COVID-19 and associations with frailty and multimorbidity: a prospective analysis of UK Biobank participants

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Disparities in Coronavirus Disease 2019 Clinical Outcomes and Vaccination Coverage Among Migrants With Human Immunodeficiency Virus in the PISCIS Cohort: A Population-Based Propensity Score-Matched Analysis

Background

Coronavirus disease 2019 (COVID-19) disproportionately affects migrants and ethnic minorities, including those with human immunodeficiency virus (HIV). Comprehensive studies are needed to understand the impact and risk factors.

Methods

Using data from the PISCIS cohort of people with HIV (PWH) in Catalonia, Spain, we investigated COVID-19 outcomes and vaccination coverage. Among 10 640 PWH we compared migrants and non-migrants assessing rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, diagnosis, and associated clinical outcomes through propensity score matching and multivariable Cox regression.

Results

The cohort (mean age, 43 years; 83.5% male) included 57.4% (3053) Latin American migrants. Migrants with HIV (MWH) had fewer SARS-CoV-2 tests (67.8% vs 72.1%, P < .0001) but similar COVID-19 diagnoses (29.2% vs 29.4%, P = .847) compared to Spanish natives. Migrants had lower complete vaccination (78.9% vs 85.1%, P < .0001) and booster doses (63.0% vs 65.5%, P = .027). COVID-19 hospitalizations (8.1% vs 5.1%, P < .0001) and intensive care unit (ICU) admissions (2.9% vs 1.2%, P < .0001) were higher among migrants, with similar hospitalization duration (5.5 vs 4.0 days, P = .098) and mortality (3 [0.2%] vs 6 [0.4%], P = .510). Age ≥40 years, CD4 counts <200 cells/μL, ≥2 comorbidities, and incomplete/nonreception of the SARS-CoV-2 vaccine increased the risk of severe COVID-19 among migrants.

Conclusions

MWH had lower rates of SARS-CoV-2 testing and vaccination coverage, although the rates of COVID-19 diagnosis were similar between migrants and non-migrants. Rates of COVID-19-associated hospitalizations and ICU admissions were higher among migrants in comparison with non-migrants, with similar hospitalization duration and mortality. These findings can inform policies to address disparities in future pandemic responses for MWH.

Investigation of the relationships between frailty, nutritional status and muscle strength and the incidence and severity of Covid-19 among the residents of nursing homes. Results from the SENIOR cohort

Few studies have investigated the factors associated with the incidence of Covid-19 in nursing homes. The aim of this study was to investigate the relationships between frailty, nutritional status, muscle strength and the Covid-19 incidence and severity in nursing home residents. Data from the last two years of follow-up of the SENIOR (Sample of Elderly Nursing homes individuals: an Observational Research) cohort were used. A total of 75 participants of the cohort were included, 56 % of whom had Covid-19. After adjustment for covariates, no association was found between frailty, nutritional status or grip strength and the incidence and severity of Covid-19.

Approach to COVID-19 in older adults and indications for improving the outcomes

Background: COVID-19 continues to present challenges in the care of older adults with frailty and/or comorbidities and very old patients, who can be hospitalized with severe COVID-19 despite full vaccination. Frailty is a heterogeneous syndrome characterized by an increased aging-related vulnerability due to a reduced physiological reserve and function of systemic organs, and is associated with an impairment of activities of daily living. Frail older adults remain at elevated risk of mortality from COVID-19 compared to older adults without frailty, and some pre-existing risk factors such as malnutrition, prolonged bed rest, and the association with comorbidities can aggravate the SARS-CoV-2 infection. Furthermore, the severity of COVID-19 can impact on long-term functioning of older patients surviving from the infection. Persistent symptoms are another emerging problem of the post-vaccination phase of pandemic, as most patients suffer from chronic symptoms which can become debilitating and affect the daily routine. Aim of this review: In this complex relationship, the evaluation of COVID-19 in vulnerable categories is still a matter of high interest and personalized care plans based on a comprehensive geriatric assessment, tailored interventions; specific therapeutic algorithms among older adults are thus recommended in order to improve the outcomes.

Patients with low ALT levels are at increased risk for severe COVID-19

Introduction

Frailty is a known risk factor for many diseases, including COVID-19. However, many frail patients are undiagnosed as the diagnosis can be cumbersome. Alanine transaminase (ALT) is found not only in the liver but also in the muscle tissue, and multiple studies show that frail sarcopenic patients have lower ALT. Frail patients are at increased risk for severe COVID-19. We evaluated the association between pre-infection low ALT and the risk for severe COVID-19.

Methods

We collected data regarding all subjects tested for SARS-CoV-2 between 1 March 2020 and 31 December 2021 from a national state-mandatory HMO in Israel, serving more than 1.3 million patients. Clinical and laboratory data were collected, including ALT from the year prior to infection. Severe COVID-19 was defined either as death, ICU admission, or ≥10 hospitalization days. Patients with low ALT (ALT ≤ 10 IU/l) were compared with patients with normal ALT (11-40 IU/l). Patients younger than 18 years with a diagnosis of liver disease and with ALT > 40 IU/l were excluded.

Results

During the study period, 58,961 patients tested positive for SARS-CoV-2. The patients in the low ALT group were younger (40.53 vs. 42.73, p < 0.001), less likely to be males (12.3 vs. 38.7%, p < 0.001), and had lower BMI (25.97 vs. 27.15, p < 0.001). The patients in the low ALT group had higher mortality (2.36 vs. 0.57%, p < 0.001), more ICU hospitalizations (0.49 vs. 0.41%, p = 0.47), and more prolonged hospitalizations [2.63% (95% CI 2-3.2%) vs. 0.98% (95% CI 0.86-1.1%) p < 0.001]. In multivariate logistic regression analyses, low ALT was associated with an increased risk of severe COVID-19, with increased mortality (OR 1.88, 95% CI 1.37-2.56) and prolonged hospitalization (OR 1.78, 95% CI 1.33-2.35).

Conclusion

Low ALT level prior to infection is a significant risk factor for morbidity and mortality from COVID-19 infection. Further studies are warranted to address treatment options for this population.

Association between ethnic background and COVID-19 morbidity, mortality and vaccination in England: a multistate cohort analysis using the UK Biobank

OBJECTIVES

Despite growing evidence suggesting increased COVID-19 mortality among people from ethnic minorities, little is known about milder forms of SARS-CoV-2 infection. We sought to explore the association between ethnic background and the probability of testing, testing positive, hospitalisation, COVID-19 mortality and vaccination uptake.

DESIGN

A multistate cohort analysis. Participants were followed between 8 April 2020 and 30 September 2021.

SETTING

The UK Biobank, which stores medical data on around half a million people who were recruited between 2006 and 2010.

PARTICIPANTS

405 541 subjects were eligible for analysis, limited to UK Biobank participants living in England. 23 891 (6%) of participants were non-white.

PRIMARY AND SECONDARY OUTCOME MEASURES

The associations between ethnic background and testing, testing positive, hospitalisation and COVID-19 mortality were studied using multistate survival analyses. The association with single and double-dose vaccination was also modelled. Multistate models adjusted for age, sex and socioeconomic deprivation were fitted to estimate adjusted HRs (aHR) for each of the multistate transitions.

RESULTS

18 172 (4.5%) individuals tested positive, 3285 (0.8%) tested negative and then positive, 1490 (6.9% of those tested positive) were hospitalised, and 129 (0.6%) tested positive at the moment of hospital admission (ie, direct hospitalisation). Finally, 662 (17.4%) died after admission. Compared with white participants, Asian participants had an increased risk of negative to positive transition (aHR 1.24 (95% CI 1.02 to 1.52)), testing positive (95% CI 1.44 (1.33 to 1.55)) and direct hospitalisation (1.61 (95% CI 1.28 to 2.03)). Black participants had an increased risk of hospitalisation following a positive test (1.71 (95% CI 1.29 to 2.27)) and direct hospitalisation (1.90 (95% CI 1.51 to 2.39)). Although not the case for Asians (aHR 1.00 (95% CI 0.98 to 1.02)), black participants had a reduced vaccination probability (0.63 (95% CI 0.62 to 0.65)). In contrast, Chinese participants had a reduced risk of testing negative (aHR 0.64 (95% CI 0.57 to 0.73)), of testing positive (0.40 (95% CI 0.28 to 0.57)) and of vaccination (0.78 (95% CI 0.74 to 0.83)).

CONCLUSIONS

We identified inequities in testing, vaccination and COVID-19 outcomes according to ethnicity in England. Compared with whites, Asian participants had increased risks of infection and admission, and black participants had almost double hospitalisation risk, and a 40% lower vaccine uptake.

Frailty after COVID-19: The wave after?

The COVID-19 pandemic poses an ongoing public health challenge, with a focus on older adults. Given the large number of older persons who have recovered from COVID-19 and reports of long-lasting sequelae, there is reasonable concern that the COVID-19 pandemic may lead to a long-term deterioration in the health of older adults, i.e., a potential "wave of frailty." Therefore, it is critical to better understand the circumstances surrounding the development of frailty as a result of COVID-19, as well as the underlying mechanisms and factors contributing to this development. We conducted a narrative review of the most relevant articles published on the association between COVID-19 and frailty through January 2023. Although few studies to date have addressed the effects of COVID-19 on the onset and progression of frailty, the available data suggest that there is indeed an increase in frailty in the elderly as a result of COVID-19. Regarding the underlying mechanisms, a multicausal genesis can be assumed, involving both direct viral effects and indirect effects, particularly from the imposed lockdowns with devastating consequences for the elderly: decreased physical activity, altered diet, sarcopenia, fatigue, social isolation, neurological problems, inflammation, and cardiovascular morbidity are among the possible mediators. Since the COVID-19 pandemic is leading to an increase in frailty in the elderly, there is an urgent need to raise awareness of this still little-known problem of potentially great public health importance and to find appropriate prevention and treatment measures.

Improving Nutritional Status Was Associated with Decreasing Disease Severity and Shortening of Negative Conversion Time of PCR Test in Non-ICU Patients with COVID-19

Background

Nutrition is an important prevention in old patients with COVID-19. However, in China, there are few studies on the correlation between nutrition and COVID-19.

Methods

A total of 148 hospitalized COVID-19 (65.7 ± 16.0 [range: from 21 to 101] years old) patients were enrolled in this study. The information of demographic, biochemical results, vaccination doses, types of COVID-19, PCR test negative conversion time, and scores of Mini Nutritional Assessment Short Form (MNA-SF) for evaluating nutritional status were recorded. We first explored the relationships between MNA-SF performance and the severities of COVID-19 in the groups with non-vaccinated, vaccinated, and all the patients using multivariable ordinal logistic regression. Further, we explored the relationships between performance of MNA-SF and the time of negative conversion of PCR in the groups with non-vaccinated, vaccinated, and all the patients using COX proportional hazards survival regression.

Results

Group of patients with malnutrition or at risk of malnutrition group was associated with older of the age, those who had not been vaccinated, in fewer people who were asymptomatic type and in more people who showed longer of the negative conversion time of PCR, lower of the BMI, and the lower of the hemoglobin level. Each additional increase of one point of MNA-SF was associated with a 17% decrease in the odds of a worse type of COVID-19 in all patients, and the significant result exists in non-vaccinated patients. One point increase of MNA-SF was associated with increased 11% of hazard ratios of turning negative of PCR and well-nourished group was associated with increased 46% of hazard ratio of turning negative of PCR.

Conclusion

Higher nutrition is associated with less severity of COVID-19, especially in the non-vaccinated group. Higher nutrition is also associated with shorter time of turning negative of PCR in non-ICU COVID-19 patients.

Nutritional and physical activity issues in frailty syndrome during the COVID-19 pandemic

'Frailty' has been described as 'a state of increased vulnerability of the individual caused by an impairment of homeostasis as a result of endogenous or exogenous stress'. Frail individuals are depicted by a dramatic change in health status following an apparently minor insult and a higher risk of adverse health-related outcomes such as osteoporosis and sarcopenia, falls and disability, and fragility fractures. Frailty is a condition of increasing importance due to the global ageing of the population during the last decades. Central to the pathophysiology of frailty is a mechanism that is partially independent of ageing, but most likely evolves with ageing: the cumulative level of molecular and cellular damage in every subject. Furthermore, an uncorrected nutrition and a sedentary behaviour play a pivotal role in worsening the syndrome. In January 2020, a cluster of a genus of the family Coronaviridae was isolated as the pathogen of the new coronavirus disease (COVID-19). Since then, this infection has spread worldwide causing one of the most dramatic pandemics of the modern era, with more than 500 million confirmed cases all over the world. The clinical spectrum of SARS-CoV-2 severity ranges from asymptomatic conditions to mild symptoms, such as fever, cough, ageusia, anosmia and asthenia, up to most severe conditions, such as acute respiratory distress syndrome (ARDS) and multi-organ failure leading to death. Primary evidence revealed that the elderly frail subjects were more susceptible to the disease in its most intense form and were at greater risk of developing severe COVID-19. Factors contributing to the severity of COVID-19, and the higher mortality rate, are a poor immune system activity and long-standing inflammatory status of the frail subjects compared with the general population. Further recent research also suggested a potential role of sedentary behaviour, metabolic chronic disorders linked to it and uncorrected nutritional status. Thus, the aim of this review was to evaluate the different studies and evidence related to COVID-19 pandemic, both nutritional status and physical activity, and, also, to provide further information on the correct nutritional approach in this peculiar pathological condition.

Association Between Pollution and Frailty in Older People: A Cross-Sectional Analysis of the UK Biobank

OBJECTIVES

Frailty is a relevant issue in older people, being associated with several negative outcomes. Increasing literature is reporting that pollution (particularly air pollution) can increase the risk of frailty, but the research is still limited. We aimed to investigate the potential association of pollution (air, noise) with frailty and prefrailty among participants 60 years and older of the UK Biobank study.

DESIGN

Cross-sectional.

SETTINGS AND PARTICIPANTS

Older participants (age ≥ 60 years) participating to the UK Biobank.

METHODS

Frailty and prefrailty presence were ascertained using a model including 5 indicators (weakness, slowness, weight loss, low physical activity, and exhaustion). Air pollution was measured through residential exposures to nitrogen oxides (NO_x) and particulate matter (PM_2.5, PM_2.5-10, PM₁₀). The average residential sound level during the daytime, the evening, and night was used as an index for noise pollution.

RESULTS

A total of 220,079 subjects, aged 60 years and older, was included. The partial proportional odds model, adjusted for several confounders, showed that the increment in the exposure to NO_x was associated with a higher probability of being in both the prefrail and frail category [odds ratio (OR) 1.003; 95% CI 1.001-1.004]. Similarly, the increase in the exposure to PM_2.5-10 was associated with a higher probability of being prefrail and frail (OR 1.014; 95% CI 1.001-1.036), such as the increment in the exposure to PM_2.5 that was associated with a higher probability of being frail (OR 1.018; 95% CI 1.001-1.037).

CONCLUSIONS AND IMPLICATIONS

Our study indicates that the exposure to air pollutants as PM_2.5, PM_2.5-10, or NO_x might be associated with frailty and prefrailty, suggesting that air pollution can contribute to frailty and indicating that the frailty prevention and intervention strategies should take into account the dangerous impact of air pollutants.

Prevalence and association of frailty with SARS-CoV-2 infection in older adults in Southern Switzerland-Findings from the Corona Immunitas Ticino Study

BACKGROUND

Frailty is an age-associated state of increased vulnerability to stressors that strongly predicts poor health outcomes. Epidemiological evidence on frailty is limited during the COVID-19 pandemic, and whether frailty is associated with the risk of infection is unknown.

OBJECTIVES

We derived a robust Frailty Index (FI) to measure the prevalence of frailty and its risk factors in community-dwelling older adults in Southern Switzerland (Ticino), and we explored the association between frailty and serologically confirmed SARS-CoV-2 infection.

METHODS

In September 2020, we recruited a random sample of community-dwelling older adults (65 +) in the Corona Immunitas Ticino prospective cohort study (CIT) and assessed a variety of lifestyle and health characteristics. We selected 30 health-related variables, computed the Rockwood FI, and applied standard thresholds for robust (FI < 0.1), pre-frail (0.1 ≤ FI < 0.21), and frail (FI ≥ 0.21).

RESULTS

Complete data for the FI was available for 660 older adults. The FI score ranged between zero (no frailty) and 0.59. The prevalence of frailty and pre-frailty were 10.3% and 48.2% respectively. The log-transformed FI score increased by age similarly in males and females, on average by 2.8% (p < 0.001) per one-year increase in age. Out of 481 participants with a valid serological test, 11.2% were seropositive to either anti-SARS-CoV-2 IgA or IgG. The frailty status and seropositivity were not statistically associated (p = 0.236).

CONCLUSION

Advanced age increases the risk of frailty. The risk of COVID-19 infection in older adults may not differ by frailty status.

Factors associated with mortality in hospitalised, non-severe, older COVID-19 patients - the role of sarcopenia and frailty assessment

BACKGROUND

COVID-19 has affected older persons the most. The propensity to have severe COVID-19 or die of the infection was especially prevalent among older subjects with multimorbidity, frailty and sarcopenia. The aim of our study was to check which of the simple clinical biomarkers, including the assessment of muscle and frailty, would associate with the survival and the length of hospital stay in older patients with COVID-19. An additional aim was to report the influence of chronic diseases, chronic medication use, and COVID-19 signs and symptoms on the aforementioned outcome measures.

METHODS

The CRACoV study was a prospective single-center (University Hospital in Krakow, Krakow, Poland) observational study of clinical outcomes in symptomatic COVID-19 patients that required hospital treatment. We analysed data of persons aged ≥ 65 years. We assessed muscular parameters in accordance with EWGSOP2, frailty with the Rockwood Clinical Frailty Scale. We used the data of the initial and 3-month assessment. Demographic characteristics, past medical history, and baseline laboratory values were gathered as a part of routine care. We calculated sex and age, and additionally number-of-diseases adjusted odds ratios of mortality associated with studied factors and betas of the relation with these factors and the length of hospital stay.

RESULTS

The mean (standard deviation, SD) age of 163 participants (44.8% women, 14.8% died) was 71.8 (5.6) years, age range 65-89 years. One score greater SARC-F was associated with 34% (p = 0.003) greater risk of death, and 16.8 h longer hospital stay (p = 0.01). One score greater Rockwood was associated with 86% (p = 0.002) greater risk of death, but was unrelated to the length of hospital stay. Hand grip strength and dynapenia were unrelated to mortality, but dynapenia was related to longer hospital stay. Probable sarcopenia was associated with 441% (p = 0.01) greater risk of death.

CONCLUSIONS

In conclusion, the patient assessment with SARC-F and the Rockwood Clinical Frailty Scale may significantly improve the prediction of outcomes in older patients with COVID-19 and by extension might be of use in other acute severe infections. This, however, requires further research to confirm.

Tobacco use and risk of COVID-19 infection in the Finnish general population

Empirical evidence, primarily based on hospital-based or voluntary samples, suggests that current smokers have a lower risk of COVID-19 infection than never smokers. In this study, we used nationally representative data to examine the association between tobacco use and the risk of having a confirmed COVID-19 case. We explored several forms of tobacco use, contributing to separate the role of nicotine from smoking. We used data from 44,199 participants from three pooled national health surveys in Finland (FinSote 2018-2020). The primary outcome was a confirmed COVID-19 case. We examined current smoking, moist smokeless tobacco (snus), e-cigarettes with and without nicotine and nicotine replacement therapy products. Current daily smokers had a relative risk of 1.12 of a confirmed COVID-19 case (95% CI 0.65; 1.94) in fully adjusted models compared with never smokers. Current snus use was associated with a 68% higher risk of a confirmed COVID-19 case (RR 1.68, 95% CI 1.02; 2.75) than never users. We did not find conclusive evidence of associations between e-cigarettes with and without nicotine and nicotine replacement therapy products and the risk of confirmed COVID-19 cases. Our findings suggest that nicotine might not have a protective role in the risk of COVID-19 as previously hypothesized.

Aetiological and prognostic roles of frailty, multimorbidity and socioeconomic characteristics in the development of SARS-CoV-2 health outcomes: protocol for systematic reviews of population-based studies

INTRODUCTION

There is growing evidence that the impact of COVID-19 crisis may be stronger for individuals with multimorbidity, frailty and lower socioeconomic status. Existing reviews focus on few, mainly short-term effects of COVID-19 illness and patients with single chronic disease. Information is also largely missing for population representative samples.Applying population-based approach, the systematic reviews will have two objectives: (1) to evaluate the aetiological roles of frailty, multimorbidity and socioeconomic status on SARS-CoV-2 infection probability, hospitalisation, intensive care unit (ICU) admission, mechanical ventilation and COVID-19 related mortality among general population and (2) to investigate the prognostic roles of frailty, multimorbidity and socioeconomic characteristics on the risk of hospitalisation, ICU admission, mechanical ventilation, COVID-19 mortality, functioning, quality of life, disability, mental health and work absence.

METHODS AND ANALYSIS

For this ongoing work, four databases were searched: PubMed, Embase, WHO COVID-19 Global literature on coronavirus disease and PsycINFO, for the period between January 2020 and April 7 2021. Peer-reviewed published literature in English and all types of population-based studies will be considered. Studies using standard tools to assess multimorbidity such as disease count, comorbidity indices or disease combinations will be retained, as well as studies with standard scales and scores for frailty or measurement of a socioeconomic gradient. Initial search included 10 139 articles, 411 for full-text reading. Results will be summarised by risk factor, objective and outcome. The feasibility of meta-analysis will be determined by the findings and will aim to better understand uncertainties of the results. Quality of studies will be assessed using standardised scales.

ETHICS AND DISSEMINATION

The study will be based on published evidence, and it is exempt from the ethical approval. This work is part of the Population Health Information Research Infrastructure (PHIRI) project. Dissemination of the results will imply conference presentation, submission for scientific publication and PHIRI project report.

PROSPERO REGISTRATION NUMBER

CRD42021249444.

Spread of Covid-19 in haemodialysis centres; the effects of ventilation and communal transport

Aims

Hemodialysis (HD) patients are at increased risk of respiratory infections, due to increased use of communal travel, waiting areas, close proximity to others when dialysing, and contact with healthcare personnel. We wished to determine the major factors associated with transmission of COVID‐19 within dialysis centres.

Methods

We compared the differences in the number of COVID‐19 infections in patients and staff in 5 dialysis centres during the 1st COVID‐19 pandemic between March and June 2020, and analyzed differences between centres. Isolation policies and infection control practices were identical between centres.

Results

224 (30.3%) patients tested positive for COVID‐19, by reverse transcriptase polymerase chain reaction, ranging from 4.8% (centre 1 size 55 patients) to 41.5% (centre 5–248 patients) p = 0.007. Communal transport had a significant effect; with 160 of 452 (35.4%) patients using communal testing positive compared to 22.2% of those not using communal transport (X214.5, p < 0.001). Staff sickness varied; 35 of 36 (97.3% centre 5) dialysis staff contracting COVID‐19, compared to 60% from centre 4 (189 patients 30 staff) (p < 0.001). Whereas centre 5 had no natural ventilation, and fan assisted ventilation did not meet standards for air changes and air circulation, centre 4 met ventilation standards.

Conclusions

Although there are many potential risk factors accounting for the increased risk of COVID‐19 infection in hemodialysis patients, we found that differences in communal transport for patients and ventilation between centres was a major contributor accounting for the differences in patients testing positive for COVID‐19 and staff sickness rates. This has important practical applications for designing kidney dialysis centres.

Noncommunicable diseases risk factors and the risk of COVID-19 among university employees in Indonesia

Introduction

Noncommunicable diseases (NCDs) are still a major public health problem in Indonesia. Studies have shown that risk factors of NCDs are associated with coronavirus disease 2019 (COVID-19) severity and mortality. However, it is unclear whether NCD risk factors are also risks for new COVID-19 cases. This study aimed to obtain an NCD risk profile among university employees and its associations with contracting COVID-19.

Methods

A cross-sectional study was conducted in October 2021. Participants were administrative employees of Universitas Indonesia (UI), Depok City, West Java. Assessment of NCD risk factors was based on the World Health Organization STEPwise approach to NCD risk factor surveillance (WHO STEPS). Demographic, working, and medical-history data were obtained electronically by using a Google Form. Physical and laboratory examinations were done in the Integrated Post for NCDs. Risks were expressed as adjusted odds ratio (OR_adj) and 95% confidence interval (CI) in multivariate analyses.

Results

A total of 613 employees were enrolled. Men were predominant (54.8%), and about 36% of them work in shift as security personnel. About 66.7% were overweight or obese and 77.8% had hypertension. There were 138 (22.8%) employees who had COVID-19. Nearly all (95.6%) had been fully vaccinated against COVID-19. At-risk waist circumference (OR_adj 1.72, 95% CI 1.15–2.56, p = 0.008) and total cholesterol level of 200–239 mg/dL (OR_adj 2.30, 95% CI 1.19–4.44, p = 0.013) were independent risk factors, but shift work (OR_adj 0.52, 95% CI 0.34–0.80, p = 0.003) was protective against COVID-19.

Conclusion

The prevalence of NCD risk factors among university administrative employees was high, increasing the risk of contracting COVID-19. A behavioral intervention program to manage NCD risk factors at the university level is urgently needed according to the Health Promoting University framework.

Association of shorter leucocyte telomere length with risk of frailty

BACKGROUND

Frailty is a multidimensional syndrome of decline that affects multiple systems and predisposes to adverse health outcomes. Although chronological age is the major risk factor, inter-individual variation in risk is not fully understood. Leucocyte telomere length (LTL), a proposed marker of biological age, has been associated with risk of many diseases. We sought to determine whether LTL is associated with risk of frailty.

METHODS

We utilized cross-sectional data from 441 781 UK Biobank participants (aged 40-69 years), with complete data on frailty indicators and LTL. Frailty was defined as the presence of at least three of five indicators: weaker grip strength, slower walking pace, weight loss in the past year, lower physical activity, and exhaustion in the past 2 weeks. LTL was measured using a validated qPCR method and reported as a ratio of the telomere repeat number (T) to a single-copy gene (S) (T/S ratio). Association of LTL with frailty was evaluated using adjusted (chronological age, sex, deprivation, smoking, alcohol intake, body mass index, and multimorbidity) multinomial and ordinal regression models, and results are presented as relative risk (RRR) or odds ratios (OR), respectively, alongside the 95% confidence interval (CI). Mendelian randomization (MR), using 131 genetic variants associated with LTL, was used to assess if the association of LTL with frailty was causal.

RESULTS

Frail participants (4.6%) were older (median age difference (95% CI): 3 (2.5; 3.5) years, P = 2.73 × 10-33 ), more likely to be female (61%, P = 1.97 × 10-129 ), and had shorter LTL (-0.13SD vs. 0.03SD, P = 5.43 × 10-111 ) than non-frail. In adjusted analyses, both age and LTL were associated with frailty (RRR = 1.03 (95% CI: 1.02; 1.04) per year of older chronological age, P = 3.99 × 10-12 ; 1.10 (1.08; 1.11) per SD shorter LTL, P = 1.46 × 10-30 ). Within each age group (40-49, 50-59, 60-69 years), the prevalence of frailty was about 33% higher in participants with shorter (-2SD) versus longer telomeres (+2SD). MR analysis showed an association of LTL with frailty that was directionally consistent with the observational association, but not statistically significant (MR-Median: OR (95% CI): 1.08 (0.98; 1.19) per SD shorter LTL, P = 0.13).

CONCLUSIONS

Inter-individual variation in LTL is associated with the risk of frailty independently of chronological age and other risk factors. Our findings provide evidence for an additional biological determinant of frailty.

Association of Frailty, Organ Support, and Long-Term Survival in Critically Ill Patients With COVID-19

Few studies have explored the effect of frailty on the long-term survival of COVID-19 patients after ICU admission. Furthermore, the Clinical Frailty Scale (CFS) validity in critical care patients remains debated. We investigated the association between frailty and 6-month survival in critically ill COVID-19 patients. We also explored whether ICU resource utilization varied according to frailty status and examined the concurrent validity of the CFS in this setting.

Physical decline and cognitive impairment in frail hypertensive elders during COVID-19

BACKGROUND

Hypertension is common in older adults and its incidence increases with age. We investigated the correlation between physical and cognitive impairment in older adults with frailty and hypertension.

METHODS

We recruited frail hypertensive older adults during the COVID-19 pandemic, between March 2021 and December 2021. Global cognitive function was assessed through the Montreal Cognitive Assessment (MoCA), physical frailty assessment was performed following the Fried criteria, and all patients underwent physical evaluation through 5-meter gait speed test.

RESULTS

We enrolled 203 frail hypertensive older adults and we found a significant correlation between MoCA score and gait speed test (r: 0.495; p<0.001) in our population. To evaluate the impact of comorbidities and other factors on our results, we applied a linear regression analysis with MoCA score as a dependent variable, observing a significant association with age, diabetes, chronic obstructive pulmonary disease (COPD), and gait speed test.

CONCLUSIONS

Our study revealed for the first time a significant correlation between physical and cognitive impairment in frail hypertensive elderly subjects.

Insights into Cardiovascular Defects and Cardiac Epigenome in the Context of COVID-19

Although few in number, studies on epigenome of the heart of COVID-19 patients show that epigenetic signatures such as DNA methylation are significantly altered, leading to changes in expression of several genes. It contributes to pathogenic cardiac phenotypes of COVID-19, e.g., low heart rate, myocardial edema, and myofibrillar disarray. DNA methylation studies reveal changes which likely contribute to cardiac disease through unknown mechanisms. The incidence of severe COVID-19 disease, including hospitalization, requiring respiratory support, morbidity, and mortality, is disproportionately higher in individuals with co-morbidities. This poses unprecedented strains on the global healthcare system. While their underlying conditions make patients more susceptible to severe COVID-19 disease, strained healthcare systems, lack of adequate support, or sedentary lifestyles from ongoing lockdowns have proved detrimental to their underlying health conditions, thus pushing them to severe risk of congenital heart disease (CHD) itself. Prophylactic vaccines against COVID-19 have ushered new hope for CHD. A common connection between COVID-19 and CHD is SARS-CoV-2’s host receptor ACE2, because ACE2 regulates and protects organs, including the heart, in various ways. ACE2 is a common therapeutic target against cardiovascular disease and COVID-19 which damages organs. Hence, this review explores the above regarding CHDs, cardiovascular damage, and cardiac epigenetics, in COVID-19 patients.

Reliability of fr-AGILE tool to evaluate multidimensional frailty in hospital settings for older adults with COVID-19

Aims

The study assesses the reliability of fr-AGILE, a validated rapid tool used for the evaluation of multidimensional frailty in older adults hospitalized with COVID-19.

Methods

Two different staff members independently assessed the presence of frailty in 144 patients aged ≥ 65 years affected by COVID-19 using the fr-AGILE tool. The internal consistency of fr-AGILE was evaluated by examining the item-total correlations and the Kuder–Richardson (KR) formula. The inter-rater reliability was evaluated using linear weighted kappa.

Results

Multidimensional frailty severity increases with age and is associated to higher use of non-invasive ventilation (p = 0.025), total severity score on chest tomography (p = 0.001) and in-hospital mortality (p = 0.032). Fr-AGILE showed good internal consistency (KR-20 = 0.742) and excellent inter-rater reliability (weighted kappa = 0.752 and 0.878 for frailty score and frailty degree, respectively).

Conclusions

fr-AGILE tool can quickly identify and quantify multidimensional frailty in hospital settings for older patient affected by COVID-19.

Risk of SARS-CoV-2 infection in migrants and ethnic minorities compared with the general population in the European WHO region during the first year of the pandemic: a systematic review

BACKGROUND

Migrants and ethnic minorities have suffered a disproportionate impact of the COVID-19 pandemic compared to the general population from different perspectives. Our aim was to assess specifically their risk of infection in the 53 countries belonging to the World Health Organization European Region, during the first year of the pandemic.

METHODS

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42021247326). We searched multiple databases for peer-reviewed literature, published on Medline, Embase, Scisearch, Biosis and Esbiobase in 2020 and preprints from PubMed up to 29/03/2021. We included cross-sectional, case-control, cohort, intervention, case-series, prevalence or ecological studies, reporting the risk of SARS-CoV-2 infection among migrants, refugees, and ethnic minorities.

RESULTS

Among the 1905 records screened, 25 met our inclusion criteria and were included in the final analysis. We found that migrants and ethnic minorities during the first wave of the pandemic were at increased exposure and risk of infection and were disproportionately represented among COVID-19 cases. However, the impact of COVID-19 on minorities does not seem homogeneous, since some ethnic groups seem to be more at risk than others. Risk factors include high-risk occupations, overcrowded accommodations, geographic distribution, social deprivation, barriers to access to information concerning preventive measures (due to the language barrier or to their marginality), together with biological and genetic susceptibilities.

CONCLUSIONS

Although mixed methods studies will be required to fully understand the complex interplay between the various biological, social, and cultural factors underlying these findings, the impact of structural determinants of health is evident. Our findings corroborate the need to collect migration and ethnicity-disaggregated data and contribute to advocacy for inclusive policies and programmatic actions tailored to reach migrants and ethnic minorities.

Frailty but not sarcopenia nor malnutrition increases the risk of developing COVID-19 in older community-dwelling adults

Background

The identification of coronavirus disease 2019 (COVID-19) risk factors is requested to implement prevention strategies.

Aim

To explore the associations between the COVID-19 incidence and malnutrition, sarcopenia, and frailty, identified as potential risk factors in previous cross-sectional studies.

Methods

Malnutrition, sarcopenia, and frailty were assessed at the last available follow-up from the Sarcopenia and Physical Impairments with Advancing Age (SarcoPhAge) cohort (i.e., the fifth year that ended in 2019) according to the Mini-Nutritional Assessment short-form, the European Working Group on Sarcopenia in Older People (EWGSOP2), and the Fried criteria, respectively. Information regarding the COVID-19 was gathered by phone calls interviews in April 2021 to measure its self-declared incidence. Adjusted Cox regressions and Kaplan–Meier curves were performed.

Results

The present study included 241 participants [median age 75.6 (73.0–80.6) years, 63.1% women]. Among them, 27 participants (11.2%) developed the non-fatal Covid-19. No significant increased risks of COVID-19 were observed in patients with malnutrition [adjusted HR 1.14 (0.26–5.07)] and sarcopenia [adjusted HR 1.25 (0.35–4.42)]. Nevertheless, the incidence of COVID-19 was significantly higher in frail (44.4%) than in robust participants (8.5%) [Adjusted HR 7.01 (2.69–18.25)], which was confirmed by the Kaplan–Meier curves (p < 0.001). Among the frailty syndrome components, a low physical activity level was the only one significantly associated with an increased risk of COVID-19 [adjusted HR 5.18 (1.37–19.54)].

Conclusion

Despite some limitations in the methodology of this study (i.e., limited sample size, COVID-19 incidence self-reported and not assessed systematically using objective measurements) requiring careful  consideration, an increased risk to develop COVID-19 was observed in the presence of the frailty syndrome. Further investigations are needed to elaborate on our findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01991-z.

Frailty but not sarcopenia nor malnutrition increases the risk of developing COVID-19 in older community-dwelling adults

BACKGROUND

The identification of coronavirus disease 2019 (COVID-19) risk factors is requested to implement prevention strategies.

AIM

To explore the associations between the COVID-19 incidence and malnutrition, sarcopenia, and frailty, identified as potential risk factors in previous cross-sectional studies.

METHODS

Malnutrition, sarcopenia, and frailty were assessed at the last available follow-up from the Sarcopenia and Physical Impairments with Advancing Age (SarcoPhAge) cohort (i.e., the fifth year that ended in 2019) according to the Mini-Nutritional Assessment short-form, the European Working Group on Sarcopenia in Older People (EWGSOP2), and the Fried criteria, respectively. Information regarding the COVID-19 was gathered by phone calls interviews in April 2021 to measure its self-declared incidence. Adjusted Cox regressions and Kaplan-Meier curves were performed.

RESULTS

The present study included 241 participants [median age 75.6 (73.0-80.6) years, 63.1% women]. Among them, 27 participants (11.2%) developed the non-fatal Covid-19. No significant increased risks of COVID-19 were observed in patients with malnutrition [adjusted HR 1.14 (0.26-5.07)] and sarcopenia [adjusted HR 1.25 (0.35-4.42)]. Nevertheless, the incidence of COVID-19 was significantly higher in frail (44.4%) than in robust participants (8.5%) [Adjusted HR 7.01 (2.69-18.25)], which was confirmed by the Kaplan-Meier curves (p < 0.001). Among the frailty syndrome components, a low physical activity level was the only one significantly associated with an increased risk of COVID-19 [adjusted HR 5.18 (1.37-19.54)].

CONCLUSION

Despite some limitations in the methodology of this study (i.e., limited sample size, COVID-19 incidence self-reported and not assessed systematically using objective measurements) requiring careful  consideration, an increased risk to develop COVID-19 was observed in the presence of the frailty syndrome. Further investigations are needed to elaborate on our findings.

Epidemiologic Characteristics of and Prognostic Factors for COVID-19 Among Hospitalized Patients: Updated Implications From Hubei Province, China

Introduction: The roles of some indicators in the prognosis of patients with coronavirus disease-19 (COVID-19) remain unclear and controversial. This study aimed to explore the epidemiologic characteristics of and prognostic factors for COVID-19 to provide updated recommendations for its prevention, diagnosis, and treatment.

Methods: For this retrospective study, demographic, epidemiologic, and clinical data were extracted from the medical records of patients admitted to the Maternal and Child Hospital of Hubei Province (Optical Valley) with COVID-19 between February 19, 2020, and March 19, 2020. The primary outcome was the prognosis that was determined at discharge as mentioned in the medical records. Descriptive statistics, univariate analyses, and stepwise logistic regression analysis were used for data analysis.

Results: Of the 1,765 patients included, 93.1% were cured and the mortality was 1.8%. Univariate analyses identified 63 factors significantly associated with COVID-19 prognosis. Logistic regression analysis revealed that a poorer prognosis was associated with undergoing resuscitation, complex disease manifestations, consultation with outside specialists, elevated basophil or lymphocyte counts, an albumin (ALB)/globulin (A/G) ratio > 2.4, and elevated levels of serum aspartate aminotransferase (AST) or creatinine. Patients had a better prognosis if the following conditions were met: dry cough reported as an initial symptom, fatigue as a clinical manifestation, and a diagnosis based on laboratory testing.

Conclusion: To prevent clinical deterioration, clinicians should provide special care to patients who underwent resuscitation, with a critical disease, or requiring consultation with outside specialists. Extra attention should be paid to patients with high basophil or lymphocyte counts, a high A/G ratio, and elevated AST or creatinine levels.

Implications of Frailty in COVID-19

As the global coronavirus disease-19 (COVID-19) pandemic caused by severe acute respiratory distress syndrome coronavirus 2 continues to cause higher mortality and hospitalization rates among older adults, strategies such as frailty screening have been suggested for resource allocation and clinical management. Frailty is a physiologic condition characterized by a decreased reserve to stressors and is associated with disability, hospitalization, and death. Measuring frailty can be a useful tool to determine the risk and prognosis of COVID-19 patients in the acute setting, and to provide higher quality of care for vulnerable individuals in the outpatient setting. A literature review was conducted to examine current research regarding frailty and COVID-19. Frailty can inform holistic care of COVID-19 patients, and further investigation is needed to elucidate how measuring frailty should guide treatment and prevention of COVID-19.

Survival of COVID-19 with Multimorbidity Patients

BACKGROUND

The outbreak of SARS-CoV-2 abruptly disseminated in early 2020, overcoming the capacity of health systems to respond the pandemic. It was not until the vaccines were launched worldwide that an increase in survival was observed. The objectives of this study were to analyse the characteristics of survivors and their relationship with comorbidities. We had access to a database containing information on 16,747 hospitalized patients from Mexico, all infected with SARS-CoV-2, as part of a regular follow-up. The descriptive analysis looked for clusters of either success or failure. We categorized the samples into no comorbidities, or one and up to five coexisting with the infection. We performed a logistic regression test to ascertain what factors were more influential in survival. The main variable of interest was survival associated with multimorbidity factors. The database hosted information on hospitalized patients from Mexico between March 2020 through to April 2021. Categories 2 and 3 had the largest number of patients. Survival rates were higher in categories 0 (64.8%), 1 (57.5%) and 2 (51.6%). In total, 1741 (10.5%) patients were allocated to an ICU unit. Mechanical ventilators were used on 1415 patients, corresponding to 8.76%. Survival was recorded in 9575 patients, accounting for 57.2% of the sample population. Patients without comorbidities, younger people and women were more likely to survive.

Direct and Indirect Effects of COVID-19 in Frail Elderly: Interventions and Recommendations

Frailty is a state of vulnerability to stressors because of a decreased physiological reserve, resulting in poor health outcomes. This state is related to chronic conditions, many of which are risk factors for outcomes in elderly patients having SARS-COV-2. This review aims to describe frailty as a physiological vulnerability agent during the COVID-19 pandemic in elderly patients, summarizing the direct and indirect effects caused by the SARS-COV-2 infection and its prognosis in frail individuals, as well as the interventions and recommendations to reduce their effects. Cohort studies have shown that patients with a Clinical Frailty Scale higher than five have a higher risk of mortality and use of mechanical ventilation after COVID-19; nonetheless, other scales have also associated frailty with longer hospital stays and more severe forms of the disease. Additionally, the indirect effects caused by the pandemic have a negative impact on the health status of older people. Due to the above, a holistic intervention is proposed based on a comprehensive geriatric assessment for frail patients (preventive or post-infection) with emphasis on physical activity and nutritional recommendations, which could be a potential preventive intervention in viral infections by COVID-19.

Factors associated with COVID-19 viral and antibody test positivity and assessment of test concordance: a retrospective cohort study using electronic health records from the USA

OBJECTIVES

To identify factors associated with COVID-19 test positivity and assess viral and antibody test concordance.

DESIGN

Observational retrospective cohort study.

SETTING

Optum de-identified electronic health records including over 700 hospitals and 7000 clinics in the USA.

PARTICIPANTS

There were 891 754 patients who had a COVID-19 test identified in their electronic health record between 20 February 2020 and 10 July 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Per cent of viral and antibody tests positive for COVID-19 ('positivity rate'); adjusted ORs for factors associated with COVID-19 viral and antibody test positivity; and per cent concordance between positive viral and subsequent antibody test results.

RESULTS

Overall positivity rate was 9% (70 472 of 771 278) and 12% (11 094 of 91 741) for viral and antibody tests, respectively. Positivity rate was inversely associated with the number of individuals tested and decreased over time across regions and race/ethnicities. Antibody test concordance among patients with an initial positive viral test was 91% (71%-95% depending on time between tests). Among tests separated by at least 2 weeks, discordant results occurred in 7% of patients and 9% of immunocompromised patients. Factors associated with increased odds of viral and antibody positivity in multivariable models included: male sex, Hispanic or non-Hispanic black or Asian race/ethnicity, uninsured or Medicaid insurance and Northeast residence. We identified a negative dose effect between the number of comorbidities and viral and antibody test positivity. Paediatric patients had reduced odds (OR=0.60, 95% CI 0.57 to 0.64) of a positive viral test but increased odds (OR=1.90, 95% CI 1.62 to 2.23) of a positive antibody test compared with those aged 18-34 years old.

CONCLUSIONS

This study identified sociodemographic and clinical factors associated with COVID-19 test positivity and provided real-world evidence demonstrating high antibody test concordance among viral-positive patients.

Patterns of multimorbidity and risk of severe SARS-CoV-2 infection: an observational study in the U.K

BACKGROUND

Pre-existing comorbidities have been linked to SARS-CoV-2 infection but evidence is sparse on the importance and pattern of multimorbidity (2 or more conditions) and severity of infection indicated by hospitalisation or mortality. We aimed to use a multimorbidity index developed specifically for COVID-19 to investigate the association between multimorbidity and risk of severe SARS-CoV-2 infection.

METHODS

We used data from the UK Biobank linked to laboratory confirmed test results for SARS-CoV-2 infection and mortality data from Public Health England between March 16 and July 26, 2020. By reviewing the current literature on COVID-19 we derived a multimorbidity index including: (1) angina; (2) asthma; (3) atrial fibrillation; (4) cancer; (5) chronic kidney disease; (6) chronic obstructive pulmonary disease; (7) diabetes mellitus; (8) heart failure; (9) hypertension; (10) myocardial infarction; (11) peripheral vascular disease; (12) stroke. Adjusted logistic regression models were used to assess the association between multimorbidity and risk of severe SARS-CoV-2 infection (hospitalisation/death). Potential effect modifiers of the association were assessed: age, sex, ethnicity, deprivation, smoking status, body mass index, air pollution, 25-hydroxyvitamin D, cardiorespiratory fitness, high sensitivity C-reactive protein.

RESULTS

Among 360,283 participants, the median age was 68 [range 48-85] years, most were White (94.5%), and 1706 had severe SARS-CoV-2 infection. The prevalence of multimorbidity was more than double in those with severe SARS-CoV-2 infection (25%) compared to those without (11%), and clusters of several multimorbidities were more common in those with severe SARS-CoV-2 infection. The most common clusters with severe SARS-CoV-2 infection were stroke with hypertension (79% of those with stroke had hypertension); diabetes and hypertension (72%); and chronic kidney disease and hypertension (68%). Multimorbidity was independently associated with a greater risk of severe SARS-CoV-2 infection (adjusted odds ratio 1.91 [95% confidence interval 1.70, 2.15] compared to no multimorbidity). The risk remained consistent across potential effect modifiers, except for greater risk among older age. The highest risk of severe infection was strongly evidenced in those with CKD and diabetes (4.93 [95% CI 3.36, 7.22]).

CONCLUSION

The multimorbidity index may help identify individuals at higher risk for severe COVID-19 outcomes and provide guidance for tailoring effective treatment.

Changes in psychological distress before and during the COVID-19 pandemic among older adults: the contribution of frailty transitions and multimorbidity

AIM

To investigate changes in psychological distress in community-dwelling older adults before and during the coronavirus disease 2019 (COVID-19) pandemic and the contribution of frailty transitions and multimorbidity in predicting the psychological distress.

METHODS

Prospective repeated-measures cohort study on a sample of participants aged 60 and over. A total of 2, 785 respondents at the baseline (May 2019) were followed during the COVID-19 (August 2020). The changes in psychological distress before and during the COVID-19 were assessed using generalised estimation equations with adjusting for sex, age, education, economic status, marital status, tea drinking status, smoking status, alcohol drinking status, sedentary time, sleep quality and activities of daily living.

RESULTS

The psychological distress of older people has significantly increased in August 2020 compared with May 2019. Both older adults who remained frail and transitioned into frail state reported more psychological distress during the COVID-19. Similarly, both pre-existing multimorbidity and emerging multimorbidity groups were associated with more psychological distress. The group of frailty progression who reported new emerging multimorbidity showed more increase in psychological distress in comparison with those who remained in the non-frail state who reported no multimorbidity.

CONCLUSION

Psychological distress has increased among the community-dwelling older adults during the COVID-19 pandemic, and sustained and progressive frail states as well as multimorbidity were all associated with a greater increase of psychological distress. These findings suggest that future public health measures should take into account the increased psychological distress among older people during the COVID-19 pandemic, and the assessment of frailty and multimorbidity might help in warning of psychological distress.

Different aspects of frailty and COVID-19: points to consider in the current pandemic and future ones

BACKGROUND

Older adults at a higher risk of adverse outcomes and mortality if they get infected with Severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2). These undesired outcomes are because ageing is associated with other conditions like multimorbidity, frailty and disability. This paper describes the impact of frailty on coronavirus disease 2019 (COVID-19) management and outcomes. We also try to point out the role of inflamm-ageing, immunosenescence and reduced microbiota diversity in developing a severe form of COVID-19 and a different response to COVID-19 vaccination among older frail adults. Additionally, we attempt to highlight the impact of frailty on intensive care unit (ICU) outcomes, and hence, the rationale behind using frailty as an exclusion criterion for critical care admission. Similarly, the importance of using a time-saving, validated, sensitive, and user-friendly tool for frailty screening in an acute setting as COVID-19 triage. We performed a narrative review. Publications from 1990 to March 2021 were identified by searching the electronic databases MEDLINE, CINAHL and SCOPUS. Based on this search, we have found that in older frail adults, many mechanisms contribute to the severity of COVID-19, particularly cytokine storm; those mechanisms include lower immunological capacity and status of ongoing chronic inflammation and reduced gut microbiota diversity. Higher degrees of frailty were associated with poor outcomes and higher mortality rates during and after ICU admission. Also, the response to COVID-19 vaccination among frail older adults might differ from the general population regarding effectiveness and side effects. Researches also had shown that there are many tools for identifying frailty in an acute setting that could be used in COVID-19 triage, and before ICU admission, the clinical frailty scale (CFS) was the most recommended tool.

CONCLUSION

Older frail adults have a pre-existing immunopathological base that puts them at a higher risk of undesired outcomes and mortality due to COVID-19 and poor response to COVID-19 vaccination. Also, their admission in ICU should depend on their degree of frailty rather than their chronological age, which is better to be screened using the CFS.

Body Mass Index, Multi-Morbidity, and COVID-19 Risk Factors as Predictors of Severe COVID-19 Outcomes

Purpose

The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes.

Patients

Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens.

Measures

Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death.

Results

Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes.

Conclusion

Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.

Association of frailty status with adverse clinical outcomes in patients with COVID-19: protocol for a systematic review and dose-response meta-analysis

INTRODUCTION

Frailty status has been recognised as an important prognostic factor of adverse clinical outcomes in various clinical settings. Recently, the role of frailty status in adverse clinical outcomes for COVID-19-infected patients has received increasing attention with controversial results. Hence, we will conduct a comprehensive dose-response meta-analysis to quantitatively evaluate the association between frailty status and adverse clinical outcomes in patients with COVID-19.

METHODS

The researchers will systematically search PubMed, EMBase, Cochrane Library, ISI Knowledge via Web of Science and MedRxiv or BioRxiv databases (from inception until December 2020) to identify all retrospective and prospective cohort studies. All-cause mortality during hospitalisation will be set as the primary outcome. Univariable or multivariable meta-regression and subgroup analyses will be conducted for the comparison between frail versus non-frail categories. Sensitivity analyses will be used to assess the robustness of our results by removing each included study one at a time to obtain and evaluate the remaining overall estimates of all-cause mortality. To conduct a dose-response meta-analysis for the potential linear or restricted cubic spline regression relationship between frailty status and all-cause mortality, studies with three or more categories will be included.

ETHICS AND DISSEMINATION

In accordance with the Institutional Review Board/Independent Ethics Committee of the First Affiliated Hospital of Baotou Medical College, ethical approval is not an essential element for the systematic review protocol. This meta-analysis will be disseminated through publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020220226.

The impact of frailty on survival in elderly intensive care patients with COVID-19: the COVIP study

BACKGROUND

The COVID-19 pandemic has led highly developed healthcare systems to the brink of collapse due to the large numbers of patients being admitted into hospitals. One of the potential prognostic indicators in patients with COVID-19 is frailty. The degree of frailty could be used to assist both the triage into intensive care, and decisions regarding treatment limitations. Our study sought to determine the interaction of frailty and age in elderly COVID-19 ICU patients.

METHODS

A prospective multicentre study of COVID-19 patients ≥ 70 years admitted to intensive care in 138 ICUs from 28 countries was conducted. The primary endpoint was 30-day mortality. Frailty was assessed using the clinical frailty scale. Additionally, comorbidities, management strategies and treatment limitations were recorded.

RESULTS

The study included 1346 patients (28% female) with a median age of 75 years (IQR 72-78, range 70-96), 16.3% were older than 80 years, and 21% of the patients were frail. The overall survival at 30 days was 59% (95% CI 56-62), with 66% (63-69) in fit, 53% (47-61) in vulnerable and 41% (35-47) in frail patients (p < 0.001). In frail patients, there was no difference in 30-day survival between different age categories. Frailty was linked to an increased use of treatment limitations and less use of mechanical ventilation. In a model controlling for age, disease severity, sex, treatment limitations and comorbidities, frailty was independently associated with lower survival.

CONCLUSION

Frailty provides relevant prognostic information in elderly COVID-19 patients in addition to age and comorbidities. Trial registration Clinicaltrials.gov: NCT04321265 , registered 19 March 2020.

Frailty and comorbidity in predicting community COVID-19 mortality in the U.K. Biobank: The effect of sampling

BACKGROUND/OBJECTIVES

Frailty has been linked to increased risk of COVID-19 mortality, but evidence is mainly limited to hospitalized older individuals. This study aimed to assess and compare predictive abilities of different frailty and comorbidity measures for COVID-19 mortality in a community sample and COVID-19 inpatients.

DESIGN

Population-based cohort study.

SETTING

Community.

PARTICIPANTS

We analyzed (i) the full sample of 410,199 U.K. Biobank participants in England, aged 49-86 years, and (ii) a subsample of 2812 COVID-19 inpatients with COVID-19 data from March 1 to November 30, 2020.

MEASUREMENTS

Frailty was defined using the physical frailty phenotype (PFP), frailty index (FI), and Hospital Frailty Risk Score (HFRS), and comorbidity using the Charlson Comorbidity Index (CCI). PFP and FI were available at baseline, whereas HFRS and CCI were assessed both at baseline and concurrently with the start of the pandemic. Inpatient COVID-19 cases were confirmed by PCR and/or hospital records. COVID-19 mortality was ascertained from death registers.

RESULTS

Overall, 514 individuals died of COVID-19. In the full sample, all frailty and comorbidity measures were associated with higher COVID-19 mortality risk after adjusting for age and sex. However, the associations were stronger for the concurrent versus baseline HFRS and CCI, with odds ratios of 20.40 (95% confidence interval = 16.24-25.63) comparing high (>15) to low (<5) concurrent HFRS risk category and 1.53 (1.48-1.59) per point increase in concurrent CCI. Moreover, only the concurrent HFRS or CCI significantly improved predictive ability of a model including age and sex, yielding areas under the receiver operating characteristic curve (AUC) >0.8. When restricting analyses to COVID-19 inpatients, similar improvement in AUC was not observed.

CONCLUSION

HFRS and CCI constructed from medical records concurrent with the start of the pandemic can be used in COVID-19 mortality risk stratification at the population level, but they show limited added value in COVID-19 inpatients.

Smoking and COVID-19: A Literature Review of Cohort Studies in Non-Chinese Population Settings

BACKGROUND

Smoking history and its potential association with COVID-19 has attracted many researchers and the lay public alike. However, the studies published to date have several methodological limitations and are mainly from China. We set out to synthesize evidence on smoking and COVID-19 relationship drawn on cohort studies only which are published in non-Chinese population settings.

METHOD

A systematic literature search was undertaken drawn on predefined eligibility criteria and a comprehensive search strategy following the PRISMA guideline between January 2020 and August 2020, excluding preprints and gray literature. Three specific outcomes were examined: smoking history, SARS-CoV2 infection, and COVID-19 severity.

RESULTS

Of an eligible 40 full-text studies, 7 cohort studies outside of China were finally included in this literature review through independent reviewing. Four studies were from the UK, 2 from the United States, and 1 from Turkey. The sample size ranged from 200 to more than 5000 participants. The findings broadly point to 1 direction, a higher smoking prevalence and an increased risk of smoking history on both SARS-CoV2 infection and on COVID-19 severity.

CONCLUSION

A smoking history (either current or past) seems to negatively impact both SARS-CoV2 infection and COVID-19 severity. However, such an observation strengthens the argument to continue smoking cessation efforts both for individuals and for the general population health and well-being.

The Impact of Frailty on COVID-19 Outcomes: A Systematic Review and Meta-analysis of 16 Cohort Studies

BACKGROUND

Frail patients are increasingly vulnerable to stress, which is mainly manifested by a reduced physiologic reserve in metabolic and immune systems and neuromuscular system. Several studies found a significant association of frailty with COVID-19 severity to support the evidence for the application of frailty assessment. However, there were contradictory results in other studies. Thus we conducted a systematic review and meta-analysis to synthesize the current studies to investigate impact of frailty on COVID-19 outcomes and provide evidence-based decisions in clinical practice.

OBJECTIVE

We aimed to synthesize the current studies to investigate impact of frailty on COVID-19 outcomes and provide evidence-based decisions in clinical practice.

DESIGN

A systematic review and Meta-analysis of 16 cohort studies.

PARTICIPANTS

Patients with COVID-19.

METHODS

A systematic retrieving for potential literature was conducted in several public electronic databases, including Medline(OvidSP), EMBASE, Pubmed and Chinese databases(China National Knowledge Infrastructure,Wanfang and Weipu) on August 1, 2020.The literature research was updated on October 26, 2020. Newcastle Ottawa Scale for cohort studies was used for quality assessment. RevMan (Version 5.3) and Stata 14.0 were used to synthesize the pooled effects.

RESULTS

According to the predefined inclusion and exclusion criteria, sixteen studies of 4324 patients were included in the final analysis. Frailty was significantly associated with increased risk of all-cause mortality among patients with COVID-19, with pooled adjusted odds ratios of 1.81 (95% confidence intervals:1.48,2.21, I2=87.0%, P<0.001). The result was consistent in stratified analysis to according to age, patient source, definitions of frailty, study quality, and adjustment method. Frailty was significant associated with an increased risk of COVID-19 severity, admission to intensive care unit, application of invasive mechanical ventilation, long-length stay.

CONCLUSIONS

In this meta-analysis, we found frailty was significantly associated with an increased risk of clinical adverse events (all- cause mortality, COVID-19 severity, admission to the intensive care unit, application of invasive mechanical ventilation, long-length stay). Given the epidemic of COVID-19 and shortage of medical resources, paying more attention to screening frailty would contribute to disease management and resource allocation among patients with COVID-19.

Modifiable and non-modifiable risk factors for COVID-19, and comparison to risk factors for influenza and pneumonia: results from a UK Biobank prospective cohort study

OBJECTIVES

We aimed to investigate demographic, lifestyle, socioeconomic and clinical risk factors for COVID-19, and compared them to risk factors for pneumonia and influenza in UK Biobank.

DESIGN

Cohort study.

SETTING

UK Biobank.

PARTICIPANTS

49-83 year olds (in 2020) from a general population study.

MAIN OUTCOME MEASURES

Confirmed COVID-19 infection (positive SARS-CoV-2 test). Incident influenza and pneumonia were obtained from primary care data. Poisson regression was used to study the association of exposure variables with outcomes.

RESULTS

Among 235 928 participants, 397 had confirmed COVID-19. After multivariable adjustment, modifiable risk factors were higher body mass index and higher glycated haemoglobin (HbA1C) (RR 1.28 and RR 1.14 per SD increase, respectively), smoking (RR 1.39), slow walking pace as a proxy for physical fitness (RR 1.53), and use of blood pressure medications as a proxy for hypertension (RR 1.33). Higher forced expiratory volume in 1 s (FEV1) and high-density lipoprotein (HDL) cholesterol were both associated with lower risk (RR 0.84 and RR 0.83 per SD increase, respectively). Non-modifiable risk factors included male sex (RR 1.72), black ethnicity (RR 2.00), socioeconomic deprivation (RR 1.17 per SD increase in Townsend Index), and high cystatin C (RR 1.13 per SD increase). The risk factors overlapped with pneumonia somewhat, less so for influenza. The associations with modifiable risk factors were generally stronger for COVID-19, than pneumonia or influenza.

CONCLUSION

These findings suggest that modification of lifestyle may help to reduce the risk of COVID-19 and could be a useful adjunct to other interventions, such as social distancing and shielding of high risk.

Impact of SARS-CoV-2 on Male Reproductive Health: A Review of the Literature on Male Reproductive Involvement in COVID-19

Coronavirus Disease 2019 (COVID-19) has created a global pandemic. Global epidemiological results show that elderly men are susceptible to infection of COVID-19. The difference in the number of cases reported by gender increases progressively in favor of male subjects up to the age group ≥60-69 (66.6%) and ≥70-79 (66.1%). Through literature search and analysis, we also found that men are more susceptible to SARS-CoV-2 infection than women. In addition, men with COVID-19 have a higher mortality rate than women. Male represents 73% of deaths in China, 59% in South Korea, and 61.8% in the United States. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the pathogen of COVID-19, which is transmitted through respiratory droplets, direct and indirect contact. Genomic analysis has shown that SARS-CoV-2 is 79% identical to SARS-CoV, and both use angiotensin-converting enzyme 2 (ACE2) as the receptor for invading cells. In addition, Transmembrane serine protease 2 (TMPRSS2) can enhance ACE2-mediated virus entry. However, SARS-CoV-2 has a high affinity with human ACE2, and its consequences are more serious than other coronaviruses. ACE2 acts as a "gate" for viruses to invade cells and is closely related to the clinical manifestations of COVID-19. Studies have found that ACE2 and TMPRSS2 are expressed in the testis and male reproductive tract and are regulated by testosterone. Mature spermatozoon even has all the machinery required to bind SARS-CoV-2, and these considerations raise the possibility that spermatozoa could act as potential vectors of this highly infectious disease. This review summarizes the gender differences in the pathogenesis and clinical manifestations of COVID-19 and proposes the possible mechanism of orchitis caused by SARS-CoV-2 and the potential transmission route of the virus. In the context of the pandemic, these data will improve the understanding of the poor clinical outcomes in male patients with COVID-19 and the design of new strategies to prevent and treat SARS-CoV-2 infection.

COVID-19 and associations with frailty and multimorbidity: a prospective analysis of UK Biobank participants

BACKGROUND

Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease.

AIMS

We investigated, in the UK Biobank, whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19.

METHODS

502,640 participants aged 40-69 years at baseline (54-79 years at COVID-19 testing) were recruited across UK during 2006-10. A modified assessment of frailty using Fried's classification was generated from baseline data. COVID-19 test results (England) were available for 16/03/2020-01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, after adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups.

RESULTS

4510 participants were tested for COVID-19 (positive = 1326, negative = 3184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥ 4 comorbidity groupings vs 0-1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. However, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants.

DISCUSSION AND CONCLUSIONS

Frailty and multimorbidity do not appear to aid risk stratification, in terms of positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.