Hypercoagulopathy and Adipose Tissue Exacerbated Inflammation May Explain Higher Mortality in COVID-19 Patients With Obesity

Computational methods in the analysis of SARS-CoV-2 in mammals: A systematic review of the literature

SARS-CoV-2 is an enveloped RNA virus that causes severe respiratory illness in humans and animals. It infects cells by binding the Spike protein to the host's angiotensin-converting enzyme 2 (ACE2). The bat is considered the natural host of the virus, and zoonotic transmission is a significant risk and can happen when humans come into close contact with infected animals. Therefore, understanding the interconnection between human, animal, and environmental health is important to prevent and control future coronavirus outbreaks. This work aimed to systematically review the literature to identify characteristics that make mammals suitable virus transmitters and raise the main computational methods used to evaluate SARS-CoV-2 in mammals. Based on this review, it was possible to identify the main factors related to transmissions mentioned in the literature, such as the expression of ACE2 and proximity to humans, in addition to identifying the computational methods used for its study, such as Machine Learning, Molecular Modeling, Computational Simulation, between others. The findings of the work contribute to the prevention and control of future outbreaks, provide information on transmission factors, and highlight the importance of advanced computational methods in the study of infectious diseases that allow a deeper understanding of transmission patterns and can help in the development of more effective control and intervention strategies.

Association of excess visceral fat and severe illness in hospitalized COVID-19 patients in Japan: a retrospective cohort study

BACKGROUND/OBJECTIVES

Obesity, defined by body mass index (BMI), is a well-known risk factor for the severity of coronavirus disease 2019 (COVID-19). Adipose tissue distribution has also been implicated as an important factor in the body's response to infection, and excess visceral fat (VF), which is prevalent in Japanese, may contribute significantly to the severity. Therefore, this study aimed to evaluate the association of obesity and VF with COVID-19 severe illness in Japan.

SUBJECTS/METHODS

This retrospective cohort study involved 550 COVID-19 patients admitted to a tertiary care hospital with BMI and body composition data, including VF. The primary endpoint was severe illness, including death, due to COVID-19 during hospitalization. Logistic regression analysis was applied to examine the quartiles of BMI and VF on severe illness after adjusting for covariates such as age, sex, subcutaneous fat, paraspinal muscle radiodensity, and comorbidities affecting VF (COPD, cancer within 5 years, immunosuppressive agent use).

RESULTS

The median age was 56.0 years; 71.8% were males. During hospitalization, 82 (14.9%) experienced COVID-19 severe illness. In the multivariate logistic regression analysis, Q4 of BMI was not significantly associated with severe illness compared to Q1 of BMI (OR 1.03; 95% CI 0.37-2.86; p = 0.95). Conversely, Q3 and Q4 of VF showed a higher risk for severe illness compared to Q1 of VF (OR 2.68; 95% CI 1.01-7.11; p = 0.04, OR 3.66; 95% CI 1.30-10.26; p = 0.01, respectively). Stratified analysis by BMI and adjusted for covariates showed the positive association of VF with severe illness only in the BMI < 25 kg/m2 group.

CONCLUSIONS

High BMI was not an independent risk factor for COVID-19 severe illness in hospitalized patients in Japan, whereas excess VF significantly influenced severe illness, especially in patients with a BMI < 25 kg/m2.

Tachykinins and the potential causal factors for post-COVID-19 condition

The most prevalent symptoms of post-COVID-19 condition are pulmonary dysfunction, fatigue and muscle weakness, anxiety, anosmia, dysgeusia, headaches, difficulty in concentrating, sexual dysfunction, and digestive disturbances. Hence, neurological dysfunction and autonomic impairments predominate in post-COVID-19 condition. Tachykinins including the most studied substance P are neuropeptides expressed throughout the nervous and immune systems, and contribute to many physiopathological processes in the nervous, immune, gastrointestinal, respiratory, urogenital, and dermal systems and participate in inflammation, nociception, and cell proliferation. Substance P is a key molecule in neuroimmune crosstalk; immune cells near the peripheral nerve endings can send signals to the brain with cytokines, which highlights the important role of tachykinins in neuroimmune communication. We reviewed the evidence that relates the symptoms of post-COVID-19 condition to the functions of tachykinins and propose a putative pathogenic mechanism. The antagonism of tachykinins receptors can be a potential treatment target.

Obesity in Severe COVID-19 Patients Has a Distinct Innate Immune Phenotype

Obesity alters the capacity of effective immune responses in infections. To further address this phenomenon in the context of COVID-19, this study investigated how the immunophenotype of leukocytes was altered in individuals with obesity in severe COVID-19. This cross-sectional study enrolled 27 ICU COVID-19 patients (67% women, 56.33 ± 19.55 years) that were assigned to obese (BMI ≥ 30 kg/m2, n = 9) or non-obese (BMI < 30kg/m2, n = 18) groups. Monocytes, NK, and both Low-Density (LD) and High-Density (HD) neutrophils were isolated from peripheral blood samples, and surface receptors' frequency and expression patterns were analyzed by flow cytometry. Clinical status and biochemical data were additionally evaluated. The frequency of monocytes was negatively correlated with BMI, while NK cells and HD neutrophils were positively associated (p < 0.05). Patients with obesity showed a significant reduction of monocytes, and these cells expressed high levels of PD-L1 (p < 0.05). A higher frequency of NK cells and increased expression of TREM-1+ on HD neutrophils were detected in obese patients (p < 0.05). The expression of receptors related to antigen-presentation, phagocytosis, chemotaxis, inflammation and suppression were strongly correlated with clinical markers only in obese patients (p < 0.05). Collectively, these outcomes revealed that obesity differentially affected, and largely depressed, innate immune response in severe COVID-19.

Obesity Is Associated with an Impaired Baseline Repertoire of Anti-Influenza Virus Antibodies

Obesity is a risk factor for severe disease and mortality for both influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While previous studies show that individuals with obesity generate antibody responses following influenza vaccination, infection rates within the obese group were twice as high as those in the healthy-weight group. The repertoire of antibodies raised against influenza viruses following previous vaccinations and/or natural exposures is referred to here as baseline immune history (BIH). To investigate the hypothesis that obesity impacts immune memory to infections and vaccines, we profiled the BIH of obese and healthy-weight adults vaccinated with the 2010-2011 seasonal influenza vaccine in response to conformational and linear antigens. Despite the extensive heterogeneity of the BIH profiles in both groups, there were striking differences between obese and healthy subjects, especially with regard to A/H1N1 strains and the 2009 pandemic virus (Cal09). Individuals with obesity had lower IgG and IgA magnitude and breadth for a panel of A/H1N1 whole viruses and hemagglutinin proteins from 1933 to 2009 but increased IgG magnitude and breadth for linear peptides from the Cal09 H1 and N1 proteins. Age was also associated with A/H1N1 BIH, with young individuals with obesity being more likely to have reduced A/H1N1 BIH. We found that individuals with low IgG BIH had significantly lower neutralizing antibody titers than individuals with high IgG BIH. Taken together, our findings suggest that increased susceptibility of obese participants to influenza infection may be mediated in part by obesity-associated differences in the memory B-cell repertoire, which cannot be ameliorated by current seasonal vaccination regimens. Overall, these data have vital implications for the next generation of influenza virus and SARS-CoV-2 vaccines. IMPORTANCE Obesity is associated with increased morbidity and mortality from influenza and SARS-CoV-2 infection. While vaccination is the most effective strategy for preventing influenza virus infection, our previous studies showed that influenza vaccines fail to provide optimal protection in obese individuals despite reaching canonical correlates of protection. Here, we show that obesity may impair immune history in humans and cannot be overcome by seasonal vaccination, especially in younger individuals with decreased lifetime exposure to infections and seasonal vaccines. Low baseline immune history is associated with decreased protective antibody responses. Obesity potentially handicaps overall responses to vaccination, biasing it toward responses to linear epitopes, which may reduce protective capacity. Taken together, our data suggest that young obese individuals are at an increased risk of reduced protection by vaccination, likely due to altered immune history biased toward nonprotective antibody responses. Given the worldwide obesity epidemic coupled with seasonal respiratory virus infections and the inevitable next pandemic, it is imperative that we understand and improve vaccine efficacy in this high-risk population. The design, development, and usage of vaccines for and in obese individuals may need critical evaluation, and immune history should be considered an alternate correlate of protection in future vaccine clinical trials.

Implications of obesity and adiposopathy on respiratory infections; focus on emerging challenges

Obesity is characterized by excessive adipose tissue accumulation, which impacts physiological, metabolic, and immune functions. Several respiratory infections, including bacterial pneumonia, influenza, and coronavirus disease 2019, appear to be linked to unfavorable results in individuals with obesity. These may be attributed to the direct mechanical/physiological effects of excess body fat on the lungs’ function. Notably, adipose tissue dysfunction is associated with a low-grade chronic inflammatory status and hyperleptinemia, among other characteristics. These have all been linked to immune system dysfunction and weakened immune responses to these infections. A better understanding and clinical awareness of these risk factors are necessary for better disease outcomes.

Evolution of SARS-CoV-2 Variants: Implications on Immune Escape, Vaccination, Therapeutic and Diagnostic Strategies

The COVID-19 pandemic caused by SARS-CoV-2 is associated with a lower fatality rate than its SARS and MERS counterparts. However, the rapid evolution of SARS-CoV-2 has given rise to multiple variants with varying pathogenicity and transmissibility, such as the Delta and Omicron variants. Individuals with advanced age or underlying comorbidities, including hypertension, diabetes and cardiovascular diseases, are at a higher risk of increased disease severity. Hence, this has resulted in an urgent need for the development of better therapeutic and preventive approaches. This review describes the origin and evolution of human coronaviruses, particularly SARS-CoV-2 and its variants as well as sub-variants. Risk factors that contribute to disease severity and the implications of co-infections are also considered. In addition, various antiviral strategies against COVID-19, including novel and repurposed antiviral drugs targeting viral and host proteins, as well as immunotherapeutic strategies, are discussed. We critically evaluate strategies of current and emerging vaccines against SARS-CoV-2 and their efficacy, including immune evasion by new variants and sub-variants. The impact of SARS-CoV-2 evolution on COVID-19 diagnostic testing is also examined. Collectively, global research and public health authorities, along with all sectors of society, need to better prepare against upcoming variants and future coronavirus outbreaks.

COVID-19 and liver injury in individuals with obesity

Coronavirus disease 2019 is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 that manifests as a variety of clinical manifestations, including liver damage commonly detected by a hepatocellular pattern from liver function tests. Liver injury is associated with a worse prognosis overall. Conditions associated with the severity of the disease include obesity and cardiometabolic comorbidities, which are also associated with nonalcoholic fatty liver disease (NAFLD). The presence of NAFLD, similarly to obesity, is associated with an unfavourable impact on the coronavirus disease 2019 outcome. Individuals with these conditions could present with liver damage and elevated liver function tests due to direct viral cytotoxicity, systemic inflammation, ischemic or hypoxic liver damage or drug side effects. However, liver damage in the setting of NAFLD could also be attributed to a pre-existing chronic low-grade inflammation associated with surplus and dysfunctional adipose tissue in these individuals. Here we investigate the hypothesis that a pre-existing inflammatory status is exacerbated after severe acute respiratory syndrome coronavirus 2 infection, which embodies a second hit to the underestimated liver damage.

Do Body Mass Index and Nutritional Risk Score 2002 Influence the In-Hospital Mortality of Patients Following Cardiac Arrest?

BACKGROUND

Contemporarily, cardiac arrest (CA) remains one of the leading causes of death. Poor nutritional status can increase the post-CA mortality risk. The aim of this study was to determine the relationship between body mass index (BMI) and Nutritional Risk Score 2002 (NRS 2002) results and in-hospital mortality in patients admitted to the intensive care unit (ICU) after in-hospital and out-of-hospital cardiac arrest.

METHODS

A retrospective study and analysis of medical records of 161 patients admitted to the ICU of the University Clinical Hospital in Wrocław (Wrocław, Poland) was conducted.

RESULTS

No significant differences in body mass index (BMI) and nutritional risk score (NRS 2002) values were observed between non-survivors and survivors. Non-survivors had significantly lower albumin concentration (p = 0.017) and total cholesterol (TC) (p = 0.015). In multivariate analysis BMI and NRS 2002 scores were not, per se, associated with the in-hospital mortality defined as the odds of death (Model 1: p: 0.700, 0.430; Model 2: p: 0.576, 0.599). Univariate analysis revealed significant associations between the hazard ratio (HR) and TG (p ≈ 0.017, HR: 0.23) and hsCRP (p ≈ 0.018, HR: 0.34). In multivariate analysis, mortality risk over time was influenced by higher scores in parameters such as BMI (HR = 0.164; p = 0.048) and hsCRP (HR = 1.006, p = 0.002).

CONCLUSIONS

BMI and NRS 2002, on their own (unconditionally - in the whole study group) did not alter the odds of mortality in patients admitted to the intensive care unit (ICU) after in-hospital and out-of-hospital cardiac arrest. The risk of in-hospital mortality (expressed as hazard ratio - the risk over the time period of the study) increased with an increase in BMI but not with NRS 2002.

COVID-19: Has the Liver Been Spared?

The liver is a secondary and often collateral target of COVID-19 disease but can lead to important consequences. COVID-19 might directly cause a high number of complications in patients with pre-existing chronic liver disease, increasing their risk of hepatic decompensation. Moreover, it also determines indirect consequences in the management of patients with liver disease, especially in those suffering from decompensated cirrhosis and HCC, as well as in the execution of their follow-up and the availability of all therapeutic possibilities. Liver imaging in COVID-19 patients proved to be highly nonspecific, but it can still be useful for identifying the complications that derive from the infection. Moreover, the recent implementation of telemedicine constitutes a possible solution to both the physical distancing and the re-organizational difficulties arising from the pandemic. The present review aims to encompass the currently hypothesized pathophysiological mechanisms of liver injury in patients with COVID-19 mediated by both the direct invasion of the virus and its indirect effects and analyze the consequence of the pandemic in patients with chronic liver disease and liver tumors, with particular regard to the management strategies that have been implemented to face this worldwide emergency and that can be further improved.

NMR-Metabolomics in COVID-19 Research

COVID-19 stands for Corona Virus Disease 2019, which starts as a viral infection that provokes illness with different symptoms and severity. The infected individuals can be asymptomatic or present with mild, moderate, severe, and critical illness with acute respiratory distress syndrome (ARDS), acute cardiac injury, and multiorgan failure. When the virus enters the cells, it replicates and provokes responses. Most diseased individuals resolve the problems in a short time but unfortunately, some may die, and almost 3 years after the first reported cases, COVID-19 still kills thousands per day worldwide. One of the problems in not curing the viral infection is that the virus passes by undetected in cells. This can be caused by the lack of pathogen-associated molecular patterns (PAMPs) that start an orchestrated immune response, such as activation of type 1 interferons (IFNs), inflammatory cytokines, chemokines, and antiviral defenses. Before all of these events can happen, the virus uses the infected cells and numerous small molecules as sources of energy and building blocks for newly synthesized viral nanoparticles that travel to and infect other host cells. Therefore, studying the cell metabolome and metabolomic changes in biofluids might give insights into the state of the viral infection, viral loads, and defense response. NMR-metabolomics can help in solving the real-time host interactions by monitoring concentration changes in metabolites. This chapter addresses the state of the art of COVIDomics by NMR analyses and presents exemplified biomolecules identified in different world regions and gravities of illness as potential biomarkers.

Epicardial adipose tissue volume and CT-attenuation as prognostic factors for pulmonary embolism and mortality in critically ill patients affected by COVID-19

BACKGROUND/OBJECTIVES

The aim of this post-hoc analysis was to evaluate if epicardial adipose tissue (EAT) quantity and quality, as evaluated by computed tomography (CT), have a different role in the risk of mortality and pulmonary embolism in critically ill COVID-19 patients admitted to an intensive care unit (ICU).

SUBJECTS/METHODS

CT derived EAT volume and density, as well as anthropometric and blood biomarkers, were evaluated in a sample of 138 subjects, 109 men and 29 women, for whom CT images and information on pulmonary embolism were available from a total of 313 subjects who were consecutively admitted to the ICU for COVID-19 from the REINSURE-ARDS prospective registry.

RESULTS

A total of 28 patients (20.3%) died during the first 28 days after ICU admission. 26 subjects out of 138 had pulmonary embolism (18.8%). Age, weight, BMI, IL-6 levels and pulmonary embolism prevalence were significantly higher across EAT volume tertiles. Subjects who died in the first 28 days from ICU admission were older, had higher EAT volume, D-dimer, LDH and IL-6 level. After adjustment for age and gender, participants in tertile 3 of EAT volume had lower survival at 28 days from ICU admission as compared to subjects in the tertile 1, HR 2.95 (95% C.I. 1.02-8.49), but after adjusting for potential confounders the relation was no longer significant. No relation between EAT density and mortality was observed. From a binary logistic regression, subjects in tertile 3 of EAT volume and in tertile 1 of EAT density showed a 4 times and 3.6 times increased risk of pulmonary embolism, respectively.

CONCLUSIONS

ICU subjects affected by severe COVID-19 with higher EAT volume and low EAT density should be carefully monitored and managed with a prompt and aggressive approach, to prevent serious and life-threatening consequences and the increase of hospital treatment costs.

Leukocyte metabolism in obese type 2 diabetic individuals associated with COVID-19 severity

Recent studies show that the metabolic characteristics of different leukocytes, such as, lymphocytes, neutrophils, and macrophages, undergo changes both in the face of infection with SARS-CoV-2 and in obesity and type 2 diabetes mellitus (DM2) condition. Thus, the objective of this review is to establish a correlation between the metabolic changes caused in leukocytes in DM2 and obesity that may favor a worse prognosis during SARS-Cov-2 infection. Chronic inflammation and hyperglycemia, specific and usual characteristics of obesity and DM2, contributes for the SARS-CoV-2 replication and metabolic disturbances in different leukocytes, favoring the proinflammatory response of these cells. Thus, obesity and DM2 are important risk factors for pro-inflammatory response and metabolic dysregulation that can favor the occurrence of the cytokine storm, implicated in the severity and high mortality risk of the COVID-19 in these patients.

SARS-CoV-2 and Influenza Vaccines in People with Excessive Body Mass-A Narrative Review

In the face of a growing number of overweight people and two widely known viral diseases, SARS-CoV-2 and influenza, it is crucial to be aware of the impact of excess body weight on immunisation against these diseases. The aim of this review is to show the effectiveness of SARS-CoV-2 and influenza vaccines in overweight and obese patients. Excessive adipose tissue releases cytokines and maintains local hypoxia, which causes persistent low-grade inflammation. These factors make excess body mass patients' immune systems weaker. Under such conditions, the humoral response becomes less efficient, leading to a weakened ability to fight against infection and an increased risk of developing lower antibody titres. Vaccines help to reduce morbidity both in normal-weight and excess body mass people, although most studies show that patients with higher BMI tend to lose the antibodies produced more quickly. It is shown that the most effective vaccines (in terms of preventing the infection and potential post-illness complications) are the BNT162b2 vaccine against SARS-CoV-2 and the inactivated influenza vaccine against influenza among both obese and non-obese subjects.

Obesity and Coronavirus Disease 2019

The coronavirus disease 2019 (COVID-19) pandemic has brought severe challenges to global public health. Many studies have shown that obesity plays a vital role in the occurrence and development of COVID-19. Obesity exacerbates COVID-19, leading to increased intensive care unit hospitalization rate, high demand for invasive mechanical ventilation, and high mortality. The mechanisms of interaction between obesity and COVID-19 involve inflammation, immune response, changes in pulmonary dynamics, disruptions of receptor ligands, and dysfunction of endothelial cells. Therefore, for obese patients with COVID-19, the degree of obesity and related comorbidities should be evaluated. Treatment methods such as administration of anticoagulants and anti-inflammatory drugs like glucocorticoids and airway management should be actively initiated. We should also pay attention to long-term prognosis and vaccine immunity and actively address the physical and psychological problems caused by longterm staying-at-home during the pandemic. The present study summarized the research to investigate the role of obesity in the incidence and progression of COVID-19 and the psychosocial impact and treatment options for obese patients with COVID-19, to guide the understanding and management of the disease.

Bothrops moojeni snake venom induces an inflammatory response in preadipocytes: Insights into a new aspect of envenomation

Bothrops envenomation is a public health problem in Brazil. Despite the advances in the knowledge of the pathogenesis of systemic and local effects induced by Bothrops venom, the target tissues to this venom are not completely characterised. As preadipocytes are important cells of the adipose tissue and synthesize inflammatory mediators, we investigated the ability of B. moojeni snake venom (Bmv) to stimulate an inflammatory response in 3T3-L1 preadipocytes in vitro, focusing on (1) the release of PGE2, IL-6, TNF-α, MCP-1, KC, leptin and adiponectin; (2) the mechanisms involved in PGE2 release and (3) differentiation of these cells. Cytotoxicity of Bmv was determined by MTT assay. The concentrations of PGE2, cytokines and adipokines were quantified by EIA. Participation of the COX-1 and COX-2 enzymes, NF-κB and PGE2 receptors (EP1-4) was assessed using a pharmacological approach, and protein expression of the COX enzymes and P-NF-κB was analysed by western blotting. Preadipocyte differentiation was quantified by Oil Red O staining. Bmv (1 μg/mL) induced release of PGE2, IL-6 and KC and increased expression of COX-2 in preadipocytes. Basal levels of TNF-α, MCP-1, leptin and adiponectin were not modified. Treatment of cells with SC560 (COX-1 inhibitor) and NS398 (COX-2 inhibitor) inhibited Bmv-induced PGE2 release. Bmv induced phosphorylation of NF-κB, and treatment of the cells with TPCK and SN50, which inhibit distinct NF-κB domains, significantly reduced Bmv-induced PGE2 release, as did the treatment with an antagonist of PGE2 receptor EP1, unlike treatment with antagonists of EP2, EP3 or EP4. Bmv also induced lipid accumulation in differentiating cells. These results demonstrate that Bmv can activate an inflammatory response in preadipocytes by inducing the release of inflammatory mediators; that PGE2 production is mediated by the COX-1, COX-2 and NF-κB pathways; and that engagement of EP1 potentiates PGE2 synthesis via a positive feedback mechanism. Our findings highlight the role of the adipose tissue as another target for Bmv and suggest that it contributes to Bothrops envenomation by producing inflammatory mediators.

Evaluation of Hematologic Parameters in Patients with COVID-19 Following Mesenchymal Stem Cell Therapy

At present, severe acute respiratory syndrome coronavirus 2 is spreading and has caused over 188 million confirmed patients and more than 4,059,101 deaths. Currently, several clinical trials are done using mesenchymal stem cell (MSC) therapy in patients with coronavirus disease 2019 (COVID-19). These cells have shown safety and effectiveness, implying a promising clinical application in patients with COVID-19. Studies have shown that abnormalities in hematological measures such as white blood cells count, neutrophilia, elevated neutrophil to lymphocyte ratio, inflammatory markers, and lactate dehydrogenase can be used to assess the severity of COVID-19 disease and the response to therapy following MSC treatment. Our study has aimed to review the role of hematological factors in determination of responsiveness to MSC therapy and disease severity in COVID-19 patients.

Obesity and Infection: What Have We Learned From the COVID-19 Pandemic

Objective

The critical role played by the nutritional status in the complications, duration of hospitalization and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) has emerged from several research studies in diverse populations. Obesity has been associated with an increased risk of serious complications, as the adipose tissue appears to have significant effects on the immune response. The aim of this narrative review was to investigate the relationship between COVID-19 and obesity.

Methods

We performed a review of papers in the English language derived from PubMed, Science Direct, and Web of Science. The primary outcomes investigated were the severity of the disease, admission to the intensive care unit (ICU), need for intubation, and mortality.

Results and Conclusion

Review of 44 eligible studies from 18 countries around the world revealed evidence that obesity increases the risk of severe COVID-19 complications, ICU admission, intubation and mortality. Patients with a higher body mass index (BMI) appear to be more vulnerable to SARS-CoV-2 infection, with more severe illness requiring admission to ICU and intubation, and to have higher mortality. A healthy body weight should be targeted as a long-term prevention measure against acute complications of infection, and in the event of COVID-19, overweight and obese patients should be monitored closely.

Reviving the mutual impact of SARS-COV-2 and obesity on patients: From morbidity to mortality

Obesity-related metabolic dysfunction, endothelium imbalance, chronic inflammation, immune dysregulation, and its comorbidities may all have a role in systemic inflammation, leading to the pulmonary fibrosis and cytokine storm, which leads to failure of lung function, which is a hallmark of severe SARS-CoV-2 infection. Obesity may also disrupt the function of mucociliary escalators and cooperation of epithelial cell's motile cilia in the airway, limiting the clearance of the coronavirus that causes severe acute respiratory syndrome (SARS-CoV-2). Adipose tissues in obese patients have a greater number of proteases and receptors for SARS-CoV-2 admittance, proposing that they could serve as an accelerator and reservoir for this virus, boosting immunological response and systemic inflammation. Lastly, anti-inflammatory cytokines such as anti-IL-6 and the infusion of mesenchymal stem cells could be used as a modulation therapy of immunity to help COVID-19 patients. Obesity, on the other hand, is linked to the progress of COVID-19 through a variety of molecular pathways, and obese people are part of the SARS-CoV-2 susceptible individuals, necessitating more protective measures.

Increased body mass index linked to decreased neutralizing antibody titers of inactivated SARS-CoV-2 vaccine in healthcare workers

Objective

Obesity is an important risk factor for COVID-19. However, whether obesity affects SARS-CoV-2 antibody production is unclear. This study aimed to identify the influence of obesity on neutralizing antibody production of an inactivated SARS-CoV-2 vaccine to better guide vaccination strategies.

Methods

This cross-sectional study recruited a total of 239 healthcare workers (age, 21-50 years) from Suining Central Hospital during 22-23 April 2021. An electronic questionnaire on basic characteristics was completed by all participants. A general physical exam and fasting blood sampling by venipuncture were performed. Peripheral leukocyte counts and the ratios of leukocyte subsets, hepatorenal function, and the neutralizing antibody titers against SARS-CoV-2 were measured.

Results

Among 239 healthcare workers, the participants with underweight, normal weight, overweight, and obesity accounted for 10.88%, 64.44%, 23.01%, and 1.67%, respectively. The highest peripheral monocyte counts were observed in the group with obesity, whereas the lowest were observed in the group with normal weight. Similar results were obtained with respect to percentage of peripheral monocytes. Participants with obesity had higher peripheral eosinophil counts and percentages than the other three groups. The median neutralizing antibody titer was 12.70 AU/mL, with 85.36% (n = 204) of participants were sufficiently protected against SARS-CoV-2. The lowest neutralizing antibody titers were observed in the group with obesity, whereas the highest were observed in the group that was underweight. Additionally, high BMI was significantly associated with high peripheral monocyte counts [B (95% CI) = 0.008 (0.002, 0.013)] and low neutralizing antibody titers [B (95% CI) = -1.934 (-3.663, -0.206)].

Conclusions

Obesity could induce chronic inflammation, and associated with lower neutralizing antibody titers against SARS-CoV-2 after inactivated SARS-CoV-2 vaccination.

Long COVID: A New Challenge for Prevention of Obesity in Women

The long COVID affects individuals that do not recover for several weeks or months following the onset of symptoms of COVID-19. Obesity could play a role in the long COVID syndrome. During the pandemic, various factors contributed greatly to aggravating obesity in women leading to a pro-inflammatory and prothrombotic status. The present commentary explores the relationship between long COVID and obesity in women.

Detection of SARS-CoV-2 in subcutaneous fat but not visceral fat, and the disruption of fat lymphocyte homeostasis in both fat tissues in the macaque

The well documented association between obesity and the severity of SARS-CoV-2 infection raises the question of whether adipose tissue (AT) is impacted during this infection. Using a model of SARS-CoV-2 infection in cynomolgus macaques, we detected the virus within subcutaneous AT (SCAT) but not in visceral AT (VAT) or epicardial AT on day 7 post-infection. We sought to determine the mechanisms responsible for this selective detection and observed higher levels of angiotensin-converting-enzyme-2 mRNA expression in SCAT than in VAT. Lastly, we evaluated the immunological consequences of SARS-CoV-2 infection on AT: both SCAT and VAT T cells showed a drastic reduction in CD69 expression, a standard marker of resident memory T cell in tissue, that is also involved in the migratory and metabolic properties of T cells. Our results demonstrate that in a model of mild infection, SCAT is selectively infected by SARS-CoV-2 although changes in the immune properties of AT are observed in both SCAT and VAT.

Subcutaneous fat tissue expresses higher angiotensin-converting-enzyme 2 mRNA than visceral fat tissue and is selectively infected by SARS-Cov-2, while both fat tissues show drastic reduction in CD69 expression in T cells.

Re-Do Surgery after Sleeve Gastrectomy: A Single Center Comparison between Roux-en-Y Gastric Bypass and One Anastomosis Gastric Bypass

Introduction: According to the high rate of patients requiring a Re-Do surgery after a primary Sleeve Gastrectomy, due to failure on weight loss, this study proposes a comparison between RYGB and OAGB as a secondary intervention for morbidly obese patients. Methods: A retrospective review of patients who underwent revisional surgery to convert SG to RYGB or OAGB at our institution from November 2011 to November 2019 was performed. Results: A subset of sixty-three patients with previous SG underwent revisional surgery due to failure of the primary intervention. The OAGB group (n = 17) had a mean BMI at the time of the sleeve of 62 kg/m2 and a mean BMI of 50.7 kg/m2, the length of the Omega was 139.35 cm. The RYGB (n = 46) group showed a mean BMI of 47 kg/m2 at the time of the sleeve and a BMI of 34.8 kg/m2 at the time of the revision. The RYGB was performed according to the 70/120 cm standard for all the patients. One patient also had a revision from secondary OAGB to RYGB due to persistent biliary reflux, in this case the biliary branch was settled at 150 cm and the alimentary at 50 cm. Conclusions: The outcomes in the OAGB group showed a 29%WL and a 47%EWL (out of a 17%WL and 28%EWL at the time of the sleeve), on the other side the RYGB group reached a 33%WL and 72%EWL (out of a 25%WL and a 54%EWL at the time of the sleeve). According to our data we assume that RYGB is more effective in terms of weight loss as a revisional surgery after sleeve

Respiratory and nonrespiratory COVID-19 complications in patients with obesity: recent developments

This narrative review summarizes recent reports to provide an updated understanding of the multiorgan effects of SARS-CoV-2 infection in obese individuals. A PubMed search of 528 primary articles was performed, with inclusion based on novelty, relevance and redundancy. Obesity confers an increased risk for hospitalization, intensive care unit admission, severe pneumonia, intubation and acute kidney injury in COVID-19 patients. Obesity is also associated with higher levels of inflammatory and thrombotic markers. However, the associations between obesity and mortality or cardiac injury in COVID-19 patients remain unclear. Obesity is a risk factor for several respiratory and nonrespiratory COVID-19 complications. Future work is needed to further explore these relationships and optimize the management of obese COVID-19 patients.

Polycystic ovary syndrome and risks for COVID-19 infection: A comprehensive review : PCOS and COVID-19 relationship

This comprehensive review aimed to evaluate the relationship between SARS-CoV-2 infection (the cause of coronavirus disease 2019, or COVID-19) and the metabolic and endocrine characteristics frequently found in women with polycystic ovary syndrome (PCOS). In the general population, COVID-19 is more severe in subjects with dyslipidemia, obesity, diabetes mellitus, and arterial hypertension. Because these conditions are comorbidities commonly associated with PCOS, it was hypothesized that women with PCOS would be at higher risk for acquiring COVID-19 and developing more severe clinical presentations. This hypothesis was confirmed in several epidemiological studies. The present review shows that women with PCOS are at 28%-50% higher risk of being infected with the SARS-CoV-2 virus at all ages and that, in these women, COVID-19 is associated with increased rates of hospitalization, morbidity, and mortality. We summarize the mechanisms of the higher risk of COVID-19 infection in women with PCOS, particularly in those with carbohydrate and lipid abnormal metabolism, hyperandrogenism, and central obesity.

Basic mechanisms of SARS-CoV-2 infection. What endocrine systems could be implicated?

Although SARS-CoV-2 viral attacks starts by the interaction of spike protein (S Protein) to ACE2 receptor located at the cell surface of respiratory tract and digestive system cells, different endocrine targets, endocrine organs and metabolic conditions are of fundamental relevance for understanding disease progression and special outcomes, in particular those of fatal consequences for the patient. During pandemic, moreover, a specific phenotype of COVID-19 metabolic patient has been described, characterized by being at particular risk of worse outcomes. In the present paper we describe the mechanism of viral interaction with endocrine organs, emphasizing the specific endocrine molecules of particular relevance explaining COVID-19 disease evolution and outcomes.

Aging versus youth: Endocrine aspects of vulnerability for COVID-19

Coronavirus Disease 2019 (COVID-19) is characterized with a wide range of clinical presentations from asymptomatic to severe disease. In patients with severe disease, the main causes of mortality have been acute respiratory distress syndrome, cytokine storm and thrombotic events. Although all factors that may be associated with disease severity are not yet clear, older age remains a leading risk factor. While age-related immune changes may be at the bottom of severe course of COVID-19, age-related hormonal changes have considerable importance due to their interactions with these immune alterations, and also with endothelial dysfunction and comorbid cardiometabolic disorders. This review aims to provide the current scientific evidence on the pathogenetic mechanisms underlying the pathway to severe COVID-19, from a collaborative perspective of age-related immune and hormonal changes together, in accordance with the clinical knowledge acquired thus far.

ASSOCIATION BETWEEN UNDERWEIGHT AND EXCESS BODY WEIGHT BEFORE SARS-COV-2 INFECTION AND CLINICAL OUTCOMES OF COVID-19: MULTICENTER STUDY

Objectives

The present study aimed to identify associations between extremes in body weight status (underweight and excess body weight) before a COVID-19 diagnosis and clinical outcomes in patients infected with SARS coronavirus type 2.

Methods

A multicenter cohort study was conducted in eight different states in northeastern Brazil. Demographic, clinical (previous diagnosis of comorbidities), and anthropometric (self-reported weight and height) data about individuals who tested positive for COVID-19 were collected. Outcomes included hospitalization, mechanical ventilation, and death. Multivariable logistic regression models, adjusted based on age, sex and previous comorbidities, were used to assess the effects of extremes in body weight status on clinical outcomes.

Results

A total of 1308 individuals were assessed (33.6% were elderly individuals). The univariable analyses showed that only hospitalization was more often observed among underweight (3.2% versus 1.2%) and overweight (68.1% versus 63.3%) individuals. In turn, cardiovascular diseases were more often observed in all clinical outcomes (hospitalization: 19.7% versus 4.8%; mechanical ventilation: 19.9% versus 13.5%; death: 21.8% versus 14.1%). Based on the multivariable analysis, body weight status was not associated with risk of hospitalization (underweight: odds ratio [OR]: 1.10; 95% confidence interval [CI] 95%, 0.50–2.41 and excess body weight: OR: 0.81; 95 CI, 0.57–1.14), mechanical ventilation (underweight: OR: 0.92; 95% CI, 0.52–1.62 and excess weight: OR: 0.90; 95% CI, 0.67–1.19), and death (underweight: OR: 0.61; 95% CI, 0.31–1.20 and excess body weight: OR 0.88; 95% CI, 0.63–1.23).

Conclusions

Being underweight and excess body weight were not independently associated with clinical outcomes in patients with COVID-19 in the herein analyzed cohort. This finding indicates that the association between these variables may be confounded by both age and comorbidities.

The Immune Response to SARS-CoV-2: Mechanisms, Aging, Sequelae and Vaccines

This review seeks to clarify the factors involved in the various immune responses to SARS-CoV-2 infection and the mechanisms that influence the development of COVID-19 with severe evolution. The innate immune response that evolves against SARS-CoV-2 in a complex way is highlighted, integrating multiple pathways by coronaviruses to evade it, in addition to characterizing the adaptive immune response, which can lead to an effective immune response or can contribute to immunopathological imbalance. In turn, host-dependent biomarkers such as age, gender, ABO blood group, and risk factors that contribute to the critical and varied progress of COVID-19 immunopathogenesis were analyzed. Finally, the potential vaccine candidates are presented, capable of generating immune protection with humoral and/or cellular neutralizing responses, in favor of blocking and destroying both the new human coronavirus and its variants, which cause the current pandemic.

The impact of obesity on hospitalized patients with COVID-19 infection in the Eastern Province of Saudi Arabia

This study aimed to assess the association of obesity with the severity and outcome of COVID-19 infection. A retrospective observational study was performed from March to September 2020 in Saudi Arabia. Baseline and laboratory data were collected from the inpatient health record system. The cohort was divided into three groups based on body mass index. Following this, the severity and outcome of COVID-19 disease were analyzed between the three groups. Of the 502 COVID-19 cases included, 244 (48.5%) were obese. Obesity was significantly associated with severe (53.5%) or critical (28%) COVID-19 infection (P<0.001) and a higher need for ICU admission (35.8%, P=0.034). Multivariate analysis showed that overweight/obesity was an independent risk factor of severe (P<0.001) as well as critical COVID-19 infection (P=0.026, respectively) and a predictor of a higher risk of ICU admission (P=0.012). Class I obesity was associated with severe-critical COVID-19 disease (33.6%, P=0.042) compared to other obesity classes. Obesity is an independent risk factor for severe-critical COVID-19 infection and a higher risk of ICU admission. Clinicians should give special attention to such populations and prioritize vaccination programs to improve outcomes.

Why should obese youth be prioritized in COVID-19 vaccination programs? A nationwide retrospective study

Background

The dominant effect of age on COVID-19 mortality obscures the impact of other risk factors. Although the elderly is at a greater risk of severe disease and death due to COVID-19, the interaction of obesity and age was not carefully assessed. This analysis is especially critical for prioritizing groups to receive COVID-19 vaccination.

Methods

Starting with 1,120,767 unvaccinated individuals registered in a Brazilian surveillance system, we selected 313,898 hospitalized COVID-19 patients aged 20 to 89 who had a BMI ≥ 25 kg/m² and cardiovascular diseases (CVD) or diabetes, as well as individuals with no risk factors associated with severe COVID-19. Patient data were stratified by age, obesity, BMI, and comorbidities, and subsequently, subjected to crude and adjusted odds ratio, hazard ratio, and Kaplan–Meier curves. Disease outcomes were invasive and non-invasive ventilatory support, intensive care unit (ICU) admission, and death.

Findings

Obesity alone is a risk factor for in-hospital mortality and is more significant than cardiovascular disease and diabetes. Furthermore, obesity, cardiovascular disease, and diabetes increase the risk of severity and death by COVID-19 more significantly in young adults than in the elderly. When categorizing patients by obesity classes, the severity of obesity was found to be associated with a higher risk of admission to the ICU and death from COVID-19 than the non-obese young adults or elderly population.

Interpretation

Our findings highlight the increased risk of severe COVID-19 on the Brazilian obese youth. As SARS-CoV-2 may become a recurrent seasonal infection, future vaccination campaigns against COVID-19 should prioritize obese young individuals.

Fundings

This work was supported by the Brazilian National Council for Scientific and Technological Development (grant number 313662/2017-7 and 307356/2017-5; the São Paulo Research Foundation (grant numbers 2018/14933-2); and CAPES.

Evaluating Possible Mechanisms Linking Obesity to COVID-19: a Narrative Review

Currently, pneumonia caused by the coronavirus disease 2019 (COVID-19) is a pandemic. To date, there is no specific antiviral treatment for the disease, and universal access to the vaccine is a serious challenge. Some observational studies have shown that COVID-19 is more common in countries with a high prevalence of obesity and that people with COVID-19 have a higher body mass index. In these studies, obesity increased the risk of disease, as well as its severity and mortality. This study aimed to review the mechanisms that link obesity to COVID-19.

Mechanisms contributing to adverse outcomes of COVID-19 in obesity

A growing amount of epidemiological data from multiple countries indicate an increased prevalence of obesity, more importantly central obesity, among hospitalized subjects with COVID-19. This suggests that obesity is a major factor contributing to adverse outcome of the disease. As it is a metabolic disorder with dysregulated immune and endocrine function, it is logical that dysfunctional metabolism contributes to the mechanisms behind obesity being a risk factor for adverse outcome in COVID-19. Emerging data suggest that in obese subjects, (a) the molecular mechanisms of viral entry and spread mediated through ACE2 receptor, a multifunctional host cell protein which links to cellular homeostasis mechanisms, are affected. This includes perturbation of the physiological renin-angiotensin system pathway causing pro-inflammatory and pro-thrombotic challenges (b) existent metabolic overload and ER stress-induced UPR pathway make obese subjects vulnerable to severe COVID-19, (c) host cell response is altered involving reprogramming of metabolism and epigenetic mechanisms involving microRNAs in line with changes in obesity, and (d) adiposopathy with altered endocrine, adipokine, and cytokine profile contributes to altered immune cell metabolism, systemic inflammation, and vascular endothelial dysfunction, exacerbating COVID-19 pathology. In this review, we have examined the available literature on the underlying mechanisms contributing to obesity being a risk for adverse outcome in COVID-19.

Understanding the Link Between Obesity and Severe COVID-19 Outcomes: Causal Mediation by Systemic Inflammatory Response

BACKGROUND

Obesity is an established risk factor for severe COVID-19 outcomes. The mechanistic underpinnings of this association are not well-understood.

OBJECTIVE

To evaluate the mediating role of systemic inflammation in obesity-associated COVID-19 outcomes.

METHODS

This hospital-based, observational study included 3828 SARS-CoV-2-infected patients who were hospitalized February to May 2020 at Massachusetts General Hospital (MGH) or Columbia University Irving Medical Center/New York Presbyterian Hospital (CUIMC/NYP). We use mediation analysis to evaluate whether peak inflammatory biomarkers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], D-dimer, ferritin, white blood cell count and interleukin-6) are in the causal pathway between obesity (BMI ≥ 30) and mechanical ventilation or death within 28 days of presentation to care.

RESULTS

In the MGH cohort (n = 1202), obesity was associated with greater likelihood of ventilation or death (OR = 1.73; 95% CI = [1.25, 2.41]; P = 0.001) and higher peak CRP (P < 0.001) compared with nonobese patients. The estimated proportion of the association between obesity and ventilation or death mediated by CRP was 0.49 (P < 0.001). Evidence of mediation was more pronounced in patients < 65 years (proportion mediated = 0.52 [P < 0.001] vs 0.44 [P = 0.180]). Findings were more moderate but consistent for peak ESR. Mediation by other inflammatory markers was not supported. Results were replicated in CUIMC/NYP cohort (n = 2626).

CONCLUSION

Findings support systemic inflammatory pathways in obesity-associated severe COVID-19 disease, particularly in patients < 65 years, captured by CRP and ESR. Contextualized in clinical trial findings, these results reveal therapeutic opportunity to target systemic inflammatory pathways and monitor interventions in high-risk subgroups and particularly obese patients.

Obesity as a mortality risk factor in the medical ward: a case control study

BACKGROUND

Research regarding the association between severe obesity and in-hospital mortality is inconsistent. We evaluated the impact of body mass index (BMI) levels on mortality in the medical wards. The analysis was performed separately before and during the COVID-19 pandemic.

METHODS

We retrospectively retrieved data of adult patients admitted to the medical wards at the Mount Sinai Health System in New York City. The study was conducted between January 1, 2011, to March 23, 2021. Patients were divided into two sub-cohorts: pre-COVID-19 and during-COVID-19. Patients were then clustered into groups based on BMI ranges. A multivariate logistic regression analysis compared the mortality rate among the BMI groups, before and during the pandemic.

RESULTS

Overall, 179,288 patients were admitted to the medical wards and had a recorded BMI measurement. 149,098 were admitted before the COVID-19 pandemic and 30,190 during the pandemic. Pre-pandemic, multivariate analysis showed a "J curve" between BMI and mortality. Severe obesity (BMI > 40) had an aOR of 0.8 (95% CI:0.7-1.0, p = 0.018) compared to the normal BMI group. In contrast, during the pandemic, the analysis showed a "U curve" between BMI and mortality. Severe obesity had an aOR of 1.7 (95% CI:1.3-2.4, p < 0.001) compared to the normal BMI group.

CONCLUSIONS

Medical ward patients with severe obesity have a lower risk for mortality compared to patients with normal BMI. However, this does not apply during COVID-19, where obesity was a leading risk factor for mortality in the medical wards. It is important for the internal medicine physician to understand the intricacies of the association between obesity and medical ward mortality.

COVID-19 autopsy cases: detection of virus in endocrine tissues

PURPOSE

The SARS-CoV-2 genome has been detected in a variety of human samples including blood, urine, semen, and faeces. However, evidence of virus presence in tissues other than lung are limited.

METHODS

We investigated whether SARS-CoV-2 could be detected in 50 autoptic specimens of endocrine organs from 29 patients who died of COVID-19.

RESULTS

The virus was detected in 25 specimens including ten abdominal subcutaneous adipose tissue samples (62%), six testes (67%), and nine thyroid (36%) samples. The analysis of multiple endocrine organ samples obtained from the same patients showed that, in virus-positive cases, the viral genome was consistently detected in all but two matched specimens.

CONCLUSION

Our findings show that the virus spread into endocrine organs is a common event in severe cases. Further studies should assess the rate of the phenomenon in clinically mild cases. The potential long-term effects of COVID-19 on endocrine functions should be taken into consideration.

Patients with Post-Covid-19 Syndrome are at risk of malnutrition and obesity: findings of outpatient follow-up

ABSTRACT Objective To evaluate the nutritional and functional status, swallowing disorders, and musculoskeletal manifestations of patients with Post-Covid-19 Syndrome, stratified by the Appendicular Skeletal Muscle Mass Index. Methods This is a cross-sectional study with patients diagnosed with Post-Covid-19 Syndrome after discharge from the intensive care unit of a university hospital. The evaluated outcomes were: nutritional status (Mini Nutritional Assessment, bioimpedance and anthropometry), swallowing disorders (Dysphagia Risk Evaluation Protocol), functional status (Post-Covid-19 Functional Status Scale), and musculoskeletal manifestations. According to the Appendicular Skeletal Muscle Mass Index, patients were stratified in terms of loss or not loss of muscle mass. Results Thirty-eight patients were included in the study, 20 stratified into the no loss of muscle mass group (17 females; 49.45±12.67 years) and 18 into the loss of muscle mass group (18 males; 61.89±12.49 years). Both groups were at risk of malnutrition (Mini Nutritional Assessment scores between 17–23.5 points; No Loss of Muscle Mass Group: 21.82±3.93; Loss of Muscle Mass Group: 23.33±3.41) and obesity (No Loss of Muscle Mass Group: 33.76±6.34; Loss of Muscle Mass Group: 30.23±3.66). The groups differed in terms of bioimpedance parameters (except fat mass) and age. However, there were no differences in swallowing alterations, functional status, and musculoskeletal manifestations. Conclusion Patients with Post-Covid-19 Syndrome, stratified according to the Appendicular Skeletal Muscle Mass Index, were at risk of malnutrition and obesity. The persistence of fatigue, weakness, myalgia and arthralgia at 6 months after hospital discharge is noteworthy. These findings emphasize the importance of comprehensive care for patients with Post-Covid-19 Syndrome.

COVID-19 Outcome Relates With Circulating BDNF, According to Patient Adiposity and Age

Background and Aims: We evaluated adipose tissue-derived hormones, body composition, serum metabolic profile, levels of brain-derived neurotrophic factor (BDNF), and the association of these parameters with the clinical outcome in patients with COVID-19. We sought to examine whether obesity, sex, and age influence the adipose tissue endocrine response to the disease.

Methods: This prospective study investigated 145 hospitalized patients with COVID-19. Patients were categorized based on their body mass index (BMI), sex and age, and were also classified regarding their outcome after hospitalization as: (a) Non-ICU: patients hospitalized who did not receive intensive care; (b) ICU-survivor: patients admitted to the intensive care unit and discharged; (c) ICU-death: patients who died. Blood samples were collected by the hospital staff between the first and third day of hospitalization. Serum leptin, adiponectin and BDNF concentrations, triglycerides, total cholesterol and cholesterol fractions were performed following the manufacturer's guidelines.

Results: We demonstrate that BDNF levels predict intensive care (IC) need (p < 0.01). This association was found to be stronger in patients >60y (p = 0.026). Neither leptin nor adiponectin concentration was associated with IC requirement or with patient's outcome, while the BDNF/adiponectin ratio was closely associated with worsened outcomes (p < 0.01). BDNF concentration was similar between sexes, however tended to be lower in male patients (p = 0.023). In older patients, BDNF concentration was lower than that of younger patients (p = 0.020). These age and sex-specific differences should be considered when employing these potential markers for prognosis assessment. While appetite and body composition regulating hormones secreted by the white adipose tissue are not reliable predictors of disease severity, the ratio BDNF/adiponectin was indicative of patient status.

Conclusion: Thus, we propose that serum BDNF content and BDNF/adiponectin ratio may serve as tools predicting worsened prognosis in COVID-19, especially for male patients.

Impact of visceral fat on the prognosis of coronavirus disease 2019: an observational cohort study

Background

Clarification of the risk factors for coronavirus disease 2019 (COVID-19) severity is strongly warranted for global health. Recent studies have indicated that elevated body mass index (BMI) is associated with unfavorable progression of COVID-19. This is assumed to be due to excessive deposition of visceral adipose tissue (VAT); however, the evidence investigating the association between intra-abdominal fat and COVID-19 prognosis is sparse. We therefore investigated whether measuring the amount of intra-abdominal fat is useful to predict the prognosis of COVID-19.

Methods

The present study enrolled 53 consecutive cases of COVID-19 patients aged ≥ 20 years with chest computed tomography (CT) scans. The VAT area, total adipose tissue (TAT) area, and VAT/TAT ratio were estimated using axial CT images at the level of the upper pole of the right kidney. Severe COVID-19 was defined as death or acute respiratory failure demanding oxygen at ≥ 6 L per minute, a high-flow nasal cannula, or mechanical ventilation. The association of VAT/TAT with the incidence of progression to a severe state was estimated as a hazard ratio (HR) using Cox regression analysis. To compare the prediction ability for COVID-19 disease progression between BMI and VAT/TAT, the area under the receiver operating characteristic curve (AUC) of each was assessed.

Results

A total of 15 cases (28.3% of the whole study subjects) progressed to severe stages. The incidence of developing severe COVID-19 increased significantly with VAT/TAT (HR per 1% increase = 1.040 (95% CI 1.008–1.074), P = 0.01). After adjustment for potential confounders, the positive association of VAT/TAT with COVID-19 aggravation remained significant (multivariable-adjusted HR = 1.055 (95% CI 1.000–1.112) per 1% increase, P = 0.049). The predictive ability of VAT/TAT for COVID-19 becoming severe was significantly better than that of BMI (AUC of 0.73 for VAT/TAT and 0.50 for BMI; P = 0.0495 for the difference).

Conclusions

A higher ratio of VAT/TAT was an independent risk factor for disease progression among COVID-19 patients. VAT/TAT was superior to BMI in predicting COVID-19 morbidity. COVID-19 patients with high VAT/TAT levels should be carefully observed as high-risk individuals for morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06958-z.

Neurological manifestations of COVID-19 in patients: from path physiology to therapy

Coronavirus is a family of ARN positive single-stranded belonging to the family of Coronaviridae. There are several families of coronavirus that transmit more or less serious diseases. However, the so-called coronavirus-19 (SARS-CoV2) is the one that is currently causing most of the problems; in fact, biological dysfunctions that this virus causes provoke damage in various organs, from the lung to the heart, the kidney, the circulatory system, and even the brain. The neurological manifestations caused by viral infection, as well as the hypercoagulopathy and systemic inflammation, have been reported in several studies. In this review, we update the neurological mechanisms by which coronavirus-19 causes neurological manifestation in patients such as encephalomyelitis, Guillain-Barré syndrome, lacunars infarcts, neuropsychiatry disorders such as anxiety and depression, and vascular alterations. This review explains (a) the possible pathways by which coronavirus-19 can induce the different neurological manifestations, (b) the strategies used by the virus to cross the barrier system, (c) how the immune system responds to the infection, and (d) the treatment than can be administered to the COVID-19 patients.

The Use of Extracorporeal Membrane Oxygenation in COVID-19 Patients with Severe Cardiorespiratory Failure: The Influence of Obesity on Outcomes

Extracorporeal membrane oxygenation (ECMO) in the management of severely ill patients with COVID-19 has been reported in more than 5,827 cases worldwide according to the Extracorporeal Life Support Organization (ELSO). Several pre-existing conditions have been linked to an increase in COVID-19 mortality risk including obesity. The purpose of this research is to review the clinical experience from a cohort of 342 COVID-19 patients treated with ECMO in which 61.7% (211/342) are confirmed obese. Following institutional review board approval, we reviewed all 342 COVID-19 patients supported with ECMO between March 17, 2020 and March 18, 2021, at 40 American institutions from a multi-institutional database. Descriptive statistics comparing survivors to non-survivors were calculated using chi-square, Welch's ANOVA, and Kruskal-Wallis rank sum test as appropriate. Multivariable logistic regression was used to estimate the effect of body mass index (BMI) on the odds of survival while adjusting for age, gender, chronic renal failure, diabetes, asthma, hypertension, and pre-ECMO P/F ratio. Descriptive analysis showed that obese patients were more likely to be hypertensive (58.1% vs. 32%, p < .001), diabetic (42% vs. 30%, p < .05), and female (35% vs. 21%, p < .05), and had longer median days from intubation to cannulation (4.0 vs. 2.0, p < .05). Obese patients appeared to also have a slightly lower median age (47.9 vs. 50.5, p = .07), higher incidence of asthma (17.8% vs. 10.2%, p = .09), and a slightly lower pre-ECMO PaO₂/FiO₂ ratio (67.5 vs. 77.5, p = .08) though these differences were slightly less statistically reliable. Results from the logistic regression model suggest no statistically reliable association between BMI and odds of survival. Age had a moderately large and statistically reliable negative association with survival; the relative odds of survival for a 59-year-old patient were approximately half those of a 41-year-old patient (OR = .53, 95% CI: .36-.77, p < .001). Obesity does not seem to be a major risk factor for poor outcomes in COVID-19 patients supported with ECMO; however, age was moderately negatively associated with survival. The potential influence of other comorbidities on odds of survival among these patients warrant further investigation.

Aggressive Anticoagulation May Decrease Mortality in Obese Critically Ill COVID-19 Patients

Background

Obesity is a widely accepted risk factor for the development of severe COVID-19. We sought to determine the survival benefit of early initiation of aggressive anticoagulation in obese critically ill COVID-19 patients.

Methods

We retrospectively reviewed 237 intubated patients at a single academic accredited bariatric center and stratified them based on their BMI into 2 groups, obese (BMI > 30) and non-obese (BMI ≤ 30). We used chi-square tests to compare categorical variables such as age and sex, and two-sample t-tests or Mann Whitney U-tests for continuous variables, including important laboratory values. Cox proportional-hazards regression models were utilized to determine whether obesity was an independent predictor of survival and multivariable analysis was performed to compare risk factors that were deemed significant in the univariable analysis. Survival with respect to BMI and its association with level of anticoagulation in the obese cohort was evaluated using Kaplan–Meier models.

Results

The overall mortality in the obese and non-obese groups was similar at 47% and 44%, respectively (p = 0.65). Further analysis based on the level of AC showed that obese patients placed on early aggressive AC protocol had improved survival compared to obese patients who did not receive protocol based aggressive AC (ON-aggressive AC protocol 26% versus OFF-aggressive AC protocol 61%, p = 0.0004).

Conclusions

The implementation of early aggressive anticoagulation may balance the negative effects of obesity on the overall mortality in critically ill COVID-19 patients.

Graphical abstract

Dietary Changes and Anxiety during the Coronavirus Pandemic: Differences between the Sexes

The SARS-CoV-2 (COVID-19) pandemic has been associated with both increased anxiety, deterioration in diet and weight gain. These associations may differ by sex. The present report examines differences by sex in diet quality in order to determine whether associations between diet and psychological stress during the initial phase of the COVID-19 pandemic differed by sex. This online study is available internationally in seven languages. The Mediterranean Diet Score was used to measure diet quality, while the General Anxiety Disorder 7-point scale (GAD-7) was used to measure anxiety. Findings were compared by self-reported sex (male vs. female). A total of 3797 respondents provided informed consent and met eligibility criteria, of whom 526 women were omitted due to being pregnant or six months or less post-partum, or due to reproductive status not being reported. Thus, 3271 individuals are included in the present report, of whom 71.2% were women. The median age of women was 30 (interquartile range (IQR) = 16) years vs. 31 (IQR = 19) years, p = 0.079. The median diet quality score was 9 (IQ = 3) in both women and men (p = 0.75). Despite the overall similarity in diet score, several components of the score differed significantly by sex. Women reported consuming significantly more olive oil, daily servings of vegetables, and weekly servings of sweet baked goods. Men reported consuming significantly more sweetened/carbonated drinks, red meat, alcohol, legumes, and hummus/tahini. Women reported a GAD-7 score of 6 (IQR = 8), while men reported 3 (6), p < 0.001. An inverse association was detected between the Mediterranean diet score and the GAD-7 score in both women (rho = −0.166, p < 0.001) and men (rho = −0.154, p < 0.001), and the correlation coefficients did not differ by sex (p = 0.76). Mediterranean diet score and age both reduced the odds of elevated anxiety (GAD-7 ≥ 10), while female sex, deterioration of diet quality during the outbreak, unemployment, and completing the survey in English increased the odds of this outcome. During the COVID-19 lockdowns, overall diet quality did not differ by sex; however, some differences by sex in components of the total score were detected. Moderate to severe anxiety was positively associated with female sex and poorer diet quality even after controlling for age, employment status, and the language in which the survey was performed.

Immunometabolic Dysregulation at the Intersection of Obesity and COVID-19

Obesity prevails worldwide to an increasing effect. For example, up to 42% of American adults are considered obese. Obese individuals are prone to a variety of complications of metabolic disorders including diabetes mellitus, hypertension, cardiovascular disease, and chronic kidney disease. Recent meta-analyses of clinical studies in patient cohorts in the ongoing coronavirus-disease 2019 (COVID-19) pandemic indicate that the presence of obesity and relevant disorders is linked to a more severe prognosis of COVID-19. Given the significance of obesity in COVID-19 progression, we provide a review of host metabolic and immune responses in the immunometabolic dysregulation exaggerated by obesity and the viral infection that develops into a severe course of COVID-19. Moreover, sequela studies of individuals 6 months after having COVID-19 show a higher risk of metabolic comorbidities including obesity, diabetes, and kidney disease. These collectively implicate an inter-systemic dimension to understanding the association between obesity and COVID-19 and suggest an interdisciplinary intervention for relief of obesity-COVID-19 complications beyond the phase of acute infection.

Are fatty nuts a weighty concern? A systematic review and meta-analysis and dose-response meta-regression of prospective cohorts and randomized controlled trials

Nuts are recommended for cardiovascular health, yet concerns remain that nuts may contribute to weight gain due to their high energy density. A systematic review and meta-analysis of prospective cohorts and randomized controlled trials (RCTs) was conducted to update the evidence, provide a dose-response analysis, and assess differences in nut type, comparator and more in subgroup analyses. MEDLINE, EMBASE, and Cochrane were searched, along with manual searches. Data from eligible studies were pooled using meta-analysis methods. Interstudy heterogeneity was assessed (Cochran Q statistic) and quantified (I² statistic). Certainty of the evidence was assessed by Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Six prospective cohort studies (7 unique cohorts, n = 569,910) and 86 RCTs (114 comparisons, n = 5873) met eligibility criteria. Nuts were associated with lower incidence of overweight/obesity (RR 0.93 [95% CI 0.88 to 0.98] P < 0.001, "moderate" certainty of evidence) in prospective cohorts. RCTs presented no adverse effect of nuts on body weight (MD 0.09 kg, [95% CI -0.09 to 0.27 kg] P < 0.001, "high" certainty of evidence). Meta-regression showed that higher nut intake was associated with reductions in body weight and body fat. Current evidence demonstrates the concern that nut consumption contributes to increased adiposity appears unwarranted.

Functional and tissue enrichment analyses suggest that SARS-CoV-2 infection affects host metabolism and catabolism mediated by interference on host proteins

Infection by SARS-CoV-2, the causative agent of COVID-19, is critically connected with host metabolism. Through functional enrichment analysis, the present study aims to evaluate the biological processes involving host proteins interfered by SARS-CoV-2 to verify the potential metabolic impact of the infection. Furthermore, tissue enrichment analyses and differential gene expression of host proteins were applied to understand the interference by SARS-CoV-2 on tissue levels. Results based on functional and tissue-specific enrichment analyses, presented in this study, suggest that SARS-CoV-2, mediated interference on host proteins, can affect the metabolism and catabolism of molecular building blocks and control intracellular mechanisms, including gene expression in metabolism-related organs, to support viral demands. Thus, SARS-CoV-2 can broadly affect the host metabolism and catabolism at tissue and physiological levels contributing to a more severe disease.

COVID-19 and Obesity: Role of Ectopic Visceral and Epicardial Adipose Tissues in Myocardial Injury

In March 2020, the WHO declared coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a global pandemic. Obesity was soon identified as a risk factor for poor prognosis, with an increased risk of intensive care admissions and mechanical ventilation, but also of adverse cardiovascular events. Obesity is associated with adipose tissue, chronic low-grade inflammation, and immune dysregulation with hypertrophy and hyperplasia of adipocytes and overexpression of pro-inflammatory cytokines. However, to implement appropriate therapeutic strategies, exact mechanisms must be clarified. The role of white visceral adipose tissue, increased in individuals with obesity, seems important, as a viral reservoir for SARS-CoV-2 via angiotensin-converting enzyme 2 (ACE2) receptors. After infection of host cells, the activation of pro-inflammatory cytokines creates a setting conducive to the "cytokine storm" and macrophage activation syndrome associated with progression to acute respiratory distress syndrome. In obesity, systemic viral spread, entry, and prolonged viral shedding in already inflamed adipose tissue may spur immune responses and subsequent amplification of a cytokine cascade, causing worse outcomes. More precisely, visceral adipose tissue, more than subcutaneous fat, could predict intensive care admission; and lower density of epicardial adipose tissue (EAT) could be associated with worse outcome. EAT, an ectopic adipose tissue that surrounds the myocardium, could fuel COVID-19-induced cardiac injury and myocarditis, and extensive pneumopathy, by strong expression of inflammatory mediators that could diffuse paracrinally through the vascular wall. The purpose of this review is to ascertain what mechanisms may be involved in unfavorable prognosis among COVID-19 patients with obesity, especially cardiovascular events, emphasizing the harmful role of excess ectopic adipose tissue, particularly EAT.

Endocrinology in the Time of COVID-19: A Rapid Evolution of Knowledge and Care

American singer-writer and visual artist Bob Dylan produced the song "The Times They Are a-Changin" in the 1960s, which became a rallying cry for the civil rights and anti-war movements in that decade [...].