Medical Nutrition Therapy in Hospitalized Patients With SARS-CoV-2 (COVID-19) Infection in a Non-critical Care Setting: Knowledge in Progress

Estimated glomerular filtration rates are higher when creatinine-based equations are compared with a cystatin C-based equation in coronavirus disease 2019

OBJECTIVES

Estimations of glomerular filtration rate (eGFR) are based on analyses of creatinine and cystatin C, respectively. Coronavirus disease 2019 (COVID-19) patients in the intensive care unit (ICU) often have acute kidney injury (AKI) and are at increased risk of drug-induced kidney injury. The aim of this study was to compare creatinine-based eGFR equations to cystatin C-based eGFR in ICU patients with COVID-19.

METHODS

After informed consent, we included 370 adult ICU patients with COVID-19. Creatinine and cystatin C were analyzed at admission to the ICU as part of the routine care. Creatinine-based eGFR (ml/min) was calculated using the following equations, developed in chronological order; the Cockcroft-Gault (C-G), Modified Diet in Renal Disease (MDRD)1999, MDRD 2006, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Lund-Malmö revised (LMR) equations, which were compared with eGFR calculated using the cystatin C-based Caucasian Asian Pediatric Adult (CAPA) equation.

RESULTS

The median eGFR when determined by C-G was 99 ml/min and interquartile range (IQR: 67 ml/min). Corresponding estimations for MDRD1999 were 90 ml/min (IQR: 54); MDRD2006: 85 ml/min (IQR: 51); CKD-EPI: 91 ml/min (IQR: 47); and for LMR 83 ml/min (IQR: 41). eGFR was calculated using cystatin C and the CAPA equation value was 70 ml/min (IQR: 38). All differences between creatinine-based eGFR versus cystatin C-based eGFR were significant (p < .00001).

CONCLUSIONS

Estimation of GFR based on various analyses of creatinine are higher when compared with a cystatin C-based equation. The C-G equation had the worst performance and should not be used in combination with modern creatinine analysis methods for determination of drug dosage in COVID-19 patients.

Shrunken Pore Syndrome Is Frequently Occurring in Severe COVID-19

A selective decrease in the renal filtration of larger molecules is attributed to the shrinkage of glomerular pores, a condition termed Shrunken Pore Syndrome (SPS). SPS is associated with poor long-term prognosis. We studied SPS as a risk marker in a cohort of patients with COVID-19 treated in an intensive care unit. SPS was defined as a ratio < 0.7 when the estimated glomerular filtration rate (eGFR), determined by cystatin C, calculated by the Cystatin C Caucasian-Asian-Pediatric-Adult equation (CAPA), was divided by the eGFR determined by creatinine, calculated by the revised Lund−Malmö creatinine equation (LMR). Clinical data were prospectively collected. In total, SPS was present in 86 (24%) of 352 patients with COVID-19 on ICU admission. Patients with SPS had a higher BMI, Simplified Physiology Score (SAPS3), and had diabetes and/or hypertension more frequently than patients without SPS. Ninety-nine patients in the total cohort were women, 50 of whom had SPS. In dexamethasone-naïve patients, C-reactive protein (CRP ), TNF-alpha, and interleukin-6 did not differ between SPS and non-SPS patients. Demographic factors (gender, BMI) and illness severity (SAPS3) were independent predictors of SPS. Age and dexamethasone treatment did not affect the frequency of SPS after adjustments for age, sex, BMI, and acute severity. SPS is frequent in severely ill COVID-19 patients. Female gender was associated with a higher proportion of SPS. Demographic factors and illness severity were independent predictors of SPS.

Nutritional risk at hospital admission is associated with prolonged length of hospital stay in old patients with COVID-19

BACKGROUND & AIMS

To investigate the association of nutritional risk at admission with the length of hospital stay (LOS) and mortality in older patients with COVID-19.

METHODS

Retrospective monocentric study in an acute geriatric hospital. Data were collected after an extensive review of medical records and the nutritional risk was assessed according to the Nutritional Risk Screening (NRS). Univariate and multivariate (adjusted for age, sex and comorbidity burden) Cox proportional-hazard and linear regression models were used to investigate the association with the above-mentioned outcomes.

RESULTS

Of a total of 245 patients (86.1 ± 6.4 yrs), 50.6% had a severe nutritional risk with an NRS≥5/7 at admission. Lower BMI, cognitive impairment and swallowing disorders were more prevalent in the patients with a higher NRS. A NRS≥5 was not associated with mortality but prolonged by more than 3 days the LOS among the 173 survivors (β 3.69; 0.71-6.67 95% CI; p = 0.016), with a discharge rate delayed by 1.8 times (HR 0.55; 0.37-0.83 95% CI; p = 0.101).

CONCLUSION

Among the survivors of COVID-19 in an acute geriatric hospital, a NRS ≥5 at admission was associated with a longer LOS, but not with mortality.

Characterization of the expressed RNA variants from young patients with critical and non-critical SARS-CoV-2 infection

Background

Since the COVID-19 outbreak emerged, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has continuously evolved into variants with underlying mutations associated with increased transmissibility, potential escape from neutralizing antibodies, and disease severity. Although intensive research is ongoing worldwide to understand the emergence of SARS-CoV-2 variants, there is a lack of information on what constitutes the expressed RNA variants in critical and non-critical comorbidity-free young patients. The study sought  to characterize the expressed RNA variants from young patients with critical and non-critical forms of SARS-CoV-2 infection.

Methodology

The bulk ribonucleic acid (RNA) sequencing data with the identifier GSE172114 were downloaded from the Gene Expression Omnibus (GEO) database. The study participants were divided into critical, n = 46, and non-critical, n = 23. FastQC version 0.11.9 and Cutadapt version 3.7 were used to assess the read quality and perform adapter trimming, respectively. Spliced Transcripts Alignment to a Reference (STAR) version 2.7.10a was used to align reads to the human (hg38) reference genome. Genome Analysis Tool Kit (GATK) best practice was followed to call variants using the rnavar pipeline, part of the nf-core pipelines.

Results

Our research demonstrates that critical and non-critical SARS-CoV-2-infected individuals are characterized by a unique set of expressed RNA variants. The expressed gene variants are enriched on the innate immune response, specifically neutrophil-mediated immune response. On the other hand, the expressed gene variants are involved in both innate and cellular immune responses.

Conclusion

Deeply phenotyped comorbidity-free young patients with critical and non-critical SARS-CoV-2 infection are characterized by a unique set of expressed RNA variants. The findings in this study can inform the patient classification process in health facilities globally when admitting young patients infected with SARS-CoV-2.

Nutritional support protocol for patients with COVID-19

BACKGROUND & AIMS

COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19.

METHODS

A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients.

RESULTS

The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge.

CONCLUSION

Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

A Secure Artificial Intelligence-Enabled Critical Sars Crisis Management Using Random Sigmoidal Artificial Neural Networks

Since December 2019, the pandemic COVID-19 has been connected to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Early identification and diagnosis are essential goals for health practitioners because early symptoms correlate with those of other common illnesses including the common cold and flu. RT-PCR is frequently used to identify SARS-CoV-2 viral infection. Although this procedure can take up to 2 days to complete and sequential monitoring may be essential to figure out the potential of false-negative findings, RT-PCR test kits are apparently in low availability, highlighting the urgent need for more efficient methods of diagnosing COVID-19 patients. Artificial intelligence (AI)-based healthcare models are more effective at diagnosing and controlling large groups of people. Hence, this paper proposes a novel AI-enabled SARS detection framework. Here, the input CT images are collected and preprocessed using a block-matching filter and histogram equalization (HE). Segmentation is performed using Compact Entropy Rate Superpixel (CERS) technique. Features of segmented output are extracted using Histogram of Gradient (HOG). Feature selection is done using Principal Component Analysis (PCA). The suggested Random Sigmoidal Artificial Neural Networks (RS-ANN) based classification approach effectively diagnoses the existence of the disease. The performance of the suggested Artificial intelligence model is analyzed and related to existing approaches. The suggested AI system may help identify COVID-19 patients more quickly than conventional approaches.

Nutritional therapy for hospitalized patients with COVID-19: A narrative and integrative review

Hospitalized patients affected by coronavirus disease 19 (COVID-19) have a sustained pro-inflammatory state and recurrent gastrointestinal symptoms that correlate with a decline in the nutritional status, which is directly related to poor immune response and clinical evolution. Nutritional therapy has proven crucial in COVID-19 treatment through the provision of adequate amounts of nutrients. Since the beginning of the pandemic, medical societies have mobilized to provide practical nutritional guidelines to support decision-making; despite this, there are only a few studies dedicated to compiling the most relevant recommendations. In this narrative review, we aimed to summarize and stratify the current scientific literature on nutritional support for hospitalized COVID-19 patients. We carried out a literature review from three databases between January 2020 and July 2021, using nutrition therapy (or medical nutrition or enteral nutrition or parental nutrition or nutritional support) and COVID-19 (SARS-CoV-2 infection) as the search terms. Only those studies that evaluated adult hospitalized patients with admissions to wards, specific clinics, or intensive care units were included. The nutritional intervention considered was that of specific nutritional support via oral, enteral, or parenteral modes. A total of 37 articles were included. In general, the nutritional care provided to COVID-19 patients follows the same premises as for other patients, i.e., it opts for the most physiological route and meets nutritional demands based on the clinical condition. However, some protocols that minimize the risk of contamination exposure for the health team have to be considered. Energy requirements varied from 15 kcal/kg/day to 30 kcal/kg/day and protein goals from 1.2 g/kg/day to 2 g/kg/day. In both cases, the ramp protocol for increased supply should be considered. In cases of enteral therapy, ready-to-use diet and continuous mode are recommended. Attention to refeeding syndrome is essential when parenteral nutrition is used.

COVID-19 and liver dysfunction: What nutritionists need to know

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus-2 has brought serious challenges for the medical field. Patients with COVID-19 usually have respiratory symptoms. However, liver dysfunction is not an uncommon presentation. Additionally, the degree of liver dysfunction is associated with the severity and prognosis of COVID-19. Prevention, diagnosis, and treatment of malnutrition should be routinely recommended in the management of patients with COVID-19, especially in those with liver dysfunction. Recently, a large number of studies have reported that nutrition therapy measures, including natural dietary supplements, vitamins, minerals and trace elements, and probiotics, might have potential hepatoprotective effects against COVID-19-related liver dysfunction via their antioxidant, antiviral, anti-inflammatory, and positive immunomodulatory effects. This review mainly focuses on the possible relationship between COVID-19 and liver dysfunction, nutritional and metabolic characteristics, nutritional status assessment, and nutrition therapy to provide a reference for the nutritionists while making evidence-based nutritional decisions during the COVID-19 pandemic.

Forest-bathing and physical activity as weapons against COVID-19: a review

Strengthening the immune system in order to better withstand the threat of COVID-19 is an important way to ensure the protection of our health against the current pandemic associated with SARS-CoV-2. There are many ways to achieve this, but with current circumstances, certain modalities stand out as being the most valid and are certainly worth greater consideration. Here we review the effects that particular immuno-strengthening activities can have on limiting the severity of COVID-19 disease as well as preventing virus infection. Physical activity, in particular, should not be discounted as an important method of prevention of viral diseases as it triggers many biological processes within the human body which in turn lead to heightened natural defences against viral infections. When exercise is performed in forested areas, these protective health benefits may be increased since many plant species emit biogenic volatile compounds (VOCs) which, when inhaled, have many protective properties. These VOCs have been shown in particular to have immunostimulatory effects on the human body and, thus, they could be of use in the prevention and/or treatment of COVID-19. Being amongst trees may also help to alleviate stress and anxiety, lowering cortisol levels and consequently helping the proper functioning of the immune system. In the following work, we have performed an analysis of the available scientific literature which looks at the effects of physical exercise as well as 'forest-bathing' on the immune system's ability to fight disease, especially of course as it relates to COVID-19. Our review aims at shedding light on the benefits of exercising outdoors in green areas and suggests reforestation as a protective measure against future outbreaks.

Adherence to COVID-19 nutritional guidelines and their impact on the clinical outcomes of hospitalized COVID-19 patients

Background & aims

Coronavirus disease 2019 (COVID-19) patients are at high risk of malnutrition, and their doctors are part of a multidisciplinary team, including nutritionists. However, adherence to nutritional guidelines may be difficult in the context of capacity constraints during the COVID-19 pandemic. The aim of this study was to investigate barriers to doctors' adherence to nutritional guidelines and the impacts of guideline adherence on the outcomes of hospitalized COVID-19 patients.

Methods

A multinational electronic survey involving 51 doctors was conducted between November 2020 and January 2021 from 17 COVID-19-designated hospitals in countries with high (Indonesia) and low (Vietnam) numbers of confirmed COVID-19 cases.

Results

In general, doctors reported concerns related to nutritional practices in patients with Covid-19 which included feeling stress when performing medical nutritional therapy (65%), lacking self-efficacy or confidence in performing nutritional care (49%), lacking clear nutritional guidelines (45%), and experiencing budget limitations (33%). A regression analysis adjusted for age, country, and the number of hospitalized COVID-19 cases revealed that guideline knowledge (β: −1.01 (−1.78, −0.23); p = 0.012) and awareness of guidelines (β: −1.37 (−2.66, −0.09); p = 0.037) were negatively correlated with the length of stay of critically ill COVID-19 patients, but non-significant after adjusting for specialization of the doctor. When stratified according to country, a significant relationship between guideline adherence and length of stay of critically ill patients was only found in Vietnam [guideline adherence: β: −0.55 (−1.08, −0.03); p = 0.038; guideline knowledge: β: −1.01 (−1.9, −0.13); p = 0.027] after adjusting for age, specialty, and number of hospitalized COVID-19 cases. In Indonesia, the significant relationship between guideline adherence and mortality of COVID-19 patients remained strong (β: −14 (−27, −1); p = 0.033) after adjusting for age, specialty, and number of hospitalized COVID-19 cases

Conclusions

Inadequate nutritional knowledge is a key barrier to guideline adherence, and this was international and may be related to doctors' specialties and the COVID-19 pandemic. Adherence to nutritional guidelines may represent a prognostic factor for survival in COVID-19 patients.

The Nutrition-COVID-19 Interplay: a Review

Purpose of Review

Nutritional status is affected by the COVID-19 pandemic, directly or indirectly. Even with the recent rollout of the coronavirus disease 2019 (COVID-19) vaccines and availability of medicines such as remdesivir, and monoclonal antibodies, host nutritional status is pivotal in the fight against the acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and outcomes. The purpose of this review is to discuss the effects of COVID-19-related lockdown on lifestyle behaviors, and the nutritional consequences, and the direct sequelae of the infection on nutrition including potential nutritional interventions.

Recent Findings

The COVID-19-related lockdown imposed radical changes in lifestyle behaviors with considerable short-term and long-term health and nutritional consequences including weight gain and obesity and increased cardiometabolic risk, consistently linked to worsened prognosis. The extent of the impact was dependent on food insecurity, overall stress and disordered eating, physical inactivity, and exposure to COVID-19-related nutrition information sources. COVID-19 could directly induce inflammatory responses and poor nutrient intake and absorption leading to undernutrition with micronutrient deficiencies, which impairs immune system function with subsequent amplified risk of infection and disease severity. Nutrition interventions through nutrition support, dietary supplementation, and home remedies such as use of zinc, selenium, vitamin D, and omega-3 fatty acids showed the most significant promise to mitigate the course of COVID-19 infection and improve survival rates.

Summary

The nutrition-COVID-19 relationship and related dietary changes mimic a vicious cycle of the double burden of malnutrition, both obesity and undernutrition with micronutrient deficiencies, which promote infection, disease progression, and potential death.

Vitamins and other immune-supportive elements as cofactors for passing the COVID-19 pandemic

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a viral disease that causes a respiratory disorder, started in December of 2019 in China. Several vitamins and trace elements could help in enhancing host immunity producing antioxidant or anti-inflammatory action. This work aimed to identify the role of different nutrition, vitamins, and trace elements on the immunity status of the infected subject and the possibility of the beneficial role of these elements in the management of COVID-19.

MAIN BODY

After collecting (PubMed, scholar, OVID, Embase, Cochrane Library) and investigating published articles, testing the effect of these elements on viral infection, it was found that most of these elements have a significant role during viral infection through a different mechanism, like antioxidant, anti-inflammatory, and immunomodulation. Nutritional interventions in COVID-19 infections are very important currently, and it was reported that vitamin C and D reduce the risk of acute respiratory infections. In addition, low vitamin A diets compromise the effectiveness of inactivated bovine coronavirus vaccines. Administration of N-acetyl cysteine showed a beneficial inhibitory effect in viral infections and enhanced glutathione production. The deficiency of selenium on COVID-19 subjects has a significant impact on the clinical outcome of the subjects. In addition, supplementation with vitamins proved to enhance immune response during viral infection. Vitamins and trace elements not only showed a beneficial effect but also Omega 3 fatty acids showed an immunomodulating effect during infections.

SHORT CONCLUSIONS

Assessment of levels for these trace elements at the baseline and providing supplementation containing different vitamins and elements could result in better control and clinical outcomes in the case of COVID-19.

Is butyrate a natural alternative to dexamethasone in the management of CoVID-19?

Coronavirus disease 2019 (CoVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 has affected more than 100 million lives. Severe CoVID-19 infection may lead to acute respiratory distress syndrome and death of the patient, and is associated with hyperinflammation and cytokine storm. The broad spectrum immunosuppressant corticosteroid, dexamethasone, is being used to manage the cytokine storm and hyperinflammation in CoVID-19 patients. However, the extensive use of corticosteroids leads to serious adverse events and disruption of the gut-lung axis. Various micronutrients and probiotic supplementations are known to aid in the reduction of hyperinflammation and restoration of gut microbiota. The attenuation of the deleterious immune response and hyperinflammation could be mediated by short chain fatty acids produced by the gut microbiota. Butyric acid, the most extensively studied short chain fatty acid, is known for its anti-inflammatory properties. Additionally, butyric acid has been shown to ameliorate hyperinflammation and reduce oxidative stress in various pathologies, including respiratory viral infections. In this review, the potential anti-inflammatory effects of butyric acid that aid in cytokine storm depletion, and its usefulness in effective management of critical illness related to CoVID-19 have been discussed.