Association between body-mass index,patient characteristics,and obesity-related comorbidities among COVID-19 patients: A prospective cohort study

ObjectiveObesity is a major risk factor for adverse outcomes after COVID-19 infection. However, it is unknown if the worse outcomes are due to the confounding effect of demographic and obesity-related comorbidities. The study objective is to analyze associations between body mass index, patient characteristics, obesity-related comorbidity, and clinical outcomes in COVID-19 patients.MethodsIn this prospective cohort study, we chose patient records between March 1st, 2020, and December 1st, 2022, in a large tertiary care center in southeast Wisconsin in the United States. Patients over the age of 18 who tested positive were included in the study. Clinical outcomes included hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and mortality rates. We examined the characteristics of patients who had positive clinical outcomes. We created unadjusted logistic regression models, sequentially adjusting for demographic and comorbidity variables, to assess the independent associations between BMI, patient characteristics, obesity-related comorbidities, and clinical outcomes.ResultsFrom a record of 1.67 million inpatients and outpatients at Froedtert Health Center, 55,299 (BMI: 30.5 ± 7.4 kg/m², 62.5 % female) tested COVID-19 positive during the study period. 17,580 (31.8 %) patients were admitted to hospitals, and of hospitalized patients required ICU admission. 1038 (36.3 %) required mechanical ventilation, and 462 (44.5 %) died after a positive test for COVID-19. We found female patients show a higher hospitalization rate, while male patients have a higher rate of ICU admission, mechanical ventilation, and mortality. Obesity-related comorbidities are associated with worse outcomes compared to simple obesity without comorbidities. In logistic regression models, we found four similar V-shaped associations between BMI and four clinical outcomes. Patients with a BMI of 25 kg/m² are at the lowest risk for clinical outcomes. Patients with a BMI lower than 18 kg/m² or higher than 30 kg/m² are associated with a higher risk of hospitalization, ICU, mechanical ventilation, and death. After adjusting the model for demographic factors and hypertension and diabetes as two common comorbidities, we found that demographic factors do not significantly increase the risk. Obesity alone does not significantly increase the risk of severe clinical outcomes. Obesity-related comorbidities, on the other hand, resulted in a significantly higher risk of outcomes.ConclusionObesity alone does not increase the risk of worse clinical outcomes after COVID-19 infection. It may suggest that the worse clinical outcomes of patients with obesity are mediated via hypertension and type 2 diabetes. Patients with obesity and comorbidities have a higher risk of poor outcomes. Obesity-related comorbidities, including hypertension and diabetes, are independently associated with poorer clinical outcomes among COVID-19 patients. At a BMI of more than 30 kg/m² or less than 18 kg/m², we found an increase in the risk of severe COVID-19 outcomes leading to hospitalization, ICU, mechanical ventilation, and death. The increased risk of severe outcomes is not attributed to patient characteristics but can be attributed to hypertension and diabetes.     

Does there exist an obesity paradox in COVID-19? Insights of the international HOPE-COVID-19-registry

BackgroundObesity has been described as a protective factor in cardiovascular and other diseases being expressed as ‘obesity paradox’. However, the impact of obesity on clinical outcomes including mortality in COVID-19 has been poorly systematically investigated until now. We aimed to compare clinical outcomes among COVID-19 patients divided into three groups according to the body mass index (BMI).MethodsWe retrospectively collected data up to May 31^st, 2020. 3635 patients were divided into three groups of BMI (<25 kg/m²; n = 1110, 25?30 kg/m²; n = 1464, and >30 kg/m²; n = 1061). Demographic, in-hospital complications, and predictors for mortality, respiratory insufficiency, and sepsis were analyzed.ResultsThe rate of respiratory insufficiency was more recorded in BMI 25?30 kg/m² as compared to BMI < 25 kg/m² (22.8% vs. 41.8%; p < 0.001), and in BMI > 30 kg/m² than BMI < 25 kg/m², respectively (22.8% vs. 35.4%; p < 0.001). Sepsis was more observed in BMI 25?30 kg/m² and BMI > 30 kg/m² as compared to BMI < 25 kg/m², respectively (25.1% vs. 42.5%; p = 0.02) and (25.1% vs. 32.5%; p = 0.006). The mortality rate was higher in BMI 25?30 kg/m² and BMI > 30 kg/m² as compared to BMI < 25 kg/m², respectively (27.2% vs. 39.2%; p = 0.31) (27.2% vs. 33.5%; p = 0.004). In the Cox multivariate analysis for mortality, BMI < 25 kg/m² and BMI > 30 kg/m² did not impact the mortality rate (HR 1.15, 95% CI: 0.889?1.508; p = 0.27) (HR 1.15, 95% CI: 0.893?1.479; p = 0.27). In multivariate logistic regression analyses for respiratory insufficiency and sepsis, BMI < 25 kg/m² is determined as an independent predictor for reduction of respiratory insufficiency (OR 0.73, 95% CI: 0.538?1.004; p = 0.05).ConclusionsHOPE COVID-19-Registry revealed no evidence of obesity paradox in patients with COVID-19. However, Obesity was associated with a higher rate of respiratory insufficiency and sepsis but was not determined as an independent predictor for a high mortality.     

Nutritional risk,not obesity,is associated with mortality in critically ill COVID-19 patients

BackgroundDespite the identification of obesity as a risk factor for higher rates of hospital and Intensive Care Unit (ICU) admissions and complications due to COVID-19, the association between obesity and mortality in critically ill COVID-19 patients remains controversial, and the nutritional risk is little considered. Hence, our study sought to evaluate the association between obesity, nutritional risk, and mortality in critically ill patients diagnosed with COVID-19.MethodsRetrospective study were condutcted including adult critically ill COVID-19 patients admitted to an ICU between April 2020 and March 2021. Clinical and laboratory data were collected from electronic medical records. Obesity was classified by body mass index ≥ 30 kg/m^2. A mNUTRIC score of ≥ 5 indicated high nutritional risk. Multiple Cox Regression was used to estimate the association between mNUTRIC, obesity, and mortality.ResultsFrom 71 patients aged 59 (± 15) years, 71.8 % were male. The frequencies of obesity (58.7 %) and death (49.3 %) were high, but obesity was not associated with mortality. Based on mNUTRIC, 85.9 % of patients were at high nutritional risk, presenting a higher frequency of mortality than patients at low nutritional risk (50.8 % vs 40.0 %; p = 0.014). Multiple Cox Regression showed that for each unit increase in mNUTRIC score the probability of death almost doubled, regardless of the presence of obesity (HR = 1.74; p < 0.001).ConclusionsA higher nutritional risk was positively associated with mortality in critically ill COVID-19 patients, regardless of obesity, showing the importance of early identification of nutritional risk for appropriate nutritional interventions in this population.     

Outcomes of COVID-19: Disparities by ethnicity

ObjectivesTo investigate the role of ethnicity in COVID-19 outcome disparities in a cohort in Kuwait.MethodsThis is a retrospective analysis of 405 individuals infected with SARS-CoV-2 in Kuwait. Outcomes such as symptoms severity and mortality were considered. Multivariate logistic regression models were used to report the odds ratios (OR) for ICU admission and dying from COVID-19.ResultsThe cohort included 290 Arabs and 115 South Asians. South Asians recorded significantly higher COVID-19 death rates compared to Arabs (33% vs. 7.6%, P value<0.001). When compared to Arabs, South Asians also had higher odds of being admitted to the ICU (OR = 6.28, 95% CI: 3.34–11.80, p < 0.001). South Asian patients showed 7.62 (95% CI: 3.62–16.02, p < 0.001) times the odds of dying from COVID-19.ConclusionCOVID-19 patients with South Asians ethnicity in Kuwait are more likely to have worse prognosis and outcome when compared to patients with Arab ethnicity. This suggest a possible role for ethnicity in COVID-19 outcome disparities and this role is likely to be multifactorial.     

Effect of BMI on safety of bariatric surgery during the COVID-19 pandemic,procedure choice,and safety protocols – An analysis from the GENEVA Study

BackgroundIt has been suggested that patients with a Body Mass Index (BMI) of > 60 kg/m² should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach.MethodsWe conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI - Group I (BMI<50 kg/m²), Group II (BMI 50–60 kg/m²), and Group III (BMI>60 kg/m²). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed.ResultsThis study included 7084 patients (5197;73.4 % females). The mean preoperative weight and BMI were 119.49 ± 24.4 Kgs and 43.03 ± 6.9 Kg/m^2, respectively. Group I included 6024 (85 %) patients, whereas Groups II and III included 905 (13 %) and 155 (2 %) patients, respectively.The 30-day mortality rate was higher in Group III (p = 0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p = <0.001). A significantly higher proportion of patients in group III received Sleeve Gastrectomy or One Anastomosis Gastric Bypass compared to other groups. Patients with a BMI of > 70 kg/m² had a 30-day mortality of 7.7 % (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass.ConclusionThe 30-day mortality rate was significantly higher in patients with BMI > 60 kg/m². There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection.     

The role of obesity in inflammatory markers in COVID-19 patients

Obesity has emerged as a significant risk factor for severe COVID-19 worldwide. Given both COVID-19 infection and obesity have been associated with increased systemic inflammation, we evaluated inflammatory markers in obese and non-obese individuals hospitalized for COVID-19 at Massachusetts General Hospital. We hypothesized that obese patients would have a more exuberant inflammatory response as evidenced by higher initial and peak inflammatory markers along with worse clinical outcomes. Of the 781 patients, 349 were obese (45%). Obese individuals had higher initial and peak levels of CRP and ESR as well as higher peak d-dimer (P < 0.01 for all) in comparison to non-obese individuals, while. IL-6 and ferritin were similar. In addition, obese individuals had a higher odds of requiring vasopressor use (OR 1.54, 95% CI 1.00–2.38, P = 0.05), developing hypoxemic respiratory failure (OR 1.58, 95% CI 1.04–2.40, P = 0.03) and death (OR 2.20, 95% CI 1.31–3.70, P = 0.003) within 28 days of presentation to care. Finally, higher baseline levels of CRP and D-dimer were associated with worse clinical outcomes even after adjustment for BMI. Our findings suggest greater disease severity in obese individuals is characterized by more exuberant inflammation.     

Impact of prior bariatric surgery on risk and severity of COVID-19 infection: A meta-analysis of observational studies

BackgroundThe association of prior bariatric surgery (BS) with infection rate and prognosis of coronavirus disease 2019 (COVID-19) remains unclear. We conducted a meta-analysis of observational studies to address this issue.MethodsWe searched databases including MEDLINE, Embase, and CENTRAL from inception to May, 2022. The primary outcome was risk of mortality, while secondary outcomes included risk of hospital/intensive care unit (ICU) admission, mechanical ventilation, acute kidney injury (AKI), and infection rate.ResultsEleven studies involving 151,475 patients were analyzed. Meta-analysis showed lower risks of mortality [odd ratio (OR)= 0.42, 95% CI: 0.27–0.65, p < 0.001, I² = 67%; nine studies; 151,113 patients, certainty of evidence (COE):moderate], hospital admission (OR=0.56, 95% CI: 0.36–0.85, p = 0.007, I² =74.6%; seven studies; 17,810 patients; COE:low), ICU admission (OR=0.5, 95% CI: 0.37–0.67, p < 0.001, I² =0%; six studies; 17,496 patients, COE:moderate), mechanical ventilation (OR=0.52, 95% CI: 0.37–0.72, p < 0.001, I² =57.1%; seven studies; 137,992 patients, COE:moderate) in patients with prior BS (BS group) than those with obesity without surgical treatment (non-BS group). There was no difference in risk of AKI (OR=0.74, 95% CI: 0.41–1.32, p = 0.304, I² =83.6%; four studies; 129,562 patients, COE: very low) and infection rate (OR=1.05, 95% CI: 0.89–1.22, p = 0.572, I² =0%; four studies; 12,633 patients, COE:low) between the two groups. Subgroup analysis from matched cohort studies demonstrated associations of prior BS with lower risks of mortality, ICU admission, mechanical ventilation, and AKI.ConclusionOur results showed a correlation between prior BS and less severe COVID-19, which warrants further investigations to verify.     

Association between Hyperglycemia at Hospital Presentation and Hospital Outcomes in COVID-19 Patients with and without Type 2 Diabetes: A Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients

This study aimed to determine the relationships among hyperglycemia (HG), the presence of type 2 diabetes (T2D), and the outcomes of COVID-19. Demographic data, blood glucose levels (BG) measured on admission, and hospital outcomes of COVID-19 patients hospitalized at Boston University Medical Center from 1 March to 4 August 2020 were extracted from the hospital database. HG was defined as BG > 200 mg/dL. Patients with type 1 diabetes or BG < 70 mg/dL were excluded. A total of 458 patients with T2D and 976 patients without T2D were included in the study. The mean ± SD age was 56 ± 17 years and 642 (45%) were female. HG occurred in 193 (42%) and 42 (4%) of patients with and without T2D, respectively. Overall, the in-hospital mortality rate was 9%. Among patients without T2D, HG was statistically significantly associated with mortality, ICU admission, intubation, acute kidney injury, and severe sepsis/septic shock, after adjusting for potential confounders (p < 0.05). However, only ICU admission and acute kidney injury were associated with HG among patients with T2D (p < 0.05). Among the 235 patients with HG, the presence of T2D was associated with decreased odds of mortality, ICU admission, intubation, and severe sepsis/septic shock, after adjusting for potential confounders, including BG (p < 0.05). In conclusion, HG in the subset of patients without T2D could be a strong indicator of high inflammatory burden, leading to a higher risk of severe COVID-19.     

Low 25-Hydroxyvitamin D Levels on Admission to the Intensive Care Unit May Predispose COVID-19 Pneumonia Patients to a Higher 28-Day Mortality Risk: A Pilot Study on a Greek ICU Cohort

We aimed to examine whether low intensive care unit (ICU) admission 25-hydroxyvitamin D (25(OH)D) levels are associated with worse outcomes of COVID-19 pneumonia. This was a prospective observational study of SARS-CoV2 positive critically ill patients treated in a multidisciplinary ICU. Thirty (30) Greek patients were included, in whom 25(OH)D was measured on ICU admission. Eighty (80%) percent of patients had vitamin D deficiency, and the remaining insufficiency. Based on 25(OH)D levels, patients were stratified in two groups: higher and lower than the median value of the cohort (15.2 ng/mL). The two groups did not differ in their demographic or clinical characteristics. All patients who died within 28 days belonged to the low vitamin D group. Survival analysis showed that the low vitamin D group had a higher 28-day survival absence probability (log-rank test, p = 0.01). Critically ill COVID-19 patients who died in the ICU within 28 days appeared to have lower ICU admission 25(OH)D levels compared to survivors. When the cohort was divided at the median 25(OH)D value, the low vitamin D group had an increased risk of 28-day mortality. It seems plausible, therefore, that low 25(OH)D levels may predispose COVID-19 patients to an increased 28-day mortality risk.     

Evaluation of anorexia and analysis of related factors in patients with COVID-19

ObjectiveCOVID-19 may cause an anorexic situation. This in turn leads to underfeeding, puts the patient in an energy protein malnutrition state, develops the hyperinflammation, weakens the immunity, and makes COVID-19 conditions more dangerous. Meanwhile, the more severe inflammation conditions in the body, the more severe the anorexia, which in turn affect the disease severity. Studies evaluating appetite in COVID-19 patients are very rare; therefore, we evaluated anorexia and analyzed the related factors in patients with COVID-19.Material and methodsIn this cross sectional study, adult patients’ ≥18 years old with the positive real-time fluorescence polymerase chain reaction for COVID-19 were included. The patients were classified as mild, moderate, and severe based on the WHO classification. We measured the appetite score, weight, height, body mass index (BMI), depression and anxiety score, at admission for every patient.ResultsA total of 301 patients participated in the study. The prevalence of admission anorexia was 58%, and this rate was significantly more in the severe group compared to the mild and moderate groups (P < 0.001). Comorbidities, depression and anxiety were independently correlated with anorexia risk [(OR = 3.6, 95% CI 1.68–7.70, P = 0.001), (OR = 1.23, 95% CI 1.16–1.30, P < 0001), and (OR = 1.24, 95% CI 1.17–1.31, P < 0001)], respectively. This correlation was adherence to a U-shape association for BMI, which means BMI < 18.5 (OR = 3.35, 95% CI 1.8–10.42, P < 0001) and BMI ≥30 (OR = 2.45, 95% CI 1.02–6.53, P = 0.048) were related to higher risk of anorexia.ConclusionWe reported a high prevalence of anorexia (58%) in COVID-19 patients, which was positively correlated with disease severity. Furthermore, any factor worsening inflammatory state, including underweight, obesity, comorbidities, depression and anxiety can exacerbate anorexia in these patients.     

COVID-19 infection and body weight: A deleterious liaison in a J-curve relationship

During the course of the COVID-19 pandemic, obesity has been shown to be an independent risk factor for high morbidity and mortality. Obesity confers poor outcomes in younger (<60 years) patients, an age-group considered low-risk for complications, a privilege that is negated by obesity. Findings are consistent, the higher the body mass index (BMI) the worse the outcomes. Ectopic (visceral) obesity also promotes proinflammatory, prothrombotic, and vasoconstrictive states, thus enhancing the deleterious effects of COVID-19 disease. Less, albeit robust, evidence also exists for a higher risk of COVID-19 infection incurred with underweight. Thus, the relationship of COVID-19 and BMI has a J-curve pattern, where patients with both overweight/obesity and underweight are more susceptible to the ailments of COVID-19. The pathophysiology underlying this link is multifactorial, mostly relating to the inflammatory state characterizing obesity, the impaired immune response to infectious agents coupled with increased viral load, the overexpression in adipose tissue of the receptors and proteases for viral entry, an increased sympathetic activity, limited cardiorespiratory reserve, a prothrombotic milieu, and the associated comorbidities. All these issues are herein reviewed, the results of large studies and meta-analyses are tabulated and the pathogenetic mechanisms and the BMI relationship with COVID-19 are pictorially illustrated.     

Obesity and symptoms and quality of life indicators of individuals with disabilities

BackgroundHealth risks of obesity are well known, but effects of obesity on health-related quality of life (HRQOL) have not been well-studied in people with physical disabilities.Objective/hypothesisWe examined the association between obesity and HRQOL in people with disabilities relative to the general US population. We hypothesized (a) overall, individuals with disabilities will report worse HRQOL than the general US population and (b) obese individuals with disabilities will report worse HRQOL than non-obese individuals.MethodsIndividuals with muscular dystrophy, multiple sclerosis, post-polio syndrome, and spinal cord injury (N = 1849) completed Patient Reported Outcomes Measurement Information System (PROMIS) measures of fatigue, pain interference, physical and social function, depression, sleep disturbance, and sleep-related impairment. Participants were classified as obese or non-obese based on self-reported weight and height (BMI) and/or waist circumference (WC). PROMIS T-scores were compared to norms and between obesity groups.ResultsMean BMI was 26.4 kg/m² with 23.4% classified as obese. Mean WC was 37.5 inches (males) and 34.0 inches (females); 26.4% reported abdominal obesity. Based on BMI and/or WC, 33.3% (n = 616) were classified obese. Compared to PROMIS norms, obese individuals reported worse HRQOL on all domains (p < 0.0001). Compared to non-obese individuals, obese individuals reported worse functioning on all domains except depression (p < 0.01). Obese individuals with MS and MD reported worse outcomes than non-obese counterparts.ConclusionsObesity in people with physical disabilities is associated with poorer HRQOL. More research is needed to inform clinicians in identifying obese patients and helping them achieve healthy weight, reduce symptom burden, and improve QOL.     

新型冠状病毒肺炎患者重症转归风险预测

目的 建立新型冠状病毒肺炎（COVID-19）患者转归为重症的预测模型,为早期、动态地监测患者转归提供更加全面、准确、及时的指标。方法 基于患者的入院检测指标和轻、重症分型,以及检测指标的动态改变（即入院后两次检测指标测量值差）等输入变量,使用XGBoost方法建立预测模型,评估患者在入院之后转归为重症的风险。然后将入选的患者从入院随访至出院,观察其病情转归情况,对模型预测结果进行验证。结果 在100例COVID-19患者的训练集中,筛选出具有较高评分的预测变量并建立模型,计算出预测变量取值的高风险范围：血氧饱和度<94%、外周血白细胞计数>8.0×10⁹个、SBP变化<-2.5 mmHg（1 mmHg=0.133 kPa）、心率>90次/min、有多发小斑片影、年龄>30岁、心率变化<12.5次/min。训练集的模型预测结果的敏感率为61.7%,漏诊率为38.3%;使用模型对测试集进行预测的敏感性为75.0%,漏诊率为25.0%。结论 与传统的预测判断方法（即采用入院时第一次检测的指标和重症入选条件进行评估患者是否为轻、重症）相比,模型的预测考虑到了COVID-19患者的基线生理指标与病情变化指标,因此能够全面、准确地预测患者重症转归的风险,减少重症患者的漏诊率。     

The association between obesity and pressure ulcer development in critically ill patients: A prospective cohort study

BackgroundPressure ulcers (PUs) are one of the leading potentially preventable adverse events in the hospital. Critically ill patients are at risk for the development of PUs. The primary aim of the study was to investigate the relation of PUs and obesity in critically ill ICU patients.MethodsA single center prospective cohort study was conducted on adult patients with obesity (defined as a body mass index BMI ≥ 30 kg/m²) and patients without obesity (BMI 18?25 kg/m²) admitted to the intensive care unit between May 2013 and July 2017 with an ICU length of stay of at least 3 days without pre-existing PUs at admission.Results851 of 1205 patients (70.6%) had a normal BMI and 354 (29.4%) had a BMI ≥ 30 kg/m² and were considered obese. Overall, 157 patients (13.0%) developed PUs; 112/851 (13.2%) of patients without obesity and 45/354 (12.7%) of patients with obesity (p = 0.907). There was no difference in the severity (p = 0.609) and PU location (p = 0.261). Mean days to PU development was 11.1; 11.7 days for patients without obesity and 9.5 days for patients with obesity (p = 0.270). Mean days to PU recovery was 13.2, which was 14.1 days for patients without obesity and 10.8 days for patients with obesity (p = 0.215). A multivariate logistic regression model showed no significant correlation between the occurrence of PUs in the ICU and obesity (OR 0.875 with 95% CI 0.528–1.448, p = 0.594). Subgroup analysis showed that patients with morbid obesity (BMI ≥ 40 kg/m²) developed PUs earlier during ICU admission when compared to patients without obesity (p = 0.004).ConclusionOur study demonstrates that obesity is not an independent risk factor for the development of PUs in the ICU. However, patients with morbid obesity might develop PUs earlier compared to patients without obesity.     

Length of Hospital Stay and Survival of Hospitalized COVID-19 Patients During the Second Wave of the Pandemic: A Single Centre Retrospective Study from Slovenia

BackgroundAs of writing, there are no publications pertaining to the prediction of COVID-19-related outcomes and length of stay in patients from Slovene hospitals.ObjectivesTo evaluate the length of regular ward and ICU stays and assess the survival of COVID-19 patients to develop better prediction models to forecast hospital capacity and staffing demands in possible further pandemic peaks.MethodsIn this retrospective, single-site study we analysed the length of stay and survival of all patients, hospitalized due to the novel coronavirus (COVID-19) at the peak of the second wave, between November 18th 2020 and January 27th 2021 at the University Clinic Golnik, Slovenia.ResultsOut of 407 included patients, 59% were male. The median length of stay on regular wards was 7.5 (IQR 5–13) days, and the median ICU length of stay was 6 (IQR 4–11) days. Age, male sex, and ICU stay were significantly associated with a higher risk of death. The probability of dying in 21 days at the regular ward was 14.4% (95% CI [10.9–18%]) and at the ICU it was 43.6% (95% CI [19.3-51.8%]).ConclusionThe survival of COVID-19 is strongly affected by age, sex, and the fact that a patient had to be admitted to ICU, while the length of hospital bed occupancy is very similar across different demographic groups. Knowing the length of stay and admission rate to ICU is important for proper planning of resources during an epidemic.     

Dietetic-Led Nutrition Interventions in Patients with COVID-19 during Intensive Care and Ward-Based Rehabilitation: A Single-Center Observational Study

Background: In this study, a report of dietitian-led nutrition interventions for patients with COVID-19 during ICU and ward-based rehabilitation is provided. As knowledge of COVID-19 and its medical treatments evolved through the course of the pandemic, dietetic-led interventions were compared between surge 1 (S1) and surge 2 (S2). Methods: A prospective observational study was conducted of patients admitted to the ICU service in a large academic hospital (London, UK). Clinical and nutrition data were collected during the first surge (March–June 2020; n = 200) and the second surge (November 2020–March 2021; n = 253) of COVID-19. Results: A total of 453 patients were recruited. All required individualized dietetic-led interventions during ICU admission as the ICU nutrition protocol did not meet nutritional needs. Feed adjustments for deranged renal function (p = 0.001) and propofol calories (p = 0.001) were more common in S1, whereas adjustment for gastrointestinal dysfunction was more common in S2 (p = 0.001). One-third of all patients were malnourished on ICU admission, and all lost weight in ICU, with a mean (SD) total percentage loss of 8.8% (6.9%). Further weight loss was prevented over the remaining hospital stay with continued dietetic-led interventions. Conclusions: COVID-19 patients have complex nutritional needs due to malnutrition on admission and ongoing weight loss. Disease complexity and evolving nature of medical management required multifaceted dietetic-led nutritional strategies, which differed between surges.     

The Impact of COVID-19 on the Prevalence,Mortality, and Associated Risk Factors for Mortality in Patients with Hip Fractures: A Meta-Analysis

ObjectiveThis study aimed to assess (1) the prevalence of COVID-19 in patients with hip fracture; (2) the mortality rate of patients with hip fracture associated with COVID-19; (3) risk factors associated with mortality in patients with hip fracture; and (4) the effects of COVID-19 on surgical outcomes of patients with hip fracture.DesignMeta-analysis.Setting and ParticipantsPatients with hip fractures during COVID-19.MethodsPubMed, Web of Science, and Embase were systematically reviewed. The outcomes included the prevalence of COVID-19, case fatality rate, 30-day mortality, cause of death, risk factors associated with the mortality of patients with hip fracture, time to surgery, surgical time, and length of hospitalization. Risk ratio or weight mean difference with 95% confidence intervals were used to pool the estimates.ResultsA total of 60 studies were included in this meta-analysis. The pooled estimate showed that the prevalence of COVID-19 was 21% in patents with hip fractures. Patients with hip fracture with COVID-19 had an increased 30-day mortality risk compared with those without the infection. The main causes of death were respiratory failure, COVID-19–associated pneumonia, multiorgan failure, and non–COVID-19 pneumonia. The hospitalization was longer in patients with COVID-19 when compared with those without the infection, but was shorter in patients during the pandemic period. The surgery time and time to surgery were not significantly different between patients during or before the pandemic period and in those with or without COVID-19.Conclusions and ImplicationsThe 30-day mortality rate was significantly higher in patients with hip fracture with COVID-19 infection than those without. Patients with COVID-19 had a higher all-cause mortality rate than those without. This information can be used by the medical community to guide the management of patients with hip fracture with COVID-19.     

The Association Between Chronic Disease and Serious COVID-19 Outcomes and Its Influence on Risk Perception: Survey Study and Database Analysis

BackgroundCOVID-19, a viral respiratory disease first reported in December 2019, quickly became a threat to global public health. Further understanding of the epidemiology of the SARS-CoV-2 virus and the risk perception of the community may better inform targeted interventions to reduce the impact and spread of COVID-19.ObjectiveIn this study, we aimed to examine the association between chronic diseases and serious outcomes following COVID-19 infection, and to explore its influence on people’s self-perception of risk for worse COVID-19 outcomes.MethodsThis study draws data from two databases: (1) the nationwide database of all confirmed COVID-19 cases in Portugal, extracted on April 28, 2020 (n=20,293); and (2) the community-based COVID-19 Barometer survey, which contains data on health status, perceptions, and behaviors during the first wave of COVID-19 (n=171,087). We assessed the association between relevant chronic diseases (ie, respiratory, cardiovascular, and renal diseases; diabetes; and cancer) and death and intensive care unit (ICU) admission following COVID-19 infection. We identified determinants of self-perception of risk for severe COVID-19 outcomes using logistic regression models.ResultsRespiratory, cardiovascular, and renal diseases were associated with mortality and ICU admission among patients hospitalized due to COVID-19 infection (odds ratio [OR] 1.48, 95% CI 1.11-1.98; OR 3.39, 95% CI 1.80-6.40; and OR 2.25, 95% CI 1.66-3.06, respectively). Diabetes and cancer were associated with serious outcomes only when considering the full sample of COVID-19–infected cases in the country (OR 1.30, 95% CI 1.03-1.64; and OR 1.40, 95% CI 1.03-1.89, respectively). Older age and male sex were both associated with mortality and ICU admission. The perception of risk for severe COVID-19 disease in the study population was 23.9% (n=40,890). This was markedly higher for older adults (n=5235, 46.4%), those with at least one chronic disease (n=17,647, 51.6%), or those in both of these categories (n=3212, 67.7%). All included diseases were associated with self-perceptions of high risk in this population.ConclusionsOur results demonstrate the association between some prevalent chronic diseases and increased risk of worse COVID-19 outcomes. It also brings forth a greater understanding of the community’s risk perceptions of serious COVID-19 disease. Hence, this study may aid health authorities to better adapt measures to the real needs of the population and to identify vulnerable individuals requiring further education and awareness of preventive measures.     

Presenting Characteristics,Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in Pakistan: Retrospective Observational Study

BackgroundCOVID-19 became a pandemic rapidly after its emergence in December 2019. It belongs to the coronavirus family of viruses, which have struck a few times before in history. Data based on previous research regarding etiology and epidemiology of other viruses from this family helped played a vital role in formulating prevention and precaution strategies during the initial stages of this pandemic. Data related to COVID-19 in Pakistan were not initially documented on a large scale. In addition, due to a weak health care system and low economic conditions, Pakistan’s population, in general, already suffers from many comorbidities, which can severely affect the outcome of patients infected with COVID-19.ObjectiveCOVID-19 infections are coupled with a manifestation of various notable outcomes that can be documented and characterized clinically. The aim of this study was to examine these clinical manifestations, which can serve as indicators for early detection as well as severity prognosis for COVID-19 infections, especially in high-risk groups.MethodsA retrospective observational study involving abstraction of demographic features, presenting symptoms, and adverse clinical outcomes for 1812 patients with COVID-19 was conducted. Patients were admitted to the four major hospitals in the Rawalpindi-Islamabad region of Pakistan, and the study was conducted from February to August 2020. Multivariate regression analysis was carried out to identify significant indicators of COVID-19 severity, intensive care unit (ICU) admission, ventilator aid, and mortality. The study not only relates COVID-19 infection with comorbidities, but also examines other related factors, such as age and gender.ResultsThis study identified fever (1592/1812, 87.9%), cough (1433/1812, 79.1%), and shortness of breath (998/1812, 55.1%) at the time of hospital admission as the most prevalent symptoms for patients with COVID-19. These symptoms were common but not conclusive of the outcome of infection. Out of 1812 patients, 24.4% (n=443) required ICU admission and 21.5% (n=390) required ventilator aid at some point of disease progression during their stay at the hospital; 25.9% (n=469) of the patients died. Further analysis revealed the relationship of the presented symptoms and comorbidities with the progression of disease severity in these patients. Older adult patients with comorbidities, such as hypertension, diabetes, chronic kidney disease, and asthma, were significantly affected in higher proportions, resulting in requirement of ICU admission and ventilator aid in some cases and, in many cases, even mortality.ConclusionsOlder adult patients with comorbidities, such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease, are at increased risk of developing severe COVID-19 infections, with an increased likelihood of adverse clinical outcomes.     

Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities

ObjectiveTo compare 30-day mortality in long-term care facility (LTCF) residents with and without COVID-19 and to investigate the impact of 31 potential risk factors for mortality in COVID-19 cases.DesignRetrospective cohort study.Setting and ParticipantsAll residents of LTCFs registered in Senior Alert, a Swedish national database of health examinations in older adults, during 2019-2020.MethodsWe selected residents with confirmed COVID-19 until September 15, 2020, along with time-dependent propensity score–matched controls without COVID-19. Exposures were COVID-19, age, sex, comorbidities, medications, and other patient characteristics. The outcome was all-cause 30-day mortality.ResultsA total of 3731 residents (median age 87 years, 64.5% female) with COVID-19 were matched to 3731 controls without COVID-19. Thirty-day mortality was 39.9% in COVID-19 cases and 5.7% in controls [relative risk 7.05, 95% confidence interval (CI) 6.10-8.14]. In COVID-19 cases, the odds ratio (OR) for 30-day mortality was 2.44 (95% CI 1.57-3.81) in cases aged 80-84 years, 2.99 (95% CI 1.93-4.65) in cases aged 85-89 years, and 3.28 (95% CI 2.11-5.10) in cases aged ≥90 years, as compared with cases aged <70 years. Other risk factors for mortality among COVID-19 cases included male sex (OR, 2.60, 95% CI 2.22-3.05), neuropsychological conditions (OR, 2.18; 95% CI 1.76-2.71), impaired walking ability (OR, 1.45, 95% CI 1.17-1.78), urinary and bowel incontinence (OR 1.51, 95% CI 1.22-1.85), diabetes (OR 1.36, 95% CI 1.14-1.62), chronic kidney disease (OR 1.37, 95% CI 1.11-1.68) and previous pneumonia (OR 1.57, 95% CI 1.32-1.85). Nutritional factors, cardiovascular diseases, and antihypertensive medications were not significantly associated with mortality.Conclusions and ImplicationsIn Swedish LTCFs, COVID-19 was associated with a large excess in mortality after controlling for an extensive number of risk factors. Beyond older age and male sex, several prevalent clinical risk factors independently contributed to higher mortality. These findings suggest that reducing transmission of COVID-19 in LTCFs will likely prevent a considerable number of deaths.