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Harsono D, Deng Y, Chung S, Barakat LA, Friedland G, Villanueva M, Yager JE, Justen M, Edelman EJ. Prevalence and Correlates of Physical Inactivity Among Individuals with HIV During the First COVID-19 Wave: A Cross-sectional Survey. AIDS Behav 2024; 28:1531-1545. [PMID: 37824037 DOI: 10.1007/s10461-023-04170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
Physical activity is associated with improved health outcomes among people with HIV (PWH). In the recent pandemic context, policies designed to mitigate COVID-19 transmission may result in an increase in sedentary lifestyle and decreased physical activity. In this study, we aimed to characterize self-reported physical activity and factors associated with physical inactivity during the first wave of the COVID-19 pandemic among a sample of PWH engaged in care. We also described whether psychological coping strategies measured by the Brief COPE differed based on physical activity levels. Among 260 surveyed PWH in two HIV clinics in the US Northeast, 28.5% (n = 74) met the criteria for being physically active according to the Centers for Disease Control and Prevention (CDC)'s physical activity guidelines. Receiving care in New Haven, CT, presence of a detectable HIV viral load, every day tobacco use, and unhealthy alcohol use were associated with physical inactivity. Problem-focused coping, emotion-focused coping, and avoidance-focused coping strategies were found to be protective against physical inactivity. In adjusted analysis, only problem-focused coping continued to be significantly associated with lower odds of reporting physical inactivity. Efforts are urgently needed to promote physical activity among PWH, including among those without problem-focused coping strategies.
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Affiliation(s)
- Dini Harsono
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA.
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Sangyun Chung
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Lydia A Barakat
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gerald Friedland
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Merceditas Villanueva
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- AIDS Care Program, Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica E Yager
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | | | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, 135 College St, Suite 200, New Haven, CT, 06510, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Burnham EL, Pomponio R, Perry G, Offner PJ, Ormesher R, Peterson RA, Jolley SE. Prevalence of Alcohol Use Characterized by Phosphatidylethanol in Patients With Respiratory Failure Before and During the COVID-19 Pandemic. CHEST CRITICAL CARE 2024; 2:100045. [PMID: 38818345 PMCID: PMC11138642 DOI: 10.1016/j.chstcc.2023.100045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Alcohol misuse is overlooked frequently in hospitalized patients, but is common among patients with pneumonia and acute hypoxic respiratory failure. Investigations in hospitalized patients rely heavily on self-report surveys or chart abstraction, which lack sensitivity. Therefore, our understanding of the prevalence of alcohol misuse before and during the COVID-19 pandemic is limited. RESEARCH QUESTION In critically ill patients with respiratory failure, did the proportion of patients with alcohol misuse, defined by the direct biomarker phosphatidylethanol, vary over a period including the COVID-19 pandemic? STUDY DESIGN AND METHODS Patients with acute hypoxic respiratory failure receiving mechanical ventilation were enrolled prospectively from 2015 through 2019 (before the pandemic) and from 2020 through 2022 (during the pandemic). Alcohol use data, including Alcohol Use Disorders Identification Test (AUDIT)-C scores, were collected from electronic health records, and phosphatidylethanol presence was assessed at ICU admission. The relationship between clinical variables and phosphatidylethanol values was examined using multivariable ordinal regression. Dichotomized phosphatidylethanol values (≥ 25 ng/mL) defining alcohol misuse were compared with AUDIT-C scores signifying misuse before and during the pandemic, and correlations between log-transformed phosphatidylethanol levels and AUDIT-C scores were evaluated and compared by era. Multiple imputation by chained equations was used to handle missing phosphatidylethanol data. RESULTS Compared with patients enrolled before the pandemic (n = 144), patients in the pandemic cohort (n = 92) included a substantially higher proportion with phosphatidylethanol-defined alcohol misuse (38% vs 90%; P < .001). In adjusted models, absence of diabetes, positive results for COVID-19, and enrollment during the pandemic each were associated with higher phosphatidylethanol values. The correlation between health care worker-recorded AUDIT-C score and phosphatidylethanol level was significantly lower during the pandemic. INTERPRETATION The higher prevalence of phosphatidylethanol-defined alcohol misuse during the pandemic suggests that alcohol consumption increased during this period, identifying alcohol misuse as a potential risk factor for severe COVID-19-associated respiratory failure. Results also suggest that AUDIT-C score may be less useful in characterizing alcohol consumption during high clinical capacity.
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Affiliation(s)
- Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Raymond Pomponio
- Department of Medicine, Biostatistics and Informatics, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora CO
| | - Grace Perry
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Patrick J Offner
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Ryen Ormesher
- Colorado School of Public Health, and Internal Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora CO
| | - Ryan A Peterson
- Department of Medicine, Biostatistics and Informatics, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora CO
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
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Lewis SA, Cinco IR, Doratt BM, Blanton MB, Hoagland C, Newman N, Davies M, Grant KA, Messaoudi I. Chronic alcohol consumption dysregulates innate immune response to SARS-CoV-2 in the lung. EBioMedicine 2023; 97:104812. [PMID: 37793211 PMCID: PMC10562860 DOI: 10.1016/j.ebiom.2023.104812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Alcohol consumption is widespread with over half of the individuals over 18 years of age in the U.S. reporting alcohol use in the last 30 days. Moreover, 9 million Americans engaged in binge or chronic heavy drinking (CHD) in 2019. CHD negatively impacts pathogen clearance and tissue repair, including in the respiratory tract, thereby increasing susceptibility to infection. Although, it has been hypothesized that chronic alcohol consumption negatively impacts COVID-19 outcomes; the interplay between chronic alcohol use and SARS-CoV-2 infection outcomes has yet to be elucidated. METHODS In this study we employed luminex, scRNA sequencing, and flow cytometry to investigate the impact of chronic alcohol consumption on SARS-CoV-2 anti-viral responses in bronchoalveolar lavage cell samples from humans with alcohol use disorder and rhesus macaques that engaged in chronic drinking. FINDINGS Our data show that in both humans (n = 6) and macaques (n = 11), the induction of key antiviral cytokines and growth factors was decreased with chronic ethanol consumption. Moreover, in macaques fewer differentially expressed genes mapped to Gene Ontology terms associated with antiviral immunity following 6 month of ethanol consumption while TLR signaling pathways were upregulated. INTERPRETATION These data are indicative of aberrant inflammation and reduced antiviral responses in the lung with chronic alcohol drinking. FUNDING This study was supported by NIH 1R01AA028735-04 (Messaoudi), U01AA013510-20 (Grant), R24AA019431-14 (Grant), R24AA019661 (Burnham), P-51OD011092 (ONPRC core grant support). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Affiliation(s)
- Sloan A Lewis
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine, USA
| | - Isaac R Cinco
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky, USA
| | - Brianna M Doratt
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky, USA
| | - Madison B Blanton
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky, USA; Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, USA
| | - Cherise Hoagland
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, USA
| | - Natali Newman
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, USA
| | - Michael Davies
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, USA
| | - Kathleen A Grant
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, USA
| | - Ilhem Messaoudi
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky, USA.
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Yeo YH, He X, Lv F, Zhao Y, Liu Y, Yang JD, Zu J, Ji F, Nguyen MH. Trends of Cirrhosis-related Mortality in the USA during the COVID-19 Pandemic. J Clin Transl Hepatol 2023; 11:751-756. [PMID: 36969898 PMCID: PMC10037514 DOI: 10.14218/jcth.2022.00313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/01/2022] [Accepted: 08/12/2022] [Indexed: 12/04/2022] Open
Abstract
Immunocompromised status and interrupted routine care may render patients with cirrhosis vulnerable to the coronavirus disease 2019 (COVID-19) pandemic. A nationwide dataset that includes more than 99% of the decedents in the U.S. between April 2012 and September 2021 was used. Projected age-standardized mortality during the pandemic were estimated according to prepandemic mortality rates, stratified by season. Excess deaths were determined by estimating the difference between observed and projected mortality rates. A temporal trend analysis of observed mortality rates was also performed in 0.83 million decedents with cirrhosis between April 2012 and September 2021 was included. Following an increasing trend of cirrhosis-related mortality before the pandemic, with a semiannual percentage change (SAPC) of 0.54% [95% confidence interval (CI): (0.0-1.0%), p=0.036], a precipitous increase with seasonal variation occurred during the pandemic (SAPC 5.35, 95% CI: 1.9-8.9, p=0.005). Significantly increased mortality rates were observed in those with alcohol-associated liver disease (ALD), with a SAPC of 8.44 (95% CI: 4.3-12.8, p=0.001) during the pandemic. All-cause mortality of nonalcoholic fatty liver disease rose steadily across the entire study period with a SAPC of 6.79 (95% CI: 6.3-7.3, p<0.001). The decreasing trend of HCV-related mortality was reversed during the pandemic, while there was no significant change in HBV-related deaths. While there was significant increase in COVID-19-related deaths, more than 55% of the excess deaths were the indirect impact of the pandemic. We observed an alarming increase in cirrhosis-related deaths during the pandemic especially for ALD, with evidence in both direct and indirect impact. Our findings have implications on formulating policies for patients with cirrhosis.
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Affiliation(s)
- Yee Hui Yeo
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xinyuan He
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Fan Lv
- School of Mathematics and Statistics, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yunyu Zhao
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yi Liu
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jian Zu
- School of Mathematics and Statistics, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Fanpu Ji
- Department of Infectious Diseases, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
- National & Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Correspondence to: Mindie H. Nguyen, Division of Gastroenterology and Hepatology, Stanford University Medical Center, 750 Welch Road, Suite 210, Palo Alto, CA 94304, USA. ORCID: https://orcid.org/0000-0002-6275-4989. Tel: +1-650-498-5691, Fax: +1-650-498-5692, E-mail: ; Fanpu Ji, Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 Xi Wu Road, Xi’an, Shaanxi 710004, China. ORCID: https://orcid.org/0000-0002-1463-8035. Tel/Fax: +86-29-87678223, E-mail: or
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA
- Correspondence to: Mindie H. Nguyen, Division of Gastroenterology and Hepatology, Stanford University Medical Center, 750 Welch Road, Suite 210, Palo Alto, CA 94304, USA. ORCID: https://orcid.org/0000-0002-6275-4989. Tel: +1-650-498-5691, Fax: +1-650-498-5692, E-mail: ; Fanpu Ji, Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 Xi Wu Road, Xi’an, Shaanxi 710004, China. ORCID: https://orcid.org/0000-0002-1463-8035. Tel/Fax: +86-29-87678223, E-mail: or
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Kim A, Ortega-Ribera M, McMullen MR, Bellar A, Taiwo M, Pathak V, Streem D, Dasarathy J, Welch N, Dasarathy S, Vachharajani V, Nagy LE. Altered Anti-Viral Immune Responses in Monocytes in Overweight Heavy Drinkers. iScience 2023; 26:107133. [PMID: 37361874 PMCID: PMC10268809 DOI: 10.1016/j.isci.2023.107133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
Alcohol abuse causes increased susceptibility to respiratory syndromes like bacterial pneumonia and viral infections like SARS-CoV-2. Heavy drinkers (HD) are at higher risk of severe COVID-19 if they are also overweight, yet the molecular mechanisms are unexplored. Single-cell RNA-seq (scRNA-seq) was performed on peripheral blood mononuclear cells from lean or overweight HD and healthy controls (HC) after challenge with a dsRNA homopolymer (PolyI:C) to mimic a viral infection and/or with lipopolysaccharide (LPS). All monocyte populations responded to both PolyI:C and LPS with pro-inflammatory gene expression. However, expression of interferon stimulated genes, essential for inhibiting viral pathogenesis, was greatly reduced in overweight patients. Interestingly, the number of upregulated genes in response to PolyI:C challenge was far greater in monocytes from HD compared to HC, including much stronger pro-inflammatory cytokine and interferon-γ signaling responses. These results suggest increased body weight reduced anti-viral responses while heavy drinking increased pro-inflammatory cytokines.
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Affiliation(s)
- Adam Kim
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
- - Department of Medicine, University of Connecticut Health Center, Farmington, CT
| | - Martí Ortega-Ribera
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
| | - Megan R McMullen
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
| | - Annette Bellar
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
| | - Moyinoluwa Taiwo
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
| | - Vai Pathak
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
| | - David Streem
- - Lutheran Hospital, Cleveland Clinic, Cleveland, OH
| | | | - Nicole Welch
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
- - Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH
- - Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH
| | - Srinivasan Dasarathy
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
- - Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH
- - Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH
| | - Vidula Vachharajani
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
- - Department of Critical Care Medicine Cleveland Clinic Respiratory Institute, Cleveland, OH
| | - Laura E Nagy
- - Northern Ohio Alcohol Center, Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH
- - Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH
- - Department of Molecular Medicine, Case Western Reserve University, Cleveland, OH
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Lewis SA, Cinco IR, Doratt BM, Blanton MB, Hoagland C, Davies M, Grant KA, Messaoudi I. Chronic alcohol consumption dysregulates innate immune response to SARS-CoV-2 in the lung. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.02.539139. [PMID: 37205543 PMCID: PMC10187161 DOI: 10.1101/2023.05.02.539139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Alcohol consumption is widespread with over half of the individuals over 18 years of age in the U.S. reporting alcohol use in the last 30 days. Moreover, 9 million Americans engaged in binge or chronic heavy drinking (CHD) in 2019. CHD negatively impacts pathogen clearance and tissue repair, including in the respiratory tract, thereby increasing susceptibility to infection. Although, it has been hypothesized that chronic alcohol consumption negatively impacts COVID-19 outcomes; the interplay between chronic alcohol use and SARS-CoV-2 infection outcomes has yet to be elucidated. Therefore, in this study we investigated the impact of chronic alcohol consumption on SARS-CoV-2 anti-viral responses in bronchoalveolar lavage cell samples from humans with alcohol use disorder and rhesus macaques that engaged in chronic drinking. Our data show that in both humans and macaques, the induction of key antiviral cytokines and growth factors was decreased with chronic ethanol consumption. Moreover, in macaques fewer differentially expressed genes mapped to Gene Ontology terms associated with antiviral immunity following 6 month of ethanol consumption while TLR signaling pathways were upregulated. These data are indicative of aberrant inflammation and reduced antiviral responses in the lung with chronic alcohol drinking.
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Affiliation(s)
- Sloan A. Lewis
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California Irvine
| | - Isaac R. Cinco
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky
| | - Brianna M. Doratt
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky
| | - Madison B. Blanton
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky
- Pharmaceutical Sciences, College of Pharmacy, University of Kentucky
| | - Cherise Hoagland
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University
| | - Michael Davies
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University
| | - Kathleen A. Grant
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University
| | - Ilhem Messaoudi
- Microbiology, Immunology and Molecular Genetics, College of Medicine, University of Kentucky
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Swanson GR, Schwartz BA, Joyce C, Keshavarzian A. Binge drinking alcohol and circadian misalignment in night shift nurses is associated with decreased resiliency to COVID-19 infection. Alcohol Clin Exp Res 2023; 47:908-918. [PMID: 37526580 DOI: 10.1111/acer.15052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Nurses and other first responders are at high risk of exposure to the SARS-CoV2 virus, and many have developed severe COVID-19 infection. A better understanding of the factors that increase the risk of infection after exposure to the virus could help to address this. Although several risk factors such as obesity, diabetes, and hypertension have been associated with an increased risk of infection, many first responders develop severe COVID-19 without established risk factors. As inflammation and cytokine storm are the primary mechanisms in severe COVID-19, other factors that promote an inflammatory state could increase the risk of COVID-19 in exposed individuals. Alcohol misuse and shift work with subsequent misaligned circadian rhythms are known to promote a pro-inflammatory state and thus could increase susceptibility to COVID-19. To test this hypothesis, we conducted a prospective, cross-sectional observational survey-based study in nurses using the American Nursing Association network. METHOD We used validated structured questionnaires to assess alcohol consumption (the Alcohol Use Disorders Identification Test) and circadian typology or chronotype (the Munich Chronotype Questionnaire Shift -MCTQ-Shift). RESULTS By latent class analysis (LCA), high-risk features of alcohol misuse were associated with a later chronotype, and binge drinking was greater in night shift workers. The night shift was associated with more than double the odds of COVID-19 infection of the standard shift (OR 2.67, 95% CI: 1.18 to 6.07). Binge drinkers had twice the odds of COVID-19 infection of those with low-risk features by LCA (OR: 2.08, 95% CI: 0.75 to 5.79). CONCLUSION Working night shifts or binge drinking may be risk factors for COVID-19 infection among nurses. Understanding the mechanisms underlying these risk factors could help to mitigate the impact of COVID-19 on our at-risk healthcare workforce.
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Affiliation(s)
- Garth R Swanson
- Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, Illinois, USA
- Section of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Benjamin A Schwartz
- Section of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Cara Joyce
- Department of Medicine, Loyola University Stritch School of Medicine, Chicago, Illinois, USA
| | - Ali Keshavarzian
- Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, Illinois, USA
- Section of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Impact of Alcohol Misuse on Requirements for Critical Care Services and Development of Hospital Delirium in Patients With COVID-19 pneumonia. Crit Care Explor 2023; 5:e0829. [PMID: 36713630 PMCID: PMC9876025 DOI: 10.1097/cce.0000000000000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Alcohol misuse has been associated with increased morbidity in the setting of pulmonary infections, including the need for critical care resource utilization and development of delirium. How alcohol misuse impacts morbidity and outcomes among patients admitted with COVID-19 pneumonia is not well described. We sought to determine if alcohol misuse was associated with an increased need for critical care resources and development of delirium among patients hospitalized with COVID-19 pneumonia. DESIGN Retrospective cohort study. SETTING Twelve University of Colorado hospitals between March 2020 and April 2021. PATIENTS Adults with a COVID-19 diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was admission to the ICU. Secondary outcomes included need for mechanical ventilation, development of delirium, and in-hospital mortality. Alcohol misuse was defined by International Classification of Diseases, 10th Revision codes. Of 5,979 patients hospitalized with COVID-19, 26% required ICU admission and 15.4% required mechanical ventilation. Delirium developed in 4.5% and 10.5% died during hospitalization. Alcohol misuse was identified in 4%. In analyses adjusted for age, sex, body mass index, diabetes, and liver disease, alcohol misuse was associated with increased odds of ICU admission (adjusted odds ratio [aOR], 1.46; p < 0.01), mechanical ventilation (aOR, 1.43; p = 0.03), and delirium (aOR, 5.55; p < 0.01) compared with patients without misuse. Mortality rates were not associated with alcohol misuse alone, although the presence of both alcohol misuse and in-hospital delirium significantly increased odds of in-hospital death (aOR, 2.60; p = 0.04). CONCLUSIONS Among patients hospitalized with COVID-19, alcohol misuse was associated with increased utilization of critical care resources including ICU admission and mechanical ventilation. Delirium was an important modifiable risk factor associated with worse outcomes in hospitalized patients with alcohol misuse, including increased odds of death.
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Zsichla L, Müller V. Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors. Viruses 2023; 15:175. [PMID: 36680215 PMCID: PMC9863423 DOI: 10.3390/v15010175] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.
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Affiliation(s)
- Levente Zsichla
- Institute of Biology, Eötvös Loránd University, 1117 Budapest, Hungary
- National Laboratory for Health Security, Eötvös Loránd University, 1117 Budapest, Hungary
| | - Viktor Müller
- Institute of Biology, Eötvös Loránd University, 1117 Budapest, Hungary
- National Laboratory for Health Security, Eötvös Loránd University, 1117 Budapest, Hungary
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Thompson HM, Sharma B, Smith DL, Bhalla S, Erondu I, Hazra A, Ilyas Y, Pachwicewicz P, Sheth NK, Chhabra N, Karnik NS, Afshar M. Machine Learning Techniques to Explore Clinical Presentations of COVID-19 Severity and to Test the Association With Unhealthy Opioid Use: Retrospective Cross-sectional Cohort Study. JMIR Public Health Surveill 2022; 8:e38158. [PMID: 36265163 PMCID: PMC9746674 DOI: 10.2196/38158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/23/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has exacerbated health inequities in the United States. People with unhealthy opioid use (UOU) may face disproportionate challenges with COVID-19 precautions, and the pandemic has disrupted access to opioids and UOU treatments. UOU impairs the immunological, cardiovascular, pulmonary, renal, and neurological systems and may increase severity of outcomes for COVID-19. OBJECTIVE We applied machine learning techniques to explore clinical presentations of hospitalized patients with UOU and COVID-19 and to test the association between UOU and COVID-19 disease severity. METHODS This retrospective, cross-sectional cohort study was conducted based on data from 4110 electronic health record patient encounters at an academic health center in Chicago between January 1, 2020, and December 31, 2020. The inclusion criterion was an unplanned admission of a patient aged ≥18 years; encounters were counted as COVID-19-positive if there was a positive test for COVID-19 or 2 COVID-19 International Classification of Disease, Tenth Revision codes. Using a predefined cutoff with optimal sensitivity and specificity to identify UOU, we ran a machine learning UOU classifier on the data for patients with COVID-19 to estimate the subcohort of patients with UOU. Topic modeling was used to explore and compare the clinical presentations documented for 2 subgroups: encounters with UOU and COVID-19 and those with no UOU and COVID-19. Mixed effects logistic regression accounted for multiple encounters for some patients and tested the association between UOU and COVID-19 outcome severity. Severity was measured with 3 utilization metrics: low-severity unplanned admission, medium-severity unplanned admission and receiving mechanical ventilation, and high-severity unplanned admission with in-hospital death. All models controlled for age, sex, race/ethnicity, insurance status, and BMI. RESULTS Topic modeling yielded 10 topics per subgroup and highlighted unique comorbidities associated with UOU and COVID-19 (eg, HIV) and no UOU and COVID-19 (eg, diabetes). In the regression analysis, each incremental increase in the classifier's predicted probability of UOU was associated with 1.16 higher odds of COVID-19 outcome severity (odds ratio 1.16, 95% CI 1.04-1.29; P=.009). CONCLUSIONS Among patients hospitalized with COVID-19, UOU is an independent risk factor associated with greater outcome severity, including in-hospital death. Social determinants of health and opioid-related overdose are unique comorbidities in the clinical presentation of the UOU patient subgroup. Additional research is needed on the role of COVID-19 therapeutics and inpatient management of acute COVID-19 pneumonia for patients with UOU. Further research is needed to test associations between expanded evidence-based harm reduction strategies for UOU and vaccination rates, hospitalizations, and risks for overdose and death among people with UOU and COVID-19. Machine learning techniques may offer more exhaustive means for cohort discovery and a novel mixed methods approach to population health.
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Affiliation(s)
- Hale M Thompson
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
- Center for Education, Research, and Advocacy, Department of Social and Behavioral Research, Howard Brown Health, Chicago, IL, United States
| | - Brihat Sharma
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Dale L Smith
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Sameer Bhalla
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Ihuoma Erondu
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Aniruddha Hazra
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Yousaf Ilyas
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Paul Pachwicewicz
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Neeral K Sheth
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Neeraj Chhabra
- Department of Emergency Medicine, Rush University Medical College, Rush University Medical Center, Chicago, IL, United States
| | - Niranjan S Karnik
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Majid Afshar
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
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11
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Muralidharan A, Bauer C, Katafiasz DM, Pham D, Oyewole OO, Morwitzer MJ, Roy E, Bailey KL, Reid SP, Wyatt TA. Malondialdehyde acetaldehyde adduction of surfactant protein D attenuates SARS-CoV-2 spike protein binding and virus neutralization. Alcohol Clin Exp Res 2022; 47:95-103. [PMID: 36352814 PMCID: PMC9878066 DOI: 10.1111/acer.14974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Over 43% of the world's population regularly consumes alcohol. Although not commonly known, alcohol can have a significant impact on the respiratory environment. Living in the time of the COVID-19 pandemic, alcohol misuse can have a particularly deleterious effect on SARS-CoV-2-infected individuals and, in turn, the overall healthcare system. Patients with alcohol use disorders have higher odds of COVID-19-associated hospitalization and mortality. Even though the detrimental role of alcohol on COVID-19 outcomes has been established, the underlying mechanisms are yet to be fully understood. Alcohol misuse has been shown to induce oxidative damage in the lungs through the production of reactive aldehydes such as malondialdehyde and acetaldehyde (MAA). MAA can then form adducts with proteins, altering their structure and function. One such protein is surfactant protein D (SPD), which plays an important role in innate immunity against pathogens. METHODS AND RESULTS In this study, we examined whether MAA adduction of SPD (SPD-MAA) attenuates the ability of SPD to bind SARS-CoV-2 spike protein, reversing SPD-mediated virus neutralization. Using ELISA, we show that SPD-MAA is unable to competitively bind spike protein and prevent ACE2 receptor binding. Similarly, SPD-MAA fails to inhibit entry of wild-type SARS-CoV-2 virus into Calu-3 cells, a lung epithelial cell line, as well as ciliated primary human bronchial epithelial cells isolated from healthy individuals. CONCLUSIONS Overall, MAA adduction of SPD, a consequence of alcohol overconsumption, represents one mechanism of compromised lung innate defense against SARS-CoV-2, highlighting a possible mechanism underlying COVID-19 severity and related mortality in patients who misuse alcohol.
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Affiliation(s)
- Abenaya Muralidharan
- Department of Pathology and Microbiology, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Christopher Bauer
- Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Dawn M. Katafiasz
- Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Danielle Pham
- Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Opeoluwa O. Oyewole
- Department of Pathology and Microbiology, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - M. Jane Morwitzer
- Department of Pathology and Microbiology, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Enakshi Roy
- Department of Pathology and Microbiology, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Kristina L. Bailey
- Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA,Veterans Affairs Nebraska‐Western Iowa Health Care SystemOmahaNebraskaUSA
| | - St Patrick Reid
- Department of Pathology and Microbiology, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Todd A. Wyatt
- Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA,Veterans Affairs Nebraska‐Western Iowa Health Care SystemOmahaNebraskaUSA,Department of Environmental, Agricultural and Occupational Health, College of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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12
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Forsyth CB, Voigt RM, Swanson GR, Bishehsari F, Shaikh M, Zhang L, Engen P, Keshavarzian A. Alcohol use disorder as a potential risk factor for COVID-19 severity: A narrative review. Alcohol Clin Exp Res 2022; 46:1930-1943. [PMID: 36394508 PMCID: PMC9722573 DOI: 10.1111/acer.14936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/25/2022] [Accepted: 08/31/2022] [Indexed: 11/19/2022]
Abstract
In Dec. 2019-January 2020, a pneumonia illness originating in Wuhan, China, designated as coronavirus disease 2019 (COVID-19) was shown to be caused by a novel RNA coronavirus designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). People with advanced age, male sex, and/or underlying health conditions (obesity, type 2 diabetes, cardiovascular disease, hypertension, chronic kidney disease, and chronic lung disease) are especially vulnerable to severe COVID-19 symptoms and death. These risk factors impact the immune system and are also associated with poor health, chronic illness, and shortened longevity. However, a large percent of patients without these known risk factors also develops severe COVID-19 disease that can result in death. Thus, there must exist risk factors that promote exaggerated inflammatory and immune response to the SARS-CoV-2 virus leading to death. One such risk factor may be alcohol misuse and alcohol use disorder because these can exacerbate viral lung infections like SARS, influenza, and pneumonia. Thus, it is highly plausible that alcohol misuse is a risk factor for either increased infection rate when individuals are exposed to SARS-CoV-2 virus and/or more severe COVID-19 in infected patients. Alcohol use is a well-known risk factor for lung diseases and ARDS in SARS patients. We propose that alcohol has three key pathogenic elements in common with other COVID-19 severity risk factors: namely, inflammatory microbiota dysbiosis, leaky gut, and systemic activation of the NLRP3 inflammasome. We also propose that these three elements represent targets for therapy for severe COVID-19.
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Affiliation(s)
- Christopher B. Forsyth
- Department of Internal Medicine, Section of Gastroenterology, Rush University Medical Center, Chicago, IL 60612
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
- Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, IL 60612
- Rush University Graduate College, Rush University Medical Center, Chicago, IL 60612
| | - Robin M. Voigt
- Department of Internal Medicine, Section of Gastroenterology, Rush University Medical Center, Chicago, IL 60612
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
- Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, IL 60612
- Rush University Graduate College, Rush University Medical Center, Chicago, IL 60612
| | - Garth R. Swanson
- Department of Internal Medicine, Section of Gastroenterology, Rush University Medical Center, Chicago, IL 60612
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
- Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, IL 60612
- Rush University Graduate College, Rush University Medical Center, Chicago, IL 60612
| | - Faraz Bishehsari
- Department of Internal Medicine, Section of Gastroenterology, Rush University Medical Center, Chicago, IL 60612
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
- Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, IL 60612
- Rush University Graduate College, Rush University Medical Center, Chicago, IL 60612
| | - Maliha Shaikh
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
| | - Lijuan Zhang
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
| | - Phillip Engen
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
| | - Ali Keshavarzian
- Department of Internal Medicine, Section of Gastroenterology, Rush University Medical Center, Chicago, IL 60612
- Rush Center for Integrated Microbiome and Chronobiology Research, Rush University Medical Center, Chicago, IL 60612
- Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, IL 60612
- Rush University Graduate College, Rush University Medical Center, Chicago, IL 60612
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13
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Duarte-Millán MA, Mesa-Plaza N, Guerrero-Santillán M, Morales-Ortega A, Bernal-Bello D, Farfán-Sedano AI, García de Viedma-García V, Velázquez-Ríos L, Frutos-Pérez B, De Ancos-Aracil CL, Soria Fernández-Llamazares G, Toledano-Macías M, Cristóbal-Bilbao R, Luquín-Ciuro N, Marrero-Francés J, Piedrabuena-García SI, Satué-Bartolomé JA, Gonzalo-Pascua S, Rivilla-Jiménez M, Carpintero-García L, Ayala-Larrañaga I, García-Bermúdez V, Lara-Montes C, Llerena-Riofrío ÁR, RIvas-Prado L, Walter S, Escriba-Barcena A, San Martín López JV, Ruíz-Giardín JM. Prognostic factors and combined use of tocilizumab and corticosteroids in a Spanish cohort of elderly COVID-19 patients. J Med Virol 2021; 94:1540-1549. [PMID: 34845754 PMCID: PMC9015514 DOI: 10.1002/jmv.27488] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 05/08/2021] [Accepted: 11/28/2021] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID‐19) infection in elderly patients is more aggressive and treatments have shown limited efficacy. Our objective is to describe the clinical course and to analyze the prognostic factors associated with a higher risk of mortality of a cohort of patients older than 80 years. In addition, we assess the efficacy of immunosuppressive treatments in this population. We analyzed the data from 163 patients older than 80 years admitted to our institution for COVID‐19, during March and April 2020. A Lasso regression model and subsequent multivariate Cox regression were performed to select variables predictive of death. We evaluated the efficacy of immunomodulatory therapy in three cohorts using adjusted survival analysis. The mortality rate was 43%. The mean age was 85.2 years. The disease was considered severe in 76.1% of the cases. Lasso regression and multivariate Cox regression indicated that factors correlated with hospital mortality were: age (hazard ratio [HR] 1.12, 95% confidence interval [CI]: 1.03–1.22), alcohol consumption (HR 3.15, 95% CI: 1.27–7.84), CRP > 10 mg/dL (HR 2.67, 95% CI: 1.36–5.24), and oxygen support with Venturi Mask (HR 6.37, 95% CI: 2.18–18.62) or reservoir (HR 7.87, 95% CI: 3.37–18.38). Previous treatment with antiplatelets was the only protective factor (HR 0.47, 95% CI: 0.23–0.96). In the adjusted treatment efficacy analysis, we found benefit in the combined use of tocilizumab (TCZ) and corticosteroids (CS) (HR 0.09, 95% CI: 0.01–0.74) compared to standard treatment, with no benefit of CS alone (HR 0.95, 95% CI: 0.53–1.71). Hospitalized elderly patients suffer from a severe and often fatal form of COVID‐19 disease. In this regard, several parameters might identify high‐risk patients upon admission. Combined use of TCZ and CS could improve survival. The COVID‐19 disease in the elderly population (> 80 years) is severe in most cases. We analyze which parameters at admission may be useful to better stratify the risk of mortality. Oxygen demand on admission is the most accurate parameter to determine prognosis. A combined use of corticosteroids and tocilizumab may improve overall survival versus corticosteroids alone or standard of care.
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Affiliation(s)
| | - Nieves Mesa-Plaza
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - David Bernal-Bello
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Ana I Farfán-Sedano
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Laura Velázquez-Ríos
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Begoña Frutos-Pérez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - María Toledano-Macías
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Nuria Luquín-Ciuro
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Jorge Marrero-Francés
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - Sonia Gonzalo-Pascua
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Marta Rivilla-Jiménez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Ibone Ayala-Larrañaga
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Celia Lara-Montes
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Luis RIvas-Prado
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Stefan Walter
- Methodological Support Unit, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - José M Ruíz-Giardín
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
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