The impact of smoking status and smoking-related comorbidities on COVID-19 patient outcomes: A causal mediation analysis.

INTRODUCTION: Smoking history is a known risk factor for significant chronic diseases as well as pulmonary infections; however, the impact of smoking status on COVID-19 outcomes has not been conclusively characterized. This study aims to evaluate the association of smoking status on COVID-19 outcomes, and to explore the mechanism by which smoking and smoking-related comorbidities relate to COVID-19 outcomes. METHODS: Patients admitted with SARS-CoV-2 infection from November 2020 through January 2021 were included in this study. Causal mediation models investigating the associations between smoking status and the outcomes of mortality, intensive care unit (ICU) admission, advanced respiratory support, mechanical ventilation, ICU length of stay, and hospital length of stay, through mediation via smoking-related comorbidities, were examined. RESULTS: Active smokers did not experience worse COVID-19 outcomes once hospitalized. Former smokers had a higher odds of mortality (total effect OR 1.59, 95% CI 1.07-2.38, p=.01; indirect effect OR 1.45, 95% CI 1.09-1.93, p<.001), and advanced respiratory support (total effect OR 1.31, 95% CI 1.04-1.67, p=.02; indirect effect OR 1.26, 95% C1.03-1.54, p=.02), which were mediated by smoking-related comorbidities. While there was a non-significant increase in the total effect for mechanical ventilation, smoking-related comorbidities were significant mediators for their increased need (total effect OR 1.40, 95% CI 0.92-2.14, p=.13; indirect effect OR 1.47, 95% CI 1.10-1.87, p<.001). CONCLUSION: While active smokers did not experience worse COVID-19 outcomes compared to never smokers, these results should be interpreted with caution. Compared to never smokers, former smokers had greater odds of mortality, advanced respiratory support, and mechanical ventilation which was significantly mediated through smoking-related comorbidities. IMPLICATIONS: Previous studies have linked smoking status with worse COVID-19 outcomes, and have inferred that smoking-related comorbidities may play a role in these findings. This causal mediation analysis provides statistical evidence supporting this hypothesis, clarifying the risk that smoking-related comorbidities impart on COVID-19 outcomes in those with a smoking history.

COVID-19 patients with obesity at risk for worse outcomes despite younger age and fewer inflammatory derangements.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a viral pulmonary infection that can progress to cytokine storm syndrome because of widespread dysregulated inflammatory response. Many patients at risk for severe COVID-19 manifestation have been identified as those with preexisting conditions of pulmonary origin, as well as conditions that impair appropriate immune response, such as obesity. OBJECTIVES: The aim of this study is to describe the manifestation, clinical course, and inflammatory biomarker milieu of COVID-19 in patients with obesity. SETTING: University Hospital Philadelphia, Pennsylvania. METHODS: In this retrospective cohort study, 600 patients who were positive for COVID-19 were stratified by World Health Organization (WHO) obesity class and their presenting symptoms, disease biomarkers, demographics, and outcomes (intubation rate, intensive care unit [ICU] admission, length of stay [LOS], and mortality) were investigated. RESULTS: Age was inversely related to obesity class; patients of obesity class III presented 12.9 years younger than patients of normal weight (P < .0001). Initial ferritin lab values were negatively correlated with increasing obesity class (P = .0192). Normal or near-normal lymphocyte profile was noted in patients with obesity compared with patients without obesity (P = .0017). Patients with obesity had an increased rate of ICU admission (P = .0215) and increased length of stay (P = .0004), but no differences in intubation rate (P = .3705) or mortality (P = .2486). CONCLUSION: Patients with obesity were more likely to present to the hospital at a younger age, with reduced levels of COVID-19 related biomarker disturbances, and increased LOS and ICU admission rates, although were not at increased risk for mortality.

The effects of the COVID-19 pandemic on patients with obesity undergoing bariatric care.

BACKGROUND: Patients with obesity are at increased risk of developing severe COVID-19. The pandemic has caused delays in preoperative preparation, progression, and completion of bariatric surgeries. OBJECTIVES: The aim of this study was to evaluate the impact of COVID-19 restrictions on bariatric surgery patients and assess their concern of COVID-19 as they continue the preoperative process. SETTING: Philadelphia, Pennsylvania METHODS: A questionnaire was administered to patients to assess the impact of COVID-19 on their weight loss goals, physical activity, and diet. Time points assessed were initial bariatric consultation (T1), as well as the beginning (T2), and the end (T3) of lockdown restrictions in the region. RESULTS: Seventy-four participants were invited and 50 completed the survey, for a response rate of 67.6%. The average age of participants was 44.1 years. Two-thirds of patients reported significant concern that COVID-19 would affect their weight loss goals. Patients reported significant improvements in their diet from T1 to T2 (P < .01). However, at T3, some patients returned to behaviors held at T1, with snacking behaviors significantly increasing between T2 and T3 (P < .01). Physical activity decreased in 60% of patients between T2 to T3. The vast majority (90%) wanted to have their surgery as soon as possible; 56% reported low levels of concern for COVID-19 infection. CONCLUSION: Bariatric patients were highly motivated to proceed with bariatric surgery despite the risks imposed by the pandemic.