Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection : A Retrospective Cohort Study

Pharmacovigilance in Vaccines: Importance, Main Aspects, Perspectives, and Challenges-A Narrative Review

Pharmacovigilance plays a central role in safeguarding public health by continuously monitoring the safety of vaccines, being critical in a climate of vaccine hesitancy, where public trust is paramount. Pharmacovigilance strategies employed to gather information on adverse events following immunization (AEFIs) include pre-registration data, media reports, clinical trials, and societal reporting. Early detection of AEFIs during clinical trials is crucial for thorough safety analysis and preventing serious reactions once vaccines are deployed. This review highlights the importance of societal reporting, encompassing contributions from community members, healthcare workers, and pharmaceutical companies. Technological advancements such as quick response (QR) codes can facilitate prompt AEFI reporting. While vaccines are demonstrably safe, the possibility of adverse events necessitates continuous post-marketing surveillance. However, underreporting remains a challenge, underscoring the critical role of public engagement in pharmacovigilance. This narrative review comprehensively examines and synthesizes key aspects of virus vaccine pharmacovigilance, with special considerations for specific population groups. We explore applicable legislation, the spectrum of AEFIs associated with major vaccines, and the unique challenges and perspectives surrounding pharmacovigilance in this domain.

The interplay of aging, adipose tissue, and COVID-19: a potent alliance with implications for health

Obesity has emerged as a significant public health challenge. With the ongoing increase in life expectancy, the prevalence of obesity is steadily growing, particularly among older age demographics. The extension of life expectancy frequently results in additional years of vulnerability to chronic health issues associated with obesity in the elderly.The concept of SARS-CoV-2 directly infecting adipose tissue stems from the fact that both adipocytes and stromal vascular fraction cells express ACE2, the primary receptor facilitating SARS-CoV-2 entry. It is noteworthy that adipose tissue demonstrates ACE2 expression levels similar to those found in the lungs within the same individual. Additionally, ACE2 expression in the adipose tissue of obese individuals surpasses that in non-obese counterparts. Viral attachment to ACE2 has the potential to disturb the equilibrium of renin-angiotensin system homeostasis, leading to an exacerbated inflammatory response.Consequently, adipose tissue has been investigated as a potential site for active SARS-CoV-2 infection, suggesting its plausible role in virus persistence and contribution to both acute and long-term consequences associated with COVID-19.This review is dedicated to presenting current evidence concerning the presence of SARS-CoV-2 in the adipose tissue of elderly individuals infected with the virus. Both obesity and aging are circumstances that contribute to severe health challenges, heightening the risk of disease and mortality. We will particularly focus on examining the mechanisms implicated in the long-term consequences, with the intention of providing insights into potential strategies for mitigating the aftermath of the disease.

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Association between COVID-19 diagnosis and postoperative outcomes in sleeve gastrectomy and Roux-en-Y gastric bypass: A national cohort study

BACKGROUND

We seek to determine the association between COVID-19 diagnosis and postoperative outcomes following bariatric surgery.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database, patients undergoing sleeve gastrectomy and gastric bypass without a COVID-19 diagnosis were 2:1 propensity-score matched to those with COVID-19 infection pre or postoperatively.

RESULTS

1369 (0.74 ​%) and 1331 (0.72 ​%) patients had a COVID-19 diagnosis within 14 days prior to or 30 days after their operation, respectively. Patients with preoperative COVID-19 infection had equivalent outcomes to COVID-19 negative patients (all p ​> ​0.05). Postoperative COVID-19 diagnosis was associated with worse outcomes including increased risk of anastomotic/staple line leak (1.1 ​% vs 0.1 ​%, p ​< ​0.001), postoperative pneumonia (2.9 ​% vs 0.1 ​%, p ​< ​0.001), and 30-day reoperation (2.1 ​% vs 0.9 ​%, p ​= ​0.002).

CONCLUSIONS

Postoperative diagnosis of COVID-19 after bariatric surgery is associated with worse outcomes; however, it is safe to perform these procedures on patients recently convalesced from COVID-19 infection.

Characteristics and outcomes of a hospitalized cohort with reduced mortality from COVID-19, White Mountain apache tribal lands, April 1 - July 31, 2020

BACKGROUND

Widespread transmission of COVID-19 continues to threaten public health, particularly of rural, American Indian communities. Although COVID-19 risk factors for severe disease and clinical characteristics are well described in the general population, there has been little shared on hospitalized American Indian populations.

METHODS

In this observational study, we performed chart extractions on all persons hospitalized with COVID-19 from April 1 through July 31, 2020 among an exclusively American Indian population living on or near Tribal lands in eastern Arizona. We provide descriptive statistics for the cohort stratified by presentation, comparing those who self-presented or were referred by an outreach program. Exploratory analyses were performed to identify risk factors for morbidity and mortality.

RESULTS

During the observation period, 2262 persons were diagnosed with COVID-19 and 490 (22%) were hospitalized. Hospitalized persons had a median age of 54 years; 92% had at least one comorbidity, 72% had greater than one comorbidity, and 60% had a BMI of > 30. Most persons required supplemental oxygen (83%), but the majority (62%) only required nasal cannula and only 11% were intubated. The case fatality rates were 1.7% for the population, 7.1% among hospitalizations, and 9.3% among hospitalized patients 50 years and older. All rates that are significantly lower than those reported nationally during the same period.

CONCLUSIONS

We observed a cohort of American Indian patients hospitalized secondary to COVID-19 with greater number of comorbidities compared to the general population but with lower mortality rates. We posit that the primary driver of mortality reduction for this population and the hospitalized cohort was a community-based referral program that led to disproportionately lower fatality rates among the oldest persons.

Predicting COVID-19 outcomes with the Edmonton Obesity Staging System

BACKGROUND

Multiple studies have demonstrated a correlation between a high body mass index and discriminatory COVID-19 outcomes. Studies appear to indicate that there is a correlation between obesity-related comorbidities and less favorable outcomes.

OBJECTIVES

The primary aim of the current investigation is to conduct a thorough assessment of the correlation between BMI and comorbidities associated with obesity, and their potential impact on the severity and consequences of COVID-19 infection among patients receiving care in a tertiary healthcare setting.

DESIGN

Retrospective cohort.

SETTINGS

Tertiary rehabilitation center, Riyadh, Saudi Arabia.

PATIENTS AND METHODS

The study included all individuals who received medical treatment and tested positive for COVID-19 by means of RT-PCR during the period from March to September 2020. COVID-19 patients were classified using Edmonton Obesity Staging System (EOSS).

MAIN OUTCOME MEASURES

COVID-19-related complications, including pneumonia and cytokine release syndrome, as well as the time length to COVID-19 negativization.

SAMPLE SIZE

315 patients.

RESULTS

The median (25th-75th percentiles) age of the patients was 38 (31.5-49) years old. Males outnumbered females, and 66% of patients were non-Saudis. Forty-eight patients (15.2%) had obesity class I, whereas 13 patients (4.1%) had class II. Thirty-two patients (10.2%) were classified as EOSS stage 1, 105 patients (33.3%) were classified as EOSS stage 2, and 25 patients (7.9%) were assigned to EOSS stage 3. Males predominated in EOSS stages 1 and 2, whereas females predominated in stage 3. In EOSS stage 3, 52% of cases had moderate severity and 48% had severe illness.

CONCLUSIONS

EOSS distinguishes the COVID-19 risks of poor outcomes beyond BMI. Patients who were overweight or obese but remained in the stage 1 of the EOSS had a lower risk of a poor COVID-19 outome than normal-weight patients. The health status of obese patients is a more precise indicator of the progression of COVID-19 during hospitalization than BMI alone.

LIMITATIONS

Given the limited capacity of urgent care facilities to conduct a comprehensive evaluation of comorbidities and other relevant outcomes in all patients, it is plausible that certain patients may have been erroneously classified with an EOSS stage 2 diagnosis, when in fact they ought to have been assigned a stage 3 diagnosis.

Association of obesity on the outcome of critically ill patients affected by COVID-19

OBJECTIVE

To evaluate the impact of obesity on ICU mortality.

DESIGN

Observational, retrospective, multicentre study.

SETTING

Intensive Care Unit (ICU).

PATIENTS

Adults patients admitted with COVID-19 and respiratory failure.

INTERVENTIONS

None.

PRIMARY VARIABLES OF INTEREST

Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. Body mass index (BMI) impact on ICU mortality was studied as (1) a continuous variable, (2) a categorical variable obesity/non-obesity, and (3) as categories defined a priori: underweight, normal, overweight, obesity and Class III obesity. The impact of obesity on mortality was assessed by multiple logistic regression and Smooth Restricted cubic (SRC) splines for Cox hazard regression.

RESULTS

5,206 patients were included, 20 patients (0.4%) as underweight, 887(17.0%) as normal, 2390(46%) as overweight, 1672(32.1) as obese and 237(4.5%) as class III obesity. The obesity group patients (n = 1909) were younger (61 vs. 65 years, p < 0.001) and with lower severity scores APACHE II (13 [9-17] vs. 13[10-17, p < 0.01) than non-obese. Overall ICU mortality was 28.5% and not different for obese (28.9%) or non-obese (28.3%, p = 0.65). Only Class III obesity (OR = 2.19, 95%CI 1.44-3.34) was associated with ICU mortality in the multivariate and SRC analysis.

CONCLUSIONS

COVID-19 patients with a BMI > 40 are at high risk of poor outcomes in the ICU. An effective vaccination schedule and prolonged social distancing should be recommended.

Obesity as a Risk Factor for Complications and Mortality in Individuals with SARS-CoV-2: A Systematic Review

This systematic review aimed to analyze the available studies that identified overweight and/or obesity as a risk factor for mortality, use of respiratory support, and changes in biochemical markers in adults hospitalized with SARS-CoV-2. The PubMed, Web of Science, and Scopus databases were searched using PRISMA guidelines until January 2024. The protocol was registered with PROSPERO (code: CRD42024501551). Of the 473 articles, only 8 met the inclusion criteria (e.g., adult individuals aged 18 or over diagnosed with COVID-19 individuals with overweight and/or obesity). In addition, the Downs and Black tool was used to assess the quality of the studies. The studies analyzed totaled 9782 adults hospitalized for COVID-19, indicating that overweight and obesity are present in more than half of adults. Diseases such as diabetes mellitus and hypertension are more prevalent in adults with obesity. The systematic review also highlighted that a higher incidence of respiratory support is related to a higher incidence of hospitalization in intensive care units and that adults with overweight and obesity have a higher risk of mortality from COVID-19. Biochemical markers such as procalcitinin, C-reactive protein, and interleukin-6 are associated with the severity of COVID-19 infection. This systematic review exposed overweight and/or obesity as a risk factor for worse COVID-19 disease, as well as for the need for intensive care, respiratory support, mortality, and changes in essential blood markers.

Association of Body Mass Index with Multiple Organ Failure in Hospitalized Patients with COVID-19: A Multicenter Retrospective Cohort Study

Purpose: This study examines whether excessive adipose tissue, as measured by the body mass index (BMI), is associated with higher systemic markers of inflammation and higher risk of severe acute organ failure among patients with coronavirus disease 2019 (COVID-19). Methods: This was a multicenter retrospective cohort study of 1370 hospitalized adults (18 years or older) with COVID-19 during the first wave of the pandemic. Patient-level variables were extracted from the electronic medical record. The primary predictor variable was the BMI at time of hospital admission, in accordance with the World Health Organization classification. Multivariable logistic regression analyses examined the association of BMI with the composite of acute respiratory distress syndrome (ARDS), as defined by the use of high-flow nasal canula, non-invasive ventilation, or mechanical ventilation, severe acute kidney injury (AKI), as defined by acute dialysis requirement, or in-hospital death. Results: After adjustment for important cofounders, the BMI stratum of > 40 kg/m2 (compared to the BMI < 25 kg/m2 reference group) was associated with higher odds for the composite of ARDS, severe AKI, or in-hospital death (adjusted odds ratio [ORadj] 1.69; 95% confidence interval [CI]1.03, 2.78). As a continuous variable, BMI (per 5-kg/m2 increase) remained independently associated with the composite outcome (ORadj 1.13; 95% CI 1.03, 1.23); patients in higher BMI categories exhibited significantly higher peak levels of C-reactive protein (CRP), a systemic marker of inflammation (P = .01). In a sub-cohort of 889 patients, the association of BMI with the composite outcome was no longer significant after adjustment for the peak level of CRP. Conclusions: Among hospitalized patients with COVID-19, a higher BMI is associated with higher risk of severe organ failure or in-hospital death, which dissipates after adjustment for CRP level. This supports the hypothesis that inflammation is a downstream mediator of adipose tissue on acute organ dysfunction.

The impact of body mass index on long-term survival after ICU admission due to COVID-19: A retrospective multicentre study

Objective

The impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs.

Design

Retrospective multicentre study.

Setting

92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database.

Participants

All patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations.

Interventions and main outcome measures

The primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients.

Results

We examined 2,931 patients; the median BMI was 30.2 (IQR 25.6-36.0) kg/m2. Patients with a BMI ≥30 kg/m2 were younger (median [IQR] age 57.7 [46.2-69.0] vs. 63.0 [50.0-73.6]; p < 0.001) than those with a BMI <30 kg/m2. Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m2 (35.4%) and 18.5-24.9 kg/m2 (31.1%), while lowest for BMI ≥40 kg/m2 (14.5%). After adjusting for confounders and with BMI 18.5-24.9 kg/m2 category as a reference, only the BMI ≥40 kg/m2 category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34-0.76).

Conclusions

The obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m2 was associated with a higher survival time of up to two years.

Uncovering associations between pre-existing conditions and COVID-19 Severity: A polygenic risk score approach across three large biobanks

OBJECTIVE

To overcome the limitations associated with the collection and curation of COVID-19 outcome data in biobanks, this study proposes the use of polygenic risk scores (PRS) as reliable proxies of COVID-19 severity across three large biobanks: the Michigan Genomics Initiative (MGI), UK Biobank (UKB), and NIH All of Us. The goal is to identify associations between pre-existing conditions and COVID-19 severity.

METHODS

Drawing on a sample of more than 500,000 individuals from the three biobanks, we conducted a phenome-wide association study (PheWAS) to identify associations between a PRS for COVID-19 severity, derived from a genome-wide association study on COVID-19 hospitalization, and clinical pre-existing, pre-pandemic phenotypes. We performed cohort-specific PRS PheWAS and a subsequent fixed-effects meta-analysis.

RESULTS

The current study uncovered 23 pre-existing conditions significantly associated with the COVID-19 severity PRS in cohort-specific analyses, of which 21 were observed in the UKB cohort and two in the MGI cohort. The meta-analysis yielded 27 significant phenotypes predominantly related to obesity, metabolic disorders, and cardiovascular conditions. After adjusting for body mass index, several clinical phenotypes, such as hypercholesterolemia and gastrointestinal disorders, remained associated with an increased risk of hospitalization following COVID-19 infection.

CONCLUSION

By employing PRS as a proxy for COVID-19 severity, we corroborated known risk factors and identified novel associations between pre-existing clinical phenotypes and COVID-19 severity. Our study highlights the potential value of using PRS when actual outcome data may be limited or inadequate for robust analyses.

In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay

BACKGROUND

Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight.

METHODS

This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay.

RESULTS

One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013).

CONCLUSION

In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

Prevalence of overweight and obesity and their effect on COVID-19 severity and hospitalization among younger than 50 years versus older than 50 years population: A systematic review and meta-analysis

Cohort studies have shown that both overweight and obesity have their impact by increasing hospitalization with COVID-19. We conducted a systematic literature search in PubMed, Google Scholar, and MedRxiv databases following the PRISMA guidelines. Statistical analyses were performed using STATA software version 16 MP (Stata Corp, College Station, TX, USA) and Med Calc software version 22.009(Med Calc software Ltd, Ostend, Belgium). The primary outcome was to measure the prevalence of overweight and obesity and their impact on the risk of hospitalization among COVID-19 patients under and above 50 years of age. In total, 184 studies involving 2,365,377 patients were included. The prevalence of overweight was highest among those younger than 50 years of age over those older than 50 years of age, (26.33% vs. 30.46%), but there was no difference in obesity (36.30% vs. 36.02%). Overall, the pooled prevalence of overweight and obesity among hospitalized COVID-19 patients was 31.0% and 36.26%, respectively. Compared with normal weight, the odds of hospitalization with overweight (odds ratio [OR] 2.186, 95% confidence interval [CI] [1.19, 3.99], p < 0.01) and obesity (OR 3.069, 95% CI [1.67, 5.61], p < 0.001) in those younger than 50 years and obesity (OR 3.977, 95% CI [2.75, 5.73], p < 0.001) in the older than 50 years age group were significantly high. The increased prevalence of overweight and obesity among the under 50 years age group and obesity among the older than 50 years age group significantly increased the rate of COVID-19 infections, severity and hospitalization.

Fibrotic-Like Pulmonary Radiographic Patterns Are Not Associated With Adverse Outcomes in COVID-19 Chronic Critical Illness

OBJECTIVES

Pulmonary fibrosis is a feared complication of COVID-19. To characterize the risks and outcomes associated with fibrotic-like radiographic abnormalities in patients with COVID-19-related acute respiratory distress syndrome (ARDS) and chronic critical illness.

DESIGN

Single-center prospective cohort study.

SETTING

We examined chest CT scans performed between ICU discharge and 30 days after hospital discharge using established methods to quantify nonfibrotic and fibrotic-like patterns.

PATIENTS

Adults hospitalized with COVID-19-related ARDS and chronic critical illness (> 21 d of mechanical ventilation, tracheostomy, and survival to ICU discharge) between March 2020 and May 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We tested associations of fibrotic-like patterns with clinical characteristics and biomarkers, and with time to mechanical ventilator liberation and 6-month survival, controlling for demographics, comorbidities, and COVID-19 therapies. A total of 141 of 616 adults (23%) with COVID-19-related ARDS developed chronic critical illness, and 64 of 141 (46%) had a chest CT a median (interquartile range) 66 days (42-82 d) after intubation. Fifty-five percent had fibrotic-like patterns characterized by reticulations and/or traction bronchiectasis. In adjusted analyses, interleukin-6 level on the day of intubation was associated with fibrotic-like patterns (odds ratio, 4.40 per quartile change; 95% CI, 1.90-10.1 per quartile change). Other inflammatory biomarkers, Sequential Organ Failure Assessment score, age, tidal volume, driving pressure, and ventilator days were not. Fibrotic-like patterns were not associated with longer time to mechanical ventilator liberation or worse 6-month survival.

CONCLUSIONS

Approximately half of adults with COVID-19-associated chronic critical illness have fibrotic-like patterns that are associated with higher interleukin-6 levels at intubation. Fibrotic-like patterns are not associated with longer time to liberation from mechanical ventilation or worse 6-month survival.

The association between obesity with treatment duration, ICU length of stay and the risk of death in critically ill patients with COVID-19

BACKGROUND

Despite the confirmed association between higher BMI with increased risk of the acute respiratory distress syndrome (ARDS), the association between obesity with mortality in critically ill patients with coronavirus disease 2019 (COVID-19) is not clear. The present study aimed to investigate the association between obesity with treatment duration, ICU length of stay, and the risk of death in critically ill patients with COVID-19.

METHODS

This case-control study was performed on 223 patients with COVID-19 including 148 surviving patients as the control group and 75 eventually dead patients as the case group in Rasht, Iran. Data on demographic factors, comorbidities, anthropometric measurements, the length of hospitalization and the mortality were obtained from patients' medical records.

RESULTS

The mortality rate was significantly associated with weight (OR = 1.04, 95% CI: 1.002-1.083, p = .04), but not with BMI after adjustments for age, gender, length of stay in ICU, chronic diseases and smoking. The results did not change after further adjustments for biochemical and pathological factors.

CONCLUSIONS

Weight was positively associated with mortality after controlling for confounding variables. Further studies should consider the patient's body composition such as fat mass to establish the relationship between obesity and COVID-19 outcomes.

Muscle strength and mobility of individuals with COVID-19 compared with non-COVID-19 in intensive care

BACKGROUND

Critical illness may affect muscle strength and mobility.

OBJECTIVES

To compare muscle strength, mobility, and in intensive care unit (ICU)-acquired weakness (ICUAW) prevalence among individuals with COVID-19 and other critical illnesses; to identify factors associated with muscle strength, mobility, and length of stay in COVID-19; and to determine the Perme Intensive Care Unit Mobility Score (PICUMS) cut-off point for ICUAW.

METHODS

We included individuals aged ≥18 in ICU who require mechanical ventilation. We excluded those diagnosed with neuromusculoskeletal diseases or who did not understand the study procedures. The Medical Research Council - sum score (MRC-SS) and the PICUMS were applied before ICU and hospital discharge. Analysis of covariance, Quade´s test, and Fisher's exact test compared groups. Partial correlations were analized between the MRC-SS and PICUMS with clinical variables. Regression models identified the predictors of hospital length of stay. The ROC curve verified the PICUMS related to ICUAW. Significance was set as P<.05.

RESULTS

25 individuals were included in the COVID-19 group and 23 in the non-COVID-19 group. No between-groups difference was observed in MRC-SS and PICUMS at discharge from ICU or hospital. The MRC-SS and PICUMS at ICU discharge predicted the length of hospital stay in the COVID-19 group. The PICUMS cut-off related to ICUAW was 18.

CONCLUSIONS

Muscle strength, mobility, and ICUAW are similar between COVID-19 and non-COVID-19. However, muscle strength and mobility at ICU discharge are associated with the length of stay during COVID-19. A PICUMS<18 at ICU discharge may indicate impaired physical functioning due to ICUAW.

Is There a Relationship Between Epicardial Adipose Tissue, Inflammatory Markers, and the Severity of COVID-19 Pneumonia?

Objectives

Epicardial adipose tissue (EAT) is a type of visceral adipose tissue with pro-inflammatory properties. We sought to examine the relationship between the EAT volume and attenuation measured on non-contrast chest computed tomography (CT), inflammation markers, and the severity of COVID-19 pneumonia.

Methods

One hundred and twenty-five patients who are over 18 years old who applied to our hospital and were found to have COVID-19 polymerase chain reaction (+) on nasopharyngeal swab sample and COVID-19 pneumonia on chest CT were included in the study. At admission, C-reactive protein (CRP), procalcitonin, fibrinogen, leukocytes, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lactate dehydrogenase (LDH), ferritin, and d-dimer were evaluated. EAT volume and attenuation were measured on chest CT. Patients who were hospitalized and discharged from the ward were categorized as Group 1, whereas patients who required intensive care admission and/or died were classified as Group 2. The primary endpoint of our study was defined as death, hospitalization in the intensive care unit, and discharge. The relationship between disease severity and EAT and other inflammatory markers was investigated.

Results

One hundred and six individuals were in Group 1 and 19 patients were in Group 2. Of the 125 individuals, 46 were women and 79 were men. The mean age was 58.5±15.9 years. Group 2 patients were older. Regarding measurements of the EAT volume and attenuation; there was no statistically significant difference between the groups determined. The patients in Group 2 had statistically substantially higher values for urea, creatinine, LDH, d-dimer, troponin T, procalcitonin, CRP, and neutrophil/lymphocyte ratio in their laboratory tests. When compared to patients in Group 1, patients in Group 2 had statistically significantly lower albumin values (p<0.001). In obese patients, EAT volume was statistically significantly higher and EAT attenuation was found to be lower.

Conclusion

In our study, no relationship was found between critical COVID-19 disease and EAT volume and attenuation, which is an indicator of EAT inflammation. Inflammatory markers from routine laboratory tests can be used to predict critical COVID-19 disease. No relationship was found between obesity and critical COVID-19 disease.

ABO Blood Type and Metabolic Markers in COVID-19 Susceptibility and Severity: A Cross-Sectional Study

Background and Aims: To evaluate the effect of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus on the function and metabolic changes, as well as the relationship of the virus with blood groups. Methods and Results: This cross-sectional study included a matched sample of adult individuals with coronavirus disease 2019 (COVID-19) (n = 114) or without (controls; n = 236). Blood samples were collected and processed for triglycerides (TGs), total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, and blood typing analysis. The results showed that subjects with COVID-19 had higher TG and lower HDL-C levels compared with the control group. As for blood typing, the risk of COVID-19 was higher in subjects with blood group A than in those with blood group B and in those with other blood groups. In addition, an association of COVID-19 with blood type and Rh A- was observed. When related to the severity of COVID-19 symptoms, blood type A was more protective against moderate/severe symptoms compared with blood type O. In addition, individuals with blood type O were 2.90 times more likely to have symptoms moderate/severe symptoms of COVID-19 than those with other blood groups and individuals with type A blood were less likely to have severe/moderate symptoms of COVID-19 compared with individuals without type A blood. Conclusion: The results suggest that blood type may play a role in susceptibility to SARS-CoV-2 infection and add evidence that infection with the novel coronavirus may be associated with changes in lipid metabolism.

Obesity Paradox in Lung Diseases: What Explains It?

BACKGROUND

Obesity is a globally increasing health problem that impacts multiple organ systems and a potentially modifiable risk factor for many diseases. Obesity has a significant impact on lung function and is strongly linked to the pathophysiology that contributes to lung diseases. On the other hand, reports have emerged that obesity is associated with a better prognosis than for normal weight individuals in some lung diseases, including pneumonia, acute lung injury/acute respiratory distress syndrome, chronic obstructive pulmonary disease, and lung cancer. The lesser mortality and better prognosis in patients with obesity is known as obesity paradox. While obesity paradox is both recognized and disputed in epidemiological studies, recent research has suggested possible mechanisms.

SUMMARY

In this review, we attempted to explain and summarize these factors and mechanisms, including immune response, pulmonary fibrosis, lung function, microbiota, fat and muscle reserves, which are significantly altered by obesity and may contribute to the obesity paradox in lung diseases. We also discuss contrary literature that attributes the "obesity paradox" to confounding.

KEY MESSAGES

The review will illustrate the possible role of obesity in the prognosis or course of lung diseases, leading to a better understanding of the obesity paradox and provide hints for further basic and clinical research in lung diseases.

Body Mass Index and Cause-Specific Mortality after Lung Transplantation in the United States

Rationale: Low and high body mass index (BMI) are associated with increased mortality after lung transplantation. Why extremes of BMI might increase risk of death is unknown. Objectives: To estimate the association of extremes of BMI with causes of death after transplantation. Methods: We performed a retrospective study of the United Network for Organ Sharing database, including 26,721 adults who underwent lung transplantation in the United States between May 4, 2005, and December 2, 2020. We mapped 76 reported causes of death into 16 distinct groups. We estimated cause-specific hazards for death from each cause using Cox models. Results: Relative to a subject with a BMI of 24 kg/m2, a subject with a BMI of 16 kg/m2 had 38% (hazard ratio [HR], 1.38; 95% confidence interval [95% CI], 0.99-1.90), 82% (HR, 1.82; 95% CI, 1.34-2.46), and 62% (HR, 1.62; 95% CI, 1.18-2.22) increased hazards of death from acute respiratory failure, chronic lung allograft dysfunction (CLAD), and infection, respectively, and a subject with a BMI of 36 kg/m2 had 44% (HR, 1.44; 95% CI, 0.97-2.12), 42% (HR, 1.42; 95% CI, 0.93-2.15), and 185% (HR, 2.85; 95% CI, 1.28-6.33) increased hazards of death from acute respiratory failure, CLAD, and primary graft dysfunction, respectively. Conclusions: Low BMI is associated with increased risk of death from infection, acute respiratory failure, and CLAD after lung transplantation, whereas high BMI is associated with increased risk of death from primary graft dysfunction, acute respiratory failure, and CLAD.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

AUTHORS' CONCLUSIONS

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

Lifestyle Changes during the SARS-CoV-2 Pandemic as Predictors of BMI Changes among Men and Women in Poland

BACKGROUND

Social isolation during the SARS-CoV-2 pandemic affected people's body weight, therefore, this study was designed to evaluate the association between lifestyle elements and the change in BMI during lockdown.

METHODS

This retrospective observational study involved 290 questionnaires completed by adult participants divided into three groups according to BMI change during isolation. The structured questionnaire included a general description of the study objective and collected data regarding sociodemographics, anthropometrics, physical activity, sedentary behaviour, sleep duration, and food intake pre- and during COVID-19 lockdown.

RESULTS

A decrease or increase in BMI was found in 23.6% and 47.8% of women and 18.5% and 42.6% of men, respectively. Among those who lost weight, 46.5% of women and 40% of men followed a diet of their own choice, 30.2% of women and 25% of men changed their product mix and reduced their intake, 40% of men stopped eating outside the home. An increase in BMI was associated with increased food intake (32.2% of women and 28.3% of men), increased sleep duration on weekdays (49.2% of women and 43.5% of men) and, in more than 50% of subjects, decreased physical activity. In women, increased BMI was associated with the highest frequency of snacking (p = 0.0003), the highest intake of sweets (p = 0.0021), and in men with the highest intake of alcohol (p = 0.0017).

CONCLUSIONS

The observed changes in BMI during social isolation were the result of lifestyle modifications including dietary behaviour and differed by gender.

Global prevalence and effect of comorbidities and smoking status on severity and mortality of COVID-19 in association with age and gender: a systematic review, meta-analysis and meta-regression

A COVID-19 patient often presents with multiple comorbidities and is associated with adverse outcomes. A comprehensive assessment of the prevalence of comorbidities in patients with COVID-19 is essential. This study aimed to assess the prevalence of comorbidities, severity and mortality with regard to geographic region, age, gender and smoking status in patients with COVID-19. A systematic review and multistage meta-analyses were reported using PRISMA guidelines. PubMed/MEDLINE, SCOPUS, Google Scholar and EMBASE were searched from January 2020 to October 2022. Cross-sectional studies, cohort studies, case series studies, and case-control studies on comorbidities reporting among the COVID-19 populations that were published in English were included. The pooled prevalence of various medical conditions in COVID-19 patients was calculated based on regional population size weights. Stratified analyses were performed to understand the variations in the medical conditions based on age, gender, and geographic region. A total of 190 studies comprising 105 million COVID-19 patients were included. Statistical analyses were performed using STATA software, version 16 MP (StataCorp, College Station, TX). Meta-analysis of proportion was performed to obtain pooled values of the prevalence of medical comorbidities: hypertension (39%, 95% CI 36-42, n = 170 studies), obesity (27%, 95% CI 25-30%, n = 169 studies), diabetes (27%, 95% CI 25-30%, n = 175), and asthma (8%, 95% CI 7-9%, n = 112). Moreover, the prevalence of hospitalization was 35% (95% CI 29-41%, n = 61), intensive care admissions 17% (95% CI 14-21, n = 106), and mortality 18% (95% CI 16-21%, n = 145). The prevalence of hypertension was highest in Europe at 44% (95% CI 39-47%, n = 68), obesity and diabetes at 30% (95% CI, 26-34, n = 79) and 27% (95%CI, 24-30, n = 80) in North America, and asthma in Europe at 9% (95% CI 8-11, n = 41). Obesity was high among the ≥ 50 years (30%, n = 112) age group, diabetes among Men (26%, n = 124) and observational studies reported higher mortality than case-control studies (19% vs. 14%). Random effects meta-regression found a significant association between age and diabetes (p < 0.001), hypertension (p < 0.001), asthma (p < 0.05), ICU admission (p < 0.05) and mortality (p < 0.001). Overall, a higher global prevalence of hypertension (39%) and a lower prevalence of asthma (8%), and 18% of mortality were found in patients with COVID-19. Hence, geographical regions with respective chronic medical comorbidities should accelerate regular booster dose vaccination, preferably to those patients with chronic comorbidities, to prevent and lower the severity and mortality of COVID-19 disease with novel SARS-CoV-2 variants of concern (VOC).

Mortality in COVID-19 older patients hospitalized in a geriatric ward: Is obesity protective?

BACKGROUNDS

To investigate the relationship between obesity and 30-day mortality in a cohort of older hospitalized COVID-19 inpatients.

METHODS

Included patients were aged 70 years or more; hospitalized in acute geriatric wards between March and December 2020; with a positive PCR for COVID-19; not candidate to intensive care unit admission. Clinical data were collected from patients electronic medical records. Data on 30-day mortality were retrieved from the hospital administrative database.

RESULTS

Patients included (N = 294) were on average 83.4 ± 6.7 years old, 50.7% were women, and 21.7% were obese (BMI > 30 kg/m²). At 30-day, 85 (28.9%) patients were deceased. Compared to survivors in bivariable analysis, deceased patients were older (84.6 ± 7.6 vs 83.0 ± 6.3 years), more frequently with very complex health status (63.5% vs 39.7%, P < .001), but less frequently obese (13.4% vs 24.9%, P = .033) at admission. Over their stay, deceased patients more frequently (all P < .001) developed radiologic signs of COVID-19 (84.7% vs 58.9%), anorexia (84.7% vs 59.8%), hypernatremia (40.0% vs 10.5%), delirium (74.1% vs 30.1%), and need for oxygen (87.1% vs 46.4%) compared to survivors. In multivariable analysis that controlled for all markers of poor prognosis identified in bivariable analysis, obese patients remain with 64% (adjOR 0.36, 95%CI 0.14-0.95, P = .038) lower odds to be deceased at 30-day than non-obese patients.

CONCLUSIONS

In this population of older COVID-19 inpatients, an inverse association between obesity and 30-day mortality was observed even after adjusting for all already-known markers of poor prognosis. This result challenges previous observations in younger cohorts and would need to be replicated.

A method for comparing multiple imputation techniques: A case study on the U.S. national COVID cohort collaborative

Healthcare datasets obtained from Electronic Health Records have proven to be extremely useful for assessing associations between patients' predictors and outcomes of interest. However, these datasets often suffer from missing values in a high proportion of cases, whose removal may introduce severe bias. Several multiple imputation algorithms have been proposed to attempt to recover the missing information under an assumed missingness mechanism. Each algorithm presents strengths and weaknesses, and there is currently no consensus on which multiple imputation algorithm works best in a given scenario. Furthermore, the selection of each algorithm's parameters and data-related modeling choices are also both crucial and challenging. In this paper we propose a novel framework to numerically evaluate strategies for handling missing data in the context of statistical analysis, with a particular focus on multiple imputation techniques. We demonstrate the feasibility of our approach on a large cohort of type-2 diabetes patients provided by the National COVID Cohort Collaborative (N3C) Enclave, where we explored the influence of various patient characteristics on outcomes related to COVID-19. Our analysis included classic multiple imputation techniques as well as simple complete-case Inverse Probability Weighted models. Extensive experiments show that our approach can effectively highlight the most promising and performant missing-data handling strategy for our case study. Moreover, our methodology allowed a better understanding of the behavior of the different models and of how it changed as we modified their parameters. Our method is general and can be applied to different research fields and on datasets containing heterogeneous types.

Obesity Is Associated with Attenuated Tissue Immunity in COVID-19

Rationale: Obesity affects 40% of U.S. adults, is associated with a proinflammatory state, and presents a significant risk factor for the development of severe coronavirus disease (COVID-19). To date, there is limited information on how obesity might affect immune cell responses in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Objectives: To determine the impact of obesity on respiratory tract immunity in COVID-19 across the human lifespan. Methods: We analyzed single-cell transcriptomes from BAL in three ventilated adult cohorts with (n = 24) or without (n = 9) COVID-19 from nasal immune cells in children with (n = 14) or without (n = 19) COVID-19, and from peripheral blood mononuclear cells in an independent adult COVID-19 cohort (n = 42), comparing obese and nonobese subjects. Measurements and Main Results: Surprisingly, we found that obese adult subjects had attenuated lung immune or inflammatory responses in SARS-CoV-2 infection, with decreased expression of IFN-α, IFN-γ, and TNF-α (tumor necrosis factor α) response gene signatures in almost all lung epithelial and immune cell subsets, and lower expression of IFNG and TNF in specific lung immune cells. Peripheral blood immune cells in an independent adult cohort showed a similar but less marked reduction in type-I IFN and IFNγ response genes, as well as decreased serum IFNα, in obese patients with SARS-CoV-2. Nasal immune cells from obese children with COVID-19 also showed reduced enrichment of IFN-α and IFN-γ response genes. Conclusions: These findings show blunted tissue immune responses in obese patients with COVID-19, with implications for treatment stratification, supporting the specific application of inhaled recombinant type-I IFNs in this vulnerable subset.

The Role of Nutrition in Mitigating the Effects of COVID-19 from Infection through PASC

The expansive and rapid spread of the SARS-CoV-2 virus has resulted in a global pandemic of COVID-19 infection and disease. Though initially perceived to be acute in nature, many patients report persistent and recurrent symptoms beyond the infectious period. Emerging as a new epidemic, "long-COVID", or post-acute sequelae of coronavirus disease (PASC), has substantially altered the lives of millions of people globally. Symptoms of both COVID-19 and PASC are individual, but share commonality to established respiratory viruses, which include but are not limited to chest pain, shortness of breath, fatigue, along with adverse metabolic and pulmonary health effects. Nutrition plays a critical role in immune function and metabolic health and thus is implicated in reducing risk or severity of symptoms for both COVID-19 and PASC. However, despite the impact of nutrition on these key physiological functions related to COVID-19 and PASC, the precise role of nutrition in COVID-19 infection and PASC onset or severity remains to be elucidated. This narrative review will discuss established and emerging nutrition approaches that may play a role in COVID-19 and PASC, with references to the established nutrition and clinical practice guidelines that should remain the primary resources for patients and practitioners.

Rationing scarce healthcare capacity: A study of the ventilator allocation guidelines during the COVID-19 pandemic

In the United States, even though national guidelines for allocating scarce healthcare resources are lacking, 26 states have specific ventilator allocation guidelines to be invoked in case of a shortage. While several states developed their guidelines in response to the recent COVID-19 pandemic, New York State developed these guidelines in 2015 as "pandemic influenza is a foreseeable threat, one that we cannot ignore." The primary objective of this study is to assess the existing procedures and priority rules in place for allocating/rationing scarce ventilator capacity and propose alternative (and improved) priority schemes. We first build machine learning models using inpatient records of COVID-19 patients admitted to New York-Presbyterian/Columbia University Irving Medical Center and an affiliated community health center to predict survival probabilities as well as ventilator length-of-use. Then, we use the resulting point estimators and their uncertainties as inputs for a multiclass priority queueing model with abandonments to assess three priority schemes: (i) SOFA-P (Sequential Organ Failure Assessment based prioritization), which most closely mimics the existing practice by prioritizing patients with sufficiently low SOFA scores; (ii) ISP (incremental survival probability), which assigns priority based on patient-level survival predictions; and (iii) ISP-LU (incremental survival probability per length-of-use), which takes into account survival predictions and resource use duration. Our findings highlight that our proposed priority scheme, ISP-LU, achieves a demonstrable improvement over the other two alternatives. Specifically, the expected number of survivals increases and death risk while waiting for ventilator use decreases. We also show that ISP-LU is a robust priority scheme whose implementation yields a Pareto-improvement over both SOFA-P and ISP in terms of maximizing saved lives after mechanical ventilation while limiting racial disparity in access to the priority queue.

BMI-adjusted adipose tissue volumes exhibit depot-specific and divergent associations with cardiometabolic diseases

For any given body mass index (BMI), individuals vary substantially in fat distribution, and this variation may have important implications for cardiometabolic risk. Here, we study disease associations with BMI-independent variation in visceral (VAT), abdominal subcutaneous (ASAT), and gluteofemoral (GFAT) fat depots in 40,032 individuals of the UK Biobank with body MRI. We apply deep learning models based on two-dimensional body MRI projections to enable near-perfect estimation of fat depot volumes (R2 in heldout dataset = 0.978-0.991 for VAT, ASAT, and GFAT). Next, we derive BMI-adjusted metrics for each fat depot (e.g. VAT adjusted for BMI, VATadjBMI) to quantify local adiposity burden. VATadjBMI is associated with increased risk of type 2 diabetes and coronary artery disease, ASATadjBMI is largely neutral, and GFATadjBMI is associated with reduced risk. These results - describing three metabolically distinct fat depots at scale - clarify the cardiometabolic impact of BMI-independent differences in body fat distribution.

Direct Extubation to High-Flow Nasal Cannula versus Noninvasive Ventilation in Obese Subjects

BACKGROUND

Patients who are obese have a higher risk of acute respiratory failure after extubation in the ICU. This study aimed to compare the extubation of subjects who were critically ill and obese to high-flow nasal cannula (HFNC) versus noninvasive ventilation (NIV) to determine whether HFNC can aid in reducing postextubation respiratory failure and the re-intubation rate.

METHODS

In this randomized controlled trial, subjects who were obese, defined as individuals with a body mass index ≥ 30 kg/m2, were randomly assigned to receive HFNC (n = 60) versus 60 subjects treated with NIV applied immediately after extubation. The primary outcome was the incidence of postextubation respiratory failure and re-intubation rate within 72 h. Secondary outcomes included oxygenation, breathing frequency, subjective dyspnea, ICU and hospital length of stay, and ICU mortality at day 28.

RESULTS

Compared with NIV, HFNC reduced the risk of respiratory failure by 8.4%, 95% CI 6.2-12.8%. Even though the rate of re-intubation was lower in the HFNC group versus in the NIV group, no statistical significance was observed (11.6% vs 16.6%; difference 5%, 95% CI 2.5%-8.2%). In 48-h periods and 72 h after extubation, the mean PaO2 /FIO2 significantly increased in the HFNC group compared with the NIV group. Both groups had low dyspnea levels 72 h after extubation. No difference was detected between the groups in breathing frequency. In addition, the 2 groups had no significant difference in ICU and hospital length of stay. The HFNC and NIV groups had comparable hospital mortality rates. The multivariable logistic regression analysis revealed the presence of severe obesity, comorbidities, a higher severity score, and hypercapnia remained as factors associated with an increased risk of re-intubation.

CONCLUSIONS

Postextubation application of HFNC may prevent respiratory failure in patients who are obese. (ClinicalTrials.gov registration NCT04035351.).

[Risk factors at admission associated with intubation in patients with COVID-19]

Background

Intubation rates up to 33% have been found in patients diagnosed with COVID-19. Some cohorts have reported the presence of dyspnea in 84.1% of intubated patients, being this the only symptom associated with intubation. Oxygen saturation < 90% and increased respiratory rate have also been described as predictors of intubation.

Objective

To analyze the risk factors associated with intubation in patients hospitalized for COVID-19 at their admission.

Material and methods

An observational, retrospective, analytical, cross-sectional study was carried out. The universe of study consisted of patients over 18 years of age hospitalized due to a diagnosis of SARS-CoV-2 virus infection from April 1, 2020 to April 31, 2021 in the Hospital de Especialidades (Specialties Hospital) "Dr. Bernardo Sepúlveda Gutiérrez" at the National Medical Center.

Results

The mean age of intubated patients was 59.17 years (95% confidence interval [95% CI] -9.994 to -3.299, p < 0.001). Overall, 76.7% (230) of patients had a history of one or more preexisting comorbidities, including hypertension in 42.3% (127), obesity in 36.7% (110), and diabetes mellitus in 34.3% (103).

Conclusions

The main clinical characteristics of patients hospitalized for COVID-19 in our center who required intubation are very similar to those observed in different centers, including male sex, age over 50 years and obesity, which were the most common.

Influence of obesity on incidence of thrombosis and disease severity in patients with COVID-19: From the CLOT-COVID study

BACKGROUND

The influence of obesity on the development of thrombosis and severity of coronavirus disease 2019 (COVID-19) remains unclear.

METHOD

The CLOT-COVID study was a retrospective multicenter cohort study enrolling 2894 consecutive hospitalized patients with COVID-19 between April 2021 and September 2021 among 16 centers in Japan. The present study consisted of 2690 patients aged over 18 years with available body mass index (BMI), who were divided into an obesity group (BMI ≥30) (N = 457) and a non-obesity group (BMI <30) (N = 2233).

RESULTS

The obesity group showed more severe status of COVID-19 at admission compared with the non-obesity group. The incidence of thrombosis was not significantly different between the groups (obesity group: 2.6 % versus non-obesity group: 1.9 %, p = 0.39), while the incidence of a composite outcome of all-cause death, or requirement of mechanical ventilation or extracorporeal membrane oxygenation during hospitalization was significantly higher in the obesity group (20.1 % versus 15.0 %, p < 0.01). After adjusting confounders in the multivariable logistic regression model, the risk of obesity relative to non-obesity for thrombosis was not significant (adjusted OR, 1.39; 95 % CI, 0.68-2.84, p = 0.37), while the adjusted risk of obesity relative to non-obesity for the composite outcome was significant (adjusted OR, 1.85; 95 % CI, 1.39-2.47, p < 0.001).

CONCLUSIONS

In the present large-scale observational study, obesity was not significantly associated with the development of thrombosis during hospitalization; however, it was associated with severity of COVID-19.

Clinical significance of prediabetes, undiagnosed diabetes and diagnosed diabetes on critical outcomes in COVID-19: Integrative analysis from the Japan COVID-19 task force

AIM

Diabetes mellitus (DM) is a known risk factor for severe coronavirus disease 2019 (COVID-19), but the clinical impact of undiagnosed diabetes and prediabetes in COVID-19 are unclear particularly in Japan. We clarify the difference in clinical characteristics, including age, sex, body mass index and co-morbidities, laboratory findings and critical outcomes, in a large Japanese COVID-19 cohort without diabetes, with prediabetes, undiagnosed diabetes and diagnosed diabetes, and to identify associated risk factors.

MATERIALS AND METHODS

This multicentre, retrospective cohort study used the Japan COVID-19 Task Force database, which included data on 2430 hospitalized COVID-19 patients from over 70 hospitals from February 2020 to October 2021. The prevalence of prediabetes, undiagnosed diabetes and diagnosed diabetes were estimated based on HbA1c levels or a clinical diabetes history. Critical outcomes were defined as the use of high-flow oxygen, invasive positive-pressure ventilation or extracorporeal membrane oxygenation, or death during hospitalization.

RESULTS

Prediabetes, undiagnosed diabetes and diagnosed diabetes were observed in 40.9%, 10.0% and 23.0%, respectively. Similar to diagnosed diabetes, prediabetes and undiagnosed diabetes were risk factors for critical COVID-19 outcomes (adjusted odds ratio [aOR] [95% CI]: 2.13 [1.31-3.48] and 4.00 [2.19-7.28], respectively). HbA1c was associated with COVID-19 severity in prediabetes patients (aOR [95% CI]: 11.2 [3.49-36.3]), but not other groups.

CONCLUSIONS

We documented the clinical characteristics and outcomes of Japanese COVID-19 patients according to HbA1c levels or diabetes co-morbidity. As well as undiagnosed and diagnosed diabetes, physicians should be aware of prediabetes related to COVID-19 severity.

Effect of Obesity on Clinical Outcomes in COVID-19 Patients

Background Obesity is a well-known risk factor for developing severe coronavirus disease 2019 (COVID-19). In this study, we sought to determine the relationship between obesity and poor outcomes in patients with COVID-19 patients at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Methods We conducted a single-centered descriptive study of adult COVID-19 patients hospitalized between March 1 and December 31, 2020, at KAUH. Patients were classified according to body mass index (BMI) as overweight (BMI 25-29.9 kg/m²) or obese (BMI ≥30 kg/m²). The main outcomes were admission to the intensive care unit (ICU), intubation, and death. Results Data were analyzed from 300 COVID-19 patients. Most study participants were overweight (61.8%), and 38.2% were obese. The most significant comorbidities were diabetes (46.8%) and hypertension (41.9%). Both hospital mortality (10.4% for obese; 3.8% for overweight, p = 0.021) and intubation rates (34.6% for obese; 22.7% for overweight, p = 0.004) were significantly higher among obese patients than overweight patients. There was no significant difference in terms of ICU admission rate between both groups. However, intubation rates (34.6% for obese; 22.7% for overweight, p = 0.004) and hospital mortality (10.4% for obese; 3.8% for overweight, p = 0.021) were significantly higher among obese patients than overweight patients. Conclusions This study aimed to describe the effect of high BMI on the clinical outcome of COVID-19 patients in Saudi Arabia. Obesity is significantly correlated with poor clinical outcomes in COVID-19. It is also associated with higher mortality and the need for mechanical ventilation necessitating intensive care unit admission. Patients with higher BMI should be prioritized in the hospital setting, as they have a higher potential of developing severe COVID-19 complications and sequelae.

Vitamin C as a Potential Interplaying Factor between Obesity and COVID-19 Outcome

(1) Background: Obesity is a risk factor for severe COVID-19 outcomes. Obesity can interfere with the action of vitamin C. The study aimed to investigate the association between BMI and severe outcomes of COVID-19 while considering vitamin C levels; (2) Methods: This was a retrospective study of 63 COVID-19 patients treated at the NMC Royal Hospital, United Arab Emirates; (3) Results: There was no significant difference in vitamin C levels among patients in all BMI categories (p > 0.05). The risk of severe COVID-19 significantly increased by 5.4 times among class 1 obese patients compared with normal BMI (OR = 5.40, 95%CI: (1.54−21.05), p = 0.010). Vitamin C did not affect the risk of COVID-19 severity or mortality across BMI categories (p = 0.177, p > 0.05, respectively). The time till viral clearance was significantly different among patients in different BMI categories when vitamin C levels were considered (p = 0.02). Although there was no significant difference in vitamin C levels across BMI categories, there was a significant interaction between vitamin C levels and viral clearance rate in obese patients; (4) Conclusions: Given the safety of vitamin C supplements and our findings, proper vitamin C uptake and supplementation for patients of various BMI levels are encouraged.

Soluble Urokinase Plasminogen Activator Receptor and Venous Thromboembolism in COVID-19

Background Venous thromboembolism (VTE) contributes significantly to COVID-19 morbidity and mortality. The urokinase receptor system is involved in the regulation of coagulation. Levels of soluble urokinase plasminogen activator receptor (suPAR) reflect hyperinflammation and are strongly predictive of outcomes in COVID-19. Whether suPAR levels identify patients with COVID-19 at risk for VTE is unclear. Methods and Results We leveraged a multinational observational study of patients hospitalized for COVID-19 with suPAR and D-dimer levels measured on admission. In 1960 patients (mean age, 58 years; 57% men; 20% Black race), we assessed the association between suPAR and incident VTE (defined as pulmonary embolism or deep vein thrombosis) using logistic regression and Fine-Gray modeling, accounting for the competing risk of death. VTE occurred in 163 (8%) patients and was associated with higher suPAR and D-dimer levels. There was a positive association between suPAR and D-dimer (β=7.34; P=0.002). Adjusted for clinical covariables, including D-dimer, the odds of VTE were 168% higher comparing the third with first suPAR tertiles (adjusted odds ratio, 2.68 [95% CI, 1.51-4.75]; P<0.001). Findings were consistent when stratified by D-dimer levels and in survival analysis accounting for death as a competing risk. On the basis of predicted probabilities from random forest, a decision tree found the combined D-dimer <1 mg/L and suPAR <11 ng/mL cutoffs, identifying 41% of patients with only 3.6% VTE probability. Conclusions Higher suPAR was associated with incident VTE independently of D-dimer in patients hospitalized for COVID-19. Combining suPAR and D-dimer identified patients at low VTE risk. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04818866.

Allograft inflammatory factor-1-like is a situational regulator of leptin levels, hyperphagia, and obesity

Mouse models enable the study of genetic factors affecting the complex pathophysiology of metabolic disorders. Here, we identify reductions in leptin levels, food intake, and obesity due to high-fat diet, accompanied by increased leptin sensitivity, in mice that harbor the E2a-Cre transgene within Obrq2, an obesity quantitative trait locus (QTL) that includes the leptin gene. Interestingly, loss of allograft inflammatory factor-1-like (AIF1L) protein in these transgenic mice leads to similar leptin sensitivity, yet marked reversal of the obesity phenotype, with accelerated weight gain and increased food intake. Transgenic mice lacking AIF1L also have low circulating leptin, which suggests that benefits of enhanced leptin sensitivity are lost with further impairment of leptin expression due to loss of AIF1L. Together, our results identify AIF1L as a genetic modifier of Obrq2 and leptin that affects leptin levels, food intake, and obesity during the metabolic stress imposed by HFD.

Reduction in risk of death among patients admitted with COVID-19 between first and second epidemic waves in New York City

Background

Many regions have experienced successive epidemic waves of COVID-19 since the emergence of SARS-CoV-2 with heterogeneous differences in mortality. Elucidating factors differentially associated with mortality between epidemic waves may inform clinical and public health strategies.

Methods

We examined clinical and demographic data among patients admitted with COVID-19 during the first (March-August 2020) and second (August 2020-March 2021) epidemic waves at an academic medical center in New York City.

Results

Hospitalized patients (N = 4631) had lower overall and 30-day in-hospital mortality, defined as death or discharge to hospice, during the second wave (14% and 11%) than the first (22% and 21%). The wave 2 in-hospital mortality decrease persisted after adjusting for several potential confounders. Adjusting for the volume of COVID-19 admissions, a measure of health system strain, accounted for the mortality difference between waves. Several demographic and clinical patient factors were associated with an increased risk of mortality independent of wave; SARS-CoV-2 cycle threshold, Do-Not-Intubate status, oxygen requirement, and intensive care unit admission.

Conclusions

This work suggests that increased in-hospital mortality rates observed during the first epidemic wave were partly due to strain on hospital resources. Preparations for future epidemics should prioritize evidence-based patient risks, treatment paradigms, and approaches to augment hospital capacity.

MAGI1 inhibits interferon signaling to promote influenza A infection

We have shown that membrane-associated guanylate kinase with inverted domain structure-1 (MAGI1), a scaffold protein with six PSD95/DiscLarge/ZO-1 (PDZ) domains, is involved in the regulation of endothelial cell (EC) activation and atherogenesis in mice. In addition to causing acute respiratory disease, influenza A virus (IAV) infection plays an important role in atherogenesis and triggers acute coronary syndromes and fatal myocardial infarction. Therefore, the aim of this study is to investigate the function and regulation of MAGI1 in IAV-induced EC activation. Whereas, EC infection by IAV increases MAGI1 expression, MAGI1 depletion suppresses IAV infection, suggesting that the induction of MAGI1 may promote IAV infection. Treatment of ECs with oxidized low-density lipoprotein (OxLDL) increases MAGI1 expression and IAV infection, suggesting that MAGI1 is part of the mechanistic link between serum lipid levels and patient prognosis following IAV infection. Our microarray studies suggest that MAGI1-depleted ECs increase protein expression and signaling networks involve in interferon (IFN) production. Specifically, infection of MAGI1-null ECs with IAV upregulates expression of signal transducer and activator of transcription 1 (STAT1), interferon b1 (IFNb1), myxovirus resistance protein 1 (MX1) and 2'-5'-oligoadenylate synthetase 2 (OAS2), and activate STAT5. By contrast, MAGI1 overexpression inhibits Ifnb1 mRNA and MX1 expression, again supporting the pro-viral response mediated by MAGI1. MAGI1 depletion induces the expression of MX1 and virus suppression. The data suggests that IAV suppression by MAGI1 depletion may, in part, be due to MX1 induction. Lastly, interferon regulatory factor 3 (IRF3) translocates to the nucleus in the absence of IRF3 phosphorylation, and IRF3 SUMOylation is abolished in MAGI1-depleted ECs. The data suggests that MAGI1 inhibits IRF3 activation by maintaining IRF3 SUMOylation. In summary, IAV infection occurs in ECs in a MAGI1 expression-dependent manner by inhibiting anti-viral responses including STATs and IRF3 activation and subsequent MX1 induction, and MAGI1 plays a role in EC activation, and in upregulating a pro-viral response. Therefore, the inhibition of MAGI1 is a potential therapeutic target for IAV-induced cardiovascular disease.

Effects of mild obesity on outcomes in Japanese patients with COVID-19: a nationwide consortium to investigate COVID-19 host genetics

BACKGROUND

Obesity is reported to be a risk factor for severe disease in patients with coronavirus disease 2019 (COVID-19). However, there are no specific reports on the risk of severe disease according to body mass index (BMI) in Japan. Thus, this study aimed to investigate the effect of obesity stratified by BMI on the severity of COVID-19 in the general Japanese population.

METHODS

From February 2020 to May 2021, 1 837 patients aged ≥18 years were enrolled in the Japan COVID-19 Task Force. Patients with known BMI and disease severity were analyzed. Severity was defined as critical if the patient was treated in the intensive care unit, required invasive mechanical ventilation, or died.

RESULTS

Class 1 obesity (25.0 ≤ BMI < 30.0 kg/m²), class 2 obesity (30.0 ≤ BMI < 35.0 kg/m²), and class 3 or 4 obesity (BMI ≥ 35 kg/m²) were present in 29%, 8%, and 3% of the cases, respectively. Multiple logistic regression analysis with known risk factors for critical illness indicated that class 2 obesity was an independent risk factor for oxygenation (adjusted odds ratio, 4.75) and critical cases (adjusted odds ratio, 1.81). Class 1 obesity and class 3 or 4 obesity were independent risk factors for oxygen administration (adjusted odds ratios 2.01 and 3.12, respectively), but not for critical cases. However, no differences in the mortality rates were observed between the BMI classes (P = 0.5104).

CONCLUSION

Obesity is a risk factor for respiratory failure in Japanese patients with COVID-19, regardless of the degree of obesity. However, it may not cause severe COVID-19 in a dose-response relationship with BMI. COVID-19 patients with mild obesity may benefit from aggressive intensive care.

Association of obesity with COVID-19 diseases severity and mortality: A meta-analysis of studies

Background

The literature on COVID-19 infection is growing every single day, and evidence of presence or absence of association between obesity and COVID-19 adverse outcomes should be revisited. Therefore, this study summarizes the pooled association of obesity with COVID-19 adverse outcomes and mortality.

Methods

We searched PubMed and Science direct databases using specific terms and defined criteria. Data were analyzed using Comprehensive Meta-Analysis V2 (Biostat, Englewood, NJ, USA)) random-effect models were used to calculate the odds ratio (OR) with 95% confidence intervals (95% CIs) of infection severity and mortality associated with obesity.

Results

Results revealed that obesity is not associated with COVID-19 mortality (OR = 1.1; 95%CI: 0.8 to 1.3) but with other adverse outcomes (OR = 2.4; 95%CI: 1.7 to 3.3).

Conclusion

Our findings support previous findings that obesity is associated with COVID-19 severity.

COVID-19 and Thrombosis Complication in Children

Since it was discovered in Wuhan in December 2019, most studies on COVID-19 have been centered on symptomatic adults. An expanded pro-inflammatory cytokine reaction, abnormal clot formation, overactive platelets, and hypercoagulable state are among the well-known clinical characteristics of endothelial dysfunction that may arise in patients with COVID-19. These conditions can lead to venous thromboembolism, arterial thrombosis, and pulmonary embolism. To date, the predominance of thromboembolic complications in children infected with severe acute respiratory syndrome coronavirus 2 has not been fully documented, and there is no explicit recommendation for the prevention of thrombosis in children.

Silhouette images enable estimation of body fat distribution and associated cardiometabolic risk

Inter-individual variation in fat distribution is increasingly recognized as clinically important but is not routinely assessed in clinical practice, in part because medical imaging has not been practical to deploy at scale for this task. Here, we report a deep learning model trained on an individual’s body shape outline—or “silhouette” —that enables accurate estimation of specific fat depots of interest, including visceral (VAT), abdominal subcutaneous (ASAT), and gluteofemoral (GFAT) adipose tissue volumes, and VAT/ASAT ratio. Two-dimensional coronal and sagittal silhouettes are constructed from whole-body magnetic resonance images in 40,032 participants of the UK Biobank and used as inputs for a convolutional neural network to predict each of these quantities. Mean age of the study participants is 65 years and 51% are female. A cross-validated deep learning model trained on silhouettes enables accurate estimation of VAT, ASAT, and GFAT volumes (R²: 0.88, 0.93, and 0.93, respectively), outperforming a comparator model combining anthropometric and bioimpedance measures (ΔR² = 0.05–0.13). Next, we study VAT/ASAT ratio, a nearly body-mass index (BMI)—and waist circumference-independent marker of metabolically unhealthy fat distribution. While the comparator model poorly predicts VAT/ASAT ratio (R²: 0.17–0.26), a silhouette-based model enables significant improvement (R²: 0.50–0.55). Increased silhouette-predicted VAT/ASAT ratio is associated with increased risk of prevalent and incident type 2 diabetes and coronary artery disease independent of BMI and waist circumference. These results demonstrate that body silhouette images can estimate important measures of fat distribution, laying the scientific foundation for scalable population-based assessment.

A Myocardial Infarction Following a Mild Case of COVID-19 in a 26-Year-Old Male

A well-known complication of COVID-19 is hypercoagulability in both the venous and arterial circulation. Most cases of hypercoagulability-related complications have been described in hospitalized patients with severe diseases and multiple comorbidities. However, this report outlines a case of myocardial infarction in a young patient with no prior medical history after only a mild course of COVID-19. His symptoms resolved after a mild 12-day illness course that did not require hospitalization or supplemental oxygen. Three days after the resolution of his symptoms (15 days after testing positive), the patient presented to the emergency department with crushing chest pain and was found to have complete thrombotic occlusion of his left anterior descending artery. Hypercoagulability in COVID-19 patients is suspected to be caused by vascular endothelial injury and cytokine storm. This has been demonstrated in the arterial and venous circulation, as seen in histopathology samples as well as increased incidence of acute limb ischemia in COVID-19 patients. Additionally, COVID-19 is known to have myocardial involvement, as demonstrated by elevations in cardiac enzymes and cardiac imaging findings that may persist months after initial infection. Those affected by COVID-19 may have dangerous cardiovascular complications that persist after the resolution of the acute viral illness.

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.