation, we observed increasing odds with higher classes of obesity in comparison to normal BMI or patients without obesity (class I: OR 1.38, 95% CI 1.20 to 1.59, 10 studies, 187,895 participants, moderate certainty; class II: OR 1.67, 95% CI 1.42 to 1.96, 6 studies, 171,149 participants, high certainty; class III: OR 2.17, 95% CI 1.59 to 2.97, 12 studies, 174,520 participants, high certainty). However, we did not observe a dose-response relationship across increasing obesity classifications for ICU admission and hospitalisation.

AUTHORS' CONCLUSIONS

Our findings suggest that obesity is an important independent prognostic factor in the setting of COVID-19. Consideration of obesity may inform the optimal management and allocation of limited resources in the care of COVID-19 patients.

Prediction of in-hospital mortality rate in COVID-19 patients with diabetes mellitus using machine learning methods

Background

Since its emergence in December 2019, until June 2022, coronavirus 2019 (COVID-19) has impacted populations all around the globe with it having been contracted by ~ 535 M people and leaving ~ 6.31 M dead. This makes identifying and predicating COVID-19 an important healthcare priority.

Method and Material

The dataset used in this study was obtained from Shahid Beheshti University of Medical Sciences in Tehran, and includes the information of 29,817 COVID-19 patients who were hospitalized between October 8, 2019 and March 8, 2021. As diabetes has been shown to be a significant factor for poor outcome, we have focused on COVID-19 patients with diabetes, leaving us with 2824 records.

Results

The data has been analyzed using a decision tree algorithm and several association rules were mined. Said decision tree was also used in order to predict the release status of patients. We have used accuracy (87.07%), sensitivity (88%), and specificity (80%) as assessment metrics for our model.

Conclusion

Initially, this study provided information about the percentages of admitted Covid-19 patients with various underlying disease. It was observed that diabetic patients were the largest population at risk. As such, based on the rules derived from our dataset, we found that age category (51-80), CPR and ICU residency play a pivotal role in the discharge status of diabetic inpatients.

Stratifying risk outcomes among adult COVID-19 inpatients with high flow oxygen: The R4 score

BACKGROUND

High flow oxygen therapy (HFO) is a widely used intervention for pulmonary complications. Amid the coronavirus infectious disease 2019 (COVID-19) pandemic, HFO became a popular alternative to conventional oxygen supplementation therapies. Risk stratification tools have been repurposed -and new ones developed- to estimate outcome risks among COVID-19 patients. This study aims to provide a simple risk stratification system to predict invasive mechanical ventilation (IMV) or death among COVID-19 inpatients on HFO.

METHODS

Among 529 adult inpatients with COVID-19 pneumonia, we selected unadjusted clinical risk factors for developing the composite endpoint of IMV or death. The risk for the primary outcome by each category was estimated using a Cox proportional hazards model. Bootstrapping was used to validate the results.

RESULTS

Age above 62, eGFR under 60 ml/min, room air SpO2 ≤89 % upon admission, history of hypertension, history of diabetes, and any comorbidity (cancer, cardiovascular disease, COPD/ asthma, hypothyroidism, or autoimmune disease) were considered for the score. Each of the six criteria scored 1 point. The score was further simplified into 4 categories: 1) 0 criteria, 2) 1 criterion, 3) 2-3 criteria, and 4) ≥4 criteria. Taking the first category as the reference, risk estimates for the primary endpoint were HR; 2.94 [1.67 - 5.26], 4.08 [2.63 - 7.05], and 6.63 [3.74 - 11.77], respectively. In ROC analysis, the AUC for the model was 0.72.

CONCLUSIONS

Our score uses simple criteria to estimate the risk for IMV or death among COVID-19 inpatients with HFO. Higher category reflects consistent increases in risk for the endpoint.

Trends in the morbidity and mortality of coronavirus disease 2019 in different ethnic groups and gender in a large Brazilian city

As the coronavirus disease 2019 (COVID-19) outbreak spread, evidence has emerged that gender and race would bear a disproportionate impact on the morbimortality of COVID-19. Here, we conducted a retrospective observational study using the TabNet/Departamento de informática do sistema único de saúde platform of the city of São Paulo. COVID-19 records from March 2020 through December 2021 were included, and we evaluated the temporal trends of confirmed cases and case fatality rate by gender and ethnicity. Statistical analysis was performed using the R-software and BioEstat-software, considering p < 0.05 significant. From March/2020 to December/2021, 1 315 160 COVID-19 confirmed cases were recorded (57.1% females), and 2973 deaths were due to COVID-19. Males presented higher median mortality (0.44% vs. 0.23%; p < 0.05) and intensive care unit (ICU) admission rates (0.34% vs. 0.20%; p < 0.05). Men were also associated with a higher risk of death (risk ratio [RR] = 1.28; p < 0.05) and a higher chance of requiring ICU care (RR = 1.29; p < 0.05). Black ethnicity was associated with a higher risk of death (RR = 1.19; p < 0.05). White patients were more likely to require ICU admission (RR = 1.13; p < 0.05), whereas Browns were associated with a protective effect (RR = 0.86; p < 0.05). Furthermore, men presented a higher chance of death than women across the three major ethnic groups: Whites (RR = 1.33; p < 0.05), Blacks (RR = 1.24; p < 0.05), and Browns (RR = 1.35; p < 0.05). In this study of COVID-19 in São Paulo, men were associated with worse outcomes, including in the three major ethnicities in the population. Blacks exhibited a higher risk of death, Whites were more likely to require intensive care, and Browns were at protection from ICU hospitalization.

Clinical Characteristics and Outcomes among Vaccinated and Unvaccinated Patients with Cardiovascular Disease Who Were Hospitalized for COVID-19 in Brazil: Retrospective Cohort

INTRODUCTION

COVID-19 in Brazil has already caused, and it still causes, several impacts on health, economy, and education. The risk factors for death involved those with cardiovascular diseases (CVD), which were prioritized for the vaccination of COVID-19.

OBJECTIVE

To investigate the clinical characteristics and outcomes between vaccinated and unvaccinated patients with cardiovascular diseases hospitalized for COVID-19 in Brazil in the year 2022.

METHODS

A retrospective cohort was analyzed from the year 2022, with cases being hospitalized by COVID-19 being drawn from SIVEP-GRIPE surveillance. We compared clinical characteristics, comorbidities, and outcomes between CVD carriers and non-carriers, and we also compared vaccinated with two doses vs. those that are unvaccinated in CVD carriers. We performed chi-square, odds ratio, logistic regression, and survival analysis.

RESULTS

We included, in the cohort, 112,459 hospital inpatients. An amount of 71,661 (63.72%) of the hospitalized patients had CVD. Regarding deaths, 37,888 (33.69%) died. Regarding vaccination against COVID-19, 20,855 (18.54%) people were not vaccinated with any dose among those with CVD. Death p- < 0.001 (OR 1.307-CI 1.235-1.383) and fever p- < 0.001 (OR 1.156-CI 1.098-1.218) were associated with the unvaccinated CVD carriers, and diarrhea p-0.015 (OR 1.116-CI 1.022-1.218), dyspnea p-0.022 (OR 1.074-CI 1.011-1.142), and respiratory distress p-0.021 (OR 1.070-CI 1.011-1.134) were also recorded. Those patients who possessed predictors of death, including invasive ventilation (p- < 0.001 (OR 8.816-CI 8.313-9.350)), were admitted to the ICU p- < 0.001 (OR 1.754-CI 1.684-1.827), and some had respiratory distress p- < 0.001 (OR 1.367-CI 1.312-1.423), dyspnea p < 0.001 (OR 1.341-CI 1.284-1.400), O₂ saturation < 95% p- < 0. 001 (OR 1.307-CI 1.254-1.363), they were unvaccinated against COVID-19 p- < 0.001 (OR 1.258-CI 1.200-1.319), they were of male sex p- < 0.001 (OR 1.179-CI 1.138-1.221), they had diarrhea p-0.018 (OR 1.081-CI 1.013-1.154), and they may have been old p < 0.001 (OR 1.034-CI 1.033-1.035). Survival was shorter for the unvaccinated p-0.003, and p- <0.001.

CONCLUSIONS

We highlight the predictors of death for those unvaccinated against COVID-19 in this research, and we evidenced the benefits of the COVID-19 vaccine in reducing deaths in hospitalized CVD patients.

Intensive Care and Organ Support Related Mortality in Patients With COVID-19: A Systematic Review and Meta-Analysis

To perform a systematic review and meta-analysis to generate estimates of mortality in patients with COVID-19 that required hospitalization, ICU admission, and organ support.

DATA SOURCES

A systematic search of PubMed, Embase, and the Cochrane databases was conducted up to December 31, 2021.

STUDY SELECTION

Previously peer-reviewed observational studies that reported ICU, mechanical ventilation (MV), renal replacement therapy (RRT) or extracorporeal membrane oxygenation (ECMO)-related mortality among greater than or equal to 100 individual patients.

DATA EXTRACTION

Random-effects meta-analysis was used to generate pooled estimates of case fatality rates (CFRs) for in-hospital, ICU, MV, RRT, and ECMO-related mortality. ICU-related mortality was additionally analyzed by the study country of origin. Sensitivity analyses of CFR were assessed based on completeness of follow-up data, by year, and when only studies judged to be of high quality were included.

DATA SYNTHESIS

One hundred fifty-seven studies evaluating 948,309 patients were included. The CFR for in-hospital mortality, ICU mortality, MV, RRT, and ECMO were 25.9% (95% CI: 24.0-27.8%), 37.3% (95% CI: 34.6-40.1%), 51.6% (95% CI: 46.1-57.0%), 66.1% (95% CI: 59.7-72.2%), and 58.0% (95% CI: 46.9-68.9%), respectively. MV (52.7%, 95% CI: 47.5-58.0% vs 31.3%, 95% CI: 16.1-48.9%; p = 0.023) and RRT-related mortality (66.7%, 95% CI: 60.1-73.0% vs 50.3%, 95% CI: 42.4-58.2%; p = 0.003) decreased from 2020 to 2021.

CONCLUSIONS

We present updated estimates of CFR for patients hospitalized and requiring intensive care for the management of COVID-19. Although mortality remain high and varies considerably worldwide, we found the CFR in patients supported with MV significantly improved since 2020.

Effect of a Senior Cardiology Nursing Role on Streamlining Assessment of Emergency Cardiology Presentations During COVID-19: An Observational Study

INTRODUCTION

The Emergency Cardiology Coordinator (ECC) was a senior nursing role implemented from 14 April 2020 to 15 September 2020 at the Gold Coast Hospital and Health Service in South-East Queensland, Australia to streamline and expedite assessment of patients presenting to the Emergency Department (ED) with suspected cardiac problems. ECC implementation occurred in the context of the emergence of COVID-19. Evaluation of the impact of the ECC role focussed primarily on the time interval from triage to cardiology consult (TTCC).

METHODS

ED and Cardiology Department data were extracted from electronic medical records for the period 2 September 2019 to 1 March 2021. The TTCC for each presenting problem (chest pain, palpitations, shortness of breath, altered level of consciousness) was compared between patients seen by the ECC and those not seen on the days the ECC worked. The effect of COVID-19 on TTCC was assessed by an interrupted time series analysis. Data recorded by the ECC included patients seen and interventions provided.

RESULTS

The ECC saw 378 patients. Most presented with chest pain (269/378, 71.2%). The ECC determined that 68.8% (260/378) required a cardiac assessment. Following COVID-19 the median weekly TTCC increased by 0.029 hours (1.74 min) each week on average relative to that beforehand (p=0.008). For patients seen by the ECC the median TTCC was 2.07 hours (interquartile range [IQR]: 1.44, 3.16) compared to 2.58 hours (IQR: 1.73, 3.80; p=0.007) for patients not seen by the ECC. Chest pain (ECC: 1.94 hours; no ECC: 2.41 hours; p=0.06) and non-obvious cardiac presenting problems (ECC: 1.77 hours; no ECC 3.05 hours; p=0.004) displayed the largest reductions in TTCC when the ECC was involved. Presentations with palpitations, respiratory distress and altered level of consciousness had similar TTCCs.

CONCLUSION

The ECC role resulted in an overall decrease in TTCC despite the role coinciding with the emergence of COVID-19. In order to clarify the optimal strategy for the ECC role, further analyses involving patient risk factors and presenting problems along with a health economic evaluation of this model of care and the effect on patient outcomes will be required.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Pyridostigmine reduces mortality of patients with severe SARS-CoV-2 infection: A phase 2/3 randomized controlled trial

Background:

Respiratory failure in severe coronavirus disease 2019 (COVID-19) is associated with a severe inflammatory response. Acetylcholine (ACh) reduces systemic inflammation in experimental bacterial and viral infections. Pyridostigmine increases the half-life of endogenous ACh, potentially reducing systemic inflammation. We aimed to determine if pyridostigmine decreases a composite outcome of invasive mechanical ventilation (IMV) and death in adult patients with severe COVID-19.

Methods:

We performed a double-blinded, placebo-controlled, phase 2/3 randomized controlled trial of oral pyridostigmine (60 mg/day) or placebo as add-on therapy in adult patients admitted due to confirmed severe COVID-19 not requiring IMV at enrollment. The primary outcome was a composite of IMV or death by day 28. Secondary outcomes included reduction of inflammatory markers and circulating cytokines, and 90-day mortality. Adverse events (AEs) related to study treatment were documented and described.

Results:

We recruited 188 participants (94 per group); 112 (59.6%) were men; the median (IQR) age was 52 (44–64) years. The study was terminated early due to a significant reduction in the primary outcome in the treatment arm and increased difficulty with recruitment. The primary outcome occurred in 22 (23.4%) participants in the placebo group vs. 11 (11.7%) in the pyridostigmine group (hazard ratio, 0.47, 95% confidence interval 0.24–0.9; P = 0.03). This effect was driven by a reduction in mortality (19 vs. 8 deaths, respectively).

Conclusion:

Our data indicate that adding pyridostigmine to standard care reduces mortality among patients hospitalized for severe COVID-19.

The World-Wide Adaptations of Diabetic Management in the Face of COVID-19 and Socioeconomic Disparities: A Scoping Review

Diabetes is an increasingly prevalent chronic disease throughout the world. It is imperative for patients to have access to reliable treatment and resources in order to avoid long-term complications. Economic and social factors contribute to the accessibility of these resources and have a direct impact on diabetes management. Socioeconomic status (SES) presents challenges to diabetic management due to financial and geographical access to care, medications, educational resources, healthy food options, and physical activity. The coronavirus (COVID-19) pandemic exacerbated these challenges, especially during the height of lockdowns. Therefore, it is important to gain insight into how the pandemic challenged diabetes management, taking into consideration socioeconomic disparities. The objective is to assess how the COVID-19 pandemic has impacted the care of chronic diabetic patients internationally and determine how these outcomes vary between patients of different socioeconomic classes. The following study was designed as a scoping review and utilized PubMed, EMBASE, CINAHL, and Web of Science. A Boolean search strategy combined search terms as follows: (((COVID-19) AND (diabetes)) AND ((socioeconomic factors) OR (social inequality OR standard of living))) AND (treatment OR management). Inclusion criteria included studies addressing diabetic patients, socioeconomic variables (income, occupation, level of education, and ethnicity), glycemic control, and degree of access to quality healthcare. Studies exploring the pathophysiology of COVID-19 or diabetes mellitus were excluded. In addition, studies were chosen between the years 2020 and 2022. The search resulted in 214 articles. The full-text assessment was then conducted on the remaining 67 articles. After screening for eligibility and relevance, 19 articles were retained for this review. The results of this study indicate that 8 out of the 18 studies revealed worse outcomes for those with diabetes mellitus and concomitant COVID-19 infection. Patients with diabetes were more likely to be hospitalized and represent a larger percentage of COVID-19 fatalities. In addition, patients with diabetes and co-morbid COVID-19 infection were more likely to have a higher hemoglobin A1c (HbA1c), belong to a lower SES, and have worse glycemic control due to pandemic-associated lockdown. In order to combat the effects of the pandemic, many countries created novel and innovative management strategies. Overall, there are positive and negative effects from the pandemic on diabetic management strategies. This scoping review identified successes in diabetic treatment under pandemic conditions and areas that need optimization. The successful adaptations of many nations convey the capacity for new policy implementation to care for diabetic patients regardless of SES.

Mortality Risk Factors for Coronavirus Infection in Hospitalized Adults in Brazil: A Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic has presented high morbidity and mortality, with associated high socioeconomic costs. Brazil ranks third in the number of COVID-19 cases, behind only India and the United States.

OBJECTIVE

To analyze risk factors for mortality in adults hospitalized with COVID-19 in Brazil.

METHODS

Observational retrospective cohort study including data from all Brazilian states and regions. The study included information from 468,226 in-hospital patients from all regions of Brazil from 1 January 2021 to 31 July 2021. Data from the influenza epidemiological surveillance system were used. The participants were adults hospitalized with COVID-19. A Cox regression model was used to analyze factors associated with mortality in adults with COVID-19.

RESULTS

The in-hospital mortality lethality was 37.5%. The risk factors associated with COVID-19 mortality were older age, with a linear increase with increments in age, male sex, black or mixed race, low education level, comorbidities, use of ventilatory support, and living in the southeast, north, or northeast regions of the country.

CONCLUSIONS

Our results illustrate the severity of the COVID-19 pandemic in Brazil and reinforce that policies and practices to deal with this disease should focus on groups and regions with higher risk, whereas public policies should promote nonpharmacological measures and vaccination in the Brazilian population.

Impact of the COVID-19 Pandemic on Diabetes Care for Adults With Type 2 Diabetes in Ontario, Canada

OBJECTIVES

The COVID-19 pandemic and related public health prevention measures have led to a disruption of the delivery of routine care and may have had an impact on the quality of diabetes care. Our aim in this study was to evaluate the extent to which structure, process and outcome quality measures in diabetes care changed in the first 6 months of the pandemic compared with previous periods.

METHODS

A before-and-after observational study was conducted of all community-living Ontario residents >20 years of age and living with diabetes. The patients were divided into 3 cohorts: a pandemic cohort, alive March to September 2020 (n=1,393,404); reference cohort 1, alive March to September 2019 (n=1,415,490); and reference cohort 2, alive September 2019 to February 2020 (n=1,444,000). Outcome measures were in-person/virtual visits to general practitioners and specialists, eye examinations, glycated hemoglobin (A1C) and low-density lipoprotein (LDL) testing, filled prescriptions, and admissions to emergency departments (EDs) and hospitals for acute and chronic diabetes complications.

RESULTS

The probability of an in-person visit to a general practitioner decreased by 47% (95% confidence interval [CI], 47% to 47%) in the pandemic period compared with both previous periods. The probability of having an eye exam was lower by 43% (95% CI, 44% to 43%), an A1C test by 28% (95% CI, 29% to 28%) and an LDL test by 31% (95% CI, 31% to 31%) in the pandemic period compared with the same 6-month period the year before. There were very small decreases in drug prescriptions and decreases of 18% and 16% in ED and hospital visits for complications.

CONCLUSIONS

We observed disruptions to both structure and process measures of diabetes care in Ontario during the first wave of the pandemic.

Profile of Brazilian inpatients with COVID-19 vaccine breakthrough infection and risk factors for unfavorable outcome

Objective.

To characterize the epidemiological and clinical profile of individuals more likely to become infected with SARS-CoV-2 after the fully vaccination schedule in order to profile priority groups to receive a booster dose in situations of vaccine doses shortage as well as for maintenance of personal protective care.

Methods.

This cross-sectional study used data from hospitalized COVID-19 patients aged ≥18 years, who had been fully vaccinated and had a SARS-CoV-2 infection positive diagnosis collected from the SIVEP-Gripe database (Influenza Epidemiological Surveillance Information System) from January 18, 2021 to September 15, 2021. Demographic data, clinical symptoms and preexisting medical conditions (comorbidities) were analyzed. The primary outcome was in-hospital death.

Results.

The majority of hospitalized patients with vaccine breakthrough infection were ≥60 years old, male, with critical or severe COVID-19. The fatality rate was extremely high (50.27%) and more pronounced in elderly groups. The most prevalent symptoms were cough, dyspnea, respiratory distress, and low blood oxygen saturation. The most frequent comorbidities were heart disease and diabetes. High fatality rates were observed among patients admitted to the intensive care units (72.88%) and those who required invasive mechanical ventilation (87.82%). The main risk factors for an unfavorable outcome were older age, respiratory compromise, inactivated virus vaccine immunization, and preexisting medical conditions.

Conclusions.

We characterized the profile of hospitalized Brazilian patients with COVID-19 vaccine breakthrough infection and the risk factors for an unfavorable outcome. These data allow to identify priority groups to receive a booster dose and to continue using personal protection.

Characterization of demographic data, clinical signs, comorbidities, and outcomes according to the race in hospitalized individuals with COVID-19 in Brazil: An observational study

Background

Brazil is a multiracial country with five major official races: White, Black, individuals with multiracial backgrounds, Asian, and Indigenous. Brazil is also one of the epicentres of the Coronavirus Disease (COVID)-19 pandemic. Thus, we evaluated how the races of the Brazilian population contribute to the outcomes in hospitalized individuals with COVID-19, and we also described the clinical profile of the five official Brazilian races.

Methods

We performed an epidemiological analysis for the first 67 epidemiological weeks of the COVID-19 pandemic in Brazil (from February 22, 2020, to April 04, 2021) using the data available at OpenDataSUS of the Brazilian Ministry of Health, a data set containing data from Brazilian hospitalized individuals. We evaluated more than 30 characteristics, including demographic data, clinical symptoms, comorbidities, need for intensive care unit and mechanical ventilation, and outcomes.

Results

In our data, 585 655 hospitalized individuals with a positive result in SARS-CoV-2 real-time chain reaction (RT-PCR) were included. Of these total, 309 646 (52.9%) identified as White, 31 872 (5.4%) identified as Black, 7108 (1.2%) identified as Asian, 235 108 (40.1%) identified as individuals with multiracial background, and 1921 (0.3%) identified as Indigenous. The multivariate analysis demonstrated that race was significative to predict the death being that Black (OR = 1.43; 95% CI = 1.39-1.48), individuals with multiracial background (OR = 1.36; 95% CI = 1.34-1.38), and Indigenous (OR = 1.91; 95% CI = 1.70-2.15) races were more prone to die compared to the White race. The Asian individuals did not have a higher chance of dying due to SARS-CoV-2 infection compared to White individuals (OR = 0.99; 95% CI = 0.94-1.06). In addition, other characteristics contributed as such as being male (OR = 1.17; 95% CI = 1.16-1.19), age (mainly, +85 years old – OR = 23.02; 95% CI = 20.05-26.42) compared to 1-year-old individuals, living in rural areas (OR = 1.22; 95% CI = 1.18-1.26) or in peri-urban places (OR = 1.25; 95% CI = 1.11-1.40), and the presence of nosocomial infection (OR = 1.91; 95% CI = 1.82-2.01). Among the clinical symptoms, the main predictors were dyspnoea (OR = 1.25; 95% CI = 1.23-1.28), respiratory discomfort (OR = 1.30; 95% CI = 1.28-1.32), oxygen saturation <95% (OR = 1.40; 95% CI = 1.38-1.43). Also, among the comorbidities, the main predictors were the presence of immunosuppressive disorder (OR = 1.44; 95% CI = 1.39-1.49), neurological disorder (OR = 1.21; 95% CI = 1.17-1.25), hepatic disorder (OR = 1.41; 95% CI = 1.34-1.50), diabetes mellitus (OR = 1.40; 95% CI = 1.37-1.42), cardiopathy (OR = 1.13; 95%CI = 1.11-1.14), hematologic disorder (OR = 1.34; 95% CI = 1.24-1.43), Down syndrome (OR = 1.61; 95% CI = 1.43-1.81), renal disease (OR = 1.15; 95% CI = 1.11-1.18), and obesity (OR = 1.18; 95% CI = 1.15-1.21). Individuals on intensive care unit (OR = 2.25; 95% CI = 2.22-2.29) and on invasive (OR = 10.92; 95% CI = 10.66-11.18) or non-invasive (OR = 1.33; 95% CI = 1.30-1.35) mechanical ventilation were more prone to die.

Conclusions

Alongside several clinical symptoms and comorbidities, we associated race with an enhanced risk of death in Black individuals, individuals with multiracial backgrounds, and Indigenous peoples.

A Brief Analysis of a New Device to Prevent Early Intubation in Hypoxemic Patients: An Observational Study

The need for mechanical ventilation is one of the main concerns related to the care of patients with COVID-19. The aim of this study is to evaluate the efficacy of a bubble device for oxygen supplementation. This device was implemented for the selected patients hospitalized with severe COVID-19 pneumonia with persistent low oxygen saturation. Patients were selected in three major COVID-19 hospitals of Bahia state in Brazil from July to November 2020, where they remained with the device for seven days and were monitored for different factors, such as vital signs, oximetry evaluation, and arterial blood gasometry. Among the 51 patients included in the study, 68.63% successfully overcame hypoxemia without the necessity to be transferred to mechanical ventilation, whereas 31.37% required tracheal intubation (p value < 0.05). There was no difference of note on the analysis of the clinical data, chemistry, and hematological evaluation, with the exception of the SpO2 on follow-up days. Multivariate analysis revealed that the independent variable, male sex, SpO2, and non-inhaled mask, was associated with the necessity of requiring early mechanical ventilation. We concluded that this bubble device should be a prior step to be utilized before indication of mechanical ventilation in patients with persistent hypoxemia of severe COVID-19 pneumonia.

Association of Obesity With COVID-19 Severity and Mortality: An Updated Systemic Review, Meta-Analysis, and Meta-Regression

Background

Obesity affects the course of critical illnesses. We aimed to estimate the association of obesity with the severity and mortality in coronavirus disease 2019 (COVID-19) patients.

Data Sources

A systematic search was conducted from the inception of the COVID-19 pandemic through to 13 October 2021, on databases including Medline (PubMed), Embase, Science Web, and Cochrane Central Controlled Trials Registry. Preprint servers such as BioRxiv, MedRxiv, ChemRxiv, and SSRN were also scanned.

Study Selection and Data Extraction

Full-length articles focusing on the association of obesity and outcome in COVID-19 patients were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for study selection and data extraction. Our Population of interest were COVID-19 positive patients, obesity is our Intervention/Exposure point, Comparators are Non-obese vs obese patients The chief outcome of the study was the severity of the confirmed COVID-19 positive hospitalized patients in terms of admission to the intensive care unit (ICU) or the requirement of invasive mechanical ventilation/intubation with obesity. All-cause mortality in COVID-19 positive hospitalized patients with obesity was the secondary outcome of the study.

Results

In total, 3,140,413 patients from 167 studies were included in the study. Obesity was associated with an increased risk of severe disease (RR=1.52, 95% CI 1.41-1.63, p<0.001, I2 = 97%). Similarly, high mortality was observed in obese patients (RR=1.09, 95% CI 1.02-1.16, p=0.006, I2 = 97%). In multivariate meta-regression on severity, the covariate of the female gender, pulmonary disease, diabetes, older age, cardiovascular diseases, and hypertension was found to be significant and explained R2 = 40% of the between-study heterogeneity for severity. The aforementioned covariates were found to be significant for mortality as well, and these covariates collectively explained R2 = 50% of the between-study variability for mortality.

Conclusions

Our findings suggest that obesity is significantly associated with increased severity and higher mortality among COVID-19 patients. Therefore, the inclusion of obesity or its surrogate body mass index in prognostic scores and improvement of guidelines for patient care management is recommended.

Risk of hospitalization and mortality due to COVID-19 in people with obesity: An analysis of data from a Brazilian state

The aim of this article is to assess the odds ratio of hospitalization and mortality due to COVID-19 in people with obesity using data from residents of Espírito Santo, Brazil. An observational, quantitative, cross-sectional study was carried out from the database available on the official channel of the State Health Secretariat of Espírito Santo. Crude odds ratio estimates (ORs) referring to the association between variables were calculated, as well as adjusted odds ratios (adjusted odds ratios—OR adj.) and their respective 95% confidence intervals (CI 95%). The results indicate that men, non-white, no education or with lower education level and age over 40 years old were more likely to be hospitalized and died of COVID-19. People with obesity are at risk of hospitalization and death due to COVID-19 54% and 113% higher than people who do not have obesity. People with obesity had a higher chance of hospitalization when they were over 40 years old, had breathing difficulty, and the comorbidities diabetes (2.18 higher) and kidney disease (4.10 higher). The odds ratio of death for people with obesity over 60 years old was 12.51 higher, and those who were hospitalized was 17.9 higher compared to those who were not hospitalized.

An overview of Brazilian working age adults vulnerability to COVID-19

Brazil is a country of continental dimensions, where many smaller countries would fit. In addition to demographic, socioeconomic, and cultural differences, hospital infrastructure and healthcare varies across all 27 federative units. Therefore, the evolution of COVID-19 pandemic did not manifest itself in a homogeneous and predictable trend across the nation. In late 2020 and early 2021, new waves of the COVID-19 outbreak have caused an unprecedented sanitary collapse in Brazil. Unlike the first COVID-19 wave, in subsequent waves, preliminary evidence has pointed to an increase in the daily reported cases among younger people being hospitalized, overloading the healthcare system. In this comprehensive retrospective cohort study, confirmed cases of hospitalization, ICU admission, IMV requirement and in-hospital death from Brazilian COVID-19 patients throughout 2020 until the beginning of 2021 were analyzed through a spatio-temporal study for patients aged 20-59 years. All Brazilian federative units had their data disaggregated in six periods of ten epidemiological weeks each. We found that there is a wide variation in the waves dynamic due to SARS-CoV-2 infection, both in the first and in subsequent outbreaks in different federative units over the analyzed periods. As a result, atypical waves can be seen in the Brazil data as a whole. The analysis showed that Brazil is experiencing a numerical explosion of hospitalizations and deaths for patients aged 20-59 years, especially in the state of São Paulo, with a similar proportion of hospitalizations for this age group but higher proportion of deaths compared to the first wave.

Neurological Prognostic Factors in Hospitalized Patients with COVID-19

We aimed to search whether neurological symptoms or signs (NSS) and the MEWS (Modified Early Warning Score) score were associated with in-hospital mortality or oxygen requirement during the first 14 days of hospitalization in COVID-19 patients recruited at the University Hospital in Krakow, Poland. The detailed clinical questionnaires on twenty NSS were either filled out by patients prospectively or retrospectively assessed by neurologists based on daily medical records. NSS were considered high or low-risk if they were associated with increased or decreased mortality in the univariable analysis. This cohort study included 349 patients with COVID-19 (median age 64, interquartile range (51-77), women 54.72%). The presence of high-risk NSS (decreased level of consciousness, delirium, seizures, and symptoms of stroke or transient ischemic attack) or its combination with the absence of low-risk NSS (headache, dizziness, decreased mood, and fatigue) increased the risk of in-hospital mortality in SARS-CoV-2 infection 3.13 and 7.67-fold, respectively. The presence of low-risk NSS decreased the risk of in-hospital mortality in COVID-19 patients more than 6-fold. Death in patients with SARS-CoV-2 infection, apart from NSS, was predicted by older age, neoplasm, and higher MEWS scores on admission. High-risk NSS or their combination with the absence of low-risk NSS increased the risk of oxygen requirement during hospitalization in COVID-19 patients 4.48 and 1.86-fold, respectively. Independent predictors of oxygen therapy during hospitalization in patients with SARS-CoV-2 infection were also older age, male sex, neoplasm, and higher MEWS score on admission.

Measuring misclassification of Covid-19 as garbage codes: Results of investigating 1,365 deaths and implications for vital statistics in Brazil

The purpose of this article is to quantify the amount of misclassification of the Coronavirus Disease-2019 (COVID-19) mortality occurring in hospitals and other health facilities in selected cities in Brazil, discuss potential factors contributing to this misclassification, and consider the implications for vital statistics. Hospital deaths assigned to causes classified as garbage code (GC) COVID-related cases (severe acute respiratory syndrome, pneumonia unspecified, sepsis, respiratory failure and ill-defined causes) were selected in three Brazilian state capitals. Data from medical charts and forensic reports were extracted from standard forms and analyzed by study physicians who re-assigned the underlying cause based on standardized criteria. Descriptive statistical analysis was performed and the potential impact in vital statistics in the country was also evaluated. Among 1,365 investigated deaths due to GC-COVID-related causes, COVID-19 was detected in 17.3% in the age group 0-59 years and 25.5% deaths in 60 years and over. These GCs rose substantially in 2020 in the country and were responsible for 211,611 registered deaths. Applying observed proportions by age, location and specific GC-COVID-related cause to national data, there would be an increase of 37,163 cases in the total of COVID-19 deaths, higher in the elderly. In conclusion, important undercount of deaths from COVID-19 among GC-COVID-related causes was detected in three selected capitals of Brazil. After extrapolating the study results for national GC-COVID-related deaths we infer that the burden of COVID-19 disease in Brazil in official vital statistics was probably under estimated by at least 18% in the country in 2020.

Under pressure: Women's leadership during the COVID-19 crisis

We study the effect of women's public leadership in times of crisis. We use a regression discontinuity design in close mayoral races between male and female candidates to understand the impact of having a woman as a mayor during the COVID-19 pandemic in Brazil. Female leadership reduced deaths and hospitalizations per 100 thousand inhabitants while increasing enforcement of non-pharmaceutical interventions. These results are not due to measures taken before the pandemic or other observable mayoral characteristics such as education or political preferences. The effects are stronger in municipalities where Brazil's far-right president, who publicly disavowed the importance of non-pharmaceutical interventions, had a higher vote share in the 2018 election. Overall, our findings provide credible evidence that female leaders outperformed male ones when dealing with a global policy issue. They also showcase that local leaders can counteract policies implemented by populist leaders at the national level.

Impact of COVID-19 in patients with multiple myeloma based on a global data network

The COVID-19 pandemic has represented a major cause of morbidity/mortality worldwide, overstressing health systems. Multiple myeloma (MM) patients show an increased risk for infections and they are expected to be particularly vulnerable to SARS-CoV-2 infection. Here we have obtained a comprehensive picture of the impact of COVID-19 in MM patients on a local and a global scale using a federated data research network (TriNetX) that provided access to Electronic Medical Records (EMR) from Health Care Organizations (HCO) all over the world. Through propensity score matched analyses we found that the number of new diagnoses of MM was reduced in 2020 compared to 2019 (RR 0.86, 95%CI 0.76-0.96) and the survival of newly diagnosed MM cases decreased similarly (HR 0.61, 0.38-0.81). MM patients showed higher risk of SARS-CoV-2 infection (RR 2.09, 1.58-2.76) and a higher excess mortality in 2020 (difference in excess mortality 9%, 4.4-13.2) than non-MM patients. By interrogating large EMR datasets from HCO in Europe and globally, we confirmed that MM patients have been more severely impacted by COVID-19 pandemic than non-MM patients. This study highlights the necessity of extending preventive measures worlwide to protect vulnerable patients from SARS-CoV-2 infection by promoting social distancing and an intensive vaccination strategies.

Evaluation of Treatment Outcome for Pneumonia among Pre-Vaccinated COVID-19 Patients with/without Comorbidity in a Public Hospital in Bengkulu, Indonesia

Pneumonia is one of the common complications of SARS-CoV-2 infection where most patients have moderate to severe symptoms that pose a higher risk for death. This study aims to evaluate the treatment outcome of COVID-19-associated Pneumonia among patients with/without comorbidity in a public hospital in Indonesia. This is a retrospective cohort study involving unvaccinated confirmed COVID-19 patients admitted to the hospital between March and December 2020. All confirmed COVID-19 patients with Pneumonia (n = 1522) treated at the hospital were included. The majority of patients (99%) had mild COVID-19 symptoms while the remaining had moderate symptoms. The median age was about 32 years old and the average treatment duration was 6.25 ± 1.83 days. Most patients (88.8%) received a combination of azithromycin and oseltamivir. There was a very significant relationship (p < 0.001) between comorbidities with treatment and duration of treatment of Pneumonia in COVID-19 patients. Although most patients had Pneumonia and comorbidities, they were successfully treated with azithromycin and oseltamivir combination following approximately five days of treatment.

Factors That Influence Mortality in Critically Ill Patients with SARS-CoV-2 Infection: A Multicenter Study in the Kingdom of Saudi Arabia

BACKGROUND

SARS-CoV-2 infection has a high mortality rate and continues to be a global threat, which warrants the identification of all mortality risk factors in critically ill patients.

METHODS

This is a retrospective multicenter cohort study conducted in five hospitals in the Kingdom of Saudi Arabia (KSA). We enrolled patients with confirmed SARS-COV-2 infection admitted to any of the intensive care units from the five hospitals between March 2020 and July 2020, corresponding to the peak of recorded COVID-19 cases in the KSA.

RESULTS

In total, 229 critically ill patients with confirmed SARS-CoV-2 infection were included in the study. The presenting symptoms and signs of patients who died during hospitalization were not significantly different from those observed among patients who survived. The baseline comorbidities that were significantly associated with in-hospital mortality were diabetes (62% vs. 48% among patients who died and survived (p = 0.046)), underlying cardiac disease (38% vs. 19% (p = 0.001)), and underlying kidney disease (32% vs. 12% (p < 0.001)).

CONCLUSION

In our cohort, the baseline comorbidities that were significantly associated with in-hospital mortality were diabetes, underlying cardiac disease, and underlying kidney disease. Additionally, the factors that independently influenced mortality among critically ill COVID-19 patients were high Activated Partial Thromboplastin Time (aPTT )and international normalization ratio (INR), acidosis, and high ferritin.

Estimation of the risk of COVID-19 mortality among physicians in Egypt

The risk of COVID-19 mortality among physicians in Egypt has not been estimated yet. Using data from the Egyptian Ministry of Health and Population (MoHP), the Central Agency for Public Mobilization And Statistics (CAPMAS) in Egypt, and the Egyptian Medical Syndicate, this report aimed to roughly estimate this risk. We found that, up to April 28th, 2021, the deaths of physicians contributed to 3.7% of COVID-19 mortality in Egypt, and physicians were almost 19 times more likely to die of COVID-19 compared with the general population above the median age (>24.5 years). Still, this contribution could be overestimated because the MoHP might have failed to report a significant number of COVID-19 deaths among the general population.

Can prognostic nutritional index predict mortality in intensive care patients with COVID-19?

OBJECTIVES

PNI is a calculated parameter using the albumin and the lymphocyte count from the CBC, which demonstrates the immunological and nutritional status of the patient. The aim of this study is to show the relationship between PNI and mortality in COVID-19 patients and to reveal a PNI cut-off value for mortality.

MATERIALS AND METHODS

Data of 690 PCR positive COVID-19 ICU patients were recorded. COVID-19 ICU patients were divided into two groups; the first group consisted of survivors, while the second group consisted of patients who died in the ICU. Patients were also evaluated in two groups according to the PNI cut-off value that predicted mortality (PNI ≤ 42.00, PNI ≥ 43) and were compared in terms of demographics, laboratory parameters, clinical findings and mortality rates.

RESULTS

When 690 COVID-19 patients were divided into two groups as survivors (50.6%) and deceased (49.4%) in intensive care, PNI value was significantly lower in the deceased group compared to the surviving group (P < .001). The PNI cut-off value predicting mortality was determined as ≤42. Patients were classified into two groups according to the PNI cut-off value. PNI ≤42 was determined as an independent risk factor for mortality (OR:2.9 P < .001). AUC values for PNI, albumin, and lymphocyte were 0.628, 0.612, and 0.590, respectively; P < .001 for all.

CONCLUSION

PNI is an inexpensive method that can be easily calculated on the basis of routine laboratory parameters. We believe that the PNI value of COVID-19 patients on admission to the ICU may be an independent factor to predict mortality.

COVID-19 Vaccinations: A Comprehensive Review of Their Safety and Efficacy in Special Populations

COVID-19 has been spreading worldwide since late 2019. There is no definitive cure to date. Global vaccination programs are urgently required to confer herd immunity, reducing the incidence of COVID-19 infections and associated morbidity and mortality. However, a significant proportion of special populations are hesitant to receive vaccination due to their special conditions, namely, age (pediatrics and geriatrics), immunocompromised state, autoimmune diseases, chronic cardiovascular and pulmonary conditions, active or treated cancers, and pregnancy. This review aims to evaluate the existing evidence of COVID-19 vaccinations on these special populations and to provide clues to guide vaccination decision making to balance the benefits and risks of vaccinations.

Intensive Care Unit prioritization: The impact of ICU bed availability on mortality in critically ill patients who requested ICU admission in court in a Brazilian cohort

PURPOSE

To assess hospital mortality in patients who requested ICU admission in court due to the scarcity of ICU beds in the Brazilian public health system and the consequences of these judicial litigations.

MATERIAL AND METHODS

Retrospective cohort study that included adult patients from the public health system of the Federal District, Brazil, who claimed ICU admission in court from January 2017 to December 2019.

RESULTS

Of the 1752 patients, 1031 were admitted to ICU (58.8%). Hospital mortality was 61.1% (1071/1752). Of the requests, 768 (43.8%) were made by patients with priority levels III or IV, resulting in the ICU admission of 33.9% of these patients. Denial of ICU admission (p < 0.001) increased mortality. ICU admission reduced hospital mortality in patients classified as priority level I (p < 0.001), priority level II (p < 0.001), and priority level III (p < 0.001), but not as priority level IV (p = 0.619).

CONCLUSION

A large proportion of patients was denied ICU admission and it was associated with an increased mortality. A considerable portion of the ICU-admitted patients were classified as priority level III and IV, impairing the ICU admission of patients with priority level I which are the ones with the greatest benefit from it.

The Association of Asthma With COVID-19 Mortality: An Updated Meta-Analysis Based on Adjusted Effect Estimates

Background

The association of asthma with the risk for mortality among coronavirus disease 2019 (COVID-19) patients is not clear.

Objective

To investigate the association between asthma and the risk for mortality among COVID-19 patients.

Methods

We performed systematic searches through electronic databases including PubMed, EMBASE, and Web of Science to identify potential articles reporting adjusted effect estimates on the association of asthma with fatal COVID-19. A random-effects model was conducted to estimate pooled effects. Sensitivity analysis, subgroup analysis, meta-regression, Begg's test and Egger's test were also performed.

Results

Based on 62 studies with 2,457,205 cases reporting adjusted effect estimates, COVID-19 patients with asthma had a significantly reduced risk for mortality compared with those without it (15 cohort studies: 829,670 patients, pooled hazard ratio [HR] = 0.88, 95% confidence interval [CI], 0.82-0.95, I² = 65.9%, P < .001; 34 cohort studies: 1,008,015 patients, pooled odds ratio [OR] = 0.88, 95% CI, 0.82-0.94, I² = 39.4%, P = .011; and 11 cross-sectional studies: 1,134,738 patients, pooled OR = 0.87, 95% CI, 0.78-0.97, I² = 41.1%, P = .075). Subgroup analysis based on types of adjusted factors indicated that COVID-19 patients with asthma had a significantly reduced risk for mortality among studies adjusting for demographic, clinical, and epidemiologic variables (pooled OR = 0.87, 95% CI, 0.83-0.92, I² = 36.3%, P = .013; pooled HR = 0.90, 95% CI, 0.83-0.97, I² = 69.2%, P < .001), but not among studies adjusting only for demographic variables (pooled OR = 0.88, 95% CI, 0.70-1.12, I² = 40.5%, P = .097; pooled HR = 0.82, 95% CI, 0.64-1.06, I² = 0%, P = .495). Sensitivity analysis proved that our results were stable and robust. Both Begg's test and Egger's test indicated that potential publication bias did not exist.

Conclusions

Our data based on adjusted effect estimates indicated that asthma was significantly related to a reduced risk for COVID-19 mortality.

COVID-19 in medium-sized municipalities in the 14 health macro-regions of Minas Gerais, Brazil

The present study focused on the scenario of confirmed cases of SARS-CoV-2 infection in the state of Minas Gerais (MG), Brazil, from March 2020 to March 2021. We evaluated the evolution of COVID-19 prevalence and death in one municipality from each of the 14 health macro-regions of MG state. Socio-demographic characteristics and variables related to the municipalities were analyzed. The raw dataset used in this study was freely sourced from the website Brasil.io. From the raw dataset, two time series were extracted: the cumulative confirmed cases of COVID-19 and cumulative death counts, and they were compared to the state data using a nowcasting approach. In order to make time series comparisons possible, all data was normalized per 100,000 inhabitants. When analyzing in light of colored wave code interventions initiated in August 2020 in MG, for the majority of the municipalities, there was an absence of clear influence on prevalence and deaths. The national holidays in the first semester of 2020 had a small impact on the COVID-19 prevalence of the municipalities, but the holidays in the second semester of 2020 and beginning of 2021 caused important impacts on COVID-19 prevalence. The low number of ICU beds in some municipalities contributed to the higher number of deaths. The analysis showed here is expected to contribute to the improvement of decision making of the MG government, as it opened a huge possibility to have the total macro-regions and state data analyzed.

N-acetyl-cysteine reduces the risk for mechanical ventilation and mortality in patients with COVID-19 pneumonia: a two-center retrospective cohort study

BACKGROUND

N-acetyl-cysteine (NAC) has been previously shown to exert beneficial effects in diverse respiratory diseases, through antioxidant and anti-inflammatory actions. Our aim was to evaluate NAC potential impact in hospitalised patients with COVID-19 pneumonia, in terms of progression to severe respiratory failure (SRF) and mortality.

PATIENTS AND METHODS

This retrospective, two-centre cohort study included consecutive patients hospitalised with moderate or severe COVID-19 pneumonia. Patients who received standard of care were compared with patients who additionally received NAC 600 mg bid orally for 14 days. Patients' clinical course was recorded regarding (i) the development of SRF (PO₂/FiO₂ <150) requiring mechanical ventilation support and (ii) mortality at 14 and 28 days.

RESULTS

A total of 82 patients were included, 42 in the NAC group and 40 in the control group. Treatment with oral NAC led to significantly lower rates of progression to SRF as compared to the control group (p < .01). Patients in the NAC group presented significantly lower 14- and 28-day mortality as compared to controls (p < .001 and p < .01 respectively). NAC treatment significantly reduced 14- and 28-day mortality in patients with severe disease (p < .001, respectively). NAC improved over time the PO2/FiO2 ratio and decreased the white blood cell, CRP, D-dimers and LDH levels. In the multivariable logistic regression analysis, non-severe illness and NAC administration were independent predictors of 28-days survival.

CONCLUSION

Oral NAC administration (1200 mg/d) in patients with COVID-19 pneumonia reduces the risk for mechanical ventilation and mortality. Our findings need to be confirmed by properly designed prospective clinical trials.