The D-side of COVID-19: musculoskeletal benefits of vitamin D and beyond

Serum 25-hydroxyvitamin D levels and health outcomes of hospitalization owing to COVID-19: a retrospective cross-sectional study

OBJECTIVE

We investigated the role of serum 25(OH)D (25-hydroxyvitamin D) in COVID-related health outcomes.

METHODS

We conducted a retrospective cross-sectional study using data of the National Center of Disease Control and Public Health, Georgia. We extracted patient data including length of hospital stay, transfer to the intensive care unit, requirement for oxygen therapy, treatment with glucocorticoids, and symptoms. After obtaining written informed consent, 384 individuals were enrolled. We divided participants into three groups according to 25(OH)D levels: group 1 = 25(OH)D <12 ng/mL (n = 83), group 2 = 25(OH)D 12-20 ng/mL (n = 141), and group 3 = 25(OH)D >20 ng/mL (n = 160).

RESULTS

The odds ratio (OR) for hospitalization in group 1 versus group 2 was 8.7 (95% confidence interval [CI] 3.6-21.3) and 5.6 for group 1 versus 3 (95% CI 2.7-11.9). Regarding oxygen therapy, OR = 28.41 for group 1 versus 2 (95% CI 3.7-220.5) and OR = 5.2 for group 1 versus 3 (95% CI 1.9-14.1). Regarding treatment with glucocorticoids, OR = 3.7 for group 1 versus 2 (95% CI 1.1-12.5) and OR = 8.4 for group 1 versus 3 (95% CI 1.8-40.7).

CONCLUSION

COVID-19-related morbidity was associated with decreased serum 25(OH)D levels. Future studies should investigate the potential role of vitamin D sufficiency in preventing SARS-CoV-2 infection and mortality.

Predictive value of C-reactive protein for disease severity and survival in COVID-19 patients: a systematic review and meta-analysis

Coronavirus disease 2019 (COVID-19) is an infectious disease that can develop multiple complications and even be life-threatening. The aim of this study is to summarize current evidence of C-reactive protein's (CRP) predictive value for disease severity and survival of COVID-19 patients, focusing on curing patients and reducing the risk of death. We systematically searched related studies from four large databases: Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang Database, all published between December 2019 and June 2021. Then, we implemented meta-analysis using random-effects models through STATA 15.1 and Review Manager 5.3. We also implemented sensitivity analysis and used funnel plots to check publication bias. From the systematic search of the four databases, we were able to identify 18 studies containing a total of 3052 patients. Meta-analysis results showed that 1) CRP levels were lower in non-severe patients than in severe patients (Standardized Mean Difference (SMD) =  - 0.87 mg/L, 95% Confidence Interval (CI) = [ - 1.27, - 0.47], p < 0.001); 2) CRP levels were lower in non-intensive care unit (ICU) patients than in ICU patients (SMD = - 1.39 mg/L, 95% CI = [- 1.68, - 1.11], p < 0.001), and 3) CRP levels were lower in survivors than in non-survivors (SMD =- 1.32 mg/L, 95% CI = [- 1.95, - 0.69], p < 0.001). Sensitivity analysis showed these results were stable. Funnel plots indicated no publication bias. The CRP level may timely reflect disease severity and predict survival of COVID-19 patients and may be worthy of further popularization and application in clinic practice.

A Comparison of Cognitive Performance, Depressive Symptoms, and Incidence of Falls in Brazilian Older Women with and without a Confirmed History of COVID-19

The study aimed to compare cognitive performance, depressive symptoms, and the incidence of falls in Brazilian older women with and without a confirmed history of COVID-19. This cross-sectional study included 188 women (60-89 years), divided into two groups: one with a history of COVID-19 (n = 139), and one without any history of COVID-19 (n = 49). The instruments used were the Cognitive Telephone Screening Instrument (COGTEL) test battery, the Trail Making Test (TMT), the Geriatric Depression Scale (GDS-15), and the self-reported history of falls since the beginning of mandatory confinement. The higher the age, the higher the incidence of falls. The highest prevalence of falls (57.1%) occurred in the COVID-19 group (p = 0.001), the members of which also indicated a better cognitive performance in the COGTEL test (p = 0.017), TMT-B (p = 0.004), and ∆TMT (B-A) (p = 0.004). In turn, the depressive symptoms were more severe in the COVID-19 group (p < 0.001). We observed that COVID-19 infection without hospitalization did not affect the cognitive performance of older adult women. Future studies should be carried out to monitor the mental health of older adult Brazilian women. Moreover, regardless of their history of COVID-19, older adults should participate in a physical training program focused on preventing falls.

Survival following vertebral compression fractures in population over 65 years old

BACKGROUND

Lower mortality has been demonstrated when vertebral compression fractures (VCFs) are treated surgically (vertebral augmentation) vs. conservatively.

AIMS

To analyze the overall survival in patients over 65 who suffer a VCF, to review the principal causes of death, and to detect which factors are associated with a greater risk of mortality.

METHODS

Patients over 65 years old diagnosed with acute, non-pathologic thoracic or lumbar VCF, treated consecutively from January 2017 to December 2020, were retrospectively selected. Those patients with follow-ups under 2 years or who required arthrodesis were excluded. Overall survival was estimated by the Kaplan-Meier method. Differences in survival were tested through the log-rank test. Multivariable Cox regression was used to assess the association of covariates and time to death.

RESULTS

A total of 492 cases were included. Overall mortality was 36.2%. Survival rate at 1-, 12-, 24-, 48-, and 60-month follow-up was 97.4%, 86.6%, 78.0%, 64.4%, and 59.4%, respectively. Infection was the leading cause of death. The independent factors associated with a higher mortality risk were age, male, oncologic history, non-traumatic mechanism, and comorbidity during hospitalization. No statistical difference was found when comparing the two survival curves by treatment (vertebral augmentation vs. conservative) over time.

CONCLUSION

Overall mortality rate was 36.2% after a median follow-up of 50.5 months (95% CI 48.2; 54.2). Age, male sex, history of oncological disease, non-traumatic mechanism of the fracture, and any comorbidity during hospitalization were identified as variables independently associated with a higher risk of mortality following a VCF in the elderly.

COVID-19 Pandemic and Osteoporosis in Elderly Patients

Coronavirus disease 2019 (COVID-19), which is caused by an infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is rapidly becoming a worldwide epidemic and poses a significant threat to human life and health. SARS-CoV-2 can cause damage to organs throughout the body through ACE2 receptors. It may have direct and indirect effects on osteoclasts, and osteoblasts and lead to osteoporosis. Vitamin D (VitD) is a key hormone for bone health and has immunomodulatory actions of relevance in the context of the COVID-19 pandemic. Vitamin D deficiency has a significant positive association with both infection and the mortality rate of COVID-19. Elderly patients infected by COVID-19 were more likely to develop acute respiratory distress syndrome (ARDS), which was primarily caused by an inflammation storm. The production of proinflammatory cytokines increases with COVID-19 infection and immobilization may result in bone loss and bone resorption in seriously ill patients, especially aging patients. It is well known that glucocorticoids are beneficial in the treatment of acute respiratory distress syndrome (ARDS) because they reduce inflammation and improve the functioning of the lung and extrapulmonary organs. Glucocorticoid therapy is widely used to treat patients with COVID-19 in most parts of the world. During COVID-19 clinical treatment, glucocorticoids may accelerate bone loss in elderly people, making them more susceptible to the development of osteoporosis. Therefore, it is worthwhile to draw the attention of clinicians and researchers to the linkages and interactions between COVID-19, glucocorticoids, and osteoporosis (especially in elderly patients).

Incidence of hip fractures during the COVID-19 pandemic in the Brazilian public health care system

This study compared the incidence of hip fractures before and during the COVID-19 pandemic in Brazil, aged ≥ 60 years excluding all fractures related to any trauma. There was a significant reduction in the number of hip fractures and the length of hospital stay during the period of social isolation.

PURPOSE

To compare the incidence of hip fractures before and during the COVID-19 pandemic in Brazil and in the main regions of the country in patients covered by the Brazilian public health care system (SUS). As far as we are aware, no studies have evaluated the impact of COVID-19 pandemic on hip fractures in Brazil.

METHODS

Descriptive, cross-sectional study in individuals aged ≥ 60 years who presented with a hip fracture before and during the COVID-19 pandemic and received treatment covered by the SUS. The data were collected from the DATASUS electronic database. We calculated the incidence, mortality, lethality, duration of hospitalization, and average reimbursement associated with the treatment of the fractures.

RESULTS

There was a significant reduction in the incidence of hip fractures among individuals aged ≥ 60 years in Brazil during the period of social isolation due to COVID-19. The observed incidence was 15.58/10,000 inhabitants between March and December 2020 and 16.07/10,000 inhabitants in the same period of 2019 (p < 0.005; main decline observed in the age groups > 70 years). The average length of hospital stay reduced from 8.35 days in 2019 to 7.33 days in 2020, following a similar pattern of reduction across all regions. The Southeast was the only region with a significant reduction in mortality during the pandemic (relative risk 0.90, 95% confidence interval 0.84-0.97, p < 0.005).

CONCLUSION

During the COVID-19 pandemic in Brazil, the incidence rate of hip fractures and the associated duration of hospital stay decreased among patients aged ≥ 60 years.

The Immunologic Profile of Vitamin D and Its Role in Different Immune-Mediated Diseases: An Expert Opinion

Historically, vitamin D is recognized as an essential component for the maintenance of the musculoskeletal system. The immunomodulatory role of vitamin D in health and disease has gained much interest in recent years due to the many pathologies that share underlying immunological features where vitamin D has been shown to exert a potential role. Evidence from pre-clinical studies show that vitamin D elicits biological effects on both the innate and adaptive immune systems. Furthermore, in vivo studies have shown that administration of vitamin D can lead to changes in or the development of a range of immune-related diseases. This encourages the hypothesis that data derived from clinical and epidemiological studies connect vitamin D with the incidence and severity of many immune-mediated disorders such as rheumatoid arthritis, diabetes, and infectious diseases. Since some other immune-mediated diseases share similar features to that of viral infection such as COVID-19, in this review, we examined these other areas and the role of vitamin D in these diseases.

Vertebral fractures and mortality risk in hospitalised patients during the COVID-19 pandemic emergency

BACKGROUND AND OBJECTIVE

Bone fragility has been linked to COVID-19 severity. The objective of this study was to evaluate whether a diagnosis of vertebral fracture (VF) increased mortality risk in COVID-19 patients and whether this effect was greater than in those without COVID-19.

METHODS

We assessed VFs by computed tomography (CT) in a cohort of 501 patients consecutively admitted to the emergency department (ED) for clinical suspicion of SARS-CoV-2 infection during the first wave of pandemic emergency. Of those, 239 had a confirmed diagnosis of COVID-19.

RESULTS

VF prevalence was similar between COVID-19 and non-COVID-19 groups (22.2 vs. 19%; p = 0.458). Death rates were similar between COVID-19 and non-COVID-19 groups at both 30 (15.8 vs. 12.2%; p = 0.234) and 120 days (21.8 vs. 17.6%; p = 0.236). The mortality risk was higher in COVID-19 patients either with one or multiple fractures compared to those without VFs, at 30 and 120 days, but statistical significance was reached only in those with multiple VFs (30-day HR 3.03, 95% CI 1.36-6.75; 120-day HR 2.91, 95% CI 1.43-5.91). In the non-COVID-19 group, the 30-day mortality risk was significantly higher in patients either with one (HR 7.46, 95% CI 3.12-17.8) or multiple fractures (HR 6.2, 95% CI 2.75-13.98) compared to those without VFs. A similar effect was observed at 120 days. After adjustment for age, sex and bone density, mortality risk remained associated with VFs in the non-COVID-19 group only.

CONCLUSIONS

VFs were not independently associated with short-term mortality in patients with COVID-19, but they strongly increased mortality risk in those without COVID-19.

Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution

Background

Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection.

Main body

We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives.

Conclusions

Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.

Vitamin D: Dosing, levels, form, and route of administration: Does one approach fit all?

The 4th International Conference on Controversies in Vitamin D was held as a virtual meeting in September, 2020, gathering together leading international scientific and medical experts in vitamin D. Since vitamin D has a crucial role in skeletal and extra-skeletal systems, the aim of the Conference was to discuss improved management of vitamin D dosing, therapeutic levels and form or route of administration in the general population and in different clinical conditions. A tailored approach, based on the specific mechanisms underlying vitamin D deficiency in different diseases that were discussed, was recommended. Specifically, in comparison to healthy populations, higher levels of vitamin D and greater amounts of vitamin D were deemed necessary in osteoporosis, diabetes mellitus, obesity (particularly after bariatric surgery), and in those treated with glucocorticoids. Emerging and still open issues were related to target vitamin D levels and the role of vitamin D supplementation in COVID-19 since low vitamin D may predispose to SARS-CoV-2 infection and to worse COVID-19 outcomes. Finally, whereas oral daily cholecalciferol appears to be the preferred choice for vitamin D supplementation in the general population, and in most clinical conditions, active vitamin D analogs may be indicated in patients with hypoparathyroidism and severe kidney and liver insufficiency. Parenteral vitamin D administration could be helpful in malabsorption syndromes or in states of vitamin D resistance.Specific guidelines for desired levels of vitamin D should be tailored to the different conditions affecting vitamin D metabolism with the goal to define disease-specific normative values.

The Renin-Angiotensin System: A Key Role in SARS-CoV-2-Induced COVID-19

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), was first identified in Eastern Asia (Wuhan, China) in December 2019. The virus then spread to Europe and across all continents where it has led to higher mortality and morbidity, and was declared as a pandemic by the World Health Organization (WHO) in March 2020. Recently, different vaccines have been produced and seem to be more or less effective in protecting from COVID-19. The renin-angiotensin system (RAS), an essential enzymatic cascade involved in maintaining blood pressure and electrolyte balance, is involved in the pathogenicity of COVID-19, since the angiotensin-converting enzyme II (ACE2) acts as the cellular receptor for SARS-CoV-2 in many human tissues and organs. In fact, the viral entrance promotes a downregulation of ACE2 followed by RAS balance dysregulation and an overactivation of the angiotensin II (Ang II)-angiotensin II type I receptor (AT1R) axis, which is characterized by a strong vasoconstriction and the induction of the profibrotic, proapoptotic and proinflammatory signalizations in the lungs and other organs. This mechanism features a massive cytokine storm, hypercoagulation, an acute respiratory distress syndrome (ARDS) and subsequent multiple organ damage. While all individuals are vulnerable to SARS-CoV-2, the disease outcome and severity differ among people and countries and depend on a dual interaction between the virus and the affected host. Many studies have already pointed out the importance of host genetic polymorphisms (especially in the RAS) as well as other related factors such age, gender, lifestyle and habits and underlying pathologies or comorbidities (diabetes and cardiovascular diseases) that could render individuals at higher risk of infection and pathogenicity. In this review, we explore the correlation between all these risk factors as well as how and why they could account for severe post-COVID-19 complications.

Diagnosis and Management of Osteoporosis During COVID-19: Systematic Review and Practical Guidance

It is acknowledged that the COVID-19 pandemic has caused profound disruption to the delivery of healthcare services globally. This has affected the management of many long-term conditions including osteoporosis as resources are diverted to cover urgent care. Osteoporosis is a public health concern worldwide and treatment is required for the prevention of further bone loss, deterioration of skeletal micro-architecture, and fragility fractures. This review provides information on how the COVID-19 pandemic has impacted the diagnosis and management of osteoporosis. We also provide clinical recommendations on the adaptation of care pathways based on experience from five referral centres to ensure that patients with osteoporosis are still treated and to reduce the risk of fractures both for the individual patient and on a societal basis. We address the use of the FRAX tool for risk stratification and initiation of osteoporosis treatment and discuss the potential adaptations to treatment pathways in view of limitations on the availability of DXA. We focus on the issues surrounding initiation and maintenance of treatment for patients on parenteral therapies such as zoledronate, denosumab, teriparatide, and romosozumab during the pandemic. The design of these innovative care pathways for the management of patients with osteoporosis may also provide a platform for future improvement to osteoporosis services when routine clinical care resumes.

Vitamin D and Platelets: A Menacing Duo in COVID-19 and Potential Relation to Bone Remodeling

Global data correlate severe vitamin D deficiency with COVID-19-associated coagulopathy, further suggesting the presence of a hypercoagulable state in severe COVID-19 patients, which could promote thrombosis in the lungs and in other organs. The feedback loop between COVID-19-associated coagulopathy and vitamin D also involves platelets (PLTs), since vitamin D deficiency stimulates PLT activation and aggregation and increases fibrinolysis and thrombosis. Vitamin D and PLTs share and play specific roles not only in coagulation and thrombosis but also during inflammation, endothelial dysfunction, and immune response. Additionally, another ‘fil rouge’ between vitamin D and PLTs is represented by their role in mineral metabolism and bone health, since vitamin D deficiency, low PLT count, and altered PLT-related parameters are linked to abnormal bone remodeling in certain pathological conditions, such as osteoporosis (OP). Hence, it is possible to speculate that severe COVID-19 patients are characterized by the presence of several predisposing factors to bone fragility and OP that may be monitored to avoid potential complications. Here, we hypothesize different pervasive actions of vitamin D and PLT association in COVID-19, also allowing for potential preliminary information on bone health status during COVID-19 infection.

Vitamin D deficiency and COVID-19: A case-control study at a tertiary care hospital in India

Background

As the pandemic COVID-19 affected developing and developed countries, there is no proven treatment options available yet. The anti-inflammatory, antiviral and immune modulator effect of Vitamin D could be beneficial to COVID-19.

Aim

To find out the possible association between Vitamin D and COVID-19.

Methods

The present case-control study was conducted at tertiary care hospital, AIIMS, Patna, Bihar, India. Total 156 cases and 204 controls were enrolled in the study after obtaining informed consent. Categorization of the patients were done based on clinical severity and level of Vitamin D. The association between these categories with different variables were analyzed using regression analysis and other statistical tests.

Results

The status of Vitamin D (optimal, mild to moderate deficiency and severe deficiency) differed significantly among cases and controls. Diabetes and hypertension were most prevalent comorbidities among cases. On regression analysis, the difference in Vitamin D level was significant (aOR, 3.295; 95%CI, 1.25-8.685). The association between Vitamin D status and clinical severity group was statistically significant among cases. Among all variables, age, diabetes, hypertension and clinical severity were associated with worst outcome.

Conclusion

Vitamin D status appears to be strongly associated with COVID-19 clinical severity. After COVID-19 confirmation, Vitamin D level should be measured in all patients and curative plus preventive therapy should be initiated.

Aging & COVID-19 susceptibility, disease severity, and clinical outcomes: The role of entangled risk factors

The emergence of Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) in late 2019 has been associated with a high rate of mortality and morbidity. It has been determined that the old population are not only at an increased risk for affliction with COVID-19 infection, but also atypical presentations, severe forms of the disease, and mortality are more common in this population. A plethora of mechanisms and risk factors contribute to the higher risk of infection in the old population. For instance, aging is associated with an increment in the expression of Angiotensin-Converting Enzyme-2 (ACE-2), the receptor for SARS-CoV-2 spike protein, which precipitates replication of the virus in the old population. On the other hand, immune dysregulation and changes in gut microbiota as a result of aging can contribute to the cytokine storm, one of the main indicators of disease severity. Decrement in sex steroids, especially in women, as well as growth hormone, both of which have crucial roles in immune regulation, is a key contributor to disease severity in old age. Senescence-associated oxidative stress and mitochondrial dysfunction in both pneumocytes and immune cells contribute to the severity of infection in an exacerbative manner. In addition, lifestyle-associated factors such as nutrition and physical activity, which are compromised in old age, are known as important factors in COVID-19 infection. Aging-associated comorbidities, especially cardiovascular diseases and diabetes mellitus, also put older adults at an increased risk of complications, and disease severity.

Osteoporosis care amidst the prolonged pandemic

As SARS-CoV-2 stunned and overtook everyone's lives, multiple daily briefings, protocols, policies and incident command committees were mobilized to provide frontline staff with the tools, supplies and infrastructure needed to address the COVID-19 pandemic. Medical resources were immediately shifted. In light of the necessity for self-isolation, telemedicine was expanded, although there has been concern than non-pandemic disorders were being ignored. Ambulatory care services such as bone densitometry and osteoporosis centered clinics came to a near halt. Progress with fracture prevention has been challenged. Despite the prolonged pandemic and the consequent sense of exhaustion, we must re-engage with chronic bone health concerns and fracture prevention. Creating triaging systems for bone mineral testing and in person visits, treating individuals designated as high risk of fracture using fracture risk assessment tools such as FRAX, maintaining telemedicine, leveraging other bone health care team members to monitor and care for osteoporotic patients, and re-engaging our primary care colleagues will remain paramount but challenging. The pandemic persists. Thus, we will summarize what we have learned about COVID-19 and bone health and provide a framework for osteoporosis diagnosis, treatment, and follow-up with the extended COVID-19 pandemic. The goal is to preserve bone health, with focused interventions to sustain osteoporosis screening and treatment initiation/maintenance rates.

COVID-19 and the Endocrine System: A Comprehensive Review on the Theme

Background and aim. The review aimed to summarize advances in the topic of endocrine diseases and coronavirus disease 2019 (COVID-19). Methods. Scientific and institutional websites and databases were searched and data were collected and organized, when plausible, to angle the discussion toward the following clinical issues. (1) Are patients with COVID-19 at higher risk of developing acute or late-onset endocrine diseases or dysfunction? (2) May the underlying endocrine diseases or dysfunctions be considered risk factors for poor prognosis once the infection has occurred? (3) Are there defined strategies to manage endocrine diseases despite pandemic-related constraints? Herein, the authors considered only relevant and more frequently observed endocrine diseases and disorders related to the hypothalamic-pituitary region, thyroid and parathyroid glands, calcium-phosphorus homeostasis and osteoporosis, adrenal glands, and gonads. Main. Data highlight the basis of some pathophysiological mechanisms and anatomical alterations of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-induced endocrine dysfunctions. Some conditions, such as adrenal insufficiency and cortisol excess, may be risk factors of worse clinical progression once the infection has occurred. These at-risk populations may require adequate education to avoid the SARS-CoV-2 infection and adequately manage medical therapy during the pandemic, even in emergencies. Endocrine disease management underwent a palpable restraint, especially procedures requiring obligate access to healthcare facilities for diagnostic and therapeutic purposes. Strategies of clinical triage to prioritize medical consultations, laboratory, instrumental evaluations, and digital telehealth solutions should be implemented to better deal with this probably long-term situation.

The link between COVID-19 and VItamin D (VIVID): A systematic review and meta-analysis

BACKGROUND

Disease severity and mortality rates due to COVID-19 infection are greater in the elderly and chronically ill patients, populations at high risk for vitamin D deficiency. Vitamin D plays an important role in immune function and inflammation. This systematic review and meta-analysis assesses the impact of vitamin D status and supplementation on COVID-19 related mortality and health outcomes.

METHODS

We searched four databases until December 18th 2020, and trial registries until January 20th 2021. Two reviewers screened the studies, collected data, assessed the risk of bias, and graded the evidence for each outcome across studies, independently and in duplicate. Pre-specified outcomes of interest were mortality, ICU admission, invasive and non-invasive ventilation, hospitalization, time of hospital stay, disease severity and SARS-CoV-2 positivity. We only included data from peer-reviewed articles in our primary analyses.

RESULTS

We identified 31 peer-reviewed observational studies. In our primary analysis, there was a positive trend between serum 25(OH)D level <20 ng/ml and an increased risk of mortality, ICU admission, invasive ventilation, non-invasive ventilation or SARS-CoV-2 positivity. However, these associations were not statistically significant. Mean 25(OH)D levels was 5.9 ng/ml (95% CI [-9.5, -2.3]) significantly lower in COVID-19 positive, compared to negative patients. The certainty of the evidence was very low. We identified 32 clinical trial protocols, but only three have published results to-date. The trials administer vitamin D doses of 357 to 60,000 IU/day, from one week to 12 months. Eight megatrials investigate the efficacy of vitamin D in outpatient populations. A pilot trial revealed a significant decrease in ICU admission with calcifediol, compared to placebo (OR = 0.003), but the certainty of the evidence was unclear. Another small trial showed that supplementation with cholecalciferol, 60,000 IU/day, decreased fibrinogen levels, but did not have an effect on D-dimer, procalcitonin and CRP levels, compared to placebo. The third trial did not find any effect of vitamin D supplementation on COVID-19 related health outcomes.

CONCLUSION

While the available evidence to-date, from largely poor-quality observational studies, may be viewed as showing a trend for an association between low serum 25(OH)D levels and COVID-19 related health outcomes, this relationship was not found to be statistically significant. Calcifediol supplementation may have a protective effect on COVID-19 related ICU admissions. The current use of high doses of vitamin D in COVID-19 patients is not based on solid evidence. It awaits results from ongoing trials to determine the efficacy, desirable doses, and safety, of vitamin D supplementation to prevent and treat COVID-19 related health outcomes.

Association between population vitamin D status and SARS-CoV-2 related serious-critical illness and deaths: An ecological integrative approach

BACKGROUND

Vitamin D population status may have possible unappreciated consequences to the coronavirus disease 2019 (COVID-19) pandemic. Α significant association between vitamin D sufficiency and reduction in clinical severity and inpatient mortality from COVID-19 disease has recently been shown, while a recent study has claimed lower COVID-19 cases in European countries with a better vitamin D status. Low serum 25-hydroxyvitamin-D [25(OH)D] was identified as an independent risk factor for COVID-19 infection and hospitalization, and administration of 0.532 mg (21280 IU) of calcifediol or 25(OH)D, followed by 0.266 mg on days 3 and 7 and then weekly until discharge or intensive care unit admission significantly reduced the need for intensive care unit treatment.

AIM

To elucidate the role of vitamin D European population status in the COVID-19 pandemic, data from the Worldometer were analyzed.

METHODS

Linear regression explored the correlation between published representative-standardized population vitamin D concentrations and the number of total cases/million (M), recovered/M, deaths/M and serious-critically ill/M from COVID-19 for 26 European countries populated > 4 M (Worldometer). Life expectancy was analyzed with semi-parametric regression. Weighted analysis of variance/analysis of covariance evaluated serious-critical/M and deaths/M by the vitamin D population status: Deficient < 50, insufficient: 50-62.5, mildly insufficient > 62.5-75 and sufficient > 75 nmol/L, while controlling for life expectancy for deaths/M. Statistical analyses were performed in XLSTAT LIFE SCIENCE and R (SemiPar Library).

RESULTS

Linear regression found no correlation between population vitamin D concentrations and the total cases-recovered/M, but negative correlations predicting a reduction of 47%-64%-80% in serious-critical illnesses/M and of 61%-82%-102.4% in deaths/M further enhanced when adapting for life expectancy by 133-177-221% if 25(OH)D concentrations reach 100-125-150 nmol/L, sustained on August 15, 2020, indicating a truthful association. Weighted analysis of variance was performed to evaluate serious-critical/M (r 2 = 0.22) by the vitamin D population status and analysis of covariance the deaths/M (r 2 = 0.629) controlling for life expectancy (r 2 = 0.47). Serious-critical showed a decreasing trend (P < 0.001) from population status deficient (P < 0.001) to insufficient by 9.2% (P < 0.001), to mildly insufficient by 47.6% (P < 0.044) and to sufficient by 100% (reference, P < 0.001). For deaths/M the respective decreasing trend (P < 0.001) was 62.9% from deficient (P < 0.001) to insufficient (P < 0.001), 65.15% to mildly insufficient (P < 0.001) and 78.8% to sufficient (P = 0.041).

CONCLUSION

Achieving serum 25(OH)D 100-150 nmol/L (40-60 ng/mL) (upper tolerable daily doses followed by maintenance proposed doses not requiring medical supervision, Endocrine Society) may protect from serious-critical illness/death from COVID-19 disease.

Vitamin D status of Arab Gulf residents screened for SARS-CoV-2 and its association with COVID-19 infection: a multi-centre case-control study

OBJECTIVES

Vitamin D status in patients with COVID-19 is an on-going controversial issue. This study aims to determine differences in the serum 25(OH)D concentrations of Arab Gulf adult residents screened for SARS-CoV-2 and its association with risk of COVID-19 infection together with other comorbidities.

METHODS

In this multi-center, case-control study, a total of 220 male and female adults presenting with none to mild symptoms were screened for COVID-19 (n = 138 RT-PCR-confirmed SARS-CoV-2 positive and 82 negative controls). Medical history was noted. Anthropometrics were measured and non-fasting blood samples were collected for the assessment of glucose, lipids, inflammatory markers and serum 25(OH)D concentrations.

RESULTS

Serum 25(OH)D levels were significantly lower in the SARS-CoV-2 positive group compared to the negative group after adjustment for age and BMI (52.8 nmol/l ± 11.0 versus 64.5 nmol/l ± 11.1; p = 0.009). Being elderly (> 60 years) [Odds ratio 6 (95% Confidence Interval, CI 2-18; p = 0.001) as well as having type 2 diabetes (T2D) [OR 6 (95% CI 3-14); p < 0.001)] and low HDL cholesterol (HDL-c) [OR 6 (95% CI 3-14); p < 0.001)] were significant risk factors for COVID-19 infection independent of age, sex and obesity.

CONCLUSIONS

Among Arab Gulf residents screened for SARS-CoV-2, serum 25(OH) D levels were observed to be lower in those who tested positive than negative individuals, but it was the presence of old age, diabetes mellitus and low-HDL-c that were significantly associated with risk of COVID-19 infection. Large population-based randomized controlled trials should be conducted to assess the protective effects of vitamin D supplementation against COVID-19.

COVID-19: Role of Nutrition and Supplementation

At the end of 2019, a new coronavirus (COVID-19) appeared on the world scene, which mainly affects the respiratory system, causing pneumonia and multi-organ failure, and, although it starts with common symptoms such as shortness of breath and fever, in about 2-3% of cases it leads to death. Unfortunately, to date, no specific treatments have been found for the cure of this virus and, therefore, it is advisable to implement all possible strategies in order to prevent infection. In this context, it is important to better define the role of all behaviors, in particular nutrition, in order to establish whether these can both prevent infection and improve the outcome of the disease in patients with COVID-19. In the literature, it is widely shown that states of malnutrition, overweight, and obesity negatively affect the immune system, leading to viral infections, and several studies have shown that nutritional interventions can act as immunostimulators, helping to prevent viral infections. Even if several measures, such as the assumption of a specific diet regimen, the use of dietary supplements, and other similar interventions, are promising for the prevention, management, and recovery of COVID-19 patients, it is important to highlight that strong data from randomized clinical trials are needed to support any such assumption. Considering this particular scenario, we present a literature review addressing several important aspects related to diet and SARS-CoV-2 infection, in order to highlight the importance of diet and supplementation in prevention and management of, as well as recovery from COVID-19.

Vitamin D Status in Hospitalized Patients with SARS-CoV-2 Infection

BACKGROUND

The role of vitamin D status in COVID-19 patients is a matter of debate.

OBJECTIVES

To assess serum 25-hydroxyvitamin D (25OHD) levels in hospitalized patients with COVID-19 and to analyze the possible influence of vitamin D status on disease severity.

METHODS

Retrospective case-control study of 216 COVID-19 patients and 197 population-based controls. Serum 25OHD levels were measured in both groups. The association of serum 25OHD levels with COVID-19 severity (admission to the intensive care unit, requirements for mechanical ventilation, or mortality) was also evaluated.

RESULTS

Of the 216 patients, 19 were on vitamin D supplements and were analyzed separately. In COVID-19 patients, mean ± standard deviation 25OHD levels were 13.8 ± 7.2 ng/mL, compared with 20.9 ± 7.4 ng/mL in controls (P < .0001). 25OHD values were lower in men than in women. Vitamin D deficiency was found in 82.2% of COVID-19 cases and 47.2% of population-based controls (P < .0001). 25OHD inversely correlates with serum ferritin (P = .013) and D-dimer levels (P = .027). Vitamin D-deficient COVID-19 patients had a greater prevalence of hypertension and cardiovascular diseases, raised serum ferritin and troponin levels, as well as a longer length of hospital stay than those with serum 25OHD levels ≥20 ng/mL. No causal relationship was found between vitamin D deficiency and COVID-19 severity as a combined endpoint or as its separate components.

CONCLUSIONS

25OHD levels are lower in hospitalized COVID-19 patients than in population-based controls and these patients had a higher prevalence of deficiency. We did not find any relationship between vitamin D concentrations or vitamin deficiency and the severity of the disease.

Falls as One of the Atypical Presentations of COVID-19 in Older Population

Introduction:

Studies revealed COVID-19 atypical symptoms such as falls, delirium, confusion, dizziness, unusual fatigue in older patients. Falls in the older population and their consequences are one of the leading causes of disability; they significantly reduce the quality of life and lead to loss of independence and impaired social functioning. The aim of this study is to present the possible correlation between COVID-19 and diseases of the musculoskeletal system, in particular the occurrence of fall-related injuries.

Significance:

This article highlights the importance of falls as one of the atypical symptoms of COVID-19 infection in older adults, which is not directly associated with infection and could be misinterpreted.

Methods:

The conducted meta-analysis is based on a review of the scientific literature available in English, French, Dutch, Polish in the PubMed/MEDLINE, Cochrane Library, Embase, Scopus, PEDro, GBL databases from December 1, 2019 to July 30, 2020, covering Clinical Trial, Randomized Controlled Trial, Meta-Analysis, Systematic Reviews and Case Reports. The following keywords were taken into account: fall, (hip/pertrochanteric/proximal femur) fracture, aged and COVID-19. Twenty-seven references were accepted for final analysis.

Results:

It was found that symptoms such as falls observed in the older adults can be associated with COVID-19 infection. Falls and slips are also the most common mechanism for hip fracture during the pandemic outbreak.

Conclusions:

According to authors of this study, atypical presentations of COVID-19 should be considered when screening and testing the people at increased risk due to their age. However, further prospective studies are urgently needed to investigate the possible correlation between COVID-19 and falls in older adults.

Recent findings on the Coronavirus disease 2019 (COVID-19); immunopathogenesis and immunotherapeutics

Severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) is responsible for recent ongoing public health emergency in the world. Sharing structural and behavioral similarities with its ancestors [SARS and Middle East Respiratory Syndrome (MERS)], SARS-CoV-2 has lower fatality but faster transmission. We have gone through a long path to recognize SARS and MERS, therefore our knowledge regarding SARS-CoV-2 is not raw. Various responses of the immune system account for the wide spectrum of clinical manifestations in Coronavirus disease-2019 (COVID-19). Given the innate immune response as the front line of defense, it is immediately activated after the virus entry. Consequently, adaptive immune response is activated to eradicate the virus. However, this does not occur in every case and immune response is the main culprit causing the pathological manifestations of COVID-19. Lethal forms of the disease are correlated with inefficient and/or insufficient immune responses associated with cytokine storm. Current therapeutic approach for COVID-19 is in favor of suppressing extreme inflammatory responses, while maintaining the immune system alert and responsive against the virus. This could be contributing along with administration of antiviral drugs in such patients. Furthermore, supplementation with different compounds, such as vitamin D, has been tested to modulate the immune system responses. A thorough understanding of chronological events in COVID-19 contributing to the development of a highly efficient treatment has not figured out yet. This review focuses on the virus-immune system interaction as well as currently available and potential therapeutic approaches targeting immune system in the treatment of COVID-19 patients.

Association Between Vitamin D and Novel SARS-CoV-2 Respiratory Dysfunction - A Scoping Review of Current Evidence and Its Implication for COVID-19 Pandemic

OBJECTIVES

To assess the association between vitamin D deficiency and increased morbidity/mortality with COVID-19 respiratory dysfunction.

DESIGN

Scoping review.

DATA SOURCES

Ovid MEDLINE (1946 to 24 of April 2020) and PubMed (2020 to 17 of September 2020).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

A search using the search terms: [(cholecalciferol or ergocalciferol or vitamin D2 or vitamin D3 or vitamin D or 25OHD) and (SARS-CoV-2 or coronavirus or COVID or betacoronavirus or MERS-CoV or SARS-CoV or respiratory infection or acute respiratory distress syndrome or ARDS)]m.p. was conducted on the 24/04/2020 (Search A) and 17/09/2020 (Search B).

RESULTS

91 studies were identified as being concerned with Acute Respiratory Infection (ARI)/Acute Respiratory Distress Syndrome (ARDS) and vitamin D, and 25 publications specifically explored the role of vitamin D deficiency in the development and progression of SARS-CoV-2/COVID-19 related ARDS. Search "A" identified three main themes of indirect evidence supporting such an association. Consistent epidemiological evidence exists linking low vitamin D levels to increased risk and severity of respiratory tract infections. We also report on plausible biological processes supporting such an association; and present weaker evidence supporting the benefit of vitamin D supplementation in reducing the risk and severity of ARIs. Uncertainty remains about what constitutes an appropriate dosing regimen in relation to reducing risk/severity of ARI/ARDS. More recent evidence (Search B) provided new insights into some direct links between vitamin D and COVID-19; with a number of cohort and ecological studies supporting an association with PCR-positivity for SARS-CoV-2 and vitamin D deficiency. The exact efficacy of the vitamin D supplementation for prevention of, or as an adjunct treatment for COVID-19 remains to be determined; but a number of randomized control trials (RCTs) currently underway are actively investigating these potential benefits.

CONCLUSION

Our rapid review of literature supports the need for observational studies with COVID-19 infected populations to measure and assess vitamin D levels in relation to risk/severity and outcomes; alongside RCTs designed to evaluate the efficacy of supplementation both in preventive and therapeutic contexts. The overlap in the vitamin D associated biological pathways with the dysregulation reported to drive COVID-19 outcomes warrants further investigation.

Is there a link between vitamin D status, SARS-CoV-2 infection risk and COVID-19 severity?

The outbreak of COVID-19 emerged in December 2019 rapidly spread across the globe and has become pandemic. Little is known about the protective factors of this infection, which is equally distributed between genders and different ages while severe and poor prognosis cases are strongly associated to old males and the presence of comorbidities. Thus, preventive measures aiming at reducing the number of infection and/or their severity are strongly needed. Vitamin D has got great attention and has been claimed as potentially protective against the infection since it may be associated with immunocompetence, inflammation, aging, and those diseases involved in determining the outcomes of COVID-19. This narrative review aims at collecting the literature available on the involvement of the vitamin D status in the pathogenesis of COVID-19 and the putative utility of vitamin D supplementation in the therapeutics. It emerges that a poor vitamin D status seems to associate with an increased risk of infection whereas age, gender and comorbidities seem to play a more important role in COVID-19 severity and mortality. While randomized control trials are needed to better inquire into this topic, vitamin D supplementation may be useful beside its potential effects on SARS-CoV-2 infection and COVID-19.

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology

PURPOSE

To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology.

METHODS

Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality.

RESULTS

Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality.

CONCLUSION

Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.