Diarrhea and altered inflammatory cytokine pattern in severe coronavirus disease 2019: Impact on disease course and in-hospital mortality

Dynamics of oxidative stress and immune responses in neonatal calves during diarrhea

Oxidative stress is the imbalanced redox status between oxidant production and their scavengers leading to intestinal physiological dysfunction. However, the role of systemic and local oxidative status during neonatal calf diarrhea is not known. This study assessed systemic (serum) and local (fecal) oxidative status when calves either naturally developed diarrhea or naturally recovered. Healthy calves were enrolled in the study at d 18 of age, and their health status was monitored from the enrollment. Based on their enteric health status on d 21 and 28, calves were grouped as continuous diarrhea from d 21 to 28 (n = 14), diarrhea at d 21 but recovered at d 28 (DH group, n = 19), healthy at d 21 but developed diarrhea at d 28 (HD group, n = 15), and healthy throughout the study (HH group, n = 16). Serum and fecal samples were collected at d 21 and 28 from all calves in the morning 2 h after feeding. Dynamics of oxidative stress indicators including reactive oxygen species (ROS), malondialdehyde (MDA), H2O2, 8-hydroxy-2'-deoxyguanosine (8-OHDG), glutathione peroxidase, superoxide dismutase, catalase (CAT), and total antioxidant capacity and inflammatory indicators TNF-α, IL-1β, IL-4, IL-6, IL-10, and IFN-γ were evaluated using serum samples. In addition, fecal oxidative stress indicators ROS and MDA were measured. Serum ROS, MDA, 8-OHDG, as well as fecal ROS and MDA, were higher, whereas serum CAT and H2O2 were lower in diarrheic calves than those of healthy calves. Serum ROS, MDA, and 8OHDG and fecal ROS and MDA increased in the HD group from d 21 to 28 as they developed diarrhea. In contrast, all these oxidative stress markers decreased in the DH group from d 21 to 28 as they recovered. However, serum H2O2 had an opposite changing trend, which became lower in the HD group and higher in the DH group at d 28. In conclusion, both systemic and local oxidative stress markers and cytokine profiles altered as calves moved from being healthy to having diarrhea or vice versa. Serum ROS, MDA, and 8-OHDG can be used to develop biomarkers to screen calves prone to enteric infections during the preweaning period.

Vitamin D Deficiency (VDD) and Benefits of Supplementation in Veterans with IBS-D

Many veterans deployed to Gulf War areas suffer from persistent chronic diarrhea that is disabling and affects their quality of life. The causes for this condition have eluded investigators until recently and recent literature has shed light on the effect of vitamin D on the brain-gut axis. This study focused on determining clinical causes contributing to diarrhea and assessed whether reversing the identified causes, specifically vitamin D deficiency (VDD), could reduce the incidence of diarrhea in Gulf War veterans (GWVs). All patients completed a workup that included serologies (IBD, celiac), routine laboratory tests (CBC, chemistry panels, TSH, T4, CRP), cultures for enteric pathogens (C diff, bacteria, viruses, small intestinal bacterial overgrowth (SIBO)), and upper and lower endoscopies with histology and a trial of cholestyramine to exclude choleretic diarrhea and rifaximin for dysbiosis. A total of 4221 veterans were screened for chronic diarrhea, yielding 105 GWVs, of which 69 GWVs had irritable bowel syndrome with diarrhea (IBS-D). Paired t-tests demonstrated that all GWVs had VDD (t-11.62, df68 and sig(2-tailed) 0.0001) (defined as a vitamin D level less than 30 ng/mL with normal ranges of 30-100 ng/mL) but no positive serologies, inflammatory markers, abnormal endoscopies, cultures, or histology to explain their persistent diarrhea. There was no correlation with age, BMI, or inflammation. Some zip codes had a higher frequency of GWVs with VDD, but the number of deployments had no impact. Treatment with vitamin D supplementation (3000-5000 units), given in the morning, based on weight, reduced the number of bowel movements per day (p < 0.0001) without causing hypercalcemia. We suggest that VDD is important in the etiology of IBS-D in GWVs and that vitamin D supplementation significantly reduces diarrhea.

Emerging mechanistic insights of selective autophagy in hepatic diseases

Macroautophagy (hereafter referred to as autophagy), a highly conserved metabolic process, regulates cellular homeostasis by degrading dysfunctional cytosolic constituents and invading pathogens via the lysosomal system. In addition, autophagy selectively recycles specific organelles such as damaged mitochondria (via mitophagy), and lipid droplets (LDs; via lipophagy) or eliminates specialized intracellular pathogenic microorganisms such as hepatitis B virus (HBV) and coronaviruses (via virophagy). Selective autophagy, particularly mitophagy, plays a key role in the preservation of healthy liver physiology, and its dysfunction is connected to the pathogenesis of a wide variety of liver diseases. For example, lipophagy has emerged as a defensive mechanism against chronic liver diseases. There is a prominent role for mitophagy and lipophagy in hepatic pathologies including non-alcoholic fatty liver disease (NAFLD), hepatocellular carcinoma (HCC), and drug-induced liver injury. Moreover, these selective autophagy pathways including virophagy are being investigated in the context of viral hepatitis and, more recently, the coronavirus disease 2019 (COVID-19)-associated hepatic pathologies. The interplay between diverse types of selective autophagy and its impact on liver diseases is briefly addressed. Thus, modulating selective autophagy (e.g., mitophagy) would seem to be effective in improving liver diseases. Considering the prominence of selective autophagy in liver physiology, this review summarizes the current understanding of the molecular mechanisms and functions of selective autophagy (mainly mitophagy and lipophagy) in liver physiology and pathophysiology. This may help in finding therapeutic interventions targeting hepatic diseases via manipulation of selective autophagy.

COVID-19 and Gut Injury

COVID-19 induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently a pandemic and it has led to more than 620 million patients with 6.56 million deaths globally. Males are more susceptible to COVID-19 infection and associated with a higher chance to develop severe COVID-19 than females. Aged people are at a high risk of COVID-19 infection, while young children have also increased cases. COVID-19 patients typically develop respiratory system pathologies, however symptoms in the gastrointestinal (GI) tract are also very common. Inflammatory cell recruitments and their secreted cytokines are found in the GI tract in COVID-19 patients. Microbiota changes are the key feature in COVID-19 patients with gut injury. Here, we review all current known mechanisms of COVID-19-induced gut injury, and the most acceptable one is that SARS-CoV-2 binds to angiotensin-converting enzyme 2 (ACE2) receptor on host cells in the GI tract. Interestingly, inflammatory bowel disease (IBD) is an inflammatory disorder, but the patients with IBD do not have the increased risk to develop COVID-19. There is currently no cure for COVID-19, but anti-viruses and monoclonal antibodies reduce viral load and shorten the recovery time of the disease. We summarize current therapeutics that target symptoms in the GI tract, including probiotics, ACE2 inhibitors and nutrients. These are promising therapeutic options for COVID-19-induced gut injury.

COVID-19 induces gastrointestinal symptoms and affects patients' prognosis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection caused the pandemic of coronavirus disease 2019 (COVID-19). Gastrointestinal (GI) involvement is common among patients with COVID-19, and GI symptoms can appear earlier than respiratory symptoms. Except for direct infectious effects, patients infected with SARS-CoV-2 are at risk of complications requiring gastroenterological management. Diarrhea is the most common GI symptom in patients with COVID-19 and occurs in up to half of them. Other GI symptoms, such as anorexia, discomfort, nausea, abdominal pain, loss of taste sensation, and vomiting, have been reported. GI symptoms are associated with a poor prognosis. Fecal viral excretion may have clinical significance because of the possible fecal-oral transmission of infection. In the present narrative review article, six different aspects of studies published to date are summarized as follows: GI manifestations of COVID-19, the roles of fecal-oral transmission, poor prognosis of GI symptoms; abnormal abdominal imaging findings, COVID-19 in patients with irritable bowel disease, and prevention and control of SARS-CoV-2 infection in the digestive endoscopy room. Timely understanding of the association between COVID-19 and the digestive system and effective preventive measures are critical to improve this disease and help clinicians take appropriate measures to mitigate further transmission.

Time evolution of cytokine profiles associated with mortality in COVID-19 hospitalized patients

Background

High cytokine levels have been associated with severe COVID-19 disease. Although many cytokine studies have been performed, not many of them include combinatorial analysis of cytokine profiles through time. In this study we investigate the association of certain cytokine profiles and its evolution, and mortality in SARS-CoV2 infection in hospitalized patients.

Methods

Serum concentration of 45 cytokines was determined in 28 controls at day of admission and in 108 patients with COVID-19 disease at first, third and sixth day of admission. A principal component analysis (PCA) was performed to characterize cytokine profiles through time associated with mortality and survival in hospitalized patients.

Results

At day of admission non-survivors present significantly higher levels of IL-1α and VEGFA (PC3) but not through follow up. However, the combination of HGF, MCP-1, IL-18, eotaxine, and SCF (PC2) are significantly higher in non-survivors at all three time-points presenting an increased trend in this group through time. On the other hand, BDNF, IL-12 and IL-15 (PC1) are significantly reduced in non-survivors at all time points with a decreasing trend through time, though a protective factor. The combined mortality prediction accuracy of PC3 at day 1 and PC1 and PC2 at day 6 is 89.00% (p<0.001).

Conclusions

Hypercytokinemia is a hallmark of COVID-19 but relevant differences between survivors and non-survivors can be early observed. Combinatorial analysis of serum cytokines and chemokines can contribute to mortality risk assessment and optimize therapeutic strategies. Three clusters of cytokines have been identified as independent markers or risk factors of COVID mortality.

Gut Microbiota and COVID-19: Potential Implications for Disease Severity

The SARS-CoV-2 pandemic resulted in an unprecedented global crisis. SARS-CoV-2 primarily causes lung infection trough the binding of the virus with the ACE-2 cell receptor located on the surface of the alveolar epithelial cells. Notably, ACE-2 cell receptors are also expressed in the epithelial cells of the intestinal tract (GI). Recent data showed that the microbial communities of the GI might act as local and systematic inflammatory modulators. Gastrointestinal symptoms, including diarrhea, are frequently observed in infected individuals, and recent released data indicate that SARS-CoV-2 may also spread by fecal–oral transmission. Moreover, the gut microbiota’s ecosystem can regulate and be regulated by invading pathogens, including viruses, facilitating an effective immune response, which in turn results in less severe diseases. In this regard, increased SARS-CoV-2 mortality and morbidities appear to be frequently observed in elderly immunocompromised patients and in people with essential health problems, such as diabetes, who, indeed, tend to have a less diverse gut microbiota (dysbiosis). Therefore, it is important to understand how the interaction between the gut microbiota and SARS-CoV-2 might shape the intensity of the infection and different clinical outcomes. Here, we provide insights into the current knowledge of dysbiosis during SARS-CoV-2 infection and methods that may be used to re-establish a more correct microbiota composition.

Predictors of Intensive Care Unit Admission in Patients with Confirmed Coronavirus Disease 2019: A Cross-Sectional Study

Background

The coronavirus disease 2019 (COVID-19) has become the leading source of pneumonia outbreaks in the world. The present study aimed to compare the condition of intensive care unit (ICU) and non-ICU COVID-19 patients in terms of epidemiological and clinical features, laboratory findings, and outcomes in three cities across Iran.

Methods

In a cross-sectional study, 195 COVID-19 patients admitted to five hospitals across Iran during March-April 2020 were recruited. Collected information included demographic data, laboratory findings, symptoms, medical history, and outcomes. Data were analyzed using SPSS software with t test or Mann-Whitney U test (continuous data) and Chi square test or Fisher's exact test (categorical variables). P<0.05 was considered statistically significant.

Results

Of the 195 patients, 57.4% were men, and 67.7% had at least one comorbidity. The prevalence of stroke, chronic obstructive pulmonary disease, and autoimmune diseases was higher in ICU than in non-ICU patients (P=0.042, P=0.020, and P=0.002, respectively). Compared with non-ICU, ICU patients had significantly higher white blood cell (WBC) count (P=0.008), cardiac troponin concentrations (P=0.040), lactate dehydrogenase levels (P=0.027), erythrocyte sedimentation rates (P=0.008), and blood urea nitrogen (BUN) (P=0.029), but lower hematocrit levels (P=0.001). The mortality rate in ICU and non-ICU patients was 48.1% and 6.1%, respectively. The risk factors for mortality included age>40 years, body mass index<18 Kg/m², hypertension, coronary artery disease, fever, cough, dyspnea, ST-segment changes, pericardial effusion, and a surge in WBC and C-reactive protein, aspartate aminotransferase, and BUN.

Conclusion

A high index of suspicion for ICU admission should be maintained in patients with positive clinical and laboratory predictive factors.

Analysis of post COVID-19 condition and its overlap with myalgic encephalomyelitis/chronic fatigue syndrome

BACKGROUND

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease (COVID-19) triggers the development of numerous pathologies and infection-linked complications and exacerbates existing pathologies in nearly all body systems. Aside from the primarily targeted respiratory organs, adverse SARS-CoV-2 effects were observed in nervous, cardiovascular, gastrointestinal/metabolic, immune, and other systems in COVID-19 survivors. Long-term effects of this viral infection have been recently observed and represent distressing sequelae recognised by the World Health Organisation (WHO) as a distinct clinical entity defined as post-COVID-19 condition. Considering the pandemic is still ongoing, more time is required to confirm post COVID-19 condition diagnosis in the COVID-19 infected cohorts, although many reported post COVID-19 symptoms overlap with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

AIMS OF REVIEW

In this study, COVID-19 clinical presentation and associated post-infection sequelae (post-COVID-19 condition) were reviewed and compared with ME/CFS symptomatology.

KEY SCIENTIFIC CONCEPTS OF REVIEW

The onset, progression, and symptom profile of post COVID-19 condition patients have considerable overlap with ME/CFS. Considering the large scope and range of pro-inflammatory effects of this virus, it is reasonable to expect development of post COVID-19 clinical complications in a proportion of the affected population. There are reports of a later debilitating syndrome onset three months post COVID-19 infection (often described as long-COVID-19), marked by the presence of fatigue, headache, cognitive dysfunction, post-exertional malaise, orthostatic intolerance, and dyspnoea. Acute inflammation, oxidative stress, and increased levels of interleukin-6 (IL-6) and tumor necrosis factor α (TNFα), have been reported in SARS-CoV-2 infected patients. Longitudinal monitoring of post COVID-19 patients is warranted to understand the long-term effects of SARS-CoV-2 infection and the pathomechanism of post COVID-19 condition.

Comparison of laboratory characteristics of gastrointestinal symptoms and nongastrointestinal symptoms in patients infected with COVID-19: a systematic review and meta-analysis

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic poses a massive crisis to global public health. Gastrointestinal (GI) symptoms are increasingly reported in COVID-19. The characteristics of laboratory findings of COVID-19 are critical for clinical diagnosis and treatment.

OBJECTIVES

The study aimed to summarize laboratory features in COVID-19 with GI symptoms and non-GI symptoms.

DESIGN

This study was a systematic review and meta-analysis. Electronic literature searches were conducted for studies that included patients infected COVID-19 with GI symptoms and non-GI symptoms. GI symptoms included diarrhea, abdominal pain, nausea and vomiting, and anorexia. This study used a random-effects model to assess pooled data.

DATA SOURCES AND METHODS

We systematically searched PubMed, Embase, Cochrane, Web of Science for studies through 31 October 2021, with no language restrictions. We used the following search terms: 'COVID-19' OR '2019-nCoV' OR 'SARS-CoV-2' OR 'coronavirus 2019' OR 'severe acute respiratory syndrome coronavirus 2' OR 'coronavirus' OR 'novel coronavirus' OR 'nCoV' AND 'gastrointestinal symptoms' OR 'digestive symptoms' AND 'clinical feature' OR 'clinical characteristics.' Data mostly originated from Chinese and American studies.

RESULTS

Of 796 identified studies, 14 were eligible and were included in our analysis (N = 8396 participants). Meta-analysis showed that GI symptoms group had an elevated alanine aminotransferase (ALT) [pooled mean difference (MD), 4.5 U/L; 95% confidence interval, [0.45, 8.55]; p = 0.03; I ² = 87%]. No publication bias was detected by Begg's and Egger's regression test (p = 0.130). COVID-19 with the GI symptoms also showed a trend toward decreased white blood cell count, lymphopenia, neutrophilia, thrombocytopenia and elevated total bilirubin.

CONCLUSION

GI symptoms are common in COVID-19. No significant differences were found in most laboratory indicators except elevated ALT.

REGISTRATION

CRD42020209039 (PROSPERO).

Twelve Months with COVID-19: What Gastroenterologists Need to Know

Corona virus disease-19 (COVID-19) is the latest global pandemic. COVID-19 is mainly transmitted through respiratory droplets and, apart from respiratory symptoms, patients often present with gastrointestinal symptoms and liver involvement. Given the high percentage of COVID-19 patients that present with gastrointestinal symptoms (GIS), in this review, we report a practical up-to-date reference for the physician in their clinical practice with patients affected by chronic gastrointestinal (GI) diseases (inflammatory bowel disease, coeliac disease, chronic liver disease) at the time of COVID-19. First, we summarised data on the origin and pathogenetic mechanism of SARS-CoV-2. Then, we performed a literature search up to December 2020 examining clinical manifestations of GI involvement. Next, we illustrated and summarised the most recent guidelines on how to adhere to GI procedures (endoscopy, liver biopsy, faecal transplantation), maintaining social distance and how to deal with immunosuppressive treatment. Finally, we focussed on some special conditions such as faecal-oral transmission and gut microbiota. The rapid accumulation of information relating to this condition makes it particularly essential to revise the literature to take account of the most recent publications for medical consultation and patient care.

Contribution of CD4+ T cell mediated inflammation to diarrhoea in patients with COVID-19

OBJECTIVES

This study aimed to explore the role of CD4+ T cells in the mechanisms of COVID-19 related diarrhoea.

METHODS

Lymphocyte subsets were analysed in COVID-19 patients, and the expression of angiotensin-converting enzyme 2 (ACE2), the transmembrane protease, serine 2 (TMPRSS2), and CD4+ T cell-related indicators in the colon were compared between patients with and without diarrhoea. Correlation analyses were performed for ACE2 and other indicators to identify the relationship between SARS-CoV-2 infection and CD4+ mediated inflammation. The expression and distribution of CD4+ T cell-associated chemokines and their receptors were detected to determine the possibility of migration of CD4+ T cells to inflammation sites.

RESULTS

The CD4+ T cell counts and percentages and CD4/CD8 ratio showed the most significant differences between the two groups. The diarrhoea group expressed higher levels of ACE2, Tbet, and TNFα at both the mRNA and protein levels, with no difference from the non-diarrhoea group for the percentage of ACE2+TNFα+ cells, indicating an indirect association between ACE2 and TNFα. The mRNA expression of CXCL10, CXCL11, and CXCR3, and the number of CD4+CXCR3+T cells was increased in the diarrhoea group.

CONCLUSIONS

CD4+ T cell-mediated inflammation may contribute to COVID-19 related diarrhoea. CXCR3+ mediated migration of CD4+ T cells into the gut may perpetuate inflammation.

Are gastrointestinal symptoms associated with higher risk of Mortality in COVID-19 patients? A systematic review and meta-analysis

BACKGROUND

Gastrointestinal symptoms have been reported in patients with COVID-19. Several clinical investigations suggested that gastrointestinal symptoms were associated with disease severity of COVID-19. However, the relevance of gastrointestinal symptoms and mortality of COVID-19 remains largely unknown. We aim to investigate the relationship between gastrointestinal symptoms and COVID-19 mortality.

METHODS

We searched the PubMed, Embase, Web of science and Cochrane for studies published between Dec 1, 2019 and May 1, 2021, that had data on gastrointestinal symptoms in COVID-19 patients. Additional literatures were obtained by screening the citations of included studies and recent reviews. Only studies that reported the mortality of COVID-19 patients with/without gastrointestinal symptoms were included. Raw data were pooled to calculate OR (Odds Ratio). The mortality was compared between patients with and without gastrointestinal symptoms, as well as between patients with and without individual symptoms (diarrhea, nausea/vomiting, abdominal pain).

RESULTS

Fifty-three literatures with 55,245 COVID-19 patients (4955 non-survivors and 50,290 survivors) were included. The presence of GI symptoms was not associated with the mortality of COVID-19 patients (OR=0.88; 95% CI 0.71-1.09; P=0.23). As for individual symptoms, diarrhea (OR=1.01; 95% CI 0.72-1.41; P=0.96), nausea/vomiting (OR=1.16; 95% CI 0.78-1.71; P=0.46) and abdominal pain (OR=1.55; 95% CI 0.68-3.54; P=0.3) also showed non-relevance with the death of COVID-19 patients.

CONCLUSIONS

Gastrointestinal symptoms are not associated with higher mortality of COVID-19 patients. The prognostic value of gastrointestinal symptoms in COVID-19 requires further investigation.

Interleukin-6 in SARS-CoV-2 induced disease: Interactions and therapeutic applications

Interleukin-6 (IL-6) is a multi-tasking cytokine that represents high activity in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and cancer. High concentration of this pleiotropic cytokine accounts for hyperinflammation and cytokine storm, and is related to multi-organ failure in patients with SARS-CoV-2 induced disease. IL-6 promotes lymphopenia and increases C-reactive protein (CRP) in such cases. However, blockade of IL-6 is not a full-proof of complete response. Hypoxia, hypoxemia, aberrant angiogenesis and chronic inflammation are inter-related events occurring as a response to the SARS-CoV-2 stimulatory effect on high IL-6 activity. Taking both pro- and anti-inflammatory activities will make complex targeting IL-6 in patient with SARS-CoV-2 induced disease. The aim of this review was to discuss about interactions occurring within the body of patients with SARS-CoV-2 induced disease who are representing high IL-6 levels, and to determine whether IL-6 inhibition therapy is effective for such patients or not. We also address the interactions and targeted therapies in cancer patients who also have SARS-CoV-2 induced disease.

[Two consecutive attacks of diarrhea in 15 COVID-19 patients: An antibiotic-associated one following the viral one]

Of the 971 patients admitted to our Clinic with suspected COVID-19, 15 (1.5%) presented with two consecutive attacks of diarrhea. One of those patients (a 47-year-old woman) required admission to the intensive care unit and mechanical ventilation. She died on the 11th day of hospitalization (18th day of illness). The first attack of diarrhea in those patients occurred on the 6 th (4th-7th) day of disease and lasted 3 (3-5) days. The second attack of diarrhea developed 11 (8-12) days after the initial onset of diarrhea. Despite the existing trend, the difference in the duration of the diarrhea and the maximum number of bowel movements per day between the first and second attacks was not statistically significant (p = 0.130; p = 0.328). There was no significant difference between the patients with a double attack of diarrhea and those with no diarrhea, regarding the results of the complete blood count, biochemical blood tests, and inflammation biomarkers.

Prolonged NHE Activation may be both Cause and Outcome of Cytokine Release Syndrome in COVID-19

The release of cytokines and chemokines such as IL-1β, IL-2, IL-6, IL-7, IL-10, TNF-α, IFN-γ, CCL2, CCL3, and CXCL10 is increased in critically ill patients with COVID-19. Excessive cytokine release during COVID-19 is related to increased morbidity and mortality. Several mechanisms are put forward for cytokine release syndrome during COVID-19. Here we have mentioned novel pathways. SARS-CoV-2 increases angiotensin II levels by rendering ACE2 nonfunctional. Angiotensin II causes cytokine release via AT₁ and AT₂ receptors. Moreover, angiotensin II potently stimulates the Na+/H+ exchanger (NHE). It is a pump found in the membranes of many cells that pumps Na+ inward and H+ outward. NHE has nine isoforms. NHE1 is the most common isoform found in endothelial cells and many cells. NHE is involved in keeping the intracellular pH within physiological limits. When the intracellular pH is acidic, NHE is activated, bringing the intracellular pH to physiological levels, ending its activity. Sustained NHE activity is highly pathological and causes many problems. Prolonged NHE activation in COVID-19 may cause a decrease in intracellular pH through H+ ion accumulation in the extracellular area and subsequent redox reactions. The activation reduces the intracellular K+ concentration and leads to Na+ and Ca²⁺ overload. Increased ROS can cause intense cytokine release by stimulating NF-κB and NLRP3 inflammasomes. Cytokines also cause overstimulation of NHE. As the intracellular pH decreases, SARS-CoV-2 rapidly infects new cells, increasing the viral load. This vicious circle increases morbidity and mortality in patients with COVID-19. On the other hand, SARS-CoV-2 interaction with NHE3 in intestinal tissue is different from other tissues. SARS-CoV-2 can trigger CRS via NHE3 inhibition by disrupting the intestinal microbiota. This review aimed to help develop new treatment models against SARS-CoV-2- induced CRS by revealing the possible effects of SARS-CoV-2 on the NHE.

Improving growth performance and blood profile by feeding autolyzed yeast to improve pork carcass and meat quality

The 63 commercial pigs were divided into three groups consisting of seven replicates of three piglets each. The experimental diets were (1) control diet, (2) diet with autolyzed yeast (AY) 0.5%, and (3) diet with AY 1.0%. Compared to the control group, using AY 0.5% in the diet reduced average daily feed intake (ADFI) and improved feed conversion ratio (FCR) (p < 0.05). The blood urea nitrogen (BUN) and neutrophil/lymphocyte ratio (N/L) in blood decreased with the addition of AY 0.5% (p < 0.05). The pH at 6-h postmortem of meat in the 0.5% AY diet group was higher than for the control group (p < 0.05). Backfat thickness (p = 0.09) and P2-backfat thickness (p = 0.07) tended to decrease, while the fat free index (FFI; p = 0.07) tended to increase with 0.5% AY supplementation. The protein percentage (p = 0.07) and the a* value (redness) (p = 0.08) in the meat tended to increase, and the springiness increased with 0.5% AY supplementation (p < 0.05). An appropriate level of AY supplementation can impact positively on the physiological functions in swine with a consequent seems to improve in qualitative traits of the meat quality.

Pathogenesis and Mechanism of Gastrointestinal Infection With COVID-19

As a new infectious disease, COVID-19 is spread through the respiratory tract in most cases. Its source and pathological mechanism are not clear. The most common clinical feature is pulmonary infection. Also, a lot patients have gastrointestinal symptoms. Angiotensin-converting enzyme 2 (ACE2) is a functional cellular receptor for SARS-CoV-2, which is like SARS-CoV, a coronavirus associated with severe acute respiratory syndrome (SARS) outbreak in 2003. The tissues and cells expressing ACE2 are potential targets for SARS-CoV-2 infection, and the high expression of ACE2 in intestinal epithelial cells marks that SARS-CoV-2 may directly infect intestinal epithelial cells. Recent studies also suggest that SARS-CoV-2 existed and replicated in intestinal environment for a long time. The interaction between SARS-CoV-2 and RAS system leads to the decrease of local anti-inflammatory ability. The virus cycle leads to excessive imbalance of immune response and cytokine release. The downregulation of ACE2 after viral infection leads to gastrointestinal dysfunction. The above are the causes of gastrointestinal symptoms. Here, we reviewed the possible causes and mechanisms of gastrointestinal symptoms caused by COVID-19. Additionally, we discussed the influence of gastrointestinal symptoms on the prognosis of patients.

Two consecutive attacks of diarrhea in 15 COVID-19 patients: An antibiotic-associated one following the viral one

Of the 971 patients admitted to our Clinic with suspected COVID-19, 15 (1.5%) presented with two consecutive attacks of diarrhea. One of those patients (a 47-year-old woman) required admission to the intensive care unit and mechanical ventilation. She died on the 11th day of hospitalization (18th day of illness). The first attack of diarrhea in those patients occurred on the 6th (4th-7th) day of disease and lasted 3 (3-5) days. The second attack of diarrhea developed 11 (8-12) days after the initial onset of diarrhea. Despite the existing trend, the difference in the duration of the diarrhea and the maximum number of bowel movements per day between the first and second attacks was not statistically significant (p = 0.130; p = 0.328). There was no significant difference between the patients with a double attack of diarrhea and those with no diarrhea, regarding the results of the complete blood count, biochemical blood tests, and inflammation biomarkers.

Gastrointestinal manifestations and possible mechanisms of COVID-19 in different periods

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has become a pandemic worldwide. Although COVID-19 mainly affects the respiratory system, gastrointestinal (GI) manifestations have been frequently reported in such cases, even as initial symptoms. There have been several studies on different GI manifestations in patients with mild and severe disease or in remission. In this review article we summarized different GI manifestations of COVID-19 at various disease stages and the possible mechanisms based on published literatures, as well as the significance of GI manifestations in systemic inflammatory injury.

Association between initial symptoms and subsequent hospitalization in outpatients with COVID-19: A cohort study

BACKGROUND

Most individuals with coronavirus disease 2019 (COVID-19) experience mild symptoms and are managed in the outpatient setting. The aim of this study was to determine whether self-reported symptoms at the time of diagnosis can identify patients at risk of clinical deterioration.

METHODS

This was a retrospective cohort study of 671 outpatients with laboratory-confirmed COVID-19 diagnosed in Toronto between March 1 and October 16, 2020. We examined the association between patients' baseline characteristics and self-reported symptoms at the time of diagnosis and the risk of subsequent hospitalization.

RESULTS

Of 671 participants, 26 (3.9%) required hospitalization. Individuals aged 65 years or older were more likely to require hospitalization (odds ratio [OR] 5.29, 95% CI 2.19 to 12.77), whereas those without medical comorbidities were unlikely to be hospitalized (OR 0.02, 95% CI 0.00 to 0.17). After adjusting for age and presence of comorbidities, sputum production (adjusted OR [aOR] 5.01, 95% CI 1.97 to 12.75), arthralgias (aOR 4.82, 95% CI 1.85 to 12.53), diarrhea (aOR 4.56, 95% CI 1.82 to 11.42), fever (aOR 3.64, 95% CI 1.50 to 8.82), chills (aOR 3.62, 95% CI 1.54 to 8.50), and fatigue (aOR 2.59, 95% CI 1.04 to 6.47) were associated with subsequent hospitalization.

CONCLUSIONS

Early assessment of symptoms among outpatients with COVID-19 can help identify individuals at risk of clinical deterioration. Additional studies are needed to determine whether more intense follow-up and early intervention among high-risk individuals can alter the clinical trajectory of and outcomes among outpatients with COVID-19.

Early viral versus late antibiotic-associated diarrhea in novel coronavirus infection

Diarrhea is one of the manifestations of the novel coronavirus disease (COVID-19), but it also develops as a complication of massive antibiotic therapy in this disease. This study aimed to compare these types of diarrhea.We included patients with COVID-19 in a cohort study and excluded patients with chronic diarrhea, laxative use, and those who died during the first day of hospitalization.There were 89 (9.3%), 161 (16.7%), and 731 (75.7%) patients with early viral, late antibiotic-associated, and without diarrhea, respectively. Late diarrhea lasted longer (6 [4-10] vs 5 [3-7] days, P < .001) and was more severe. Clostridioides difficile was found in 70.5% of tested patients with late diarrhea and in none with early diarrhea. Presence of late diarrhea was associated with an increased risk of death after 20 days of disease (P = .009; hazard ratio = 4.7). Patients with late diarrhea had a longer hospital stay and total disease duration, and a higher proportion of these patients required intensive care unit admission. Oral amoxicillin/clavulanate (odds ratio [OR] = 2.23), oral clarithromycin (OR = 3.79), and glucocorticoids (OR = 4.41) use was a risk factor for the development of late diarrhea, while ceftriaxone use (OR = 0.35) had a protective effect. Before the development of late diarrhea, decrease in C-reactive protein levels and increase in lymphocyte count stopped but the white blood cell and neutrophil count increased. An increase in neutrophils by >0.6 × 109 cells/L predicted the development of late diarrhea in the coming days (sensitivity 82.0%, specificity 70.8%, area under the curve = 0.791 [0.710-0.872]).Diarrhea in COVID-19 is heterogeneous, and different types of diarrhea require different management.

ACE2 in the Gut: The Center of the 2019-nCoV Infected Pathology

The 2019-nCoV is a rapidly contagious pneumonia caused by the recently discovered coronavirus. Although generally the most noticeable symptoms are concentrated in the lungs, the disorders in the gastrointestinal tract are of great importance in the diagnosis of 2019-nCoV. The angiotensin-converting enzyme 2 (ACE2), an important regulator of many physiological functions, including blood pressure and nutrients absorption, is recently identified as a vital entry for 2019-nCoV to enter host cells. In this review, we summarize its functions both physiologically and pathologically. We also elaborate its conflicting roles from the clews of contemporary researches, which may provide significant indications for pharmacological investigations and clinical uses.

Acid pH Increases SARS-CoV-2 Infection and the Risk of Death by COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can infect a broad range of human tissues by using the host receptor angiotensin-converting enzyme 2 (ACE2). Individuals with comorbidities associated with severe COVID-19 display higher levels of ACE2 in the lungs compared to those without comorbidities, and conditions such as cell stress, elevated glucose levels and hypoxia may also increase the expression of ACE2. Here, we showed that patients with Barrett's esophagus (BE) have a higher expression of ACE2 in BE tissues compared to normal squamous esophagus, and that the lower pH associated with BE may drive this increase in expression. Human primary monocytes cultured in reduced pH displayed increased ACE2 expression and higher viral load upon SARS-CoV-2 infection. We also showed in two independent cohorts of 1,357 COVID-19 patients that previous use of proton pump inhibitors is associated with 2- to 3-fold higher risk of death compared to those not using the drugs. Our work suggests that pH has a great influence on SARS-CoV-2 Infection and COVID-19 severity.

Gut microbial signature and gut-lung axis: A possible role in the therapy of COVID-19

The impact of gut as the origin of different disorders has led to the "gut-origin concept" of diseases. The gut microbiome regulates host defenses against viral infections, thus dysbiosis can play a major role in triggering the cascade of inflammation and causing immune imbalances in COVID-19 patients. It appears that gut microbial signature in COVID-19 patients can be used as a potential diagnostic, therapeutic, and even a prognostic marker. Personalized nutrition therapy can be used by profiling the gut microbiota of individual patients and specialized probiotics/synbiotics to modify gut dysbiosis. Hence, improving overall immune responses can be recommended in these patients.

Neuropathy in COVID-19 associated with dysbiosis-related inflammation

Although COVID-19 affects mainly lungs with a hyperactive and imbalanced immune response, gastrointestinal and neurological symptoms such as diarrhea and neuropathic pains have been described as well in patients with COVID-19. Studies indicate that gut-lung axis maintains host homeostasis and disease development with the association of immune system, and gut microbiota is involved in the COVID-19 severity in patients with extrapulmonary conditions. Gut microbiota dysbiosis impairs the gut permeability resulting in translocation of gut microbes and their metabolites into the circulatory system and induce systemic inflammation which, in turn, can affect distal organs such as the brain. Moreover, gut microbiota maintains the availability of tryptophan for kynurenine pathway, which is important for both central nervous and gastrointestinal system in regulating inflammation. SARS-CoV-2 infection disturbs the gut microbiota and leads to immune dysfunction with generalized inflammation. It has been known that cytokines and microbial products crossing the blood-brain barrier induce the neuroinflammation, which contributes to the pathophysiology of neurodegenerative diseases including neuropathies. Therefore, we believe that both gut-lung and gut-brain axes are involved in COVID-19 severity and extrapulmonary complications. Furthermore, gut microbial dysbiosis could be the reason of the neurologic complications seen in severe COVID-19 patients with the association of dysbiosis-related neuroinflammation. This review will provide valuable insights into the role of gut microbiota dysbiosis and dysbiosis-related inflammation on the neuropathy in COVID-19 patients and the disease severity.

The roles of nausea and vomiting in COVID-19: did we miss something?

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an international public health emergency. Although respiratory symptoms predominate the clinical manifestations of COVID-19, gastrointestinal symptoms have been observed in a subset of patients. Notably, some patients have nausea/vomiting as the first clinical manifestation of COVID-19, which is often overlooked by people. It is now clear that not only the lungs, the gastrointestinal tract could also be attacked by SARS-CoV-2. Its host receptor angiotensin-converting enzyme 2 (ACE2), which acts as a gateway to infection, has been found to be highly expressed in the gastrointestinal epithelium and may lead to the development of nausea/vomiting. Raise awareness of these symptoms and take timely intervention would help people combat the pandemic. This review discussed epidemiology, mechanisms, management, and prevention of COVID-19 related nausea and vomiting.

SARS-CoV-2-associated gastrointestinal and liver diseases: what is known and what is needed to explore

BACKGROUND

The pandemic of COVID19 which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first described in China as an unexplained pneumonia transmitted by respiratory droplets. Gastrointestinal (GI) and liver injury associated with SARS-CoV-2 infection were reported as an early or sole disease manifestation, mainly outside China. The exact mechanism and incidence of GI and liver involvement are not well elucidated.

MAIN BODY

We conducted a PubMed search for all articles written in the English language about SARS-CoV-2 affecting the GI and liver. Following data extraction, 590 articles were selected. In addition to respiratory droplets, SARS-CoV-2 may reach the GI system through the fecal-oral route, saliva, and swallowing of nasopharyngeal fluids, while breastmilk and blood transmission were not implicated. Moreover, GI infection may act as a septic focus for viral persistence and transmission to the liver, appendix, and brain. In addition to the direct viral cytopathic effect, the mechanism of injury is multifactorial and is related to genetic and demographic variations. The most frequently reported GI symptoms are diarrhea, nausea, vomiting, abdominal pain, and bleeding. However, liver infection is generally discovered during laboratory testing or a post-mortem. Radiological imaging is the gold standard in diagnosing COVID-19 patients and contributes to understanding the mechanism of extra-thoracic involvement. Medications should be prescribed with caution, especially in chronic GI and liver patients.

CONCLUSION

GI manifestations are common in COVID-19 patients. Special care should be paid for high-risk patients, older males, and those with background liver disease.

COVID-19-associated diarrhea

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) recently emerged as a highly virulent respiratory pathogen that is known as the causative agent of coronavirus disease 2019 (COVID-19). Diarrhea is a common early symptom in a significant proportion of patients with SARS-CoV-2 infection. SARS-CoV-2 can infect and replicate in esophageal cells and enterocytes, leading to direct damage to the intestinal epithelium. The infection decreases the level of angiotensin-converting enzyme 2 receptors, thereby altering the composition of the gut microbiota. SARS-CoV-2 elicits a cytokine storm, which contributes to gastrointestinal inflammation. The direct cytopathic effects of SARS-CoV-2, gut dysbiosis, and aberrant immune response result in increased intestinal permeability, which may exacerbate existing symptoms and worsen the prognosis. By exploring the elements of pathogenesis, several therapeutic options have emerged for the treatment of COVID-19 patients, such as biologics and biotherapeutic agents. However, the presence of SARS-CoV-2 in the feces may facilitate the spread of COVID-19 through fecal-oral transmission and contaminate the environment. Thus gastrointestinal SARS-CoV-2 infection has important epidemiological significance. The development of new therapeutic and preventive options is necessary to treat and restrict the spread of this severe and widespread infection more effectively. Therefore, we summarize the key elements involved in the pathogenesis and the epidemiology of COVID-19-associated diarrhea.

Epidemiological and clinical characteristics of non-severe and severe pediatric and adult COVID-19 patients across different geographical regions in the early phase of pandemic: a systematic review and meta-analysis of observational studies

This systematic and meta-review aimed to compare clinical presentation, outcomes, and care management among patients with COVID-19 during the early phase of the pandemic. A total of 77 peer-reviewed publications were identified between January 1, 2020 and April 9, 2020 from PubMed, Google Scholar, and Chinese Medical Journal databases. Subsequently, meta-analysis of 40 non-overlapping studies, comprising of 4844 patients from seven countries, was conducted to see differences in clinical characteristics and laboratory outcomes across patients from different geographical regions (Wuhan, other parts of China and outside China), severity (non-severe, severe and fatal) and age groups (adults and children). Patients from Wuhan had a higher mean age (54.3 years) and rates of dyspnea (39.5%) compared with patients from other parts of China and outside China. Myalgia, fatigue, acute respiratory distress syndrome (ARDS) and fatalities were also significantly more prevalent among Wuhan patients. A significant dose–response increase in prevalence of diabetes, D-dimer, white blood cells, neutrophil levels and ARDS was seen from non-severe to severe and fatal outcomes. A significant increase in mean duration of symptom onset to admission was seen between non-severe cases (4.2 days) and severe and fatal cases (6.3 days and 8.8 days, respectively). Proportion of asymptomatic cases was higher in children (20%) compared with adults (2.4%). In conclusion, patients with COVID-19 from Wuhan displayed more severe clinical disease during the early phase of the pandemic, while disease severity was significantly lesser among pediatric cases. This review suggests that biomarkers at admission may be useful for prognosis among patients with COVID-19.

Diarrhoea in adults with coronavirus disease-beyond incidence and mortality: a systematic review and meta-analysis

AIM

Diarrhoea is a relatively common manifestation of coronavirus disease (COVID-19), but there is no systematic review which comprehensively describes it beyond its incidence and impact on prognosis. This study aims to provide a detailed systematic review of diarrhoea in adults with COVID-19.

METHODS

A PUBMED and Scopus search (until 7 September 2020) was performed. Studies that were limited to describing incidence of diarrhoea and its effect on prognosis were excluded.

RESULTS

Twenty-six papers including 7860 patients with COVID-19 were subjected to synthesis. Mean duration of diarrhoea was 4.2 (3.6-4.9) days (range 1-16 days), whereas mean bowel movement count was 4.6 (3.8-5.3) and maximum was 20 per day. Diarrhoea started on an average 5.1 (3.8-6.5) days after disease onset but was the first manifestation in 4.3% patients. Stool occult blood was detected in 6.8% of patients with diarrhoea, while 53.3% cases had watery diarrhoea. Patients with diarrhoea also had elevated faecal calprotectin. Viral genome in faeces was detected more often in patients with diarrhoea and most often in patients without respiratory symptoms. Fever, myalgia and respiratory symptoms were observed with the same incidence in patients with and without diarrhoea. Similarly, there were no differences noted in complete blood count and most inflammation biomarkers between patients with and without diarrhoea. However, nausea, vomiting abdominal pain, sneezing and headache were more common in patients with diarrhoea. Diarrhoea was the main manifestation of COVID-19 in 6.1% of cases and this form of the disease had specific features.

CONCLUSIONS

Diarrhoea in COVID-19 needs further investigation.

Quality of Life: A Prospective Randomized Trial of Palliative Volumetric Arc Therapy Versus 3-Dimensional Conventional Radiation Therapy

PURPOSE

Volumetric arc therapy (VMAT) is a radiation therapy (RT) technique that spares normal tissues from high and intermediate RT doses but increases the volume of tissues receiving low doses of RT compared with 3-dimensional conformal RT (3DCRT). We hypothesized that palliative VMAT would reduce the detriment to patient quality of life (QOL) compared with palliative 3DCRT.

METHODS AND MATERIALS

This phase 2 trial randomized patients to palliative RT using VMAT or 3DCRT to 1 painful site of metastatic disease in the trunk. Treating physicians could choose 8 Gy in 1 fraction or 20 Gy in 5 fractions to stratify randomization. The primary endpoint was the change in European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC QLQ-C30) global health status QOL subscale at 1 week after RT. Repeated measures analysis of variance was used to assess the relationship of patient QOL over time with other factors.

RESULTS

From July 2014 to November 2017, 37 patients who underwent 3DCRT and 32 patients who underwent VMAT were randomized into the study. Median overall survival was 9 months. Overall pain responses to RT were equivalent (P = .53) between the techniques. Patient compliance in returning QOL questionnaires was 94%, 81%, and 69% at baseline, 1 week after RT, and 1 month after RT, respectively. At 1 week after RT, change in global QOL was not significantly (P = .31) different between VMAT versus 3DCRT. At 4 weeks after RT, VMAT induced significantly (P = .049) less global QOL deterioration than 3DCRT did. Patients who underwent VMAT maintained better physical (P = .012), role (P = .041), and social (P = .025) functioning, but they reported more diarrhea symptoms (P = .017) than in the 3DCRT group.

CONCLUSIONS

Palliative VMAT and 3DCRT did not differ in their ability to control pain; however, palliative VMAT induced fewer QOL detriments than 3DCRT did at 4 weeks after RT.

Implications of SARS-CoV-2 infection for neurogastroenterology

BACKGROUND

Coronavirus disease 2019 (COVID-19) is associated with gastrointestinal and hepatic manifestation in up to one fifth of patients. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of COVID-19, infects gastrointestinal epithelial cells expressing angiotensin-converting enzyme 2 (ACE2) receptors triggering a cascade of events leading to mucosal and systemic inflammation. Symptomatic patients display changes in gut microbiota composition and function which may contribute to intestinal barrier dysfunction and immune activation. Evidence suggests that SARS-CoV-2 infection and related mucosal inflammation impact on the function of the enteric nervous system and the activation of sensory fibers conveying information to the central nervous system, which, may at least in part, contribute symptom generation such as vomiting and diarrhea described in COVID-19. Liver and pancreas dysfunctions have also been described as non-respiratory complications of COVID-19 and add further emphasis to the common view of SARS-CoV-2 infection as a systemic disease with multiorgan involvement.

PURPOSE

The aim of this review was to highlight the current knowledge on the pathophysiology of gastrointestinal SARS-CoV-2 infection, including the crosstalk with the gut microbiota, the fecal-oral route of virus transmission, and the potential interaction of the virus with the enteric nervous system. We also review the current available data on gastrointestinal and liver manifestations, management, and outcomes of patients with COVID-19.

Gastroenterology manifestations and COVID-19 outcomes: A meta-analysis of 25,252 cohorts among the first and second waves

A meta-analysis was performed to identify patients with coronavirus disease 2019 (COVID-19) presenting with gastrointestinal (GI) symptoms during the first and second pandemic waves and investigate their association with the disease outcomes. A systematic search in PubMed, Scopus, Web of Science, ScienceDirect, and EMBASE was performed up to July 25, 2020. The pooled prevalence of the GI presentations was estimated using the random-effects model. Pairwise comparison for the outcomes was performed according to the GI manifestations' presentation and the pandemic wave of infection. Data were reported as relative risk (RR), or odds ratio and 95% confidence interval. Of 125 articles with 25,252 patients, 20.3% presented with GI manifestations. Anorexia (19.9%), dysgeusia/ageusia (15.4%), diarrhea (13.2%), nausea (10.3%), and hematemesis (9.1%) were the most common. About 26.7% had confirmed positive fecal RNA, with persistent viral shedding for an average time of 19.2 days before being negative. Patients presenting with GI symptoms on admission showed a higher risk of complications, including acute respiratory distress syndrome (RR = 8.16), acute cardiac injury (RR = 5.36), and acute kidney injury (RR = 5.52), intensive care unit (ICU) admission (RR = 2.56), and mortality (RR = 2.01). Although not reach significant levels, subgroup-analysis revealed that affected cohorts in the first wave had a higher risk of being hospitalized, ventilated, ICU admitted, and expired. This meta-analysis suggests an association between GI symptoms in COVID-19 patients and unfavorable outcomes. The analysis also showed improved overall outcomes for COVID-19 patients during the second wave compared to the first wave of the outbreak.

Nervous system diseases are associated with the severity and mortality of patients with COVID-19: a systematic review and meta-analysis

Coronavirus disease 2019 (COVID-19) has become a global pandemic. Previous studies showed that comorbidities in patients with COVID-19 are risk factors for adverse outcomes. This study aimed to clarify the association between nervous system diseases and severity or mortality in patients with COVID-19. We performed a systematic literature search of four electronic databases and included studies reporting the prevalence of nervous system diseases in COVID-19 patients with severe and non-severe disease or among survivors and non-survivors. The included studies were pooled into a meta-analysis to calculate the odds ratio (OR) with 95% confidence intervals (95%CI). We included 69 studies involving 17 879 patients. The nervous system diseases were associated with COVID-19 severity (OR = 3.19, 95%CI: 2.37 to 4.30, P < 0.001) and mortality (OR = 3.75, 95%CI: 2.68 to 5.25, P < 0.001). Specifically, compared with the patients without cerebrovascular disease, patients with cerebrovascular disease infected with COVID-19 had a higher risk of severity (OR = 3.10, 95%CI: 2.21 to 4.36, P < 0.001) and mortality (OR = 3.45, 95% CI: 2.46 to 4.84, P < 0.001). Stroke was associated with severe COVID-19 disease (OR = 1.95, 95%CI: 1.11 to 3.42, P = 0.020). No significant differences were found for the prevalence of epilepsy (OR = 1.00, 95%CI: 0.42 to 2.35, P = 0.994) and dementia (OR = 2.39, 95%CI: 0.55 to 10.48, P = 0.247) between non-severe and severe COVID-19 patients. There was no significant association between stroke (OR = 1.79, 95%CI: 0.76 to 4.23, P = 0.185), epilepsy (OR = 2.08, 95%CI: 0.08 to 50.91, P = 0.654) and COVID-19 mortality. In conclusion, nervous system diseases and cerebrovascular disease were associated with severity and mortality of patients with COVID-19. There might be confounding factors that influence the relationship between nervous system diseases and COVID-19 severity as well as mortality.

Outcomes in Patients With COVID-19 Disease and High Oxygen Requirements

Background

Approximately 19% of people infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) progress to severe or critical stages of the coronavirus disease 2019 (COVID-19) with a mortality rate exceeding 50%. We aimed to examine the characteristics, mortality rates, intubation rate, and length of stay (LOS) of patients hospitalized with COVID-19 disease with high oxygen requirements (critically ill).

Methods

We conducted a retrospective analysis in a single center in Brooklyn, New York. Adult hospitalized patients with confirmed COVID-19 disease and high oxygen requirements were included. We performed multivariate logistic regression analyses for statistically significant variables to reduce any confounding.

Results

A total of 398 patients were identified between March 19th and April 25th, 2020 who met the inclusion criteria, of which 247 (62.1%) required intubation. The overall mortality rate in our study was 57.3% (n = 228). The mean hospital LOS was 19.1 ± 17.4 days. Patients who survived to hospital discharge had a longer mean LOS compared to those who died during hospitalization (25.4 ± 22.03 days versus10.7 ± 1.74 days). In the multivariate analysis, increased age, intubation and increased lactate dehydrogenase (LDH) were each independently associated with increased odds of mortality. Diarrhea was associated with decreased mortality (OR 0.4; CI 0.16, 0.99). Obesity and use of vasopressors were each independently associated with increased intubation.

Conclusions

In patients with COVID-19 disease and high oxygen requirements, advanced age, intubation, and higher LDH levels were associated with increased mortality, while diarrhea was associated with decreased mortality. Gender, diabetes, and hypertension did not have any association with mortality or length of hospital stay.

Safety in Endoscopy for Patients and Healthcare Workers During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is still wreaking havoc in many parts of the world and poses a great burden to healthcare systems worldwide. Mitigation and suppression strategies have been implemented globally but the disease has proven to be difficult to contain. Initially many elective gastrointestinal endoscopies were cancelled to reduce the risk of infection and conserve personal protective equipment, but many endoscopy units are now faced with the dilemma of resuming endoscopy service during the pandemic as indefinitely postponing diagnostic procedures may lead to a delay in the diagnosis and treatment of malignancies. Further concerns are surfacing as COVID-19 is now known to affect the gastrointestinal tract and may potentially be spread via the fecal-oral route. Until more effective drugs and vaccines are available, it is unlikely that the pandemic will wind down in the near future. Maintaining a balance between protecting healthcare workers and patients from being infected on the one hand and providing timely and effective clinical care on the other will become increasingly important as the pandemic persists. In this narrative review, the risk of COVID-19 infection for healthcare workers and patients undergoing endoscopy, and recommendations on maintaining safe, high-quality endoscopy practice will be discussed.

Association of Peripheral Lymphocyte and the Subset Levels With the Progression and Mortality of COVID-19: A Systematic Review and Meta-Analysis

Current evidence is controversial in the association between peripheral lymphocyte levels and the progression and mortality of Corona Virus Disease 2019 (COVID-19), and this meta-analysis aimed to clarify the association. A systematic search was conducted in public databases to identify all relevant studies, and the study-specific odds ratio (OR) and 95% confidence intervals (CI) were pooled. Finally, 16 studies were identified with a total of 1,873 progressive COVID-19 cases and 5,177 stable COVID-19 cases. In COVID-19 progression, lymphocyte levels showed a significant negative correlation (OR: 0.68, 95% CI: 0.51-0.89), but it was not significant in the subsets of CD3+ T cells (OR: 0.97, 95% CI: 0.93-1.02), CD4+ T cells (OR: 0.93, 95% CI: 0.80-1.08), CD8+ T cells (OR: 0.96, 95% CI: 0.92-1.00), B cells (OR: 0.98, 95% CI: 0.92-1.04), or NK cells (OR: 0.80, 95% CI: 0.61-1.04). In COVID-19 mortality, lymphocyte levels showed a significant negative correlation (OR: 0.41, 95% CI: 0.20-0.85), but it was not significant in the subsets of CD3+ T cells (OR: 0.95, 95% CI: 0.86-1.05), CD4+ T cells (OR: 1.06, 95% CI: 0.86-1.31), CD8+ T cells (OR: 0.38, 95% CI: 0.14-1.01), B cells (OR: 0.98, 95% CI: 0.92-1.04), or NK cells (OR: 0.80, 95% CI: 0.61-1.04). In conclusion, current evidence suggests a significant negative association of peripheral lymphocyte levels with COVID-19 progression and mortality, but it was not significant in the subsets of CD3+ T cells, CD4+ T cells, CD8+ T cells, B cells, and NK cells.