ABSTRACT
Introduction: Proton pump inhibitors (PPIs) play an indispensable role in the treatment of acid-secretion disorders and are one of the most widely used drugs. This study aimed to investigate the association between proton pump inhibitors (PPI) use and COVID-19-related mortality and hospitalizations. Aims & Methods: This population-based matched cohort study included all individuals diagnosed with the first episode of COVID-19 up to August 15, 2021, in Croatia. We classified patients based on exposure to PPIs and burden of PPI-requiring conditions as: 1. Non-users (patients without issued PPI prescriptions and treatmentrequiring conditions), 2. Possible users (patients without issued PPI prescriptions but with recorded treatment-requiring conditions), and;3. Users (patients with issued PPI prescriptions). Users were further divided into three groups based on the intensity of PPI prescriptions to investigate the dose effect of PPIs. In addition to the comparison of users to non-users, we compared: 1. Users to possible users to isolate the effect of PPIs and 2. Possible users to non-users to isolate the effect of comorbidities treated with PPIs on COVID-19-related mortality and hospitalization. Log-binomial regression with robust sandwich variance estimation was used to calculate relative risk and 95% confidence intervals after exact matching in respect to a range of pre-COVID-19 characteristics (in primary analysis: age (binned to 5 years), sex, vaccination status, time period in the course of the pandemic, Charlson comorbidity index, presence of ACE inhibitor therapy and comorbidities: atrial fibrillation, autoimmune diseases, cancer, chronic heart failure, chronic obstructive lung disease, ischemic or cerebrovascular diseases, chronic renal disease and immunocompromised state;in sensitivity analysis with an alternative set of covariates). Result(s): Among 433609 COVID-19 patients, 332389 were identified as nonusers, 18170 as possible users, and 55098 as users of PPIs. Users to non-users, users to possible users, and possible users to non-users were matched 48453 to 325005, 41195 to 17334, and 17466 to 316168 subjects per group, respectively. A small difference in COVID-19 related mortality and hospitalizations was observed after matching users to non-users [RRmortality = 1.23 (95%CI 1.16 - 1.30) and RRhospitalization = 1.46 (95%CI 1.38 - 1.54)] and possible users to non-users [RRmortality = 1.24 (95%CI 1.13 to 1.37) and RRhospitalization = 1.26 (95%CI 1.16 - 1.37)]. However, there was no relevant difference between users and possible users in COVID-19-related mortality [RR= 0.93 (95%CI 0.85 - 1.02)] or hospitalizations [RR = 1.04 (0.97 - 1.13)]. Dose effect was not observed in any comparison involving users. Sensitivity analysis yielded comparable results. Conclusion(s): The comparison of possible to non-users, and users to possible users indicates that the risk observed in the comparison of users and non-users of PPI is likely attributable to the burden of comorbidities treated with PPIs and not the effect of the PPIs.
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Introduction: The impact of COVID-19 has been of great concern in patients with inflammatory bowel disease (IBD) due to the possibility of increased risk of severe outcomes, which can result in increased hospital admission or increased mortality. Aims & Methods: This study aims to estimate the effect of IBD on mortality and the risk of hospitalizations in patients diagnosed with COVID-19. We included all COVID-19 patients in Croatia from the begging of the pandemic till the 15thof August 2021 and compared the COVID-19-related mortality and hospitalization risk in IBD patients vs general population and ulcerative colitis (UC) vs Crohn's disease (CD) patients. In all comparisons, patients were exactly matched on age, sex, vaccination status, time period of the pandemic, Charlson comorbidity index, important pharmacological therapy and relevant comorbidities. For sensitivity analysis, UC and CD patients were also matched using the optimal full + exact matching algorithm due to a smaller number of patients with the same set of covariates (except age was supplied as a continuous variable;and vaccination status, Charlson comorbidity index, and age binned to 10 years were supplied as exact covariates). Log-binomial regression with a robust sandwich variance estimator was used to calculate relative risk and 95% confidence intervals (RR and 95%CI) for outcomes (mortality and hospitalization). Result(s): We identified 3067 IBD patients among 433609 COVID-19 patients. Crude proportions of COVID-19-related mortality in unmatched data and calculated relative risk after matching indicated no difference in mortality of IBD and non-IBD patients [2.8% vs 2.7%, and RR = 0.85 (95%CI 0.60 - 1.19)]. On the other hand, the hospitalization rate was higher in IBD population both prior to matching (6.1% vs 4.5%) and after matching [RR = 1.43 (95%CI 1.17 - 1.75)]. Among 3067 IBD patients, we identified 2061 UC and 797 CD patients (for 209 patients IBD was unspecified). Unmatched comparison indicated an increased risk for COVID-19-related death (3.2% vs 1.8%) and hospitalization (6.1% and 5.8%) in patients suffering from UC. However, after matching using two different matching algorithms, we found no difference in mortality risk [RRprimary = 0.55 (95%CI 0.18 - 1.61), and RRsensitivity = 1.14 (95%CI 0.57 - 2.30)] nor hospitalization risk [RRprimary = 1.14 (95%CI 0.72 - 1.80) and RRsensitivity = 0.92 (95%CI 0.62 - 1.35)] between UC and CD. Conclusion(s): Our results indicate that IBD patients have a greater risk for hospitalization related to COVID-19 than the general population. On the other hand, COVID-19-related mortality risk is not increased in IBD patients, and no difference in COVID-19-related mortality and hospitalization was observed between UC and CD patients.
ABSTRACT
Until recently, obesity was one of the greatest public health issues. At the moment, the world is counting deaths from COVID-19, and raging obesity pandemic is not in the focus. While the quarantine is the mainstay of COVID-19 prevention, it also opposes obesity prevention. Obesity is a risk factor for severe COVID-19 infection. Treatment of obesity during quarantine is challenging;trying to lose weight without the opportunity for outdoor activity or access to fresh and healthy foods may lead to frustration, depression and overeating. Therefore, we propose that patients should focus on preventing new weight gain instead of losing weight. It can be achieved by practicing indoor physical exercise together with adequate diet. The diet should be opposite from, "Western diet pattern'' and include foods easily obtainable during quarantine;with longer shelf life, but also rich in anti-inflammatory and immune-modulatory bioactive compounds. These characteristics of the diet make it simple to implement during quarantine, it helps in the process maintaing weight and supports immune system-all what is required to possibly reduce the risk of severe COVID-19 infection. The anti-inflammatory properties from given diet have beneficial role, especially in obese patients, as they have low grade chronic inflammation which additionally may worsen clinical course of COVID-19 infection.
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Background: The risk of COVID-19 in patients with IBD is considered comparable to general population. However, it has been hypothesized that patients on immunosuppressive therapy could be more susceptible to SARS-CoV-2, mainly due to well-known association of immunosuppressive therapy and increased risk of viral infections. Our aim was to examine the frequency of COVID-19 infection among tertiary center IBD patients treated with biological therapy. Methods: These are descriptive data including IBD patients on biological therapy which are regularly followed in Croatian referral IBD center at the University Hospital Centre Zagreb, Croatia. Patients on adalimumab were excluded since they are not regularly followed and are receiving therapy at home. SARS-CoV-2 infection was identified as RNA positive nasopharyngeal swab. Disease activity was measured using Harvey-Bradshaw Index (HBI) in CD, partial Mayo score (pMayo) in UC, and CRP. COVID-19 was defined as mild as any of the symptoms consistent with COVID-19 without shortness of breath, dyspnea, abnormal chest imaging and room SpO2>=97%. Results: Out of total 234 patients on infliximab 15 (6.4%) had COVID-19, which was the case for 3 out of 48 (6.2%) patients on vedolizumab. We have not documented COVID-19 among 67 patients on ustekinumab and 10 on golimumab. Among infected there were 9 patients with CD, 8 UC and 1 IBD unclassified, 61.1% were male and average age was 37 (SD 12). All patients had mild clinical picture with symptoms lasting around 3 days. Overall, 3 UC patients on infliximab had worsening of IBD symptoms (bloody stools and diarrhea) in approximate time to and after COVID infection (increase of pMayo by >=2 points) with only 1 patient requiring glucocorticoid therapy. One male patient had prolonged post-COVID syndrome in terms of fatigue and mild dyspnea over 4 months, but suffered from bronchial asthma. There was no difference in HB index, pMayo or CRP before and after COVID-19 infection (p>0.05). Loss of smell and taste was present 3 patients. Conclusion: Our analysis was limited to IBD patients scheduled to receive a visit;hence it could not represent general IBD population. However, according to the results of other studies, we did not gain the impression of increased risk of infection or poorer clinical outcome in IBD patients on biological therapy. In addition, study from Singh AK et al. reported worse outcomes of COVID-19 IBD patients in UC, but not on biological therapy, which is also in line with our observation (1).
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The COVID-19 pandemics is posing unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Patients with worst outcomes and higher mortality are reported to include immunocompromised subjects, namely older adults and polymorbid individuals and malnourished people in general. ICU stay, polymorbidity and older age are all commonly associated with high risk for malnutrition, representing per se a relevant risk factor for higher morbidity and mortality in chronic and acute disease. Also importantly, prolonged ICU stays are reported to be required for COVID-19 patients stabilization, and longer ICU stay may per se directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function which may lead to disability, poor quality of life and additional morbidity. Prevention, diagnosis and treatment of malnutrition should therefore be routinely included in the management of COVID-19 patients. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing concise guidance for nutritional management of COVID-19 patients by proposing 10 practical recommendations. The practical guidance is focused to those in the ICU setting or in the presence of older age and polymorbidity, which are independently associated with malnutrition and its negative impact on patient survival.
ABSTRACT
BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.
Subject(s)
Child Health , Consensus , Delphi Technique , Nutrition Assessment , Remote Consultation/instrumentation , Remote Consultation/methods , Adult , COVID-19 , Child , Dietetics/instrumentation , Dietetics/methods , Evidence-Based Practice , Female , Humans , Male , Nutritional Status , Pediatrics/instrumentation , Pediatrics/methods , SARS-CoV-2ABSTRACT
Introduction: Obesity is among the risk factors for more severe forms of COVID-19. Obese people have higher prevalence of fatty liver and liver fibrosis. Aims & Methods: We aimed to investigate prevalence and severity od liver steatosis and fibrosis as assessed by transient elastography and their correlation with (a) the clinical severity of COVID-19 and (b) with 30-days mortality among non-critically ill patients hospitalized with COVID-19. We included patients >18 years, capable of giving informed consent, without conditions affecting liver stiffness measurement (LSM) (ALT>5xULN, congestive liver disease, extrahepatic biliary obstruction, infiltrative liver neoplasms). Transient elastography was used to assess liver stiffness and controlled attenuation parameter (CAP) for grading liver steatosis. Clinical severity of COVID-19 was assessed by 4C Mortality Score (4CMS) (Knight SR et al. BMJ2020). Results: A total of 218 patients were included (145/218 (66.5%) males, median age 65 years, IQR (56 - 71), median BMI 28.2 kg/m2, IQR (25.4 - 31.4). History of chronic liver disease was present in 10/218 (4.6%) patients. Median 4CMS was 7, IQR (5 - 9), and 25/218 (11.5%) patients required high flow oxygen therapy (HFOT). A total of 15 patients died during 30 days from admission (7.9% of 191 patients with 30 days follow-up). Median LSM was 5.2 kPa, IQR (4.1 - 6.5) with 41/218 (18.8%) of patients presenting with LSM of >7 kPa and 11/218 (5%) with LSM >10 kPa. LSM was higher in patients with history of chronic liver disease (median 8.1 kPa vs 5.1 kPa;P=0.004), higher bilirubin (Rho=0.18;P=0.016) and higher GGT (Rho=0.25;P=0.001). Median LSM IQR was 13%, IQR (9 - 20). LSM IQR was weakly associated with higher BMI (Rho=0.14;P=0.038). No significant associations of LSM or LSM IQR with other laboratory and clinical parameters were found. Median CAP was 274 dB/m, IQR (232 - 320.5). CAP was associated with higher BMI (Rho=0.43;P<0.001). There was no significant association of CAP with LSM in an overall cohort, but a subgroup of patients with chronic liver disease (N=10) showed strong negative correlation between CAP and LSM (Rho=-0.81;P=0.005). No significant associations of CAP with other laboratory and clinical parameters were found. LSM IQR was not correlated to LSM or CAP values. Neither LSM, LSM IQR nor CAP were associated with 4CMS (P>0.05), although there was a tendency for a higher CAP values in patients with higher 4CMS (P=0.071). Also neither LSM nor CAP had significant association with the need for HFOT and 30-day mortality (P>0.05). However, patients who died had significantly lower LSM IQR (median 8.5% vs 14%;P=0.006), and those with LSM IQR ≤5% had 13 times higher risk of death (OR=13.2;95% C.I. 3.5 - 50.1). LSM IQR ≤5% was more frequently observed among patients on HFOT as well (28.6% vs 10.3%;P=0.038). Through multivariate logistic regression model building process investigating associations of LSM, LSM IQR, CAP, age, sex, BMI, 4CMS and need for HFOT with 30 day mortality, LSM IQR ≤5% (adjusted OR=19.4;P<0.001), 4CMS (adjusted OR=1.3;P=0.050) and need for HFOT (adjusted OR=14.0;P<0.001) were recognized as mutually independent predictors of higher mortality. Conclusion: Whereas LSM and CAP as non-invasive surrogates of liver fibrosis and steatosis failed to show correlation with disease severity and outcomes of patients with COVID-19, LSM IQR<5% was highly associated with the risk of 30-day mortality, independently of composite mortality score and the level of non-invasive oxygen support.
ABSTRACT
The COVID-19 pandemics is posing unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Patients with worst outcomes and higher mortality are reported to include immunocompromised subjects, namely older adults and polymorbid individuals and malnourished people in general. ICU stay, polymorbidity and older age are all commonly associated with high risk for malnutrition, representing per se a relevant risk factor for higher morbidity and mortality in chronic and acute disease. Also importantly, prolonged ICU stays are reported to be required for COVID-19 patients stabilization, and longer ICU stay may per se directly worsen or cause malnutrition, with severe loss of skeletal muscle mass and function which may lead to disability, poor quality of life and additional morbidity. Prevention, diagnosis and treatment of malnutrition should therefore be routinely included in the management of COVID-19 patients. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing concise guidance for nutritional management of COVID-19 patients by proposing 10 practical recommendations. The practical guidance is focused to those in the ICU setting or in the presence of older age and polymorbidity, which are independently associated with malnutrition and its negative impact on patient survival. © 2020 Hrvatski Lijecnicki Zbor. All rights reserved.