Novel Coronavirus Disease (COVID-19) in Italian Patients: Gender Differences in Presentation and Severity

Sex differences in COVID-19 symptom severity and trajectories among ambulatory adults

Background

The ongoing COVID-19 pandemic has led to hundreds of millions of infections worldwide. Although differences in COVID-19 hospitalization rates between males and females have been described, many infections in the general population have been mild, and the severity of symptoms during the course of COVID-19 in non-hospitalized males and females is not well understood.

Methods

We conducted a case-ascertained study to examine household transmission of SARS-CoV-2 infections in Nashville, Tennessee, between April 2020 and April 2021. Among enrolled ambulatory adult participants with laboratory-confirmed SARS-CoV-2 infections, we assessed the presence and severity of symptoms (total, systemic, and respiratory) daily using a symptoms severity questionnaire, from illness onset and throughout the 2-week follow-up period. We compared the mean daily symptom severity scores (0-3: none, mild, moderate, and severe) and change in symptoms between males and females using a multivariable linear mixed effects regression model.

Results

The analysis included 223 enrolled adults with SARS-CoV-2 infection (58% females, mostly white, non-Hispanic) from 146 households with 2917 total daily symptom reports. The overall mean severity of total symptoms reported over the illness period was 1.04 and 0.90 for females and males, respectively. Mean systemic and respiratory scores were higher for females than for males (p < 0.001). In multivariable analyses, females reported more severe total and systemic symptoms during the illness period compared with males. However, no significant differences in reported respiratory symptoms were observed.

Conclusions

Our findings indicate that among ambulatory adults with SARS-CoV-2 infections, females reported slightly higher symptom severity during their illness compared with males.

Predictors and Outcomes of Extracorporeal Membrane Oxygenation in COVID-19 Patients With ARDS: A Propensity-Matched Analysis of National Inpatient Sample

Extracorporeal membrane oxygenation (ECMO) is a significant treatment modality for COVID-19 patients on ventilators. The current data is limited for understanding the indicators and outcomes of ECMO in COVID-19 patients with acute respiratory distress syndrome (ARDS). The National Inpatient Sample (NIS) database from 2020 was queried in this study. Among 1,666,960 patients admitted with COVID-19, 99,785 (5.98%) patients developed ARDS, and 60,114 (60.2%) were placed on mechanical ventilation. Of these mechanically ventilated COVID-ARDS patients, 2580 (4.3%) were placed on ECMO. Patients with ECMO intervention had higher adjusted odds (aOR) of blood loss anemia (aOR 9.1, 95% CI: 6.16-13.5, propensity score-matched (PSM) 42% vs 5.4%, P < 0.001), major bleeding (aOR 3.79, 95% CI: 2.5-5.6, PSM 19.9% vs 5.9%, P < 0.001) and acute liver injury (aOR 1.7, 95% CI: 1.14-2.6 PSM 14% vs 6%, P = 0.009) compared to patients without ECMO intervention. However, in-hospital mortality, acute kidney injury, transfusions, acute MI, and cardiac arrest were insignificant. On subgroup analysis, patients placed on veno-arterial ECMO had higher odds of cardiogenic shock (aOR 13.4, CI 3.95-46, P < 0.0001), cardiac arrest (aOR 3.5, CI 1.45-8.47, P = 0.0057), acute congestive heart failure (aOR 4.18, CI 1.05-16.5, P = 0.042) and lower odds of major bleeding (aOR 0.26, CI 0.07-0.92). However, there was no significant difference in mortality, intracranial hemorrhage, and acute MI. Further studies are needed before considering COVID-19 ARDS patients for placement on ECMO.

Risk of SARS-CoV-2 transmission in the close contacts in a small rural area in the Veneto Region (NE-Italy): past evidence for future scenarios

Background

During the first pandemic phase of COVID-19, an epidemiological study, named First survey, was conducted on the population of a small rural area in northern Italy. In spring 2020, the results showed how a prolonged lockdown slowed down the spread of the virus.

Methods

After contacting positive First Survey subjects and their families, those who decided to join voluntarily underwent a blood test to assess the presence of qualitative lgG about 2 months after the previous one. This was to determine if IgG persisted in individuals who tested positive in the First Survey as well as to assess the antibody status of their close family members, to determine if they were unintentionally infected.

Results

Based on serological analysis, 35.1% of the samples contained blood IgG. In subjects who tested positive during the First Survey, 62.5% remained IgG positive more than 2 months later. Among family members who were exposed to a positive relative, 23.7% were infected. Linear regression analysis showed that the presence of an infected person within a household resulted in the infection spreading to the others, but not excessively. Induced isolation extinguished the infection regardless of the extent of the contagion (intra-family or extra-family). Micro-outbreaks of SARS-Cov-2 infection which arose in the same household from extra-familial infections played a decisive role on the statistical significance of IgG-positive subjects (p < 0.001).

Discussion

The study reveal 52.6% of the IgG-positive subjects in the Second Survey came from the First Survey and 47.4% were family members previously in contact with positive subjects. Data suggest that there have been undiagnosed patients feeding the spread of the virus since the beginning of the pandemic. In conclusion, for future pandemics, it will be necessary: i) to ensure the rapid isolation of symptomatic patients and the early identification of their close contacts, ii) to carry out the maximum number of tests in the shortest possible time, both on symptomatic and asymptomatic subjects, and iii) to implement information campaigns to make people aware of their risks, and implement clear, non-conflicting communication.

Same but Different-ECMO in COVID-19 and ARDS of Other Etiologies. Comparison of Survival Outcomes and Management in Different ARDS Groups

Background: COVID-19 has led to increased numbers of patients in need of venovenous extracorporeal membrane oxygenation (ECMO) support, but knowledge on management in comparison to acute respiratory distress syndrome (ARDS) of other etiologies is still lacking. We analyzed venovenous ECMO management and survival outcomes in patients with COVID-19 in comparison to influenza ARDS and pulmonary ARDS of other origin. Results: Retrospective analysis of prospective venovenous ECMO registry-based data collection was performed. One hundred consecutive venovenous ECMO patients with severe ARDS were included (41 COVID-19, 24 influenza A, 35 ARDS of other etiologies). Patients with COVID-19 had higher BMI (body mass index), lower SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, lower C-reactive protein and procalcitonin levels and less vasoactive support at ECMO initiation. Significantly more patients were mechanically ventilated for more than 7 days prior to ECMO initiation in the COVID-19 group, however they were ventilated with lower tidal volumes and more often received additional rescue therapies prior to and on ECMO. COVID-19 patients had significantly more barotrauma and thrombotic events on ECMO. There were no differences in weaning of ECMO, however duration of ECMO runs and ICU length of stay was significantly longer in the COVID-19 group. The leading cause of death in the COVID-19 group was irreversible respiratory failure, while uncontrolled sepsis and multiorgan failure were leading causes in the other 2 groups. All patients who survived ICU treatment were discharged out of hospital, and there were no differences in survival among groups at 180 days. Conclusions: Survival outcomes of venovenous ECMO patients do not differ between COVID-19 and ARDS of other pulmonary etiologies. ARDS guidelines were in greater proportion adhered to in COVID-19 patients, with, however, longer time to ECMO initiation. COVID-19 ARDS seems specific as a more single-organ disease with longer ECMO duration and irreversible respiratory failure as a main cause of ICU mortality.

How cyberchondria and decision self-efficacy shapes the acceptability of COVID-19 vaccine: A gender-based comparison

Objective

Alarmingly, the individuals' reach and coverage to get vaccinated in developing regions during the pandemic is a massive challenge for concerned authorities. This study aimed to demonstrate how cyberchondria play a significant role in a classical health belief model. Cyberchondria may influence cognitive factors (e.g. self-efficacy), which may contribute to an increase in attitude-behavior gap. Especially in the context of a health-centric scenario, it may discourage individuals to take protective measures.

Method

By using the cross-sectional research design, the authors conducted a quantitative survey in Pakistan and collected 563 responses from 303 male respondents (rural = 91; urban = 212) with (Urban M:35.5, standard deviation (SD):13.4) and rural M:37.5, SD:8.4).

Result

The findings indicate that decision self-efficacy among males is stronger than that in females. It dominates other determinants, which can dampen the individuals' intentions to get vaccinated. For instance, the effect of conspiracies and perceived seriousness was noted nonsignificant and weak. In females, perceived seriousness was stronger determinant than in males. In addition, the negative effect of decision self-efficacy was noted in the case of females, and conspiracy and cyberchondria had a negative role.

Conclusion

This study highlights valuable implications for future research in infodemic, health communication and health literacy, and practical implications for regulatory bodies and public administration.

A phase 2 randomized, double-blinded, placebo-controlled, multicenter trial evaluating the efficacy and safety of raloxifene for patients with mild to moderate COVID-19

BACKGROUND

Current available therapeutic options for Coronavirus Disease-2019 (COVID-19) are primarily focused on treating hospitalized patients, and there is a lack of oral therapeutic options to treat mild to moderate outpatient COVID-19 and prevent clinical progression. Raloxifene was found as a promising molecule to treat COVID-19 due to its activity to modulate the replication of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and act as an immunomodulator to decrease proinflammatory cytokines.

METHODS

This was a phase 2 multicenter, randomized, placebo-controlled trial to evaluate the efficacy and safety of raloxifene in adult patients with mild to moderate COVID-19 between October 2020 to June 2021 in five centers located in Italy. This was a planned 2/3 adaptive study, but due to operational difficulties, the study was discontinued during the phase 2 study segment. Participants were randomized 1:1:1 to receive oral placebo, raloxifene 60 mg, or raloxifene 120 mg by self-administration for a maximum of two weeks. The primary outcomes were the proportion of patients with undetectable SARS-CoV-2 via nasopharyngeal swabs at day 7 and the proportion of patients who did not require supplemental oxygen therapy or mechanical ventilation on day 14. Safety was assessed. The trial is registered (EudraCT 2021-002,476-39, and ClinicalTrials.gov: NCT05172050).

FINDINGS

A total of 68 participants were enrolled and randomized to placebo (n = 21), raloxifene 60 mg (n = 24), and raloxifene 120 mg (n = 23). The proportion of participants with undetectable SARS-CoV-2 after seven days of treatment with raloxifene 60 mg [36.8%, 7/19 vs. 0.0%, 0/14] and 120 mg [22.2%, 4/18 vs. 0.0%, 0/14] was better compared to placebo, [risk difference (RD) = 0·37 (95% C.I.:0·09-0·59)] and [RD = 0·22 (95% C.I.: -0·03-0·45)], respectively. There was no evidence of effect for requirement of supplemental oxygen and/or mechanical ventilation with effects for raloxifene 60 mg and raloxifene 120 mg over placebo, [RD = 0·09 (95% C.I.: -0·22-0·37)], and [RD = 0·03 (95% C.I.: -0·28-0·33)], respectively. Raloxifene was well tolerated at both doses, and there was no evidence of any difference in the occurrence of serious adverse events.

INTERPRETATION

Raloxifene showed evidence of effect in the primary virologic endpoint in the treatment of early mild to moderate COVID-19 patients shortening the time of viral shedding. The safety profile was consistent with that reported for other indications. Raloxifene may represent a promising pharmacological option to prevent or mitigate COVID-19 disease progression.

FUNDING

The study was funded by Dompé Farmaceutici SpA and supported by the funds from the European Commission - Health and Consumers Directorate General, for the Action under the Emergency Support Instrument- Grant to support clinical testing of repurposed medicines to treat SARS-COV-2 patients (PPPA-ESI-CTRM-2020-SI2.837140), and by the COVID-2020-12,371,675 Ricerca finalizzata and line 1 Ricerca Corrente COVID both funded by Italian Ministry of Health.

Demographics, comorbidities, and laboratory parameters in hospitalized patients with SARS-CoV2 infection at a community hospital in rural Pennsylvania

Introduction

Inherent differences as well as health disparities among rural and urban populations warrant further studies focused on the characteristics and outcomes in COVID-19 patients in a rural setting. The aim of this study was to describe these elements in patients infected with SARS-CoV2, hospitalized at a single center in rural Pennsylvania.

Methods

Patients with SARS-CoV2 infections hospitalized between March-December 2020 were studied. Data were obtained from electronic health records generated reports and was retrospectively analyzed. Patients were classified into three groups according to severity. Distribution of variables was studied among these three groups. Using certain variables, we ran logistic regression analysis to study the odds of death and requirement of mechanical ventilation (MV).

Results

Among 335 hospitalized patients infected with SARS-CoV2, age more than 65 years increased the severity of clinical status and in-hospital mortality. Gender did not affect odds of death nor need for MV. Hypertension was the most common comorbidity, but diabetes mellitus and chronic obstructive pulmonary disease (COPD) increased the risk of death. In terms of laboratory parameters, our data suggests that maximum LDH marginally increased the risk of death and maximum WBC marginally increased the risk of need for MV and death.

Conclusion

Through our basic analysis of various characteristics of SARS-CoV2 positive patients admitted in a rural hospital, we have identified certain risk factors associated with severe disease and increased in-hospital mortality. These were found to be largely similar to current literature from studies in urban populations, bolstering the reproducibility and generalizability of existing knowledge. This information lays the foundation for future studies to investigate the role of these factors in morbidity and mortality associated with COVID-19 in depth.

One-Year Multidisciplinary Follow-Up of Patients With COVID-19 Requiring Invasive Mechanical Ventilation

Objectives

Patients with COVID-19 frequently develop acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) admission. Data on long-term survival of these patients are lacking. The authors investigated 1-year survival, quality of life, and functional recovery of patients with COVID-19 ARDS requiring invasive mechanical ventilation.

Design

Prospective observational study.

Setting

Tertiary-care university hospital.

Participants

All patients with COVID-19 ARDS receiving invasive mechanical ventilation and discharged alive from hospital.

Interventions

Patients were contacted by phone after 1 year. Functional, cognitive, and psychological outcomes were explored through a questionnaire and assessed using validated scales. Patients were offered the possibility to undergo a follow-up chest computed tomography (CT) scan.

Measurements and Main Results

The study included all adult (age ≥18 years) patients with COVID-19–related ARDS admitted to an ICU of the authors’ institution between February 25, 2020, and April 27, 2020, who received at least 1 day of invasive mechanical ventilation (IMV). Of 116 patients who received IMV, 61 (52.6%) survived to hospital discharge. These survivors were assessed 1 year after discharge and 56 completed a battery of tests of cognition, activities of daily living, and interaction with family members. They had overall good functional recovery, with >80% reporting good recovery and no difficulties in usual activities. A total of 52 (93%) of patients had no dyspnea at rest. Severe anxiety/depression was reported by 5 (8.9%) patients. Comparing 2-month and 1-year data, the authors observed the most significant improvements in the areas of working status and exertional dyspnea. One-year chest CT scans were available for 36 patients; fibrotic-like changes were present in 4 patients.

Conclusions

All patients who survived the acute phase of COVID-19 and were discharged from the hospital were alive at the 1-year follow up, and the vast majority of them had good overall recovery and quality of life.

ECMO in COVID-19 Patients: A Systematic Review and Meta-analysis

Objective

To analyze the survival rates of patients with COVID-19 supported with extracorporeal membrane oxygenation (ECMO) and compare the survival rates of patients with COVID-19 supported with ECMO to patients with influenza supported with ECMO.

Design

A systematic review and meta-analysis to assess the impact of ECMO as supportive therapy of COVID-19.

Setting

The authors performed a search through the Cochrane, EMBASE, and MEDLINE/PubMed databases from inception to February 19, 2021, for studies reporting hospitalized patients with COVID-19 managed with ECMO.

Participants

A total of 134 studies were selected, including 6 eligible for the comparative meta-analysis of COVID-19 versus influenza.

Interventions

The authors pooled the risk ratio and random effects model.

Measurements and Main Results

The primary endpoint was the overall mortality of patients with COVID-19 receiving ECMO. Of the total number of 58,472 patients with COVID-19 reported, ECMO was used in 4,044 patients. The analysis suggested an overall in-hospital mortality of 39% (95% CI 0.34-0.43). In the comparative analysis, patients with COVID-19 on ECMO had a higher risk ratio (RR) for mortality when compared to influenza patients on ECMO: 72/164 (44%) v 71/186 (38%) RR 1.34; 95% CI 1.05-1.71; p = 0.03.

Conclusions

ECMO could be beneficial in patients with COVID-19, according to the authors’ meta-analysis. The reported mortality rate was 39%. This systematic analysis can provide clinical advice in the current era and ongoing pandemic.

High risk coronavirus disease 2019: The primary results of the CoronaHeart multi-center cohort study

BACKGROUND

Patients with Coronavirus Disease 2019 (COVID-19) may present high risk features during hospitalization, including cardiovascular manifestations. However, less is known about the factors that may further increase the risk of death in these patients.

METHODS

We included patients with COVID-19 and high risk features according to clinical and/or laboratory criteria at 21 sites in Brazil from June 10th to October 23rd of 2020. All variables were collected until hospital discharge or in-hospital death.

RESULTS

A total of 2546 participants were included (mean age 65 years; 60.3% male). Overall, 70.8% were admitted to intensive care units and 54.2% had elevated troponin levels. In-hospital mortality was 41.7%. An interaction among sex, age and mortality was found (p = 0.007). Younger women presented higher rates of death than men (30.0% vs 22.9%), while older men presented higher rates of death than women (57.6% vs 49.2%). The strongest factors associated with in-hospital mortality were need for mechanical ventilation (odds ratio [OR] 8.2, 95% confidence interval [CI] 5.4-12.7), elevated C-reactive protein (OR 2.3, 95% CI 1.7-2.9), cancer (OR 1.8, 95 %CI 1.2-2.9), and elevated troponin levels (OR 1.8, 95% CI 1.4-2.3). A risk score was developed for risk assessment of in-hospital mortality.

CONCLUSIONS

This cohort showed that patients with COVID-19 and high risk features have an elevated rate of in-hospital mortality with differences according to age and sex. These results highlight unique aspects of this population and might help identifying patients who may benefit from more careful initial surveillance and potential subsequent interventional therapies.