A higher BMI is not associated with a different immune response and disease course in critically ill COVID-19 patients

Association of obesity and the clinical course of hospitalised COVID-19 survivors

Obesity is a risk factor for chronic inflammation and severe pulmonary infections. This study aimed to assess the association between obesity and the clinical courses of hospitalised COVID-19 survivors. This cross-sectional study used the Isfahan COVID Cohort (ICC) baseline data. The ICC is an ongoing, 5-year prospective, longitudinal cohort study conducted on hospitalised COVID-19 survivors in affiliated hospitals of the Medical University of Isfahan (MUI), Iran. Patients aged 19 and over throughout Isfahan County were recruited using a consecutive sampling method 1 month after discharge. Demographic and basic characteristics, symptoms and clinical features of these patients were collected and analysed. A total of 3843 hospitalised patients with COVID-19 were included in this study. Regarding the body mass index classification in the general obesity group, the patients with overweight and obesity had more extended hospitalisation and a higher frequency of low O2 saturation compared to the normal weight patients, and the highest frequency of low O2 saturation and more extended hospitalisation was observed in patients with obesity (5.9 ± 3.8 vs. 6.8 ± 5.4 vs. 7.1 ± 5.3, respectively; p = .001 and 59% vs. 64.5% vs. 65.5%; p < .001). Furthermore, individuals with abdominal obesity had a significantly longer duration of hospitalisation compared to the non-abdominal obesity group (6.3 ± 4.6 vs. 7.0 ± 5.3; p < .001). In the fully adjusted model, a significant association was observed between abdominal obesity and an increased occurrence of low oxygen saturation compared to general obesity (odds ratio: 1.25, 95% confidence interval: 1.03-1.44). Obesity was associated with more extended hospitalisation and hypoxia in patients with COVID-19. However, no significant relationship was found between obesity and other clinical courses.

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Obesity and diabetes mellitus are associated with SARS-CoV-2 outcomes without influencing signature genes of extrapulmonary immune compartments at the RNA level

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for eliciting Coronavirus disease 2019 (COVID-19) still challenges healthcare services worldwide. While many patients only suffer from mild symptoms, patients with some pre-existing medical conditions are at a higher risk for a detrimental course of disease. However, the underlying mechanisms determining disease course are only partially understood. One key factor influencing disease severity is described to be immune-mediated. In this report, we describe a post-mortem analysis of 45 individuals who died from SARS-CoV-2 infection. We could show that although sociodemographic factors and premedical conditions such as obesity and diabetes mellitus reduced survival time in our cohort, they were not associated with changes in the expression of immune-related signature genes at the RNA level in the blood, the gut, or the liver between these different groups. Our data indicate that obesity and diabetes mellitus influence SARS-CoV-2-related mortality, without influencing the extrapulmonary gene expression of immunity-related signature genes at the RNA level.

Body Mass Index as a Major Prognostic Contributing Factor in COVID-19: A Multicentral Egyptian Study

Background

Extreme body mass index (BMI) is an influential pathophysiological risk factor for serious illnesses following lower respiratory tract infection. The purpose of the current study was to examine how the BMI of Coronavirus disease-19 (COVID-19) patients affects their prognosis.

Methods

Two hundred patients with COVID-19 admitted to Al-Azhar, Qena, Aswan, and Sohag University hospitals in Egypt were included and categorized into four groups according to their BMI. The diagnosis was made according to a real-time reverse transcription-polymerase chain reaction (rRT-PCR) positive result for the SARS-CoV-2 nucleic acid in swabs from upper respiratory tract. A detailed history, clinical examination, and outcomes (disease severity and complications, hospital stay, ICU admission, mortality) were recorded for all patients. SPSS version 24 software was used for data analysis.

Results

Average age of participants (19-90 years old), 92 (46%) males and 108 females (54%). ICU admission was significantly higher among underweight patients (75%) and obese patients (78.6%). The majority of underweight (62.5%) and obese (57.1%) patients had critical disease. Invasive mechanical ventilation (MV) is frequently used in underweight (50%) and obese patients (42.9%) patients. Adult respiratory distress syndrome (ARDS), cardiac, neurological, and hematological complications, and incidence of myalgia and bed sores were most frequent among obese and overweight patients. Acute kidney injury was significantly higher among underweight patients (37.5%) and obese patients (28.6%) than among other classes (p=0.004). Frequency of endocrine complications was significantly higher in underweight patients than that in other classes (p=0.01). The majority of underweight (75%) and obese patients (50%) deteriorated and died, whereas the majority of normal-weight patients (90.3%) and overweight patients (75.8%) improved and were discharged (p< 0.001).

Conclusion

Body mass index is a major contributing factor to the outcome of patients with COVID-19, and patients with extreme of body mass index were associated with the worst prognosis.

Obesity in Severe COVID-19 Patients Has a Distinct Innate Immune Phenotype

Obesity alters the capacity of effective immune responses in infections. To further address this phenomenon in the context of COVID-19, this study investigated how the immunophenotype of leukocytes was altered in individuals with obesity in severe COVID-19. This cross-sectional study enrolled 27 ICU COVID-19 patients (67% women, 56.33 ± 19.55 years) that were assigned to obese (BMI ≥ 30 kg/m2, n = 9) or non-obese (BMI < 30kg/m2, n = 18) groups. Monocytes, NK, and both Low-Density (LD) and High-Density (HD) neutrophils were isolated from peripheral blood samples, and surface receptors' frequency and expression patterns were analyzed by flow cytometry. Clinical status and biochemical data were additionally evaluated. The frequency of monocytes was negatively correlated with BMI, while NK cells and HD neutrophils were positively associated (p < 0.05). Patients with obesity showed a significant reduction of monocytes, and these cells expressed high levels of PD-L1 (p < 0.05). A higher frequency of NK cells and increased expression of TREM-1+ on HD neutrophils were detected in obese patients (p < 0.05). The expression of receptors related to antigen-presentation, phagocytosis, chemotaxis, inflammation and suppression were strongly correlated with clinical markers only in obese patients (p < 0.05). Collectively, these outcomes revealed that obesity differentially affected, and largely depressed, innate immune response in severe COVID-19.

THE ROLE OF OBESITY AND PLASMA ADIPOCYTOKINES IN IMMUNE DYSREGULATION IN SEPSIS PATIENTS

Introduction: The dysregulated immune response in sepsis is highly variable, ranging from hyperinflammation to immunoparalysis. Obesity is associated with the release of inflammatory mediators from adipose tissue, known as adipocytokines, causing a chronic inflammatory state. Perhaps counterintuitively, obesity is also associated with lower mortality in sepsis patients. We investigated the association between obesity, circulating adipocytokine concentrations, immune dysregulation, and outcome in sepsis patients. Methods In this secondary analysis of a prospective study, plasma concentrations of the adipocytokines leptin, adiponectin, and resistin were assessed in 167 patients at diagnosis of sepsis due to pneumonia, bacteremia, or acute cholangitis. Adipocytokines were compared between patients with normal weight (body mass index [BMI], 18.5-24.9 kg/m 2 ; n = 67), overweight (BMI, 25.0-29.9 kg/m 2 ; n = 56), and obesity (BMI ≥30 kg/m 2 ; n = 42), as well as between immunological endotypes: hyperinflammation (n = 40), immunoparalysis (n = 62), and unclassified (n = 55). Results: Higher circulating concentrations of leptin were observed in patients with obesity compared with patients with normal weight ( P = 0.008) and overweight ( P = 0.02), whereas adiponectin and resistin plasma concentrations were not different ( P = 0.08 and P = 0.85, respectively). Resistin concentrations were associated with immunological endotypes, with the highest levels found in hyperinflammatory patients ( P < 0.001). Furthermore, resistin concentrations were predictive for 28-day mortality (adjusted odds ratio, 1.03 per 10 ng/mL; P = 0.04). These associations were not found for leptin and adiponectin. Conclusion: Obesity and BMI-related adipocytokines are not related to the development of a hyperactive or suppressed immune response as defined by ferritin and mHLA-DR expression in sepsis patients. Although resistin is related to the immune response and an increased risk of adverse clinical outcomes, these associations are similar in patients with normal weight, overweight, and obesity. This implies that the relationship between resistin and clinical outcome is likely driven by the inflammatory response and not by obesity itself. Taken together, although there exists a strong association between inflammation and sepsis mortality, our results do not point toward a role for obesity and BMI-related adipocytokines in immune dysregulation in sepsis patients.

GENETIC VARIANTS AND SERUM PROFILES OF CYTOKINES IN COVID-19 SEVERITY

ABSTRACT

Background: Patients with severe coronavirus disease 2019 (COVID-19) are at an increased risk of acute respiratory distress syndrome and mortality. This is due to the increased levels of pro-inflammatory cytokines that amplify downstream pathways that are controlled by immune regulators. Objective: This study aimed to investigate the association between cytokine genetic variants, cytokine serum levels/profiles, and disease severity in critically and noncritically ill COVID-19 patients. Methods: This cross-sectional study recruited 646 participants who tested positive for severe acute respiratory syndrome coronavirus 2 from six collection sites across the United Arab Emirates. Medical files were accessed to retrieve clinical data. Blood samples were collected from all participants. Patients were divided into two clinical groups, noncritical (n = 453) and critical (n = 193), according to World Health Organization classification guidelines for COVID-19 patients. Cytokine analyses were conducted on serum of a subset of the cohort, specifically on 426 participants (noncritical, 264; critical, 162). Candidate gene analyses of 33 cytokine-related genes (2,836 variants) were extracted from a genome-wide association study to identify genetic variants with pleiotropic effects on a specific cytokine and the severity of COVID-19 disease. Results: Age, body mass index (BMI), and pre-existing medical conditions were found to be significant risk factors that contribute to COVID-19 disease severity. After correcting for age, sex, and BMI, IP-10 ( P < 0.001), IFN ( P = 0.001), IL-6 ( P < 0.001), and CXCL-16 ( P < 0.001) serum levels were significantly higher among critical COVID-19 cases, when compared with noncritically ill patients. To investigate if the genetic variants involved in the serum cytokine levels are associated with COVID-19 severity, we studied several genes. Single nucleotide polymorphisms in IL6 (rs1554606; odd ratio (OR) G = 0.67 [0.66, 0.68]; P = 0.017), IFNG (rs2069718; OR G = 0.63 [0.62, 0.64]; P = 0.001), MIP (rs799187; OR A = 1.69 [1.66, 1.72]; P = 0.034), and CXCL16 (rs8071286; OR A = 1.42 [1.41, 1.44]; P = 0.018) were found to be associated with critically ill patients. Polymorphisms in the CXCL10 , CCL2 , IL1 , CCL7 , and TNF genes were not associated with the COVID-19 critical phenotype. The genotypes of IL-6 (gene, IL6 [7p15.3]) and CXCL-16 (gene, CXCL16 [17p13.2]) were significantly associated with the serum levels of the respective cytokine in critical cases of COVID-19. Conclusion: Data obtained from measuring cytokine levels and genetic variant analyses suggest that IL-6 and CXCL-16 could potentially be used as potential biomarkers for monitoring disease progression of COVID-19 patients. The findings in this study suggest that specific cytokine gene variants correlate with serum levels of the specific cytokine. These genetic variants could be of assistance in the early identification of high-risk patients on admission to the clinic to improve the management of COVID-19 patients and other infectious diseases.

Body Mass Index and Clinical Outcomes in Adult COVID-19 Patients of Diverse Ethnicities

(1) Background: Body mass index (BMI) was observed to affect COVID-19 outcomes; however, the complete spectrum of clinical outcomes concerning BMI remains unexplored. The current study aimed to investigate the correlation between BMI and the severity and mortality of COVID-19, as well as ICU admission, radiological findings, clinical presentation, and time to viral clearance. (2) Methods: This retrospective study included 1796 multiethnic patients with COVID-19 treated at NMC Royal Hospital, Abu Dhabi, UAE. (3) Results: COVID-19’s adjusted odds of severity increased by 3.7- and 21.5-fold in classes I and III, respectively (p = 0.001). The odds of mortality were not significantly different after adjustment for age, sex, and race. The adjusted odds of ICU admission increased significantly by 3-fold and non-significantly by 4-fold in obesity classes I and II, respectively. Pneumonia was significantly higher in patients who were overweight and class I, II, and III obese. Furthermore, class III obese patients had a greater risk of presenting with combined respiratory and gastrointestinal manifestations (p < 0.001). The median time to viral clearance with a BMI > 40 kg/m2 was moderately higher than that with a BMI < 40 kg/m2. (4) Conclusions: High BMI was associated with pneumonia, ICU admission, severity, and mortality due to COVID-19.

Nutritional risk, not obesity, is associated with mortality in critically ill COVID-19 patients

Background

Despite the identification of obesity as a risk factor for higher rates of hospital and Intensive Care Unit (ICU) admissions and complications due to COVID-19, the association between obesity and mortality in critically ill COVID-19 patients remains controversial, and the nutritional risk is little considered. Hence, our study sought to evaluate the association between obesity, nutritional risk, and mortality in critically ill patients diagnosed with COVID-19.

Methods

Retrospective study were condutcted including adult critically ill COVID-19 patients admitted to an ICU between April 2020 and March 2021. Clinical and laboratory data were collected from electronic medical records. Obesity was classified by body mass index ≥ 30 kg/m^2. A mNUTRIC score of ≥ 5 indicated high nutritional risk. Multiple Cox Regression was used to estimate the association between mNUTRIC, obesity, and mortality.

Results

From 71 patients aged 59 (± 15) years, 71.8 % were male. The frequencies of obesity (58.7 %) and death (49.3 %) were high, but obesity was not associated with mortality. Based on mNUTRIC, 85.9 % of patients were at high nutritional risk, presenting a higher frequency of mortality than patients at low nutritional risk (50.8 % vs 40.0 %; p = 0.014). Multiple Cox Regression showed that for each unit increase in mNUTRIC score the probability of death almost doubled, regardless of the presence of obesity (HR = 1.74; p < 0.001).

Conclusions

A higher nutritional risk was positively associated with mortality in critically ill COVID-19 patients, regardless of obesity, showing the importance of early identification of nutritional risk for appropriate nutritional interventions in this population.

Mid-regional proadrenomedullin, C-terminal proendothelin-1 values, and disease course are not different in critically ill SARS-CoV-2 pneumonia patients with obesity

Background/objectives

Patients affected by obesity and Coronavirus disease 2019, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), appear to have a higher risk for intensive care (ICU) admission. A state of low-grade chronic inflammation in obesity has been suggested as one of the underlying mechanisms. We investigated whether obesity is associated with differences in new inflammatory biomarkers mid-regional proadrenomedullin (MR-proADM), C-terminal proendothelin-1 (CT-proET-1), and clinical outcomes in critically ill patients with SARS-CoV-2 pneumonia.

Subjects/methods

A total of 105 critically ill patients with SARS-CoV-2 pneumonia were divided in patients with obesity (body mass index (BMI) ≥ 30 kg/m², n = 42) and patients without obesity (BMI < 30 kg/m², n = 63) and studied in a retrospective observational cohort study. MR-proADM, CT-proET-1 concentrations, and conventional markers of white blood count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) were collected during the first 7 days.

Results

BMI was 33.5 (32–36.1) and 26.2 (24.7–27.8) kg/m² in the group with and without obesity. There were no significant differences in concentrations MR-proADM, CT-proET-1, WBC, CRP, and PCT at baseline and the next 6 days between patients with and without obesity. Only MR-proADM changed significantly over time (p = 0.039). Also, BMI did not correlate with inflammatory biomarkers (MR-proADM rho = 0.150, p = 0.125, CT-proET-1 rho = 0.179, p = 0.067, WBC rho = −0.044, p = 0.654, CRP rho = 0.057, p = 0.564, PCT rho = 0.022, p = 0.842). Finally, no significant differences in time on a ventilator, ICU length of stay, and 28-day mortality between patients with or without obesity were observed.

Conclusions

In critically ill patients with confirmed SARS-CoV-2 pneumonia, obesity was not associated with differences in MR-proADM, and CT-proET-1, or impaired outcome.

Trial registration

Netherlands Trial Register, NL8460.

Association of Obesity With COVID-19 Severity and Mortality: An Updated Systemic Review, Meta-Analysis, and Meta-Regression

Background

Obesity affects the course of critical illnesses. We aimed to estimate the association of obesity with the severity and mortality in coronavirus disease 2019 (COVID-19) patients.

Data Sources

A systematic search was conducted from the inception of the COVID-19 pandemic through to 13 October 2021, on databases including Medline (PubMed), Embase, Science Web, and Cochrane Central Controlled Trials Registry. Preprint servers such as BioRxiv, MedRxiv, ChemRxiv, and SSRN were also scanned.

Study Selection and Data Extraction

Full-length articles focusing on the association of obesity and outcome in COVID-19 patients were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for study selection and data extraction. Our Population of interest were COVID-19 positive patients, obesity is our Intervention/Exposure point, Comparators are Non-obese vs obese patients The chief outcome of the study was the severity of the confirmed COVID-19 positive hospitalized patients in terms of admission to the intensive care unit (ICU) or the requirement of invasive mechanical ventilation/intubation with obesity. All-cause mortality in COVID-19 positive hospitalized patients with obesity was the secondary outcome of the study.

Results

In total, 3,140,413 patients from 167 studies were included in the study. Obesity was associated with an increased risk of severe disease (RR=1.52, 95% CI 1.41-1.63, p<0.001, I2 = 97%). Similarly, high mortality was observed in obese patients (RR=1.09, 95% CI 1.02-1.16, p=0.006, I2 = 97%). In multivariate meta-regression on severity, the covariate of the female gender, pulmonary disease, diabetes, older age, cardiovascular diseases, and hypertension was found to be significant and explained R2 = 40% of the between-study heterogeneity for severity. The aforementioned covariates were found to be significant for mortality as well, and these covariates collectively explained R2 = 50% of the between-study variability for mortality.

Conclusions

Our findings suggest that obesity is significantly associated with increased severity and higher mortality among COVID-19 patients. Therefore, the inclusion of obesity or its surrogate body mass index in prognostic scores and improvement of guidelines for patient care management is recommended.

Comparing body mass index and obesity-related comorbidities as predictors in hospitalized COVID-19 patients

The association between body mass index (BMI) and poor COVID-19 outcomes in patients has been demonstrated across numerous studies. However, obesity-related comorbidities have also been shown to be associated with poor outcomes. The purpose of this study was to determine whether BMI or obesity-associated comorbidities contribute to elevated COVID-19 severity in non-elderly, hospitalized patients with elevated BMI (≥25 kg/m² ). This was a single-center, retrospective cohort study of 526 hospitalized, non-elderly adult (aged 18-64) COVID-19 patients with BMI ≥25 kg/m² in suburban New York from March 6 to May 11, 2020. The Edmonton Obesity Staging System (EOSS) was used to quantify the severity of obesity-related comorbidities. EOSS was compared with BMI in multivariable regression analyses to predict COVID-19 outcomes. We found that higher EOSS scores were associated with poor outcomes after demographic adjustment, unlike BMI. Specifically, patients with increased EOSS scores had increased odds of acute kidney injury (adjusted odds ratio [aOR] = 6.40; 95% CI 3.71-11.05), intensive care unit admission (aOR = 10.71; 95% CI 3.23-35.51), mechanical ventilation (aOR = 3.10; 95% CI 2.01-4.78) and mortality (aOR = 5.05; 95% CI 1.83-13.90). Obesity-related comorbidity burden as determined by EOSS was a better predictor of poor COVID-19 outcomes relative to BMI, suggesting that comorbidity burden may be driving risk in those hospitalized with elevated BMI.

Body mass index and its association with COVID-19 clinical outcomes: Findings from the Philippine CORONA study

Background and aims

To explore the association between body mass index (BMI) and adverse outcomes in a large cohort of patients with coronavirus disease 2019 (COVID-19).

Methods

This is a secondary analysis of a 37-site, nationwide, multicenter, retrospective cohort study that investigated the clinical and neurological outcomes of adult patients with confirmed COVID-19 admitted from February to December 15, 2020.

Results

We analyzed 4,463 patients with BMI and outcome data. A total of 790 (17.7%) and 710 (15.9%) had the primary outcome of in-hospital mortality and need for invasive mechanical ventilation (IMV), respectively. There was no significant association between WHO BMI groups and these outcomes. Using Asia-Pacific cutoffs showed a significant association between obesity and in-hospital mortality risk (P = 0.012). Being underweight was an independent predictor of prolonged IMV requirement regardless of BMI criteria used (P < 0.01). Obesity correlated with the need for intensive care unit admission using Asia-Pacific cutoffs (P = 0.029). There was a significant association between any BMI abnormality and odds of severe/critical COVID-19 (P < 0.05). Obese patients with concomitant acute neurological presentation/diagnosis during their COVID-19 admission were shown to have lower odds of neurologic recovery (P < 0.05).

Conclusions

We found BMI abnormalities to be associated with several adverse clinical and neurologic outcomes, although such associations may be more evident with the use of race-specific BMI criteria.

Geraniin inhibits whole blood IFN-γ and IL-6 and promotes IL-1β and IL-8, and stimulates calcium-dependent and sucrose-sensitive erythrocyte death

Correlations between circulating cytokine levels and disease states are well established, and pharmacological modulation of the immune response is thus an important aspect of the assessment of investigational new drugs. Moreover, chemotherapy-related anemia is a major obstacle in cancer treatment. Geraniin (GRN), a tannin extracted from Geranium and other plants, possesses promising antitumor potential. However, the effect of GRN on whole blood (WB) cytokine response and RBC physiology remains unexplored. Heparinized blood from consented, healthy adults was challenged with 100 ng/mL of lipopolysaccharide (LPS) with and without pretreatment with 10 μM of GRN for 24 h at 37 °C, and tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-6, IL-8, and IL-10 were assayed by ELISA. Moreover, single-cell RBC suspensions were treated with 5-100 μM of GRN for 24 or 48 h at 37 °C and cytotoxicity and canonical eryptotic markers were examined by flow cytometry. It was revealed that GRN significantly attenuated LPS-induced IFN-γ levels, increased IL-1β, decreased IL-6 only in absence of LPS, and aggravated LPS-induced IL-8 while together with LPS significantly diminished IL-10. Furthermore, GRN induced dose-responsive, Ca²⁺-dependent, and sucrose-sensitive hemolysis, along with phosphatidylserine exposure and Ca²⁺ accumulation with no appreciable cell shrinkage or oxidative damage. GRN was also selectively toxic to platelets, significantly delayed reticulocyte maturation, and significantly disrupted leukocyte proportions. In conclusion, GRN regulates the WB cytokine response and promotes premature hemolysis and eryptosis. This study provides insights into the therapeutic utility of GRN in a highly relevant cellular model system.

Association Between Obesity and COVID-19 Disease Severity in Saudi Population

BACKGROUND

The persistent coronavirus disease 2019 (COVID-19) outbreak has placed a significant burden on the scientific and medical professions. The study examined the association between body mass index (BMI), stratified by category, and severe form of COVID-19, and to explore the influence of demographic characteristics and other known risk factors.

METHODS

This was a retrospective analysis based on COVID-19 data from the Saudi Arabian Ministry of Health. Data were collected for all patients admitted to three main hospitals in Riyadh region between March 1st and July 30, 2020. The effects of BMI, demographic characteristics, clinical presentation, and comorbidities on infection severity were investigated.

RESULTS

A total of 950 patients were included in the study (70% male, 85% aged younger than 60 years old). A total of 55 (5.8%) patients were underweight, 263 (27.7%) were normal weight, 351 (37%) were overweight, 161 (17%) were obese class I, 76 (8%) were obese class II, and 44 (4.6%) were obese class III. Cough, fever, and shortness of breath were the most common symptoms among overweight patients. According to the findings of a bivariate logistic regression study, class III obesity was significantly associated with a more severe form of COVID-19 (odds ratio, 2.874; 95% confidence interval, 1.344-6.149).

CONCLUSION

This study revealed that patients with a BMI ≥40 kg/m² had a higher risk of severe COVID-19 than those with normal weight. This suggests that obesity is a risk factor for severe COVID-19 and influences disease presentation.

Predictors for extubation failure in COVID-19 patients using a machine learning approach

INTRODUCTION

Determining the optimal timing for extubation can be challenging in the intensive care. In this study, we aim to identify predictors for extubation failure in critically ill patients with COVID-19.

METHODS

We used highly granular data from 3464 adult critically ill COVID patients in the multicenter Dutch Data Warehouse, including demographics, clinical observations, medications, fluid balance, laboratory values, vital signs, and data from life support devices. All intubated patients with at least one extubation attempt were eligible for analysis. Transferred patients, patients admitted for less than 24 h, and patients still admitted at the time of data extraction were excluded. Potential predictors were selected by a team of intensive care physicians. The primary and secondary outcomes were extubation without reintubation or death within the next 7 days and within 48 h, respectively. We trained and validated multiple machine learning algorithms using fivefold nested cross-validation. Predictor importance was estimated using Shapley additive explanations, while cutoff values for the relative probability of failed extubation were estimated through partial dependence plots.

RESULTS

A total of 883 patients were included in the model derivation. The reintubation rate was 13.4% within 48 h and 18.9% at day 7, with a mortality rate of 0.6% and 1.0% respectively. The grandient-boost model performed best (area under the curve of 0.70) and was used to calculate predictor importance. Ventilatory characteristics and settings were the most important predictors. More specifically, a controlled mode duration longer than 4 days, a last fraction of inspired oxygen higher than 35%, a mean tidal volume per kg ideal body weight above 8 ml/kg in the day before extubation, and a shorter duration in assisted mode (< 2 days) compared to their median values. Additionally, a higher C-reactive protein and leukocyte count, a lower thrombocyte count, a lower Glasgow coma scale and a lower body mass index compared to their medians were associated with extubation failure.

CONCLUSION

The most important predictors for extubation failure in critically ill COVID-19 patients include ventilatory settings, inflammatory parameters, neurological status, and body mass index. These predictors should therefore be routinely captured in electronic health records.

Pandemics of the 21st Century: The Risk Factor for Obese People

The number of obese adults and children is increasing worldwide, with obesity now being a global epidemic. Around 2.8 million people die annually from clinical overweight or obesity. Obesity is associated with numerous comorbid conditions including hypertension, cardiovascular disease, type 2 diabetes, hypercholesterolemia, hypertriglyceridemia, nonalcoholic fatty liver disease, and cancer, and even the development of severe disease after infection with viruses. Over the past twenty years, a number of new viruses has emerged and entered the human population. Moreover, influenza (H1N1)pdm09 virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have caused pandemics. During pandemics, the number of obese patients presents challenging and complex issues in medical and surgical intensive care units. Morbidity amongst obese individuals is directly proportional to body mass index. In this review, we describe the impact of obesity on the immune system, adult mortality, and immune response after infection with pandemic influenza virus and SARS-CoV-2. Finally, we address the effect of obesity on vaccination.

Update on neurological symptoms in patients infected with severe acute respiratory syndrome coronavirus-2

Novel coronavirus 19 (COVID-19) is the latest and most intense epidemic, which is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In addition to causing respiratory symptoms, SARS-CoV-2 can have severe effects on the nervous system. Clinically, COVID-19 patients have been reported ranging from mild hypogeusia and hyposmia to severe neurological disorders, such as encephalopathy, encephalitis, strokes, and seizures syndrome. However, the pathological mechanisms of this SARS-CoV-2 neuro aggressiveness remain unclear, so it is of great significance to explore the neurological effects of SARS-CoV-2 infection. To facilitate clinicians to timely recognize the manifestations of COVID-19 patients with neurological injury and timely treatment, the author hereby reviews the latest research progress in the possible pathways, clinical manifestations, and pathogenesis of COVID-19 patients with nerve injury.

Coronavirus Disease 2019 as Cause of Viral Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

Coronavirus disease 2019 is a heterogeneous disease most frequently causing respiratory tract infection, which can induce respiratory failure and multiple organ dysfunction syndrome in its severe forms. The prevalence of coronavirus disease 2019-related sepsis is still unclear; we aimed to describe this in a systematic review.

DATA SOURCES

MEDLINE (PubMed), Cochrane, and Google Scholar databases were searched based on a prespecified protocol (International Prospective Register for Systematic Reviews: CRD42020202018).

STUDY SELECTION

Studies reporting on patients with confirmed coronavirus disease 2019 diagnosed with sepsis according to sepsis-3 or according to the presence of infection-related organ dysfunctions necessitating organ support/replacement were included in the analysis. The primary end point was prevalence of coronavirus disease 2019-related sepsis among adults hospitalized in the ICU and the general ward. Among secondary end points were the need for ICU admission among patients initially hospitalized in the general ward and the prevalence of new onset of organ dysfunction in the ICU. Outcomes were expressed as proportions with respective 95% CI.

DATA EXTRACTION

Two reviewers independently screened and reviewed existing literature and assessed study quality with the Newcastle-Ottawa Scale and the Methodological index for nonrandomized studies.

DATA SYNTHESIS

Of 3,825 articles, 151 were analyzed, only five of which directly reported sepsis prevalence. Noting the high heterogeneity observed, coronavirus disease 2019-related sepsis prevalence was 77.9% (95% CI, 75.9-79.8; I2 = 91%; 57 studies) in the ICU, and 33.3% (95% CI, 30.3-36.4; I2 = 99%; 86 studies) in the general ward. ICU admission was required for 17.7% (95% CI, 12.9-23.6; I2 = 100%) of ward patients. Acute respiratory distress syndrome was the most common organ dysfunction in the ICU (87.5%; 95% CI, 83.3-90.7; I2 = 98%).

CONCLUSIONS

The majority of coronavirus disease 2019 patients hospitalized in the ICU meet Sepsis-3 criteria and present infection-associated organ dysfunction. The medical and scientific community should be aware and systematically report viral sepsis for prognostic and treatment implications.

Factors Associated with 90-Day Mortality in Invasively Ventilated Patients with COVID-19 in Marseille, France

Objectives: To describe clinical characteristics and management of intensive care units (ICU) patients with laboratory-confirmed COVID-19 and to determine 90-day mortality after ICU admission and associated risk factors. Methods: This observational retrospective study was conducted in six intensive care units (ICUs) in three university hospitals in Marseille, France. Between 10 March and 10 May 2020, all adult patients admitted in ICU with laboratory-confirmed SARS-CoV-2 and respiratory failure were eligible for inclusion. The statistical analysis was focused on the mechanically ventilated patients. The primary outcome was the 90-day mortality after ICU admission. Results: Included in the study were 172 patients with COVID-19 related respiratory failure, 117 of whom (67%) received invasive mechanical ventilation. 90-day mortality of the invasively ventilated patients was 27.4%. Median duration of ventilation and median length of stay in ICU for these patients were 20 (9–33) days and 29 (17–46) days. Mortality increased with the severity of ARDS at ICU admission. After multivariable analysis was carried out, risk factors associated with 90-day mortality were age, elevated Charlson comorbidity index, chronic statins intake and occurrence of an arterial thrombosis. Conclusion: In this cohort, age and number of comorbidities were the main predictors of mortality in invasively ventilated patients. The only modifiable factor associated with mortality in multivariate analysis was arterial thrombosis.

Explaining the unexpected COVID-19 trends and potential impact across Africa

Official COVID-19 case counts and mortality rates across Africa are lower than had been anticipated. Research reports, however, indicate far higher exposure rates than the official counts in some countries. Particularly in Western and Central Africa, where mortality rates are disproportionately lower than the rest of the continent, this occurrence may be due to immune response adaptations resulting from (1) frequent exposure to certain pro-inflammatory pathogens, and (2) a prevalence of low-grade inflammation coupled with peculiar modifications to the immune response based on one's immunobiography. We suggest that the two factors lead to a situation where post infection, there is a rapid ramp-up of innate immune responses, enough to induce effective defense and protection against plethora pathogens. Alongside current efforts at procuring and distributing vaccines, we draw attention to the need for work towards appreciating the impact of the apparently widespread, asymptomatic SARS-CoV-2 infections on Africa's populations vis a vis systemic inflammation status and long-term consequences for public health.

Explaining the unexpected COVID-19 trends and potential impact across Africa

Official COVID-19 case counts and mortality rates across Africa are lower than had been anticipated. Research reports, however, indicate far higher exposure rates than the official counts in some countries. Particularly in Western and Central Africa, where mortality rates are disproportionately lower than the rest of the continent, this occurrence may be due to immune response adaptations resulting from (1) frequent exposure to certain pro-inflammatory pathogens, and (2) a prevalence of low-grade inflammation coupled with peculiar modifications to the immune response based on one's immunobiography. We suggest that the two factors lead to a situation where post infection, there is a rapid ramp-up of innate immune responses, enough to induce effective defense and protection against plethora pathogens. Alongside current efforts at procuring and distributing vaccines, we draw attention to the need for work towards appreciating the impact of the apparently widespread, asymptomatic SARS-CoV-2 infections on Africa's populations vis a vis systemic inflammation status and long-term consequences for public health.

Nutritional risk and clinical outcomes in critically ill adult patients with COVID-19

INTRODUCTION

the COVID-19 pandemic put the world's population at risk. As the relationship between nutritional risk and clinical outcomes in critically ill patients with COVID-19 is still poorly understood, a multidisciplinary research team of the Argentine Society of Intensive Care (SATI) conducted a multicenter study aimed to define nutritional features, and to evaluate the relationship between nutritional risk and relevant clinical outcomes for COVID-19 patients in an intensive care unit (ICU).

METHODS

a multicenter, prospective, observational study including twelve Argentinian ICUs was conducted between March and October 2020. Inclusion criteria were: adult patients older than 18 years who were admitted to the ICU with a COVID-19 diagnosis were included. Clinical data included comorbidities scores, and nutritional screening tools such as the Subjective Global Assessment (SGA), the Nutritional Risk Screening (NRS) 2002, and the modified NUTRIC score (mNUTRIC SCORE) were used. In addition, clinical outcomes including overall mortality, mechanical ventilation (MV) days, and ICU and hospital length of stay (LOS) were recorded.

RESULTS

a total of 285 ICU patients met our inclusion criteria. Mean age was 61.24 (SD = 14.6) years; APACHE-II, 14.2 (SD = 6.6); Charlson Comorbidity Index (CCI), 2.3 (SD = 2.3). Most patients were admitted from the emergency room to the ICU. Hypertension, obesity, and diabetes were the most common comorbidities. Nutritional assessment showed that 36.9 % were SGA B+C, and 46 % were obese. Mean ICU LOS was 22.2 (SD = 19.5), and hospital LOS was 28.1 (SD = 21.9) days. Of all patients, 90.2 % underwent MV, and MV days were 20.6 (SD = 15.6). The univariate and multivariate analyses showed that risk factors for COVID-19 mortality were (odds ratio [95 % confidence interval]): SGA score of B or C: 2.13 [1.11-4.06], and NRS 2002 ≥ 3: 2.25 [1.01-5.01].

CONCLUSIONS

in the present study, nutritional status (SGA) and NRS 2002 were major mortality risk factors for CODIV-19 patients in the ICU.

Body Mass Index and Mortality in Coronavirus Disease 2019 and Other Diseases: A Cohort Study in 35,506 ICU Patients

Supplemental Digital Content is available in the text.

OBJECTIVES:

Obesity is a risk factor for severe coronavirus disease 2019 and might play a role in its pathophysiology. It is unknown whether body mass index is related to clinical outcome following ICU admission, as observed in various other categories of critically ill patients. We investigated the relationship between body mass index and inhospital mortality in critically ill coronavirus disease 2019 patients and in cohorts of ICU patients with non-severe acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and multiple trauma.

DESIGN:

Multicenter observational cohort study.

SETTING:

Eighty-two Dutch ICUs participating in the Dutch National Intensive Care Evaluation quality registry.

PATIENTS:

Thirty-five–thousand five-hundred six critically ill patients.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Patient characteristics and clinical outcomes were compared between four cohorts (coronavirus disease 2019, nonsevere acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and multiple trauma patients) and between body mass index categories within cohorts. Adjusted analyses of the relationship between body mass index and inhospital mortality within each cohort were performed using multivariable logistic regression. Coronavirus disease 2019 patients were more likely male, had a higher body mass index, lower Pao₂/Fio₂ ratio, and were more likely mechanically ventilated during the first 24 hours in the ICU compared with the other cohorts. Coronavirus disease 2019 patients had longer ICU and hospital length of stay, and higher inhospital mortality. Odds ratios for inhospital mortality for patients with body mass index greater than or equal to 35 kg/m² compared with normal weight in the coronavirus disease 2019, nonsevere acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and trauma cohorts were 1.15 (0.79–1.67), 0.64 (0.43–0.95), 0.73 (0.61–0.87), and 0.81 (0.57–1.15), respectively.

CONCLUSIONS:

The obesity paradox, which is the inverse association between body mass index and mortality in critically ill patients, is not present in ICU patients with coronavirus disease 2019–related respiratory failure, in contrast to nonsevere acute respiratory syndrome coronavirus 2 viral and bacterial respiratory infections.

Obesity May Not Be Associated with 28-Day Mortality, Duration of Invasive Mechanical Ventilation and Length of Intensive Care Unit and Hospital Stay in Critically Ill Patients with Severe Acute Respiratory Syndrome Coronavirus-2: A Retrospective Cohort Study

Background and Objectives: The aim of this study was to investigate the association between obesity and 28-day mortality, duration of invasive mechanical ventilation and length of stay at the Intensive Care Unit (ICU) and hospital in patients admitted to the ICU for SARS-CoV-2 pneumonia. Materials and Methods: This was a retrospective observational cohort study in patients admitted to the ICU for SARS-CoV-2 pneumonia, in a single Dutch center. The association between obesity (body mass index > 30 kg/m²) and 28-day mortality, duration of invasive mechanical ventilation and length of ICU and hospital stay was investigated. Results: In 121 critically ill patients, pneumonia due to SARS-CoV-2 was confirmed by RT-PCR. Forty-eight patients had obesity (33.5%). The 28-day all-cause mortality was 28.1%. Patients with obesity had no significant difference in 28-day survival in Kaplan–Meier curves (log rank p 0.545) compared with patients without obesity. Obesity made no significant contribution in a multivariate Cox regression model for prediction of 28-day mortality (p = 0.124), but age and the Sequential Organ Failure Assessment (SOFA) score were significant independent factors (p < 0.001 and 0.002, respectively). No statistically significant correlation was observed between obesity and duration of invasive mechanical ventilation and length of ICU and hospital stay. Conclusion: One-third of the patients admitted to the ICU for SARS-CoV-2 pneumonia had obesity. The present study showed no relationship between obesity and 28-day mortality, duration of invasive mechanical ventilation, ICU and hospital length of stay. Further studies are needed to substantiate these findings.

Differential association between inflammatory cytokines and multiorgan dysfunction in COVID-19 patients with obesity

To investigate the mechanisms underlying the SARS-CoV-2 infection severity observed in patients with obesity, we performed a prospective study of 51 patients evaluating the impact of multiple immune parameters during 2 weeks after admission, on vital organs' functions according to body mass index (BMI) categories. High-dimensional flow cytometric characterization of immune cell subsets was performed at admission, 30 systemic cytokines/chemokines levels were sequentially measured, thirteen endothelial markers were determined at admission and at the zenith of the cytokines. Computed tomography scans on admission were quantified for lung damage and hepatic steatosis (n = 23). Abnormal BMI (> 25) observed in 72.6% of patients, was associated with a higher rate of intensive care unit hospitalization (p = 0.044). SARS-CoV-2 RNAaemia, peripheral immune cell subsets and cytokines/chemokines were similar among BMI groups. A significant association between inflammatory cytokines and liver, renal, and endothelial dysfunctions was observed only in patients with obesity (BMI > 30). In contrast, early signs of lung damage (ground-glass opacity) correlated with Th1/M1/inflammatory cytokines only in normal weight patients. Later lesions of pulmonary consolidation correlated with BMI but were independent of cytokine levels. Our study reveals distinct physiopathological mechanisms associated with SARS-CoV-2 infection in patients with obesity that may have important clinical implications.

Association between obesity and hospital mortality in critical COVID-19: a retrospective cohort study

BACKGROUND

The impact of obesity on outcomes in acute respiratory distress syndrome (ARDS) is not well understood and remains controversial. Recent studies suggest that obesity might be associated with higher morbidity and mortality in respiratory disease caused by SARS-CoV-2 (COVID-19 disease). Our objective was to evaluate the association between obesity and hospital mortality in critical COVID-19 patients.

METHODS

We conducted a retrospective cohort study in a tertiary academic center located in Montréal between March and August 2020. We included all consecutive adult patients admitted to the ICU for COVID-19-confirmed respiratory disease. Our main outcome was hospital mortality. We estimated the association between obesity, using the body mass index as a continuous variable, and hospital survival by fitting a multivariable Cox proportional hazards model.

RESULTS

We included 94 patients. Median [q1, q3] body mass index (BMI) was 29 [26-32] kg/m² and 37% of patients were obese (defined as BMI > 30 kg/m²). Hospital mortality for the entire cohort was 33%. BMI was significantly associated with hospital mortality (hazard ratio [HR] = 2.49 per 10 units BMI; 95% CI, from 1.69 to 3.70; p < 0.001) even after adjustment for sex, age and obesity-related comorbidities (adjusted HR = 3.50; 95% CI from 2.03 to 6.02; p < 0.001).

CONCLUSIONS

Obesity was prevalent in hospitalized patients with critical illness secondary to COVID-19 disease and a higher BMI was associated with higher hospital mortality. Further studies are needed to validate this association and to better understand its underlying mechanisms.